4.1 Introduction
In this module, you will take a closer look at how CBT practitioners navigate the therapy process. You will learn how and why treatment manuals are used to form the structure of a client's therapy, how therapists formulate a case and how therapy blueprints are used at the end of therapy to promote lasting change.
Fact
There are an estimated 1.5 million people with a learning disability in the UK. Therefore, it is important that therapists have access to manuals appropriate for this client group.
Source: www.nhs.uk
4.2 Treatment Manuals
One of the key advantages of CBT is its structure, because it means that researchers can readily compare and contrast outcomes across multiple forms of therapy.Although therapists can use their discretion in terms of the exercises they recommend to a client, a course of CBT typically follows a predetermined route. It is much easier to research the outcome of a structured form of therapy, compared to more nebulous treatments such as psychoanalysis and traditional person-centred therapy. There are many manuals available that target specific problems.
For instance
In the previous module you learned about CBT-E. Therapists delivering this intervention will use a manual or course outline to determine the topic of conversation in each session and to use as guidance when it comes to setting homework tasks. Therapy manuals also include worksheets and forms that a client can use to challenge maladaptive thoughts and behaviours. These ready-made resources save the therapist time.
If a therapist works for the NHS or another established service, they will be given appropriate manuals and materials upon joining. However, if they are in private practice, they can choose their preferred approach from the many manuals available. They can be purchased via mainstream and specialist bookstores or found free of charge online. The better manual is one that contains interventions that are tailored to the client's needs; such as a CBT manual that is designed to help therapists working with depressed clients, anxious clients, older clients and so forth.
Clients and treatment manuals
Treatment manuals are not just useful for therapists. CBT is a transparent therapy and a client will sometimes be provided with a copy of the manual. Some programmes offer two versions of the same manual - one for the therapist and one for the client. It may be necessary to write the latter version in simpler language, but the basic ideas contained in each will be the same. A therapist must use their judgement in deciding whether and when a client should receive a copy. Some clients may want to know in advance which exercises they will be expected to undertake, whereas others would find the information overwhelming.
Activity: Looking at a Treatment Manual
Estimated time: 10+ minutes
If you visit the UCL London site you can download and view a manual for people with learning disabilities and common mental disorders.
Look at the table of contents.
Do you think this manual is sufficiently detailed, or do you think that the authors might have missed some key information? Why?
4.3 What is a Case Formulation?
A case formulation can be thought of as a hypothesis. It outlines the nature of a client's problems, the faulty cognitions and unhelpful behaviours that maintain these difficulties and their goals for therapy. It is an important process, not only in terms of an individual client's therapy, but also for the CBT paradigm as a whole. This is because in mainstream CBT, case formulation entails labelling a client's problem. For instance, they might be given a label of depression, anxiety, or OCD. Research into CBT focuses on how well it works for particular groups of clients and this is only feasible if the researchers can compare clients who have been given the same diagnostic label.
What to consider when carrying out a case formulation
There is no single procedure that CBT therapists must follow when carrying out formulations. However, most practitioners agree that it is necessary to gather the following pieces of information:
The presenting problem
The issues that have prompted the client to seek help, or the issues that have resulted in a referral from their doctor.
Examples of presenting problems include:
Feelings of deep depression, compulsions and obsessions, binge eating and alcohol misuse. A presenting problem is easily identified.
A client's diagnosis
If they have been referred by a doctor or other practitioner, the client may have been given a diagnosis. Every client will respond differently to exercises and homework assignments, but having a formal diagnosis to work with gives the therapist a head start.
Key core beliefs
As psychological distress is maintained by underlying core beliefs, a therapist needs to establish early on how the client views themselves, the world and the future.
For instance
A client with depression may hold the core belief that they are unlovable. If the client is to recover, they will need to relinquish this belief.
Key dysfunctional assumptions
In a similar vein, a therapist needs to uncover a client's maladaptive life rules. A client's 'shoulds, oughts and musts' frequently keep them locked in a state of distress. Until they are eradicated, the client will continue to engage in the same maladaptive thoughts and behaviours.
Vulnerability factors
A vulnerability factor is anything that makes an individual more likely to experience a problem. Genetics are one such factor. If a client reports that several members of their immediate family have similar symptoms, it is likely that genetic vulnerability has played a role in their current condition. Another vulnerability factor is experience. CBT is acknowledged as a present-focused therapy, but it does not overlook the past entirely. Indeed, a person's past experiences can shed light on why they have adopted unhelpful thinking styles in the first place.
An abusive childhood can contribute to feelings of inadequacy and can prompt a client to believe that the world is a fundamentally unsafe place. There is no exact formula that can predict whether or not specific vulnerabilities will interact to produce mental health conditions in any one individual. However, just knowing that there are goodreasons why they are experiencing mental illness can come as a relief to a client. At the same time, therapists should emphasise that genetic inheritance or past experiences do not mean that an individual cannot recover and go on to enjoy a good life. Depressed clients in particular are prone to fatalistic thinking, so this kind of reassurance is important.
Vicious cycles
Thoughts, feelings and behaviours often fit together to maintain a client's problems. A therapist needs to understand the cycles before they can work with the client to break them apart.
For instance
Someone who feels depressed will often spend less time doing positive activities that they enjoy, because they do not have sufficient motivation. Their lack of enjoyment and achievement makes them feel even more depressed, which promotes further inertia and so on.
Modifiers and triggers
A modifier is anything that makes a noticeable positive or negative difference to a client's state of mind.
For instance
Someone with depression might feel worse when visiting their parents - this would be a negative modifier. On the other hand, they may feel slightly better after spending the afternoon with a trusted friend - this would be a positive modifier. A trigger is something that set a problem into motion. Whereas a modifier changes the way in which
a client experiences a problem, a trigger can be thought of as a starting pistol - a client would otherwise have escaped a problem or experience.
For example
Someone with Generalised Anxiety Disorder (GAD) might find that their symptoms are triggered whenever their partner has to leave the country on a business trip. In this situation, they may find themselves unable to control their anxieties.
Critical incidents
Whereas a trigger is often an everyday (or at least relatively unexceptional) occurrence, a critical incident is a notable life event that took place shortly before the onset of a client's symptoms. A critical incident can cause an individual to experience mental health problems for the first time, or it can reawaken difficulties that the client thought had been resolved long ago.Common critical incidents include bereavement, divorce, or redundancy. It is usual for a therapist to begin the formulation by taking notes whilst discussing a client's problems during a therapy session, before later presenting the information as a diagram.
Formulation should be a transparent process. Unless client and therapist agree on the nature of the client's problems, the treatment is unlikely to be successful. Clients feel patronised if their therapist insists that their personal view of the situation is incorrect.
4.4 The Role of Psychometric Tests in CBT
Psychometric tests are standardised tests that measure an individual's personality traits, motivation, values, preferences and cognitive abilities.
In the context of CBT, these tests are particularly relevant as specialised tests have been designed to measure factors such as:
*Logical and critical reasoning
*Learning and development
*Language and comprehension
*Problem solving
*Decision making and judgement
While some debaters argue that psychometric tests are not always reliable, they do provide a framework whereby practitioners can identify patterns and predict behavioural outcomes. Moreover, these tests can be administered at different intervals during therapy to monitor outcome.
There are numerous CBT psychometric tests available to rate and measure the following characteristics:
*ADHD
*Addiction
*Anger
*Anxiety
*Assertiveness
*Bipolar Tendencies
*Eating Disorders
*Moodiness
*Obsessive Compulsive Disorders
*PTSD
*Sleep
*Sociability
*Suicidality
As a rule, only those with a medical degree can make a formal diagnosis that will go on a client's medical records. However, regardless of whether a client arrives for their first therapy session with a formal diagnosis, a therapist may use written tests as a means of assessing which symptoms are affecting the client at the present time. A therapist might not be able to make an official diagnosis, but an experienced practitioner will be able to spot common patterns that occur in clients with various mental health problems. They can also use their common sense in interpreting test results.
Some of the most frequently used psychometric tests are listed below:
*AEDM - Anger/Emotional Distress Measure (DSM-5)
*ASM - Agoraphobia Severity Measure (DSM-5)
*FQ - Fear Questionnaire
*GAD-7 - Generalised Anxiety Disorder
*HAI - Health Anxiety Inventory
*GDS - Goldberg's Depression Scale
*PHQ-9 - Patient Health Questionnaire (Depression)
*Mood Disorder Questionnaire (MDQ)
These are available online and in therapy training manuals. Most are simple to administer and score.They can be administered at regular intervals as therapy progresses. Keeping a record of a client's scores allows them to track progress and readjust goals andinterventions as required.
Fact
A survey run by the free UK-based online CBT resourceGet Self Help found that 97% of its users rated the resources as “helpful” or “very helpful”. This suggests that online resources have a big role to play in contemporary CBT practice.
Source: www.getselfhelp.co.uk
4.5 Three Approaches to Formulation
A therapist can devise their own method of formulation, but many choose to follow recommendations laid down by others. There are too many formulation styles to address in this module, but here are three widely-used approaches that can be used as a basis for understanding a client's problems:
Jacqueline Persons Style Formulation
This is based on Persons' work as laid out in her book, The Case Formulation Approach To Cognitive Behavioural Therapy. This formula emphasises maintaining factors. The therapist starts by making a list of a client's problems, then working with the client to hypothesise which psychological mechanisms (e.g. maladaptive thoughts and core beliefs) keep them going.
Therapist and client will then collaborate in thinking about why the client adopted these mechanisms in the first place. The approach takes into account the triggers, vulnerabilities and precipitating factors that underlie the client's current psychological distress. When putting together a treatment plan, this formulation method urges the therapist to think about potential barriers to treatment and how they can be anticipated and overcome.
Functional Analysis with Intervention Planning
This approach emphasises the context of a client's behaviour - that is, the ways in which their environment acts as a cue. It also invites the client to consider the consequences of their behaviour. A client will often appreciate that their behaviours are destructive, but fail to appreciate precisely how they are supported and maintained by their environment. Given that many environmental cues and triggers are beyond a client's control, it makes sense to plan their reactions in advance with the help of their therapist.
Functional analysis also prompts a therapist and their client to look at why the behaviours 'pay off'. Examining the antecedents, behaviours and consequences builds a foundation for meaningful change.
For instance
A depressed client may report that when they are invited to go out with friends (antecedent), they decline the invitation because they have no motivation to take part in a social situation (behaviour) and then call their partner in a bid to gain sympathy and understanding (behaviour). The consequence is that the client feels alienated from their friends, but they have succeeded in gaining their partner's attention, which makes them feel supported.
Having mapped out the relationships between antecedents, behaviours and consequences, the client might see their problems from a new perspective. To continue with the above example, the client may feel surprised when they realise that their seemingly unhelpful behaviour actually yields a payoff, which makes it more likely to happen again in the future. It is not unusual for the same behaviour to result in both positive and negative consequences.
This model can then be used as a means for planning interventions. Someone who acts in a self-destructive manner and seeks payoff by looking to others for sympathy can make a conscious decision to break the chain by pledging not to call a friend or partner afterwards. The rationale behind this approach is that if a behaviour does not result in a reward of some kind, it is less likely to be repeated in the future. When the consequence of the behaviour is loneliness instead of sympathy, there is less incentive to do it.
Moving back a step, interventions can also target behaviours. To stop the ABC pattern outlined previously, the individual could decide in advance that they will accept any offers made by their friends, even if they do not feel like going out. They might decide that they will turn up to the event, but allow themselves to leave after an hour if it proves too overwhelming. Along with social situations, emotions are another category of antecedents, often preceding destructive behaviour and negative consequences.
For instance
Someone who routinely binge eats whenever they experience unpleasant emotions might list anger, sadness and anxiety as factors that prompt them to engage in destructive behaviour. A therapist could suggest that the client experiments with new behaviours instead, such as distracting themselves from the emotion or using a relaxation exercise.
However, they could also encourage the client to think about making changes at the antecedent stage. If the client experienced negative feelings less often, this would indirectly help them reduce their rate of binge eating. There are several interventions that would tackle the root cause and therefore short-circuit the process.
For example
Their therapist could improve the client's overall mood by challenging their core beliefs. The client would still need to work on changing their behavioural responses to unpleasant emotions, because no one can feel calm and happy all of the time, but removing self-inflicted distress would reduce the average amount of binge eating the client engaged in over the course of a week.
Judith Beck Style Formulation
Judith Beck, daughter of Aaron Beck, is a CBT therapist who has devised various techniques and treatment strategies based on his original work. Her formulation takes into account both longitudinal and cross-sectional factors. The therapist begins by asking about the client's history, gathering information about any notable events in childhood and adolescence. Having discussed the feelings triggered by these events and the subsequent effect on the client's life, the therapist will uncover the client's core beliefs. The next step in the formulation process is to elicit the client's life rules, attitudes and conditional assumptions.
For example
If a client was taken into care
as a nine-year-old because their mother could not look after them, they
might have developed the core belief that 'people are unreliable' and the rule
that if they do not allow themselves to get too close to someone else,
then they will not be abandoned or hurt again. These beliefs may serve a
purpose, but ultimately they are destructive because they prevent the
kind of meaningful intimacy that enriches most people's lives. This can
leave an individual vulnerable to depression and social isolation.
Beck style formulations also seek to establish what kind of coping mechanisms a client currently uses to deal with feelings of distress. To continue with the example above, a client who feels alienated from others might start to abuse alcohol. Other coping mechanisms include overspending, binge eating, escaping reality by watching too much TV or spending time online and self-harm. The formulation also takes into account positive coping mechanisms, such as keeping a journal, spending time with family and friends and exercising.
Finally, a therapist using this approach will work with the client to uncover how the latter's behaviours and feelings are shaped by situations and automatic thoughts. They will explain to the client that although we cannot control our automatic thoughts - they are automatic, after all! - we can change what they mean to us and changing their meaning will have a direct bearing on what we do and how we feel as a result. This analysis can be broken down like this: Situation, Automatic Thought, Meaning Of Automatic Thought, Emotion and Behaviour.
For example
Let's say that a client suffering from an eating disorder finds that they feel compelled to burn off hundreds (or even thousands) of calories and restrict their food intake after meeting a woman they believe to be significantly thinner and more attractive than themselves.
The analysis would work as follows:
Situation: Meeting a thin, attractive woman.
Automatic thought: “She's better than me. I'm so ugly!”
Meaning Of Automatic Thought: “This thought is correct. I must act on it.”
Emotion: Sadness, jealousy, embarrassment.
Behaviour: Compulsive exercising and dieting, resulting in subsequent bingeing and self-hatred.
This information provides a sound starting point for various exercises and interventions. The client's therapist might point out that whilst the client cannot avoid all social situations and they cannot stop their automatic thoughts, they do not have to believe everything they think! They can choose to challenge their negative thoughts, channel their negative emotions in a more constructive way, or both.
Activity: A Screening Test for Depression
Estimated time: 5-10 minutes
Visit this website Think CBT to view an online copy of the Hamilton Depression Rating Scale (HAM- D). (It is important to note that this is not a self-diagnosis tool, but a brief test designed to help mental healthcare professionals pick up depressive symptoms in clients). Imagine that you are administering this test to a client. Would it be easy to administer to any client,or would it be harder in some cases than others? Why?
4.6 Devising Treatment Goals and a Treatment Plan
Once the therapy formulation is complete, the next step is to decide on the client's treatment goals. Initially, the client may have trouble putting their goals into words. An anxious client might say, “I want to stop feeling so worried all the time and get back to my old self”. This is a statement of intent, not a concrete goal. In order to draw up an appropriate treatment plan, a therapist needs to know the client's intended destination and select interventions accordingly.
Goals should be specific, measurable, achievable, relevant and timely (SMART) and below are a few examples:
*“I want to spend at least three evenings each week with my wife and children, beginning next week”
*“I want to drink no more than four glasses of wine per week by the end of the year”
*“I want to achieve complete sobriety within one month”
*“I want to get a new job within three months”
*“I want to be able to take a one-hour train journey alone by the end of this year”
4.7 What is a Therapy Blueprint?
A therapy blueprint is a document that guides the client's personal reflection at the end of therapy and encourages them to draw on what they have learned on future occasions. The blueprint may be given as homework in the final stages of therapy, or it may be completed in the final session with the help of the therapist.
The blueprint will contain spaces for the following:
Reflections on the problem that brought the client to therapy in the first place
By the end of therapy, a client should possess an in-depth understanding of their issues and how their thoughts, emotions and behaviours interact to cause and maintain them. They should realise that their distress is not irrational, but is underpinned by a consistent set of thoughts and behaviours.
Reflections on the most valuable lessons the client learned in therapy
Clients do not just learn about their problems during therapy - they also learn more about themselves.
For instance
A client might walk away from therapy knowing that they have the ability to change their own problems, that the future does not have to resemble the past and that people can be trusted.
Reflections on the coping strategies that the client can use in the future
CBT equips clients with the skills they need to handle any difficult situations that will inevitably arise in the future. Skills such as processing unpleasant emotions, assertive communication and breathing exercises can be used in a number of challenging scenarios.
Reflections on the client's personal goals
A client should be encouraged to set goals for the coming month, six months, a year and over the long term. This will inspire them to look to the future and reaffirm their sense of life purpose.
Any other reflections
The therapy process is different for each individual and every client walks away with their own set of insights.
Formulation and the Jacqueline Persons Style Formulation.
If the therapist wants to gain further insight into a client's symptoms, they can use psychometric tests, which can also be repeated at a later date to track the client's progress. Taken together, a formulation and the results of psychometric tests are used to inform a set of therapy goals. These should be specific, relevant, timely and appropriate to the client's situation. As therapy draws to a close, the client should be given an opportunity to reflect on what they have learned during the process and encouraged to set goals for the future.
Module Summary
Although CBT practitioners modify exercises and homework to suit the client's needs and personality, CBT is often a highly structured therapy. There are manuals available for various psychological conditions, including depression, anxiety, eating disorders and addictions. CBT programmes may also include versions of the manual that can be given to clients, together with a workbook that can be used as part of the client's homework exercises.
The first step in the therapy process is creating a therapy formulation. This is a detailed hypothesis of how a client's thoughts, feelings and behaviours interact to maintain a psychological problem. There are various approaches a therapist can use, including Functional Analysis, the Beck Style
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