Cognitive Behavioural Assessment and Formulation

Transcription

1 Florence Nightingale School of Nursing & Midwifery Cognitive Behavioural Assessment and Formulation Cheryl Jordan

2 Objectives: Critically reflect on frameworks and approaches to assessment in CBT Identify and discuss factors which are maintaining the problem as proposed by CBT theory Understand the practicalities and process of the CBT formulation Understand the role of measurement in CBT assessment and practice Discuss the advantages and limitations of utilising this framework in standard mental health nursing practice

3 Assessment What skills are required in assessment? What do you think the differences might be when undertaking a cognitive behavioural assessment?

4 Cognitive formulation (Beck 1976) Early Experience Core Beliefs Rules and Assumptions Critical Incident About self/others /world Conditional statements If..then I must.. Situations or events where rules are broken or assumptions activated Somatics Emotion thoughts These elements interact in a vicious cycle Behaviour

5 Structure of a therapy session Greetings and mood check Agenda setting Homework and review of previous session Focused work for the session Negotiation of homework linked to work in session and formulation Elicitation of effectiveness of session and feedback.

6 Process of Assessment Gather Information Analyse info using CBT theory Develop hypotheses about important processes Decide what further Info will help test hypotheses initial ideas about formulation Discuss with client and modify as necessary Agreed working formulation Modify formulation Note further info acquired During treatment Treatment plans

7 Formulation Helps client and therapist understand the problem Bridge between CBT theory about problem development and maintenance and clients experience Shared rationale and guide for therapy Opens up new ways of thinking Helps therapist understand/predict difficulties in therapy or therapeutic relationship

8 Current problem What s the problem? Ask for a recent example What? Where? When? With Whom? Why? physical Critical Incident Thoughts Behaviour What does it mean to you? Affect What s going through your mind when you feel..? What do you feel most. About? How frequent? how intense? Duration? Do you notice anything happening in your body? What do you do or feel like doing when you feel..? What s the consequences of doing this?

9 Maintaining process: anxiety Fear of a particular situation /object No change to fear beliefs Client does not learn coping Strategies or expose beliefs to disconfirmation Escape/avoidance

10 Maintaining processes: depression Depression Negative thoughts ( activity is seen as pointless) Loss of positive rewards Reduced activity

11 Video Clip Watch the clip Analyse the information elicited by the therapist, use CBT theory to understand what the problem is and what might be maintaining it. Take note of the questions the therapist asks to elicit the information and how the CBT approach is introduced.

12 Core beliefs and assumptions Downward arrow technique. If that where true what would that mean to you? Rules/assumptions Core beliefs What does it mean to you if /when.? If that were true what would it mean to you/ about you?

13 History Early Experience Medical/psych history Previous experience of therapy Family & relationships Themes within the family

14 Cognitive formulation (Beck 1976) Early Experience Core Beliefs Rules and Assumptions Critical Incident About self/others /world Conditional statements If..then I must.. Situations or events where rules are broken or assumptions activated Somatics Thoughts Affect These elements interact in a vicious cycle Behaviour

15 Problems and Goals Problem: I feel X ( emotion) about X ( situation) and this leads to X ( behaviour) Overall goal: I would like to feel X ( emotion) about X ( situation) and this would lead to X ( behaviour) Smart goals : set week to week ( Dryden W, 2001)

16 Role play exercise Divide into groups of 4 Cheryl to play patient Plan your questions to elicit info on the following: Group 1: thoughts Group 2: emotions/physical sensation Group 3:behaviour Group 4: situation Patients goals for therapy 1 person from each group to ask the questions Others observe Carry out assessment. In your small groups begin to construct a formulation, need anymore info? Present formulation to Cheryl and the group. What could you do to test out whether the formulation is accurate?

17 Formulation Art or science? Do different therapists agree the exact same formulation for the same client? (Beiling & Kuyken 2003) Is treatment based on formulation more effective? (Schulte et al 1992) ( Ghaderi, 2006)

18 Suitability Inclusion: 1. Can access thoughts and feelings 2. Accepts some responsibility for change 3. Understands a CBT rationale and basic formulation 4. Able to form a good enough relationship with therapist 5. A degree of optimism Exclusion 1. Impaired cognitive functioning 2. Currently in crisis 3. Unwilling to let go of avoidance behaviours 4. Pronounced pessimism about therapy ( Wills F 2008)

19 Types of measurement Self-ratings (SUDs) Diaries Questionnaires / outcome measures Physiological responses

20 score Making good use of data BDI scores session number Series1

21 Measurement scales BDi PHQ9 BAI GAD 7 HAD Ybocs Liebowitz social anxiety scale Multi dimensional perfectionism scale Dysfunctional assumption scale

22 BDI 1.Beck Depression Inventory is a series of questions developed to measure the intensity, severity and depth of depression in patients with psychiatric diagnoses. 2.The BDI is a 21 item self-report rating inventory measuring characteristic attitudes and symptoms of depression (Beck et al., 1961) 3. It is not a diagnostic tool for depression. 4. It takes 5-10 minutes to complete. Encyclopedia of Mental Disorders:

23 HISTORY OF BDI First developed by Aaron Beck in Adapted in Copyrighted in BDI-I was revised in > BDI-II was published in 1996 in response to DSM-IV 1994.

24 HOW TO USE BDI-II? It has 21 self-rating questions. It takes 5-10 minutes to complete. It has to be subjective to the client, focusing on feeling of past one week Designed for use by trained professionals. (Groth-Marnat,1990)

25 BDI-II - TWO FACTORS APPROACH 1. Somatic symptoms. 2. Cognitive symptoms. Somatic symptoms consist of 13 items: Sadness, lack of pleasure, tearfulness, agitation, loss of interest, indecisiveness, loss of energy, change in sleep pattern, irritability, poor appetite, poor concentration, tiredness and loss of libido. Cognitive symptoms consists of 8 items. pessimism, past failures, feelings of guilt, punishment feelings, self dislike, self critical, feelings of worthlessness and retardation.

26 HOW TO USE AND SCORE BDI-II? It has 21 assessment criteria. Each criteria has 4 statements and a score of 0-3 is assigned for each statement. Eg: (0) I do not feel sad (1) I feel sad (2)I am sad all the time and can t snap out of it (3) I am so bad or unhappy that I can t stand it

27 Scoring of BDI-II The standard cut-off point are as follows: indicates a person is not depressed mild-moderate depression moderate-severe depression signifies severe depression The higher the score, the more severe the depression.

28 Strengths It has two subscales which help determine the primary cause of the depression. Its short and easy to use and subjective to clients own feelings. It is an instrument widely used in research and CBT. Sensitive to changes for use in monitoring and evaluation It has helped develop other self rating scale, eg: Beck Anxiety Inventory, Beck Hopelessness Scale, Beck Scale for Suicide Ideation. Available in many different languages

29 Weakness Score can be exaggerated or minimised by client. Concomitant physical illness can inflate the score rather than depression. Social expectation may elicit different response (e.g. postal survey) (Bowling, A.2005)

30 PHQ 9 Quick Depression Assessment Indication: all new patients in primary care also tested in clinical specialty areas Widely used - Adapted by England IAPT (IAPT, 2007) and commonly used in Primary Care Settings Self-administered tool Sensitive to change (Lowe et al, 2004)

31 GAD 7 This easy to use self-administered patient questionnaire is used as a screening tool and severity measure for generalised anxiety disorder. The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of not at all, several days, more than half the days, and nearly every day, respectively, and adding together the scores for the seven questions.

32 BAI Screen for anxiety with the Beck Anxiety Inventory (BAI ). Patients respond to 21 items rated on a scale from 0 to 3. Each item is descriptive of subjective, somatic, or panicrelated symptoms of anxiety. Screen Anxiety BAI has been found to discriminate well between anxious and nonanxious diagnostic groups in a variety of clinical populations.

33 Homework Recommend some reading Eg, CBT for dummies Information gathering Getselfhelp.co.uk

34 Taking it forward Think about one of your own fears and consider to what extent they are maintained by the way you think about them and behave in relation to them.

35 Cognitive behavioural strategies Two main methods Questioning unhelpful beliefs Devising behavioural tests

36 Cognitive behavioural strategies Two main methods Questioning unhelpful beliefs Devising behavioural tests

37 Types of question Evidence for questions Evidence against questions Alternative view questions consequences of questions

38 Guided discovery Principles : Ask a series of questions to uncover relevant information outside of the client s awareness Tease out : false assumptions, inconsistencies in belief, contradictory views Double standards Faulty conclusions Develop a way forward

39 Cognitive behavioural therapy Behavioural Experiments Involve testing predictions about physical, social or psychological danger or gathering information Focus is on belief change through experience Experiment must have a clear hypothesis from client, followed by a task that tests out that belief in an appropriate setting

40 What is a good Socratic question? The client has the ability to answer or work out an answer The answer reveals new perspectives

41 People are generally better persuaded by the reasons which they themselves discovered, than by those which have come into the minds of others. (Pascal 17 th Century French Philosopher)

42 Examples of socratic style questioning Exercise: Socrates in action Clinical application

43 References Branch R, Dryden W, 2008, The cognitive behaviour counselling Primer. Athenoeum Press, UK. Dryden W, 2001 Reason to change. Whurr. London Grant et al, 2008 Assessment and Case Formulation in Cognitive Behavioural Therapy. SAGE Publications. London. Westbrook et al, 2011 An introduction to CBT..Skills and applications. Sage. London Wills F, 2008 Skills In Cognitive Behaviour Counselling & Psychotherapy. Sage publications. London.