A critical reflective and analytical research based written conceptualisation and therapeutic plan for a common human problem in Cognitive Behaviour Psychotherapy terms. This essay has been particularly difficult for the writer to achieve due to the challenges they face in the transition from a Person Centred Counsellor to a Cognitive Behavioural Therapist in Training. The writer hopes to achieve a comprehensive critical reflection and analytical research based on a common human problem that has been assessed in the clinical setting.
The essay includes Padesky five area systems and a disorder specific conceptualisation, including a diagram, which can be found in the appendix. The essay is research based; including information about prevalence, incidence and outcomes using Cognitive Behavioural Therapy. The writer has also included DSM /ICD diagnostic criteria for as evidence of the diagnosis and this is too available in more detail in appendix. To conclude the essay the reader will provide a detailed therapeutic plan for the treatment of the common human problem as assessed.
Presentation of the client; The client in this essay as signed consent forms to be used as a case study for the purpose of the training required for the course. For the purpose of this essay I am going to call this client Cliff. Cliff has been to see his GP as he was struggling with Cliff (2010) “black thoughts” as the client calls them; risk assessment has been completed and can be seen in appendix. Cliff is a 43 year old male, who lives in a shared house with one other male.
He is currently unemployed and became unemployed in February 2010. In the past twelve months he has suffered two significant bereavements those being his father and his sister in law and more recently he has spilt from his girlfriend, not his choice and is struggling with this decision. However Cliff is presenting with signs of depression and during the assessment process it became evident that his depressive episode has been current before the bereavement and relationship split.
See Appendix A for full case details (page….. ). Before beginning with Cliff’s referral it would be appropriate to discuss Cognitive Behaviour Therapy (CBT) and the evidence for the success of treatment outcomes for mental health patients using this therapy. CBT is one of many different types of ‘talking therapies’ it as a collaborative and direct approach to deal with emotional and psychiatric disorders. This means being transparent and open asking direct questions to the client to ascertain the clients’ problems.
In contrast to the therapy the therapist as come from being Person Centred School of therapy, CBT is present focused, time bound, highly structured, and goal orientated. Reflecting on does CBT work; there are numerous writers for and against CBT. CBT is constantly evolving by what is called “evidence-based-practice”, and this form of psychotherapy is constantly synchronized with the latest recommendations from the research suggesting what works best.
NICE (2009) The National Institute for Health and Clinical Excellence states CBT has a solid evidence base for effective treatment for a number of diagnoses, including depression and schizophrenia, which is where the IAPT service evolved from. Husain (2009) published an article stating high-profile clinical psychologist has delivered a hard-hitting criticism of cognitive-behavioural therapy (CBT) claiming it is simplistic and “does not work” Dr Oliver James accused government ministers of being “downright dishonest” when they claimed that new NHS CBT-trained therapists will cure half of 900,00 people of their depression and anxiety. There is not a single scientific study which supports that claim,” says Dr James. “Being cheap, quick and simplistic, CBT naturally appeals to the government. Yet the fact is, it doesn’t work,” added Dr James. However NICE (2000) guidance is used widely and is respected by the NHS and is designed to promote good health and prevent ill health, it is based on the best evidence they can find and takes into account the development, consistent, reliability based on development processes.
Taking all researchers in thoughts into account and the therapist’s own experience, CBT does work in giving structure to a client’s therapy and recovery and equally the client’s relapse prevention. To ensure IAPT services’ are working to a high standard in September 2007 the Department of Health published “The competences required delivering an effective cognitive and behavioural therapy for people with depression and with anxiety disorders” (Anthony D. Roth and Stephen Pilling, DOH, September 2007).
The publication was the result of a project commissioned by the Improving Access to Psychological Therapies (IAPT) programme, with additional funding from Skills for Health and the Centre for Outcomes, Research and Effectiveness (CORE). This project stemmed from a recognition that the success of the IAPT initiative would rest on the success of competent practitioners who were able to offer effective CBT interventions at both a low and high-intensity level.
Roth and Pilling describe a model which identifies the activities that characterise effective CBT interventions for people with anxiety and depression. The model organises the CBT competences into five domains (generic, basic, specific, problem-specific and met competences) and presents a ‘map’ of how the competences fit together. In their report they outline a variety of potential uses for the CBT competence framework, including its use in commissioning, service organization, clinical governance, supervision, training, registration and research.
Following receiving GP referral; with a GP diagnosis of low mood and suicidal thoughts. With this information the therapist used ICD 10 and DSM-IV to look at the symptoms of low mood to aid the assessment process however not to direct the assessment process. DSM-IV(2000) and ICD-10 WHO (2007) criteria which are used widely within the service are the most widely used criteria for diagnosing depressive conditions. Major depressive disorder is classified as a mood disorder in DSM-IV. DSM-IV (2000), the diagnosis hinges on the presence of single or recurrent major depressive episodes.
Further qualifiers are used to classify both the episode itself and the course of the disorder. The category Depressive Disorder Not Otherwise Specified is diagnosed if the depressive episode’s manifestation does not meet the criteria for a major depressive episode. The ICD-10 system does not use the term major depressive disorder, but lists very similar criteria for the diagnosis of a depressive episode (mild, moderate or severe); the term recurrent may be added if there have been multiple episodes without mania.
During the assessment process the therapist describes the skills she used as guided discovery stating she feels more comfortable with this way of open questioning rather than Socratic dialogue. She always describes using the downward arrow to establish if the depression was there before the relationship split, which was evident it was as Cliff reports doing nothing only waiting for his girlfriend to come home from work and that would be the highlight of his day. A risk assessment was taken into account due to the GP acknowledgment of suicidal thoughts.
Cliff strengths’ are that he see these thoughts as negative, knows where he can get support from and has found ways to combat these thoughts by going for a walk, he as strong positive protective factors and his children and brother support him. However from the assessment the therapist diagnosed cliff with Depression comorbidity with anxiety using ICD-10 criteria, the reasons for this were the levels of anxiety Cliff was describing in the assessment process and suggested “he was worried about having to return to work and this kept him awake worrying at night”.
However Cliff wanted to work on his depression and to get rid of the thought/feeling of “can’t be bothered”. In an agreement depression was the main focus of the assessment and the essay will concentrate on this, the treatment plan you will read later in the essay will touch on some anxiety with mainly behaviour activation as requested by Cliff, Cliff is very motivated to recover from his current state as he wants to return back to work and rebuild his life.
The therapist used ICD-10 as during classroom discussion she felt more easy to work with this as she didn’t feel medically she understood the DSM-IV, however can see the advantages for DSM-IV; A starting point for developing diagnostic tools (DSM provides a list of symptoms – an excellent place to start from in terms of diagnosing someone). Practically there has to be a ‘cut-off’ point somewhere between disordered and non-disordered, DSM helps establishes this.
It gives a common language of communication between doctors, patients, public, and media. Constant revision of the DSM and new editions pushes research forward. The therapist suggests more use of the DSM-IV will aid understanding and comprehensive usage in future to help both therapist and clients. The ICD-10; http://apps. who. int/classifications/apps/icd/icd10online/, is where the therapist states the diagnosis comes from with a both presenting symptoms of anxiety and depression; F41. 2 Mixed anxiety and depressive disorder
This category should be used when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used. Anxiety depression (mild or not persistent). Depression refers to both negative affect low mood/ absence of positive ffect loss of interest and pleasure in most activities and is usually accompanied by an assortment of emotional, cognitive, physical and behavioural symptoms. It is the most common psychiatric disorder and carries significant external/environment factors such as high burden in terms of treatment costs, effect on families and carers and loss of workplace productivity. Depression is currently ranked fourth in terms of global disease burden by the World Health Organization (WHO 2000). Gen Hospital Psychiatry 1992) The prevalence of major depression in people seen in primary care is between 5% and 10%, and two to three times as many people have depressive symptoms but do not meet the criteria for major depression. Two thirds of adults will at some time experience depressed mood of sufficient severity to influence their activities. 6% of adults have an episode of depression, and more than 15% of the population will experience an episode during their lifetime.
The difficulty of this assessment is the therapist needs to identify with the client a priority list to work on the difficulties, keeping within evidence-based therapy approaches, using their ability to case conceptualise and providing ways in which both the therapist and the client can work collaboratively to describe the presenting issue, understanding in the terms of CBT and together finding ways of relieving the distress and building client strengths and resilience. This is defined by Kuyken W, Padesky C.
A, Dudley R (2009) P. 3 as “Case Conceptualisation is a process whereby the therapist and client work collaboratively first to describe and then to explain the issues a client presents in therapy. Its primary function is to guide therapy in order to relieve client distress and build client resilience. ” For this to be successful the assessment process must both off worked collaboratively and is evidence in their approach to Padesky’s (1995) five area and Cliff’s input into this. See Appendix B for full diagram (page…. ). he therapist states they use the Padesky 5 area model for all her current assessments, she uses this for the purpose of it being generic and this is useful for Cliff’s to see his difficulties’ and to understand them and is very useful in the early stages of treatment for Cliff to see how their problems are maintained and can clearly see the relationship between thoughts, physical symptoms, mood, behaviour and environment. The other case conceptualisation the therapist could of used in this assessment is a problem specific model, (Grant, Townsend, Mills,
Cockx 2009) state; it has been evidenced that therapist has an ethical duty to work with clients using problem specific models of case conceptualisation where and when they exist, with the problem specific disorder being depression from the GP referral; The Beck Depression Inventory (BDI, BDI-II) being specific. (http://www. minddisorders. com/A-Br/Beck-Depression-Inventory. html 2010)defines The Beck Depression Inventory (BDI) is a series of questions developed to measure the intensity, severity, and depth of depression in patients with psychiatric diagnoses.
Its long form is composed of 21 questions, each designed to assess a specific symptom common among people with depression. A shorter form is composed of seven questions and is designed for administration by primary care providers. Aaron T. Beck, a pioneer in cognitive therapy, first designed the BDI. This was designed in 1961 by Dr. Aaron T. Beck. (Beck 1987) recognized that depression had both physical and emotional components. The Beck Depression Inventory is a series of questions that bring up physical symptoms like fatigue, as well as emotional ones, like feeling unhappy.
The goal is to create a balanced picture of the patient’s emotional and physical state that can be used to assess the patient for depression. However is suggested by the therapist that this can be skewed depending on the type of day the patient is having rather than in the padesky’s model where they look at a particular day or problem double with the lack of use the therapist as of the inventory of depression, it is suggested that it can be useful. The therapist as a comprehensive knowledge of the disorder and with this being a training case a five areas generic model is suffice.
It is also important to acknowledge that clients are idiosyncratic individuals and even thought their emotional problem may be very well documented and familiar to the therapist, the client should be involved in the case conceptualisation as it is a means of understanding the client’s presenting problem and not every client will fit into a pre-existing model. For this assessment to be completed the therapist was able to put Cliff at ease with the skills of being able to build a therapeutic relationship, aiding Cliff to open up and tell his problems to the client in a empowered way.
The therapeutic alliance refers to the relationship between a therapist and Cliff. There is evidence that a strong therapeutic alliance predicts better outcomes in therapy which can be found; www. nice. org. uk/CG90 (2009) See appendix D (page…. ). A strong therapeutic alliance is evident when the client feels comfortable with the therapist, has a sense of common goals or purpose with the therapist, and feels a sense of safety and trust in the therapy process this was established by the therapeutic alliance that was maintained through the assessment.
For the therapist with a core profession in Person centred Counselling this was particular difficult for the transition to be made as it is felt crucially important for the core conditions to be in place for the counselling to be effective and found it difficult for this not to be acknowledge within CBT. The therapist acknowledges because of its scientific basis and structure approach it has been difficult to make the transition whilst considering the core conditions as the therapist is more focused on the getting the treatment plan correct.
From the research done the common criticism of CBT is that it undervalues the core conditions as outlined by Rogers (1980) however on reflection this is not the case it is significant to point of divergence between Rogerian and CBT considered the core conditions to be both necessary and sufficient for the therapeutic change to occur, whilst CBT recognises the conditions as desirable and necessary but not sufficient to bring about client change. Branch. R, Dryden. W (2008) p33.
Whilst researching for this essay it is noted that the mention of core conditions in much of CBT Literature is Sparse, however they are a key feature of the overall CBT approach. Gilbert and Leahy (2007) have helped fill in this difference with their writings on the role of the therapeutic relationship in CBT. The assessment is still continuing with Cliff and him currently keeping an activity diary to identify what he is doing during the week, as he reports he is doing nothing at all.
During clinical supervision the therapist has started to think about a treatment plan and follows is their description of a plan and the rationale for this, this is still in a pure theory stage. In mental health, the treatment plan refers to a written document that outlines the progression of therapy. A treatment plan may be highly formalised or may consist of loosely handwritten notes, depending on the documentation requirements of the insurance company and facility, the preference of the therapist and the severity of the presenting problem.
No matter how formalised, however, the treatment plan is always subject to change as therapy progresses. Generally treatment plans have four parts: identified problems, goals for treatment, methods of achieving these goals; and estimated time to meet this goal. (Intervention 1) – Education regarding the nature of depression, the shame and fears, family roles. The rational for this is to socialise Cliff to the diagnosis and CBT, to continue developing a therapeutic alliance. Intervention 2)- Activity scheduling the rationale for this is when a client is presenting with depression they often withdraw or avoid activities this will help Cliff with planning his week and hopefully encourage his job hunting. (Intervention 3) – Thought diaries the rationale for this is to get cliff to explore what helpful thinking would help him, avoiding the pitting self. (Intervention 4) – Empathy for own distress – development of empathy for self, which will help Cliff to not “beat” his self-up for his depression. Intervention 5) – breathing exercises the rationale for this is that Cliff describes anxiety attacks as part what helps maintain his depression and avoidance, by doing this it will help recognise his anxiety attacks, refocus his attention giving time for positive thoughts to be put in place. The therapists plan for relapse prevention plays a major role in the preparation of ending and giving Cliff strategies to aid his recovery. (Minddisorder. com 2009) describes relapse prevention as; In the course of illness, relapse is a return of symptoms after a period of time when no symptoms are present.
Any strategies or treatments applied in advance to prevent future symptoms are known as relapse prevention. The strategies to be put into place for Cliff will be to recognise his low mood triggers and to gain understanding on what he needs to keep working on to maintain his therapeutic goal, looking at his beliefs and thoughts and to continue working on these. In Conclusion throughout this this essay the therapist has been assessing one skills and ability as a scientific practitioner and is adhering to a scientist-practitioner model of practice and utilises techniques that have been scientifically validated through extensive research.
It is widely accepted that cognitive–behavioural therapy is effective in treating a host of mental illnesses. The essay was particularly difficult to write with it being academic and the therapist is usually writing case studies for evidence of ones competences. From this essay the therapist has established a number of key competences that they need to develop to achieve a competent Cognitive Behavioural Therapist this mainly being around assessment and diagnosis and the evidence to counterbalance the diagnosis being made. (3189 Words) References Books: Branch. R and Dryden W (2008).
The Cognitive Behavioural Primer. PCCS BOOKS Ltd. Ross-on-wye. Grant. A, townsend. M, Mills. J and Cockx. A (2009). Assessment and Case Formulation in Cognitive Behavioural Therapy. Sage Publication Ltd. London. Kuyken. W, Padesky, C and Dudley. R (2009). Collaborative Case Conceptualisation working effectively with clients in Cognitive-behavioural Therapy. The Guilford Press. London. Website: http://apps. who. int/classifications/apps/icd/icd10online/ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. , text revision). Washington, DC: Author. ttp://www. psychminded. co. uk/news/news2009/march09/oliver-james-cbt003. htm Mind over Mood: Greenberger & Padesky (1995) www. padesky. com http://www. who. int/mental_health/management/depression/definition/en/ Gen Hosp Psychiatry. 1992 Jul;14(4):237-47 Bibliography Books: Branch. R and Willson. R (2010) Cognitive Behavioural Therapy for Dummies. John Wiley & Sons, Ltd. Colchester. Branch. R and Dryden W (2008). The Cognitive Behavioural Primer. PCCS BOOKS Ltd. Ross-on-wye. Gilbert. P (2007). Psychotherapy and Counselling for Depression Third Edition. Sage Publication Ltd. London.
Grant. A, townsend. M, Mills. J and Cockx. A (2009). Assessment and Case Formulation in Cognitive Behavioural Therapy. Sage Publication Ltd. London. Kuyken. W, Padesky, C and Dudley. R (2009). Collaborative Case Conceptualisation working effectively with clients in Cognitive-behavioural Therapy. The Guilford Press. London. Oxford Medical Publication(1989). Cognitive Behaviour Therapy For Psychiatric Problems A practical Guide. Oxford University Press. Oxford. Wells. A (1997) Cognitive Therapy of Anxiety Disorders – A Practical Manual and Conceptual Guide. John Wiley & Sons, Ltd.
Colchester. Website: http://www. minddisorders. com/Py-Z/Relapse-and-relapse-prevention. html#ixzz1ABVvbhuJ http://apps. who. int/classifications/apps/icd/icd10online/ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. , text revision). Washington, DC: Author. http://www. psychminded. co. uk/news/news2009/march09/oliver-james-cbt003. htm Mind over Mood: Greenberger & Padesky (1995) www. padesky. com http://www. who. int/mental_health/management/depression/definition/en/ Gen Hosp Psychiatry. 1992 Jul;14(4):237-47 Appendix
