Individual Treatment Plan for Particular Case - Essay Example

? Individual Treatment Plan of Case Study Priscilla CBT is a structured form of psychotherapy resulting from a marriage between behavior modification strategies, which rooted in behavioral science, and cognitive therapy, which is linked to cognitive models of psychopathology. The main premise supporting CBT is that emotional problems or disorders result from learned responses and can be altered by new learning. Although the specifics of CBT may vary when implemented to different clients, several defining features remain constant. These include obtaining a problem list from the client; assessing the client for any unstated problems; establishing the developmental and maintenance processes for the client’s problems; case conceptualization of the client’s problem; goal setting; and the intervention plan. These are the steps that have been used in this paper to diagnose Priscilla’s problem and come up with an appropriate intervention plan. Individual Treatment Plan of Case Study Priscilla Introduction The cognitive therapy model is grounded on the perception that stressful conditions such as depression, anxiety, and anger are often maintained or exacerbated by blown up or prejudiced ways of thinking. As such, the role of the therapist is to aid the client in recognizing their idiosyncratic mode of thinking and changing it by applying evidence and logic (Townend, Grant, Mulhern, & Short, 2010). Cognitive therapists involve patients in scientific and rational thinking by asking them to examine the presuppositions leading to their depressive or anxious conditions (Clark & Beck, 2011). The therapists ask the client to look at the preponderance of the evidence to reach tentative conclusions and to remain skeptical about all ways of knowing. This paper examines the cognitive, behavioral therapy treatment plan for a client named Priscilla. Biographical Information My client is called Priscilla. She is 42 years old. She is married. My client has neither brother nor sister. However, she has a very close friend who, due to the close relationship, people almost consider her as her sister. My client has kids, and this is evidenced by her need for a housekeeper. My client has been managing her family affairs well. She has been having a healthy relationship with her husband. At her workplace, my client has been a peacemaker as evidence by her mediation for the warring groups. As such, my client appears to be a good negotiator. My client is also hard working. She manages her demanding career an event organizer with her family life. Presenting Problems My client has a difficulty concentrating due to domination of thoughts surrounding the loss of her best friend. She also exhibits aspects of a major depressive episode, including problems sleeping, as evidenced by the fact that she can only seep for two or three hours in a night. Priscilla has also problems while communicating as she becomes highly irritated as evidence by her argumentative aspect while talking. My client also experiences dizzy spells, which make her concentration at work difficult. She also harbors a feeling of losing control, or simply being unable to cope. Priscilla is also nervous, tensed, and wound-up. In cognitive, behavioral therapy, a problem list is a list of the client’s problem organized hierarchically in priority order. Although the problems exhibited by my client concur with common features of anxiety, there are a number of problems that my client does not experience, though they are aspects of anxiety. For instance, my client exhibits no fear of physical injury or death, fear of going crazy, or even fear of negative evaluation by others. Further, Priscilla does not seem to have any frightening thoughts, images, or memories. She has no perceptions of unreality or detachment, confusion, poor memory, impatience, or difficult in reasoning. Assessment of client Client assessment in cognitive, behavioral therapy is a two-way process between the therapist and client, enabling information collection by the therapist and an opportunity for the client to identify if they are comfortable with the therapist, the therapist’s style, and cognitive behavioral psychotherapy as a therapeutic approach. One of the best approaches of client assessment is the idiographic approach. This is because the approach is personal rather than disease-oriented. It is based on a behavioral and functional analysis, which is essential in a psychotherapeutic context (Grant, Townend, & Mills, 2008). The approach is also advantageous because it is able to overcome the categorical limitations of diagnostic classification systems. The approach is also able to accommodate a more multidimensional approach and acknowledges contextual factors. In addition to the problems experienced by my client, there is a need for carrying out assessment in order to establish any additional information about the client. There are different areas that the client can be assessed to provide more information. For instance, I may assess the client’s mental status. Sample of assessment questions to ask and note from my client In assessing the client’s mental status, I may need to question her on a number of areas such as: Appearance: How does the client appear? Is she caring for herself? Does she appear anxious or agitated or depressed? Mood: Does the client feel low or depressed? Doe she experience any other emotions such as guilt and shame? Does she have mood swings? Irritability: Is my client irritable or agitated? Hopelessness: How does the client view the future in terms of optimism or pessimism? Risk/self-harm/suicide: Are any indicators or risk present for self-respect/self- harm/abuse/suicide? Does the client have suicidal thoughts or wishes? Has the client made any plans for suicide? Does the client have access to means for suicide? Is the client a danger to others? The processes of case formulation and assessment are interlinked. The principle aims of assessment are to establish what the person’s problem is, determine the impact of the condition, in the case of Priscilla, depression, determine the impact of the condition on the client’s life, ascertain the predisposing, precipitating, and maintaining factors, as well as establish a baseline against which to evaluate the effectiveness of interventions. Clinical measures are used to support the clinical assessment, quantify the extent of the problem and establish a baseline to measure improvement (Stracervic, 2009). In a depression case like that of my client, it is essential that a risk component be integrated into the assessment process. It is helpful to differentiate between ideation and intent, but also to recognize that ideation can lead to intent. If concerns are sufficient regarding the possibility of a suicidal attempt, local risk management must be followed. When there is accurate and agreed data in respect to the maintenance cycle of the condition, the focus of the session can switch to the factors that have made the client vulnerable to the current condition. These can be from the client’s early experience, assumptions, and rules for living (Hersen & Rosqvist, 2008). Developmental and maintenance processes When coming up with a treatment for a client, it is important to examine what precipitated before the client found himself or herself in the current condition or what are called triggers. After that has been established, the therapist also goes to examine those contexts that make the condition severe. Information about what makes the problem develop, triggers, and modifiers are useful in a number of ways. First, it starts to give the therapist useful clues about possible beliefs and maintaining processes, by considering what themes might lie behind the variables discovered (Butler, Fenell, & Hackmann, 2010). If someone is especially anxious in situations where their behavior might be observed by others, perhaps there is some element of fear of negative evaluation. If the client is particularly depressed when the client perceives others as rejecting him or her, perhaps the client harbors some beliefs of being unlovable or unworthy. These clues can then prompt further questions, which can help to confirm or refute the initial guesses. Another benefit of gathering information on triggers is that it can be useful in the treatment. It may be helpful in identifying targets for treatment; or in planning interventions (Hofmann & Reinecke, 2010). The history of a client is also important in contributing to the present condition of a client. The client’s history and the development of the problem can be assessed through examining vulnerability factors, precipitating factors and modifying factors. Vulnerability factors examine anything in the person’s history which might have made the client vulnerable to developing a problem. However, this factor does not by itself necessarily mean that the client will develop a problem. In the case of my client, her growing up as a lone child while she was still young can be termed as a vulnerability factor, which makes her vulnerable to depression. However, for depression to develop, other events need to come in to play. These are events like my client’s demanding career, the loss of her best friend, and the leaving of her housekeeper, bestowing more duties to her. In cognitive, behavioral therapy terms, the main factor believed to contribute to such vulnerability is the development of particular beliefs, either in the form of assumptions of core beliefs (Stracervic, 2009). For instance, my client feels like losing it all. She has a pervasive sense of hopelessness. The events or situations which actually provoke the onset of a problem are known as the precipitants. In the standard cognitive therapy model, they are known as critical incidents. Precipitants are factors which seem to be closely associated with the actual onset of a problem or with a significant worsening of a long-standing problem. Although there may be a single significant event which precipitates a problem, it is often the case that there is no single event, but rather a series of more minor stresses, any of which the client might have coped with, but which overwhelm the client when they occur together in a relatively brief time (Townend, Grant, Mulhern, & Short, 2010). My client developed her current condition due to a number of precipitants. One of the problems that have led to the current condition of Priscilla is stress at her workplace. Her job as an events manager has exposed her to so much demanding conditions. The role that landed my client to her present condition is the one in which she was supposed to organize a big show for the opening of a new dance hall. In her capacity, my client worked with different people with different expectations for the event. In particular, the set designer had set high standards for the event and even threatened to walk out of the event if my client provided materials that did not match the caliber of his standards. My client had to coax this volatile man. The situation was even made worse by the fact that opening of the hall was uncertain. This was orchestrated by bad weather and strike, factors that have made the completion of constructing the hall less certain. Another precipitant that contributed to the current condition is the increase in responsibilities at her home because her house help had to leave to help her sick relative. As if this was not enough, my client also lost a very close friend who she had been friends with since her childhood who died in a tragic car accident (Hofmann & Reinecke, 2010). When preparing a treatment or intervention plan, it is important to examine the maintaining processes of the client’s condition. Maintenance patterns are psychological processes that keep a problem going. These are often of vicious circles, or feedback loops: cycles in which the original thought, behavior, affective or physiological response gives rise to effects, which ultimately feed back to the original symptom so as to maintain or even worsen it (Townend, Grant, Mulhern, & Short, 2010). One of the maintaining processes that contribute to my client’s condition is catastrophic interpretation. This is a central cognitive process in panic disorder and can also be important in clients with other problems such as health anxiety of obsessive-compulsive disorder. The central idea is that bodily or cognitive changes – most often symptoms caused by anxiety, such as increased heart rate, breathing difficulties or other signs of autonomic arousal – are interpreted as indicating some immediate and serious threat. For instance, my client is anxious about the future and, hence, the symptoms of anxiety make her feel like losing it. They contribute to her hopeless situation (Butler, Fenell, & Hackmann, 2010). Case formulation The basis for the structure of cognitive case formulation, and for subsequent therapeutic interventions, derives from the cognitive model. This hypothesizes that the emotions and behavior of people are influenced by their perception of events rather than by events directly. Gathering information around personal meaning making by bath client and therapist constitutes developing collaborative case formulation and is by its very nature ongoing and always incomplete. Case formulation has been defined as a provisional map of a person’s presenting problems that describes the territory of the problems and explains the process that caused and maintained the problems (Persons, 2008). The merging and ongoing formulation should contain strong positive and optimistic focus. The problems should be described using deconstructive language, or in the past tense. In contrast, goals are stated constructively. This implies that the client’s goals should respect the vision of how they would like things to be different in their life. By engaging in this future-oriented dialogue, the therapist strives to role model and inculcates curiosity and hopefulness in the client (Westbrook, Kennerly, & Kirk, 2007). A case formulation is an individualized theory about a person’s problems based on a more general cognitive, behavioral theory. Specifically, in tandem with a comprehensive assessment of the client, a case formulation marries individual knowledge of problems with knowledge and intricacies of the cognitive model and with research and theoretical literature related to the difficulties. The chief function of case formulation is to help a therapist devise an effective therapy plan, through a credible, systematic and collaboratively developed formulation framework. From this framework, the therapist can understand the client and the client can understand how her problems, and possible solutions to them, hang together (Westbrook, Kennerly, & Kirk, 2007). In the development of this framework, the therapist needs to change the goals of immediacy and comprehensiveness. In addition, she must efficiently identify what is needed to help the client, and avoid areas that may be intriguing or interesting but which have little direct relevance in helping the client tackle his or her problems. A case formulation should also strive to strike a balance between simplicity and complexity because the more complex a case formulation is, the more difficult it may be to demonstrate its reliability and validity (Dziegielewski, 2010). It is important to remember that the theory about a client’s difficulties emerging from a case formulation is simply ‘a best guess’ as to the ways in which underlying cognitions maintain problematic behaviors. From this standpoint, decisions around amending of discarding elements of the formulation are based on whether interventions seem to help the client achieve his or her therapy goals (Grant, Townend & Mills, 2008). There are many models that can be used in case formulation. However, in the case of my client, the model that will be used is the problem-specific model developed by Persons. This model is based on the perspective of evidence-based practice. Therapists have an ethical duty to work with clients using problem-specific, or validated models case formulation for specific problems, where and when those exist (Otto & Hofmann, 2009). Persons case formulation model Person’s case formulation model occurs at three levels. The first level is at the case level which explains relationship’s among the client’s problems, and helps select treatment targets. The second level is the problem level which provides a conceptualization of a clinical syndrome. The last level is the situation level, which offers a ‘mini-formulation’ of reactions to particular situations. In the matter of my client, the case-level formulation will be used. The case-level formulation proposes hypotheses about the mechanisms causing the client’s problems, the precipitants that are activating the mechanisms, and the origins of those mechanisms, and ties all of these elements together into a coherent whole (Hofmann & Reinecke, 2010). The heart of the case-level formulation is a description of psychological mechanisms that cause and maintain the client’s problems and symptoms. In developing a mechanism hypothesis, there are two strategies. The first strategy is to use a disorder formulation that underpins and EST. The second strategy is to use a more general psychological theory such as one of the cognitive learning, or emotion theories. In the case of Priscilla, I will use Beck’s cognitive theory, which views symptoms as consisting of linked automatic thoughts, behaviors, and emotions that result from the activation of schemas by stressful life events. To individualize a case-level formulation based on Beck’s model, the therapist needs to identify the likely origins of the client’s schemas, the particular schemas themselves, the particular precipitants that are activating them, and the resulting symptoms and problems. The origins and precipitants of my client’s condition were discussed earlier (Clark & Beck, 2011). In summary, my client’s overt difficulties include lack of concentration at her workplace and insomnia, in which she sleeps for only two to three hours a night. She is also argumentative. Her irrational beliefs include the thought of ‘losing it’ and being unable to go on. The formulation of my client’s case can be formulated as follows: The death of Priscilla’s best friend was a UCS condition that led to the development of PTSD symptoms. Depressive symptoms that pre-existed the critical event also promoted her current hopeless situation. Priscilla’s condition of being an only child might have been affected by the loss of her close friend whom she considered to be her more of a sister than a friend. Priscilla’s depressed condition leads to dizzy spells that impair her working concentration. Her depression affects her communication skills making her grumpy and difficult talk to. Early Experience (being an only child) Core beliefs about self, others and the world (the world is useless without her friend) Underlying assumptions/rules (Her friend meant everything to her/ was like her sister) Activating event/critical incident (death of her close friend) Cognitive reactions-Behavioral reactions-Affective reactions-Physiological reactions Diagram: Outline of the case formulation for Priscilla (chart adapted from (Wright, 2009). Goal setting Goal setting is an important aspect of cognitive, behavioral therapy. It helps the therapist in determining what the treatment or interventions hopes to achieve in the long run. Goals and objectives are set after the therapist has developed a problem list. In setting goals and objectives, the therapist asks himself or herself what the client needs to do to restore him or her to normal functioning. A goal is a short clinical statement of the condition the therapists expects to change in the client. The intention of the client should be stated in general terms, and then specify the condition of the client that will result from the treatment. Goals should be aimed at more than doing away with the pathology (Clark & Beck, 2011). They should be directed toward the client leaning new and more functional methods of coping. Goals should focus on more than stopping the old, dysfunctional behavior. They should concentrate on replacing it with something more effective (Stracervic, 2009). The following are goals that I may set when handling Priscilla’s case: 1. My client will have an optimistic view of the future. 2. My client will learn to cope with the death of her best friend. 3. My client will concentrate on her work. 4. My client will learn healthy communication skills. 5. My client will sleep comfortably on a regular basis. Intervention plan The first meeting with my client would consist of assessment sessions in which the client completes a structures interview designed to assess the frequency and severity of her depression symptoms. I will ask my client to provide details about her life history and any traumatic experiences. In the first session, my client reveals that she is an only child and that the death of her best friend who many considered her as her sister triggered her current situation. During the assessment process, my client frequently makes hopeless statements and displayed a tendency to view the world in a pessimistic manner. I will hypothesize that my client is not very close to any other people, hence; the loss she feels like the world is not worthy living without her friend. In the third session, my client confesses of the demanding chores at her home. She says that her house help used to assist her in the chores, but now that she has left to take care of her sick relative, she is all by herself at her home. I hypothesize that her increased household chores might have made her stressful. In the next, session, I will give my client homework in which I will stimulate events on what she would feel if she found another house help to aid in her chores, and considered the death of her friend as an avoidable circumstance in one’s life. In the fourth session, I challenge my client’s depressive condition through Socratic questioning (Westbrook, Kennerly, & Kirk, 2007). Through this approach, I challenge my client’s maladaptive cognitions about the traumatic loss of her friend. In the fifth session, the client will take a homework assignment to write a detailed account of her most traumatic incident for homework. I will explain that this is different from the impact statement, and should detail the specifics of the trauma, including physical sensations, thoughts and feelings (Clark & Beck, 2011). I ask the client to complete the account as soon as possible and to read it daily until the next session. My client and I discuss the importance of real engagement with the account each reading. I also ask my client to be careful not to engage in any avoidance behaviors when writing or reading the account, but to allow herself to fully feel the emotions associated with the traumatic event. As the client becomes more skilled at challenging her maladaptive thoughts, the focus of therapy becomes a more clear integration of the trauma-exposure work and the cognitive-skills work. The sixth session focused on reading a final impact statement and discussing the meaning of the traumatic event (Hersen & Rosqvist, 2008). My client’s final rendition of her impact statement is remarkably different from her original. My client no longer harbored feelings of losing hope, and although, she was still unease with the loss of her friend, her perception of the future changed to one with some hope. She begins to see a sense of coping with the loss of her close friend, and not allowing her depressed condition to affect her marriage. My client also starts to appreciate the need to extend her social circles to include more friends who she can rely upon in her times of difficulties. She also stops feelings of loneliness for being an only child, and appreciates the presence of her family as being there for her. My client also acknowledges the need for a better rest, as failing to sleep will only make her anxious, and make her concentration at work poor. Conclusion As mentioned earlier, the cognitive therapy model is grounded on the perception that stressful conditions such as depression, anxiety, and anger are often maintained or exacerbated by blown up or prejudiced ways of thinking. In the case Priscilla, she had blown up the loss of her close friend and the stress from work and household chores. By inducing positive thinking on her, the client was able to realize that losing a close friend is not an easy thing to cope with, but it should not be an excuse for one to lose hope in life. She could reduce the stress from her household chores by getting another house help, which will leave her with more time to concentrate in her job and have enough rest. References Butler, G., Fenell, M., & Hackmann, A. (2010). Cognitive-behavioral therapy for anxiety disorders: mastering clinical challenges. New York: Guilford Press. Clark, D., & Beck, A. T. (2011). Cognitive therapy of anxiety disorders: science and practice. New York: Guilford Press. Dziegielewski, S. (2010). DSM-IV TR in action. London: John Wiley & Sons. Grant, A., Townend, M., & Mills, J. (2008). Assessment and case formulation in cognitive behavioral therapy. London: SAGE. Hersen, M., & Rosqvist, J. (2008). Handbook of psychological assessment, case conceptualization, and treatment. New York: John Wiley & Sons. Hofmann, S., & Reinecke, M. (2010). Cognitive-behavioral therapy with adults: a guide to empirically-informed assessment and intervention. Cambridge: CUP. Otto, M., & Hofmann, S. (2009). Avoiding treatment failures in the anxiety disorders. New York: Springer. Persons, J. (2008). The case formulation approach to cognitive-behavior therapy. New York: Guilford Press. Stracervic, V. (2009). Anxiety disorders in adults: a clinical guide. Oxford: OUP. Townend, M., Grant, A., Mulhern, R., & Short, N. (2010). Cognitive behavioral therapy in mental health care. London: SAGE. Westbrook, D., Kennerly, H., & Kirk, J. (2007). An introduction to cognitive behavior therapy: skills and applications. London: SAGE. Wright, J. (2009). Cognitive-behavior therapy for severe mental illness: an illustrated guide. New York: American Psychiatric Pub. Read More