Cognitive Behavioural Therapy 3 Formulation / Case conceptualisation
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1 Cognitive Behavioural Therapy 3 Formulation / Case conceptualisation Dr Tess Patterson tess.patterson@otago.ac.nz Senior Lecturer Clinical Psychologist Psychological Medicine Department
2 Formulation An individualised picture that helps us to understand or explain a client s problems A CBT model to develop Description of current problem why and how problems may have developed Key maintaining processes hypothesised to maintain the problem
3 Formulation Based on assessment information Hypothesis for what you think is going on Changes over time with ongoing information and feedback Collaborative Informs treatment Provides a rationale for treatment Guides treatment approaches
4 Focus of CBT formulation Mostly on current maintenance problems Processes that start a problem not the same ones that keep it going Easier to get evidence of what is occurring now rather than attempting to recall how things were that happened many years ago Easier to change processes that are keeping the problem going than past developmental events If it is due to past events, you are working on the impact it is having now onthoughts, feelings, behaviours
5 Assessment Not just a symptom checklist or life history Use a CBT approach Cognitions Emotions Behaviour Physiological symptoms
6 Problem Description Cognition words or images I can t its useless I m going to die What goes through your mind? Emotions/ affect Angry, worried usually one word Behaviour What they client does/ doesn t do observable/ actions Physiological symptoms Autonomic arousal (heart rate, breathing, nausea )
7 Factors affect the problem Triggers Modifiers Variables Situational Social/ interpersonal Cognitive Topics / thoughts Behavioural Physioloical affect
8 Consequences of the problem What the client has lost/ impact of the problem How have significant others responded to the problem Coping strategies
9 Critical Maintaining factors Psychological processes that keep a problem going Cycles of thought, behaviour or feeling that ultimately feedback into the problem or make it worse
10 Safety behaviours
11 Escape / avoidance
12 Maintenance cycle in depression
13 Catastrophic misinterpretation
14 Scanning or hypervigilance
15 Self fulfilling prophesies
16 Performance anxiety
17 Fear of fear
18 Perfectionism
19 Short term reward
20 Problem development/ the past Vulnerability factors Precipitating factors Modifying factors
21 Order of assessment No right or wrong Sometimes client driven But best to start with current problem What is the problem that brought you here What is it that you are hoping will change
22 Communicating formulations Diagrams the easiest Or a short verbal description
23 Basic Model - depression (childhood) experiences Core beliefs [Cognitive triad helpless, unlovable, worthless] Conditional assumptions Situation Automatic Thoughts Feelings Behaviour 23
24 Basic Model - depression (childhood) experiences Bullied, perfectionist Core beliefs [Cognitive triad worthless] Situation Lower than expected grade Conditional assumptions Automatic Thoughts If I succeed at University then. I always stuff up. Why bother? sadness Feelings Behaviour miss lectures 24
25
26 Buying goods with eftpos I don t want people to think poorly of me. If I shake people will see me as inferior What if I shake. Image of self shaking violently Grip eftpos tightly Tense arms Move slowly Carry cash Trembling, hot, sweaty, mind racing
27 hypochondriasis
28 hypochondriasis Cancer is common. I ll get it. I wouldn t cope with it Go to doctor Numerous doctors Pay for tests Worrying, need to find out Frequent scanning of body for pain, symptoms Lump feeling in throat I ve got throat cancer. I m going to die
29
30
31 Neglect Sexual abuse borderline intellectual functioning Sex with young person ok Wont get into trouble no concept of harm Not know rules Vulnerable child People around Puberty Sexual urges availability harmful sexual behaviours It will be ok I want to have sex Strong arousal erection/ urge Get the person alone, play a game Not notice child/ not think about it Not harmful Masturbated to memories Rules not explicit Sex reinforcing
32 Reading See Chapter 2 of Massachusetts General Hospital handbook of CBT (2016) 32
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