Case Formulation [TOP]
Dudley and Kuyken (2006) suggest using the five P’s when formulating a case with Cognitive Behavioural Therapy. These five P’s are: the presenting issues, predisposing factors, precipitating factors, perpetuating factors / maintaining factors and the protective factors. The presenting issues are the presenting problems in relation to the client’s emotions, behaviours and thoughts. Predisposing factors are described as the longitudinal factors that increase the client’s risk to the problem. The precipitating factors are factors related to the proximal events that have triggered the problem. Perpetuating factors are also known as the maintaining factors, and these factors maintain the problem. Finally, the protective factors pertain to a client’s resilience and/ or strengths that enable the person to have emotional health and may serve to enable recovery in therapy.
Case formulations in CBT change, depending on the client and what is brought out in a session and therefore, is a work in progress, which enables planning and is used collaboratively with the client, allowing them to agree or disagree with the formulation. This collaboration of the case formulation empowers the client to be aware and have insight into themselves, but also to understand their problem. The below section formulates Noluthando’s case, in relation to the presenting issues, predisposing factors, precipitating factors, perpetuating factors and protective factors from a Cognitive Behavioural Therapy approach.
Presenting Issues [TOP]
Noluthando’s presenting problem is described above, under the headings “presenting problem and reason for referral”. When looking at Noluthando’s emotions, she displayed a depressed mood and suppressed most of the feelings that she was experiencing. Noluthando had become withdrawn in her behaviour and was not engaging in activities that she previously enjoyed. According to Noluthando, she was not eating and had lost her appetite, as well as having difficulty in sleeping. She was also closing herself down from communicating with others by being quiet and not opening up to others. She had thoughts of not feeling good enough and thoughts of being a failure. Her emotions, behaviours and thoughts revealed Noluthando’s depression.
Predisposing Factors [TOP]
Noluthando reported that she could not remember a time when her mother was not drinking alcohol and witnessing her father abusing her mother. Her mother’s abuse of drinking alcohol might have prevented Noluthando and her mother from forming a secure attachment in her early childhood. Noluthando had never had an open and communicative relationship with her parents, which suggests that the model she received from her parents, on communicating and openness, was absent in her early years as a child. According to Seroczynski, Jacquez, and Cole (2006), depressed adolescents generally have experienced distressing home lifestyles and come from troubled homes.
Noluthando lost her maternal grandparents at a young age and reported being particularly close to her grandmother. She still thinks about her often and may have still been dealing with her loss. Lloyd (1980) describes research that shows that the experiencing of early loss/bereavement in childhood has a high correlation with subsequent severity of suicide attempts and depression later in life. According to Kaplan, Sadock, and Grebb (1994), life events that may be experienced as stressful, may result in a person’s first episode of a mood disorder.
Precipitating Factors [TOP]
Noluthando reported finding it difficult to attend a school that is so far from home. Being far away from home may be difficult because of the thoughts she may have about what is happening at home in her absence. She said that she feels responsible for the events and problems at home and has a sense of failure, as she does not take any action to help her mother when she witnesses her father abusing her. The silence that surrounded Noluthando’s father’s HIV positive status further isolated her from her family, and placed another emotional burden for her to carry, which is not acknowledged within the family system. Negative core beliefs of parents and parenting styles which are poor in nature, may cause insecure attachments in childhood and are associated with an increase in depressive features later in life as described by Shah (2000). Rothschild (1999) says that disturbances and problems in early childhood relationships have shown to increase vulnerability to depression.
Perpetuating Factors/Maintaining Factors [TOP]
Noluthando was uncommunicative and this means, for her, that she does not speak about her feelings or difficulties that she is experiencing. The silence makes it difficult for her to reach out to someone when problems become too much for her and when she needs help. This made her vulnerable to the suicide attempt she made earlier in 2010. Kaplan, Sadock, and Grebb (1994) attribute suicide attempt rates as being higher in persons who are socially isolated.
Noluthando had lost her appetite, had little interest in food and had lost weight. Her difficulties in eating, affect her mood and can affect her energy levels, adding to her depressed mood state. Noluthando has difficulty sleeping and wakes early in the morning, which may leave her with little energy during the day, consequently affecting her mood. The loss of appetite and difficulty with sleeping reveal problems in basic health maintenance that need attention when working with depression (Leahy & Holland, 2000).
The more Noluthando suppresses her feelings and thoughts, the more she ruminates and forms negative automatic thoughts. When she closes herself off from feeling, she prevents herself from opening up and developing new relationships and working on her present relationships. The suppression of feelings is a defence mechanism that Noluthando uses that is causing harm to her relationships and possible forming of new relationships. Vaillant (1999) describes defensive mechanisms as being the unconscious trying to cope with psychological stress. Properties of defences are unconscious, managing affect, being discrete from one another, are reversible, and may be adaptive or pathological. The DSM IV-TR (2000) places defences in different levels, and suppression is placed under level seven, which is a high adaptive level and allows for optimal adaptation and handling of difficulties.
Noluthando had disengaged herself from activities that she used to enjoy, i.e. attending church activities, reading, etc. Her lack of activity may aid/feed the depression. The lack of activity provides her with more time to think about the negative aspects of her life and maintains her ruminating state. This also isolates her further from the emotional support of her friends and peers, confirming her belief that she is alone and cannot share her difficulties with others. Westbrook et al. (2008) describe how a reduction in activity results in a low mood as there is no engagement in activities that the person used to find enjoyable, and a sense of pleasure and achievement is lost.
Protective Factors [TOP]
Noluthando reported being passionate about drama and although she had lost interest in much of her activities, drama is still something she enjoys. Her involvement in drama may give her a sense of belonging, a feeling of being pro-social with her peer group, forming part of a community group, and may provide an opportunity for feelings of responsibility and success, which are protective factors against depression, as described by Barrett and Turner (2004). Noluthando has a close relationship with two adults, namely her cousin, and, after the suicide attempt, she developed a deeper relationship with one of her older sisters. These relationships are social protective factors, according to Barrett and Turner (2004). Noluthando immediately set goals in the initial stages of therapy (to open up more with others), making known her motivation to feeling better and improving her level of functioning.
Noluthando and the Six Cycles Maintenance Model of Depression [TOP]
There are different models and ways of conceptualising when working with depression from a CBT approach. I found the Six Cycles Maintenance Model of depression useful when working with Noluthando’s case. The model was adapted from a Cognitive Behavioural Therapy model of anxiety disorders. According to Moorey (2010), the model for depression was developed based on a CBT understanding of maintenance factors in depression. The model is considered useful in conceptualising cases and when used in treatment planning, when working with depression.
Moorey’s (2010) Six Cycles of depression include: automatic negative thinking, rumination and self-attacking, mood and emotion, withdrawal and avoidance, unhelpful behaviours, physical symptoms and motivation. Automatic negative thinking is the negative thoughts one experiences in any given event or situation that are biased from a negative perspective. Cognitive distortions and their misinterpretations also fall within this cycle. The cycle of rumination involves thinking about a negative event, in which thoughts are about what one could have done differently, how it happened and what went wrong. Ruminations may form part of the past or present, as part of this cycle. Self-attacking describes how one persistently attacks and provides criticism to the self. Mood and emotion as a cycle involves feeling in a low mood, feelings of sadness and emptiness, anxiety and irritability. The depressed person’s mood may serve as a feedback loop as they may feel that their mood makes them feel as though they are no fun to be around. This leads to further self-attacking. The withdrawal and avoidance cycle is a significant maintenance factor in depression. When a person is in a depressed mode, they may feel worthless and may have thoughts of failure, which results in less engagement in activities than what they used to take part in and enjoy. The disengagement of activities prevents the negative thoughts from being tested and reduces the possibility of finding pleasure in activities that one enjoys. The unhelpful behaviour cycle describes behaviours that try to compensate for unpleasant feelings and negative beliefs. The cycle of motivation and physical symptoms describes the biological symptoms of depression and may lock the person into the depressive mode. Feelings of inadequacy may result in the person with depression, leaving them with feeling worthless and with nothing to offer. The environment also forms part of the six cycles and may trigger and maintain depression. The environment may include a person’s home, school, work, friends, family, etc. The six cycles do not naturally occur in a step-by-step fashion and clients will not necessarily fall into all six cycles (Moorey, 2010).
Moorey’s (2010) Six Cycles Maintenance Model of depression helps to provide an understanding of Noluthando’s depression from a CBT approach. Noluthando’s automatic negative thinking includes thoughts such as thinking she is a failure, thoughts that she is to blame for what happens at home and her family life, and thoughts that something is inherently wrong with her. Her ruminations include thoughts of feeling as though she is to blame and feelings of guilt, as she feels that perhaps she could do something different to change the circumstances within her family. She then places much pressure and responsibility on herself for aspects of her life that are beyond her control. Her mood and emotions include feelings of being depressed, guilt, irritability, inadequacy, and suppression from having any feeling. Noluthando’s withdrawal and avoidance cycle include her disengagement from activities that she used to enjoy, such as: taking part in church activities, socialising with friends, and reading. The unhelpful behaviours that she engages in are her inactivity, the suicide attempt she made earlier in the year, not eating, and avoiding her feelings. Noluthando’s loss of appetite, the difficulties she experiences in sleeping, and loss of energy pertain to the physical symptoms and motivation cycle.
The Treatment Plan [TOP]
In working with Noluthando, I experienced difficulty in following a treatment model strictly, and this will further be elaborated on through the discussion on what happened in therapy, below. The reasons that I found implementing the therapy model difficult at times, was that often Noluthando was in an uncommunicative state and I feared developing a further barrier between us, and at times, it felt inappropriate and damaging to the relationship. However, the treatment plan was followed and was often naturally integrated into therapy. I battled at times (this was part of my process of integration of using CBT and focusing on the therapeutic relationship, and seeing them as separate constructs) to find the balance of the implementation of the therapeutic relationship and using technique.
Moorey (2010) reveals ways to break the cycle of depression / or the six cycles maintenance model. When applying this treatment model to Noluthando, I tried to work with the automatic negative thinking cycle, by testing negative thoughts and beliefs. This involved confronting her negative beliefs, the way she thinks about things, and testing them against reality and other viewpoints. When working with her ruminations and the self-attacking cycle, I used problem-solving and the development of compassion. Part of Noluthando’s therapy involved self-awareness of her thought processes and ruminations, psycho-education on problem-solving and practicing of this in and outside of therapy. Developing compassion would be important for Noluthando, as she frequently believed that she was a failure and needed to learn to be gentler with herself. To help with Noluthando’s mood, we collaborated in recognising mood shifts, as she needed to become more aware of what she was feeling as she often used suppression as a defence mechanism against feeling. In approaching the withdrawal and avoidance cycle, I suggested that Noluthando start to slowly engage herself in activities again and to start opening up, rather than isolating herself. Noluthando could deal with her unhelpful behaviour cycle by not avoiding her feelings, eating when it is difficult, and to rather engage in problem-solving and reaching out to someone for help when things do become too difficult. Psycho-education aided in this. In terms of the motivation and the physical symptoms cycle, it benefited her to become aware of her symptoms, to keep healthy through exercise, and sleeping and eating in a healthier way.
Implementing the above does not mean that the environment/context will change in which Noluthando finds herself in. It is of value to create awareness of this for Noluthando and for her to come to an understanding of how to live in her environment and possible alternatives to this.
Jocelyn works as a Human Resources Manager for a large international organisation. She is becoming more and more stressed at work as the company is constantly changing and evolving. It is a requirement of her job that she keeps up with this change by implementing new strategies as well as ensuring focus is kept on her main role of headhunting new employees.
She finds that she is working twelve-hour days, six days a week and doesn’t have time for her friends and family. She has started yelling at staff members when they ask her questions and when making small mistakes in their work. Concerned about her stress levels, Jocelyn decided to attend a counselling session.
Below is an extract from Jocelyn’s first session with her counsellor:
Transcript from counselling session
Counsellor: So Jocelyn, let’s spend a few minutes talking about the connection between your thoughts and your emotions. Can you think of some times this week when you were frustrated with work?
Jocelyn: Yes, definitely. It was on Friday and I had just implemented a new policy for staff members. I had imagined that I would get a lot of phone calls about it because I always do but I ended up snapping at people over the phone.
Counsellor: And how were you feeling at that time?
Jocelyn: I felt quite stressed and also annoyed at other staff members because they didn’t understand the policy.
Counsellor: And what was going through your mind?
Jocelyn: I guess I was thinking that no-one appreciates what I do.
Counsellor: Okay. You just identified what we call an automatic thought. Everyone has them. They are thoughts that immediately pop to mind without any effort on your part. Most of the time the thought occurs so quickly you don’t notice it but it has an impact on your emotions. It’s usually the emotion that you notice, rather than the thought. Often these automatic thoughts are distorted in some way but we usually don’t stop to question the validity of the thought. But today, that’s what we are going to do?
The counsellor proceeds to work through the cognitive behaviour process with Jocelyn as follow:
Step 1 — Identify the automatic thought
Together, the counsellor and Jocelyn identified Jocelyn’s automatic thought as: “No-one appreciates what I do”.
Step 2 — Question the validity of the automatic thought
To question the validity of Jocelyn’s automatic thought, the counsellor engages in the following dialogue:
Counsellor: Tell me Jocelyn, what is the effect of believing that ‘no-one appreciates you?’
Jocelyn: Well, it infuriates me! I feel so undervalued and it puts me in such a foul mood.
Counsellor: Okay, now I’d just like you to think for a moment what could be the effect if you changed that way of thinking
Jocelyn: You mean, if I didn’t think that ‘no-one appreciates me’?
Jocelyn: I guess I’d be a lot happier in my job. Ha, ha, I’d probably be nicer to be around. I’d be less snappy, more patient.
Step 3 — Challenge core beliefs
To challenge Jocelyn’s core belief, the counsellor engages in the following dialogue:
Counsellor: Jocelyn, I’d like you to read through this list of common false beliefs and tell me if you relate to any of them (hands Jocelyn the list of common false beliefs).
Jocelyn: (Reads list)Ah, yes,I can see how I relate to number four, ‘that it’s necessary to be competent and successful in all those things which are attempted’.That’s so true for me.
Counsellor: The reason these are called “false beliefs” is because they are extreme ways of perceiving the world. They are black or white and ignore the shades of grey in between.
Applications of CBT
Cognitive approaches have been applied as means of treatment across a variety of presenting concerns and psychological conditions. Cognitive approaches emphasise the role of thought in the development and maintenance of unhelpful or distressing patterns of emotion or behaviour.
Beck originally applied his cognitive approach to the treatment of depression. Cognitive therapy has also been successfully used to treat such conditions as anxiety disorders, obsessive disorders, substance abuse, post-traumatic stress, eating disorders, dissociative identity disorder, chronic pain and many other clinical conditions. In addition, it has been widely utilised to assist clients in enhancing their coping skills and moderating extremes in unhelpful thinking.