Cognitive Behavioral Therapy Issues - Case Study Example

Cognitive Behavioural Therapy: Case Study [Name] [Professor Name] [Course] [Date] Table of Contents Table of Contents 1 Abstract: 2 Overview 3 Case Analysis based on CBT perspective 4 Using the Five Area Model 6 Area 2: Altered thinking 7 Area 3: Altered emotions 7 Area 4: Altered physical symptoms 7 Area 5: Altered behaviour 7 Identifying unhelpful behaviours 8 Agreeing on Targets for Change 8 Use of pie chart to jointly agree on targets to prioritise 9 Selection of targets 11 Providing cognitive-behavioural therapy 12 Effectiveness of traditional CBT approach and the Five Areas Model to John’s situation 13 Conclusion 14 Table of Figures Figure 1: Showing correlation among thoughts, behaviours and emotions (Gagnon 2013) 4 Figure 2: Completed pie chart for selecting targets (Wright, Williams & Garland, 2002) 9 Abstract: Cognitive Behavioural Therapy (CBT) refers to a short-term action-oriented and problem-centred psychosocial intervention. Indications from meta-analysis and randomised controlled trial depict CBT as an effective intervention for mental disorders such as generalised anxiety, depression, obsessive compulsive disorders, eating disorders, panic disorders and other personality disorder. The approach has further been applied as an optional adjunct to interventions in the management of bipolar and schizophrenia. This essay analyses a case study to reveal the key principles and goals of CBT. It further analyses a patient’s case in the case study using a CBT perspective. An outline of how a cognitive behavioural counsellor might work with the client and an evaluation of whether the Five Areas CBT approach used is appropriate for working with the patient is explored. Cognitive Behavioural Therapy: Case Study Overview Cognitive Behaviour Therapy is a short-term action-oriented and problem-centred psychosocial intervention. Effective CBT interventions integrate certain principles (Binggeli, 2010). This form of psychotherapy has proved effective in helping individuals to overcome a range of psychosocial problems such as undergoing anxiety or depression (Whitfield and Williams, 2003). The approach is based upon empirically informed principles and focuses on the thought patterns and behaviour of an individual that maintain maladaptive and adaptive behaviour (Wright, Williams and Garland, 2002). Basically, this treatment intervention assumes that these patterns have been learned by the subjects and that they can be unlearned or discarded when the subjects can learn new patterns. It is therefore based on the idea that human thoughts trigger human emotions and how humans react to situations, external objects, people and events (Butler at al, 2006). Its major objective is therefore to make people feel and behave appropriately by changing their thought and behaviour pattern. Hence, this treatment approach is based on the idea that human emotions, behaviour and thoughts are interlinked (see Figure 1). Figure 1: Showing correlation among thoughts, behaviours and emotions (Gagnon 2013) Effective CBT intervention underlies on a number of principles. These include Collaboration between the patient and the psychologist, tailored to the individual, focusing on the ‘here and now’, acceptance of the person, structure and education, teaching of skills and techniques, and brief and time-limited (Gagnon, 2013). Accordingly, it focuses on current problems that are relevant to the patient. It also has a distinct underlying model to the treatment being offered. In addition, it is collaborative as its delivery is built on effective relationship with the psychologist. Further, it is essentially a psycho-educational form of psychotherapy (Binggeli, 2010). Case Analysis based on CBT perspective In the case study, John, who is the patient, has failed to hold onto a job and this has left him in financial difficulties. In addition, his condition causes disagreements and prevents him from having children against his will and that of his wife. He mentions that he does get stressed and sometimes feels shaken, sweats and feels like he is going to die. Based on John’s thoughts, behaviours and emotions, an integrative multisystem model can be used to conceptualize his plan treatment. The assessment would hence centre on cognitive and behavioural observations, although factors such as social and interpersonal would as well be considered. Towards this end, a 2-way relationship between behaviour and cognition is recommended: in which cognitive processes have the capacity to influence his behaviour, and change in behaviour have the capacity to influence cognitions (Wright, 2006). Since cognition and behaviour are interlinked (see Figure 1), they can be used to analyse John’s condition at both the behavioural and cognitive level. Therefore, a practical model such as the Five Areas Model CBP approach can be used to disrupt the cycle. It will also trigger a more adaptive response to treatment. In clinical practice, strategies are often designed to influence the behavioural and cognitive health problem (Wright, 2006). For instance, in the case scenario, cognitive techniques such as examination of thoughts and evidence that identify and alter maladaptive cognitions can be applied to John’s case. Behavioural methods can later be used to reverse his fears (Olatunji, Cisler and Deacon, 2010). In John’s situation, CBT approach can be used as an integrated part of psychosocial assessment. However, certain there certain exceptional situations it should be first considered (Williams and Garland, 2006). This includes whether the patient has targeted problem areas such as reduced activity, unhelpful thinking and unhelpful behaviour. Secondly, the patient should be suffering from significant psychosicial problems such as relationship problems, self-cutting and difficulty in working (Williams and Garland, 2006). John displays both problem areas. To assess, John’s situation, the Five Areas Model can be used as it aims to communicate the fundamental CBP principles and the primary clinical interventions comprehensively. In psychosocial analysis of John, two areas, namely thinking and behaviour are the focus of the CBT assessment and intervention. The Five Areas Model proposed to be used in John’s assessment and treatment offers a clear structure to sum up the range of problems and difficulties he faces. These can be classified in the following 5 domains. Life situation. Altered thinking. Altered feelings. Altered physical symptoms/feelings Altered behaviour Based on these five domains, the model provides a clear-cut structure enabling a detailed examination of the links between each area of specific occasions where John had felt more depressed or anxious (Wright, Williams and Garland, 2002). Using the Five Area Model Figure 2 shows the Five Area Assessment of 30-year-old John who has failed to hold onto a job due to stress. The assessment shows what he thinks about how his situation affects the way he feels emotionally and physically. It also alters her activities and behaviour. Each of the five domains is interdependent (Wright, Williams and Garland, 2002). Area 1: Relationships, situation and practical problems John faces several practical problems. Additionally, the actions around people around him can upset him or create difficulties (Wright, Williams and Garland, 2002). These include: He has financial problems, redundancy, frequent disagreements. However, he maintains a good relationship with the wife. Area 2: Altered thinking John undergoes various unhelpful thinking which characterised depression and anxiety (Williams, 2001). Area 3: Altered emotions John undergoes various mood states including low moods, fed-up, stressed, worry, frequent displeasure and lack of interest as he feels he is “going to die”, fears, feels trapped, anger, irritable and sometimes guilt. Area 4: Altered physical symptoms John undergoes some altered physical symptoms occurring due to his depressive state (Wright, Williams and Garland, 2002). The symptoms for depression John faces include: Lethargy, tiredness, and reduced energy. Incapability to have children also indicates reduced sex drive. The symptoms for anxiety John faces include: shakiness and sweatiness. Area 5: Altered behaviour Area five involves identifying the reduce activity in depression. A significant question to ask is the things John has done since he started feeling depressed. This can help identify whether John is undergoing social withdrawn or procrastinating (Wright, Williams and Garland, 2002). From the case scenario, it can be observed that John has reduced socialising, reduced interest, found life emptier and feels like he is going to die, reduced daily activity. In identifying areas of anxiety, a useful question to ask is the things John has stopped doing since he started feeling anxious. From the case scenario, it can be observed that John has feels misplaced in “wrong” environment. Additionally, he doesn’t want to work where he feels he is not liked. Identifying unhelpful behaviours A helpful question to identify any unhelpful behaviour displayed by John is “what things John has started doing in a bid to cope with the feelings of depression or anxiety.” From the case study, it can be observed that John seems to be withdrawing from other people. In addition, he seems to be actively pushing people away (Wright, Williams and Garland, 2002). These explain why he can find a job even though he has good working experience as a bar manager. Agreeing on Targets for Change Based on the findings, only one or two clinical problems should be identified for intervention (Wright, WIlliam & Garland, 2002). The Five Areas Model allows various problems to be reduced to a single model. For effective intervention in John’s situation, it is critical to identify the most important one. Thereafter, focus should be on changing one or two problem areas at a time. At this stage, there is need for collaborating with John to jointly agree on which problems to prioritise. Wright, WIlliam and Garland I2002) advise that change will be difficult without some degree of structure and focus. To ensure this, the short-term, medium-term and long-term targets should be identified. Short term changes are those that can be changed in within a week. Medium-term targets are changes that should take place in few weeks (Wright, Williams and Garland, 2002). Long-term targets are those that the patient wants to be changed over a 6-month or a one-year period. A significant concept that a cognitive behavioural counsellor might communicate with John when deciding on the targets for change is that of focusing on solving one or two questions to begin with. The clinical assessment would therefore involve working collaboratively with John to negotiate and to agree on the succession or sequence of problems that should be dealt with. The first to be tackled should be the short-term problems and successively to the medium- and long-term problem areas (Wright, Williams and Garland, 2002). A pictorial approach (see Figure 2) can be used to help in the collaborative work (with John) of identifying the first targets for change. Figure 2: Completed pie chart for selecting targets (Wright, Williams & Garland, 2002) Use of pie chart to jointly agree on targets to prioritise Since John faces a range of problems, a possible clinical difficulty with his psychiatrist would be in agreeing on which problem areas to prioritise (Williams & Garland, 2002). The pie-chart (see Figure 2) can however be useful in this process. First, the counselor would have to work collaboratively with John using the written Five Areas assessment summary (outlined above). Each of the symptoms would then be drawn onto the pie-chart (Wright, Williams and Garland, 2002). Afterwards, each of the symptoms would then be allocated a section on the chart that sums up its current contribution to John’s depression. The symptoms have to be combined from the outset in some way to ensure that the chart does not end up having numerous small segments as this would be unhelpful and may dispirit (Williams & Garland, 2002). It would therefore be more vital to some symptoms be combined to have fewer problem areas. For instance, low moods, fed-up, stressed, worry, frequent displeasure and lack of interest as he feels he is “going to die”, fears, feels trapped, anger, irritable and guilt can be generalized to be altered emotions. The problem area should then be summarized as there is a need to change this type of thinking (Hollon, Stewart and Strunk, 2006). In the same manner, a problem such as feeling trapped and that there is no scope for creativity and feeling fed up staring at the same walls the whole day could be summarized as a problem of “lack of interest.” At this juncture, the role of the counselor would be to summarize the problems into areas that offer distinct targets for change (Wright, Williams and Garland, 2002). In general, these problems revolve around: identifying and changing severe and unhelpful thoughts; problem-solving; overcoming unhelpful behaviour or reduced activity; overcoming physical symptoms problems; overcoming relationship issues; using prescribed medication effectively. This entire approach facilitates collaboration, active discussion, education in consistency with the principles of CBT, which help John to identify the targets for change. Once the general problems are established, the more specific problem areas are targeted (Wright, Williams and Garland, 2002). Selection of targets After the problem areas are summarised, the target areas to be tackled are identified. This will be the short-term targets. Factors to consider is identifying the short-term targets include. First, they have to be realistic. This means that change should be attainable over a one-week period. Secondly, John has also to be actively involved in deciding the choice, otherwise he runs the risk of becoming unmotivated or complying poorly (Wright, Williams and Garland, 2002). Once the short-term goals are established, the treatment should focus over the next few sessions that run for one week. At this point, it will be important to integrate CBP approaches within the short duration of one week. A traditional CBT one-hour treatment session (or 50minute) can be applied. Typically, it uses a distinct structure to maximise the effectiveness of the session. To ensure this, Wright, William and Garland (2002) advise that the focus should be on one or two problem areas in each session. A typical scenario in the traditional CBT session would comprise welcoming the patient (in this case John), a brief update on the mood state examination, review of symptoms and medication check, setting the agenda for the session to prioritise on things to be covered, prioritising problems and focusing the session to one or two problem areas. Next, each agenda item is discussed with John while summarising the key point at the end. Lastly, John’s Feedback on his experience with the session is discussed. Providing cognitive-behavioural therapy Cognitive behavioural therapy offers a form of cognitive and behavioural intervention. Some of these interventions can be taught to John to address his own problem areas. However, only the interventions that are relevant to his case are offered. Traditional CTB Five Area assessment can again be used as it is collaborative and scientific (Cox and D'Oyley, 2011). Here Socratic questioning can be used to ask him a series of questions as well as provide information that can help him understand much more on how he feels. Next, the counsellor can identify the negative automatic thoughts through the use of though diaries to identify the extreme and the unhelpful thoughts. A thought investigation worksheet can be used. The counsellor can them modify John’s negative thoughts or restructure his beliefs. A thought challenge worksheet can afterwards be used to challenge unhelpful and extreme thoughts (Hollon, Stewart & Strunk, 2006). Concerning behavioural deficit, the counsellor can use pleasant event scheduling, behavioural activation or graded task assignment to minimise the vicious cycle of John’s reduced inactivity. Stress inoculation plan should be used in the next stage in a step-by-step basis to reduce the vicious cycle of John’s unhelpful behaviour. With regard to problem-solving, a seven-step plan for practical problem-solving should be applied in the subsequent stage. As Williams (2001b) explained, the seven-step plan consists of re-breathing, relaxation, control of stimulus, meditation, worry period, mindfulness and visualisation. Additionally, John can be given homework to enable him to put into practice what he has learned. Effectiveness of traditional CBT approach and the Five Areas Model to John’s situation Based on the findings of the Five Areas Model for assessment, John is seen to be suffering from depression. Indeed, the model seeks to integrate the fundamental CBP principles and the primary clinical interventions in the treatment that should be offered to John. Although a didactic approach is applied to provide information about the mental disorder or the intervention, the collaborative approach used is beneficial to John as it allows him to stay motivated and to feel in control (Wright, Williams and Garland, 2002). The standardised sessions (traditional CBT Approach and Five Areas Model) allow John and the counsellor to work collaboratively and to speedily get down to the therapy. The use of session structure also offers a comprehensible idea of what should be achieved and what should be discarded. This saves on time that could have been spent on less significant areas (Butler et al, 2006). However, there are some limitations with the CBT and its Five Areas Model. For instance, the use of Five Areas CBT approach may raise high expectations of change on John since the intervention approach takes relatively less time. This should be seen as intrusive and threatening the stable state of fears of failure. This is because some theorists have posited that patients with depression may be resistant to new psychosocial interventions. In this case, slow, gradual and consistent change that takes many months to ensure improved results (Wright, Williams and Garland, 2002). Conclusion In conclusion, CBT psychosocial approach is based on the idea that mental disorders are correlated with the characteristics of changes in an individual’s behavioural and cognitive function. Based on the case analysis, it can be observed that John’s thoughts and emotions do affect his behaviour. An integrative multisystem model (Five Areas Model) is therefore used to conceptualize his problem areas and plan a treatment. Using the Five Areas model of assessment, he is seen to suffer from depression. The Five Areas Model further conceptualises a short-term, medium-term and long-term medium treatment plan. The standardised treatment plans (traditional CBT Approach and Five Areas Model) allow John and the counsellor to work collaboratively and to speedily get down to the therapy. The use of session structure also offers a comprehensible idea of what should be achieved and what should be discarded. References Binggeli, N. (2010). Introduction to Cognitive Behavioral Therapy. Web. Accessed 23 August 2013 Butler A., Chapman J., Forman, E., & Beck A. (2006). “The empirical status of cognitive-behavioral therapy: a review of meta-analyses.” Clinical Psychology Review, 26(1), 17-31.  Cox, D. & D'Oyley, H. (2011). "Cognitive-behavioral therapy with older adults." BCMJ, 53(7, 348-352 Gagnon, D. (2013). What Is Cognitive Behavioural Therapy?. Web. Accessed 23 August 2013 Hollon, S., Stewart, M., & Strunk, D. (2006).  “Enduring effects for cognitive behavior therapy in the treatment of depression and anxiety. “ Annual Review of Psychology, 57, 285–315. Olatunji, B., Cisler, J., Deacon, B. (2010). “Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings.” Psychiatric Clinics of North America, 33, 3, 557-77.   Whitfield, G. & Williams, C. (2003) "The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings." Advances in Psychiatric Treatment, 9, 21-30 Williams, C. (2001). Overcoming Depression. London: Arnold. Williams, C. (2001b) Overcoming Depression: A Five Areas Approach.London: Arnold. Williams, C. & Garland, A. (2002). "A cognitive–behavioural therapy assessment model for use in everyday clinical practice." Advances in Psychiatric Treatment, 8,172-179 Williams, C. & Garland, A. (2002). “Indentifying and challenging unhelpful thinking: a Five Areas approach.” Advances in Psychiatric Treatment, 8, Wright, B., Williams, C. & Garland, A. (2002). "Using the Five Areas cognitive–behavioural therapy model with psychiatric patients." Advances in Psychiatric Treatment, 8, 307-315 Wright, J, (2006). "Cognitive Behaviour Therapy: Basic Principles and Recent Advances." Focus, 4,173-178. Read More