Introduction to Cognitive Behavioural Therapy - Case Study Example

Introduction to Cognitive Behavioural Therapy Introduction To satisfactory meet all the set learning outcomes, this essay will attempt to critically analyze the development of Cognitive Behavioural Therapy (CBT) as well as its philosophies and principles. Through the basic structure of a detailed case study, the essay will seek to sufficiently demonstrate a deep, conceptual understanding of CBT in regard to the treatment of relatively mild to moderate health problems. The essay will also seek to evaluate a number of evidence based research projects that have been conducted supporting the use of CBT in the treatment of psychological disorders. To present a balanced appraisal; research disputing the efficacy of the use of CBT will also be appraised. The case study expressed in this essay will seek to assess the various behavioural and cognitive strategies that are found to be inherent in the Cognitive model of depression. Some of the methods that will be evaluated in this respect include evaluation, formulation, change methods and assessment. In order to adequately respect the patient’s confidentiality, as well as, maintain a considerable degree of professional practice as is set-out under the 2008 guidelines for good practice of CBT as provided for by the British Association for Behavioural and Cognitive Psychotherapies (BABCP 2008), the name of the patient presented in the case study has been changed and duly assigned the pseudonym ‘John’. Some of the more sensitive of the patient’s personal details have also been changed to ensure that they remain secure. Of note however, is that all the details pertaining to the patient’s presentation and various interventions utilized in the treatment have remained unchanged. According to Robertson (2010), cognitive behavior therapy is currently the predominant school of modern evidence-based psychological therapy. As implied by its name, CBT employs a number of both cognitive and behavioural interventions in the treatment of patients. CBT is a clear structured, educational form of therapy that uses a primarily collaborative approach in the encouragement of patients to try and establish the probably problem areas from their own perspective,by focusing on the present psychological problems that might be afflicting the patient, CBT is able to successfully work towards the establishment of probable treatment options, as well as, effective goal setting (Williams 2001). The main underlying concept that is found to be behind CBT is that of feelings and thoughts significantly affecting our behavior. This can be illustrated by the fact that people who constantly spend their time thinking of a disaster such as drowning or being lost at sea might generally find that they try to avoid being at sea or swimming in the ocean. Ronen and Freeman (2007) point out that earlier theories of CBT were essentially based on the classical Pavlovian conditioning and Skinnerian operant conditioning models. In his demonstration of classical conditioning, Pavlov initially presented food to a dog upon which he was able to observe it respond by salivating, he termed this as unconditional stimulus. He then went on to pair the food with a bell and further experiments helped to sufficiently demonstrate that it was possible to elicit salivation by using the sound of a bell alone. In this instance, the bell represented the conditioned stimulus while salivation represented the conditioned response. Skinner (1950) is seen to have greatly enhanced Thorndike’s theory of operant conditioning when he effectively defined rein forcers, as well as, the effects that these rein forcers tend to have on an individual’s behaviour (Skinner, 1953). Lewinsohn’s (1974) model of development which is primarily focused on the re-introduction of positive reinforcements that can be accessed by an individual in the treatment of depression, has been met with criticism by Salkovskis (1996) who suggest that there are some limitations to encouraging patients to specifically focus on their engagement with the more positively reinforced activities, this is because by doing so, patients can potentially end up evaluating their outcomes in a negative manner. The model of depression that was presented by Aaron Beck (1967) is largely considered as being the key benchmark of Cognitive Therapy. Beck who is the pioneer of cognitive therapy, defined CBT as being a time limited, directive and active well structured approach that can be utelised in the treatment of many of psychiatric disorders (Beck, et al, 1979). Of note however is that the key principles of the therapy were initially established by a number of theories including, the Appraisal Theory developed by Arnold (1960 that theorized how the appraisal of a situation ultimately causes an affective or emotional response,the Personal Construct Theory proposed byGeorge Kelly (1955) and the Psychological Stress Model proposed by Lazarus (1966). It was Albert Ellis’s Rational-Emotive Therapy model (1962) that helped in paving the way for Beck’s depression model. The model proposed by Ellis greatly emphasized on how our intrinsic beliefs pertaining to a given situation can ultimately cause us to develop symptoms associated with anxiety and depression. Ellis is considered as being one of the creators of the cognitive revolution in the field of psychotherapy. However according to Velten (2007), some of Ellis’s contributions have greatly been undervalued.It was Ellis who first demonstrated the existing connection between feeling and thinking; he also showed that irrational beliefs were an important factor in the creation and maintenance of emotional disturbance. The model of depression developed by Becks (1967)proposes that the assumptions and attitudes formed in an individual’s early years’ experience are responsible for the formation of negative thinking in depression systems. There are found to be numerous similarities between behavioural therapy proposed by Wolpe (1969), and the cognitive therapy proposed by Beck (1967). There is a significant amount of analogy between these two psychotherapies and especially so in regard to how the patient therapy is organized, this includes, the interview structure, the formulation of the problems, the activity and direct nature of the therapist. However, there are numerous distinctive differences relating to the techniques that are actually used in the application of the psychotherapy treatments. Differences also exist in the concepts that are used to explain how therapy has helped to discontinue maladaptive responses. The depression model proposed by Beck (1967) has however faced criticism from Teasdale (1988) who argues that the model proposed by Becks is greatly oversimplified. According to Teasdale, it is the depressed effect that is responsible for the triggering of a wide range of various negative constructs and not specific environmental stressors that activate the dysfunctional schemata. The results of investigations conducted by Beidel and Turner(1986), as well as, those conducted by Latimer and Sweet (1984), have questioned whether the positive aspect of cognitive therapy in depression is as a result of the modification of cognitive distortions which may help explain the reappearance of behavioural activation that is sometimes witnessed during the treatment of depression (Martell et al., 2001). Despite these concerns, the modification of cognitive reprocessing has managed to gain credence from the large number of therapeutic models that have been developed based on CBT. These include the Interacting Cognitive Subsystems model (Teasdale and Barnard, 1993) and the Schema Therapy model (Young et al., 2003). CBT is widely seen to be in use in the psychotherapy treatment as is evidenced by the fact that in the United Kingdom, the National Institute for Health and Clinical Excellence (NICE)recommends the use of a combination of various anti depressant medication and the use of interpersonal therapy (IPT) in the treatment of the moderate to severe forms of depression (NICE 2009). NICE also recommends the use of CBT in the treatment of various disorders like Panic disorder and General Anxiety disorder. In making its recommendations, NICE compares the evidence of the results obtained by the use of a number of treatments. According to Butler et al., (2006), CBT is one of the most comprehensively researched approaches to psychotherapy treatments, Butler points out that there are about 325 published outcome studies on CBT whose clinical outcome studies have shown CBT to generally be more effective than the use of anti-depressant medications. The results of these studies have contributed to The Department of health, identifying CBT as having the strongest research base promoting its effectiveness (DH, 2001).The use of Randomized Control Tests (RTCs) has widely been utilized in CBT research and it is as a result of this type of evidence that NICE has advocated for the use of this approach in the treatment of mental health problems (Kinsella and Garland 2008). Of note however is that not all clinical studies have been without criticism and it is important to consider the limitations that might arise as a result of the methodology that is utilized in the research. Despite this, Wampold (2001) is keen to argue that the most crucial component of therapy is to belief in the therapeutic relationship and the method by both the therapists and clients and not the actual content of the intervention that is utilized in the course of treating the patient. It was Beck (1979) who first pointed out that although opting for antidepressant medication was generally less expensive than using psychotherapy treatments, psychotherapeutic interventions are generally more effective as they serve to help patients to learn from their experiences as well as sufficiently equip these patients with necessary skills to help them in effectively handling any future depressive episodes. Beck argued that as opposed to simply being a disorder symptom, negative thinking is in actual sense a fundamental feature in the maintenance of depression. Since then, a number of research studies have been carried out in assessing the effectiveness of CBT as compared to the use of pharmacology and a study conducted on a sample size of 107 patients by Hollon et al (1996) showed that CBT is generally as effective as pharmacology in effective reduction of acute distress in patients. The results also showed that when CBT was done in what the researchers termed as an adequate fashion, it would be able to reduce subsequent risk as compared to the use of pharmacology. When the cost of therapy in CBT is taken into consideration, Lovells and Richards (2000) argue that there is actually no existing evidence base that prove that the use of self help books and computerized CBT is less effective as compared to a patient undergoing about 12-16 sessions each lasting for 1 hour every week. Wampold (2006) however discredits this premise by arguing that it does not take into consideration the research emphasizing the importance of collaborative work between the patient and the psychotherapist. Case Study: John Meeting the patient John came to my attention after he was referred to me by family members who were worried about his behaviour. Like most patients of his type, he was not very interested in the therapy and thought it was a waste of time. He, however, acknowledged that he had problems, but only argued that there was nothing he could not handle. This brought up two main issues. First, as Wampold (2001) identified, with a patient like John, establishing a trusting relationship is very important in order to avoid the patient feeling that he is just a client and you are the doctor on the other side of the desk. As Young and Bramham (2012) say, creating a power balance was important and this was to be the main issue. John was already showing signs of indifference and it was necessary to make sure that this did not get in the way for his treatment and recovery. Secondly, the fact that John was not acknowledging the need for help made him even harder to benefit from any useful cognitive behavioural therapy. As Simos (2008) says, the acknowledgment by the patient hat he or she has a problems and needs outside help is a major foundation pillar to help cognitive behavioural therapy to work. Without the patient agreeing that there is a problem that he has that needs to be solved, the application of behavioural therapy techniques can be harder to achieve and this makes it harder to treat the patient. As a result, what I had to do with John was to ease him into the system and make him feel that he was as much in total control of the situation as I was. Hollon, Derubeis and Evans (1996) study as well as that done by Kinsella and Garland (2008) indicated that the use of CBT can be very useful in treating depression, especially where a good relationship with the patient is established. Of course, the first talk was to ease off the tension and let his slowly be drawn to his problem. It is highly important to help the patient to recognize his own problem since this is the very core of cognitive therapy. In this regard, I used the first session, not for diagnosis, but for just chatting with John, sometimes even letting the conversation to border on the idea that I also did not think that he had a problem. This, as Einstein (2007) says is very important crating a foundation in which to lay the CBT treatment process. To bring him to reality, I talked to him about his past and what plans he had in the past about the future. I did this to create a time line for the events that had led him to the current situation. We also talked about the future as a way to identify his worries, since depression has a lot of worries caused by the uncertainty of the future. John had a young family that was looking up on him. He also had an elderly mother. These factors were important in the diagnosis for John as well as in the determination of what was important to him. By discussing these issues with John, he was eventually able to open up and see his problems. John eventually admitted that he was worried that he might eventually fail to provide for his family and, therefore, lose it. In this regard, John felt that he needed to do something. Establishing the relationship As a professional using CBT, I needed to make sure that John did not feel that he was being belittled. In this regard, I established a relationship based on mutual trust as well as mutual respect. In response to his initial attitude, which indicated that he was about to have an issue with regard to admitting his need for treatment, I purposely rearranged the sitting arrangement in order to makes sure he did not feel like a patient. I had recognized that his refusal to admit that the need professional help was tied to his own fears because as Robertson (2010) found out in his study, this is core to the success of this kind of treatment. Part of these fears was that he did not want to admit that he was psychologically unwell. Soon, John was able to open up and the sooner he did that, it was now possible to show him that he had an issue that needed help. Identifying Johns needs/problems As already discussed, the main issue was not for me to identify them, but for John to open his eyes with regard to them because as Felgoise (2006) says, patients’ cognition of their problems should be at the centre of the treatment process. Cognitive therapy is highly dependent on the patient’s cognition and the person attending to the patient is only used as guide to help the patient go through his problems. The patient’s cognition of his own problems is a major factor to consider with regard to the way the patient is going to be treated (Garrett, 2010). Diagnosis John displayed signs of mild to moderate depression as established in the DSM IV manual. John had the following signs which were indicative of a dysthymia. Poor sleep John admitted that he was having problem sleeping. To deal with the issue of having being awake most of the times, he had gained a habit of watching too much television and always going to the movie store to buy movies to keep him busy. This makes one of the core signs of mild to moderate depression. Low levels of energy John was displaying low levels of energy and always unable to carry out the most basic of functions. He was having problems committing to the plans he had made about expanding his business. John admitted that he was having issues with regard to being able to do even the simple tasks. This could also be associated with the fact that he had a low outlook for the future thus feeling no motivations to try and make anything work better (Robertson, 2010). Low motivation for the future After discussions with John, it was evident that he did not have a good outlook for how the future will be for him. This is very typical of people with dysthymia. John’s hopelessness was based on the fact that he had failed to achieve most of his goals. His family was becoming bigger and he was finding it harder to be able to provide for her family. He shared that he had planned to have a bigger home by this time, but had failed because his business did not grow as he had planned. In one of the sessions, John mentioned that he was afraid that her wife would leave her eventfully if he was not able to meet his financial obligations. Low self esteem As described above, John’s self esteem was very low and he was finding a hard time trying to maintain his life. He was starting to have the feeling that he was not adequate with regard to his family and his wife. John also admitted that he was feeling that his siblings were not respecting him enough. He associated this with the fact that he was having financial issues. His fear that the people around him were not respecting him had led to his low self esteem. In fact, this had been the main reason why John was refusing to attend the sessions since he felt that his family, especially the wife, was being biased about his mental ability and heath. Fatigue He also admitted to having a lot of fatigue despite the fact that he was not doing a lot of work. He admitted to be always feeling too tired and that he could hardly do anything for even a short time without feeling tired and exhausted. All these conditions indicated that John was having dysthymia and needed treatment. Fortunately, by the time we had a few sessions; John had emerged from the denial phase and now admitted that he actually did have a problem. He was now having more interest in treatment and had started feeling that the treatment would help him to overcome his problems. Poor social activity As Beck (1979) says, with regard to mild to moderate depression, the low self esteem that comes with it makes it harder for the patient to be able to socialize with people. In the case of John, he admitted to having feelings of worthlessness that made him find it hard to socialize with people. He would avoid any social situation, even with his family such as brothers and his one sister. Two issues came up with John’s situation. First, he admitted that he felt that everybody was regarding him in low light and that they did not respect him. This made him less motivated about the meeting people and preferred to be left alone, even by his wife. Secondly, because of these feeling, he was always in quarrels with people and this also made it more difficult to socialize with people. It also reduced his desire to meet people because he mostly felt that it would only lead to him having quarrels with them. Treatment and reaction In using cognitive behavioural therapy, the primary factor is making the patient to be able to see the world in a new way. Cognitive behavioural therapy recognizes that the mental and psychological health of a person is affected by their thoughts. In this regard, negative thoughts lead to poor psychological heath. In light of this, Johns treatment was geared towards making sure that he was in good shape and that he was starting to see the worse in a new way. I was also geared to make sure that he can get motivations for doing the right things. The best thing about join was the speed at which he emerged from the denial stage. Some patients can become adamant in staying at the refusal stage and this creates a barrier for them. This is even more so in situation where the cognitive behavioural therapy is being used. In cognitive behavioural therapy, the ability of the patient to recognize his problems is paramount in making sure that the patient will benefit from the treatment. John eventually started feeling better and showed improvements. 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