Usefulness of Cognitive Behavioral Therapy - Essay Example

? The history of modern cognitive behavioral therapy (CBT) is based upon the work of two influential theories and is a combination of behavioural theory, which was pioneered by Wolpe (1958) and cognitive therapy, was developed by Beck (1967). The CBT approach posits that people’s responses to situations and their interpretation of such is based upon their thoughts and beliefs. Ellis (1962) expounded on this, stating that irrational beliefs is a contributing factor to mental disorders. Beck’s cognitive theory (1967, 1976) theorizes that mental disorders, such as anxiety and depression, are maintained by distorted thoughts at three levels. At the surface are the negative automatic thoughts (NAT), which are beliefs and assumptions stored in memory as schemas (Bartlet, 1932). NAT forms the basis of the classic Beck model of depression, which is based not only on NAT about oneself, and the world and the future, but also upon maladaptive assumptions and negative schemas (Beck, 1967). The underlying cause of anxiety is a distortion in processing information is connected with the client’s overestimated concept of danger and the underestimated ability to cope (Beck, Emery & Greenberg, 1985). Activation of danger appraisals, in conjunction with physiological changes maintain different anxiety vicious circles (Simmons & Griffiths, 2009). Specific models of disorders, such as generalized anxiety disorder (GAD) are characterized by the person’s inability to cope with chronic worry. Similarly, the Social Phobia Model emphasizes the fact that, in the cognition of the person suffering from social phobia, certain situations are associated with danger (Clark & Wells, 1995). CBT is goal-oriented, and it emphasizes collaboration and active participation (Westbrook et al., 2007). CBT teaches the client how to identify, evaluate and respond to his or her dysfunctional thoughts and beliefs. Referral Sally was referred to IAPT service in NHS Foundation Trust for CBT by her general practitioner. The referral stated that Sally suffers from depression and attempted to commit suicide two months earlier. After an initial phone assessment, Sally was qualified as STEP 3 and assigned to face-to-face therapy, consisting of fifteen minute session (one hour weekly). Therapist Initial Impression: During the initial assessment, Sally appeared as a pleasant and cooperative, but anxious, young lady. At the beginning of the session, she was avoiding eye contact by nervously adjusting her scarf, trying to cover red stains all over her chest and neck. I deliberately ignored this behavior, and focused on the therapy process, which helped her to relax. She became less fidgety and our conversation went fluently. Client biographical details and recent history: Sally is a 24-year-old female, who is single and working as a training officer. Sally describes her childhood as happy, however, there were events which may have significantly influenced her current life. Her parents divorced when she was eight. This confused her, but it did not affect her as much as it could have, because both parents were there for her. She has a close relationship with her mother, although she described her as overprotective and bossy. Since the age of seven, Sally was physical and psychologically bullied by other kids at her school. Because of this, she had problems adapting to school and struggled to fit in socially to school life. Because of this, she had to change schools twice. Sally continued her education at a university in Scotland. Her teenage life was also influenced by a few dramatic events. When she was sixteen, she had her first abortion. She described this as a relief, as both she and her boyfriend were about to start university. During the first year at the university, Sally had her first depressive episode. She described her first year at university as horrible. She was bullied by her flatmates, and she felt lonely and separated from her boyfriend and family. Sally felt under pressure, and struggled with university requirements. She perceives those events as the triggers of her first depressive episode. As she felt depressed, Sally’s doctor recommended a gap year, during which time she went to New Zealand. She described that year as the happiest time of her life. She felt fully accepted and surrounded by a non-judgmental group of positive peers. She reported that she did not have to fit in anymore and could be the real Sally. She regained her confidence, and her self-esteem was boosted during that period. She came back stronger and able to cope better with the university requirements. She graduated the year after. Sally has been working for the same company for the last two years. She again perceives herself as not fitting in with the existing social network. In 2009, Sally had her second abortion, followed by her second depressive episode. After this, she attended counseling sessions for a few months. Two months before starting the therapy, when Sally went through a break-up, she discovered her pregnancy, as she became pregnant whilst a coil was in situ. She decided to terminate this pregnancy, as well, having her third abortion. After this, she was severely depressed and overdosed on her antidepressants. When talking about her self-harming history, she had a problem to name the act. Sally used terms such as “it” and “stupid thing.” She said that she felt like she had lost everything. She lost control over the situation and she could not stand it anymore. It seemed difficult for her to stay on this theme, and she kept repeating herself. I had an impression that she found it difficult to discuss it in the open. The issue remains very sensitive for her. Sally came to the therapy two months after the suicide attempt. There was also a history of depression in Sally’s family – according to Sally, her mother suffered from post-traumatic depression. Presenting Problem: Session 1 At the beginning of the session the audio recording requirement for the session was explained and the consent form was signed. Sally had previous therapy, which consisted of counseling, which did not include cognitive behavioural therapy. As I was aware of this, I focused on a detailed explanation of the CBT collaborative approach. I explained to Sally that, because CBT relies upon the active collaboration between the client and the therapist, she would not be put into a position where she felt out of control, and her active input will be extremely valuable right from the beginning of the therapy. I also explained to her that CBT is primarily based on “here and now.” And, although there is no doubt that her developmental history has contributed to who she is today, we will focus on the current problem. Initially, we discussed the course of the therapy, which would consist of six sessions, review, and further extension, depending on the development of the therapeutic interventions, up to fifteen sessions. I explained to Sally the structure of the CBT session: the length, agenda setting and what it usually includes. Also, we discussed the importance of setting goals and the role of homework in CBT therapy. We agreed to our first agenda. The first point was comparison and discussion about the scores from obtained measurements. To this end, Sally completed the PHQ-9, GAD-7 and IAPT Phobia Scales (Appendix 1). The results confirmed the GP referral for depression and anxiety. The symptoms appeared to be more intensive when compared to previous results, which were acquired by the initial phone assessment. Her PHQ-9 had increased from sixteen to twenty-one points, which indicated moderate depression. Additionally, her GAD-7 suggested an elevated level of anxiety and phobia, with a high level of avoidance. There was no indication of a suicide attempt, or a risk of suicide, in her assessments. Because of Sally’s self-harming history, obtaining the Assessing Risk in Primary Care Form (Appendix 2) was a stressing factor for her, and brought a moment of tension into the session. This was evident by her tense demeanor, and initial refusal to complete the form. She pointed out that family was a protective factor. We discussed the issues of confidentiality and it became obvious to me that it is a very sensitive subject for her. She seemed less nervous when reassured that the disclosure of information would be considered only if her life, or the life of others, was in danger and only after discussing with her the possible options. The next point on my agenda was an explanation of the CBT approach and the cognitive model based on the Hot Cross bun component (Appendix 4). We explored the function of negative thoughts in maintaining it in particular. The last point was the client’s evaluation of the problem. Client’s View of the Problem: Initially, Sally confirmed feeling down, very tired and withdrawn from society. She reported problems with concentration, poor appetite and a significant loss of weight. Furthermore, she emphasized her lack of energy. Also, Sally has been experiencing insomnia recently, in that she had not been able to sleep more than two hours for a period of five days in the week before she came to see me, so, by the time she had our session, she was struggling to stay awake. Sally also mentioned feeling hopeless and helpless, describing her feelings of hopelessness as an 8 on a scale of 1 to 10, and helplessness as a 9 on a scale of 1 to 10, where 1 means not at all and 10 means absolutely true. All described symptoms which had lasted for over three months and have affected her life. Her poor concentration at work was noticed by her manager. Moreover, Sally presented with symptoms of social phobia, as she was afraid to have a meal in public, which also had an influence on her relationship at work, as she was perceived as unsociable because she isolated herself during lunch breaks . Client’s goals: To better understand her depression, anxiety and to learn how to deal with them, so that she may overcome her social phobia, and learn to live a more fulfilling life. To have a whole meal and enjoy it in other people’s presence. Homework To think about more specific goals, such as meeting with specific people in her life to either marshal support or to confront them about past issues. Session 2 Sally met me in my office, and we agreed on agenda issues that were to be discussed. Sally came up with three different issues: meeting with her ex-boyfriend, having a meal with her father and building a support network at her work. Sally described how low she felt after meeting her ex-boyfriend. She had been in a relationship with him for eight years. During the break-up, she discovered she was pregnant. After terminating the pregnancy, she overdosed. Meeting her ex-boyfriend made her feel upset, confused and scared. Sally stated that she did not want to end up in the same situation she was in two months earlier. Sally said that he had let her down, made her feel worthless and contact with him makes her feel vulnerable. I did not reassure her, but used Socratic questions, which allowed her to find answers on how to overcome those feelings. According to Padesky and Greenerberg (1995), this type of questioning helps the client put new ideas together in a meaningful way. This questioning helped her to find strategies to protect herself better in similar situations, such as walking away when things get too confrontational and sticking up for herself better. After she had the strategies in place, she was ready to move on. Sally also had more positive news to share, as she was able to have a meal with her father, and was receiving positive support from her manager. I used the Time Line to identify potential factors in Sally’s life which caused her disorders. Session 3 Symptoms underlined by Sally in her last description and her measurements elicited more anxiety than depression (PHQ 9 and GAD 7) (Appendix 3). When asked, Sally stated that her recent anxiety symptoms have been more disturbing than the depressive one. Therefore, we collaboratively decided to concentrate on her anxiety. To collect more detailed information about the nature of Sally’s anxiety, we reviewed her recent anxiety episodes. It appeared that the most intense ones were connected with her performance in social situations. I provided her with the table of anxiety symptoms (Appendix 5) and asked her to underline those relevant to her. Sally ticked those symptoms connected with eating phobia – blushing, sweating, shaking, nausea and hot flashes. Those symptoms of anxiety fulfilled the DSM IV criteria, which defines social phobia as “marked and persistent fear of social performance situations in which embarrassment may occur” (DSM IV). Fulfillment of those criteria, together with the earlier obtained measurements, indicated social anxiety. I introduced the Clark & Wells (1995) mode of social anxiety. We elicit the model by filling the components by analogous phobic situations, ie?eating in public. I explained to Sally how her self-appraisals, self-conscious strategies and safety behaviours maintain the social phobic vicious cycle. To sum up, we drew the social anxiety model connected with phobia of eating in public (Appendix 6). Sally also brought up two issues on the agenda: her depressed friend problem and her anxiety connected with two bad days during last week which we discussed briefly. The session was busy, but clarified our next stage. As homework, Sally agreed to read about social phobia and complete the record of automatic thoughts. Session 4 We started the session by fitting NAT’s record brought by Sally into the model, which was a Sally-drawn social phobia model for going to the cinema (Appendix 7). At the beginning of the session, Sally reported that her increased self-awareness of her problem and the ability to control it made her feel better. She said that I gave her a different view on understanding her behavioural pattern and helped her to identify reasons for her behaviour. In my office, Sally was in the eating process, as this was an action that I asked her to do as part of the therapy. This experience revealed that she was unaware of time passing. When she was through with eating, she answered question that were asked a few minutes earlier. This example helped me to introduce the concept of self-processing, and Sally grasped this perfectly. She admitted that she was unable to concentrate on two things at the same time – eating, and following the flow of conversation. She had to switch off, and this explanation helped her to understand her behaviour during eating, which was that she finished the meal quickly in order to be able to attend to conversation. I asked Sally to complete the Initial Fear evaluation form (Appendix 8) in order to establish her fear level in the listed situations. Sally scored a 75% out of 100% on eating in public, 75% on restaurants, churches and movies and 75% on people seeing I am nervous. On the Social Phobia Questionnaire (SPQ) (Appendix 9), for the questions regarding eating and drinking in front of other people, she received the highest rating, which is a three out of three. During the session, I asked her to go through the most memorable event to describe her eating phobia. Supported by questions, Sally specified the NAT’s before, during and after the eating process. She was able to perfectly describe the self-image during self-processing stage, which included the fear of choking and being unable to swallow due to having too big a tongue, and identify symptoms and safety behaviours. We were seeking factors which could de-escalate the phobic situation, which were not new safety behaviours. The decrease of fear, which was accomplished by her increasing awareness of each phase of eating problems, was our answer. Encouraged by that, Sally decided to try having a meal in public the following week. Collaboratively, we established the hierarchy for her homework. To reduce her avoidance of social situations, she agreed to have a meal with a friend, and drop one of her safety behaviours – eating before going out. This behavior had previously prevented her from feeling hungry when, unable to eat, she skipped her meal. Homework Specific exposure – meal with a friend, continue thoughts record. Session 5 To begin the session, Sally presented information about her achievements in the previous week, which was a meal in public. She had dropped her safety behavior, which was eating before going out, and was able to eat a whole sandwich. This was her second meal with her friend during the last eight years. She was able to describe the whole situation, analyzing the fear in each stage of the process and was able to give a rationale for each thought, symptom and safety behaviour. Her self-evaluation brought our attention to her dysfunctional self-concept of underachievement. We discussed it as she never gave herself credit for what she achieved. As elaborated by Wells and Matthews (1994), the strategy of re-focusing attention from introspection is a very important intervention for social phobia. Following my recommendation during the session, I introduced the CBT technique of attention manipulation and we practiced the shift of attention from internal to external and vice versa. Sally grasped the idea, and was keen to practice it during next week in both stress free and anxious situations. We also discussed the role of her safety behaviours in maintaining her anxiety. I explained to her that safety behaviours increase her self-awareness of being noticeable or in danger. Sally, however, even though aware, has difficulties imagining the time without using safety behaviours. When encouraged, Sally agreed to videotape her speaking performance during the next session. She will perform under two conditions – first when practicing and later when dropping all safety behaviours. Homework: Practice shift of attention and Attend a meal: make a list of things her friends ordered, plus memorise what they were talking about. Problem formulating and therapeutic plan The evidence collected during the previous two sessions indicated both depression and anxiety disorders. Both disorders seem to have had a big impact on Sally’s life. This fact made the formulation difficult. Unable to focus on both disorders at the same time, my client prioritized her social anxiety symptoms, as these were more disturbing to her. Although we concentrated on social phobia, the awareness of Sally’s predisposition to depressive episodes reminded me of the need to re-evaluate and challenge some of her assumptions and core beliefs, in order to prevent her from relapsing. Analysing the previous sessions, I found a few issues which I wanted to focus on. By tracking recent episodes of social phobia models, and using guided discovery, we managed to increase Sally’s understanding of how safety behaviours, along with self-focus on her symptoms and performance, increase and maintain her social phobia. She understood how her safety behaviours contaminate her social situations, while increasing the likelihood of negative reactions from others. For the following sessions, we agreed to increase manipulation of Sally’s safety behaviours. We also agreed that Sally would also focus on shifting attention from internal to external in problematic situations. These strategies would help to challenge her beliefs, such as “I do not fit,” “I always lie,” “What is wrong with me?” and assumptions, such as “If they discover who I am, they will reject me.” Use of audio-visual feedback and reattribution techniques would further help us to focus on modifying Sally’s self-processing, negative thoughts, and assumptions. Behavioural experiments and the use of unacceptable behaviours would help us in testing Sally’s specific predictions. It is important to elicit those issues, as Sally’s earlier life events could be contributing factors to the development of her distorted schemata. Because she was bullied earlier in life and suffered traumatic events, including three abortions, these are incidents which could contribute to her schemata that she is worthless, does not fit in, and is worthy of rejection. These life events could also explain her inability to fit in to society, and her lack of acceptance by her peers, as well as predispositions to depression and anxiety. As stated by Butler and Hackmann (2004), “Having been criticized, rejected, or bullied or treated as odd or weird is likely to shape the person’s phobic experienced.” Challenging Sally’s assumptions and underlying core beliefs would decrease her vulnerability to relapse. We decided to discuss in details the reformulation strategies and goals for our future sessions during the next week’s review. Supervisions I voiced two concerns during my supervision. One of these is that I questioned whether a client with a self-harming history was appropriate for mew. My supervisor offered me full support if problems should appear. During the therapeutic process, she was available when I needed her advice. She directed me when I felt out of track and was not sure about the next step. I learned how to be open and admit that I needed help when doubts and difficulties appeared. Reviewing the therapy records with my supervisor helped me with self-reflection, to evaluate my work, and plan for improvement. My confidence grew during the following sessions, and I found my supervisor’s guidelines very helpful. Rationale and reflection Upon submission of this assignment, it was my first and only therapy treatment which fulfilled the requirement of a minimum of five recorded sessions with the client. The nature of the client’s problem was quite complicated, as the client had a history of self-harm and relapse of depression and anxiety symptoms. I have seen the client for the last five weeks prior to the submission deadline and those were my first completed sessions. Also, the case, although complicated, became really interesting and challenging. It gave me the opportunity to develop as a therapist, as this was the first time I was dealing with a client with a history of self-harm, therefore it enabled me to conceptualize different strategies for this type of situation. I now feel more confident that I can handle such a client in the future. Reflecting on the sessions, I have had an opportunity to observe the development of the therapeutic relationship with the client, from the moment I focused more on the interaction with the client, instead of trying to tick all the boxes from my list. Moreover, I have learned that “an effective therapist-client relationship is important for treatment, with evidence relating quality of relationship to therapeutic outcome” (Orlinsky et al., 1994). Encouraging the client to create the agenda and following it, it helped us use our time efficiently in Session 1. I also learned how effective the use of Socratic questions could be. I feel that the sessions have had a positive outcome both for my client and me. Sally is in a process of achieving her goals. Also, she was able to understand that there were events in her life which could predispose her to depression and anxiety. Being aware of that gave her the feeling of control and has helped her to deal with them. Her anxiety and depression scores have been reduced (Appendixes 10, 11, 12). I have benefited from the sessions, in that they have helped me to enhance my skills and knowledge. I have engaged in the process of learning, in order to become a professional practitioner. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. New York: American Psychiatric Publishers. Bartlett, F.C. (1932) Remembering: A Study in Experimental and Social Psychology. Cambridge: Cambridge University Press. Beck,A.T. (1967) Depression: Clinical, Experimental and Theoretical Aspects. New York: Harper & Row. Beck, A.T. (1976) Cognitive Therapy and Emotional Disorders. New York: International Universities Press. Beck, A.T., Emery, G. & Greenberg, R. (1985) Anxiety Disorders and Phobia: A Cognitive Perspective. New York: Basic Books. Clark, D.M. & Wells, A. (1995) Cognitive Therapy of Social Phobia: A Treatment Manual. Unpublished Manuscript. Ellis, A. (1962) Reason and Emotion in Psychotherapy. Oxford: Lyle Stuart. Generalized Anxiety Disorder 7 Item Scale (GAD-7). Available at: http://www.mpho.org/resource/d/34008/GAD708.19.08Cartwright.pdf Health Questionnaire (PHQ 9). Available at: http://www.thenationalcouncil.org/galleries/business-practice%20files/PHQ%20-%20Questions.pdf IAPT Phobia Scale. Available at: http://www.serene.me.uk/tests/iapt-phobia.pdf Simmons, J. & Griffiths, R. (2009) CBT For Beginners. New York: Sage Publications. Wells, A. & Mathews, G. (1994) Attention and emotion: A clinical perspective. Clinical Psychology and Psychotherapy 2.2: 134. Wells, A. (1995) Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy 23: 301-320. Wolpe, J. (1958) Psychotherapy by reciprocal inhibition. Integrative Psychological and Behavioral Science 3.4: 234-240. Read More