Assessment and Formulation Case Presentation

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Assessment and Formulation Case Presentation
Natalie Davies
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Alice

• Referral information
• 23 year old female
• History of depression and self harm whilst at
  university 3 years ago
• Depression had returned in the last 3 months,
  along with thoughts of self harm
• Living with father and step-mother, after being
  evicted from the family home along with her
  mother and sister
• Prescribed 50mg Lustral (Sertraline)

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Assessment

• Format
• Semi-structured behavioural interview (Kirk ,
  1989), also based on based on the assessment
  schedule by Grant, Townend, Mills Cockx
  (2008 ).

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Presenting Issues

• Depressive symptoms improved however...
• ...on further exploration, still occasionally
  experiencing
• Low motivation
• Tiredness
• Social withdrawal
• Self-critical thoughts
• DSM IV criteria

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Assessment tools

• IAPT Minimum Data Set
• PHQ9 11 (Moderate)
• GAD7 5 (Mild)
• WSAS 20 (Significant impairment)
• Phobia 1 2
• Phobia 2 1
• Phobia 3 0
• Disorder specific measures

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Other factors

• Medication
• Sertraline 100mg 6 weeks prior to assessment
• Risk
• No thoughts of self harm or suicide (score of 0
  on PHQ9 question 9)
• No risk of neglect
• No risk of harm to/from others

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Hot cross bun (Padesky Mooney, 1990 )
Situation At home with step-mum
Cognitive whats the point in getting up?
Physical Tired, insomnia, sleeping in the day
Mood Sad Numb
Behaviour Stay in bed, on laptop or watch TV
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Hot cross bun (Padesky Mooney, 1990)
Situation Meeting someone new
Cognitive I want to be someone different Im
not normal
Physical Butterflies in stomach, faster hear rate
Mood Anxious
Behaviour Tell lots of jokes, say I sound weird
out loud
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Predisposing factors

• Father left at age 9
• Mother stopped caring at age 11
• Home felt unstable and unsafe
• Mother harsh and critical towards Alice

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Precipitating Events

• Evicted from home, went to live with father and
  step-mother
• Step-mother critical
• First serious relationship ended

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Goals Westbrook, Kennerley, Kirk,
2007

• To feel better about myself and have more self
  belief (Long Term)
• Refined in session 2
• To accept compliments (Short Term)
• To do a stand-up comedy gig in London (Medium
  Term)
• To stick up for myself more when my step-mum
  shouts at me (Medium Term)
• To be myself and be more relaxed on dates e.g.
  telling less jokes (Medium Term)

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Longitudinal Formulation (Beck et al, 1979)

• Early experiences
• Dad left when 9 years
• Mum became neglectful at 11 years
• Core Beliefs
• Im unlovable
• Im abnormal
• Assumptions/Rules
• I can protect myself from the pain of rejection
  if I dont let people get close
• People only accept you if youre normal
• In order to be accepted I must not show the real
  me
• Compensatory strategies
• Dont let anyone get close
• Tell someone everything about me thats
  abnormal straight away
• Use of humour to detract from the real me
• Critical Incident
• Broke up from first serious girlfriend
• Moved in with Dad and Step-Mum

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• Trigger
• Date doesnt go well, reminder of ex
• NATs
• Its because theres something wrong with me
• Ill be alone forever
• Emotion Physical
• Depressed, Lonely Tired,
  tearful, low motivation
• Behaviour
• Stop going on dates, use humour more in
  interactions, withdraw from friends

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Which model?

• Beck et als (1979) cognitive model of depression
• identified assumptions and core beliefs
• developed as a result of early experiences
• rigid assumptions, resistant to change
• NATs triggered, which lead to depressed mood and
  social withdrawal

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Low Self Esteem?

• Schemas in cognitive model of depression (Beck et
  al, 1979) similar to self esteem i.e. they are a
  product of learning and, once in place, they in
  turn shape how a person perceives and makes sense
  of subsequent experiences (Fennell, 1997, p. 2)
• Low self-esteem may i) represent an aspect of a
  presenting issue ii)be a consequence of a
  presenting issue or iii) represent a longstanding
  vulnerability factor, preceding the onset of
  presenting issues

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Low Self Esteem?

• Links anxiety and compensatory/safety behaviours
  to self critical thinking and depression, and
  confirmation of the bottom line

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Cognitive Model of Low Self Esteem (Fennell, 1997)
Activation of Bottom Line A first date
Predictions Im abnormal, I wont be accepted if
I am myself
Depression
Self critical thoughts theres something wrong
with me, Ill be alone forever
Anxiety
Maladaptive Behaviour Use of humour
Confirmation of Bottom Line
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• Negative core beliefs about the self are at the
  heart of low self esteem...cognitive therapists
  wanting to understand and work with low self
  esteem can draw on theoretical concepts and
  clinical interventions already available in the
  literature e.g. Beck et al (1979). (Fennell, Ox
  guide to BEs)

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Proposed Treatment Plan
Aim Method
Socialising Alice to the CBT model Completion of hot cross buns and cross-sectional formulation
Challenging Alices self critical thoughts Completion of thought diaries
Testing Alices assumption that she has to behave how she thinks others want her to in order to be accepted or loved Exploring consequence of belief, advantages and disadvantages, identify alternative rule, behavioural experiments
Test Alices belief that she is abnormal Continuum work
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Engagement and Therapeutic Alliance

• Engaged Well
• Socialised to CBT model
• Contributes to session
• Alliance very good from the start
• Open, honest, friendly
• However, too many jokes?
• Eliciting emotion- avoidant?

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Experience Observe (Kolb 1984 and Lewin 1946)
Situation Aware of client making many jokes in
therapy session
Cognitive If I raise this it will be really
awkward Ill come across as really formal
Physical Butterflies, heart rate increased
Mood Anxious
Behaviour Avoided bringing this up in conversation
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Reflection

• Assumptions related to valuing humour in sessions
  
• I didnt fully consider the potential impact on
  the emotional expression in the session
• There is a need to validate my clients
  experiences, even if she isnt?
• Plan
• Use of humour is advantageous to the therapeutic
  alliance where appropriate, but can become a
  barrier to eliciting emotions

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Summary

• Presenting issue of mild-moderate depression,
  with a previous episode of depression 3 years ago
• Assumptions/rules led to compensatory behaviours
  which became self-perpetuating
• Treatment plan aimed at increasing confidence
  through reducing compensatory behaviours and
  testing assumptions

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Questions?