Case Formulation in Cognitive Behaviour Therapy: The Treatment of Challenging and Complex Cases [2 ed.] 0415741785, 9780415741781, 9780415741798, 9781315694191

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Case Formulation in Cognitive Behaviour Therapy

Since the successful first edition of Case Formulation in Cognitive Behaviour Therapy, there has been a proliferation of psychological research supporting the effectiveness of CBT for a range of disorders. Case formulation is the starting point for CBT treatment, and Case Formulation in Cognitive Behaviour Therapy is unique in both its focus upon formulation, and the scope and range of ideas and disorders it covers. With a range of expert contributions, this substantially updated second edition of the book includes chapters addressing the evidence base and rationale for using a formulation-driven approach in CBT; disorderspecific formulation models; the formulation process amongst populations with varying needs; formulation in supervision and with staff groups. New to the book are chapters that discuss: Formulation amongst populations with physical health difficulties Formulation approaches to suicidal behaviour Formulation with staff groups Case Formulation in Cognitive Behaviour Therapy will be an indispensable guide for experienced therapists and clinical psychologists and counsellors seeking to continue their professional development and aiming to update their knowledge with the latest developments in CBT formulation. Nicholas Tarrier has held academic appointments in Brazil and Australia and worked as a clinical psychologist in the NHS. From 1991 to 2011 he was Professor of Clinical Psychology at the University of Manchester and at the Institute of Psychiatry, King’s College London from 2011 to 2014. His main research interests have been in investigating psychosocial environments in the development of mental disorders and the development and evaluation of cognitive-behavioural and family interventions. He is now retired. Judith Johnson is a Clinical Psychologist and Lecturer at the University of Leeds and the Bradford Institute of Health Research. Her research is focused upon understanding and supporting the development of wellbeing and resilience, and how this can be applied in healthcare settings to improve interventions and service delivery.

‘Cognitive behavior therapists are scientist practitioners whose work is informed by advances in theory and research, and guided by an understanding of the unique problems and circumstances of each person they treat. Case formulation is a powerful tool for systematically identifying critical factors leading to and maintaining maladaptive functioning, and then developing, evaluating, and modifying treatment plans until the desired goals have been achieved. This second edition of Case Formulation in CBT is a treasure trove for any practicing clinician. The book includes useful introductory material on contemporary approaches to case formulation, specific chapters delving into a broad range of behavioral health problems replete with case examples, applications in non-clinical populations (such as carers and asylum seekers), and supervision. This book fills a critical gap in the need for clinicians to stay abreast with the latest advances in developing state-of-the-art case formulations essential to effective clinical practice.’ –Kim T. Mueser, PhD, Executive Director, Center for Psychiatric Rehabilitation, Professor of Occupational Therapy, Psychology and Psychiatry, Boston University ‘This authoritative edited book places the individual client squarely front and centre in formulating that person’s mental health problems and consequently in planning appropriate treatment. It presents a clear and superior alternative to the simple dissemination of treatments in the absence of formulation of the individual’s problems. I highly recommend this important book to all mental health practitioners.’ –Henry Jackson, Emeritus Professor of Clinical Psychology, University of Melbourne, Australia ‘Treatment tailoring has entered our vocabulary relatively recently and we have endorsed it but without the evidence base. This book fills this space and provides an understanding of why personalisation is vital not just for successful treatment but because it is valued by the individuals who use mental health services. Case formulation is one way of building the therapeutic collaboration essential for any therapy and also makes the therapeutic targets more focussed for both the therapist and the client. This book provides a step by step guide and evidence for benefits of specific techniques across disorders giving both clinicians and academics access to valuable information – all in one place.’ –Til Wykes, Vice Dean Psychology and System Sciences, Professor of Clinical Psychology and Rehabilitation, Co-Director Service User Research Enterprise, Institute of Psychiatry, King’s College London, UK ‘Excellence in clinical practice requires in equal parts attention to nomothetic issues, or how the individual patient resembles others generally in such broad areas as diagnostic categories or treatment response, and idiographic issues, or what is unique about the individual patient. In this age of treatment manuals it is this latter area that is most often neglected, and yet it is crucially important since clinicians see individuals and not large groups in most settings. In this excellent book, now in its second edition, idiographic case formulation is highlighted by expert clinicians from the UK and the USA. Clinical training and clinical practice cannot be complete without this perspective and all clinicians should be familiar with this excellent resource.’ –David H. Barlow, PhD, ABPP, Professor of Psychology and Psychiatry, Boston University, Founder and Director Emeritus, Center for Anxiety and Related Disorders, Boston, USA

Case Formulation in Cognitive Behaviour Therapy

The treatment of challenging and complex cases Second Edition

Edited by Nicholas Tarrier and Judith Johnson

Second edition published 2016 by Routledge 27 Church Road, Hove, East Sussex, BN3 2FA And by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2016 Nicholas Tarrier and Judith Johnson The right of Nicholas Tarrier and Judith Johnson to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2006 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Case formulation in cognitive behaviour therapy : the treatment of challenging  and complex cases / edited by Nicholas Tarrier and Judith Johnson. — Second edition.   pages cm   1.  Cognitive therapy.  2.  Cognitive therapy—Case studies.  I. Tarrier, Nicholas.  II.  Johnson, Judith, 1955–   RC489.C63.C33 2015  616.89'1425—dc23  2015004173 ISBN: 978-0-415-74178-1 (hbk) ISBN: 978-0-415-74179-8 (pbk) ISBN: 978-1-315-69419-1 (ebk) Typeset in Times by Apex CoVantage, LLC

Contents

List of figures and tables Contributors Preface  1. Introduction

vii xi xvii 1

NICHOLAS TARRIER AND JUDITH JOHNSON

  2. Case formulation and the outcome of cognitive behaviour therapy

14

JACQUELINE B. PERSONS AND JANIE J. HONG

  3. Formulation from the perspective of contextualism

38

HELEN COMBES AND CHRIS CULLEN

  4. A biopsychosocial and evolutionary approach to formulation

52

PAUL GILBERT

  5. Cognitive and metacognitive therapy case formulation in anxiety disorders 90 ADRIAN WELLS

  6. Cognitive behavioural case formulation for complex and recurrent depression 119 ANNE GARLAND

  7. Case conceptualisation in complex PTSD: Integrating theory with practice 143 DEBORAH LEE

vi  Contents

  8. A cognitive behavioural case formulation approach to the treatment of psychosis

166

SANDRA BUCCI AND NICHOLAS TARRIER

  9. Cognitive behavioural case formulation in bipolar disorder

188

ELIZABETH TYLER AND STEVEN JONES

10. Cognitive behavioural formulation for personality problems

219

HENCK VAN BILSEN AND SIMONE LINDSEY

11. Cognitive behavioural case formulation in complex eating disorder

239

HELEN STARTUP, VICTORIA MOUNTFORD, ANNA LAVENDER AND ULRIKE SCHMIDT

12. Case formulation in suicidal behaviour

265

DANIEL PRATT, PATRICIA GOODING, JAMES KELLY, JUDITH JOHNSON AND NICHOLAS TARRIER

13. Physical health problems: A framework and checklist for case formulation

284

CRAIG A. WHITE

14. Formulating collaboratively with carers

304

KATHERINE BERRY AND FIONA LOBBAN

15. Working with people seeking asylum

322

JAKE BOWLEY AND COLSOM BASHIR

16. Clinical supervision

352

HELEN BEINART AND SUE CLOHESSY

Index

371

Figures and tables

Figures 1.1  The dysfunctional system approach to case formulation 1.2  Systemic destabilisation as a result of stress and vulnerability 2.1 Case formulation-driven cognitive behaviour therapy (Copyright © Jacqueline B. Persons) 3.1 Psychological inflexibility 3.2 Psychological flexibility (adapted from Smith & Hayes, 2005) 4.1 Three types of affect regulation system (from Gilbert, The Compassionate Mind, 2009, reprinted with permission from Constable & Robinson Ltd.) 4.2  Biopsychosocial and ecological interactions 5.1 General schema model of anxiety disorders (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.) 5.2 Cognitive model of panic (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.) 5.3  An idiosyncratic panic formulation 5.4 Cognitive model of social phobia (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.) 5.5  An idiosyncratic social phobia formulation 5.6 Metacognitive model of OCD (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.) 5.7 An idiosyncratic OCD formulation 5.8 Metacognitive model of GAD (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.) 5.9  An idiosyncratic GAD formulation

7 9 15 44 44 64 75 91 95 99 100 103 106 109 110 113

viii  Figures and tables

6.1  Maintenance formulation of chronic and recurrent depression 6.2 Clinical example of the maintenance cycle of Jane’s depression 7.1  Phased-based approach for treating complex PTSD 7.2  Case formulation of PTSD 7.3  Amy’s case formulation of PTSD 7.4  Amy’s hotspot update chart 7.5 Case formulation in Complex PTSD using an Ehlers & Clarke model of persistent PTSD 8.1  A clinical model in the CBT treatment of psychosis 8.2  The experience–belief–action–confirmation (EBAC) cycle 9.1  Vulnerability-stress model (following Lam et al., 2010) 9.2  An instability heuristic for understanding bipolar disorder 9.3  Initial life chart for Laura showing self-rated mood over time 9.4a Formulation for Laura based on the Lam et al. (2010) vulnerability-stress model 9.4b  Formulation for Laura with positive coping example 9.5  Idiosyncratic mood monitoring and early warning signs 9.6  Example activity and mood record for Bill 9.7  Early warning signs and coping strategies for Laura 10.1 Generic linear formulation (from Beck, 1976) with maintenance cycle 12.1 A clinical heuristic for the Schematic Appraisal Model of Suicide (following Johnson et al., 2008) 12.2  Formulation for Steve 13.1 The relationship among acute medical situations, automatic thoughts and subsequent emotional, behavioural, or physiological reactions (Levin et al., 2013a, reproduced with permission) 13.2 The cognitive conceptualisation diagram for acute medical settings (adapted from Levin et al., 2013a with permission) 13.3  Sample cognitive conceptualisation diagram 14.1  Diagrammatic formulation 15.1 Overview of the asylum process (adapted with permission: Hermione McEwen, Freedom from Torture Training Materials North West Centre 2012, reviewed May 2014) 15.2  Top ten asylum applicant–producing countries – first quarter 2013 16.1 Quality of the SR: Supervisors’ perspectives (© Copyright Sue Clohessy) 16.2  Resolving problems in the SR

122 133 154 155 158 159 161 174 175 191 192 199 200 201 204 206 210 231 269 280 287 293 294 313 324 325 355 363

Figures and tables  ix

Tables 4.1  A brief guide to social mentalities 4.2  The case of Sally 5.1 Key diagnostic features (DSM-IV), cognitive and metacognitive themes in four anxiety disorders 8.1  Treatment aims and methods in different phases of psychosis 8.2 Aspects of psychosis that need to be assessed and possibly taken into consideration in CBT for psychosis 8.3 Semi-structured interviews and self-report measures to assess psychotic symptoms 10.1  Functional analysis 11.1  Jodie’s cognitive behavioural formulation 11.2  Morag’s cognitive behavioural formulation 11.3  Maya’s cognitive behavioural formulation 13.1 Cognitive behavioural therapy in physical health – conceptualisation checklist 14.1  Cognitive interpersonal model of shared case formulation 15.1  Key tasks during engagement 15.2  Key tasks during assessment 15.3  Tasks for psycho-education 15.4  Possible tasks during the intervention phase

58 80 92 167 168 176 229 254 257 259 300 308 336 339 341 343

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Contributors

Dr Colsom Bashir qualified as a chartered clinical psychologist following a career in the community and charitable sector. She has worked with refugees and people seeking asylum since 2006 as a psychologist. She was employed by Freedom from Torture North West (2012–14) to work with children and families who were refugees or seeking asylum and has written a number of expert witness reports. She is also currently working in physical health. Dr Helen Beinart was Director (Clinical and Professional) of the Oxford Institute of Clinical Psychology Training until October 2013. She is affiliated with the University of Oxford and Oxford Health NHS Foundation Trust, and works freelance in the field of clinical supervision. Clinically, she has worked with children, young people and their families in health and primary care settings. Over the past 20 years, she has been involved in clinical psychology training, supervisor training and research into the supervisory relationship. She is the author of numerous chapters and papers on supervision and the supervisory relationship. Dr Katherine Berry is an NIHR-funded senior research fellow and clinical psychologist who is based at the University of Manchester. Her main area of expertise is interpersonal relationships in people with a diagnosis of psychosis. After completing her PhD exploring the relevance of attachment theory in psychosis, she obtained a fellowship to develop and evaluate an intervention to improve staff–patient relationships in inpatient settings. Dr Jake Bowley is a consultant clinical psychologist who qualified in clinical psychology and trained in cognitive behaviour therapy at the University of Manchester. He worked with refugees and asylum seekers for 10 years in both the NHS and voluntary sectors. He is currently the lead for secondary care psychology in Jersey. Dr Sandra Bucci is a clinical psychologist who trained and qualified in Australia before moving to the UK in 2007. She has worked in the area of psychosis, in either a clinical or research capacity, for 15 years. She is currently a Lecturer in the School of Psychological Sciences at the University of Manchester and

xii  Contributors

her main area of research focuses on developing interventions for psychosis, including increasing access to healthcare using innovative methods of intervention delivery, and understanding the mechanisms of voice-hearing. In addition to her academic position, she is a a clinical psychologist at the complex cases team in Manchester Mental Health and Social Care Trust (MMHSCT) and works with a range of service users with complex mental health problems. Dr Sue Clohessy is Course Director of the PGCert in Supervision of Applied Psychological Practice, Clinical Tutor and the lead for supervisor training at the Oxford Institute of Clinical Psychology Training. She is affiliated with the University of Oxford and Oxford Health NHS Foundation Trust, and works clinically with adults with mental health problems. She is an accredited cognitive and behavioural psychotherapist and supervisor, with over 19 years’ experience. She is an experienced trainer and has researched and published chapters and papers on supervision. Dr Helen Combes is Principal Clinical Lecturer on the Staffordshire and Keele University Doctorate in Clinical Psychology. She is a registered clinical psychologist and BABCP accredited therapist and works with people with a range of psychological problems, and has had a long-term interest in relational frame theory and its therapeutic application through acceptance and commitment therapy. Prof. Chris Cullen is the Emeritus Professor of Clinical Psychology at Keele University. In 2012 he was awarded a Lifetime Achievement Award by the British Psychological Society, and in 2013 he was made an Honorary Fellow of the British Association for Cognitive and Behavioural Psychotherapies. Anne Garland (BA Hons, RMN, ENB 650, MSc) is employed as a Consultant Nurse in Psychological Therapies in Nottinghamshire Healthcare NHS Foundation Trust. She is clinical lead for the Trust’s Specialist Depression Service for people who suffer with chronic, recurrent and treatment-resistant depression which she helped establish. Anne has extensive clinical experience of using cognitive therapy to treat depression. She is recognised as a clinical academic who is involved in research and training in this area, and who has published widely in the field. Prof. Paul Gilbert FBPsS, PhD, OBE is Professor of Clinical Psychology at the University of Derby and Consultant Clinical Psychologist at the Derbyshire Healthcare NHS Foundation Trust. He has researched evolutionary approaches to psychopathology for over 35 years with a special focus on shame and the treatment of shame-based difficulties – for which compassion focused therapy was developed. In 2003 he was president of the BABCP and a member of the first British Government’s NICE depression guidelines for depression. He has written/edited 20 books and over 150 papers. In 2006 he established the Compassionate Mind Foundation charity with the mission statement ‘To promote

Contributors  xiii

wellbeing through the scientific understanding and application of compassion’ (www.compassionatemind.co.uk). He was awarded an OBE in March 2011. Dr Patricia Gooding is a Senior Lecturer at the University of Manchester. Her research focuses on understanding the psychological mechanisms that lead to suicidal thoughts and behaviours, and also on understanding the psychological mechanisms that confer resilience to suicidality. Dr Janie J. Hong is a partner at the Cognitive Behavior Therapy and Science Center in Oakland, California, and an Assistant Clinical Professor in the Department of Psychology at the University of California, Berkeley. Her research and clinical interests include identifying and targeting mechanisms underpinning patient problems, and developing culturally sensitive approaches to treatment. Dr Judith Johnson is a Clinical Psychologist and Lecturer at the University of Leeds and the Bradford Institute of Health Research. She graduated with a first class honours degree in Psychology from the University of Manchester in 2007, before completing a PhD in Clinical Psychology at the University of Manchester in 2010, and a Clinical Psychology Doctorate (ClinPsyD) at the University of Birmingham in 2013. Her research is focused upon understanding and supporting the development of wellbeing and resilience, and how this can be applied in healthcare settings to improve treatments and service delivery. Prof. Steven Jones is Professor of Psychology and Co-Director of the Spectrum Centre for Mental Health Research at Lancaster University. He is a qualified clinical psychologist with a particular focus on the psychology and psychological treatment of bipolar disorder. Over the last five to six years he has been particularly involved in the development and evaluation of recovery-informed interventions for people living with bipolar disorder delivered across a range of formats. Dr James Kelly is a Senior Clinical Psychologist working at Lancashire Care NHS Foundation Trust within the Early Intervention Service. He has published on the use of mobile phone technology to scaffold the delivery of cognitive behavioural suicide prevention therapy in real-world settings. He has an interest in suicide prevention, cognitive therapy for psychosis and compassion focused therapy. Dr Anna Lavender (BA, MSc, DClin Psy) is a Clinical Psychologist in the South London and Maudsley NHS Foundation Trust, and worked within the Eating Disorders Service within the Trust for 9 years. She now specialises in schema therapy for individuals with personality disorders, and is currently Primary Investigator for the UK in a trial investigating the efficacy of group schema therapy for borderline personality disorder.

xiv  Contributors

Dr Deborah Lee is a Consultant Clinical Psychologist, Head of Berkshire Traumatic Stress Service and South Central Veterans Service. She is also an honorary Senior Lecturer at University College London. She is a board member of the Compassionate Mind Foundation and author of The Compassionate Mind Approach to Recovering from Trauma, Using Compassion Focused Therapy. Dr Lee has worked in the field of trauma for 20 years and specialises in the treatment of PTSD and complex trauma. Her particular area of clinical and research interest is in shame-based PTSD and self-criticism. She has developed the use of compassion-based treatments including the use of compassionate imagery in shame-based flashbacks to enhance clinical practice in this field. She has pioneered the use of developing compassionate resilience as part of a phased-based treatment approach to complex PTSD. She has widely contributed to the dissemination of her clinical knowledge through writing and delivering clinical workshops and talks in North America and Europe. Simone Lindsey graduated from Loughborough University in 2008 with a degree in Social Psychology. Since that time Simone has worked in forensic and secure inpatient services for adults with a diagnosis of mental health difficulties and personality disorder. Simone is an accredited cognitive behavioural therapist and is currently completing a Doctorate in Clinical Psychology at the University of Essex. Prof. Fiona Lobban is Professor of Clinical Psychology at Lancaster University. She is Co-Director of the Spectrum Centre for Mental Health Research and her interest is in increasing access to psychosocial interventions for people with mental health problems and their family and friends. Dr Victoria Mountford is Principal Clinical Psychologist at the Eating Disorders Service, South London and Maudsley NHS Foundation Trust. She has specialised in working with individuals with eating disorders for many years and co-authored leading clinician guides and self-help texts. Her research interests include treatments for eating disorders, particularly CBT, and body image. She has taught widely on the subject of eating disorders. Prof. Jacqueline B. Persons is Director of the Cognitive Behavior Therapy and Science Center in Oakland, California, and Clinical Professor in the Department of Psychology at the University of California, Berkeley. She has made important contributions to the development of the case formulation in cognitive behaviour therapy, and she is also particularly interested in the process and outcome of cognitive behaviour therapy for mood and anxiety disorders in real-world clinical practice. Dr Daniel Pratt is a Lecturer in Clinical Psychology at the University of Manchester and a Clinical Psychologist for Manchester Mental Health and Social Care Trust. For the past 10 years, he has conducted research investigating

Contributors  xv

psychological models and interventions to prevent suicidal behaviour. Dr Pratt has recently completed a feasibility trial of a psychological therapy for suicidal prisoners. Prof. Ulrike Schmidt, MD, PhD, FRCPsych, is Professor of Eating Disorders and Head of the Section of Eating Disorders, King’s College London, UK, and a Consultant Psychiatrist in the South London and Maudsley NHS Foundation Trust. Until recently she chaired the Section of Eating Disorders at the Royal College of Psychiatrists. She took part in developing the NICE guidelines on eating disorders. Her research interests cover all aspects of eating disorders, but in particular the development of new treatments, including talking therapies, self-care treatments, treatments using new technologies and a range of novel brain-directed treatments. She is principal investigator of an NIHR programme grant on new treatments of anorexia nervosa. Dr Helen Startup is a clinical psychologist working for the South London and Maudsley (SLAM) Eating Disorders Service. She has been involved in research exploring mechanisms responsible for the maintenance of eating disorders (EDs) and the evaluation of suitable interventions for complex ED presentations. She also works as a clinical psychologist for Lambeth Integrated Psychological Team (SLAM) and is one of the lead researchers exploring the application of a group schema therapy intervention for those with borderline personality disorder. She is a clinical research fellow and consultant clinical psychologist for Sussex Partnership NHS Foundation Trust where she is joint theme lead for research into personality disorders. In collaboration with colleagues at the Department of Psychiatry, University of Oxford, she has also contributed to research exploring the value of brief (six sessions or less) treatments for individuals with persecutory delusions. She is an accredited CBT therapist and advanced-level schema therapist. Prof. Nicholas Tarrier completed a first class honours degree from the University of Nottingham in 1972 and an MSc in Experimental Psychology from the University of Sussex in 1973, and a PhD from the University of London, Institute of Psychiatry in 1977. He was then Professor of Psychology at the UFPb in Brazil for two years before completing his professional training in clinical psychology at the University of Manchester in 1981. He then worked as a clinical psychologist in the NHS in Salford until 1989, after which he was senior lecturer in clinical psychology at the University of Sydney, Australia. In 1991 he was appointed Professor and Head of Clinical Psychology at the University of Manchester and Consultant Clinical Psychologist in the NHS. In March 2011, he became Professor of Clinical Psychology and eMental Health at the Institute of Psychiatry, Kings College London. He retired in November 2014. He was awarded The MB Shapiro Lecture award of the Division of Clinical

xvi  Contributors

Psychology, British Psychological Society in 2007, a Trail Blazer award from the US Association for Behavioral and Cognitive Therapies in 2008 and Senior Investigator award from the National Institute for Health Research (NHS) in 2008–2013. Dr Elizabeth Tyler is a National Institute for Health Research (NIHR) fellow based at the Spectrum Centre for Mental Health Research. Elizabeth is a qualified clinical psychologist with a particular interest in working with individuals with bipolar disorder. Elizabeth’s main research interests focus on developing evidence-based interventions for individuals who have previously found it difficult to access psychological care. Henck van Bilsen is a consultant clinical psychologist and accredited cognitive behaviour therapist based at St Andrew’s in Essex. Henck specialises in complex and long-standing problems. In 2004, Henck celebrated his 25th anniversary as a clinical psychologist, having initially trained in the Netherlands. Henck is currently Head of Programmes and Psychology at St Andrew’s as well as a Visiting Teaching Fellow on the MSc in CBT course at Bucks New University. Prof. Adrian Wells, PhD, is currently Professor of Clinical and Experimental Psychopathology at the University of Manchester and Honorary Consultant Clinical Psychologist with Manchester Mental Health and Social Care Trust. He holds a Professor II appointment at the Department of Psychology at NTNU, Trondheim, Norway. Prof. Craig A. White is Divisional Clinical Lead in the Quality and Planning Division of the Quality Unit, Health and Social Care Directorates, at the Scottish Government. He trained as a clinical and health psychologist and before moving to the Scottish Government worked within the NHS in Scotland in a range of clinical lead and senior management roles. Craig has doctoral degrees from the Universities of Manchester and Glasgow and completed ­post-qualification training in cognitive psychotherapy at the University of Durham. He is a Founding Fellow of the Academy of Cognitive Therapy, a Fellow of the British Psychological Society and a Fellow of the Royal College of Physicians of Edinburgh.

Preface

We are delighted to have the opportunity to edit a second volume on case formulation in cognitive behaviour therapy (CBT), building on the success of the first edition published in 2006. Since the publication of the first edition, CBT has continued to expand on both the national and international stage with a greater variety of clinical problems being addressed along with advances in knowledge and skills, so that an ever greater population of people both in the UK and abroad have access to effective and evidence-based psychological treatments. This is to be applauded, as is the recognition of CBT at government and policy levels as an efficacious and cost-effective method of treating psychological problems and disorders. Since 2006, the field of CBT has advanced and we have asked our contributors to reflect these advances in their updated chapters. The updated edition includes chapters reflecting increasingly important issues in clinical psychology, in particular, formulation in populations with physical health problems, formulation with staff teams and carers and how to formulate in supervision. Unavoidably, some, although remarkably few, authors from the first edition have been unavailable to contribute to this update. However, we are delighted with the strong team of contributors in this second edition, and confident that this volume will further advance the field and serve as a guide and resource to clinicians and researchers now and in the future. Lastly, we would like to extend a heartfelt thanks to our contributors who, through their hard work and dedication, have given themselves and their knowledge and skills to the readers. Nicholas Tarrier and Judith Johnson August 2014

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Chapter 1

Introduction Nicholas Tarrier and Judith Johnson

In introducing this second volume on case formulation we thought it worthwhile to revisit some of the stages in the development of case formulation and review and update some of the issues that have been raised. As with all aspects of clinical practice, the process of case formulation – working towards a psychological explanation of a client’s problem – is not static. There remain numerous challenges and no doubt further challenges will arise in the future. To stop and reflect on these issues and the challenges they impose is helpful both to the individual clinician and to the clinical researcher. This is especially true with increasing changes in clinical services brought about by prevailing economic conditions and the accelerating development of new technologies. These factors potentially change the environments within which cognitive behaviour therapy (CBT) is delivered and hence in which case formulation is practiced. The Boulder model of training in clinical psychology enshrined the concept of the scientific practitioner in both the training of clinical psychologists and in the practice of psychological treatment. The historical importance of this cannot be overestimated. This represented a new paradigm in psychological practice in general and in psychological treatment in particular. The scientific practitioner established the idea that psychological knowledge can be applied to clinical problems and that this should be done in a manner in accordance with scientific methodology and convention. This has many implications, but two are important here. First, psychological treatments are evaluated and adopted based upon the results of empirical evaluation. This has now been subsumed into the wider paradigm of evidence-based practice or evidence-based health care (see, for example, Sackett, 1998). The second implication is that a psychological understanding of clinical problems is adopted to underpin psychological intervention. A seminal paper published in 1965 by Kanfer and Saslow further advanced this endeavour by proposing a psychological alternative, behavioural analysis, to the then-dominant medical conceptualisation of mental health problems. Kanfer and Saslow’s (1965) paper can really be thought of as the natural precursor to case formulation, which represented a second paradigm shift. It is interesting to look in a little more detail at what Kanfer and Saslow proposed. They dismiss psychiatric diagnosis as being limited by issues of precision, consistency,

2  Nicholas Tarrier and Judith Johnson

reliability and validity to ‘a crude and tentative approximation to a taxonomy of effective individual behaviours’ (1965: 529). Some may well argue that this situation has not radically altered over the past 40 years. Kanfer and Saslow also outlined the criticisms, current at the time, of the medical model in psychiatry with which the contemporary reader will no doubt be familiar. Their main point remains pertinent: given the wide range of variability in an individual’s circumstances and condition and the largely unknown aetiology of most psychiatric disorders, does a reduction to a crude taxonomic classification help or hinder treatment? They progressed to outline an alternative model of understanding clinical problems based upon learning theory in the form of a functional behavioural-analytic approach. This is encapsulated by: It [functional analysis] implies that additional information about the circumstances of the patient’s life pattern, relationships among his behaviours, and controlling stimuli in his social milieu and his private experience is obtained continuously until it proves sufficient to effect a noticeable change in the patient’s behaviour, thus resolving ‘the problem’. (Kanfer and Saslow, 1965: 533) Interestingly, although their model is couched in learning-theory terms, they anticipated the cognitive revolution that was to follow by including the necessity to assess subjective experience. They suggested that the clinician should collect and organise information from a number of areas: analysis of a problem situation, classification of the problem situation, motivational analysis (reinforcers), developmental analysis (including ‘biological equipment’ and ‘socio-cultural experience’), analysis of self-control, analysis of social relationships and analysis of the social-cultural-physical environment. The formulation, and Kanfer and Saslow used this term, is ‘action oriented’ (535) in that the problem is defined in operational terms so as to specify a feasible treatment option. Although written over 40 years ago there is much within this paper, both in terms of the inadequacies of psychiatric diagnosis and alternative conceptualisation of clinical problems, that modern-day cognitive behaviour therapists and clinical psychologists would find very familiar. One of the problems that this new individualised approach unveiled was how to know whether an individualised formulation of a particular person’s problem is correct and parsimonious: that is, is it true in a broad sense of the word and does it have functional value – is it clinically useful? That a formulation can be incorrect would also imply that there would be ways, potentially identifiable, by which a formulation could go wrong or deviate from accuracy. However, it may be difficult to discriminate a ‘right’ from a ‘wrong’ answer when the formulation pertains only to one individual. The nature and types of error that may contaminate clinical decision-making may include availability heuristic, representative heuristic, anchoring heuristic, biased search strategies, overconfidence and hindsight bias (Nezu and Nezu, 1989a). By this, Nezu and Nezu meant that a clinician

Introduction  3

may be subject to a number of sources of bias such as being overly influenced by recent clinical experience, being too quick to categorise or reach a conclusion on insufficient information and, without the flexibility to adjust or modify those conclusions, selectively attending to types or aspects of information and further searching for information based upon a confirmatory bias and being unable to react to new information in a way that increases accuracy and precision rather than confirms initial impressions. There is a tendency to look back retrospectively on a case with confirmatory zeal. Unfortunately, although perhaps not surprisingly, clinicians and therapists appear to be subject to all the information-processing distortions that they try to assess and rectify in their clients. The area of clinical judgement and decision making is clearly one that requires further research and clinicians would benefit from reflection upon it. A consideration of alternative explanations, a wider viewpoint and a further appraisal of possible options would perhaps benefit clinical practice. A related difficulty identified by Nezu and Nezu (1989a: 29) is how and when to select the appropriate treatment techniques from the array available. This problem is also pivotal to the work of other writers on case formulation (for example, Bruch, 1998; Persons, 1989; Turkat, 1985) and in my experience it is often the issue that trainees and students find one of the most difficult. Nezu and Nezu (1989a) rightly say that because individual formulations take into account a large array of unique characteristics across a variety of person and environmental variables it is very difficult to know how to select the most effective treatment strategy. Nezu and Nezu (1989b: 57) advocate a problem-solving approach to clinical decision-making which consists of problem orientation, problem definition and formulation, generation of alternatives, decision-making and solution implementation and verification. They also make the useful distinction between treatment strategy, tactics and methods. Treatment strategies are linked to each identified problem and provide a general approach to how that problem will be resolved, such as decreasing negative cognitive biases and self-defeating thoughts in someone with a depressed mood. Each treatment strategy should have a list of specific treatment tactics which indicate how the strategy will be achieved. For example, in the strategic example given the tactics might include monitoring automatic thoughts, investigation of the cognitive processes and identification of bias, examination of supporting evidence, generation of alternative interpretations of events, behavioural experiments to test out various expectations and so on. Nezu and Nezu (1989b) also introduce the idea of different treatment methods: they mean different ways in which tactical treatment techniques might be implemented. For example, a behavioural experiment to test out a biased interpretation of events may well be applied differently if the client is a depressed adolescent male of 14, rather than a depressed middle-aged woman with a family, or a 28-year-old man with a psychotic illness who is also depressed. The overall approach is that the formulation is a way of generating testable hypotheses about the clinical case; these hypotheses are tested through the application of treatment, and whether the formulation is functional or not will depend on the consequences – whether the

4  Nicholas Tarrier and Judith Johnson

problem is resolved. Case formulation is thus the translation of theory into therapy, but it is the function of all theories to be disproved if possible. The clinician should create explanatory structures or heuristics for understanding the client’s problems but proceed with caution not to muster evidence selectively only in their support but to examine critically why their heuristic and hypotheses may be incorrect and can be shown to be so. It is this refinement of testable hypotheses upon which treatment strategies are based that prevents cognitive behaviour therapy from becoming a mere cookbook of clinical techniques. A further ongoing issue has been whether it is possible to abandon psychiatric classification altogether or replace it with an alternative, psychologically based system of taxonomy. This has been of mixed success. One of the advantages of a classificatory system is that it lumps together clinical problems on the basis of their shared characteristics which aids research and provides a starting point for case formulation. As a method of providing a shorthand for communication it has its advantages but also brings with it the baggage of psychiatric diagnosis and by implication the medical model. Currently we have tended to stick with the extant classification as a method of organisation, largely because this is the world in which we find ourselves and because as of yet there has not arisen a viable behavioural alternative. This does not suggest that case formulation is less than an individualised approach but more that it will be carried out within an existing classificatory system which provides that shorthand. Although Kanfer and Saslow (1965) anticipated the importance of personal and subjective experience, the inclusion of this into clinical formulation and treatment following the ‘cognitive revolution’ introduced further challenges. The greater interest in unobservable cognitive products and processes rather than observable behaviour undoubtedly increased the availability of clinically powerful techniques but it also increased the possibility of biases in formulation, as described by Nezu and Nezu (1989a, 1989b). In some ways the concept of disease, rejected along with the psychiatric medical model, was in danger of being replaced by explanatory concepts such as dysfunctional assumptions, schema and similar, that could be equally diffuse (Tarrier and Calam, 2002). Persons (1989) usefully made the distinction between ‘overt difficulties’, which were the client’s ‘real life’ difficulties, and the ‘underlying psychological mechanisms’, which were the putative psychological dysfunctions which underpin the client’s overt difficulties. The overt difficulties could be described at the macro or micro levels. These distinctions not only referred to quantifiable levels of analysis, where the macro level was an overall description and the micro level was a much more detailed description of the problem, but also referred at the macro level to how the problems ‘might be described in the patient’s own terms’ (Persons, 1989: 2). The micro level includes a breakdown into the three components of cognition, behaviour and moods (emotion or affect), and includes concepts such as synchrony – the positive correlation between these three components (or lack of it as in desynchrony) – and interdependence, where a change in one component will bring about a change in the others. So not only do the macro and micro levels involve a difference in the

Introduction  5

level of description and detail; they also imply a difference in explanation. The client’s subjective description and most probably explanation or representation is characterised by the overall descriptor at the macro level, for example being depressed, anxious, having relationship problems and so on. The psychologist or clinician’s view is characterised by the more detailed micro level. A number of implications arise from this: to be effective the process of case formulation should be collaborative and not imposed, and it needs to take into account and accommodate the client’s views and beliefs about their problem. In health psychology this is known as illness representation, which is a set of complex beliefs about the origin, nature, severity, course and progress, prognosis and potential and appropriate and acceptable treatments of the client’s condition (see, for example, Leventhal et al., 1997). It seems safe to assume that anyone seeking the services of a cognitive behaviour therapist or psychologist will have similar representations or beliefs about their condition. These beliefs may be well worked out or rudimentary, and they may be held with strong conviction or be more tentative, but they do need to be assessed so that the client collaborates in the process of arriving at a case formulation. This is encapsulated in a quote from Persons (1989: 24): ‘[A] failure to agree on the problem list dooms the treatment.’ Persons gives an excellent example of this. She describes a client, after six months of unsuccessful treatment, declaring that she did not really consider that an inability to leave the house was her major problem, which instead she construed as the fact that ‘she was fragile and delicate and that she needed to stay home and rest’ (63–65). It would appear that the client’s definition of her problem was different from the therapist’s and her cognitive (illness) representation and beliefs were also contrary. Part of the case formulation should be a thorough understanding of the client’s beliefs, understanding and expectations about his/her condition and what has lead them to consultation and treatment and into the health care system. Persons’s 1989 book, Cognitive Therapy in Practice: A Case Formulation Approach, provided one of the first guidebooks on case formulation and had an immense impact in terms of formalising the procedure and in particular incorporating psychological and cognitive mechanisms. It became the natural successor to Kanfer and Saslow’s (1965) paper on behaviour analysis. Persons described the process of case formulation as having six parts: (a) creating the problem list; (b) describing the proposed underlying mechanisms; (c) accounting for the way in which the proposed mechanisms produce the problems on the problem list; (d) identifying the precipitants of current problems; (e) identifying the origins of the mechanism in the client’s early life and (f) predicting obstacles to treatment based on the formulation. Central to Persons’ process of case formulation is describing and understanding the underlying psychological mechanisms; these are in the main cognitive and information-processing factors although due attention is paid to the antecedents and consequences of any problem. Persons addresses the problem that these mechanisms are not frequently open to observation and run the potential risk of becoming causal fictions by suggesting a number of tests to which the hypothesised underlying mechanism can be subjected. The first test

6  Nicholas Tarrier and Judith Johnson

relates to how well the mechanisms account for the identified problems. This is a good criterion because a logical, comprehensive and above all parsimonious explanation has very clear advantages. Further, the formulation should easily be able to accommodate and be in accord with aspects of the client’s report, such as events associated with the onset of the problem or episode. The formulation, as an explanation, should generate specific hypotheses which when tested will support or refute the explanation. The sign of a robust formulation is that it can survive the rigours of such tests. Furthermore, the outcome of treatment based upon the formulation can also be viewed as hypothesis testing and thus there is a pragmatic test of the formulation which, if correct, should result in a good response to treatment. Persons also includes the client’s reaction to the formulation as a final test; if the formulation makes sense to the client then it has at least some validity. The formulation, in common with any hypothesis put to an experimental test, can be refined, modified or even abandoned. All advocates of case formulation agree that the testable nature of the formulation is an essential characteristic (e.g. Bruch and Bond, 1998; Persons, 1989; Tarrier and Calam, 2002), and that this should be embarked upon in a collaborative manner. There are also ethical reasons why the formulation should be shared with the client, in that they have the right to know how the therapist has formulated their problem and intends to treat it (Turkat, 1990: 12). It is very difficult to understand how without this shared information and collaborative approach the client could give informed consent to be assessed and treated. It is the collaborative nature of this activity that should help forge engagement. However, whether this is so is an empirical question and there is some evidence to suggest that, in some patient groups, it might not always be the case. Chadwick et al. (2003), in a study of case formulation as part of cognitive behaviour therapy in the treatment of psychosis, found that although the formulation strengthened the therapeutic alliance as perceived by the therapist, it did not have the same effect from the client’s viewpoint. Although a good proportion viewed the case formulation as helpful and beneficial, nearly half of what was admittedly a small sample also made negative comments. These related to a concern about the magnitude and longstanding nature of their problems, which seemed to elicit a sense of pessimism. It is worth noting that four of the six clients who made negative comments also made positive comments. This effect may have been specific to clients with chronic psychotic disorders but it may also indicate that an excessive concentration on the childhood origins of problems, which the clients indicated had occurred, is neither parsimonious nor functional. This raises a further point about the function of case formulation: it must be a precise account of the client’s problems, which must be accurate, parsimonious, comprehensive, logical and functional but which also must provide to the client a meaningful account of their problems. That is, it must have both clinical utility and subjective utility. Interestingly, AuBuchon and Malatesta (1998) describe ways in which the therapeutic relationship can be incorporated into the case formulation so that it can be utilised in the therapeutic process.

Introduction  7

Tarrier and Calam (2002) have suggested three further additions to traditional case formulation: (a) the conceptualisation of the dysfunctional system, especially relating to maintenance factors; (b) the historical background in terms of vulnerability and epidemiological factors; and (c) the important role of interpersonal and social behaviour and context. The dysfunctional system consists of a systemic and circular relationship between the problem, in its micro-level form, and antecedent and consequential events. This attempts to capture the intimate relationship between cognition, behaviour and mood in which, for example, a problem cognition could become an antecedent for another problem or be a consequence of a third (this is represented diagrammatically in Figure 1.1). The point of entry to the system is the problem as defined by the client – the macro level. This systemic analysis has advantages over a purely linear account as it better accommodates the complex interactions of different factors and how they maintain the problem. It is hypothesised that in any person’s life there are stresses and strains, both internal and external, but a natural homeostatic process regulates activity to return to a normal level of functioning. A dysfunctional system arises from a failure of this corrective feedback or homeostasis. In spite of the most atrocious experiences, many people do not go on to develop psychological disorders. Thus some type of resilience must be operating which buffers against this adversity. This resilience can be understood as a characteristic of the person, such as personality or coping mechanisms, but is likely to have been affected by aspects of their environment, such as social support or low stress levels (Johnson et al., 2011). Even when destabilisation occurs, restitution and a return to a regulated and normal mental state occurs naturally and relatively quickly in many people.

Figure 1.1 The dysfunctional system approach to case formulation.

8  Nicholas Tarrier and Judith Johnson

In others there is a tendency for feedback to destabilise and so amplify or maintain feedback processes which mitigate against self-correction; a dysfunctional system becomes established. Response patterns, cognitive, emotional and behavioural, often become entrenched and cyclical, and take on numerous secondary functions. So, because the chain of events often becomes circular rather than linear, it is easier to think of a dysfunctional system being activated in which the various components have interacting relationships which are strengthened through activation of the feedback system. To avoid some of the tautological reasoning identified by Nezu and Nezu (1989a) in identifying historical events as causal in current problems, Tarrier and Calam (2002) proposed a probabilistic model in which individual characteristics of the client’s life and experience were matched to known vulnerability and risk factors drawn from the research literature to suggest possible pathways to the origins of the current problem. Thus historical aspects of case formulation need to be founded on epidemiological data on risk factors associated with the development of any subsequent disorder. The occurrence of a clinical problem or psychological disorder is postulated to be the product of vulnerability and stress. That some common characteristics render individuals more at risk of developing a specific disorder is seen as evidence of vulnerability. Increased vulnerability results in increased risk but does not inevitably result in the occurrence of disorder; some further destabilisation or stress is required to precipitate the disorder and also trigger help seeking (this is represented in Figure 1.2). Vulnerability may well be acquired through exposure to specific environments but such contentions should be supported by the research literature. This reiterates the place of case formulation within the scientific practitioner model, in which formulation and treatment have an empirical foundation. One consequence of the development of cognitive models of psychological disorders and their strong influence on case formulation has been the potential decrease in importance being placed upon environmental (including social) factors. The focus on internal cognitive processes has distanced the analysis from the client’s social context. Meaningful social interactions and the interpersonal environment are central to human behaviour and clinical problems, and therefore their analysis needs to take centre stage in case formulation. There is good reason to do this: human beings have evolved into complex social animals with very complex social behaviours and goals. Socialisation and all that it entails is highly influential in our lives. It is also highly probable that mechanisms to elicit, maintain and regulate social interactions have also evolved and are operational in every aspect of a person’s functioning. Aspects of problems seen in the clinic may well have their origins in this social evolution (Gilbert, 2001). To emphasise the importance of social context Baumeister and Leary (1995), in their review of the need for meaningful social interactions, concluded that: (a) people naturally seek and form relationships with others; (b) efforts to dissolve relationships are strongly resisted;

Introduction  9

Figure 1.2  Systemic destabilisation as a result of stress and vulnerability.

(c) information about meaningful relationships and relationship partners are more thoroughly processed than information about other people; (d) the quality and intensity of relationships are directly associated with mood; and (e) intermittent or superficial social bonds do not result in the same mental health benefits as meaningful bonds. There is evidence that good social support has a positive effect and can impact on mental health in two ways – by buffering against stress (Cohen and McKay, 1984; Johnson et al., 2010) or through social cognition (Cohen and Willis, 1985; Rhodes and Lakey, 1999). In the former, perceived social support may impact on the appraisal of stress by providing the individual with the belief that additional resources, in the form of others, are available. In the latter the positive role of social support may be in providing access to others who can provide information about positive health-related behaviour and positive beliefs and conceptualisation of situations and self-perceptions (Penn et al., 2004). Conversely, there is also ample evidence for the negative effect of interpersonal relationships on the course and outcome of psychological and psychiatric disorders (for example, Butzlaff and Hooley, 1998; Wearden et al., 2000), further emphasising the importance of incorporating aspects of social context into case formulation and treatment. Lastly, incorporating social context into case formulation increases the treatment options available to the clinician in a range of different situations (for example, Henggeler et al., 1992; Keller et al., 2000; Tarrier and Humphreys, 2003). The advantages of the case formulation approach are that it allows a flexible and idiosyncratic understanding of each client’s individual problems irrespective

10  Nicholas Tarrier and Judith Johnson

of their diagnostic classification. It is collaborative, treats the client with true regard and takes into account the importance of their beliefs and expectations. It is sufficiently flexible to be accommodated into clinical research and is based upon an empirical foundation generated from research. It can include epidemiological information on vulnerability and risk, a systemic approach to problem maintenance and the client’s interpersonal and social context. It is further advantageous in that individualised treatment strategies, tactics and methods can be produced from the formulation that are specific to the needs of that individual. Case formulation is particularly advantageous in treating complex cases that do not conform to standard classification and pigeon-holing (Tarrier et al., 1998). Two issues have arisen since the publication of the first edition which we feel are worthy of mention. The first relates to the extensive roll-out of CBT, for example in the UK through the Improving Access to Psychological Therapies (iapt.nhs. uk), which started in 2006 with a set of very ambitious goals in increasing public access to, and availability of, effective psychological treatments. This is not the place to discuss this and other initiatives in detail but to raise the issue of the role of case formulation in such initiatives and the availability (or even the necessity) of appropriate training in individualised case formulation for IAPT practitioners. The issue here is an old one and is the possible conflict between using a pre-defined treatment protocol on a ‘one size fits all (at least with a specific disorder)’ which requires less (or even minimal training) compared to an individualised case formulation–based intervention which may require considerably more training, experience and expertise. The former would allow a much greater access to treatment and thus work to the public good but would it sacrifice quality and efficacy of treatment? Case formulation may result in much more effective treatments but would the cost, in time and money, result in greatly reduced access to treatment? The basic and quite uncomfortable question is raised: ‘is case formulation and individualised treatment necessary?’ If it is, are initiatives such as IAPT so watered down as to become ineffective and thus not good value for money? If it is not then is case formulation just an expensive and time consuming form of professional protectionism? A compromise may be that protocol-driven treatment is best targeted at simple clinical problems and case formulation best reserved for complex cases. This might be a sensible division and selective use of resources. It raises the question then, as to whether IAPT-type initiatives can be used successfully in the treatment of severe mental illnesses such as psychosis, bipolar disorder and personality disorder, which is the current aim (www.iapt.nhs. uk/smi). This debate will no doubt continue. The second issue relates to the use of new technologies in assessment and treatment platforms. The internet, computers and mobile phones have the potential to revolutionise the way we think about psychological disorders and treatment platforms. Mobile devices have the potential to access mental states in real time and carry out real-time assessments and potentially function as a platform for real-time interventions. Much has been made of the advantages of such e-CBT approaches

Introduction  11

over traditional care platforms in the context of public health and cost-effectiveness (Musiat and Tarrier, 2014). However, as of yet there is little in the way of empirical evidence to support that these benefits or ‘collateral outcomes’ occur (Musiat and Tarrier, in press). Much of computerised CBT and e-CBT is in effect the transfer of self-help material to computers or the internet and does not lend itself to case formulation. However, the potential for mobile-based intelligent systems to create and use data sets to make individual predictions and tailored interventions is exciting (Kelly et al., 2012). Whether therapists and their clients would accept artificially created formulations remains to be seen (Musiat et al., 2014). Interestingly, although the advantages for e-CBT are in populations with little access to conventional therapy (i.e. clinic-based delivery) most of the developments have been in locations where conventional therapy is widely available (Musiat and Tarrier, 2014). One can foresee, however, an opportunity in the developing world where there is little in the way of mental health service infrastructure but mobile phones are ubiquitous. Here, the use of e-CBT may leapfrog the need to develop service infrastructure, unlikely due to the cost and expertise needed, and provide access to treatment in high need and risk populations (Kahn et al., 2010; Musiat and Tarrier, 2014). In 2009, the World Health Organization urged their member states to implement e-health services in both physical and mental health care. The use of case formulation based within the e-technologies could play a pivotal role in the future delivery of effective psychological treatment to the world population. Although widely adopted, the research on case formulation continues to increase as indicated by the chapters within this second edition. There are, however, many challenges which I hope the readers of this second volume and the subsequent chapters will be stimulated to take up both in their clinical practice and also as active clinical researchers. There is a strong mutually dependent relationship between clinical research and clinical practice, and it is through this relationship, in which both the clinician and researcher identify problem areas and unanswered questions, that the practice and understanding of case formulation will expand and flourish.

References AuBuchon, P. G. and Malatesta, V. J. (1998). Managing the therapeutic relationship in behaviour therapy: The need for a case formulation. In M. Bruch and F. W. Bond (eds) Beyond Diagnosis: Case Formulation Approaches to CBT. Chichester: Wiley. Baumeister, R. F. and Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin 117: 497–529. Bruch, M. (1998). The UCL case formulation approaches. In M. Bruch and F. W. Bond (eds) Beyond Diagnosis: Case Formulation Approaches to CBT. Chichester: Wiley. Bruch, M. and Bond, F. W. (eds) (1998). Beyond Diagnosis: Case Formulation Approaches to CBT. Chichester: Wiley. Butzlaff, R. L. and Hooley, J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry 5: 547–52.

12  Nicholas Tarrier and Judith Johnson Chadwick, P. et al. (2003). Impact of case formulation in cognitive behaviour therapy for psychosis. Behaviour Research and Therapy 41: 671–80. Cohen, S. and McKay, G. (1984). Social support, stress and the buffering hypothesis: A theoretical analysis. In A. Baum et al. (eds) Handbook of Psychology and Health. Hillsdale, NJ: Lawrence Erlbaum. Cohen, S. and Willis, T. A. (1985). Stress, social support and the buffering hypothesis. Psychological Bulletin 98: 310–57. Gilbert, P. (2001). Evolutionary approaches to psychopathology: The role of natural defences. Australian and New Zealand Journal of Psychiatry 35: 17–27. Henggeler, S. W. et al. (1992). Family preservation using multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology 60: 953–61. Johnson, J. et al. (2010). Resilience as positive coping appraisals: Testing the schematic appraisals model of suicide (SAMS). Behaviour Research and Therapy 48: 179–86. Johnson, J. et al. (2011). Resilience to suicidality: The buffering hypothesis. Clinical Psychology Review 31: 563–91. Kahn, J. G. et al. (2010). ‘Mobile’ health needs and opportunities in developing countries. Health Affairs 29: 252–58. Kanfer, F. H. and Saslow, G. (1965). Behavioral analysis: An alternative to diagnostic classification. Archives of General Psychiatry 12: 529–38. Keller, M. B. et al. (2000). A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. New England Journal of Medicine 342: 1462–70. Kelly, J. A. et al. (2012). Intelligent Real Time Therapy (iRTT): Harnessing the power of machine learning to optimise the delivery of momentary cognitive-behavioural interventions. Journal of Mental Health 21: 404–14. Leventhal, H. et al. (1997). Illness representations: Theoretical foundations. In K. J. Petrie and J. A. Weinman (eds) Perceptions of Health and Illness. Amsterdam: Harwood Academic Publishers. Musiat, P. et al. (2014). Understanding the acceptability of e-mental health – attitudes and expectations towards computerised self-help treatments for mental health problems. BMC Psychiatry 14: 109. Musiat, P. and Tarrier, N. (2014). E-mental health: The future for cognitive behaviour therapy? Unpublished manuscript. Musiat, P. and Tarrier, N. (in press). Collateral outcomes in e-mental health: A systematic review of the evidence for added benefits of computerized cognitive behavior therapy interventions for mental health. Psychological Medicine. Nezu, A. M. and Nezu, C. M. (1989a). Clinical predictions. Judgment and decision making: An overview. In A. M. Nezu and C. M. Nezu (eds) Clinical Decision Making in Behaviour Therapy: A Problem Solving Perspective. Champaign, IL: Research Press. Nezu, A. M. and Nezu, C. M. (1989b). Clinical decision making in behaviour therapy. In A. M. Nezu and C. M. Nezu (eds) Clinical Decision Making in Behaviour Therapy: A Problem Solving Perspective. Champaign, IL: Research Press. Penn, D. L. et al. (2004). Supportive therapy for schizophrenia: A closer look at the evidence. Schizophrenia Bulletin 30: 101–12. Persons, J. B. (1989). Cognitive Therapy in Practice: A Case Formulation Approach. New York: Norton.

Introduction  13 Rhodes, G. L. and Lakey, B. (1999). Social support and psychological disorder: Insights from social psychology. In R. M. Kowalski and M. R. Leary (eds) The Social Psychology of Emotional and Behavioural Problems: Interfaces of Social and Clinical Psychology. Washington, DC: American Psychological Association. Sackett, D. L. (1998). Evidence-Based Medicine: How to Practice and Teach EBM. Edinburgh: Churchill Livingstone. Tarrier, N. and Calam, R. (2002). New developments in cognitive-behavioural case formulation. Epidemiological, systemic and social context: An integrative approach. Cognitive and Behavioural Psychotherapy 30: 311–28. Tarrier, N. and Humphreys, A.-L. (2003). PTSD and the social support of the inter-personal environment: Its influence and implications for treatment. Journal of Cognitive Therapy 17: 187–98. Tarrier, N. et al. (eds) (1998). Cognitive Behaviour Therapy for Complex Cases: An Advanced Guidebook for the Practitioner. Chichester: Wiley. Turkat, I. D. (1985). Behavioral Case Formulation. New York: Plenum. Turkat, I. D. (1990). The Personality Disorders: A Psychological Approach to Clinical Management. New York: Pergamon. Wearden, A. et al. (2000). A review of expressed emotion research in health care. Clinical Psychology Review 20: 633–66.

Chapter 2

Case formulation and the outcome of cognitive behaviour therapy Jacqueline B. Persons and Janie J. Hong

Cognitive behaviour therapy guided by a case formulation or by a standardised protocol Cognitive behaviour therapy guided by a case formulation CBT that is guided by a case formulation (case formulation–driven CBT) has three elements, as shown in Figure 2.1. First, the therapist collects assessment data and uses it to develop a formulation of the case. A comprehensive case formulation includes information about all of the following: (1) the patient’s problems, symptoms, and disorders; (2) the psychological mechanisms (e.g., beliefs and attitudes, contingencies, skills deficits) that cause and maintain the patient’s problems; (3) origins of the mechanisms; (4) precipitants that are activating the mechanisms to cause the symptoms and problems and (5) features of the patient or the environment that are likely to affect treatment progress, including the patient’s cultural and ethnic background, personality features, motivation for change and social support. Second, the therapist uses the formulation to select interventions and to make other treatment decisions, such as to focus on increasing the patient’s motivation to change before initiating exposure sessions, for example, in order to maximise the chances that the treatment will be successful in accomplishing the patient’s idiographic goals. Third, as the therapist implements the treatment, she collects feedback. She collects progress-monitoring data in every session to evaluate the patient’s response to the therapy and to test the formulation, and, if necessary, uses the data to revise the formulation and the treatment in order to improve the patient’s response. A case formulation–driven approach to treatment is highly individualised, and based on a lot of assessment information that is collected at the beginning of the treatment and at every step during the treatment. Treatment is informed by feedback, so that decisions the therapist makes in later sessions are guided by the results of earlier decisions and interventions. The assessment and treatment process is quite collaborative, with the patient and therapist working together at every step.

Case formulation and the outcome of CBT  15

Formulate

Intervene

Collect Feedback Figure 2.1  Case formulation-driven cognitive behaviour therapy (© Copyright Jacqueline B. Persons).

Cognitive behaviour therapy guided by a standardised protocol In a standardised protocol approach to treatment, the therapist conducts an assessment in order to make a diagnosis, and then follows the protocol to deliver the treatment. Assessment focuses on diagnosis, as most standardised protocols target a disorder, and a diagnosis is needed in order to determine which protocol is applicable. The interventions in the protocol are based on a nomothetic (general) formulation of the disorder the protocol is designed to treat. For example, Beck’s cognitive therapy for depression specifies that schemas are activated by life events to cause symptoms that are made up of mutually causal emotions, automatic thoughts and behaviours. Interventions target the mechanisms (automatic thoughts, behaviours and schemas, in the case of Beck’s cognitive model) described in the formulation. In addition to assessing diagnosis, assessment in standardised protocol therapy also focuses on getting information about the details of the patient’s symptoms, and the idiographic details of the mechanisms the protocol targets in the treatment. For example, in the case of cognitive therapy for depression (Beck et al., 1979), the therapist identifies behaviours, automatic thoughts and schemas that drive the particular patient’s depressive symptoms, and the assessment information is used to guide intervention. However, the protocol typically does not describe detailed strategies to obtain this idiographic assessment information – to obtain schema hypotheses, for example – nor does it provide guidance on how to address problems that interfere with treatment (e.g. low motivation to change) and comorbid disorders. Treatment goals are standardised: the goal of treatment is to bring the disorder to remission. Standardised protocols tend to be fixed, not feedback-guided; typically the interventions and the order in which they are delivered are pre-determined.

Randomised controlled trials comparing formulation-guided and protocol-guided CBT Several randomised trials compare outcomes of standardised protocol treatment and some type of case formulation–driven treatment. We group these studies into categories based roughly on the type of information the investigators used

16  Jacqueline B. Persons and Janie J. Hong

to develop a case formulation or individualised treatment plan, and on whether a feedback element was included in the treatment. We describe studies in which the formulation was based on diagnosis or symptoms, those in which a formulation was based on a hypothesis about the mechanisms causing or maintaining the patient’s problems and disorders, and those that included a feedback element. We describe the randomised controlled trials in each section in backwards chronological order, with more recent studies first. Case formulation based on diagnosis or symptoms Johansson and colleagues (2012) investigated the effectiveness of individually tailored internet-based CBT for depression in a randomised controlled trial in which participants were assigned to one of three groups: individually tailored CBT, standardised CBT, or the control group. Individuals in the two active treatment groups completed a specified list of treatment modules over a 10-week period, and received email support from a therapist who answered questions about the material and provided feedback on the exercises. Individuals in the standardised treatment group received a set of eight self-help chapters, whereas each individual in the individualised treatment group received chapters that were chosen by the research team from a pool of 25 chapters, and chosen based on data about the patient’s symptoms and disorders. For example, a patient with social anxiety would receive a chapter focused on that problem. Individuals assigned to the control group participated in a weekly moderated online discussion group focused on topics that related to depression or its treatment. Both active treatment groups showed large treatment gains when compared with the control group. This treatment effect was moderated by pre-treatment depression severity. That is, individuals identified as severely depressed at pre-treatment (with Beck Depression Inventory-II scores of greater than 24) experienced greater gains in the individualised treatment group at post-treatment and six months later compared to the standardised one and compared to the control group. By contrast, there was no differential effect on outcome of group assignment for individuals who were less severely depressed at pre-treatment. These results provide some support for the benefit of individualising treatment on the basis of the patient’s symptoms or disorders when patients are severely depressed. Jacobson et al. (1989) compared the outcome of individualised and standardised social learning–based marital therapy. Thirty married couples were randomly assigned to a standardised treatment or a clinically flexible treatment. The standardised treatment consisted of 20 sessions in which a series of modules was provided in order (behaviour exchange, companionship enhancement, communication training, problem-solving training, sexual enrichment and generalisation and maintenance) to all couples. In the clinically flexible version of the treatment, the decision about which modules the couple received, the order of delivery of the modules and the duration of the treatment was determined on a case-by-case basis based on the team’s judgment about each individual couple’s needs. The

Case formulation and the outcome of CBT  17

authors do not describe how the team made these decisions, but presumably the decisions were based on the nature of the couple’s presenting problems, so that if a couple did not have a sexual problem, the sexual enrichment module could be omitted from the treatment plan, for example. A social learning model was used to conceptualise all of the cases (that is, the same hypothesis about psychological mechanisms was used to conceptualise all of the cases). Although couples in both treatments showed significant gains on the two measures of global marital satisfaction, there were no differential treatment effects at post-treatment or at the six-month follow-up point. The treatments did not differ in average duration; couples in the standard treatment received 20 sessions, and those in the flexible condition received a mean of 22 sessions. Case formulation based on psychological mechanisms In another study examining the benefits of individualised internet-delivered CBT for depression, participants were randomly assigned to a standardised self-help treatment protocol, individualised email therapy or a wait-list control condition (Vernmark et al., 2010). In the individualised treatment, a case formulation was developed based on each participant’s assessment data, and therapists used the formulation to provide CBT strategies via email. The authors do not describe in detail how they developed formulations for each patient, but refer to using a functional analysis and elements of the case formulation–driven approach described by Persons (2008). The study found no difference between the two CB treatments on all depression outcome measures. Both treatments led to significantly better outcomes than the wait-list control condition. Ghaderi (2006) compared treatment for bulimia nervosa that was guided by a formulation based on a functional analysis to a standardised protocol treatment. The individualised treatment was anchored in the standardised treatment developed by Fairburn and colleagues (1993), and elements were added to or deleted from that standard treatment based on the results of a functional analysis that was conducted to identify perpetuating factors for that particular patient. For example, if the functional analysis showed that social isolation was a maintaining factor for a particular patient’s symptoms, interventions to target social isolation were included in that patient’s treatment. Patients in both treatments showed statistically significant changes and maintained their gains at the six-month follow-up point. Patients in the individualised treatment showed superior gains on 4 of approximately 22 treatment outcome variables; the treatments did not differ on the remaining variables. Ghaderi (2006) pointed out that the failure to find more differences between the treatments may in part have been due to inadequate power. Conrod and colleagues (2000) conducted a randomised controlled trial in which individuals with substance abuse problems were randomly assigned to receive interventions that matched the individual’s personality profile, interventions that did not match the individual’s personality profile or a nonspecific intervention. In

18  Jacqueline B. Persons and Janie J. Hong

the matching treatment, individuals received interventions that addressed one of four personality profiles (anxiety sensitivity, introversion-hopelessness, impulsive sensation seeking, non-impulsive sensation seeking). This study was based on findings that these profiles increase an individual’s susceptibility to using different drugs (Conrod et al., 2000). For example, individuals high in anxiety sensitivity were more likely to suffer from anxiolytic substance dependence, whereas individuals with an introversion-hopelessness profile were more likely to struggle with depressive symptoms and opioid dependence. Individuals in the matched-treatment condition received detailed, individualised feedback about their personality type and the severity of their drug use relative to norms, and learned cognitive behavioural strategies targeting their motivations for substance use based on their personality profile. Individuals in the mismatched personality profile treatment condition learned about ‘potential’ motivations to use substances (deliberately mismatched with their own profile) and strategies that ‘potentially’ could be helpful to someone with substance use problems. Those in the nonspecific condition watched a motivational film on substance use, and discussed with a therapist their reactions to the film and how it related to their personal experiences with substance use. Each treatment was delivered in a single 90-minute session. The authors do not report ANOVA testing for a main effect of treatment condition on the post-treatment data, but in planned contrasts between the different treatment conditions, they found that six months after the intervention, individuals in the personality-matched treatment condition had a significantly greater reduction in substance dependence symptoms, higher rates of abstinence from drinking alcohol and using other substances, and fewer concerns about current consumption levels than those in the nonspecific treatment condition, but did not significantly differ from those in the mismatched treatment. The authors did not find group differences in overall the amount of alcohol consumed or the frequency of prescription drug use. Schulte and colleagues (1992) randomly assigned 120 patients with various types of phobias to one of three treatments: (1) standardised in vivo exposure treatment and retraining of self-verbalisations, (2) individualised treatment in which the therapist ‘is allowed to use all therapeutic methods commonly employed in behaviour therapy and cognitive therapy’ (p. 69) or (3) a yoked control group, in which each patient received a treatment that was assigned to one of the patients in the individualised group. The individualised treatment was designed on the basis of the therapist’s ‘behavioural analysis’ (p. 68) or ‘problem analysis’ of the case, which was ‘guided by a system of meta-rules about the important items of information to be gathered and about their interpretation’ (p. 69). There were few differences among the treatments. A MANOVA showed that the three treatment conditions differed significantly at the p < .05 level for 3 of 9 outcome measures at post-treatment, 2 of the 9 measures at six-month follow up, and none at two-year follow up. No statistical tests reporting pairwise comparisons between the treatment conditions were reported.

Case formulation and the outcome of CBT  19

Schneider and Byrne (1987) randomly assigned 35 children aged 7 to 13 years old who were receiving treatment for anxiety, attention deficit disorder or conduct disorder to receive standardised or individualised social skills training. All children in the standardised group received social skills training using the same 12 modules, and those in the individualised group received a selection of modules from the standardised treatment based on an initial assessment of both symptoms (e.g. aggression) and skills that were viewed as mechanisms underpinning the child’s behavioural symptoms (e.g. social perception skills). Increases in cooperative play were statistically significantly greater for children who received individualised rather than standardised treatment; the treatments did not differ in their effects on observed aggression. Case formulation–driven treatment that included a feedback element We review two randomised trials comparing formulation-driven and standardised treatment that included a feedback element in the formulation-driven treatment: a study of modular treatment for youths (Weisz et al., 2012; Chorpita et al., 2013), and a study of behavioural treatment of alcohol abuse (Litt et al., 2009). We also briefly review research examining the effects on treatment outcome of feedback alone. Weisz et al. (2012) and Chorpita et al. (2013) compared modular, standardised and usual care for youths aged 7 to 13 who sought treatment for mood, anxiety and/or conduct problems. This study is particularly interesting, and therefore we examine it in some detail. The standardised treatment consisted of an empirically supported CBT protocol for depression (Primary and Secondary Control Enhancement Training), anxiety (Coping Cat) or conduct problems (Defiant Children) that treated the child’s main presenting problem. The modular treatment consisted of intervention modules that the therapist selected from the standardised protocols on the basis of assessment data and decision flowcharts. The flowcharts guided therapists to select modules on the basis of the child’s symptoms and problems (e.g. if anxiety was a problem, the flowchart suggested modules from the Coping Cat protocol), and to make adjustments as needed on the basis of feedback data that were obtained in every session. Thus, if another problem (e.g. conduct problems or depression) interfered with the treatment the therapist was implementing, the therapist could select modules from those protocols and if the feedback data indicated, for example, that the patient was not practicing exposure, the flowchart prompted the therapist to consider adding a reward module to increase compliance. Independent assessors collected weekly feedback data on the patient’s symptoms and problems, and on treatment compliance, and reviewed the data with the supervisor, who transmitted it to the clinician. In the usual care condition, ‘therapists agreed to use the treatment procedures that they used regularly and believed to be effective’ (Weisz et al., 2012, p. 277).

20  Jacqueline B. Persons and Janie J. Hong

The investigators compared the treatments on the child’s mean number of diagnoses at post-treatment, controlling for number of pre-treatment diagnoses. Because treatment duration varied among the conditions, the investigators examined differences between treatments on the main symptom dependent variables (Brief Problem Checklist, Top Problems Assessment, Child Behavior Checklist (CBCL) and Youth Self Report (YSR) by conducting regression analyses that compared the slope of the change trajectory for the treatments, rather than comparing the post-treatment outcomes. The investigators compared the treatments on functional impairment and services utilisation at the 12- and 24-month follow-up points. Results showed that youth who received modularised treatment had statistically significantly fewer diagnoses after treatment than those who received usual care, but did not differ from those who received standardised treatment (Weisz et al., 2012). Youths who received standardised treatment did not differ from usual care. On both the Brief Symptom Checklist and Top Problems Assessment, youths who received modular treatment had statistically significantly steeper change trajectories between baseline and post-treatment than those who received standardised treatment and those who received usual care (Weisz et al., 2012). Youths who received standardised treatment did not differ from usual care. On the two other symptoms measures, Child Behavior Checklist (CBCL) and Youth Self Report (YSR), an examination of the trajectory of change over the entire study period, including the two-year follow-up, showed that modular care was superior to usual care but not to standardised treatment (Chorpita et al., 2013). Standardised treatment did not differ from usual care. The groups did not differ on functional impairment or service utilisation (Chorpita et al., 2013). Thus, the study provides some support for the use of a case formulation–driven mode of treatment. The ‘formulation’ that guided decision making was based primarily on the patient’s symptoms and disorders, and interventions were selected from a set of modules. The strongest support for the modular treatment was seen for diagnosis, and for the two measures of symptoms and problems (Brief Problem Checklist and Top Problems Assessment) for which feedback data were collected at every session. In a treatment study of individuals with alcohol dependence, Litt and colleagues (2009) randomly assigned participants to receive a manualised or an individualised cognitive behavioural treatment program. For both groups, treatment consisted of 12, weekly 60-minute outpatient sessions. During the two weeks before treatment and the two weeks after treatment ended, the study employed an experience-sampling method in which participants answered a phone call multiple times every day, and responded to a series of questions about their current mood, thoughts, behaviours and environment. For each participant in the individualised treatment condition, a research assistant used the experience-sampling data to create a personalised functional analysis chart that was given to the participant’s therapist before the first session. Therapists used

Case formulation and the outcome of CBT  21

the data to identify the situations in which a patient was at high risk to drink or feel urges to drink, and tailored the treatment to target these vulnerabilities. Although the content of the treatment sessions was pre-determined (e. g. sessions 1–3 focused on analysing high-risk drinking situations), interventions in the individualised treatment were based on the difficulties identified in the functional analysis chart. At post-treatment, individuals in the individualised treatment had outcomes that were superior to the standardised treatment on one of the three drinking outcome variables (proportion of days abstinent). The groups did not differ in the proportion of heavy drinking days or in the proportion of individuals who remained abstinent for at least 90 days. Using the post-treatment experience-sampling data, the study found that patients in the individualised treatment reported significantly fewer urges to drink, were significantly less likely to drink in response to urges and were more likely to use adaptive coping responses than those in the standardised treatment. The study provides some support for the use of the case formulation approach, and includes all three elements of the approach we previously described. Although the study did not formally collect feedback data, the study therapists repeatedly referred to the case formulation and assessment data throughout treatment, and presumably gained informal feedback from the client as to the accuracy of the data when developing strategies to target their problems. A substantial literature (see reviews by Goodman et al., 2013 and Carlier et al., 2012, and a meta-analysis by Knaup et al., 2009) examines the effects on treatment outcome of the feedback element of the model described in Figure 2.1. Large numbers of randomised controlled trials have shown that when clinicians collect feedback data to monitor the progress of their patients, those patients have better outcomes. The effect has been shown in many disorders and problems and populations, including students seeking treatment at a university counselling centre (Lambert and Shimokawa, 2011; Reese et al., 2009), youth receiving home-based mental health treatment in community settings (Bickman, 2011), patients receiving treatment for schizophrenia or related disorders in community mental health care in Europe (Priebe et al., 2007), depressed patients treated in primary care settings (Yeung, 2012) and couples receiving treatment at a community clinic (Anker et al., 2009) or a training clinic (Reese et al., 2010). Two outcomes monitoring systems, Lambert’s OQ-45 (Lambert et al., 1996) and the Partners for Change Outcomes Monitoring System (PCOMS; Miller et al., 2005) have sufficient empirical support to be included in the US Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP). In summary, randomised controlled trials provide some evidence in support of the notion that outcome of treatment that is guided by a case formulation is superior to standardised treatment. We did not find any studies that showed that standardised treatment was superior to case formulation–driven treatment. The strongest evidence supported the use of the feedback element of the model.

22  Jacqueline B. Persons and Janie J. Hong

Uncontrolled trials Two uncontrolled trials conducted by this chapter’s first author showed that treatment of depressed (Persons et al., 1999) and depressed anxious patients (Persons et al., 2006) that is guided by a CB case formulation and weekly progress monitoring has outcomes similar to outcomes of patients receiving CBT or CBT plus pharmacotherapy in randomised controlled trials. Patients in the Persons et al. (1999, 2006) studies were adult outpatients who had completed treatment in her private practice or her group practice in Oakland, California. Minimal selection criteria were used, in order to evaluate as heterogeneous a sample as possible. Patients in the Persons et al. (1999) study met the following criteria: Initial Beck Depression Inventory (BDI) score of 14 or greater, the clinical record had a written case formulation, and a minimum of three BDI scores were available. Patients in the Persons et al. (2006) study met the following criteria: at least four sessions of symptom data on the BDI or the Burns Anxiety Inventory were available, and the patient was aged 19–75 years. All patients were treated with individual CBT, and many also received adjunct therapies, such as pharmacotherapy or couples therapy. The major weakness of these studies is the lack of a control group to which the results can be compared. The major strength is that the studies examine treatment that included all three elements of the model of case formulation–driven CBT, a heterogeneous unselected sample of patients with multiple comorbid mood and anxiety disorders, and naturalistic treatment, including multiple adjunct therapies, that was provided in a real-world clinical setting. Forand and colleagues (2011) reported results of an uncontrolled trial of CBT provided by trainees at a university-based outpatient training clinic. Treatment approximated the use of the model of case formulation–driven treatment described in Figure 2.1. Treatment was not manualised, so it was flexible and adjusted to meet the needs of the individual patient; however, there is no evidence that a formal, written case formulation was developed. The fact that ‘treatment plans are based on empirically supported treatment protocols’ (p. 615) suggests that therapists used interventions and, presumably, formulations they learned from those protocols, to guide their work. Treatment included a feedback element; therapists collected scores on measures of anxiety and/or depression at the beginning of every therapy session, and used the data ‘for assessing symptom change and treatment planning’ (p. 615). Minimal selection criteria were used to select the sample of 249 patients. Patients were selected for study if they had a primary diagnosis of a mood or anxiety disorder, a minimum Beck Depression Inventory score of 11 or Beck Anxiety Inventory score of 11 at intake and at least three sessions of symptom data. The authors found that the trainee therapists in their sample achieved rates of recovery and improvement that were comparable to those in the effectiveness and efficacy studies they used for comparison purposes, except that recovery rates for severely depressed patients were lower than in the comparison studies, and pre-post effect sizes were somewhat lower than in the comparison studies.

Case formulation and the outcome of CBT  23

In summary, these three uncontrolled trials provide some support for the notion that a case formulation-driven approach to CBT produces outcomes similar to those achieved in the randomised trials for CBT for mood and anxiety disorders. These results were obtained even in the treatment of patient populations with high degrees of comorbidity and in the case of the Forand et al. (2011) study, when treatment was provided by carefully supervised trainee therapists.

Single case studies A large number of single case studies consistently provide compelling evidence to support the treatment utility of a functional analysis. For example, Iwata et al. (1994) reported the results of 152 single-subject analyses of the reinforcing functions of self-injurious behaviour (SIB) in individuals with developmental disabilities. The investigators found that when interventions considered to be relevant to a particular function (e.g. extinction of attention for an individual whose SIB appeared to serve the function of obtaining attention) were delivered, SIB was reduced to below 10% of its baseline level in more than 80% of the cases. When interventions that did not address the function of the SIB were delivered, almost no change occurred. Many other single cases showing that when treatment is guided by the results of a functional analysis, outcome is superior to treatment that is not guided by the functional analysis; several are reviewed by Haynes et al. (1997). The large majority of case studies investigating the treatment utility of a case formulation examine the use of a functional analysis to plan treatment for children or adults with self-injurious behaviour or other severe behavioural problems. Less common are studies testing the treatment utility of functional analysis for patients with other problems. Examples include the case of the school-refusing child reported by Chorpita and colleagues (1996) and the two studies by Nelson-Gray and colleagues, described in the next paragraph, that report on results of multiple single case studies of depressed women. Nelson-Gray and colleagues (1989) reported results of single case studies of nine depressed women who each were assessed to identify deficits in any of three response classes: social skills deficits, pleasant events deficits or irrational cognitions. Patients who had deficits in one or two but not all three of these response classes were selected for study. Three patients received eight weeks of treatment that were matched to their problematic response class, three patients received treatment mismatched to their response class and three received a package treatment that addressed all the response classes. The matched and package treatments both produced significant gains on the Beck Depression Inventory, but the mismatched treatment did not. In a within-subjects study that addressed the same question (‘do depressed patients benefit more from treatment that matches their deficits than from treatment that does not address their deficits?’), McKnight et al. (1984) collected data from nine depressed women, three who had social skills deficits, three who had irrational cognitions and three who had both. All patients received alternating sessions of matched or mismatched treatment, and benefits of

24  Jacqueline B. Persons and Janie J. Hong

the previous session were assessed at the beginning of each session. All patients showed a greater reduction in depressive symptoms following matched rather than unmatched treatment. All of the single case studies reported here (and many others not reported here; e.g. Haynes et al., 1997) provide convincing evidence of the treatment utility of an individualised case formulation. In all of these single case studies, the case formulation was based on a mechanism hypothesis (typically one obtained via a functional analysis). However, none of these treatments included a feedback element. Instead, treatment was pre-determined by the results of the functional analysis, although in some cases, the accuracy of the functional analysis was tested before treatment began, and the functional hypothesis (and thus the treatment plan) was revised based on the results of the testing (Hagopian et al., 2013).

Predictors, moderators and mediators Evidence that factors typically included in case formulations influence treatment outcome or the change process provides support for the treatment utility of individualised case formulations. Therefore, we present some of that evidence here. We examine three types of influence on outcome and the change process: prediction, moderation and mediation. Predictors provide prognostic information about outcome (e.g. ethnicity predicts dropout). Moderators identify which subgroups of patients or specific factors lead to a differential response to treatment (e.g. when treatment motivation is low, high therapist adherence to the treatment leads to poor outcome, and when treatment motivation is high, high therapist adherence to the treatment leads to good outcome). Mediators explain why and how a treatment is effective (e.g. CBT for panic disorder is effective partly because it produces changes in anxiety sensitivity). Ethnicity as predictor and moderator One common finding is that individuals from ethnic minority groups are more likely to drop out of treatment than their Euro-American counterparts. For example, King and Canada (2004) showed that African Americans who began CBT for substance abuse dropped out of treatment at a rate 5 times higher than Caucasians. Austin and Wagner (2006) similarly found that Caucasian adolescent juvenile offenders in treatment for substance use problems (n = 420), dropped out at a significantly lower rate than the ethnic minority participants, with the African-American participants showing the highest rates of dropout. Using data from 11 randomised controlled trials of treatments for binge eating disorder, Thompson-Brenner et al. (2013) found that African Americans were significantly more likely to drop out of treatment than their Caucasian counterparts. McFarland and Klein (2005) found that ethnic minority patients had significantly higher risk of dropping out from treatment for dysthymic disorder than their Caucasian patients. Reasons for the increased rate of treatment dropout

Case formulation and the outcome of CBT  25

among ethnic minority clients are unclear, but these studies provide compelling evidence of the importance of considering the role of ethnicity when treatment planning. Ethnicity has also been shown to moderate the effectiveness of particular interventions. Clair et al. (2013) found that Hispanic incarcerated adolescents responded significantly better to motivational interviewing than to relaxation therapy to reduce their use of alcohol, whereas their Caucasian and African-American counterparts showed no difference in response to the two types of treatment. Patient ethnic background appears to also moderate how well the patient bonds with the therapist. In a longitudinal treatment study of 185 adolescents with a range of externalising behavioural problems, Hispanic adolescents who exhibited higher levels of problem behaviours early in treatment showed poorer treatment adherence and emotional bonding with their therapists than did Hispanics with lower levels of problem severity. By contrast, for those of African-American descent, higher levels of severity were associated with greater emotional bond and alliance with the therapist (Ryan et al., 2013). Readiness to change as a moderator Boswell and colleagues (2012) showed that readiness to change (Prochaska and DiClemente, 1986) moderates the relationship between initial symptom severity and outcome in the treatment of anxiety disorders. The study used data from an RCT examining the efficacy of a transdiagnostic CBT protocol for patients with a primary anxiety disorder diagnosis when compared to a delayed treatment condition (Farchione et al., 2012). Higher levels of initial symptom severity on both measures of anxiety and depression were significantly associated with lower levels of symptom change, and levels of readiness to change moderated this relationship. Individuals who endorsed higher levels of symptom severity and higher levels of readiness to change showed more change during treatment. Thus, when individuals reported high levels of readiness to change, a high degree of symptom severity was a positive predictor of symptom improvement at post-treatment. Another demonstration of the moderating role of patient motivation was provided by Huppert et al. (2006), who showed that high therapist adherence to the protocol was associated with poor outcome of CBT for panic disorder when patients had low motivation to change. Threat overestimation as predictor, moderator and mediator Cognitive factors that influence a person’s disorders or symptoms are commonly included in the case formulation. We review the role of threat overestimation, with a specific focus on anxiety sensitivity (a type of threat overestimation) on outcome as an example of such cognitive factors.

26  Jacqueline B. Persons and Janie J. Hong

Threat reappraisal as a mediator Overestimation of threat, that is, the faulty belief that harm from a particular situation or cue is highly likely and/or costly, is a primary treatment target in CBT for anxiety. CBT treats overestimation by teaching patients to reappraise the threat. Smits and colleagues (2012) conducted a systematic review of studies looking at whether threat reappraisal mediates cognitive behaviour therapy for anxiety disorders. The authors outlined the following criteria to determine support for a meditational role of threat reappraisal: (1) evidence of statistical mediation, (2) evidence that the change is specific to CBT and not other factors, (3) evidence that threat reappraisal causes anxiety reduction and (4) evidence that changes in anxiety are specifically related to changes in threat reappraisal. In their review the authors found that the majority of the identified studies did not test criteria 2–4 (listed above) and that none of the studies tested all four criteria. They also found that other factors (e.g. increased self-efficacy, perceived control) could independently explain the effects of CBT on anxiety, which suggests that the relationship between threat reappraisal and anxiety reduction is not specific. Despite this, the data strongly supported a relationship between threat reappraisal and anxiety reduction. Thirteen of the 25 studies reviewed examined whether threat reappraisal mediated the relationship between CBT and anxiety reduction, and all but one of them found that threat reappraisal played a statistically significant mediating role. Anxiety sensitivity as a predictor One type of threat overestimation that has featured prominently in CB treatments is anxiety sensitivity. Individuals with high anxiety sensitivity tend to interpret anxious bodily sensations (e.g. heart palpitations, dizziness, shortness of breath, depersonalisation) as being physically, psychologically and/or socially dangerous or harmful (Reiss and McNally, 1985). Several studies have found anxiety sensitivity to be a predictor of treatment outcome. For example, Teachman and colleagues (2010) found that reductions in anxiety sensitivity (assessed repeatedly) during the course of CBT for panic disorder predicted post-treatment reductions in symptom severity, panic frequency and avoidance behaviours. Anxiety sensitivity as a moderator Wolitzky-Taylor and colleagues (2012) examined treatment response of a heterogeneous sample of anxiety disorder patients who were randomly assigned to CBT or acceptance and commitment therapy (ACT). They also investigated whether anxiety sensitivity moderated the response to the different treatments. They found that the treatments did not differ in efficacy (as measured by pre-post treatment changes on the Mood and Anxiety Symptom Questionnaire). As predicted, they also found that pre-treatment levels of anxiety sensitivity moderated patients’ response to CBT, but not to ACT. Individuals with high (one standard deviation

Case formulation and the outcome of CBT  27

above the mean) or low (one standard deviation below the mean) pre-treatment anxiety sensitivity scores responded least favourably to CBT and those with scores near the mean showed favourable outcomes and demonstrated a significantly better response to CBT than individuals with similar scores in the ACT condition. Anxiety sensitivity as a mediator Smits and colleagues (2004) examined whether the efficacy of CBT in reducing panic disorder symptoms is mediated by changes in anxiety sensitivity. They collected data from panic disorder patients treated with CBT and those in a wait-list control condition. Using steps outlined by Baron and Kenny (1986), they found that anxiety sensitivity fully mediated the effects of CBT on global distress ratings, but only partially mediated the effects of CBT on panic attack frequency, agoraphobia and self-reported anxiety. Despite the strength of their findings, the authors point out that the data were correlational and did not speak to the possibility that the change in anxiety sensitivity was a consequence of (not a cause of) panic disorder symptom reduction. In this section we provided a sampling of evidence (many more studies could be cited) supporting the notion that factors that are common elements of a case formulation (ethnicity, patient motivation, threat overestimation) are predictors, moderators and mediators of change in CBT. These data provide some indirect evidence supporting the use of a case formulation that includes this information, to guide decision-making in treatment.

Implications for research, training and clinical practice We found, in the data from randomised controlled trials, uncontrolled trials and single case studies, a moderate amount of evidence to support the notion that a case formulation–driven approach to treatment leads to improved outcome. Results of the studies of predictors, moderators and mediators provided a considerable amount of evidence to support the notion that factors that are typically part of a case formulation predict or influence outcome, or mediate the change process, and these types of data indicate that using a case formulation to guide treatment has the potential to lead to improved outcome. We discuss research, training and clinical implications of our findings. We organise our discussion by the three parts of our model (Figure 2.1), taking up each part of the model in turn (the case formulation, using the formulation to guide treatment and collecting feedback data), and concluding with a discussion of the complete three-part model. Developing a case formulation We found considerable evidence that features of a typical CB case formulation (e.g. patient features such as ethnicity and motivation to change, and psychological

28  Jacqueline B. Persons and Janie J. Hong

mechanisms such as overestimation of threat) are predictors and moderators of outcome, and to a lesser extent, mediators of the change process in CBT. We discussed only a sample of potential predictors, moderators and mediators; many others deserve study. A key question for research is which aspects of the formulation have greatest treatment utility (Nelson-Gray, 2003). Is it most important to attend to ethnicity? Motivation to change? Psychological mechanisms that maintain the symptoms? Origins of the mechanisms? Related, many case formulation formats and models, and many methods for developing a case formulation, have been developed (e.g. Haynes et al., 2011; Frank and Davidson, 2014; Kuyken et al., 2009; Nezu et al., 2004; Persons, 2008; Sturmey, 2008). These methods differ in the elements they assess and emphasise. For example, Kuyken et al. (2009) emphasise assessment of strengths, whereas Frank and Davidson (2014) and Persons (2008) emphasise assessment of transdiagnostic mechanisms like contingencies, schemas, intolerance of uncertainty and perfectionism. Research is needed to identify which models and which elements of the case formulation have the greatest treatment utility. Of the many strategies for developing a formulation, our review identifies the functional analysis as the one with the greatest empirical support, perhaps because it is the single strategy that has been most often studied. We conclude that functional analysis deserves more attention from researchers, trainers and practitioners. Using the formulation to guide treatment Treatment development Evidence that features such as ethnicity, readiness to change, anxiety sensitivity and others are predictors, moderators and mediators highlights the need for research to understand how these factors affect treatment and to inform clinicians about how to effectively address them in treatment. Research along these lines has the potential to help researchers strengthen available treatments and develop new ones. Targeting factors like ethnicity is complicated by that fact that ethnicity is not a problem for which individuals seek treatment. In addition, the clinician is pressed to address the possibility of increased dropout or other culturally related responses without inflating stereotypes. One approach is to individually assess for factors that have been shown to be elevated within particular cultural groups and frequently associated with emotional difficulties (e.g. higher levels of emotion suppression among Asians; Butler et al., 2007). The clinician could then work collaboratively with the patient to examine whether changes in these factors help alleviate the individual’s symptoms or are unrelated to the presenting problems (Hong, 2013). Transdiagnostic mechanisms A strength of the case formulation–driven approach to treatment is that it allows the clinician to develop a case formulation that identifies one or more transdiagnostic

Case formulation and the outcome of CBT  29

mechanisms (e.g. perfectionism, overestimation of threat, schemas, faulty contingencies) that cause and maintain multiple symptoms and problems, giving rise to the potential that treatments that target those common mechanisms might simultaneously treat multiple symptoms and problems. An important example is acceptance and commitment therapy (ACT), which targets experiential avoidance, and has been shown to provide effective treatment for multiple disorders (Hayes et al., 2006; Ost, 2008). Other examples include treatments developed by Dugas and colleagues (Dugas et al., 1998; Dugas and Ladouceur, 2000) for intolerance of uncertainty, and by Shafran and colleagues (2002) for perfectionism. An alternate transdiagnostic treatment strategy is provided by Barlow’s unified protocol for the emotional disorders (Barlow et al., 2011), which targets several mechanisms (including low motivation to change, distorted cognitions and experiential avoidance) that maintain multiple anxiety and mood disorders. The focus on identifying and developing interventions to target transdiagnostic mechanisms is consistent with NIMH’s current research agenda (Onken et al., 2014). Modular treatment Several of the studies that demonstrate the treatment utility of the formulation (e.g. Johansson et al., 2012; Schneider and Byrne, 1987; Weisz et al., 2012) use a modular design. That is, the clinician uses a case formulation of some sort, or a decision flow chart, to select modules from a list. Modules are elements of protocols; Weisz and colleagues (2011) and Embry and Biglan (2008) use the term ‘kernels’ to describe modules, and contrast them to ‘ears’ (whole protocols). Modular treatments of this sort have huge promise, for several reasons. One is that there is evidence that clinicians are more willing to adopt flexible modular treatments than single disorder protocols (Borntrager et al., 2009). Another is that the modular strategy can make training more efficient, and help solve the problem of the proliferation of protocols (Craske, 2012). A third is that modular treatments allow clinicians the flexibility they need without exposing them to the disadvantages of too much individualisation. Our review (see the study by Schulte et al., 1992, and the usual care condition of the Weisz et al., 2012 study) hints at the possibility that too much individualisation is not a good thing. Fourth, modular treatments facilitate the treatment of patients with multiple comorbidities, and of course these are the rule, not the exception. Data supporting the effectiveness of modular treatments point to the need for more research examining the evidence-base underpinning the modules (see Embry and Biglan, 2008). Multiple comorbidities Some of the strongest results in support of the treatment utility of a case formulation arose in studies of complex cases of patients with multiple comorbidities (Weisz et al., 2012; Johansson et al., 2012). The case formulation seems likely

30  Jacqueline B. Persons and Janie J. Hong

to be most useful in the treatment of complex cases with multiple comorbidities and difficulties such as low motivation for treatment, noncompliance and poor response that raise problems for the clinician that she must address in some way (Persons, 2013). Obtaining feedback In the feedback element of a case formulation–driven approach to treatment, the therapist collects data at every session to monitor the outcome and process of treatment. The therapist collects data to assess symptoms and functioning to evaluate the degree to which the patient is accomplishing his treatment goals (outcome). The therapist also collects data about therapy process (the alliance, adherence, change in mechanisms, what the patient is learning, satisfaction with treatment) in order to test the formulation and to identify any factors (e.g. low adherence, low motivation to change) that might interfere with treatment. Large numbers of measures have been developed to assess symptoms; fewer are available to assess functioning, and even fewer to assess therapy process. To assess process, we have developed a paper and pencil scale, the Session Assignment and Feedback Scale (SAFF; Persons et al., in press) to track the patient’s homework assignments and assess all of these aspects of process at every therapy session (available at no charge at www.cbtscience.com). Other process monitoring tools have been developed by Burns (1997) and Miller et al. (2005), amongst others. The strength of the evidence supporting the benefits of collecting feedback data coupled with evidence that most practitioners do not monitor their patients’ progress (Hatfield and Ogles, 2004) indicates that this topic deserves more attention from psychotherapy trainers and practitioners. The entire three-part model A striking finding of our review was that there were almost no studies (except Weisz et al., 2012; Litt et al., 2009; and Persons et al., 1999, 2006) that examined all three elements of case formulation–driven CBT (developing a formulation, using the formulation to guide treatment and collecting feedback data). One question this finding raises is: are all three elements truly necessary? Certainly the first two are essential to a case formulation–guided treatment: the therapist develops a case formulation and uses it to guide treatment. Is a feedback element necessary? We argue that collecting feedback, or doing progress monitoring, is essential to treatment guided by a case formulation, and here is our reasoning. We do not view case formulation–guided CBT as a new treatment. Instead, we view it as a framework or systematic way to adapt nomothetic formulations and interventions, usually drawn from the empirically supported treatments, to the individual case. The idiographic case formulation is a hypothesis that we use to guide intervention. Because the formulation is a hypothesis, we must collect data to test it. And

Case formulation and the outcome of CBT  31

because our goal is to provide evidence-based treatment, we must collect data to evaluate our patient’s progress (Howard et al., 1996). Thus, we view the feedback element of the model as essential, and in fact we view it as an essential element of evidence-based treatment. If the feedback element is essential to a case formulation–driven treatment, the fact that almost no studies of the method include the feedback element is quite striking, and indicates that there is an exceedingly wide gap between the research studies of case formulation and the model of case formulation–driven CBT that we describe. Treatment development strategy The gap between the model that clinicians use to do evidence-based practice and the psychotherapy research literature may result in part from the use of the stage model of treatment development that calls for clinical scientists to develop new treatments in the lab, carry out efficacy studies there, and then carry out effectiveness studies to examine the treatment’s effectiveness in the clinic (Rounsaville et al., 2001). To bring clinical work and psychotherapy research closer together, Weisz (2014) has suggested an alternate treatment development model in which clinical scientists develop treatments with the populations of clinicians and patients who will be using them, not in the lab. Studies of clinical decision making Most of the research studies we examined focus on the use of the formulation to select interventions (e.g. Jacobson et al., 1989; Johansson et al., 2012; Schneider and Bryne, 1987; Weisz et al., 2012). Intervention selection is an important decision. But clinicians make many other types of decisions, including: when ought I bring in the patient’s significant other? Is it a good idea to shift the focus to work on increasing motivation for change? Would the patient benefit from less directiveness on my part? Is it time to make a change in the treatment plan? Research is needed to help clinicians improve their ability to answer these and the myriad other decisions they confront. Michael Lambert has shown that a clinical support tool that he developed to help clinicians handle treatment failure leads to improved outcome of these problematic cases when compared to cases where the clinician does not have access to the support tool (Harmon et al., 2005). The clinical support tool prompts the clinician to focus on several elements (e.g. readiness for change) that we would view as part of a comprehensive case formulation. A key role of the case formulation is to help the therapist make clinical decisions, and especially to identify and solve problems (e.g. low motivation, poor adherence, lack of progress). Therapists have particular difficulty making good decisions when their patients do not make progress (Hannan et al., 2005). As the model shown in Figure 2.1 illustrates, the case formulation–driven approach to

32  Jacqueline B. Persons and Janie J. Hong

treatment suggests that one possible action the therapist can take in this situation is to consider whether a different formulation of the case might suggest alternative and more helpful interventions (Persons and Eidelman, 2012). Case examples of the successful use of this strategy are provided by Persons and colleagues (2013; Persons and Mikami, 2002). Types of treatment utility Nearly all the studies of the treatment utility of the case formulation that we reviewed here examined the dependent variable of treatment outcome. A few studied dropout. A wide range of other important dependent variables merit study when we examine the treatment utility of the use of a case formulation–driven approach to work, including: patient adherence, patient acceptance of the treatment rationale (Addis and Jacobson, 2000), therapist willingness to adopt the treatment (Borntrager et al., 2009) and range of patient presentations that the treatment addresses (Chorpita et al., 2005). Single case studies Our review showed that single case studies provided valuable data. The single case design is well suited to answer questions about the role of the case formulation in treatment. We encourage researchers and clinicians to rely more on this under-used research strategy to carry out single case studies of the treatment utility of the case formulation, we encourage clinical science journals to publish those studies and we encourage trainers to teach their students how to implement single case designs; outstanding texts are available for this purpose (Barlow et al., 2009; Kazdin, 2011). Implications for clinical work As this review shows, case formulation–driven CBT is supported by a moderate, but not an overwhelming amount, of data. What are the implications of this fact for the practitioner who is striving to do evidence-based work? We offer the following suggestions for ways the clinician can strengthen the evidence base underpinning the use of a case formulation–driven approach to CBT (see also Persons, 2008). First, rely on evidence-based formulations and interventions (kernels) whenever possible. Second, rely on other evidence from the scientific literature (e.g. about attitudes toward mental illness that are common in individuals who share the patient’s ethnicity or cultural heritage) to guide decision-making. Finally, and most important, use an empirical hypothesis-testing approach to each case, where the formulation is the hypothesis, and the therapist and patient collect data to test the hypothesis and to monitor the process and outcome of treatment at every session. The key empirical question the clinician confronts is, ‘Is this patient benefitting from the treatment I am providing?’ and

Case formulation and the outcome of CBT  33

the way to answer this question is to collect feedback data to monitor the patient’s progress. This empirical approach to the case has its origins in the early history of behaviour therapy (see Hayes et al., 1999) and also exemplifies the practice of evidence-based medicine described by Sackett and colleagues (1997). Integrating science and practice The model of case formulation–driven treatment described in this chapter allows for, indeed promotes, a gorgeous and elegant overlap of clinical work and scientific research that allows the clinician to both use and contribute to science. Using this model, the treatment of every case is an n = 1 experiment, a clinical scientific enterprise. We encourage clinicians to use the model we describe here to collect data that allow them to provide high quality evidence-based care, and to contribute to the research literature by publishing single case studies and other studies based on those data.

Acknowledgements We thank Kaitlin Fronberg, Nicole M. Murman and especially Gening Jin for help with research, references and formatting.

References Addis, M. E. and Jacobson, N. S. (2000). A closer look at the treatment rationale and homework compliance in cognitive-behavioral therapy for depression. Cognitive Therapy and Research 24: 313–26. Anker, M. G. et al. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology 77: 693–704. Austin, A. and Wagner, E. F. (2006). Correlates of treatment retention among multi-ethnic youth with substance problems: Initial examination of ethnic group differences. Journal of Child and Adolescent Substance Abuse 15: 105–28. Barlow, D. H. et al. (2009). Single Case Experimental Designs: Strategies for Studying Behaviour Change (3rd ed.). Boston: Pearson Education. Barlow, D. H. et al. (2011). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. New York: Oxford University Press. Baron, R. M. and Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology 51: 1173–82. Beck, A. T. et al. (1979). Cognitive Therapy for Depression. New York: Guilford Press. Bickman, L. et al. (2011). Effects of routine feedback to clinicians on mental health outcomes of youths: Results of a randomized trial. Psychiatric Services 62: 1423–29. Borntrager, C. F. et al. (2009). Provider attitudes toward evidence-based practices: Are the concerns with the evidence or with the manuals? Psychiatric Services 60: 677–81.

34  Jacqueline B. Persons and Janie J. Hong Boswell, J. F. et al. (2012). Readiness to change as a moderator of outcome in transdiagnostic treatment. Psychotherapy Research 22: 570–78. Burns, D. D. (1997). Therapist Toolkit. Retrieved from www.feelinggood.com. Butler, E. A. et al. (2007). Emotion regulation and culture: Are the social consequences of emotion suppression culture-specific? Emotion 7: 30–48. Carlier, I. V. E. et al. (2012). Routine outcome monitoring and feedback on physical or mental health status: Evidence and theory. Journal of Evaluation in Clinical Practice 18: 104–10. Chorpita, B. et al. (2005). Identifying and selecting the common elements of evidence based interventions: A distillation and matching model. Mental Health Services Research 7: 5–25. Chorpita, B. F. et al. (1996). Systematic replication of the prescriptive treatment of school refusal behavior in a single subject. Journal of Behavior Therapy and Experimental Psychiatry 27: 1–10. Chorpita, B. F. et al. (2013). Long-term outcomes for the Child STEPs randomized effectiveness trial: A comparison of modular and standard treatment designs with usual care. Journal of Consulting and Clinical Psychology 81: 999–1009. Clair, M. et al. (2013). Ethnicity as a moderator of motivational interviewing for incarcerated adolescents after release. Journal of Substance Abuse Treatment 45: 370–75. Conrod, P. J. et al. (2000). Efficacy of brief coping skills interventions that match different personality profiles of female substance abusers. Psychology of Addictive Behaviors 14: 231–42. Craske, M. G. (2012). Transdiagnostic treatment for anxiety and depression. Depression and Anxiety 29: 749–53. Dugas, M. et al. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy 36: 215–26. Dugas, M. J. and Ladouceur, R. (2000). Treatment of GAD targeting intolerance of uncertainty in two types of worry. Behavior Modification 24: 635–57. Embry, D. D. and Biglan, A. (2008). Evidence-based kernels: Fundamental units of behavioral influence. Clinical Child Family Psychology Review 11: 75–113. Fairburn, C. G. et al. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa. In C. G. Fairburn and G. T. Wilson (eds) Binge Eating: Nature, Assessment, and Treatment. New York: Guilford Press. Farchione, T. J. et al. (2012). Unified protocol for transdiagnostic treatment of emotional disorders: A randomized controlled trial. Behavior Therapy 43: 666–78. Forand, N. R. et al. (2011). Cognitive behavioral therapy in practice: Treatment delivered by trainees at an outpatient clinic is clinically effective. Behavior Therapy 42: 612–23. Frank, R. I. and Davidson, J. (2014). A Transdiagnostic Roadmap to Case Formulation and Treatment Planning: Practical Guidance for Clinical Decision Making. Oakland, CA: New Harbinger. Ghaderi, A. (2006). Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa. Behaviour Research and Therapy 44: 273–88. Goodman, J. D. et al. (2013). Progress monitoring in mental health and addiction treatment: A means of improving care. Professional Psychology: Research and Practice 44: 231–46. Hagopian, L. P. et al. (2013). Initial functional analysis outcomes and modifications in pursuit of differentiation: A summary of 176 inpatient cases. Journal of Applied Behavior Analysis 46: 88–100.

Case formulation and the outcome of CBT  35 Hannan, C. et al. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology: In Session 61: 155–63. Harmon, C. et al. (2005). Improving outcomes for poorly responding clients: The use of clinical support tools and feedback to clients. Journal of Clinical Psychology 61: 175–85. Hatfield, D. R. and Ogles, B. M. (2004). The use of outcome measures by psychologists in clinical practice. Professional Psychology: Research and Practice 35: 485–91. Hayes, S. C. et al. (1999). The Scientist-Practitioner: Research and Accountability in the Age of Managed Care (2nd ed.). Boston, MA: Allyn and Bacon. Hayes, S. C. et al. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy 44: 1–25. Haynes, S. N. et al. (1997). Design of individualized behavioral treatment programs using functional analytic clinical case models. Psychological Assessment 9: 334–48. Haynes, S. N. et al. (2011). Behavioral Assessment and Case Formulation. Hoboken, NJ: John Wiley and Sons. Hong, J. J. (2013). An idiographic evidence-based approach to addressing cultural factors in treatment: A case example. Behavior Therapist 36: 143–46. Howard, K. I. et al. (1996). Evaluation of psychotherapy: Efficacy, effectiveness, and patient progress. American Psychologist 51: 1059–64. Huppert, J. D. et al. (2006). The interaction of motivation and therapist adherence predicts outcome in cognitive behavioral therapy for panic disorder: Preliminary findings. Cognitive and Behavioral Practice 13: 198–204. Iwata, B. A. et al. (1994). The functions of self-injurious behavior: An experimentalepidemiological analysis. Journal of Applied Behavior Analysis 27: 215–40. Jacobson, N. S. et al. (1989). Research-structured vs. clinically flexible versions of social learning-based marital therapy. Behaviour Research and Therapy 27: 173–80. Johansson, R. et al. (2012). Tailored vs. standardized internet-based cognitive behavior therapy for depression and comorbid symptoms: A randomized controlled trial. PLoS ONE 7(5): e36905. doi:10.1371/journal.pone.0036905 Kazdin, A. E. (2011). Single-Case Research Designs: Methods for Clinical and Applied Settings (2nd ed.). New York: Oxford University Press. King, A. C. and Canada, S. A. (2004). Client-related predictors of early treatment drop-out in a substance abuse clinic exclusively employing individual therapy. Journal of Substance Abuse Treatment 26: 189–95. Knaup, C. et al. (2009). Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis. British Journal of Psychiatry 195: 15–22. Kuyken, W. et al. (2009). Collaborative Case Conceptualization. New York: Guilford Press. Lambert, M. J. et al. (1996). The reliability and validity of the Outcome Questionnaire. Clinical Psychology and Psychotherapy 3: 106–16. Lambert, M. J. and Shimokawa, K. (2011). Collecting client feedback. Psychotherapy 48: 72–79. Litt, M. D. et al. (2009). Individualized assessment and treatment program for alcohol dependence: Results of an initial study to train coping skills. Addiction 104: 1837–48. McFarland, B. R. and Klein, D. N. (2005). Mental health service use by patients with dysthymic disorder: Treatment use and dropout in a 7 1/2-year naturalistic follow-up study. Comprehensive Psychiatry 46: 246–53. McKnight, D. L. et al. (1984). Importance of treating individually assessed response classes in the amelioration of depression. Behavior Therapy 15: 315–35.

36  Jacqueline B. Persons and Janie J. Hong Miller, S. D. et al. (2005). The partners for change outcome management system. Journal of Clinical Psychology 61: 199–208. Nelson-Gray, R. O. (2003). Treatment utility of psychological assessment. Psychological Assessment 15: 521–31. Nelson-Gray, R. O. et al. (1989). Effectiveness of matched, mismatched, and package treatments of depression. Journal of Behavior Therapy and Experimental Psychiatry 20: 281–94. Nezu, A. M. et al. (2004). Cognitive-Behavioral Case Formulation and Treatment Design: A Problem-Solving Approach. New York: Springer. Onken, L. S. et al. (2014). Reenvisioning clinical science: Unifying the discipline to improve the public health. Clinical Psychological Science 2(1): 22–34. Ost, L. G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy 46: 296–321. Persons, J. B. (2008). The Case Formulation Approach to Cognitive-Behavior Therapy. New York: Guilford Press. Persons, J. B. (2013). Who needs a case formulation and why: Clinicians use the case formulation to guide decision-making. Pragmatic Case Studies in Psychotherapy 9: 448–56. Persons, J. B. and Eidelman, P. (2012). Handling treatment failure successfully. Paper presented at the Association for Behavioral and Cognitive Therapies, National Harbor, Maryland. Persons, J. B. et al. (1999). Results of randomized controlled trials of cognitive therapy for depression generalize to private practice. Cognitive Therapy and Research 23: 535–48. Persons, J. B. et al. (2006). Naturalistic outcome of case formulation-driven cognitive-behaviour therapy for anxious depressed outpatients. Behaviour Research and Therapy 44: 1041–51. Persons, J. B. et al. (2013). Testing case formulation hypotheses in psychotherapy: Two case examples. Cognitive and Behavioral Practice 20: 399–409. Persons, J. B. et al. (in press). Learning from patients and practice. In L. F. Campbell (ed.) APA Handbook of Clinical Psychology (Vol. Education and Profession). Washington, DC: American Psychological Association. Persons, J. B. and Mikami, A. Y. (2002). Strategies for handling treatment failure successfully. Psychotherapy: Theory/Research/Practice/Training 39: 139–51. Priebe, S. et al. (2007). Structured patient-clinician communication and 1-year outcome in community mental healthcare. British Journal of Psychiatry 191: 420–26. Prochaska, J. O. and DiClemente, C. C. (1986). The transtheoretical approach. In J. C. Norcross (ed.) Handbook of Eclectic Psychotherapy. New York, NY: Brunner/Mazel. Reese, R. J. et al. (2009). Does a continuous feedback system improve psychotherapy outcome? Psychotherapy Theory. Research, Practice, Training 46: 418–31. Reese, R. J. et al. (2010). Effect of client feedback on couple psychotherapy outcomes. Psychotherapy Theory, Research, Practice, Training 47: 616–30. Reiss, S. and McNally, R. J. (1985). The expectancy model of fear. In S. Reiss and R. R. Bootzin (eds) Theoretical Issues in Behavior Therapy. London: Academic Press. Rounsaville, B. J. et al. (2001). A Stage Model of Behavioral Therapies Research: Getting Started and Moving on From Stage I. American Psychological Association 8: 133–42. Ryan, S. R. et al. (2013). Predictors of therapist adherence and emotional bond in multisystemic therapy: Testing ethnicity as a moderator. Journal of Child and Family Studies 22: 122–36.

Case formulation and the outcome of CBT  37 Sackett, D. L. et al. (1997). Evidence-Based Medicine: How to Practice and Teach EBM. New York: Churchill Livingstone. Schneider, B. H. and Byrne, B. M. (1987). Individualizing social skills training for behavior-disordered children. Journal of Consulting and Clinical Psychology 55: 444–45. Schulte, D. et al. (1992). Tailor-made versus standardized therapy of phobic patients. Advances in Behaviour Research and Therapy 14: 67–92. Shafran, R. et al. (2002). Clinical perfectionism: A cognitive-behavioural analysis. Behaviour Research and Therapy 40: 773–91. Smits, J. A. J. et al. (2004). Mechanism of change in cognitive-behavioral treatment of panic disorder: Evidence for the fear of fear mediational hypothesis. Journal of Consulting and Clinical Psychology 72: 646–52. Smits, J. A. J., Julian, K., Rosenfield, D., & Powers, M. B. (2012). Threat reappraisal as a mediator of symptom change in cognitive behavioral treatment of anxiety disorders: A systematic review. Journal of Consulting and Clinical Psychology, 80(4), 624–635. doi: 10.1037/a0028957 Sturmey, P. (2008). Behavioral Case Formulation and Intervention. A Functional Analytic Approach. Chichester: Wiley-Blackwell. Teachman, B. A. et al. (2010). Catastrophic misinterpretations as a predictor of symptom change during treatment for panic disorder. Journal of Consulting and Clinical Psychology 78: 1–10. Thompson-Brenner, H. et al. (2013). Race/ethnicity, education, and treatment parameters as moderators and predictors of outcome in binge eating disorder. Journal of Consulting and Clinical Psychology 81: 710–21. Vernmark, K. et al. (2010). Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression. Behaviour Research and Therapy 48: 368–76. Weisz, J. R. (2014). Building robust psychotherapies for children and adolescents. Perspectives on Psychological Science 9: 81–84. Weisz, J. R. et al. (2011). Kernels vs. ears and other questions for a science of treatment dissemination. Clinical Psychology: Science and Practice 18: 41–46. Weisz, J. R. et al. (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth. Archives of General Psychiatry 69: 274–82. Wolitzky-Taylor, K. B. et al. (2012). Moderators and non-specific predictors of treatment outcome for anxiety disorders: A comparison of cognitive behavioral therapy to acceptance and commitment therapy. Journal of Consulting and Clinical Psychology 80: 786–99. Yeung, A. S. et al. (2012). Clinical outcomes in measurement- based treatment (COMET): A trial of depression monitoring and feedback to primary care physicians. Depression and Anxiety 29: 865–73.

Chapter 3

Formulation from the perspective of contextualism Helen Combes and Chris Cullen

Some old history Much of the behavioural approach is said to have its roots in early operant and classical conditioning work with non-human animals, notably rats and pigeons. It is from this pioneering work that the importance of setting events and consequences came to be understood. In clinical work arising from behavioural approaches, consequences, in particular reinforcement, have assumed a massive significance. Behavioural clinicians have been caricatured as always looking for reinforcers – notwithstanding the fact that reinforcement is a relation, and not a thing (cf. Catania, 1992), but that’s another story. Consider then, the following (somewhat hypothetical) scenario. You are taken as a visitor to an operant laboratory (some time ago, since such experiments would rarely be carried out today) and you are shown a pigeon in an experimental chamber. All the usual paraphernalia are present, and the pigeon pecks at an illuminated key on the wall of the chamber. Nothing else happens, even though you wait for several minutes. What you notice especially is that there is no reinforcer delivered. You are then invited to explain why the pigeon is pecking in the absence of a reinforcing consequence. This is an exercise we have used many times with trainee clinicians. If the point of the exercise is not immediately obvious, consider how many clients appear to engage in behaviour which seems to be pointless, or even dangerous, in the absence of any positive pay off. Answers often given to the conundrum include: the pigeon is expecting food since the response was shaped up initially in the standard operant paradigm; the pigeon is bored; the pigeon has developed an obsessive-compulsive disorder (now we’re getting closer to real-world clinical phenomena) and so on. Eventually someone may hit upon the possibility that something unpleasant might happen if the pigeon doesn’t peck. This is the correct answer. The pigeon’s behaviour is on an avoidance schedule, and failure to peck results in some noxious event, usually electric shock. Because nothing appears to be happening, the person looking at the behaviour in the here and now, with no information about how the behaviour came to be established, will be at a loss to know how to explain it.

Formulation and contextualism  39

Early avoidance experiments used a discrete trial training approach, each presentation of the shock was preceded by a brief warning stimulus. Early theorists, puzzled by the absence of any observable reinforcers for avoidance behaviour – after all, when the animal is successful, nothing happens – theorised that it must be a reduction in the likelihood of expected shock, with concomitant reductions in fear and anxiety, which ‘did the trick’ (cf. Dinsmoor, 2001a). Thus, the hapless pigeon was said to have become anxious as a result of its history of receiving shock, and when a brief warning stimulus sounded it would spring into action to prevent the shock which would follow. The pigeon’s behaviour was being controlled by the antecedent, or preceding event. Because the bird was successful at preventing shocks its anxiety would decrease, an obvious (albeit unseen) negative reinforcer. We can imagine apparent parallels in real-world clinical situations – for instance, the client who escapes at the first sign of someone getting close to her because intimate relationships have failed in the past, with concomitant heartache. Even more challenging to explain, however, is avoidance behaviour when there is no warning stimulus (Sidman, 1953). In this paradigm, brief shocks are presented at pre-determined intervals unless the animal responds. Responding postpones the shock. Some theorists have postulated that tactile and proprioceptive stimuli generated by ineffective or non-avoidance behaviour would become aversive to the animal and hence the animal would behave in order to escape from these. Although we must always be careful of extrapolating from simple experiments with non-humans, perhaps it is not too fanciful to imagine that, just as the pigeon might avoid an electric shock by pressing a lever, we might develop lots of superficial relationships and learn to avoid any situation which might conceivably lead to the possibility of heartache. It is easy to see how behaviours can emerge through direct contact with contingencies. However, it seems that humans (and some non-human animals) may learn in different and more complex ways without direct contact with the contingencies. Whatever is the ‘correct’ theory need not concern us here. There has been much debate on this matter in the behaviour analytic literature (cf. Baron and Perone, 2001; Baum, 2001; Bersh, 2001; Branch, 2001; Dinsmoor, 2001a, 2001b; Hineline, 2001; Michael and Clark, 2001; Williams, 2001). Although this may seem remote from the concerns of clinicians, there is relevance to the problem of formulation from a behavioural standpoint. Our contention is that much clinical formulation requires not only a careful and thorough assessment of client behaviour now, and its relation to current environmental events, but also an understanding of the person’s behavioural history. Unfortunately this will rarely be clear or obvious to us, or indeed to the client. We should also point out that we are not claiming any direct analogy between real-world situations for humans and the relatively simple experimental manipulations researchers have conducted with non-humans. These may point the way to an understanding of basic processes, but we have known for many years that simple schedules rarely explain human behaviour (cf. Cullen, 1981; Poppen, 1982).

40  Helen Combes and Chris Cullen

Basic behavioural formulation Traditionally, formulation from a behavioural perspective involves a detailed description of current behaviour(s) and attempts to identify the relatively immediate antecedents and consequences which appear to be related to the behaviour. For example, a client gets upset and tearful when challenged, which leads to people not challenging. So, being upset and tearful becomes a prominent part of the person’s repertoire when they face difficult and challenging circumstances. It has typically been in services for people with intellectual disabilities that simple formulation in terms of antecedents(A)–behaviour(B)–consequences(C) has survived. In some cases these simple formulations prove to be very helpful, especially to staff groups with little experience. For example, a client presents with self-injurious behaviour, which consists of hitting himself on the side of his head. Over several days, care staff are asked to note each time he hits himself; what was going on at the time; what happened immediately after he hit himself; who was present and so on. An examination of the records shows that this tends to happen during morning and afternoon occupational therapy sessions, when he is expected to participate in various tasks. Once he starts hitting himself he is removed to another room and ‘diverted’ by a dedicated member of staff. It becomes clear that his hitting has an escape function, and also has positive consequences. Formulating the problem in this way allows questions to be asked about the value (to the client) of the tasks he is expected to do, and why he experiences one-to-one contact as so desirable – so much so that he is willing to hurt himself in order to get it. Perhaps the task can be altered so that he doesn’t want to escape from the situation, maybe by providing powerful consequences for participating. Perhaps the consequences can involve giving him dedicated one-to-one contact while productively engaged. The utility of such relatively simple formulations should not be undervalued, since they can lead to significant behavioural changes. A methodology has evolved which enables the clinician/researcher to manipulate aspects of the environment to determine whether behaviour is maintained by a consequence or is an escape response, an avoidance response or is happening because the person has nothing else to do. This analogue assessment is very useful in determining relatively simple behavioural functions (cf. Sturmey, 1995). However, it is often the case – as in the avoidance paradigm we discussed at the beginning of this chapter – that more is needed. Consider the infamous historical ‘experiment’ to condition emotional reactions in an 11-month-old child, Albert B (Watson and Rayner, 1920). Albert was made to fear a white rabbit which he had previously played with, by having a loud noise paired with presentations of the rabbit. His fear generalised to other stimuli, such as a rabbit, a dog, a fur coat and a Santa Claus mask. They had planned to reverse the fear, but Albert’s mother removed him from the institution before they could begin the reconditioning. Watson and Rayner considered the difficulty future clinicians might have in formulating an analysis of Albert’s fear; they mischievously contributed to the battle between behaviourists and the psychoanalysts which was raging at the time:

Formulation and contextualism  41

The Freudians twenty years from now, unless their hypotheses change, when they come to analyse Albert’s fear of a seal skin coat – assuming that he comes to analysis at the age – will probably tease from him the recital of a dream which upon their analysis will show that Albert at three years of age attempted to play with the pubic hair of the mother and was scolded violently for it. (We are by no means denying that this might, in some other case, condition it). If the analysts have sufficiently prepared Albert to accept such a dream when found as an explanation of his avoiding tendencies, and if the analyst has the authority and personality to put it over, Albert may be fully convinced that the dream was a true revealer of the factors which brought about the fear. (Watson and Rayner, 1920: 14) The problem the therapist has is that s/he does not have direct access to the classical or operant conditioning processes which were involved in establishing the behaviour. All they can access is the present, which includes the clients’ views on what parts of their history are relevant to their current problems. And, in Watson and Rayner’s scandalous hypothesis, what the client tells us about the dreams they may have had. This begins to emphasise the importance of the language context to understanding human behaviour. It is to this that contemporary behavioural scientists have turned their attention. Contextualism During the 1970s behaviourists became especially interested in the role language plays in human behaviour. Murray Sidman stumbled across an interesting phenomenon, which he posited may be unique to humans (there is much debate on this, which we will not cover here). He was working on a task with a young man with severe intellectual disabilities. He started by using a match to sample task (where a participant is reinforced for selecting the correct stimuli) to train a simple conditional discrimination task. From an array of arbitrary stimuli the young man was reinforced for selecting the picture of a cat upon hearing the spoken word ‘cat’. He was also taught to select the written word ‘cat’ on hearing the spoken word ‘cat’. What Sidman (1994) noted was that after being reinforced for selecting the written word ‘cat’, and the picture of a cat upon hearing the spoken word, the young man reversed the taught relationships and said the word in the presence of the written word and in the presence of the picture. The stimuli had become equivalent, without the mediation of a teacher! Now, this equivalence might seem logical, but even at its most simple level a picture of a cake is not a cake, and we would not eat the picture or the written (or spoken) word. The symbol does not have an equivalent function, but we come to believe that words and thoughts are the same as the feared event itself. For example, if I say to myself that ‘I am rubbish’ it does not mean that I am literally ‘rubbish’. And the word

42  Helen Combes and Chris Cullen

‘mum’ does not share all of the same physical attributes as Mum herself, but as I think of the word ‘mum’, images are conjured up of my mother and situations in which we have been together. It seems that as humans we begin to ascribe the same attributes to the word as to the stimulus named or described. Whilst numerous studies have shown that some of these untaught relationships can be seen in animals, there is no doubt that there is something unique about human learning. There is evidence that this non-contingent learning is related to human language, and that it is language which enables us to move beyond the direct contingencies (Horne and Lowe, 1996). Language confers many benefits on us as a species – we can learn not to run across busy roads from instruction and even to be kind of one another so that people will be kind to us. We can extrapolate from one situation to another in many ways using words, symbols and stories. It is arguably the essence of creative thought and action. It does, however, have the potential to harm us. The act of naming things means that we may begin to avoid events with which we have never had any direct contact, because through language we categorise and make connections between things without having any logical reason. We may think that we will pass out on giving a public lecture because we have heard stories of people collapsing on stage without ever having given a lecture or even having passed out ourselves! But what does this mean for us as clinicians? Sidman (1994: 536) describes formulation as a ‘descriptive system, which offers a consistent, coherent and parsimonious way of defining a phenomenon, in our case a clinical problem’. Modern behavioural formulations are contextual (Pepper, 1942). This is both a philosophy of science and a world view, although the wider ramifications of contextualism need not concern us here. The essence for a clinical formulation is to understand that all behaviour must be considered in context and this includes the language context. This is why the doyen of behavioural formulation, B. F. Skinner, emphasised that it was not the response which is the fundamental behavioural unit, but the operant – that is, the antecedent–behaviour–consequence relationship. Behaviour cannot be understood outside its immediate and historical context. Hayes (2004: 8) puts it thus: ‘Contextualists are supremely interested in function over form, because formal events literally have no meaning. An event disconnected from its history and current situational context is, in some sense, not an “event” at all.’ Consider the person walking down a street, heard talking to herself. We might see this as evidence of some form of psychosis or an actor on her way to an audition, or she could be speaking on a cell phone using a headset with a microphone. The only way we could know would be to have more information, either from the person herself or from some other reliable source. Similarly, how should we interpret a client’s score of 25 on the Beck Depression Inventory (Richard and Haynes, 2002)? Without relevant historical and present contextual information such a score tells us only that the person has a clinical level of depression. But if we knew the client’s scores over previous sessions this would tell us whether

Formulation and contextualism  43

there has been significant improvement or worsening, which is more useful in formulation that the labelling we can do by only having the score at one single point in time. The essence of all behavioural formulations is to be able to identify and understand enough of the context to inform appropriate intervention. This is not a call for trying to identify all possible contextual influences, in some kind of ever-widening circle. Contextualists hold a pragmatic view of truth, with the main criterion being successful working. Steven Hayes, writing on the relevance of contextualism, quotes from a 30-year-old text by Skinner: It is true that we could trace human behaviour not only to the physical conditions which shape and maintain it but also to the causes of those conditions, and the causes of those causes, almost ad infinitum but we need take analysis only to the point at which ‘effective action can be taken’ (Skinner, 1974: 210). That stance on truth, built into behaviour analysis, has a big impact on treatments that take a functional analytic approach. (Hayes 2004: 8) Modern contextual approaches include dialectical behaviour therapy (Linehan, 1993), acceptance and commitment therapy (Hayes et al., 1999), functional analytic psychotherapy (Tsai et al., 2008) and mindfulness-based cognitive therapy for depression. As well as adopting a broadly contextual approach, each of these therapies has other elements in common, such as Zen-inspired approaches to acceptance. The various proponents of these therapies have together produced work which identifies commonalities (cf. Hayes et al., 2004). The ACT  Model Acceptance and commitment therapy (ACT) is a contextual psychotherapy which integrates current research knowledge into a contemporary psychotherapeutic approach (cf. Smith and Hayes, 2005). ACT looks closely at the contexts in which psychological distress occurs and draws on metaphor and analogy in its application on the basis that human distress and suffering has its origins in language. Whilst language has conferred great advantage to the human species, as individuals it can make us inflexible to change and ultimately isolate and constrain us. To make sense of some of the behavioural patterns which emerge in therapy Steven Hayes and colleagues have begun to develop a structured formulatory model of human suffering. This has been termed the ‘Hexaflex’ and offers a way of linking six areas for exploration with the client. There are two sides to the coin. One is of psychological inflexibility, which is believed to underlie psychological distress and the other is of psychological flexibility, which is believed to underlie psychological wellbeing. These models coexist. When we suffer from psychological distress, however, certain processes predominate in our lives: experiential avoidance, failing to see oneself in a wider context, a loss of clarity over our

Avoidance

Inaction

Self as content

Cognitive fusion

Ill-defined values

Past and future living

Figure 3.1 Psychological inflexibility. Within ACT, each element connects and relates to the other. This is represented by the stars and arrows. On identifying evidence of inflexibility the aim is to foster flexibility.

Acceptance

Committed action

Conceptualised self

Cognitive defusion

Clear values

Present moment living

Figure 3.2  Psychological flexibility. Within an ACT model, each element connects and relates to the others. This is represented by the star and arrows (adapted from Smith & Hayes, 2005).

Formulation and contextualism  45

values, inactivity, a focus on the past or worrying about the future and cognitive fusion (see Figure 3.1). This is central to ACT and refers to the way we tend to relate to thoughts and language as if they were the events thought or spoken about. However, none of the elements within the Hexaflex is independent and as with much of language and behaviour it is inherently paradoxical: once we see the connectedness we can begin to loosen its hold on us. To aid clarification, however, we are going to offer case illustrations from each of these processes (in so far as is reasonably possible). In psychotherapeutic work, the aim of ACT is to facilitate psychological flexibility (see Figure 3.2). This is achieved in therapy through the use of metaphor, analogy and stories. Let us give some case examples that we can all easily relate to. Clear values Sometimes it seems to us that we avoid events because we have lost sight of our values. We generally focus on values at the start of therapy, although recognise that for some people this emerges later. From our position we believe that people often experience greater psychological distress if they do not think that they are living their life in accordance with their values, and if life seems to have gone off track. A very simple exercise (developed by Wilson and DuFrene, 2009) is to give someone a values record and ask them to rank their values and then to consider the extent to which they have lived their life in accordance with those values over the past week. The values include family, citizenship, marriage (couples and intimate relationships), friendships, health and well-being. The exercise which follows is with a woman whose partner has had a stroke and is repeatedly falling. The therapist and client had drawn up a values record (Wilson and DuFrene, 2009). The values record helps to highlight goals, in this case something that she can do which will help her to move forward in her life. The therapist is not climbing the mountain with the client, or even telling them how to climb the mountain, but is rather helping them to find their own path up the mountain. T: As you look through that list, if I were to tell you that you could only live your life in accordance with three of those values which would they be? C: That’s hard. Really just three, but I guess that’s true . . . how can I? T: Just hold onto identifying those three for a moment. What would it mean to achieve that – to truly live your life by those values? C: Well that would be good . . . to be healthy, live in partnership and to work with the students, I guess that’s community . . . T: And if you could have just one of those what would it be? What do you want to be remembered for? C: Oh, that’s not nice. T: It is hard to face but if you did, if you could do that, what would you see yourself doing, right now?

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C: Well this, because we have to work together . . . T: Yes, I can see that this matters, and when you go home? C: Well I guess it is about us talking together. What care does he want from me now?

Self as context It is important to recognise that feelings, thoughts and behaviour occur in context and are not a fixed part of us. To help clients to see this we might ask them to imagine themselves being an observer of a particularly difficult situation, retelling the story without judgement. We may ask the client to reflect on an event which led to them seeking therapy. The point of the exercise is to find ways to help the person see that they are the vessel for experience, not the content of the experience. One of us worked with a woman who had been involved in a road traffic accident involving a lorry. She had always conceptualised herself as a strong and active woman but the car accident had emphasised a much more vulnerable sense of self. She was invited to imagine the accident, seeing it from many different perspectives – her own position as the car driver, that of the bystander and that of the helpers. She then used humour – a characteristic she had previously had, but had not seen much of lately – to look upon the situation differently. She loved the sea and when visualising the accident as part of an exposure exercise drew from a metaphorical understanding. She saw the lorry and visualised the sea as the God ‘Neptune’ demolishing the lorry from the accident with one sweep. The client was watching from the safe distance of a bridge overlooking the bypass where the accident had happened. The client said she found this therapeutic exercise helpful in enabling her to get things into perspective and to see things more fully. She came to recognise that sometimes strength could come from vulnerability. It is possible that the exercise is one example of simple exposure, rather than of any more complex metacognitive sub-system operating. Acceptance Within the Hexaflex (see Figure 3.1) there is an element referred to as acceptance. Within clinical practice we often see avoidance as opposed to acceptance. For example, consider the couple fearful of talking about their relationship in case it makes things worse, so they stop talking and thinking about one another. It seems quite natural to avoid unpleasant situations and events, and it seems just as logical to avoid unpleasant thoughts. We get – to coin Steven Hayes’ line – stuck in our minds and not in our lives (Hayes, 2004). Acceptance is not a passive thing but is rather an active understanding of our experience. In therapy, techniques are used to highlight the ebb and flow of

Formulation and contextualism  47

thinking. In one case (see example below) the client thought that it was his fault when his father was unwell and began avoiding engaging in family activities. When asked to describe a time when things really were his fault the client shied away from the therapist’s gaze. T: This might be hard but can you tell me what is going through your mind right now? C: An image of me. I am a child . . . T: Are you willing to just close your eyes and look closely at that moment? C: [Nods] T: How old is the child? C: He’s, I’m five . . . hiding under the stairs. That is where I used to go when I was in trouble. T: OK, would you be willing to talk me through one of those times and really look carefully at it? C: I can. It is dark; I can only hear the shouting outside. I am trying to be quiet. I don’t want them to find me . . . [tears streaming down face] T: What about sensations? Notice the movement of the air against your skin . . . What sounds can you hear? Can you try to turn the sounds up? C: [Sobbing] T: If you were with that child now, a compassionate adult witnessing all this, what would you say to them? C: I can’t . . . there is nothing . . . T: Maybe a candle, a flicker of light, something that will give that child hope? C: It is not your fault . . . you are just a child; it is not your fault [sobbing]. You are not to blame. T: OK. Can you just open your eyes and tell me what is going on right here and now . . . C: Well, now as an adult, of course, how can a child be at fault? The client reported this exercise as having had a very powerful effect on his well-being, recognising and accepting the impact of his past on himself now. Being present In the above exercise it is clear that the client’s understanding of the past is colouring his predictions about the future. We see examples of this in everyday decision making – fears of how people will see the things we do prevent us making decisions which will help us in the longer term. In times of financial constraints, hospitals may decide to reduce the workforce without seeing that a fully staffed hospital is more able to provide compassionate care to others, which will in the longer term be more financially sustainable. We are fearful of having to explain our decisions to financial regulators and as such we make short-term decisions, based on unknown but feared consequences. From

48  Helen Combes and Chris Cullen

an ACT position we would not forgo an opportunity to act with compassion out of fear, instead we would encourage decision-makers to embrace longer-term outcomes. In therapy we might help people to understand this principal by sharing a metaphor. Imagine a skier who is trying not to catch an edge as they go down the slope. The more they try to avoid catching the edge the less balanced they become. It is perhaps possible that when skiing it might become more likely to happen because they are worrying about it. The message is: live life in the present and enjoy it. Cognitive defusion We use cognitive defusion techniques when people have become stuck in their thinking. To defuse thought fusion, we might ask people to label the word as a thought – ‘I am having the thought that things are my fault.’ We witness cognitive fusion when people describe thinking and feeling as if they are facts. Thought defusion enables us to loosen the relationship between ourselves and our thoughts. We might also ask people to think about something they are really ashamed about and to repeatedly go back to it. One experiment to defuse might simply be to ask someone to constantly think about the thing that concerns them, to write it down and tell it to other people. Some aspects of EMDR are close to cognitive defusion; it helps us to look at the event over and over again and to look upon it differently (cf. Shapiro and Maxfield, 2002). For example one of our clients, Mr X, had come to believe that because he had ME he must be faulty in every aspect of his life. We can see how this might happen; let us think about a clinical example of this. One of us worked with a man who believed that things had always been his fault and would be in the future. He did not believe that he could care or show compassion toward others for fear that he would hurt them (because he was ‘faulty’). First, we tried a simple defusion exercise by saying the same word over and over again. The client might be asked to think about a glass of milk and to imagine all the sensations relating to that word. They will then be asked to say the word ‘milk’ over and over again and to just notice what happens when they say the word over. For most people the words merge in sounds and then the images and feelings fall away. Mr X tried that with the word which he most feared – ‘fault’. Valued action There are various times when we might witness inaction in therapy. Behavioural experiments can help move people towards a position of action, the mindful development of small achievable goals which demonstrate that people are taking steps towards their valued life direction is another way we may facilitate action. We may find someone who is reluctant to practice things when they are at home or they may even struggle to fill in measures and forms. The client below identified strongly with the biking community. All of his life he had been a ‘biker’ and loved

Formulation and contextualism  49

the freedom it had given him. Below is a transcript of a session where there is some evidence of his inaction: T: When we met last time you had found it hard to complete the Impact of Life Events Scale because it gave you a headache. You said you would like to do it away from our session. How did you get on? C: The thing is, like, and this is no offence, but I think everything is a bit tick-boxy and things aren’t like that. I don’t think you get me. I just don’t sleep, like, and you know that – I shouldn’t need to tick the box that says that. I just want to be rid of this . . . T: Ah, OK. That was not my intention. I just wanted to get to the bottom line but I don’t want to make you do things and to tick them off. There might be something for me about understanding more precisely, perhaps by comparing with others, how much this is affecting you. C: But what is the point of keeping going over this again and again – to be honest, it pisses me off, doing this. I get a headache and then I think it’s going to come back and I would rather be at work. T: So what has brought you here? C: The other bloke. He was really clear that I could get rid of these flashbacks, but I get them and it is more that I get this sick feeling and want to take my hands off the handlebars. That’s not safe and my friends say that’s mad – well, I know it is mad (cognitive fusion). T: Well that is one view. C: Yeah, but it is my stomach too (fusion). T: I get that . . . you want to ride safely, but by having the thought you are buying into the thought that you will let go? C: Well, I wouldn’t do that. I guess I just need to get back onto the bike. There are points here where the therapist is getting into debate with the client. This does not fit with an ACT model, where we are not trying to heckle or persuade the client of the correctness of our model but rather to introduce some psychological flexibility, which will open up other courses of action. The inaction, witnessed in the therapy by going repeatedly over the same issue, has highlighted the need to plan to do something different. The goal of ACT is to begin to help clients live their lives in accordance with their values – for some this might be to live freely.

Conclusion We have discovered that there is no body of sound research which tells us that ACT is a model clearly superior in all aspects to other approaches (Ost, 2007). We are presenting it because, to us, it makes clinical sense. It is grounded in contextual behavioural science and as such has a good theoretical and evidence base. We have also discovered that it is a model with which people we have worked with have found useful, and it is to this end that we continue to practice ACT.

50  Helen Combes and Chris Cullen

There are many methods of formulation, and it becomes clear that apparently diverse models have huge overlap in their methods of formulation. Behavioural approaches have moved on in recent years. We are not tied to considerations of the here and now, or the overtly observable – but then we never were. The important elements of formulation from a radical behavioural or contextualist stance are the scientific method, and eschewing apparently explanatory constructs which have no psychological reality. Ultimately, contextual formulation takes a scientifically pragmatic approach: what is the most effective way of helping the client? So far as I am concerned, science does not establish truth or falsity; it seeks the most effective way of dealing with subject matters. (Skinner, 1988, p. 241)

References Baron, A. and Perone, M. (2001). Explaining avoidance: Two factors are still better than one. Journal of the Experimental Analysis of Behaviour 75: 357–61. Baum, W. M. (2001). Molar vs molecular as a paradigm clash. Journal of the Experimental Analysis of Behaviour 75: 338–41. Bersh, P. J. (2001). The molarity of molecular theory and the molecularity of molar theory. Journal of the Experimental Analysis of Behaviour 75: 348–50. Branch, M. N. (2001). Are responses in avoidance procedures ‘safety’ signals? Journal of the Experimental Analysis of Behaviour 75: 351–54. Catania, A. C. (1992). Learning (3rd ed.). Englewood Cliffs, NJ: Prentice Hall International. Cullen, C. (1981). The flight to the laboratory. Behavior Analyst 4: 81–83. Dinsmoor, J. A. (2001a). Stimuli inevitably generated by behaviour that avoids electric shock are inherently reinforcing. Journal of the Experimental Analysis of Behaviour 75: 311–33. Dinsmoor, J. A. (2001b). Still no evidence for temporally extended shock – frequency reduction as a reinforcer. Journal of the Experimental Analysis of Behaviour 75: 367–78. Hayes, S. C. (2004). Acceptance and commitment therapy and the new behaviour therapies: Mindfulness, acceptance, and relationship. In S. C. Hayes et al. (eds) Mindfulness and Acceptance: Expanding the Cognitive-Behavioural Tradition. New York: Guilford Press. Hayes, S. C. et al. (1999). Acceptance and Commitment Therapy: An Experimental Approach to Behaviour Change. New York: Guilford Press. Hayes, S. C. et al. (eds) (2004). Mindfulness and Acceptance: Expanding the CognitiveBehavioural Tradition. New York: Guilford Press. Hineline, B. N. (2001). Beyond the molar–molecular distinction: We need multi-scaled analyses. Journal of the Experimental Analysis of Behaviour 75: 342–47. Horne, P. and Lowe, F. (1996). On the origins of naming and other symbolic behaviour. Journal of the Experimental Analysis of Behavior 68: 185–241. Linehan, N. M. (1993). Cognitive-Behavioural Treatment of Borderline Personality Disorder. New York: Guilford Press. Michael, J. and Clark, J. W. (2001). A few minor suggestions. Journal of the Experimental Analysis of Behaviour 75: 354–57.

Formulation and contextualism  51 Ost, L. G. (2007). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy 46: 296–321. Pepper, S. C. (1942). World Hypotheses: A Study in Evidence. Berkeley: University of California Press. Poppen, R. (1982). The fixed-interval scallop in human affairs. Behavior Analyst 5:127–36. Richard, D. C. S. and Haynes, S. N. (2002). Behavioural assessment. In M. Hersen and W. Sledge (eds) Encyclopaedia of Psychotherapy. London: Academic Press. Shapiro, F. and Maxfield, L. (2002). Eye movement desensitisation and re-processing. In M. Herson and W. Sledge (eds) Encyclopaedia of Psychotherapy. London: Academic Press. Sidman, M. (1953). Avoidance conditioning with brief shock and no exteroceptive warning signal. Science 118: 157–58. Sidman, M. (1994). Equivalence Relations and Behavior: A Research Story. Boston: Authors Cooperative. Skinner, B. F. (1988). Reaction to commentary on ‘An operant analysis of problem solving’. In A. C. Catania and S. Harnard (eds) The Selection of Behaviour: The Operant Behaviourism of B. F. Skinner. Comments and Consequences. Cambridge: Cambridge University Press. Smith, S. and Hayes, S. C. (2005). Get Out of Your Mind and Into Your Life. Oakland, CA: New Harbinger. Sturmey, P. (1995). Analogue baselines: A critical review of the methodology. Research in Developmental Disabilities 16: 269–84. Tsai, M. et al. (2008). A Guide to Functional Analytic Psychotherapy: Awareness, Courage, Love and Behaviorism. New York: Springer. Watson, J. B. and Rayner, R. (1920). Conditioned emotional reactions. Journal of Experimental Psychology 3: 1–14. Williams, B. A. (2001). Two-factor theory has strong empirical evidence of validity. Journal of the Experimental Analysis of Behavior 75: 362–78. Wilson, K. G. and DuFrene, T. (2009). Mindfulness for Two. Oakland, CA: New Harbinger.

Chapter 4

A biopsychosocial and evolutionary approach to formulation Paul Gilbert

Introduction Formulation and diagnosis share overlapping features but also differ in important ways. Diagnosis addresses the question of what is the nature of a person’s difficulties (Kendell, 1975), and seeks to categorise them in terms of (say) a disorder (e.g. depression, anxiety or psychosis), a set of basic beliefs/schema, problem list or biological dysfunction. Formulation in psychological therapies may address such questions but in addition: 1) considers vulnerability, onset, trigger, maintenance and recovery factors and their treatment implications; 2) seeks to develop a functional analysis of symptoms and presentations and 3) is guided by a therapist’s theories of ‘disorders’ or the process they recognise and identify. Thus, a psychodynamic, systemic, behavioural or cognitive therapist might diagnosis a ‘disorder’ in a similar way (e.g. via symptom presentations for (say) depression or panic disorders), but would formulate the causes and treatment quite differently. Psychodynamic therapists might seek to identify unconscious motives and conflicts; systemic therapists might try to understand problems in the context of family interactions, behavioural therapists might focus on the functions of certain behaviours and cognitive therapists might explore automatic thoughts and core beliefs. While some diagnoses can be relatively culture free (one either has cancer, diabetes or heart disease or not), formulations, and especially psychological ones, are not. One recent major concern is the ‘globalisation’ of psychiatric ‘diagnoses’. For example, Watters (2010) argues that American and European diagnostic nosologies are being actively promoted as international systems. However, they can be limited, over-medicalised, culture-centric views of mental health difficulties and of mental processes. This is a serious problem particularly since some of these nosologies are thus unreliable, culturally insensitive and are fuelled in part by drug companies’ need for ‘diagnosis’ in order to market their drugs. Such approaches minimise the need to see some mental health problems as socially generated, requiring social solutions. Western-derived psychotherapies also need to be very cautious of this too because they can also over focus on the problems as ‘something wrong in the individual’ that needs correcting rather than as normal

A biopsychosocial and evolutionary approach  53

responses to abnormal or toxic environments, such as poverty, discrimination and domestic violence (Watters, 2010). So when we engage in the process of formulation it is important to try to articulate what culturally informed meaning-making systems underpin our efforts. This chapter rests on two basic paradigms for understanding mental functioning. The first is that of evolutionary psychology (Buss, 2009) and in particular social mentality theory (Gilbert 1989, 1995, 2000a, 2005, 2014). The second is the biopyschosocial approach (Gilbert 1995, 2013; Kiesler, 1999) that focuses on interactions between different domains of functioning (e.g. social, personal, biological).

An evolutionary approach Evolutionary functional analysis Evolutionary function analysis sounds a bit tricky but actually it is simply trying to understand what evolutionary pressures have shaped the functions in the human brain (Buss, 2009; Nesse, 2005). So, for example, one of the functions that animals have to perform is to eat to survive. Hence, the brain will have evolved mechanisms for detecting food and distinguishing food from poison with a whole digestive system to process species-appropriate foods. To add to this, note that human appetitive systems evolved in times of scarcity and a relative shortage of high calorie foods. When these evolved food seeking systems come into modern environments that provide easy access to very calorie-rich, high fat, salt and sugar foods, serious problems can arise, making many of us highly vulnerable to being overweight or obese (Smith, 2002; Stubbs et al., 2011). Understanding the mechanisms for food seeking, and the kinds of foods we seek out, and how these interact with the modern environments, offer ways of thinking about (formulating) the problem of obesity (Stubbs et al., 2011). We might, for example, see the problem more in terms of the food industry and focus prevention efforts there rather than (just) efforts to change individuals’ behaviours. Without the functional analysis of this kind the focus risks becoming overly individualised and potentially shaming, rather than on how innate evolved systems are interacting with (today’s abnormal) environments and how we can personally adjust (Smith, 2002). Another evolved life task requiring specific mechanisms is to detect, avoid and respond to threats. Consequently, threat processing systems are part of our basic brain systems (Gilbert, 1993; Hostinar et al., 2014; Ledoux, 1998). Threat detection–response systems are distributed throughout the body and when activated can influence cardiovascular, immune and digestive systems as well as emotion, cognition and behaviour (Panksepp, 1998). Once we understand threat functional systems we are also able think about how modern environments may be triggering them in new ways, leading to chronic stress with effects on mental health and other physical systems (Hostinar et al., 2014; Smith, 2002). So

54  Paul Gilbert

again we can begin to consider formulation in terms of how people, with our particular evolved types of mind, are interacting with their (recently highly altered) environments. In evolutionary terms this is to understand the relationship between genotype and phenotype. The genotype is our genetic potential while the phenotype is the manifest behaviour and physiological profiles that emerge from how genotypes interact with environments. People obviously vary in their genotypes and therefore phenotypes, but again the environment is key. You may have the genetic potential to be an Olympic runner, but if you grow up in the back streets of India with poor nutrition and smoke from an early age this phenotype will never manifest. The same is true of the link between obesity and diabetes. Not all people who overeat become obese and not all obese people become diabetic – but the risk substantially increases with obesity and obesity substantially increases in the Western world of fast foods. So individual differences and the way individuals are interacting with their environments are important to consider in formulation. In fact, a lot of formulation is actually assessing people’s phenotypes, that is, the way they have matured certain innate predispositions in certain contexts. For example, all humans are born with the genotype for forming attachments to care-providers. However, the environmental context will play a major role as to whether the phenotype becomes one of trust and affiliation or fear and threat focused (Belsky and Pluess, 2009; Hostinar et al., 2014; Slavich, and Cole, 2013). It follows then that when we think about formulation from an evolutionary and biopsychosocial point of view, we also have to think about the sociocultural contextual dynamics in which individuals become distressed and disordered. With our increasing understanding of neuroplasticity (Siegel, 2012), and how genetic expressions can be changed by environmental contexts (Belsky and Pluess, 2009; Slavich, and Cole, 2013), formulation and therapeutic interventions can become more science-based and less rooted in the different ‘schools’ of psychotherapy. The social mentalities Many of our major motives are social (Cozolino, 2007; Gilbert, 1989, 2005; Seigel, 2012). Indeed, the evolved pressure for social relating led to the evolution of a whole range of functional systems that are sensitive to certain social stimuli, and will analyse and respond to them in certain ways. So we can consider some of the basic evolved social functions of the human brain and how they can become a source of well-being or mental-health difficulties. Without some insight into evolutionary dynamics we miss the importance of evolved human social needs (e.g. for care, affection, appreciation and status) that when provided create the conditions for well-being and prosocial behaviour (Cacioppo, and Patrick, 2008; Cozolino, 2007; Music, 2014), and significantly influence physiological maturation including gene expression (Slavich, and Cole, 2013). Social motives give rise to what have been called social mentalities, partly because social motives require specialist processing systems (Gilbert, 1989,

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2005, 2014). For example, there is a major difference between interacting and being threatened by objects that have no minds (such as falling over, heights, getting lost) and objects that have minds such as predators or members of one’s own species. In the latter case, individuals are engaged in rapid processing with the changing dynamics of the interaction. In other words, when another mind threatens you (such as a predator or human being) or may be helpful to you, you will be analysing their movements/outputs and changing your behaviour according to what they are doing – almost moment-by-moment in the interaction. They will be doing the same to you. And if you are interacting with others over a period of time they will be remembering these interactions and the outcomes, as will you. For social interactions, individuals need to be able to process social signals and play out reciprocal role-forming interactions. Thus, a social mentality evolved with attentional, emotional, cognitive and behavioural processes that enable role formations. Key to how social mentalities are enacted in interactions, and forming the basis for understanding and experiencing ‘oneself’, is that ‘the self’ is construed in one way and ‘the other’ in another. An analogy might be two players in a game where one is attacking and the other is defending; they know how to coordinate their interactions, moment-by-moment in the overall goal of the game. Hence, the emotions, cognitions and behaviours coordinated by a mentality emerge from the actual or imagined flow (dance) of interactions between participants. For example, a sexual mentality requires that 1) individuals can notice and attend to appropriate, sexually specific signals/stimuli, 2) generate appropriate levels and patterns of physiological arousal (e.g. specific hormones for sexual arousal rather than (say) for fear or anger arousal), 3) can engage in social displays and communication behaviours that will interact with another mind to influence that mind to enact a ‘dance’ of interactions (e.g. courting), 4) move through a sequence of behaviours to fulfil the motive/desire ending in copulation. Behaviours will be constantly changing according to the feedback from the partner in the interaction. Evolving a sexual motive system but with no idea of what to pay attention to or what actions to take when opportunities arise, or how to flexibly change according to the unfolding pattern of interactions, would of course be futile and impossible. So social mentalities have to come with certain competencies. It follows, therefore, that individuals can have problems at any one of those stages. For example, some individuals may have sexual arousal to inappropriate signals, or have problems with arousal, libido or functioning (impotence); they may be shy or socially unskilled in communicating or poor at specific behaviours. Some individuals may be affectionate, others aggressive in their sexual behaviours. All social mentalities are like this: that is, there is a sequence of competencies that need to be in place for a motivational system to be appropriately executed. So, for example in the case of care-giving, individuals need to be able to pay attention to signals of need or distress, and be able to process these signals in such a way that they can respond appropriately. For care receiving and eliciting, individuals need to send appropriate signals and recognise and respond to signals coming in from others that care is being delivered. Hence, at birth babies take an interest

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in the human face and voice, know how to find a nipple and suck for milk and respond to skin–to-skin contact and cuddling with calming. As the attachment system unfolds during maturation, the child becomes sensitive to the proximity of the parent and the availability of the parent to act as a secure base and safe haven (Bowlby, 1969; Mikulincer and Shaver, 2007). Thus, the care-seeking/receiving mentality is innately set for tracking certain signals/stimuli, generating patterns of arousal and behaviour when the parent is present or absent and physiologically responding to those signals. Social mentalities can use both general and also some specialised cognitive processing systems. For example, human social relating recruits specialist competencies for theory of mind (Baron-Cohen, 2012), mentalising (Fonagy et al., 2002) and more recently social mindfulness, which can all be distinguished from general mindfulness (van Doesum et al., 2013). Different types of evolved cognitive competencies (e.g. for empathy vs reasoning vs anticipation vs language vs symbolising) can give rise to different types of problem (e.g. alexithymia, Asperger’s syndrome, anxiety, psychopathy, dyslexia) and requiring different types of intervention. In addition, these social intelligence competencies may also be role-related. For example, an individual may be very good at working out (mentalising) what an opponent is thinking or is likely to do in a competitive situation but quite poor at mentalising in a caring situation; that is to say mentalising can be role-dependent (Liotti and Gilbert, 2010). Individuals can be very empathic or caring to people they know and like, but not to people they do not know or like (Loewenstein and Small, 2007). We might be very empathic to a colleague who was in conflict with someone but not if that conflict is with us! The role specificity of social mentality competencies, and how they are used in relating, is important for formulation. So, therapists will be interested in clients’ social competencies and in particular their abilities to have some kind of empathic understanding and interest in the minds of others, in contrast to being very egocentric. Evolutionary-based formulation recognises that people can have social relating difficulties for very different reasons. For example, people with autism spectrum disorders may struggle with a whole range of social relations because the cognitive systems that provide for the attending, analysing and processing of social information (theory of mind) do not function adequately for such tasks. In contrast, people with psychopathic disorders may well have intact theory of mind but lack motivation to be caring, while narcissists are just very self-focused (Baron-Cohen, 2012). So appropriate caring and considerate and affectionate relating may be absent in these types of individuals for very different reasons. Helping them to become more prosocial may therefore require different therapeutic interventions. What helps the person with autistic spectrum difficulties may not be very helpful to the individual with psychopathic traits. Social mentality theory also points out that if human relating needs are thwarted this can lead to emotional and behavioural difficulties (Siegel, 2012; Slavich and Cole, 2013). We now know, for example, that individuals who grow up with very low levels of affection or high threat are very vulnerable to a whole range of

A biopsychosocial and evolutionary approach  57

psychopathologies (Hostinar et al., 2014). If the basic needs for a secure loving base are not met the brain is less likely to mature in a way that is conducive to well-being. In fact, these social needs are so important that their thwarting affects genetic expression with serious long-term, possibly even trans-generational, effects (Slavich and Cole, 2013). If humans were not evolved to require caring and affection then this would not be the outcome. As discussed shortly, be it in our relationships with others, or in our relationships with ourselves, friendly and affectionate relating is conducive to well-being, whereas hostile or neglectful relating is not. Basic social mentalities There are a number of basic identifiable social mentalities. These can help therapists work out where individuals seem to be thwarted in their ability to be motivated and understand or act appropriately in these roles. So, capturing the notion of reciprocal, evolved roles, some examples of social mentalities are offered. (See Table 4.1.) Care seeking This is the social mentality for the young to be motivated to signal distress or need, seek out caring others, and be responsive to care providers and their signals (Bowlby, 1969; Mikulincer and Shaver, 2007; Porges, 2007), and be physiologically regulated by them (Hofer, 1994; Cozolino, 2007; Slavich and Cole, 2013). The seeking and eliciting of care and support from affiliative others goes on throughout life and is a very major source of emotion regulation and courage building (Mikulincer and Shaver, 2007). Hence, for formulation, therapists are interested in the history of these experiences (receiving appropriate affectionate care and support vs neglect or abuse), and the way in which individuals can now use affiliative relationships (or not) with others and themselves to help regulate threat and face difficult things (Gilbert, 2000b, 2010, 2014). We might consider how competent or motivated an individual is in turning to others for help when needed. To what extent are some individuals either fearful of turning to others (perhaps because of mistrust or shame), dismissive of their need to do so, doubting of others’ competency to help, compulsively self-reliant or lacking access to others who can provide appropriate helpful/support? Care providing This is the care-giving social mentality that directs attention to be sensitive to the needs or distress of others and working out how to help others flourish. It is a major motivational system that is particularly important in the caring for offspring – sometimes referred to as nurturance (Fogel et al., 1986; Heard and Lake, 1988). Caring psychology, along with the evolution of altruism and prosocial behaviour (Bierhoff, 2005; Warneken and Tomasello, 2009), underpin

Inferior/superior, more/less powerful, harmful/benevolent Attractive/desirable

Source of: care, nurturance, protection, safeness, reassurance, stimulus, guidance Recipient of: care, protection, safeness, reassurance, stimulation, guidance Valuing one’s contribution, sharing, reciprocating, appreciating

Viewing or sensing the Other as

Adapted from Gilbert (1992). The Evolution of Powerlessness. London: Psychology Press.

Sexual

Competitive

Inferior/superior, more/less powerful, harmful/benevolent Attractive/desirable

Provider of: care, protection, safeness, reassurance, stimulation, guidance Of value to others, sharing, appreciating contributing, helping

Care-giving

Cooperation

Needing input from other(s): care, protection safeness, reassurance, stimulation, guidance

Care eliciting/seeking

Viewing or sensing the Self as

Table 4.1  A brief guide to social mentalities

Others will cheat, be non-appreciating or non-reciprocating, rejecting/ shame Involuntary subordination, shame, marginalisation, abused Unattractive/rejected

I will be overwhelmed, unable to provide, threat-focused, guilt

Others will be unavailable, withdrawn, withholding, exploitation, threatening, harmful

Associated with conscious or unconscious threats/fears

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compassion (Gilbert and Choden, 2013). These social mentalities come with various competencies such as for sympathy, empathy, distress tolerance and acquiring the wisdom to know how to help (Gilbert, 2009). In the formulation the therapist is interested in the degree to which clients are motivated and able to take a genuine caring interest in the needs of themselves and others, and are able to mentalise and empathise with themselves and others (Heard and Lake, 1988). Evidence suggests that individuals who are motivated to be caring and helpful to others have better mental health and better social relationships than individuals who are motivated for self-focused image goals (Crocker and Canevello, 2008; Crocker et al., 2010; Music, 2014). Indeed, cultivating a caring interest for others has been shown to be associated with a range of physiological changes that are associated with improved health (e.g. Weng et al., 2013). Co-operative This is the social mentality that enables coordinating actions, working together and sharing. Humans have intense motives and needs to share and operate in cooperative groups and relationships, coordinate their behaviours and work together for common goals – which gives rise to a sense of belonging (Baumeister and Leary, 1995). There is now good evidence that we are biologically set up needing to form social connections in order to thrive (Crosier et al., 2012; Hostinar et al., 2014). Cooperative relations are also the basis of altruism (Warneken and Tomasello, 2009). Indeed, the evolution of complex languages and the sharing of values, symbols and rituals facilitate cooperation and give rise to complex cultures, customs and technologies from the sharing of knowledge. There is now considerable evidence that if individuals seek but can’t create affiliative cooperative relationships they can be vulnerable to high levels of distress and mental health problems (Hostinar et al., 2014). For example, even being ‘left out’ of computer games can lead to changes in mood and self-esteem (Wesselmann et al., 2013). There is also considerable research showing that when individuals feel disconnected from affiliative and cooperative networks they can experience a sense of isolation and loneliness. Indeed, Cacioppo and Patrick (2008) reviewed a vast literature on what they called ‘the human need for connectedness’ and how loneliness is associated with a wide range of physical and mental health problems. Formulation therefore should include insight into people’s abilities and opportunities to be part of affiliative networks. Competencies for trusting and sharing are important for healthy functioning. In the formulation the therapist will be interested in the degree to which individuals can be trusting or mistrusting, cooperative or exploitative, shy and avoidant or socially competent, able to take an interest in others rather than just have a self-focused orientation. Individuals with paranoid tendencies can have difficulties in feeling and operating as group members and this is one reason why group therapy can be helpful (Braehler et al., 2013). This is similar for people with social anxiety (Bates, 2005).

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Competitive and social rank This is the social mentality that enables us to compete for resources and social place. Most mammals have evolved within socially hierarchical groups. We are therefore motivated to obtain a share of the resources available within that group, compete for social position and sexual opportunities. While we can be motivated for dominance (Johnson et al., 2012), we are also very motivated to avoid inferiority (Gilbert et al., 2007). There are many psychological difficulties that are related to problems of unwanted inferiority that can be caused by oppression or poverty but also by histories of bullying or negative evaluations by others, leading to a personal sense of inferiority and/or shame (Gilbert, 1992). The latter can manifest as a sense of shame and self-criticism (Gilbert 1998a, 2007, 2010). Although self-esteem is commonly linked with depression, McEwan et al. (2012) showed that it is not general self-esteem that is the issue but the ability to feel that one ‘cannot compete in the world’ which is linked to depression. Depressed people don’t see themselves as having ‘low esteem or poor efficacy’ when it comes to prosocial qualities such as being caring, trustworthy or conscientious. Thus, in the formulation, therapists are interested in the confidence individuals have in presenting themselves to others and generally asserting and competing for social position and resources without either being overly submissive or overly dominant-narcissistic. There is now increasing evidence that a range of mental health problems including depression, social anxiety and personality difficulties are linked to problems in how individuals compete for resources, and can often feel subordinated and intimidated, defeated, trapped and ‘powerless’ (Gilbert, 1992; Taylor et al., 2011). The issue conflicts We are constantly confronted by conflicts: whether to assert or back down, whether to cooperate or compete, whether to forgive or aggress; whether to cheat or stay loyal and whether to stay or go (e.g. in a relationship/job). Research on conflicts suggests that they can be quite disorganising of our cognitive processes. Helping people gain insight into their conflicts can be one aspect of formulation. Complex cases – particularly those from abusive backgrounds – often have many conflicts about how to deal with parents and past and current relationships. Just as we can have conflicts of motives and desires so we can have conflicts of emotions. For example, it is not uncommon to find that one emotion like anger can mask others or even be a safety strategy to avoid experiencing other emotions such as anxiety or sadness (Gilbert, 2010). Some chronic depressed people can be frightened to acknowledge anger but find sadness easy whereas some people with borderline difficulties find anger easy but grief-sadness is avoided. So in the formulation it can be important to explore potential conflicts of inner emotions and as well as most feared emotions (Gilbert et al., 2014). Sometimes simple questions like ‘what are the feelings you most fear to feel’ can illuminate or reveal this.

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One source of motivational conflict arises from how we compete for social resources and social place. Social rank motives evolved with capacities to gain and defend territories, or a social position within a hierarchy and other important resources conducive to prosperity. Issues of social rank are often involved in various kinds of conflicts where individuals wish to gain more resources than others or avoid losing them. We can strive for social position and social control but also to have needs and wishes recognised (and satisfied) by others (Gilbert, 2000c). Interpersonal conflicts, and the way they are interpreted, experienced and dealt with can play a major role in mental health. Typical conflicts are in the dimensions of self-interest versus the interests of others, autonomy versus connectedness, autonomy versus the desire for submissive security (as in some religions or problems of dependency) or the desire to get along versus the desire to get ahead. In the case formulation, simply laying out these kinds of conflicts and normalising them can be helpful. Functions of social goals There are other basic motivational systems such a desire for predictability and coherence, or competence and achievement, or meaning, but the social motivational systems are called social mentalities because they depend upon complex social interactions that can be processed moment by moment as they unfold. When people are involved in socially focused rumination and imagination, they are imagining interactional sequences and outcomes (Gilbert, 1989, 2005, 2014). Psychotherapy commonly involves helping clients relate to themselves and others in ways conducive to their and others’ well-being. So, understanding the way in which they construe and create social roles and the needs behind social roles is important for formulation. Therapists are interested in what people are motivated to do, why and how they seek out their (social) goals, what threatens their goals, and how they (defensively) react when goals are threatened. Sometimes goals and drives are for the pleasure of achieving but at other times they have defensive or compensatory functions. There is a long history to the idea that some people strive to achieve things for two different reasons. One is from the pleasure and intrinsic rewards of achievement, the other as a way to impress others and win social acceptance and social place (Gilbert, 1984). Dykman (1998) discussed these as growth seeking versus validation seeking. Growth seekers enjoy challenges and their ability to learn and mature through challenges/mistakes. Validation seekers, however, feel under constant pressure to prove themselves as likeable and acceptable to others and fear failure or mistakes. Dykman (1998) suggested that validation seekers come from difficult backgrounds of insecurity, whereas growth seekers come from secure backgrounds. It is only validation seeking that is linked to psychopathological indicators. Individuals who feel socially insecure can strive for social goals for defensive reasons, and in particular to try to avoid inferiority (Gilbert et al., 2007).

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Dunkley and colleagues (e.g. Dunkley et al., 2006) explored perfectionism and suggested two underlying factors: The first is setting and striving for personal standards, the other is striving to avoid criticism/rejection from others. The second is labelled ‘evaluative concerns’. Again it is only the evaluative concerns that are linked to psychopathology. So even in basic striving to achieve goals the social meaning and social mentalities involved are central to people’s mental health. Example Consider the situation for David. He worked hard to become a doctor and sought the status of a doctor. However, he didn’t like being a doctor. He found it very stressful and constantly ruminated about making a mistake. His history revealed his pursuit of a medical career was highly defensive and validation seeking. He came from a very critical and ambitious family of lawyers and doctors. He was, however, a talented musician and had always wanted to be a musician but under family pressure, he never pursued this. He became a doctor to fit in with his family dynamic, to win their approval which he felt was always tenuous, and to try to obtain some social standing because he was also somewhat shy. So he was highly driven but for very defensive reasons. In mid-career he became depressed and suicidal. He felt he was ‘living the wrong life’, and was ‘just stressed out all the time’. Now, relying on his good salary as a doctor, he could see no way out of his anxious job. He was critical of ‘his weakness’, for not doing what he wanted to do in life, and not coping well. He was also experiencing increasing anger towards his family which saddened and frightened him. In the formulation it helps to have a sense of the basic motivational elements of clients because therapy may well change their core values and goals; therapy is not motive, goal or value-neutral. Indeed, there are many goals that we would not endorse and try to reduce, especially those involving harming others or seeking to be sexually exploitative or deceitful, or goals that are exceptionally narcissistic. Most therapists don’t support the anorexic’s goal to be self-starving or the alcoholic’s goal to stay in a permanent stupor. Some people have goals and values because they are in the state of denial or dissociation from what’s actually important to them. So psychotherapy can’t avoid an analysis of motivation. Indeed, therapeutic approaches, such as acceptance commitment therapy, help people articulate and develop personal values and goals that are conducive to well-being (Hayes et al., 2004). Compassion focused therapy explores how values and goals are rooted in the sense of self identity (Gilbert, 2010, 2014). We also know that motivational systems themselves are regulated in complex ways. For example, we can be motivated to form certain relationships for intrinsic or extrinsic reasons (Deci and Ryan, 1985). Our motivation to engage with things we are frightened of can be strengthened in the face of helpful support but weakened in the face of isolation or opposition. Feeling competent versus incompetent in trying to pursue a social mentality is important, and fear of shame from failure

A biopsychosocial and evolutionary approach  63

may reduce the preparedness to risk the setbacks in acquiring competence. So theory of mind and mentalising (how we think others see our efforts) can impact on efforts. The emotions in formulation Emotions are in the service of motives and provide ‘the energy’ for motives (Panksepp, 1998). Indeed, in depression it’s not so much that individuals are not motivated for certain goals but rather that they’ve lost their feeling for them (Gilbert, 2013). They would very much like to enjoy a holiday or perhaps have a new job but either anxiety gets in the way or they can’t summon the energy or get no feeling from doing activities. So, these individuals can’t generate the emotions they want. In contrast, other kinds of difficulties are linked to generating emotions individuals don’t want. It is then with the avoidance of emotion (like anxiety or anger or even happiness) that individuals can get into difficulty (Gilbert et al., 2012, 2014; Hayes et al., 2004). Emotions are also more than individual experiences because they also function as social communications, conveying information about one’s social motives, values and orientation toward others (Keltner and Haidt, 1999). So, emotions influence not only the behaviour of the experiencer but also those who perceive or are recipients of emotions. So emotions and emotion displays are part of the dance of social communication (thus social mentalities) that provide the basis for our co-regulation of each other. As noted above, in the formulation, the therapist will be interested in how emotions function within relationships; are there some emotions that individuals are frightened to express, tolerate or explore? Are there emotions that are poorly regulated and damage relationships? In terms of an evolutionary formulation, emotions (and we can experience different and competing emotions at the same time) can be understood in terms of six or so categories. 1 The triggers for emotion; that is the actual stimuli and the interpretation of the stimuli that activates an emotion(s) 2 The intensity of the emotion(s) – which may well be linked to previous experience of the stimulus and the emotion(s) – e.g. anxiety linked to trauma 3 The duration of the emotion(s) which may be linked to cognitive processes such as easily coping with an emotionally arousing situation, or (in contrast) maintaining an emotion(s) through rumination, and the history of the experience of the emotion 4 The frequency of the emotion(s) which may be linked to the environments individuals are in e.g. one that regularly confronts them with stressful stimuli that stimulates emotion(s), or more positively, one involving loving relationships that regularly stimulates affiliative emotions. 5 The social contexts for emotion(s) and display rules – for example in some cultures emotion expressions are subject to gender variation; sadness and

64  Paul Gilbert

grieving being more acceptable for women, and anger and aggression more acceptable for men – especially in defence of honour. 6 The coping strategies used to prevent the emotion(s) or cope with the emotion(s) once it is underway. Trying to prevent or avoid an emotion can be due to a whole range of processes and may recruit a range of processes such as denial and dissociation. Types and functions of emotion Emotions evolved to guide animals and provide information about their relationships to their environments. Thus emotions will serve various functions. One useful heuristic for thinking about emotions is to consider the three functions of 1 2 3

threat-detection and response reward detection and response satisfaction and safeness detection and response (Gilbert, 2009, 2010).

These three emotion regulation systems can be depicted in Figure 4.1. That is something of a simplistic heuristic but quite useful for organising thoughts around formulation. Threat For the most part, threat emotions are stimulated in the presence of potential and actual harms and losses. It is now recognised that we have evolved biases towards Content, safe, connected

Driven, excited, vitality

Incentive/resourcefocused Wanting, pursuing, achieving, consuming Activating

Non-wanting/ affiliative-focused Safeness-kindness Soothing

Threat-focused Protection and safety-seeking Activating/inhibiting

Anger, anxiety, disgust

Figure 4.1 Three types of affect regulation system (from Gilbert, The Compassionate Mind, 2009, reprinted with permission from Constable & Robinson Ltd.).

A biopsychosocial and evolutionary approach  65

detecting, processing and remembering threats, sometimes called the negativity bias (Baumeister et al., 2001). Animals can respond to threats with either activating or deactivating defences. In the short term, activating defensive emotions can be helpful, such as anger, anxiety and disgust, which facilitate fight and flight and link to the sympathetic nervous system. However, there can be various situations where active defences are ineffective, don’t work or could actually be more dangerous. For example, if you can’t escape from a dominant bully then fighting with them might not be helpful, get you injured and the better defensive response would be submissiveness. In fact, there is a range of emotion and mood states that link to chronic exposure to threats which trigger deactivation. These are commonly termed defeat, helpless or despair states (Gilbert, 1992, 2002; Taylor et al., 2011). They can be linked to the dorsal vagal parasympathetic nervous system shutting down (Porges, 2007). In the formulation people will typically be presenting symptoms linked to the threat system which will be indications of either their activating (e.g. fight/flight) or deactivating (slowed up or demobilised) defences. Pleasurable emotions – reward detection and response Although we can easily distinguish threat-based emotions (often referred to as negative emotions) from rewarding pleasure ones (often referred to as positive emotions), recent research has indicated that it’s very important to distinguish two functionally very different types of positive emotion systems (Depue and Morrone-Strupinsky, 2005). One is activating, the other is calming and soothing. The activating, reward seeking systems give rise to emotion such as enjoyment, fun, excited anticipation and pleasure. Generally speaking, such positive emotions are linked to reward seeking and obtaining resources that are beneficial. As with threat, reward activation links to the sympathetic nervous system. Hence, the emotions are basically drive emotions, energising us to do what we need to do to obtain the resources, and through positive reinforcement, do the same again when needed. This system is also involved in competitive motives (and social mentalities) such as seeking dominance and social position (Depue and Morrone-Strupinsky, 2005). As noted above some individuals become very preoccupied with needing to achieve or being seen to have status. In formulation it can be useful to think about what it is that gives enjoyment and excitement for people. A range of problems can arise when people want to overly stimulate these types of pleasurable feelings and can result in addictions such as cocaine/ amphetamine, gambling, pornography etc. Sometimes these are sought as distractions from underlying depressions or anxiety. Excessive ‘activation and seeking’ types of positive affect are also implicated in hypomania (Panksepp, 1998). In contrast, anhedonia represents a loss of the ability to experience such positive affect. Formulation might also explore if some individuals are fearful of positive emotions, including happiness, partly because they associate feelings of happiness with some negative event arising as a consequence (Gilbert et al., 2012, 2014; Joshanloo, 2013).

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As noted above some people’s drive emotions are generated by threat concerns. This would be the situation where people are trying to achieve socially recognised successes, but they are doing this in order to stave off shame and rejection (see the case of David above; Dunkley et al., 2006; Dykman, 1998; Gilbert et al., 2007). Pleasurable emotions – the calming emotions As Depue and Morrone-Strupinsky (2005) describe, once resources and rewards have been obtained it’s important that animals are able to ‘rest and digest’. This will allow the body to recover and enter into states of relative calmness and quiescence. For the most part this is linked to the ventral parasympathetic autonomic nervous system which acts as a brake on the sympathetic autonomic nervous system. Emotions here are ones of feeling calm, at peace, safe and not particularly focused on achieving or doing. Sometimes, in meditation practice, this is called the ‘just being mode’. The capacity to feel safe and content is very important for well-being and in the formulation this can be explored with clients. Some clients, for example, find relaxing or experiencing states of peacefulness or contentment very difficult. History may reveal a childhood of rarely feeling safe, and if they did, harms such as an aggressive parent could hit them out of the blue. Safeness Safety and safety seeking can be distinguished from safeness. Safety is typically associated with the avoidance of harm and with vigilance to the possibility of harm. In contrast, safeness is a state where the mind has open attention without concern for threat. While threat processing and safety seeking behaviours have been very well investigated within clinical populations, feelings of safeness less so. Feelings of safeness arise in various contexts but especially in contexts of friendliness and kindness from others (Porges, 2007). Moreover, being a recipient of these qualities from others can help us face and cope with threats and aversive experiences (Gilbert, 2009). So, just as some social signals can signal threat, other social signals can signal safeness and affiliation, and trigger the parasympathetic ‘feeling safe’ system (Porges, 2007; see below). Interestingly, it is possible that massage may be a way of activating the system for those who find it difficult to have these feelings (Field et al., 2005). Gilbert (1989, 1993) suggested that understanding the nature of safeness, how it is experienced, triggered and maintained (and is different from safety as focused on as just the absence of threat) is as important to explore as threat itself. Gilbert et al. (2008) developed a self-report scale that sought to measure ‘activating’ in contrast to ‘soothing-contentment’ positive affect. Interestingly, three rather than two factors emerged from the study: activated positive affect, relaxed positive affect and safe/content positive affect. It was the safe/content positive affect that had the highest negative correlations with depression, anxiety and stress,

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self-criticism and insecure attachment. This again highlights the importance of distinguishing low threat from high safeness – they’re not the same thing. Kelly et al., (2012) found that a measure of general social safeness and capacities for feeling safe with, and connected to, others was a better predictor of vulnerability to psychopathology than negative affect, positive affect or needs for social support. Feeling safe also facilitates the development of mentalising, because if an individual is threat-focused they are more interested in avoiding threat than in understanding or thinking about the mind of the other in a reflective way (Liotti and Gilbert, 2010). Given this, the formulating therapist will be interested in the client’s past experiences of feeling safe (under what conditions and who with) and their current abilities to experience a sense of safeness; for example, do they feel safe with the therapist? Might there be material they would not feel safe exploring? Not uncommonly clients with complex difficulties can struggle with these feelings. Some clients might never have felt safe (Gilbert, 2010). For example, the child who is sleeping in bed when the parent comes in and abuses them, or the child who is loved in the morning but receives beatings from their alcoholic parent at night. These individuals often carry the experience that ‘when you begin to feel safe you let your guard down and that’s when you can be harmed – you don’t see it coming.’ In essence, the feelings of the beginnings of a sense of safeness can be linked to trauma memory (van der Hart et al., 2006). These are important to understand with complex cases because a very major emotion regulation system, which here we are calling the affiliative-soothing system, is not available for these clients and will be something the therapist needs to help develop. Attachment theory and safeness Probably the best-known theory that has focused on the issue of safeness provided through relationships is attachment theory (Bowlby, 1969, 1973, 1980). Understanding the attachment history and current attachment difficulties are often very important with complex cases (Danquah and Berry, 2013; Wallin, 2007). Bowlby focused on three evolved aspects of the parent–child relationship: The ability for the infant to gain and maintain proximity to a caring other; the ability of the caring other to provide a secure base (from which the infant/child acquires the confidence, courage and interest/curiosity to go out and explore); and the ability of the caring other to provide a safe haven and act as a soothing object (i.e. they provide for returns to the secure base if troubled or distressed and receive calming inputs and signals of care). These three aspects of creating a sense of safeness are essential to the maturation of well-being and security (Bowlby, 1969; Mikulincer and Shaver, 2007; Siegel, 2012; Music, 2014). The recognition of the importance of the attachment system in the creation of some sense of safeness is now being taken up by many therapeutic approaches (e.g. Danquah and Berry, 2013; Holmes, 2010; Wallin, 2007).

68  Paul Gilbert

There are many signals that can stimulate the affiliative-soothing system and help individuals attenuate threat processing (Moberg, 2013). These can range from facial expressions and voice tones through to being held, cuddled, stroked and touched. In fact, the role of touch is well established as a soothing, oxytocinand endorphin-releasing process (Field, 2000). In a review of massage therapies Field et al. (2005) showed that these therapies had a significant effect on reducing cortisol and increasing serotonin and dopamine. Central, of course, is the relationship with the provider of such comforting signals because the same signals offered by someone we don’t like are unlikely to be helpful and could be aversive. So again, the social mentalities are important for how social signals are experienced. Early experiences of physical contact influence genetic expression, facilitating a generally calmer disposition (Slavich and Cole, 2013). So humans, like other mammals, have evolved the capacities for affiliative relating and to respond with feeling calm (Crosier et al., 2012; Porges, 2007). Indeed, there is now considerable evidence that the ability to access the affiliative-soothing system plays a major role in affect regulation and the maturation of our social mentalities (basic motivations) and self-identity (Cozolino, 2007; Gilbert, 2009; Moberg, 2013; Siegel, 2012). Key to the soothing qualities of attachment and affiliative relating are the endorphins and oxytocin which facilitate both the provision/sending of affiliative/ caring signals and the capacity to respond to them (Carter, 1998; Dunbar, 2010; Depue and Morrone-Strupinsky, 2005; MacDonald and MacDonald, 2010). There are oxytocin receptors in the amygdala such that stimulation of affiliation releases oxytocin in the amygdala and can down-regulate threat (e.g. Kirsch et al., 2005). Recently, Stanley and Siever (2010) suggested that much of the phenomenology associated with borderline personality disorder, such as impulsivity, self-harming, emotional instability, aggressive outbursts, sensitivity to rejection and poor self-identity, can all be understood in terms of poor regulation of the affiliative system, marked by compromises to the oxytocin and endorphin systems. Linked to oxytocin is the recently evolved myelinated vagus nerve which also soothes in the presence of affiliative signals (Porges, 2007). There is increasing evidence that vagal parasympathetic tone, which underpins feelings of safeness, influences frontal cortical processes, which in turn are fundamental in trauma processing; people with poor vagal tone may struggle more with processing trauma (Gillie and Thayer, 2014). Austina et al. (2007) found that people with borderline personalities can have difficulties in accessing the myelinated vagus as a soothing process. So, the key point is that the affiliative system, mediated by various neurophysiological systems, such as endorphins, oxytocin and the vagus nerve, play very important roles in regulating threat and supporting affect regulation. In the formulation, therefore, the therapist may have thoughts about clients’ physiological readiness for processing certain material and how to facilitate their readiness to do so.

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However, as Bowlby noted, safeness isn’t just about soothing, it’s also about encouraging and facilitating development, engaging with the material and social world, building skills, knowledge and confidence. Feeling safe can allow us to just be in ‘being’ mode, but also approach life tasks in confident ways with a capacity to enjoy things in themselves (Dykman, 1998). In addition, we can feel safe when we form connections and affiliative relations in general, not just based on attachment (Crosier et al., 2012). Connected and affiliative relations also mean that people can experience drive emotions such as looking forward to seeing others and sharing pleasure and excitement through cooperative and mutual fun interactions. Indeed, one of the reasons for meeting friends and going to restaurants, for example, is to have ‘good times’ and develop social bonds. The interpersonal communications and signals that stimulate feelings of safeness with our friends create a platform for the enjoyment. If those signals change – for example, a friend appears to be in a very bad mood – this can stimulate the threat system and influence the enjoyment. In addition, affiliative relationships are able to encourage us to engage with things that are difficult. Depressed and anxious people can struggle with these interactions, and be more avoidant than engaging. In addition, research on the processing of facial expressions has found that anxiety, depression, social anxiety and attachment insecurity are associated with attentional biases. These biases are quite revealing, suggesting enhanced attention to negative/threatening facial expressions and reduced attention to positive/affiliative facial expressions (e.g. Dewitte and De Houwer, 2008; Keedwell et al., 2008; McEwan et al., 2014). So, these individuals are monitoring threat cues, not safeness and affiliative cues. Feeling safe can of course be created by a secure base and safe haven, but in additional it is about having insight into the minds of others and in particular the feelings of others; it makes people more predictable and understandable This is linked to intersubjectivity, and this too is a developmental process linked to mentalising (Cortina and Liotti, 2010). Emotional fusion In the evolutionary model, classical conditioning models of learning are central to psychotherapy and formulation – partly because it is fundamental to the way organisms learn. So, it is useful for therapists to keep in mind that a lot of learning takes place as a process of association and this is particularly true when it comes to complex cases (Gilbert, 1992). The importance of classical conditioning is sometimes forgotten in the world of cognition and schema but it is useful to have the motto in one’s mind of ‘emotions that fire together wire together.’ With this concept, therapists can help clients formulate how their emotions have become fused together. So, for example, a child who is regularly threatened or hit and sent to their room is likely to experience high levels of fear but in the context of isolation and aloneness. Over time, therefore, these two emotions will fuse together

70  Paul Gilbert

such that when the person is criticised/threatened they may feel an overwhelming sense of aloneness and rejection. Children who are sexually abused and left in their rooms or isolated from help-seeking will fuse these emotions – fear of the other and intense loneliness (Gilbert, 2010). So, when therapists are asking about specific memories it always helps to ask for the combination of emotions that might have been stimulated when a memory was laid down and help the client see how emotions get fused – thereby helping people recognise where they can have quite powerful complex and even conflicting emotional reactions to certain things. It is also the case that there can be a failure of fusion. In the normal care-based family, when children feel threatened they are able to turn to others for soothing and that experience is then associated with a reduction in fear. Over time, threat processing systems become fused and connected with emotions generated by the helpfulness and soothing from others. This not only helps to ‘fuse with’ or ‘condition to’ and thus regulate threat emotions, but also provides a sense of hope that the stress ends. It is not uncommon for people with complex difficulties to discover these kinds of experiences – love and care being available when threatened or distressed – did not happen much in their childhoods. Liotti (2000, 2009) has also written extensively on the theme of disorganised attachment. This is where people can show both approach but also fearful (avoidance) or angry behaviour to potentially caring others. He suggests that this form of attachment is likely in traumatised children who are frightened of their parents. They were confronted with threats and stresses without resolution from a soothing other. Keep in mind that the young mammalian brain, and in particular the human brain, is highly adapted to seek out soothing signals from others when in distress (Hostinar et al., 2014). A traumatised child can therefore experience a number of different difficulties. Liotti (2000, 2009) discusses how traumatised parents who display a depressed or anxious face to the infant in the context of holding/feeding is sending non-affiliative and contradictory signals. Second, the parent may be the source of threat (criticism, anger or abuse). This means that threat comes from the very individuals who are likely to be physically close and constantly present – the child is unable to get away from them and in some sense is trapped. The physical presence of the parent can therefore be a signal of threat stimulating/threat processing, rather than one of calming and safeness. Third, they will be unable to turn to them for soothing, because the child is frightened of the parent. Even when a source of threat and distress is outside of the parent–child relationship, if the child is frightened of the parent or has a poor affiliative bond, they won’t turn to them for comfort or use them as a safe haven. It is these dynamics that can create within the child ‘threat without resolution’. In that context the child will need to develop a range of safety strategies to cope with threat-distress as best they can. This can be anything from dissociation to poor impulse control. Liotti and Gumley (2008) highlight how people with psychosis can often experience the terror of ‘threat without resolution’ and are not able to use affiliative systems for calming, soothing and feeling safe. In a sense, this is the failure of a particular kind of emotional fusion – experiencing threat in the context of affiliative soothing.

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The case of trauma It is now recognised that trauma histories underpin many types of complex problem (Ecker et al., 2012; Lee, 2005; Lee and James, 2012; van der Hart et al., 2006). The tripartite approach to emotions suggests that in addition to exploring the nature of threat, therapists will need to assess the capacity to access the major threat regulators, e.g. the soothing and affiliative system (Bowyer et al., 2014; Lee, 2005; Lee and James, 2012; Hackmann, 2005). Again the emphasis is on the combinations and fusions of different emotional systems. Trauma can significantly disturb affiliative processing systems which then can’t act as a threat regulator. For example, traumas in childhood can represent rather chronic styles of family interactions. Children from traumatic, neglectful backgrounds may have few experiences of having oxytocin and parasympathetic systems stimulated and few emotional memories of feeling loved or valued. These will have major impacts on the maturation of the affiliative system and its ability to regulate threat. Research using the attachment model suggests that problematic backgrounds can give rise to different styles of attachment: avoidant-dismissive, anxious-ambivalent and disorganised (Mikulincer and Shaver, 2007; Wallin, 2007). Other types of trauma can also significantly disturb affiliative systems. For example, different types of trauma that arise in combat situations can represent trauma to the self (threat and injury), and trauma from the horrors one has seen or been involved in. Obviously, here trauma memory plays a central role. However, some of the difficulties do not emerge until individuals arrive home, and part of this problem can be understood by considering how affiliative systems have become (en)trained to different types of environment. If the therapist sees PTSD as a problem of only threat processing they will miss the fact that actually the drive and affiliative soothing systems can be equally problematic. Indeed, as noted above Gillie and Thayer (2014) have shown that more complex PTSD can be related to parasympathetic difficulties. The issue here is that combat training itself will entrain a soldier’s affiliative system to ‘their buddies’ – that is their safeness and being able to calm down depends upon their buddies being available, armed and ready for action. In attachment terms, the ‘buddies’ operate as a secure base and safe haven and will also stimulate proximity seeking. They may have had many experiences after a mission of being in the state of threat-arousal (with major flushes of dopamine as part of the drive system) and then calming down in the context of the company of their buddies and then enjoying affiliative interactions (even play). So complex fusions of different emotional experiences are being laid down in the CNS. Then these individuals come home. On the face of it they are no longer in a threatening environment and should feel reasonably settled. Certainly, if you watch programmes like ‘Mash’, that’s the implication. So it can be very distressing and in some ways traumatising itself to recognise that this is not happening. The relationships with partners can be strained for all kinds of reasons but

72  Paul Gilbert

especially because the affiliative-soothing (parasympathetic) or attachment system is not now attuned to their partners or children but to their buddies carrying guns. These signals have suddenly disappeared and so the system now can’t locate signals of safeness. In a way it’s like the separation experiments where when the parent leaves the room, the child becomes distressed. The child may not be under any threat in the room, simply the loss of safeness signals increased threat. Also, individuals can experience the proximity seeking aspects of the system and want to be with their buddies again, not with their families, which again can seem very difficult, sad and even shaming to them. In the formulation, therefore, the therapist can spend time discussing how the three circles of emotion regulation (Figure 4.1) are working for them (the kinds of emotion fusion may be operating within and between them). Hypersensitivity in the threat system is obvious for them but equally, given that the drive system has been regularly hyped up, they may be experiencing low moods due to lack of stimulation (a kind of withdrawal phenomena). And because the affiliative system has been re-entrained to their buddies they may find it difficult to relate to their families. On both counts they can feel a sense of shame because 1) they can’t connect to their families (re-entrained attachment system), 2) they may feel irritable and on edge (no safeness signals or compromised parasympathetic system) and 3) they find it difficult to find things that give them excitement or pleasure. Discussing these processes in terms of an out-of-balance or new pattern of emotional fusion in the ‘three circle affect’ regulation system – and emphasising that’s not their fault at all can partly help them to recognise that it’s going to take time and practice for these systems to rebalance themselves in the new environment and for the affiliative system to be re-entrained back into civilian and family life. It is not just about reducing threat for these individuals, it’s also about reactivating the appropriate drives, pleasures and excitement along with the affiliative (oxytocin and parasympathetic systems) in the new environment that is key. My colleague Deborah Lee (2005; Lee and James, 2012) who uses compassion focused therapy with veterans, has found this formulation and approach very helpful for them (Lee, personal communication). Note too that if the affiliative system is not working particularly well then re-scripting of trauma can be difficult (van der Hart et al., 2006). Theories without an understanding of the different types of positive emotion and the role that affiliation (with its very special physiological systems) plays in threat regulation can miss these important factors in the formulation of trauma. The non-logical mind One can use an evolutionary formulation to help clients recognise that the human brain is very tricky in many ways. One of the reasons for this is because about two million years ago our ancestors began to evolve complex cognitive abilities that would fundamentally influence the regulation of emotion and motivation. These competencies include abilities for: symbolic representation of self and other, to

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‘language’ our thinking; have theory of mind and be able to mentalise, and have meta-cognitions and meta-presentations (Suddendorf and Whitten, 2001). They give rise to the abilities for imagination, thinking systemically, anticipation, prediction, reflecting on our past and imagining numerous possible futures. What is important about these competencies, though, is recognising that these facets of mind do not always work well with some of the older motivation and emotional systems, thus making our brains by nature tricky and prone to problems (Gilbert, 1998a, 2009). It has design flaws. Moreover our attentional and cognitive processing systems are highly biased in their focus (Gilbert, 1998b; Tobena et al., 1999), especially in regard to threat – sometimes referred to as the negativity bias (Baumeister et al., 2001). Indeed, many theorists recognise that our minds are full of biases, inherent conflicts and contradictions capable of creating maladaptive, destructive loops. Some of the ruminative loops people struggle with are not (just) to do with personal schemas necessarily, but are also part of brain function. For example, if a zebra has been chased by a lion and manages to escape, it will relatively quickly calm down and go back to the herd and graze. In the case of a human, however, while they may feel relief, it is also possible that they might begin to imagine what might have happened if they had got caught – being choked by the lion and eaten alive. They may wake up in the middle of the night, fearful and imagining the possibility of two lions waiting the next time they go out. The scenario of ‘what will happen if . . .’ and ‘suppose that . . .’ is common in mental health problems. Because we are very threat-biased we have a natural tendency to imagine the worst. It is also clear that our capacity for imagination stimulates complex physiological processes. Lying in bed and creating erotic fantasies tells us just how powerful imagination can be in stimulating very specific physiological systems. Imagining ‘worse scenarios’, or ruminating on ‘threat or anger’ will therefore constantly stimulate threat systems and all their physiological profiles. Therapies using evolutionary formulations will share these kinds of insights with their clients and formulate with these insights. This does many things, one of which is to help clients realise that a lot of the problems they are struggling with are absolutely not their fault. Rather, they are partly to do with the things that happened to them during their lives and the way the brain naturally responds to threats of various kinds; how the human brain can easily create these threat-based loops and a whole series of safety strategies which can have unintended consequences. So, the evolutionary model tends to ‘normalise’ people’s experiences and focus on ‘what’s happened to them’ and ‘how they adapted’ rather than ‘what’s wrong with them’. This can play a crucial role for people who are very high in shame and have a tendency to blame themselves for the difficulties they are facing. Also, as part of the new brain came a capacity for self-recognition as ‘an object’ and self-monitoring. No chimpanzee sits under a tree monitoring their heart rate worrying about dying, or reflects on the problems of having put on too much weight, or having ruined their reputation with someone they fancy, or what

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happens after death. Humans clearly do and the newly evolved self-monitoring system has enormous impact on the regulation of emotions and behaviour. For example it is at the basis of self-criticism, types of shame and many other problems in psychopathology (Kannan and Levitt, 2013). The non-conscious mind Another reason the human brain is very tricky is the way new brain competencies and processes interact with old brain motives and emotions, creating difficulties for what actually arrives in consciousness; that is to say, a lot of non-conscious processing significantly influences emotion, cognition and behaviour (Hassin et al., 2005). In fact, it has been noted for some time that humans have at least two partially independent ways of processing information. The first is sometimes called an experiential, fast track (Epstein, 1994), implicit (Power and Brewin, 1991) or impulsive (Sheeran et al., 2013). This utilises (old brain type) heuristics, takes short cuts to reach conclusions quickly, uses crudely integrated information, is reliant on affect and how something feels, is preconscious and relies on earlier experience and conditioned emotional associations – none of which need enter consciousness. The second system is sometimes called an explicit (Epstein, 1994), slow(er) (Power and Brewin, 1991) or reflective or rational system (Sheeran et al., 2013). It evolved more recently, is able to use logical deductive and symbolic forms of reasoning in a more conscious way, and is less influenced by past events and affects. It is a system which allows us to feel one thing (e.g. anger, fear or lust) but not act them out because of awareness of potential long-term consequences, or because they don’t fit with one’s self-identity. So, there is increasing recognition that information can be processed in many different ways (e.g. fast-slow, impulsive-reflective, emotional-rational, parallel-serial, conscious-unconscious, rigid-flexible, social non-social, defensive-safe). This has major implications for formulation because if a therapist has no familiarity with the fact that what the patient needs to work on may be something they are not fully aware of, or are actively avoiding in therapy, the therapy can run into problems and blocks. The difficulty for the modern-day therapist is how to avoid some of the obvious problems with ‘interpretation’ while at the same time facilitating guided discovery into areas of non-conscious and avoided material. Many therapies now recognise the importance of experiential avoidance but there are different types of experiential avoidance and the reasons that people can struggle to process certain emotions or memories can vary. Sometimes people don’t have the competencies to process emotions, e.g. are poor at mentalising or may be alexithymic. For other people there are more active defences involved. Some may be overwhelmed by fear of losing control to an emotion or memory. Some have beliefs that their emotions are inappropriate or invalid, or are too conflicting (desire to be loved conflicting with feelings of rage or hate towards the same person). Yet for others it is an issue of shame. So in the formulation, the therapist keeps an eye on the fact that the difficulties clients start off with may change as

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the therapy unfolds, and the things the client was avoiding or unconscious of may start to appear. The biopsychosocial model A second paradigm to inform formulation is the biopsychosocial and ecological approach to mental functions (Gilbert, 1995). This is really complementary to the evolutionary model. The approach directs attention to the emergence of patterns of interaction between different systems in the brain (e.g. motives, emotions, thoughts and behaviours) and how such patterns are choreographed and shaped through social relating and ecological conditions. As noted above, even genetic expression (Bick et al., 2012; Slavich, and Cole, 2013) and personal values (Li, 2003) are choreographed through social and cultural processes and manifest in phenotypic variation (Lickliter and Honeycutt, 2003). So, social ecologies impact on health and can be related to factors such as poverty, gendered role identities and role behaviours and living in a macho/warlord society versus a free one. Local ecological conditions do much to shape identities and offer narratives for social relating (e.g. men should be tough and women submissive; Gilmore, 1990). Exploitative versus affiliative styles of social relating within groups, and the self-identities that form within them, are highly influenced by cultural factors (Cohen, 2001). A simple model that indicates a constant dynamic interplay of such processes is given in Figure 4.2.

PSYCHOLOGICAL Attitudes/values Thoughts Emotions

BIOLOGICAL Hormone Neurochemistry Immunity Genes

SOCIAL Relationships Social Roles

Physical Ecologies: Resource scarce versus resource plenty Hostile versus benign Social Ecologies:

Cooperative versus competitive Caring versus exploitative/hostile

Figure 4.2  Biopsychosocial and ecological interactions.

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So when we come to think about formulation, and the person who sits in front of us, it is useful to remember that for any one of us there are many potential versions of ourselves, influenced by both pre- and post-birth environmental factors. We can share these insights with our clients by advising them that if we, as a therapist, had been kidnapped as a 3-day-old baby into say, a violent drug gang, then this (caring therapist) version would not exist. In its place would be probably a fairly aggressive person who possibly had harmed people and might be in jail or even dead. Since one does not and cannot choose to be kidnapped as a 3-day-old baby, we come to recognise that so much of what happens to us, and the versions we have become, has been completely out of our control – a combination of genetic lottery and social conditions. This kind of information helps the client to begin to formulate their difficulties in less personal, self-blaming ways and to become much more aware of the fragility of the versions any of us could become. However, it also enables them to think about the versions of themselves they would like to become and how they can train for that version – in compassion focused therapy this is obviously training to become a compassionate self (Gilbert, 2009). Formulation then can also involve clarity about where therapy might go. In compassion focused therapy, for example, there is an orientation towards developing the compassion identity with core attributes and skills (Gilbert and Choden, 2013). One of the reasons for this is because compassion is linked into core motivational systems, and as noted above, these choreograph a whole range of attentional, emotional, behavioural and cognitive processes (Gilbert, 2010, 2012; Gilbert and Choden, 2013).

Working with individuals In an ideal world, clinicians would be holistic in their case formulation and operate, with complex cases, as part of a multi-disciplinary team and community. For example, it is important to ensure that people are not suffering for some obvious physical disorder (e.g. hypothyroidism, fatigue being due to diabetes), nor ignore physical health needs (e.g. poor diet, lack of exercise), or ecologies (e.g. poverty, abilities to gain meaningful work, social support systems). There is increasing evidence that the modern diet may be fuelling some mental health problems because of how it impacts on the immune system (Raison et al., 2010). Poor diet along with lack of exercise has been strongly linked to mental health problems. Certain working environments that come under pressure can also increase bullying within the organisation. So, it’s important to contextualise people in their lived environments and experiences. As noted before, however, formulation is focused on ‘what has happened to people and how they have adapted rather than what is wrong with people’. So, for complex cases in particular, it is important that clients are able to contextualise their problems in ways that are understandable, given the human brain and their historical and current social contexts. This lays the foundation for insight into the fact that much of what they are experiencing is not their fault. Not only is this because the human brain is very tricky at the best of times, but also because many kinds of mental health problems result from people’s efforts to adapt to difficult

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circumstances or thwarted basic needs. Especially important are thwarted attachment needs (Holmes, 2001; Wallin, 2007). So in this sense the therapist guides the client through a history review, helping them to think about the organisation of their social mentalities (basic desires and values) and emotion systems – including safety strategies and competencies for affiliative soothing. So, typically one will have a formulation that has four types of information. 1

What are the background influences that have shaped this person? This will involve the basic phenotypes – for example, their patterns of attachment, or affiliative relating, or ways of competing and asserting themselves. Therapy will contextualise difficulties in relationship to emotional memories and how these have textured their sense of self and how they experience others. Here the therapist looks at the ways in which key figures were able to meet their basic needs such as providing a (protection) secure base and (soothing) safe haven, able to help them validate and learn about their emotions, and to experience themselves as valued and cared about in the eyes of others. Commonly, in complex cases clients will have experienced thwarted needs or actual threats and harms such as neglect and critical or abusing experiences, and carry deep emotional memories relating to these which interact with basic temperament. 2 Life is obviously an unfolding process where we are constantly carrying forward experiences from the past into the present and future; past experiences shape the way we are going to adapt and relate to each new moment. So, here we are interested in what core concerns, fears and unmet needs are being carried forward from childhood. These can be distinguished between the external (fears about being shamed, rejected, marginalised, abandoned by others) and internal fears (related to emotions, memories or intrusions). For example, recovered depressed people or people suffering psychosis might recover but live in fear of their return. 3 Life experience shapes our emotions and the fusions of different emotions, our ‘drives and things we seek out in life’ but also the things that threaten us. Thus we orientate ourselves to try to achieve certain things and avoid threats, harms and losses along the way. So, here, formulation explores the basic safety strategies individuals use to handle their external and internal threats and concerns. It’s important to make this distinction between internal and external here because the way people cope with the potential to be harmed by things outside of themselves (e.g. being rejected by others) is quite different from how they deal with things they are frightened of in their own minds (coping with intense feelings of loneliness or rage or feared intrusions – as well as fusions and confusions with emotions). Formulation might also consider the strategies the person has developed to try to compensate for, or deal with, unmet needs. Are some people looking for a father or mother figure; are they constantly trying to achieve to prove themselves worthy of something; are they trying to be compulsively self-reliant and protect themselves from more hurt?

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4

Typically there are some forms of safety strategies and compensatory drives such as seeking validation, ‘people pleasing’ submissiveness or pursuing compulsive self-reliance, which will give rise to unintended and undesirable consequences. These can be explored with clients but in the climate of empathic engaging with them as understandable consequences from the flow of their lives. In compassion focused therapy one would then begin to develop compassion for these basic experiences and strategies.

This model of formulation, which many psychotherapies more or less utilise, is central to compassion focused therapy and has been used to formulate with people with complex difficulties such as psychosis (Gumley et al., 2010), bipolar disorders (Lowens, 2010) and eating disorders (Goss, 2010). Case example The details have been changed to avoid specific recognition but they are common and many therapists will be familiar with them. Sally grew up with a very critical, at times physically abusive and cold mother. She did not suffer from physical deprivation because the practical things of life – clean clothes and good food – were well provided. She recalls many experiences of being upset and frightened by her mother’s criticism and occasional physical attacks – sometimes with hair brushes. After an ‘event’, Sally’s mother would hardly talk to her for days. Her mother rarely acted as a source of comfort or help. Sally never had a sense of fun or the fact that her mother ‘took joy’ in her existence. If anything she experienced herself as ‘an annoyance’ and ‘a nuisance’. When she had problems with bullying at school, she never told anyone but would lie in bed thinking about how she could kill herself. Sally’s father was a distant character who worked away a lot and didn’t seem that interested in either Sally or his wife. He died when Sally was around 12 years old. Sally’s mother seemed to retreat into a sense of depressed bitterness as the lone parent and breadwinner. Sally remembers really wanting to be close to her father, since he was pleasant to her when he was around. She recalled feeling envious of her friends who seemed to have good relationships with their fathers. Later in life her mother told her that her father was living with another woman a lot of the time, which was why he was not there much. So, Sally was living with a mother who may have been bitter at the state of her marriage and in a home dominated by experiences of loss, emptiness, loneliness and critical others. Sally rarely, if ever, felt safe or particularly loved. So we can consider the kinds of emotional experiences that would have been part of her life and got fused together such as sense of being criticised/shamed and then isolated. For her, as for many others, experiencing shame and isolation/loneliness was part of her actual learning experience. In a desperate wish to get out of the home as quickly as possible, she left when she was 17 and got into a relationship with someone three years older than her who was kind to her but also very heavily into drugs. He was safe and not demanding but often not emotionally available. Like her father who was emotionally located outside of the family, her partner was emotionally located in his drugs rather than her.

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Sally had been suffering from depressions on and off for most of her adolescence. At times she used alcohol, and after meeting her partner, she used drugs. She had self-harmed from mid-adolescence. She was critical of herself, feeling that she was not good at anything and ‘a bit of a waste of space’. She had high levels of shame and could often ‘hear her mother’s contemptuous and angry voice’. She was frightened of hers and other people’s anger and was desperate to be wanted and approved of. She felt grateful to her partner because although he wasn’t really emotionally available to her she thought ‘who else would want me?’. She also felt he needed her which gave her something of a role. On the ward she could come over as somewhat immature, and she had a way of annoying staff by leaving the ward and getting drunk or trying to bring in painkillers for an overdose. From an evolutionary point of view we can see that Sally has many thwarted needs, developmental arrests of motivational systems. The normal motives and needs for being cared for, cared about and protected, had been block and thwarted. She had not experienced a safe/secure base or safe haven to be able to develop self-confidence in herself as a person and a woman. Her competitive mentality, to feel on a par with others and a capacity to act assertively in the world, hadn’t developed, so she presented as submissive. Indeed, some caring behaviours can also be motivated by submissive strategies of desire to be liked and avoid rejection (Catarino et al., 2014). She also wasn’t very good at cooperating and developing reciprocal friendly relationships. She felt she was ‘an outsider’ and ‘not connected’ or ‘fitting in’ anywhere. She had issues of a deep sense of loneliness and isolation in what was for her a frightening, uncaring and unpredictable world. In terms of her inner world, many of her emotions were felt to be overwhelming, chaotic and frightening, particularly those associated with anger and sadness. Making sense We can work through Sally’s difficulties in the four main headings noted above and outlined in Table 4.2. The first stage of formulation is not just to have an understanding from the therapist’s point of view, but also to enable the client to begin to make sense of their experience as a ‘life journey’. With Socratic dialogues and explorations, therapist curiosity, guided discovery and reflections, the client begins to locate their difficulties in their life experiences, emotional memories and the fact that the human brain is very tricky with a lot of negative biases built-in. The first part of formulation, then, is clarifying the emotional memories that stand out for Sally. One can then help Sally recognise that her earlier life experiences will texture the way she now experiences and relates to the world (as classically conditioned emotional memories). The therapist reminds Sally often that ‘of course this is not your fault because you would never have chosen to have those experiences.’ These emotional memories may then become targets for therapy with forms of (say) re-scripting (Arntz, 2011; Ecker et al., 2012; Hackmann, 2005; Lee, 2005, Lee and James, 2012). Some therapies see emotional memories as underpinning schemas or core beliefs but it can be useful to formulate and work directly with the

Unintended and unhelpful consequences External: Keep distance, don’t share thoughts and feelings and so don’t know if others can feel the same way I do. Stay lonely because I never really open up or relate to others. Feel no one really understand me. Only Dave – but he is often ‘out of his brain’ Internal (self-criticism): But it is all my fault, I know I should be more assertive but I am a coward. I should just get on with life and stop all this ruminating and self-pity! Sometimes I feel so confused and bad that I take an overdose.

Safety/defensive strategies External: Monitor other people, particularly facial expressions and voice tones, to try to work out what they are feeling. Try to please people, work out what they want; hide feelings that could upset people. Internal: I try to avoid heated conflicts or expressing anger – submissive, but can ruminate on resentment which fuels a sense of being ‘an unlovable self’. Try to avoid feeling ‘terrible inner loneliness’ – drink when that ‘hits’ me or may use drugs.

Key fears

External: I am frightened of being criticised by others, and feeling inadequate and vulnerable; seen as ‘not what they want’. I am afraid of others getting too close to me in case they find out something and then don’t like me. Internal: I fear the arousal of emotions like anger and have had so much anxiety I just don’t want it anymore! Sometimes I feel very sad and lonely but am frightened of allowing these emotions because they are overwhelming.

Background experiences

The Case of Sally Mother was critical and father was absent. I have many emotional memories of mother as a powerful and dominant character. She was unpredictable and I often felt frightened of her. Never really saw her as a source of comfort but I wanted to love her, and for her to know I did. Father was too absent and died when I was 12. I also tended to be shy at school and prone to being bullied – though I had a couple of close friends. Dave (partner) easy going and kind but heavy into drugs.

Table 4.2 The case of Sally

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‘raw’ emotional experience and the textures of the emotional memory rather than abstract concepts like the schema. This is especially so in view of the increasing evidence for the importance of working directly with specific emotional memories in forms of re-scripting (Ecker et al., 2012). While some clients can easily reflect on their emotional experiences, others cannot and may say it is ‘all a bit of a blank’. These clients may feel threatened, dissociated or become over-aroused when they try to reflect. So the therapist is cautious not to be overwhelming. In these cases, therapist and client are more in the here-and-now and gradually explore memories as they arise. The second level is to help Sally reflect on what she has carried forward from these experiences into later life. Here, the Socratic discussions are designed to help her consider her current core fears and concerns, reflect on her needs and ambitions and also her strengths. The evolutionary model distinguishes between what an individual is frightened about on the outside (external), and the things they might be frightened about inside of themselves (internal). External social fears and concerns are commonly focused on ‘what’s going on in the minds of others and what their intents towards self are’. Here, mentalising becomes important, because many people with these types of backgrounds can overly rely on emotional memory and simply project. That is, Sally could quickly jump to the conclusion that people are likely to be critical or hostile and very unforgiving (like mother). This is not so much a ‘cognitive bias’ as an emotional threat processing bias stemming directly from the arousal of emotional memory. In regard to internal fears, Sally has learned to monitor and regulate emotion and is avoidant of certain emotions. At this stage, then, we have an insight into the important emotional experiences which will give us insight into the maturation of the three emotion systems – the kinds of threat memories and sense of threat she is bringing forward; her drives, ambitions and hopes and the way she is able to calm and soothe herself. Next, we explore how this lived experience also gives rise to a set of safety strategies. Since one of the basic functions of all living organisms is to survive in their current environment and prevent as much harm as possible (most safety strategies are automatically developed rather than purposely chosen), they quickly become part of the implicit fast-acting processing systems. In regard to external focus, Sally’s safety strategies were typically focused on the minds of others. Sally is understandably very attentive and overly monitoring of other people’s minds and the possibility that she could be a target for criticism and rejection. From this she develops a primarily submissive orientation with a desire to please others. On the other hand, she can find herself behaving in a way which antagonises others. In regard to internal safety strategies, Sally struggles with trying to avoid feelings of rage, emptiness, sadness and just feeling ‘completely lost’, because they overwhelm her. When these feelings get too intense she turns to alcohol, drugs or self-harms because ‘tolerating them is just so horrible’ for her. Experiential avoidance is central to many therapies (Hayes et al., 2004). It is also clear that rage is a serious difficulty for people like Sally (Busch, 2009), but so is emptiness,

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feelings of being lost in the world, having no secure base or safe haven and grieving (Gilbert, 2010). So, in the formulation the therapist is interested in how she manages her own internal world of motives, desires and emotions and the conflicts of motives and emotions. In terms of her self-identity and goals, Sally is not focused on cultivating positive emotion or a positive sense of self but is constantly trying to avoid threat emotions and a sense of shame, rejection and intense loneliness. What positive emotions she might try to cultivate are usually to do with ‘reducing the sense of threat’. The ability to create feelings of peaceful contentment with a sense of safeness is ‘not part of how she operates’. Rather, she relies on drugs for these feelings. Cultivating and tolerating positive emotions, that will include drive based emotions such as enthusiasm, playfulness, joyfulness, and also soothing based emotions such as peacefulness, contentment, social safeness and connectedness, will be a major part of her CFT. Therefore the absence or difficulties with these emotions and motives will need to be acknowledged in the formulation, especially as they become part of the therapeutic tasks. The fourth element of the formulation explores the unintended and undesired consequences of her background and understandable efforts to cope with life. To illuminate the unintended and often undesired consequences of safety strategies, therapist and client can reflect together on the downsides of these internally and externally focused strategies for coping. Usually, clients can see fairly quickly that the ways in which they try to cope can actually make things worse (unintentionally) and can cut them off from sources of support. The therapist can also reflect on some of the basic drives and defensive ‘people pleasing’ and compliance type strategies. If clients can reflect that these are compensations for unmet needs then the therapist can explore if they work or not, and what the disadvantages of them are. In CFT, for example, part of the focus will be on helping Sally develop a new orientation for self-identity which will become the compassionate self which may require more self-assertion. Sally was very self-critical and disappointed in herself. Recent studies show very clearly that self-criticism stimulates the threat system and that high self-critics can even show a threat response when they are trying to be self-reassuring (Longe et al., 2010). On a daily basis, Sally will be having experiences of disappointment and anger with herself which will be stimulating threat systems and blocking her from self-validation and affiliation. Having learned to avoid painful emotions, Sally can recognise that this means that those emotions are always there in the background; that she has to constantly try to keep the lid on. Therapist and client can reflect on the difficulties of doing that and the bodily consequences. Sally was able to recognise how she couldn’t be assertive for fear of rejection and how this led her to constantly suppress her own needs and feelings and desires. Indeed, she often wasn’t clear about what they were. On the other hand, Sally was also able to recognise that she carried quite a lot of resentment/rage which was frightening to her. In fact, the fearful-submissive strategy can often lead to a rage-resentment (which can be frightening to experience), leading back to fear-submissiveness. This is not an uncommon unintended

A biopsychosocial and evolutionary approach  83

consequence of these types of safety strategies. As noted above, the question here is the speed at which Sally is able to begin to allow herself to experience these conflicts, or whether she keeps them relatively outside of conscious awareness. So, the therapist is helping the client see that the nature of their difficulties makes a lot of sense and why their experiences are ‘not their fault’, because the whole thing started off with trying to cope with a difficult life as best as they could. Commonly, however, clients recognise this, but on a superficial intellectual level, so they do not experience the implications of it. They can also see fairly quickly the difficulties which the safety strategies (e.g. being overly submissive or not processing painful emotions) generate. Unfortunately, people may then turn these back in on themselves in the form of self-criticism, thinking they are weak or something is bad about them to have this level of submissiveness or rage, or feeling their emotions are out of control. So without insight and reflection, unintended consequences can lead to secondary self-criticism. The key issue for self-criticism is that it blocks the internal affiliative processing system; i.e., self-compassion. The point of the formulation, then, is threefold. First, it is to help clients contextualise their difficulties in their ‘lived experience’, make sense of them and de-shame them. For the therapist the question is not so much ‘what’s wrong with you?’ but ‘what has happened to you?’ The second function of formulation is ‘given what has happened to you’, how can we reflect on ‘how life experiences have shaped you?’, ‘how did you try to cope and protect yourself?’, ‘how are those ways of coping (strategies and phenotypes) helping you?’ and then ‘how do they unintentionally cause you difficulties today?’, ‘what have they prevented you from developing or becoming?’ An evolutionary approach avoids the language of dysfunction and deficit and replaces it with the language of variation in functional strategies and phenotypes. The focus on ‘what have they prevented you from developing or becoming?’ opens a door to the possibility of developing and becoming something new; exploring an developing new 'versions' of self. So, a third element of formulation takes us into the territory of contracting and developing the path for the actual therapy – which will be different according to the therapeutic orientation of the therapist. In CFT the therapist spends time helping the client understand what compassion is (with a strong focus that affiliation and compassion build courage), how it can work and how to develop a compassionate orientation to the difficulties they are presenting (Gilbert, 2010, 2012; Gumley et al., 2010; Welford, 2010). So, attention is given to how compassion can support and build the courage to engage with things that are difficult and also build the courage to develop and experience more positive, enjoyable and meaningful aspects of living.

Conclusion The evolutionary approach to formulation begins with the insight that humans are an evolved animal. We inherit a set of genes that we didn’t choose but which will build a brain capable of experiencing certain motivational urges, needs and emotions. We now know that the kind of person we become is very much dependent on

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the interactions between genes and what sort of early backgrounds we have – even to the point that backgrounds influence genetic expression. This is very important information to convey to clients who often are very self-blaming, self-judging and shame prone. In addition, evolutionary therapists take a very biopsychosocial view and try to avoid locating the cause of people’s problems as some kind of ‘errors in the head’ as opposed to understandable phenotypic developments in certain contexts. This basic orientation is conveyed to clients, and sets the emotional tone for collaborative working on how to deal with what is essentially a very tricky brain that has had to cope with some very difficult early life experiences. From here the therapist and client move towards what is necessary to begin to cultivate change via cultivating different aspects of the self and different versions of the self that might be more conducive to well-being. So, therapeutic interventions may target emotions, behaviours, cognitions and sensory processing. In CFT this is obviously the compassionate self, but in other therapies it may be to do with values and goals (Hayes et al., 2004). As clients understand the nature of their suffering, as rooted in inheriting a very tricky brain and encountering life experiences that were very painful, this provides the basis for insight into why and how compassion can be helpful. However, whatever model is used, formulation should help to offer a de-shaming narrative with insights into the nature of the difficulties for both client and therapist, which also sets the framework for a step-by-step change process that clients see as desirable and doable.

References Arntz, A. (2011). Imagery rescripting for personality disorders. Cognitive and Behavioral Practice 18: 466–81. Austina, M. A. et al. (2007). Borderline personality disorder and emotion regulation: Insights from the Polyvagal Theory. Brain and Cognition 65: 69–76. Baron-Cohen, S. (2012). Zero Degrees of Empathy: A New Theory of Human Cruelty. Colchester: Penguin. Bates, T. (2005). The expression of compassion in group cognitive therapy. In P. Gilbert (ed.) Compassion: Conceptualisations, Research and Use in Psychotherapy. London: Routledge. Baumeister, R. F. et al. (2001). Bad is stronger than good. Review of General Psychology 5: 323–70. Baumeister, R. F. and Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin 117: 497–529. Belsky, J. and Pluess, M. (2009). Beyond diathesis stress: Differential susceptibility to environmental influences. Psychological Bulletin 135: 885–908. Bick, J. et al. (2012). Childhood adversity and DNA methylation of genes involved in the hypothalamus–pituitary–adrenal axis and immune system: Whole-genome and candidate-gene associations. Development and Psychopathology 24: 1417–25. Bierhoff, H. W. (2005). The psychology of compassion and altruism. In P. Gilbert (ed.) Compassion: Conceptualisations. Research and Use in Psychotherapy. London: Brunner-Routledge.

A biopsychosocial and evolutionary approach  85 Bowlby, J. (1969). Attachment and Loss: Vol. 1. Attachment. London: Hogarth Press. Bowlby, J. (1973). Attachment and Loss: Vol. 2. Separation, Anxiety and Anger. London: Hogarth Press. Bowlby, J. (1980). Attachment and Loss: Vol. 3. Loss, Sadness and Depression. London: Hogarth Press and Institute of Psycho-Analysis. Bowyer, L. et al. (2014). Developing a compassionate mind to enhance trauma focused CBT with an adolescent female. A case study. Behavioural and Cognitive Psychotherapy 42: 248–54. Braehler, C. et al. (2013). Exploring change processes in compassion focused therapy in psychosis: Results of a feasibility randomized controlled trial. British Journal of Clinical Psychology 52: 199–214. Busch, F. N. (2009). Anger and depression. Advances in Psychiatric Treatment 15: 271–76. Buss, D. A. (2009). The great struggles of life: Darwin and the emergence of evolutionary psychology. American Psychologist 64: 140–48. Cacioppo, J. T. and Patrick, W. (2008). Loneliness: Human Nature and the Need for Social Connection. New York: Norton. Carter, C. S. (1998). Neuroendocrine perspectives on social attachment and love. Psychoneuroendocrinology 23: 779–818. Catarino, F. et al. (2014). Compassion motivations: Distinguishing submissive compassion from genuine compassion and its association with shame, submissive behaviour, depression, anxiety and stress. Journal of Social and Clinical Psychology 33: 399–412. Cohen, D. (2001). Cultural variation: Considerations and implications. Psychological Bulletin 127: 451–71. Cortina, M. and Liotti, G. (2010). Attachment is about safety and protection, intersubjectivity is about sharing and social understanding: The relationship between attachment and intersubjectivity. Psychoanalytic Psychology 27: 410–41. Cozolino, L. (2007). The Neuroscience of Human Relationships: Attachment and the Developing Brain. New York: Norton. Crocker, J. and Canevello, A. (2008). Creating and undermining social support in communal relationships: The role of compassionate and self-image goals. Journal of Personality and Social Psychology 95: 555–75. Crocker, J. et al. (2010). Interpersonal goals and change in anxiety and dysphoria in first-semester college students. Journal of Personality and Social Psychology 98: 1009–24. Crosier, B. S. et al. (2012). Wired to connect: Evolutionary psychology and social networks. Annual Review of Psychology 16: 230–39. Danquah, A. N. and Berry, K. (2013). Attachment Theory in Adult Mental Health: A Guide to Clinical Practice. London: Routledge. Deci, E. L. and Ryan, R. M. (1985). Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum. Depue, R. A. and Morrone-Strupinsky, J. V. (2005). A neurobehavioral model of affiliative bonding. Behavioral and Brain Sciences 28: 313–95. Dewitte, M. and De Houwer, J. (2008). Adult attachment and attentions to positive and negative emotional face expressions. Journal of Research in Personality 42: 498–505. Dunbar, R. I. M. (2010). The social role of touch in humans and primates: Behavioural function and neurobiological mechanisms. Neuroscience and Biobehavioral Reviews 34: 260–68. Dunkley, D. M. et al. (2006). Specific perfectionism components versus self-criticism in predicting maladjustment. Personality and Individual Differences 40: 665–76.

86  Paul Gilbert Dykman, B. M. (1998). Integrating cognitive and motivational factors in depression: Initial tests of a goal-orientation approach. Journal of Personality and Social Psychology 74: 139–58. Ecker, B. et al. (2012). Unlocking the Human Brain: Eliminating Symptoms at Their Roots Using Memory Reconsolidation. Hove: Routledge. Epstein, S. (1994). Integration of the cognitive and the psychodynamic unconscious. American Psychologist 49: 709–24. Field, T. (2000). Touch Therapy. New York: Churchill Livingstone. Field, T. et al. (2005). Cortisol decreases and serotonin and dopamine increase following massage therapy. International Journal of Neuroscience 115: 1397–1413. Fogel, A. et al. (1986). Conceptualising the determinants of nurturance: A reassessment of sex differences. In A. Fogel and G. F. Melson (eds) Origins of Nurturance: Developmental, Biological and Cultural Perspectives on Caregiving. Hillsdale, NJ: Lawrence Erlbaum. Fonagy, P. et al. (2002). Affect Regulation, Mentalization, and the Development of the Self. London: Other Press. Gilbert, P. (1984). Depression: From Psychology to Brain State. London: Lawrence Erlbaum. Gilbert, P. (1989). Human Nature and Suffering. Hove: Lawrence Erlbaum. Gilbert, P. (1992). Depression: The Evolution of Powerlessness. Hove: Lawrence Erlbaum. Gilbert, P. (1993). Defence and safety: Their function in social behaviour and psychopathology. British Journal of Clinical Psychology 32: 131–53. Gilbert, P. (1995). Biopsychosocial approaches and evolutionary theory as aids to integration in clinical psychology and psychotherapy. Clinical Psychology and Psychotherapy 2: 135–56. Gilbert, P. (1998a). What is shame? Some core issues and controversies. In P. Gilbert and B. Andrews (eds) Shame: Interpersonal Behavior, Psychopathology and Culture. New York: Oxford University Press. Gilbert, P. (1998b). Evolutionary psychopathology: Why isn’t the mind better designed than it is? British Journal of Medical Psychology 71: 353–73. Gilbert, P. (2000a). Varieties of submissive behaviour: Their evolution and role in depression. In L. Sloman and P. Gilbert (eds) Subordination and Defeat. An Evolutionary Approach to Mood Disorders. Hillsdale, NJ: Lawrence Erlbaum. Gilbert, P. (2000b). Social mentalities: Internal ‘social’ conflicts and the role of inner warmth and compassion in cognitive therapy. In P. Gilbert and K. G. Bailey (eds) Genes on the Couch: Explorations in Evolutionary Psychotherapy. Hove: Psychology Press. Gilbert, P. (2000c). Varieties of submissive behaviour: Their evolution and role in depression. In L. Sloman and P. Gilbert (eds) Subordination and Defeat. An Evolutionary Approach to Mood Disorders. Hillsdale: NJ: Lawrence Erlbaum. Gilbert, P. (2002). Evolutionary approaches to psychopathology and cognitive therapy. Cognitive Psychotherapy: An International Quarterly 16: 263–94. Gilbert, P. (2005). Social mentalities: A biopsychosocial and evolutionary reflection on social relationships. In M. Baldwin (ed.) Interpersonal Cognition. New York: Guilford Press. Gilbert, P. (2007). The evolution of shame as a marker for relationship security. In J. L. Tracy, R. W. Robins and J. P. Tangney (eds) The Self-Conscious Emotions: Theory and Research. New York: Guilford Press. Gilbert, P. (2009). The Compassionate Mind: A New Approach to the Challenges of Life. London: Constable and Robinson.

A biopsychosocial and evolutionary approach  87 Gilbert, P. (2010). Compassion Focused Therapy: The CBT Distinctive Features Series. London: Routledge. Gilbert, P. (2012). Compassion focused therapy. In W. Dryden (ed.) Cognitive Behaviour Therapy. London: Sage. Gilbert, P. (2013). Depression: The challenges of an integrative, biopsychosocial, evolutionary approach. In M. Power (ed.) The Wiley-Blackwell Handbook of Mood Disorders (2nd ed.). Chichester: Wiley. Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology 53: 6–41. Gilbert, P. and Choden, K. (2013). Mindful Compassion. London: Constable-Robinson. Gilbert, P. et al. (2007). Striving to avoid inferiority: Scale development and its relationship to depression, anxiety and stress. British Journal of Social Psychology 46: 633–48. Gilbert, P. et al. (2008). Feeling safe and content: A specific affect regulation system? Relationship to depression, anxiety, stress and self-criticism. Journal of Positive Psychology 3: 182–91. Gilbert, P. et al. (2012). Fears of compassion and happiness in relation to alexithymia, mindfulness and self-criticism. Psychology and Psychotherapy 84: 239–55. Gilbert, P. et al. (2014). Fears of negative emotions in relation to fears of happiness, compassion, alexithymia and psychopathology in a depressed population: A preliminary study. Journal of Depression and Anxiety. doi:10.4172/2167-1044.S2-003 Gillie, B. L. and Thayer, J. F. (2014). Individual differences in resting heart rate variability and cognitive control in posttraumatic stress disorder published on line. Frontiers in Psychology 5: 758. Gilmore, D. D. (1990). Manhood in the Making: Cultural Concepts of Masculinity. New Haven, CT: Yale University Press. Goss, K. (2010). Compassion focused therapy for eating disorders. International Journal of Cognitive Therapy 3: 141–58. Gumley, A. et al. (2010). A compassion focused model for recovery after psychosis. International Journal of Cognitive Therapy 3: 97–112. Hackmann, A. (2005). Compassionate imagery in the treatment of early memories in axis I anxiety disorders. In P. Gilbert (ed.) Compassion: Conceptualisations, Research and Use in Psychotherapy. London: Routledge. Hassin, R. R. et al. (2005). The New Unconscious: New York: Oxford University Press. Hayes S. C. et al. (2004). Mindfulness and Acceptance: Expanding the Cognitive Behavioral Tradition. New York: Guilford Press. Heard, D. and Lake, B. (1988). The Challenge of Attachment for Caregiving. London: Routledge. Hofer, M. A. (1994). Early relationships as regulators of infant physiology and behavior. Acta Paediatrica Supplement 397: 9–18. Holmes, J. (2001). The Search for the Secure Base: Attachment Theory and Psychotherapy. Hove: Routledge. Hostinar, C. E. et al. (2014). Psychobiological mechanisms underlying the social buffering of the hypothalamic–pituitary–adrenocortical axis: A review of animal models and human studies across development. Psychological Bulletin 140: 256–82. Johnson, S. L. et al. (2012). The dominance behavioral system and psychopathology: Evidence from self-report, observational, and biological studies. Psychological Bulletin 138: 692–743. Joshanloo, M. (2013). The influence of fear of happiness beliefs on responses to the satisfaction with life scale. Personality and Individual Differences 54: 647–51.

88  Paul Gilbert Kannan, D. and Levitt, H. M. (2013). A review of client self-criticism in psychotherapy. Journal of Psychotherapy Integration 23: 166–78. Keedwell, P. et al. (2008). Neural markers of symptomatic improvement during antidepressant therapy in severe depression: Subgenual cingulate and visual cortical responses to sad, but not happy, facial stimuli are correlated with changes in symptom score. Journal of Psychopharmacology 23: 775–88. Kelly, A. C. et al. (2012). Social safeness, received social support, and maladjustment: Testing a tripartite model of affect regulation. Cognitive Therapy and Research 36: 815–26. Keltner, D. and Haidt, J. (1999). Social functions of emotions at four levels of analysis. Cognition and Emotion 13: 505–21. Kendell, R. E. (1975). The Role of Diagnosis in Psychiatry. London: Blackwell Scientific. Kiesler, D. J. (1999). Beyond the Disease Model of Mental Disorders. New York: Praeger. Kirsch, P. et al. (2005): Oxytocin modulates neural circuitry for social cognition and fear in humans. Journal of Neuroscience 25: 11489–93. Lee, D. (2005). The perfect nurturer. A model to develop a compassionate mind within the context of cognitive therapy. In P. Gilbert (ed.) Compassion: Conceptualisations, Research and Use in Psychotherapy. London: Routledge. Lee, D. and James, S. (2012). The Compassionate Mind Approach to Recovering from Trauma using Compassion Focused Therapy. London: Constable Robinson. LeDoux, J. (1998). The Emotional Brain. London: Weidenfeld and Nicolson. Li, S. C. (2003). Biocultural orchestration of developmental plasticity across levels: The impact of biology and culture in shaping the mind and behavior across the life span. Psychological Bulletin 129: 171–94. Lickliter, R. and Honeycutt, H. (2003). Developmental dynamics: Toward a biologically plausible evolutionary psychology. Psychological Bulletin 129: 819–35. Liotti, G. (2000). Disorganised attachment, models of borderline states and evolutionary psychotherapy. In P. Gilbert and B. Bailey (eds) Genes on the Couch: Explorations in Evolutionary Psychotherapy. Hove: Brunner-Routledge. Liotti, G. (2009). Attachment and dissociation. In. P. F. Dell and J. A. O’Neil (eds) Dissociation and the Dissociative Disorders: DSM-5 and Beyond. London: Routledge. Liotti, G. and Gilbert, P. (2010). Mentalising, motivations and social mentalities: Theoretical considerations and implications for psychotherapy. Psychology and Psychotherapy 84: 9–25. Liotti, G. and Gumley, A. (2008). An attachment perspective on schizophrenia: The role of disorganized attachment, dissociation and mentalization. In A. Moskowitz, I. Schafe and M. J. Dorahy (eds) Psychosis, Trauma and Dissociation. Chichester: Wiley. Loewenstein, G. and Small, D. A. (2007). The scarecrow and the tin man: The vicissitudes of human sympathy and caring. Review of General Psychology 11: 112–26. Longe, O. et al. (2010). Having a word with yourself: Neural correlates of self-criticism and self-reassurance. NeuroImage 49: 1849–56. Lowens, I. (2010). Compassion focused therapy for people with bipolar disorder. International Journal of Cognitive Therapy 3: 172–85. MacDonald, K. and MacDonald, T. M. (2010). The peptide that binds: A systematic review of oxytocin and its prosocial effects in humans. Harvard Review of Psychiatry 18: 1–21. McEwan, K. et al. (2012). An exploration of competitiveness and caring in relation to psychopathology. British Journal of Clinical Psychology 51: 19–36. McEwan, K. et al. (2014). Facial expressions depicting compassionate and critical emotions: The development and validation of a new emotional face stimulus set. PLOS ONE 9: e88783.

A biopsychosocial and evolutionary approach  89 Mikulincer, M. and Shaver, P. R. (2007). Attachment in Adulthood: Structure, Dynamics, and Change. New York: Guilford Press. Moberg, K. U. (2013). The Hormone of Closeness: The Role of Oxytocin in Relationships. London: Printer and Martin. Music, G. (2014). The Good Life: Well Being and the Neuroscience of Altruism Selfishness and Immorality. London: Routledge. Nesse, R. (2005). Evolutionary psychology and mental health. In D. Buss (ed.) The Handbook of Evolutionary Psychology. Hoboken, NJ: Wiley. Panksepp, J. (1998). Affective Neuroscience. New York: Oxford University Press. Porges, S. W. (2007). The polyvagal perspective. Biological Psychology 74: 116–43. Power, M. and Brewin, C. R. (1991). From Freud to cognitive science: A contemporary account of the unconscious. British Journal of Clinical Psychology 30: 289–310. Raison, C. L. et al. (2010). Inflammation, sanitation and consternation: Loss of contact with co-evolved, tolerogenic microorganisms and the pathophysiology and treatment of major depression. Archives of General Psychiatry 67: 1211–23. Sheeran, P. et al. (2013). Nonconscious processes and health. Health Psychology 32: 460. Siegel, D. (2012). The Developing Mind, Second Edition: How Relationships and the Brain Interact to Shape Who We Are. New York: Guilford Press. Slavich, G. M. and Cole, S. W. (2013). The emerging field of human social genomics. Clinical Psychological Science 1(3): 331–48. Smith, E. O. (2002). When Culture and Biology Collide: Why We are Stressed, Depressed and Self-Obsessed. New Brunswick, NJ: Rutgers University Press. Stanley, B. and Siever, L. J. (2010). The Interpersonal Dimension of Borderline Personality Disorder: Towards a Neuropeptide Model. American Journal of Psychiatry 167: 24–39. Stubbs, J. et al. (2011). Problems in identifying predictors and correlates of weight loss and maintenance: Implications for weight control therapies based on behaviour change. Obesity Review 12: 688–708. Suddendorf, T. and Whitten, A. (2001). Mental evolutions and development: Evidence for secondary representation in children, great apes and other animals. Psychological Bulletin 127: 629–50. Taylor, P. et al. (2011). The role of defeat and entrapment in depression, anxiety and suicide. Psychological Bulletin 137: 391–420. Tobena, A. et al. (1999). Advantages of bias and prejudice: An exploration of their neurocognitive templates. Neuroscience and Behavioral Reviews 23: 1047–58. Van der Hart, O. et al. (2006). The Haunted Self: Structural Dissociation and Treatment of Chronic Traumatization. New York: Norton. Van Doesum, N. J. et al. (2013). Social mindfulness: Skill and will to navigate the social world. Journal of Personality and Social Psychology 105: 86–103. Wallin, D. (2007). Attachment in Psychotherapy. New York: Guilford Press. Warneken, F. and Tomasello, M. (2009). The roots of human altruism. British Journal of Psychology 100: 455–71. Watters, E. (2010). Crazy Like Us: The Globalisation of the American Psyche. New York: Free Press. Welford, M. (2010). A compassion focused approach to anxiety disorders International Journal of Cognitive Therapy 3: 124–40. Weng, H. Y. et al. (2013). Compassion training alters altruism and neural responses to suffering. Psychological Science 24: 1171–80. Wesselmann, E. D. et al. (2013). Vicarious ostracism. Frontiers in Human Neuroscience 7: 153.

Chapter 5

Cognitive and metacognitive therapy case formulation in anxiety disorders Adrian Wells

Cognitive and metacognitive therapy are implemented on the basis of case formulations that aim to represent the predisposing, triggering and maintenance factors involved in individual disorders. Cognitive behaviour therapy (CBT) formulations have typically included a range of diverse components such as a problem list, dysfunctional beliefs, triggers, hypotheses concerning mechanisms of maintenance and a treatment plan (e.g. Persons, 1989). Such diversity and complexity may not provide the optimal approach in light of recent advances which place a smaller set of psychological factors at the centre of causal models of disorder. This is exemplified by the metacognitive approach (Wells, 2009) that is demonstrably more effective than CBT in some applications (van der Heiden et al., 2012; Wells et al., 2010). Case formulation should provide the therapist with a guide to what to modify in therapy, and consequently the most useful approaches will be those that reveal the factors involved in the aetiology and maintenance of anxiety disorders. This chapter presents such an approach to case formulation using empirically supported cognitive and metacognitive models for specific anxiety disorders. The CBT and metacognitive therapy (MCT) approaches differ substantially in their focus on the types of processes and underlying cognitions that are formulated. One of the aims of this chapter is to provide the reader with an opportunity to consider the implications that different theories of causal mechanisms have on the applied formulation process and in particular to raise some pertinent questions concerning the problems that can emerge from attempting to use more integrative or eclectic approaches. Cognitive therapy formulations are based on general schema theory (Beck, 1976; Beck et al., 1985). A basic tenet of this approach is that underlying beliefs and assumptions concerning danger (danger schemas) constitute vulnerability to anxiety disorder. Schemas represent knowledge or beliefs about things, for example: ‘If I show anxiety people will reject me.’ Such schemas shape interpretations of experience and when activated by precipitating events introduce distortions in processing that are manifest as negative automatic thoughts. Cognitive distortions and behavioural responses contribute to the maintenance of disorder since individuals are unable to reality-test their beliefs effectively. This approach gives rise to a general model of disorder as depicted in Figure 5.1.

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Figure 5.1 General schema model of anxiety disorders (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.).

In contrast, metacognitive therapy formulations are based on a different model in which psychological disorder does not result from negative appraisals of the self and world but from states of extended difficult to control thinking (Wells and Matthews, 1994; Wells, 2000). This model is concerned with beliefs about thoughts rather than beliefs about things. Here, psychological disorder is caused by a style of relating to negative experiences (including thoughts and beliefs) with extended processing in the form of worry, rumination and maintenance of attention on threat. This pattern of responding arises from underlying beliefs about thinking, one aspect of metacognition. Two general domains of metacognitive beliefs are postulated: positive beliefs (e.g. ‘I must worry in order to avoid danger’) and negative beliefs (e.g. ‘I have lost control of my thinking’). Apart from extended thinking, other coping behaviours are also relevant in formulating disorder maintenance as they maintain dysfunctional metacognitions through a number of pathways. The different theoretical bases of the CBT and MCT models result in different emphases in the formulations derived from them. In this chapter I will describe

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these two types of approach in more detail, beginning with the CBT perspective on panic and then introducing metacognitive approaches later in the context of obsessive compulsive disorder and generalised anxiety. I will describe methods for generating each type of case formulation and show how shifting from a cognitive to a metacognitive formulation leads the therapist to focus on different factors.

Identifying the target problem Accurate identification of the presenting problem is a necessary prerequisite to valid case formulation based on disorder-specific models. Diagnosis provides one means of identifying a presenting problem, and can be used as a basis for selecting an appropriate model. The diagnostic approach is augmented by identification of the primary or central cognitions in a presentation. There is a degree of content specificity in anxiety disorder cognitions, such that the predominant themes in negative thoughts can be used as indicators of the likely presentation. Table 5.1 presents the key diagnostic features of each anxiety disorder and the typical cognitive themes. The use of standardised diagnostic interviews such as the structured clinical interview for DSM-5, the Anxiety Disorders Interview Schedule for DSM-IV (ADIS; Brown et al., 1994) and self-report screening instruments (e.g. Zimmerman and Mattia, 2001) are recommended as a first step towards accurately identifying target disorders. This is particularly useful when there are multiple presenting problems.

Table 5.1 Key diagnostic features (DSM-IV), cognitive and metacognitive themes in four anxiety disorders Anxiety disorder

Key diagnostic features

Cognitive theme

Panic disorder

Recurrent, unexpected panic attacks followed by at least one month of persistent concern about having another attack Fear of social or performance situations in which embarrassment may occur Recurrent obsessions or compulsions that are time-consuming or cause marked distress or impairment Excessive and uncontrollable worry about a number of events, and anxiety occurring more days than not for at least six months

Misinterpretation of anxious symptoms

Social phobia Obsessive-compulsive disorder

Generalised anxiety disorder

Concern about appearing anxious in front of others; about being embarrassed Concern about being responsible for harm

Concern about the world being dangerous and inability to cope

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Differential diagnosis is aided by understanding the specificity of cognitive content. Panic disorder is usually associated with apprehension and fears about having panic attacks. In this disorder, bodily symptoms are misinterpreted as a sign of an immediate physical or mental calamity (e.g. having a heart attack) and the person with agoraphobia avoids situations because of fears that panic attacks will occur. Panic attacks may occur in the context of any anxiety disorder but this is unlikely to constitute a panic disorder if the focus is not primarily fear of having a panic attack. Social phobia is characterised by fear of humiliation and embarrassment when being the focus of attention. Avoidance occurs as a means of avoiding embarrassment and negative evaluation by others. In obsessive-compulsive disorder, fears centre on the occurrence and consequences of intrusive thoughts and urges, and on the need to perform rituals and behaviours in order to avoid negative outcomes. In OCD, intrusions are interpreted as abhorrent, repugnant and uncharacteristic of the self (i.e. they are ego-dystonic). This is not usually the case with the thoughts and worries of the patient with generalised anxiety disorder (GAD), and the intrusive thoughts about trauma in posttraumatic stress disorder (PTSD). GAD is characterised by worry about a range of topics and somatic symptoms, and a central negative cognition is the idea that worrying is uncontrollable and potentially harmful. PTSD involves intrusive recollections and thoughts about a trauma, coupled with avoidance and arousal symptoms. The focus of apprehension is typically on the possibility of future traumas and environmental threats to the self. The assessment of anxiety presentations can be complicated by medical conditions that give rise to anxiety-like symptoms. Hyperthyroidism, mitral valve prolapse, cardiac arrhythmias, tumours, vestibula disturbances and a range of other conditions can be the source of panic-like sensations and other anxiety-like symptoms, such as dizziness, cardiac symptoms, blushing, loss of balance and so on. An anxiety disorder is not diagnosed if the symptoms can be explained by medical conditions, or if the symptoms occur solely as a result of dependence on or withdrawal from substances such as caffeine or alcohol. Accurate and thorough assessment is required in order to formulate and plan an appropriate intervention.

Evidence-based, disorder-specific models In the remainder of this chapter I will describe the specific models that have been constructed and evaluated as a basis for formulating the psychological mechanisms underlying the development and persistence of specific anxiety disorders. Following a brief presentation of each model, a method for generating a formulation in each case is presented. In addition to providing a basic strategy for case formulation, I also invite the more advanced reader to consider the contrast in emphasis presented by the CBT and MCT approaches. Understanding the differences in models behind formulation is important for developing theoretical fidelity and maximising the goodness-of-fit between evidence-based models and clinical practice. Moreover, an appreciation of differences in models counteracts

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integration in formulation which is often based on some poorly reasoned amalgamation of constructs derived from various models. The weakness of such an approach can be demonstrated with a question: ‘how do you know you are combining the most important constructs from the correct models and doing so in a compatible way?’

Panic disorder Panic disorder is a good starting point for developing knowledge of formulation in anxiety because it is the least complex of the anxiety disorders. In this section, the cognitive model is presented. According to David M. Clark (1986), a particular sequence of events leads to a panic attack in panic disorder. This sequence involves the catastrophic misinterpretation of internal events, which are taken as a sign of an immediate catastrophe. The events misinterpreted are bodily sensations or mental experiences. These are often the effects of normal reactions such as those caused by postural changes in blood pressure, tiredness, excitement or anxiety/stress. The first panic attack may not involve catastrophic misinterpretation but may be due to other biological factors. However, the persistence of panic attacks in the absence of biological or chemical causes is associated with catastrophic misinterpretations. Misinterpretations are believable at their time of occurrence and involve themes such as dying, suffocating, having a heart attack or seizure and fainting or collapsing. Other common themes include losing one’s mind, going crazy or losing control of behaviour. Once misinterpretations develop, coping behaviours and selective attention to internal events contribute to problem maintenance. Some coping behaviours inadvertently exacerbate symptoms (Wells, 1997). For example, taking deep breaths due to fears of suffocating may lead to hyperventilation and associated symptoms. Coping behaviours can lead to the persistence of catastrophic beliefs in other ways. The non-occurrence of catastrophe is attributed to use of ‘safety behaviours’ (Salkovskis, 1991), thereby preventing belief change. Selective attention to bodily events increases awareness of sensations, which can act as a further trigger for misinterpretation (Clark, 1986; Wells, 1997). An augmented version of Clark’s (1986) diagrammatic model is presented in Figure 5.2. The model has been extended to include feedback loops involving safety behaviours and selective attention, and it drops the term ‘apprehension’ used in the original model in favour of ‘anxiety’. This model offers a template for case formulations. Generating a panic formulation In Clark’s (1986) model, the sequence of events leading to a panic attack involves thoughts–emotions–sensations–thoughts–emotions–sensations and so on. This sequence can begin at any point, so it may run emotions–sensations–thoughts, or sensations–thoughts–emotions. This sequence is represented in the primary

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Figure 5.2 Cognitive model of panic (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.).

vicious cycle in Figure 5.2. A sequence of this kind implies that the therapist should attempt to track the sequence in a recent panic episode in order to generate a formulation. In tracing the sequence, the therapist asks the patient to recount slowly a very recent panic attack by responding to a sequence of questions. In generating an idiosyncratic version of Figure 5.1, the therapist should not begin to track the sequence longer than a few seconds before the panic attack occurred. If this does happen, the vicious cycle stem is likely to be long and much time wasted. In plotting the formulation, the stem ends when anxiety is elicited in the sequence. This is the cue for the therapist to enter the vicious cycle and search for symptoms as a prerequisite to determining the catastrophic misinterpretation. Once misinterpretations are elicited, the next step is to obtain a rating of how much it was believed at the time of panic. The cycle is then closed by linking back to anxiety. The next step is to determine the feedback cycles involving coping behaviours and selective attention. This is accomplished by asking about the strategies the patient used to avert the threat depicted in the catastrophic misinterpretation. The therapist also asks about the development of bodily hypervigilance. I provide a recommended sequence of specific questions in Box 5.1 for the purposes of generating the case formulation.

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Box 5.1  Panic case formulation interview Introduction: I’m going to ask you about a recent typical panic attack so that we may begin to map out what happened. When was your most recent panic attack?   1 Thinking about just before you panicked: what was the very first thing that you noticed that indicated that you might panic? Was it a thought, a sensation or an emotion? Answer = thought, go to Q3, answer = sensation, go to Q2, answer = emotion, if anxiety go to Q4 and if other emotion ask: when you had that emotion what sensations did you have? Then proceed with Q2.   2 When you noticed that sensation, what thought went through your mind?   3 When you noticed that thought, how did that make you feel emotionally?   4 When you noticed that emotion, what sensations did you have?   5 When you had those sensations, what thought went through your mind?   6 How much did you believe [insert catastrophic misinterpretation] at that time?   7 What happened to your anxiety when you thought that?   8 Did you do anything to prevent [insert catastrophic misinterpretation]? What was that?   9 Did you do anything to lower anxiety? What was that? 10 Since you have developed panic do you focus attention on your body/thoughts? In what way?

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Illustrative dialogue An illustration of the use of this dialogue is given below. Note that there is additional use of probe questions, building on the basic interview questions in Box 5.1 in order to clarify meaning. This line of questioning gives rise to the formulation in Figure 5.3. Therapist: Thinking about just before you panicked. What was the very first thing that you noticed that indicated that you might panic? Was it a thought, a sensation or an emotion? It was an emotion, frustration. Patient: Therapist: When you had that emotion, what sensations did you have? I felt dizzy, vertigo I suppose you’d call it. Patient: Therapist: When you noticed that sensation, what thought went through your mind? I thought it’s going to bring it on. Patient: Therapist: When you had that thought, how did that make you feel emotionally? Patient: I felt scared and anxious. Therapist: When you noticed that emotion, what sensations did you have? I got the lot: dizziness, choking, chest tight, sweating, nausea. Patient: Therapist: When you had those sensations, what thought went through your mind? Patient: I thought I was dying of a heart attack or something. Therapist: How much did you believe you were having a heart attack at that time, on a scale of zero to 100%? Patient: I was convinced, 70%. Therapist: What happened to your anxiety when you thought that? Patient: I panicked very quickly. Therapist: Did you do anything to prevent a heart attack? Yes, I had a drink of alcohol and tried to calm down. I also took an Patient: aspirin. Therapist: How did you try to calm down? Patient: I took deep breaths and tried to slow my pulse down. Therapist: Since you developed panic do you focus more attention on your body/thoughts? Patient: I take my pulse and try to listen to my heart beating when I’m falling asleep.

From cognition to metacognition The formulation for panic presented above is based on the cognitive model. The primary focus of case conceptualisation and change is the content of catastrophic misinterpretation and the factors that contribute to the maintenance of belief in the validity of such appraisals. The cognitive approach has proven to be highly effective in this disorder and therefore the motive to provide alternative approaches is

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muted. However, the metacognitive approach could provide an alternative, a means of formulating and treating cases that fail to respond to CBT and those in particular where there is a strong disease conviction in the context of health anxiety. The metacognitive approach redirects formulation towards the control that metacognition has over extended negative processing of bodily symptoms. The primary goal of treatment is to terminate such extended processing configurations rather than challenge the validity of misinterpretations. As a consequence, the therapist must elicit the positive and/or negative metacognitions that lead to a persistence of worry about symptoms and panic attacks. For example, a patient may no longer believe that a racing heart is a sign of a heart attack; however, the individual can remain hyper vigilant for bodily sensations and can continue to worry about unexplained symptoms contributing to anxiety and vulnerability to relapse. Typical metacognitions underlying these responses include: ‘monitoring my heart-rate will help me to detect problems before it’s too late; thinking the worst about my symptoms will keep me safe; I can’t stop worrying about situations in which I might panic; worrying too much is harming my body; anxiety and worry can kill.’ The differences in conceptual focus between the CBT and the MCT approach can be seen clearly in the types of dialogue that the respective therapists have. As we have seen in the case conceptualisation interview (Box 5.1) a key question in CBT is: ‘when you had those sensations, what thought went through your mind?’ in other words: ‘how did you interpret the sensation?’ The MCT therapist would enquire differently: ‘how long have you been worrying about heart attacks; do you think this is the source of your panic?’ This would proceed to formulation of the positive and negative metacognitions behind sustained thinking (i.e. worry) of this kind. Such an approach may not necessitate the systematic formulation and challenging of repeated instances of catastrophic misinterpretations but provide a more efficient pathway to psychological change anchored in the meta-level of formulation of mental control rather than in a content-based level.

Social phobia Social phobia is characterised by a persistent fear of social or performance situations in which the individual is exposed to scrutiny. The central fear is of acting in a way that is embarrassing or humiliating. This includes a fear of showing signs of anxiety or related symptoms such as trembling, blushing, babbling or appearing odd. There may be a fear of performing ineptly by talking strangely or being unable to talk, or a concern about being boring or sounding stupid. The Clark and Wells’ (1995) cognitive model of social phobia is depicted in Figure 5.4. This model draws on several influences and combines Beckian Schemas with processes of self-monitoring and worry/rumination that are central in the metacognitive approach (Wells and Matthews, 1994). However, as we shall see later, such ‘hybridisation’ may not be needed or optimal for treatment. In social phobia, negative beliefs and/or assumptions concern the self as a social object, and/or rigid rules for social performance. Examples of beliefs are:

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Figure 5.3  An idiosyncratic panic formulation.

‘I’m stupid,’ ‘I’m boring’ and ‘I’m abnormal.’ Examples of assumptions are: ‘if I blush everyone will stare at me,’ and ‘if I show signs of anxiety everyone will think I’m stupid.’ Rigid rules include: ‘I must always be calm and collected,’ ‘I must never show I’m anxious’ and ‘I must always sound intelligent.’ Once activated these beliefs lead to negative automatic thoughts about social performance and are associated with a shift in the direction of attention. Attention becomes self-focused on feelings and symptoms, and most centrally on an impression of how the person thinks they appear to others. This impression often occurs as a mental image from an observer perspective, so called because the person sees the self as if looking back on the self from another person’s point of view. In this image, the individual’s anxious symptoms and failed performance are highly conspicuous. When self-processing does not occur as an image it is typically expressed as a ‘felt sense’, such as a feeling of being conspicuous or a feeling of looking peculiar. This image or ‘felt sense’ is accepted as an accurate portrayal of appearance, but it typically represents an exaggeration of actual appearance.

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Figure 5.4 Cognitive model of social phobia (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.).

Negative automatic thoughts and the negative self-image contribute to heightened anxiety in social situations. In order to avert the feared social outcomes represented in negative thoughts and the self-image, the individual engages in safety behaviours. For example, the person fearful of sweating wears extra layers of clothes, wears light colours and does not show his/her armpits. The individual fearful of talking strangely will mentally rehearse sentences before speaking, plan what to say and concentrate on talking fluently and clearly without pausing. There are four potential problems with safety behaviours that contribute to a persistence of the problem: (a) the non-occurrence of social catastrophe is attributed to use of the behaviour and so negative beliefs about failed performance or showing signs of anxiety persist; (b) some safety behaviours intensify or prolong unwanted symptoms (e.g. wearing extra clothing increases sweating); (c) some safety behaviours increase self-focused attention as the person focuses attention inward to monitor and gauge the effectiveness of those behaviours – the problem here is that self-attention amplifies awareness of symptoms, contributes to self-consciousness and interferes with the task

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concentration required for effective social performance and (d) safety behaviours can contaminate the social situation by making the person appear withdrawn, disinterested or unfriendly. For example, avoiding eye contact and avoiding talking about the self can lead others to think that the person is disinterested in them. Contamination of the social situation can lead to a minimisation of the positive social feedback that could normally provide opportunities for challenging negative thoughts and beliefs. Generating a social phobia formulation It is recommended as a starting point that the therapist identifies a recent situation in which the patient felt socially anxious. Questions are asked to determine the nature of the anxiety and the symptoms experienced. From here, the therapist should proceed to establishing the content of negative automatic thoughts, the nature of safety behaviours and finally the contents of the negative self-image. This sequence of questioning does not necessarily reflect the sequence of processes operating in a situation. However, clinical experience has shown that this is the simplest way of eliciting each of the components, with the aim of generating a formulation of the in-situation or maintenance factors. Underlying schemas can be explored at the initial formulation stage or included in the formulation later in treatment in order to simplify the model. Box 5.2 presents a basic interview schedule for generating a social phobia formulation.

Box 5.2  Social phobia case formulation interview Introduction: I’m going to ask you about the last time you had problems with social anxiety in a situation. I have a series of questions to help to understand what happened. 1 2 3

4 5

6

Where were you the last time you felt anxious in a social situation? How did you feel emotionally? (What physical symptoms did you have? What were the cognitive symptoms, e.g. poor memory/ concentration?) When you had those symptoms, what thoughts went through your mind? (Probe: did you think anything bad could happen? Were you concerned what others might see or think of you?) When you had those thoughts, did you do anything to prevent that feared outcome from happening? What did you do? When you were in the situation, were you self-conscious? (What impression did you have about how you appeared or how you performed? What could other people see?) Did you do anything to make yourself look better or conceal anxiety? What did you do? (continued)

102  Adrian Wells To explore schemas: 7 8 9

Do you have any negative beliefs about your ability to socialise? Do you have any life rules, like, it is bad to show anxiety, or that you must always present a favourable impression? Do you ever believe you are boring or don’t fit in? In what way?

Illustrative dialogue The following dialogue utilises the questions in Box 5.2. Notice how the therapist augments some of the initial questions to obtain a sufficient level of information, which provides the basis for the case formulation in Figure 5.5. Therapist: Where were you the last time you felt anxious in a social situation? Patient: Walking on Booth Street.

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Figure 5.5  An idiosyncratic social phobia formulation.

Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient:

How did you feel emotionally? I felt uncomfortable, like everyone was looking at me. What anxious symptoms did you have? I felt butterflies in my stomach, sweating, tension in my arms and a dry mouth. When you had those symptoms, what thoughts went through your mind? I thought, everyone is looking at me and they’ll see I’m anxious. When you had that thought, did you do anything to prevent people seeing that? I avoided looking around, kept my head down and walked quickly. Anything else? I would normally try to keep my face muscles relaxed. When you were in the situation, what impression did you have about how you appeared? What could other people see? A look of fear on my face.

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Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient:

What does that look like? Can you describe it to me? Terrified eyes, a tight mouth and a frown. Did you do anything to make yourself look better or conceal anxiety? I try to keep my face relaxed. Do you have any negative beliefs about your ability to socialise? I’m concerned people will think I’m boring. In social situations do you believe that? Yes. Do you have any beliefs about showing anxiety? If people see I’m anxious they’ll think I’m stupid.

Enhancing the metacognitive formulation of social anxiety Earlier, I drew attention to the fact that the social phobia formulation deals with the cognitive schemas rather than with metacognitions. It is unclear what advantage such an approach would provide, as metacognitive theory can explain further important features of disorder that are outside the remit of cognitive theory. A central emphasis on schema means that the cognitive model cannot explain the control of cognition and the role of the patient’s voluntary strategies in influencing control. For example, most people experience negative beliefs and thoughts about the self in social situations (e.g. ‘I’m foolish’ or ‘what if I don’t know what to say?’). The occurrence or conviction with which such cognitions are held does not determine the continuation or cessation of negative processing. In the presence of these cognitions, some individuals redirect attention onto the social task, others decide not to worry or ruminate, but the person with social anxiety disorder focuses on the self and evaluates the consequences of failed performance. I believe that these differences in response styles are crucial to emotional outcomes and are not adequately accounted for by the schema model. Furthermore, the emphasis on content of cognition rather than thinking style in schema-based formulations results in the therapist reality-testing social-self beliefs, rather than modifying the metacognitions behind these differences. The metacognitions concern positive beliefs about self-processing (‘if I focus on an inner impression of how I appear, I’ll know what people think of me; I must monitor my speech to ensure it sounds okay; if I analyse what went wrong I can avoid it next time’). They also involve negative beliefs (‘I cannot stop going over the event afterwards; I can’t stop worrying about my performance; just thinking about it can make me lose control’). These beliefs explain the excessive self-focused attention, worry (anticipatory processing), rumination (post-mortem) and thought-control behaviours exhibited. They change the focus of formulation so that a negative cognition (belief or thought) becomes a trigger for sustained processing in the form of generating an observer inner image, worrying about future performance and ruminating about past social encounters.

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This is a more elegant solution than simply combining schemas with metacognitions because it reduces the number of elements to be formulated (simplifies the model) and continues to explain the range of psychological features necessary. From a treatment perspective, the effects may be even more profound. A combination (eclectic) approach would imply that both the content of schemas along with the metacognitions giving rise to sustained processing must be challenged. However, challenging schemas and asking patients to interrogate the validity of thoughts and beliefs does not suspend the act of extended processing of the self. It uses up valuable therapy time that could be devoted to practicing changing the processing configuration and bringing it under control in the context of exposure to social situations. Furthermore, if interrogating thoughts was implemented after a patient had successfully abandoned excessive self-processing, the act of engaging in schema work would run the risk of re-instating social self-processing (e.g. evaluating beliefs about being boring) leading to a recurrence of symptoms. Challenging of beliefs should be undertaken when this facilitates the reduction of extended processing but the beliefs targeted should be metacognitive in nature. As this foray into the implications of a cognitive or metacognitive level of formulation illustrates, it is often not acceptable to simply combine aspects of these different models in an attempt to generate a better formulation. I recommend that formulation is clearly grounded in one or other of these approaches so as to reduce crucial inconsistencies at the level of conceptualisation, socialisation and choice of treatment change techniques.

Obsessive-compulsive disorder In this section, I will focus on formulation grounded in the metacognitive model of the disorder (Wells, 1997, 2000). The metacognitive model is shown in Figure 5.6. In the model, intrusive internal experiences such as thoughts, doubts and urges are considered normal events. However, in OCD, dysfunctional metacognitive beliefs about the danger, meaning and significance of these events lead the individual to worry about their occurrence. As a result, they are negatively appraised as having importance, being especially meaningful and/or dangerous. Negative metacognitive beliefs about intrusions involve one or more of the following themes: 1 Thought event fusion (TEF): the belief that thoughts and feelings mean that something bad has happened or they will have the power to make bad things happen in the future. For example: ‘thinking of accidents will make it more likely to happen,’ ‘if I have an image of a murder it means I have committed it.’ 2 Thought action fusion (TAF): the belief that having thoughts or urges will lead to the uncontrollable commission of an unwanted act. For example: ‘thinking of stabbing someone will make me do it,’ ‘if I think of hitting someone, this means I really will hit them.’

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Figure 5.6 Metacognitive model of OCD (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.).

3

Thought object fusion (TOF): the belief that thoughts, memories or feelings can be transferred into objects and be spread by contact. For example: ‘my bad thoughts can be transferred into my clothes,’ ‘I can contaminate objects with unpleasant feelings.’

Once the intrusion is imbued with negative significance, the individual uses knowledge (beliefs) about rituals or strategies for selecting and guiding anxietyand threat-reducing responses. In the model, negative appraisal of intrusions (this occurs in the form of worry) and beliefs about rituals interact in moderating the subsequent level of anxiety experienced. When the person is unable to reduce threat by completing behaviours, anxiety is elevated, but the successful commission of behaviours can lead to the temporary reduction of anxiety. However, there are several problems with the use of rituals, neutralising and avoidance behaviours. Some behaviours have counterproductive effects and increase the likelihood of further intrusions. For example, thought suppression tends to be ineffective and activates a thought monitoring plan that can maintain awareness of intrusions. Some behaviours require strict control over thinking in order to be successfully completed, and this level of control is often incomplete, leading to negative appraisal of mental states and fluctuating anxiety levels. When behaviours are successfully implemented, they prevent the individual discovering that negative

Case formulation in anxiety disorders  107

outcomes would not occur as a result of the intrusion, and so negative metacognitive beliefs about intrusions persist. A feature of the model that is incorporated in the concept of beliefs about rituals is the tendency of patients to use inappropriate internal criteria for guiding neutralising behaviours and making judgements. For example, in response to an intrusive thought (e.g. ‘have I turned off the stove?’) a patient used the criterion of having a perfect mental image of the action and what it felt like as a signal that it was safe to stop checking or repeating behaviour. Some individuals use an inverted reasoning process, such as looking for gaps in memory as evidence that an action has or has not been performed. For example, in response to an intrusive image about an accident, a patient tried to recall his entire journey home and conceded: ‘I don’t remember my whole journey home, therefore I probably caused an accident.’ The use of inappropriate criteria of this kind means that the person with OCD does not process more adaptive sources of data that would lead to challenging beliefs about the importance of the intrusion. Generating an OCD case formulation The therapist should identify the occurrence of a recent obsessional intrusion that caused distress and culminated in neutralising responses. The sequence of questions presented in Box 5.3 offers a basic interview schedule for generating a formulation.

Box 5.3  OCD case formulation interview Introduction: I’m going to ask you about the last time you were distressed by an obsessional thought and you felt compelled to respond to it. 1 2 3

4 5

6

What was the thought/image/impulse that triggered your worry or ritual? When you had that thought how did you feel emotionally (e.g. anxious/scared)? What did you think might happen as a result of having that thought? (What is the worst that could happen? What would happen if you did nothing to deal with the thought?) Do you believe these thoughts mean something? What’s the worst they could mean? How much did you believe that at the time? Did you do anything to stop [insert negative belief about thought] from happening? Did you do anything to stop yourself doubting? Did you try to prevent feeling anxious? (What did you do?) Do you believe that you must behave in certain ways in order to remain safe and stop bad things from happening? How much do you believe that? Do you have any special ways of doing things or special ways of thinking? What would happen if you no longer responded to your thoughts/doubts/feelings by doing these things? (continued)

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Illustrative dialogue The following dialogue, based around the interview in Box 5.3, gives rise to the case formulation depicted in Figure 5.7. Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient: Therapist: Patient:

When was that? This morning when I was shaving. What was the thought/image/impulse that triggered you? I had the mental picture of that child murderer. When you had that thought, how did you feel emotionally (e.g. anxious/scared)? I was freaked by it; I was anxious and annoyed that I’d have to shave again. What did you think might happen as a result of having that thought? I might become like that. Do you believe these thoughts mean something? If I think about it then they could make me take on those characteristics. How much did you believe that at the time, from zero to 100%? I do believe it, 90%. Did you do anything to stop that from happening? I washed and shaved all over again whilst keeping an image of someone I admire in mind.

Case formulation in anxiety disorders  109

Figure 5.7  An idiosyncratic OCD formulation.

Therapist: Do you believe that you must behave in certain ways in order to remain safe and stop bad things from happening? Patient: I have to think good thoughts and repeat any actions associated with bad thoughts by having good thoughts instead. If I control my thoughts, I’ll be OK. Therapist: How much do you believe that? Patient: 100%.

Generalised anxiety disorder The key feature of GAD is the occurrence of uncontrollable worry (for at least six months) about a number of different topics, in combination with a selection of specific somatic and behavioural symptoms. The worries cannot be better explained by the presence of another anxiety disorder. The somatic and behavioural symptoms should include at least three of the following: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension and sleep disturbance (DSM-IV; APA, 1994). The metacognitive model of GAD (Wells, 1995, 1997) is presented in Figure 5.8. Worry episodes have a trigger, often in the form of a negative ‘what if . . .?’ question. This activates positive metacognitive beliefs about the use of worrying as a coping strategy. Positive beliefs include themes such as: ‘worrying means I’ll be prepared,’ ‘if I worry I won’t be taken by surprise’ and ‘if I worry

110  Adrian Wells

I’ll be able to cope.’ As a consequence, the individual with GAD engages in Type 1 worrying, in which a range of negative outcomes are contemplated and ways of coping considered. This activity continues until the person reaches a desired internal state that signals that the work of worry is complete. This state is often a ‘feeling’ that is interpreted as a sign that the person will be able to cope. However, in some cases it is a sense of being prepared, or knowing that most possibilities have been covered. The occurrence of Type 1 worrying has differential effects on anxiety. It can increase anxiety as the person contemplates a range of catastrophes, but subsequently anxiety decreases as the person reaches successful completion of the activity. GAD develops when negative metacognitive beliefs about worrying are activated. There are two categories of negative belief that are important: (a) beliefs about the uncontrollability of worry and (b) beliefs about the dangers of worrying for physical, psychological and social functioning. Examples of these beliefs include: ‘worrying is uncontrollable,’ ‘worrying will damage my body and cause a heart attack,’ ‘if I worry I could become schizophrenic or lose my mind’ and ‘when people discover I worry they will reject me.’ During the course of Type 1 worrying, negative beliefs are activated and lead to the negative interpretation of worrying and the symptoms associated with it. Negative interpretations (called Type 2 worry or meta-worry) lead to an intensification of

Figure 5.8 Metacognitive model of GAD (adapted from Cognitive Therapy of Anxiety Disorders by A. Wells, 1997 © Copyright John Wiley & Sons, Ltd.).

Case formulation in anxiety disorders  111

anxiety and interfere with the person’s ability to reach an internal state signalling that they can cope. Two further processes contribute to problem maintenance. These are the behaviours that the person uses and the thought control strategies adopted. Behaviours such as avoidance of situations that may trigger concerns, seeking reassurance and information search (such as surfing the internet) are used to try to stop worrying. However, these strategies have counterproductive effects. Some increase preoccupation with worry, some increase the range of triggers for worrying and some transfer the control of worry to others. As a result, negative beliefs about the personal controllability of worry are not challenged. Some patterns of thought control strategy are also unhelpful. In particular, the person with GAD will attempt not to think thoughts that may trigger worrying. Suppression of this kind is not consistently effective and may backfire, increasing intrusions and adding to fears of uncontrollability. Furthermore, patients seldom interrupt the Type 1 worry process once activated. This is because interrupting it would be equivalent to ‘not coping’ and/or because interrupting it is inconsistent with the view that worrying is uncontrollable. As a result, the person does not discover that worrying can be interrupted. Note, however, that interruption of the catastrophising worry process is different from suppression (i.e. attempts to remove entirely the content of a thought from consciousness). Generating a GAD case formulation The therapist begins by identifying a recent occasion when the patient experienced a distressing and uncontrollable worry episode. Questioning aims to identify erroneous metacognitions, emotional responses, behaviours and thought control strategies active in the episode. A particular sequence of questioning is recommended as an efficient means of eliciting components of the model. This sequence is presented as a case formulation interview in Box 5.4.

Box 5.4  GAD case formulation interview Introduction: I’d like to focus on the last time you had a significant and uncontrollable worry episode and you were distressed by it. I’m going to ask you a series of questions about that experience. 1 2 3 4

What was the initial thought that triggered your worrying? When you had that thought, what did you then worry about? When you worried about those things, how did that make you feel emotionally? (Probe: did you feel anxious? What symptoms did you have?) When you had those feelings and symptoms, did you think something bad could happen as a result of worrying and feeling that way? (Probe: what is the worst that could happen if you continued to worry?) (continued)

112  Adrian Wells 5

6

7

8

(a) Do you believe that worrying is bad in any way? (Probe: can worry be harmful?) (b) Worrying appears to be a problem, so why don’t you stop worrying? (Probe: do you believe worrying is uncontrollable?) Apart from negative beliefs about worrying, do you think that worrying can be useful in any way? (Probes: can worrying help you cope? Does it help you foresee problems and avoid them? Are there any advantages to worrying?) When you start worrying do you do anything to try to stop it? (Probe: do you avoid situations, ask for reassurance, try to find out if there is really something to worry about?) (a) Do you use more direct strategies to try and to your thoughts, such as trying not to think about things that may trigger worrying? (b) Have you ever tried to interrupt a worry by deciding not to engage in it at the time?

Illustrative dialogue The following dialogue, based on the case formulation interview in Box 5.4, gives rise to the case formulation in Figure 5.9. Therapist: Patient: Therapist: Patient:

What was the initial thought that triggered your worrying? I had the thought of going to work and my supervisor being there. When you had that thought, what did you then worry about? I was worried that I’d ordered the wrong equipment, and what if it was a wasted journey, it would be my fault and they’d think I was incompetent.

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Figure 5.9  An idiosyncratic GAD formulation.

Therapist: When you worried about those things, how did that make you feel emotionally? Patient: I felt anxious and wanted to cry. Therapist: Any other symptoms? Patient: I was tense and had butterflies in my stomach. Therapist: When you had those feelings and symptoms, did you think something bad could happen as a result of worrying and feeling that way? Patient: Not at first, but later on I just lost it. Therapist: What did you think was happening when you lost it? Patient: I thought I was going to crack up. Therapist: Do you believe that worrying is bad in any way? Patient: I think it’s bad for your physical and mental health. Therapist: What’s the worst that could happen if you worried a lot? Patient: I think you could become mentally ill or something. Therapist: Worrying appears to be a problem, so why don’t you stop worrying? Patient: I can’t, it’s uncontrollable. Therapist: Apart from negative beliefs about worrying, do you think that worrying can be useful in any way?

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Patient: I think it means I do a good job and I don’t miss important things. Therapist: When you start worrying, do you do anything to try to stop it? Patient: I try to talk to someone to find out if there is something I should worry about. Therapist: Anything else? Patient: I try to keep busy, but it doesn’t work because I go back to the worry. Therapist: Do you avoid things that might make you worry? Patient: I try to avoid taking my work home. Therapist: Do you use strategies to try to control your thoughts, such as trying not to think about things that may trigger worrying? Patient: I try not to think about work. Therapist: Have you ever tried to interrupt a worry by deciding not to engage in it at the time? Patient: No, I feel there’s not much I can do about it.

Behavioural assessment tests (BATs) In some anxiety disorder cases, avoidance of feared situations is a significant feature of the presentation, and as a consequence it is difficult to identify a recent occasion involving anxiety around which to base formulation. A behavioural assessment test (BAT) involving exposure to an actual or analogue feared situation can be used to activate anxiety and provide the basis for the formulation interview. The therapist then configures questioning to exploring emotional, cognitive and coping responses during the BAT. For example, a patient who was fearful of drinking in public went on a ‘fact-finding mission’ with the therapist during the first treatment session. This consisted of visiting a busy café nearby and drinking cups of tea. During this mission, the therapist monitored the patient’s thoughts (‘what are you thinking is the worst that could happen right now?’), emotions (‘how do you feel emotionally?’), safety behaviours (‘are you doing anything to prevent bad things from happening?’) and self-image (‘how do you think you appear right now?’). Visible changes in emotional state and the apparent use of safety behaviours/avoidance were useful markers of the points at which to ask these questions. Aside from the use of BATS to inform formulation, self-report instruments are a valuable source of information concerning cognitions, behaviour and symptoms. Instruments such as the Social Phobia Rating Scale, the Panic Rating Scale and the Generalized Anxiety Disorder Scale (Wells, 1997) contain items assessing most of the components required for generating formulations of these disorders.

Overview of treatments As we have seen, the cognitive and metacognitive perspectives give emphasis to different processes and domains of cognition. In turn, this guides the therapist in using particular treatment strategies in each case. I have cautioned

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against the amalgamation or integration of models and treatment techniques as this is unlikely to yield superior outcomes. In fact, some of the practices of CBT and MCT are incompatible. For example, challenging thoughts is not consistent with the approach of MCT that emphasises the discontinuation of further thinking in response to negative thoughts or beliefs. Beliefs are challenged in MCT, but these are the beliefs about thoughts rather than the beliefs about things. Detailed treatment manuals for cognitive and metacognitive therapies based on the formulations described in this chapter are available elsewhere (Wells, 1997, 2009). In CBT treatment of panic disorder, the therapist focuses on challenging beliefs in the catastrophic misinterpretation of symptoms. The goal of treatment is to reduce belief in the range of catastrophic misinterpretations to zero. Some of the most powerful strategies for achieving this consist of behavioural experiments in which panicogenic symptoms are induced and the patient is asked to engage in behaviours that provide evidence that catastrophe will not occur. For example, a person fearful of her legs collapsing during a panic might be asked to induce symptoms through exposure to feared situations or through hyperventilation, and then perform a disconfirmatory act such as standing on one leg to determine if collapse occurs. Verbal re-attribution strategies involve reviewing the evidence that anxiety is harmless and has a protective function to challenge catastrophic beliefs. These methods often consist of education, in which, for example, anxiety is re-framed as part of the individual’s ‘fight or flight’ mechanism, thereby representing an advantage to the individual rather than a threat. In the treatment of social phobia, a range of strategies have been developed to deal with the unhelpful effect of safety behaviours, self-focused attention, negative self-image and negative thoughts about the consequences of failed performance. Treatment normally follows a sequence of modification. First, safety behaviours are reduced and the patient is encouraged to adopt an external focus of attention in social situations in order to potentiate disconfirmatory processing. Next, video feedback is used to challenge the distorted self-image. Video feedback is presented in a specific way, involving ‘cognitive preparation’, in which the patient is guided in constructing a detailed mental image of the conspicuousness of symptoms present in the self-image. This is followed by observing the discrepancy that exists between the internal image and the image presented on the video. The procedure does not aim to show that symptoms are not visible, but aims to show the discrepancy that exists between the internal image and the objective self. Following this stage, treatment proceeds by interrogating the social environment. Here, exposure experiments are used in which the patient observes the reactions of others while deliberately showing signs of anxiety or failed performance. The final stage of treatment consists of challenging the negative underlying beliefs about the social self. For example, a patient who believed that he was boring was asked to describe the characteristics that render someone boring. Having done so, he was then asked to rate himself on the extent to which he possessed each of the

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characteristics. He found that he possessed very few of them, and this was used as evidence to challenge his negative belief. In the treatment of OCD, the therapist focuses on negative beliefs about the meaning and power of intrusive thoughts. To facilitate engagement it is often necessary to provide information that normalises and de-stigmatises the experience of intrusions, so that the patient feels that it is safe to disclose the content of intrusions. Following this, the therapist introduces the idea that it is not the occurrence of thoughts but negative interpretation of them that is the source of the problem. Metacognitive beliefs are challenged by introducing experiments that have a metacognitive rationale. This rationale emphasises developing a de-centred relationship with intrusions, in which they are viewed as passing events in the mind, and beliefs about their meaning and power are challenged. For example, a patient who believed that having thoughts about causing accidents meant that he had caused one was asked to hold the thought in mind all of the time he was driving, and refrain from checking his journey. In this way, he was able to discover that his thoughts did not represent accurate portrayals of events. Verbal re-attribution techniques in OCD are used to question and challenge the mechanism by which patients believe that thoughts alone have special significance or power to affect outcomes. For example, one patient believed that having thoughts of stabbing her partner would lead her to commit the act. The therapist asked her what the mechanism was that would translate thoughts into actions. After some discussion she realises that thoughts become actions when there is a desire to act on them. The therapist asked if she had such a desire, which was clearly not the case, given the ego-dystonic nature of the intrusions. In the treatment of GAD, negative beliefs about uncontrollability of worry are targeted first. The techniques used here include questioning the evidence that worrying is uncontrollable, questioning how it is that worrying stops if it is uncontrollable and using a specially-devised ‘worry postponement experiment’ to challenge uncontrollability. The concept of loss of control is challenged further by experiments in which the patient is invited to try to deliberately lose control of worrying. Beliefs about the dangers of worrying are modified through education and experiments in which attempts are made to induce negative outcomes by worry alone. Positive beliefs about worrying are modified by strategies such as ‘worry modulation experiments’, in which predicted improved outcomes due to worry can be tested by deliberately increasing and decreasing worry and observing the real-world effects of doing this. For example, a patient believed that she performed better at work when she worried about making mistakes. She was asked to complete a homework task in which she worried intensely on alternate working days, while worrying little on other days. She was able to discover that worrying had little or no effect on her performance, apart from the fact that she felt better on the days she worried less.

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Conclusion In this chapter, I have described in detail individual models of specific anxiety disorders. These models are supported by empirical findings and provide a basis for idiosyncratic case formulations. They are generated through the use of specific combinations of questions. I have presented, in the form of case formulation interviews, basic questions and their sequences. The formulations capture a range of the most important causal and maintenance processes. Extracting the central components and processes is guided by a cognitive or metacognitive model of the disorder. In most instances of discrete disorders it is recommended that a specific model is used. Each formulation provides a schematic that can be shared with the patient in developing an understanding of the factors that maintain the presenting problem. Furthermore, these formulations direct the focus of treatment towards modifying particular factors. In CBT, the focus is on formulating and challenging beliefs about things (e.g. ‘what is your evidence for believing the world is a dangerous place?’); however, in MCT the focus is on learning to relate to negative thoughts in new ways that do not depend on more thinking (e.g. ‘what’s the use in worrying about dangers in the world, can you reduce the activity?’).

References American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders – Revised (4th ed.). Washington, DC: APA. Beck, A. T. (1976). Cognitive Therapy and the Emotional Disorders. New York: International Universities Press. Beck, A. T. et al. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books. Brown, T. A. et al. (1994). Anxiety Disorders Interview Schedule for DSM-IV, Adult Version. New York: Graywind. Clark, D. M. (1986). A cognitive model of panic. Behaviour Research and Therapy 24: 461–70. Clark, D. M. and Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg et al. (eds) Social Phobia: Diagnosis, Assessment and Treatment. New York: Guilford. Persons, J. B. (1989). Cognitive Therapy in Practice: A Case Formulation Approach. New York: Norton. Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. Behavioural Psychotherapy 19: 6–19. Van der Heiden, C. et al. (2012). Randomized controlled trial on the effectiveness of metacognitive therapy and intolerance-of-uncertainty therapy for generalized anxiety disorder. Behaviour Research and Therapy 50: 100–09. Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalised anxiety disorder. Behavioural and Cognitive Psychotherapy 23: 301–20. Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide. Chichester: Wiley.

118  Adrian Wells Wells, A. (2000). Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Chichester: Wiley. Wells, A. (2009). Metacognitive therapy for anxiety and depression. New York: Guilford. Wells, A. et al. (2010). A pilot randomized trial of metacognitive therapy versus applied relaxation in the treatment of adults with generalized anxiety disorder. Behaviour Research and Therapy 48: 429–34. Wells, A. and Matthews, G. (1994). Attention and Emotion: A Clinical Perspective. Hove: Erlbaum. Zimmerman, M. and Mattia, J. I. (2001). The Psychiatric Diagnostic Screening Questionnaire: Development, reliability and validity. Comprehensive Psychiatry 42: 175–89.

Chapter 6

Cognitive behavioural case formulation for complex and recurrent depression Anne Garland

Introduction Lifetime prevalence for major depressive disorders range between 2 and 15%, and three quarters of sufferers will report recurrent episodes across their lifetime. This risk of recurrence increases further with each successive episode (Ustun and Chatterji, 2001). In addition, when taken as a single diagnostic category it is estimated that by 2020 depressive disorders will be the leading cause of disability and the second leading cause of death worldwide (WHO, 1999). A number of randomised controlled trials (RCT) attest to the efficacy of cognitive therapy for chronic and recurrent depression. One example is the Newcastle-Cambridge RCT (Paykel et al., 1999) which investigated the efficacy of cognitive therapy (CT) in the treatment of residual depressive chronicity and found this to reduce depressive relapse by 46% in comparison to the treatmentas-usual group. However, there are some questions over the durability this of effect. At 5-year follow-up there was no statistical difference between the active treatment group receiving CT and the treatment-as-usual group, as measured on a range of psychometric measures, including the Hamilton Rating Scale for Depression (Hamilton, 1960) and the Beck Depression Inventory (Beck et al., 1961). However, in the active treatment group the frequency, intensity and duration of relapse was much lower than in the treatment-as-usual group (Paykel et al., 2005). Other studies have demonstrated similar efficacy (Lynch et al., 2010; Vittengl et al., 2007). In order to try to improve the durability of treatment effect, there has been a number of behavioural and cognitive treatment protocols proposed, aimed at targeting specific symptoms implicated in the persistence of depression. These include mindfulness-based cognitive therapy (MBCT; Ma and Teasdale, 2004); behavioural activation (Jacobson et al., 2001), attentional control training (Papageorgiou and Wells, 2000), re-scripting of depressive intrusive memories (Brewin et al., 2009); rumination-focused cognitive therapy (Watkins et al., 2007) compassion focused therapy (Gilbert and Procter, 2006) and acceptance and commitment therapy (Hayes et al., 1999). With the exception of MBCT (which specifically targets recurrent depression), few protocols make a distinction between their utility as a treatment for first or single episode major depressive disorder or chronic

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and recurrent depression. The most rigorously researched of these new treatment protocols is MBCT. Evidence suggests that it is an effective relapse prevention strategy amongst individuals who have experienced three or more episodes of depression in a phase of remission (Williams, 2013). Despite this specific evidence base there has been a proliferation of its application to clinical populations and presentations which reach far beyond this scope. There has also been widespread uptake of behavioural activation (BA) as a treatment for depression. The BA protocol views modifying negative automatic thoughts as redundant, and both clinicians and the research literature are questioning the validity of using cognitive interventions in the treatment of depression (Longmore and Worrell, 2007). This chapter will argue against this stance and make a case for there being strong theoretical and clinical reasons that cognitive interventions are crucial in the treatment of chronic and recurrent depression. A maintenance model of chronic and recurrent depression Unlike the cognitive therapy protocols for the anxiety disorders, when it comes to the clinical practice of cognitive therapy for depression, there is no disorder-specific maintenance model that has been empirically validated. It is standard when using cognitive therapy to treat both acute and chronic depression using the Beckian protocol (Beck et al., 1979; Moore and Garland, 2003), alongside a longitudinal formulation (Fennell, 1989; Persons, 2008). Indeed in Beck’s original protocol there is no diagrammatic representation of a longitudinal formulation of the patients’ problems; however, the concept of formulating early experiences and how these shape a person’s view of the self, world and future is implicit in the interventions described in the protocol. One of the challenges of chronic and recurrent depression is the development of a formulation that has clinical utility. What is meant by this is that it is easily understood by the patient and can be readily used by the clinician as a basis for identifying and testing out hypotheses about what is maintaining depression. In the formulation literature there is a range of proposed models for understanding the development and maintenance of depression with varying degrees of complexity. For example, in schema focused cognitive therapy, Young et al. (2003) propose the formulation of primary and secondary schema. It is fair to say that in the face of chronicity and recurrence, clinicians are prone to develop elaborate and complex formulations with a number of conditional and unconditional beliefs, which not only do not represent an integrated coherent theoretical formulation but would also require many years of therapy to address. This chapter proposes a maintenance model for chronic and recurrent depression based in the cognitive science of depression. The model has been developed by the author over a number of years within her clinical practice. It is influenced by the work of Salkovskis et al. (1998) who advocate that when working with complexity the ‘devil is in the detail’ and all interventions are predicated on the ability to develop, in collaboration with the patient, a cogent treatment rationale that uses

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this detail to make sense of the problem and act as a spring board for intervention. This model is illustrated in Figure 6.1. Whilst the model retains the vicious circle metaphor for maintenance which is inherent to cognitive therapy (Beck et al., 1979; Padesky and Mooney, 1990) this is adapted from the Salkovskis et al. (1998) maintenance model for obsessive-compulsive disorder (OCD), which proposes a ‘vicious flower’ metaphor. Moorey (2010) has developed a ‘vicious flower’ for the maintenance of depression. However, his model differs from that proposed here in that he utilises Beckian modes theory (Beck 1996) as its foundation. In contrast, the model proposed here uses the cognitive science of depression as its foundation. As Teasdale (1993) observes in his critique of Beckian cognitive therapy, Beck’s model is a clinical model built from clinical observation and it can be argued it does not wholly account for the cognitive phenomena observed in depression. Specifically, this is referring to self-critical and self-blaming rumination; autobiographical memory bias and over-general memory. As such, the model described here illustrates a series of self-maintaining processing loops. It proposes that how the depressed individual engages with emotions, the biological symptoms of depression and medication side effects is mediated by the negative bias to thought content that is manifest in depression; autobiographical memory bias and over-general recall; self-critical and self-blaming rumination and avoidance and procrastination. This allows the treatment rationale to account for the memory and information processing biases that the cognitive science of depression implicates in the persistence of depression, and the cognitive, affective and behavioural avoidance that Moore and Garland (2003) propose are central to the maintenance of depression. Thus, taking each loop in turn: Self-critical and self-blaming rumination Both negative and positive affect, biological symptoms of depression and medication side effects provide fuel for rumination, leading to the persistence and intensification of low mood. The important clinical feature here is that depressive rumination is a cognitive process. As such, treatment interventions aim not only to target the content of this but to interrupt the ruminative process. As we will see below, Teasdale (1993) proposes this interrupting of rumination as the mechanism of change in Beckian cognitive therapy. Autobiographical memory bias and over-general memory recall Once a negative mood state is instituted and depressive symptoms and medication side effects are focused upon, then the autobiographical memory bias increases the recall of other times when the patient felt this way, as well as increasing accessibility to traumatic memories from childhood. In addition, where over-general recall is present then this impedes problem solving and thus inhibits attempts to try to influence mood state and symptoms. Over-general recall is discussed further below.

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Negative bias to thought content (NATS) Negative content to thinking is a symptom of depression. Central to this maintenance loop are NATS related to perceptions that depressed mood, biological symptoms of depression and medication side effects are subjectively experienced as intolerable, uncontrollable and unremitting, which in turn generate perceptions of hopelessness and helplessness regarding the illness and the self in relation to the illness. In addition to this negative content bias, in Beck’s original model, the thinking biases of all-or-nothing thinking and sensitivity to criticism (which also have an evidence base in cognitive science) are also targets for intervention. Cognitive, affective and behavioural avoidance In this maintenance loop, avoidant coping strategies are a central feature. Thus, the suppression of depressogenic intrusive thoughts and images (Wenzlaff et al., 2001) is a common clinical feature, resulting in a rebound effect that not only

Self-critical/self-blaming rumination

negative bias to thought content (NATS)

Emotions Biological symptoms of depression Medication side effects

Cognitive, affective and behavioural avoidance

Figure 6.1  Maintenance formulation of chronic and recurrent depression.

autobiographical memory bias/overgeneral recall

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intensifies depressed mood but also enhances rumination (Wenzlaff and Luxton, 2003). In addition, as is described below, the interplay between rumination and over-general memory (Harvey et al., 2004; Williams et al., 1997) as an avoidant mode of affect regulation means that an absence of affect (or suppression of affect) is also a common clinical feature in chronic and recurrent depression (see Moore and Garland, 2003, for a clinical description). Finally behavioural avoidance plays a central maintenance factor. Some of this can be accounted for by the devastating effect of biological symptoms of depression such as lack of energy, volition and motivation, alongside exhaustion and reduced memory and concentration, which severely impacts on activities of daily living (not forgetting that side effects of some medication used in the treatment of depression can mimic these symptoms). In addition, the behavioural correlate of the helplessness and hopelessness identified in the content of thinking is defeat, passivity, withdrawal and inaction. The essence of the treatment rationale is to break the vicious circle by making interventions to tackle the maintenance cycles between emotions, biological symptoms of depression and medication side effects, and memory and processing biases and the cognitive, affective and behavioural avoidance in each loop. Figure 6.1 presents a brief overview of the cognitive science which informs this model, namely research into over-general autobiographical memory and rumination.

The cognitive science of depression Over the last 30 years, there has been a wealth of cognitive science research in relation to the role that over-general memory and rumination play in the maintenance of depressed mood. This section will discuss further the clinical implications of these cognitive processes in depression, which research suggests interact in a specific way to maintain depressed mood. The clinical implications of the cognitive science of memory and depression will be highlighted and their theoretical and practical integration into Beckian cognitive therapy illustrated using a clinical case example. Over-general autobiographical memory in depression Cognitive science suggests that in unipolar depression, memory recall for personal events (which is referred to as ‘autobiographical memory’) is biased towards negative recall. An autobiographical memory is defined as ‘memories a person has of his or own life experiences’ (Harvey et al., 2004). Thus, when mood is low the depressed mind more readily recalls past unpleasant (negative) memories and it is more difficult to recall pleasant (positive) memories. A further consistent finding in the memory and depression literature is that people with depression have difficulty recalling specific memories and more readily recall what is referred to as over-general autobiographical memories that are categoric (Williams and Scott, 1988). Thus, autobiographical memory (Williams

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et al., 2007; Watkins et al., 2000) is formulated as a hierarchy which we move through in order to retrieve specific memory representations for past events. For example, if we want to solve a problem we begin by accessing general memory descriptions and then progress in a stepwise way to more detailed memory descriptions until we reach the level of specificity we need in order to solve that problem. Generally speaking, most of us are able to move through this memory hierarchy in a fluent way, readily accessing the required level of specificity. However, what Williams and colleagues discovered in their research (Williams and Broadbent, 1986) is that people who experience depression have difficulty moving through the memory hierarchy, and during the process of searching stop at a level of general description. This is termed over-general memory. The literature defines an over-general memory as ‘a summary memory of repeated occasions’ (Harvey et al., 2004). This can be contrasted with an extended memory which, when reported, lasts longer than one day. Thus, in response to a cue word such as ‘happy’, depressed patients in comparison to healthy controls are more likely to report ‘when I go on holiday’ (an over-general memory which is a summary memory of repeated occasions of the same activity) in comparison to healthy controls who may report ‘last July when I went on holiday to Rome for a week with my sister Wendy’ (a specific memory which in recall is extended over time). The literature highlights a number of clinically important implications of over-general memory. Depressed patients who exhibit this memory bias are less effective at problem solving because they are unable to retrieve information at a sufficiently specific level to develop effective coping strategies for solving problems in the here and now (Schotte and Clum, 1987; Evans et al., 1992). In addition, over-general memory impairs future planning because, in order to change behaviour, the person needs to be able to move from a general plan to specific behaviours, e.g. from the basic plan ‘to go for a walk’, to specifying where to go, when, what to wear, etc. The ability to plan this way is significantly impaired where over-general memory is present (Williams et al., 1997), and may be linked to the higher levels of hopelessness reported by these clients. Williams has also given consideration to the role depressive rumination may play in the persistence of depression. A consistent finding is that rumination is associated with the intensification and persistence of depressed mood (Nolen-Hoeksema, 2000). Further, Watkins et al. (2000) and Watkins and Teasdale (2001) found that, if rumination is experimentally reduced, then over-general memory becomes more specific. The authors concluded, therefore, that over-general memory and rumination are intertwined in a vicious cycle where one exacerbates the other. How does over-general memory develop? In considering the clinical implications of their work, Williams et al. (2000, 2007) posit that over-general memory arises in early development and they cite literature that links its occurrence to early trauma (Henderson et al., 2002). In drawing together his own work with that of his colleagues, Williams et al. (2007) concludes that over-general memory arises from a style of processing information

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in a verbally analytic way, manifest as depressive rumination. This process he argues is outside of conscious awareness, aimed at affect regulation, and is therefore negatively reinforced (i.e. perpetuated), exactly because it allows this affect regulation to take place. As such, Williams formulates over-general memory as an avoidant retrieval style which develops to reduce the recall of specific distressing memories (see Harvey et al., 2004, for further discussion). In reaching this conclusion he draws on the work of Kuyken and Brewin (1995, 1994) who found that over-general memory was associated with a greater frequency of, and avoidance of, intrusive depressive memories. Thus, in early childhoods marked by emotional, physical or sexual abuse, this proposed mechanism of affect regulation would be a useful default coping strategy for survival in order to manage high levels of unregulated fear, anger and despair. However, as clinical experience tells us and Williams and colleagues’ research demonstrates (Williams et al., 2007), there is a downside to this survival strategy. This process of affect regulation impairs the individual’s ability to be specific about future events, reduces problem-solving skills, increases levels of hopelessness and prolongs depressed mood. In addition to considering the impact of negative affect regulation it is also worth considering the impact of an absence of positive affect generation (Dunn, 2012). More recent research in the area of autobiographical over-general memory demonstrates that childhood abuse also inhibits the recall of specific positive memories (Bunnell and Greenhoot, 2012). The work of Paul Gilbert is of interest in this arena. Gilbert (2005) argues that childhoods that are characterised by early trauma lead to a dominance of the threat system (amygdala) in the brain and as a consequence there is a much diminished or even absent capacity to generate positive affect and to self-soothe. Thus, the person with chronic and recurrent depression, with trauma in their childhood, experiences a ‘triple whammy’. That is, they readily recall over-general autobiographical memories, have a tendency to ruminate and are significantly hindered in their capacity to self-soothe and generate positive affect. In order to use standard cognitive therapy interventions in treating depression (e.g. activity scheduling, graded task assignment or modifying NATS with behavioural experiments) the patient needs to be able to retrieve information about past events in a way that they can use in the present. This is going to be problematic if the patient cannot encode and retrieve events in a specific way and if memory is dominated by over-general categoric autobiographical recall. The aim in using such interventions is to alleviate negative affect, generate feelings of pleasure and satisfaction and broaden perspective away from the negative processing biases that characterise depressogenic thinking. However, frequently patients with chronic and recurrent depression report their mood as flat or numb, and often if mood lifts, what emerges is anxiety which is experienced as intolerable. There is often an absence of positive affect, or as Gilbert (personal communication, 2012) would attest, a sense of ‘resting contentment’ (as opposed to ‘happiness’). In the Newcastle-Cambridge RCT (Paykel et al., 1999), Teasdale and colleagues (Teasdale et al., 2002) tested the mechanism of change in cognitive

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therapy. Teasdale hypothesised not that underlying beliefs form a psychological vulnerability to depression (as Beck proposed), but rather that cognitive therapy achieves its effect by influencing the way in which the individual with depression relates to cognitive phenomena. Thus, for Teasdale and colleagues, the mechanism of change in cognitive therapy is the process by which therapy helps the depressed person to see thoughts as thoughts and not as facts. This process is well recognised by clinicians, and the clinical literature describes this process as decentering. This can be illustrated as follows. Once a patient has engaged with the process of modifying negative automatic thoughts (NATS) and begun to test these out in everyday life, they quite quickly stop applying the standard Beckian questions for modifying NATS. Instead, they start to observe ‘there is one of those NATS’ and immediately switch into a different information processing loop. To return to Teasdale’s hypothesised mechanism of change, he argues that this decentring enables the client to interrupt the cycles of depressive ruminative thinking which are associated with the intensification and persistence of depressed mood (Nolen-Hoeksema, 2000). In Teasdale’s model, depressive rumination represents an affect-related schematic model that encodes across the intolerability, uncontrollability and non-remittance of depression. Thus the patient may report: ‘I feel really awful, I can’t stand this, I’ve got to get rid of this or I will be overwhelmed; I’m so weak and pathetic,’ (intolerability); ‘I should be able to control this and I can’t’; ‘there is nothing I can do to change my mood, nothing makes a difference, I am at the mercy of this depression’ (uncontrollability); ‘I will always feel like this, the depression will never go away, every day is the same never ending misery’ (unremitting). However, Teasdale argues, following a successful course of cognitive therapy, the patient when experiencing low mood is more able to prevent this low mood from activating NATS. This is because they can more readily see negative thoughts as thoughts not as facts about themselves, others or the future. Thus, the processing loop between low mood and self-critical/self-blaming ruminative thinking has been deactivated, and the patient is able to disengage from self-critical/ self-blaming depressive rumination and institute a processing loop that encodes across schematic dimensions that depressive symptoms can be tolerated, influenced and that they come and go. Thus, in the face of low mood the patient having successfully engaged in cognitive therapy may say to themselves ‘my mood is really low today, I feel dreadful, I will try and pace myself this morning, I often feel this way first thing, I will feel differently this afternoon’ (tolerability); ‘I will take a shower and go for a short walk this morning and make sure I eat something when I come back – these things sometimes help’ (controllability) or, ‘I know my mood is up and down, if I’m going to feel bad it is usually first thing, I will feel differently by this evening’ (remitting). It is from combining evidence from Teasdale’s work in the Newcastle-Cambridge trial and Mark Williams’ work cited above, that Teasdale and Williams went on to collaborate with Zindel Segal and John Kabat-Zinn to develop mindfulness-based cognitive therapy (MBCT; Teasdale et al., 2000).

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Setting the scene: The theory practice link Moore and Garland (2003) describe how to adapt and implement the Beckian treatment protocol for use with chronic and recurrent depression (Beck et al., 1979; Kinsella and Garland, 2008). The case example described here utilises the Moore and Garland approach whilst taking into account the cognitive science of memory and depression described previously, in terms of how standard Beckian cognitive therapy interventions are utilised and adapting these accordingly. The Moore and Garland adaptations to the Beckian cognitive model take into account Teasdale’s theory of the mechanism of change in cognitive therapy for depression, and when delivering the intervention consider not just what is delivered but how it is delivered. A brief summary of the adaptations proposed by Moore and Garland (2003) is as follows: •

A thorough assessment and the establishment of realistic problem and target statements (three one-hour sessions). • A treatment rationale that accounts for both content, processing and memory biases in depression and their maintenance (ongoing). • A slower pace to therapy with a minimum of 25 sessions, often extended to 30. • Detailed self-monitoring both in and out of session, throughout therapy, in order to engage with the level of specificity required to begin to influence depressed mood and target over-generality. This requires tenacity, persistence and repeated modelling in session and aims to identify, formulate and work with cognitive, affective and behavioural avoidance (ongoing). • Using standard cognitive therapy interventions (activity scheduling and graded task assignment, with a cognitive rationale); identifying and modifying NATS and conditional beliefs with behavioural experiments; using methods to maximise chances of building an alternate schematic processing loop that encodes across controllability, tolerance and remittance of depression. For example, detailed and frequent diagrammatic illustration of the maintenance cycle in action; behavioural experiments targeting breaking into the maintenance cycle (such as Theory A versus Theory B hypotheses testing); repetition and practice both in and out of session with frequent written summaries of learning (10–15 sessions). • Psycho-education about emotions, their purpose and a validation of the patient’s experience of these and where necessary how to identify, describe and label a range of salient emotions. The aim is to target cognitive and affective avoidance (ongoing). • Experiential methods to work with active affect (both negative and positive), e.g. behavioural experiments to activate and work with in vivo affect, targeting metacognitive beliefs regarding the tolerability and controllability of emotions/mood/depression. This builds skills in allowing, accepting and tolerating affect, both negative and positive (5–10 sessions).

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•

•

Working with specific intrusive depressive memories often linked to onset of depression. This includes activating memories in session and using cognitive interventions to validate and engage with memories to target meaning, i.e. modifying NATS; historical data logs to update learning (Padesky and Greenberger 1995) and where indicated re-scripting of depressive intrusive memories (Brewin et al., 2009) (4–6 sessions). Robust relapse prevention plan and practice of skills to maintain gains commenced at outset of therapy but becoming focus of final 4–6 sessions.

A further adaptation to Moore and Garland (2003) is proposed here, namely, greater emphasis is placed on the maintenance formulation described in this chapter, with reference to the longitudinal formulation only in the context of how early experiences manifest in the present in the form of intrusive depressive memories, emotional memories and present sense of self and self in relation to others and the world. The case example below will aim to present a maintenance model of chronic and recurrent depression which integrates the research evidence from the cognitive science of memory and depression integrated with Beckian cognitive therapy for depression. In addition the author will argue that a key aspect of Beck’s clinical cognitive model which is of immense utility when working with chronic and recurrent depression is actively working to modify cognition. Specifically, modifying negative automatic thoughts using behavioural experiments and the formulation and modification of conditional beliefs, and how these are manifest in how patients engage with emotions, intrusive depressive memories, depressive symptoms, cognitive processes and medication side effects.

The story of Jane Jane is a 45-year old single woman who lives alone. Prior to her first episode of depression Jane worked in a building firm as a payroll administrator. She describes a 15-year history of depression in which she experienced two distinct episodes of depression, and states that latterly her illness has taken a chronic course, marked by residual depressive symptoms. The onset of the first episode of depression was in the context of a situation at work, where Jane was sexually harassed on a number of occasions by a senior partner in the company. Jane reported this to her immediate boss (a man) who did not take any action against the individual concerned. Jane became increasingly stressed at work and despite her verbal protestations to the individual concerned, she was not able to influence his behaviour. As a result, Jane resigned from her job and found work in a different company. Jane did not seek treatment for her depression and over a period of six months she states she made a full recovery from this first episode. Four years later Jane experienced a recurrence of her depressive symptoms, which were triggered by a situation at work in which a newly

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appointed boss (a woman) was exacting in terms of expected standards of performance and critical and disapproving if these were not met. After 12 months of increasing stress, Jane took sick leave and visited her general practitioner (GP) who prescribed amitriptyline 50mg daily as a starting dose of antidepressant medication, increased to 220mg daily over a two-month period. Jane’s depression made a partial response to this treatment. After six months’ sick leave Jane lost her job and has not worked since. For the next four years Jane describes her mood as fluctuating, with periods when she would feel flat and listless and other times when her mood would be extremely low and remain so for several weeks. After one particularly bad period of low mood lasting three months, Jane once more visited her GP who referred her to secondary care services for cognitive therapy. Case formulation of relevant cognitive themes Following three one-hour assessment sessions, a number of content-based cognitive themes related to conditional beliefs seemed relevant in the development and maintenance of Jane’s depression. •

A subjective sense of feeling out of control in certain situations, which Jane stated had always been an issue for her • The importance of maintaining high standards, specifically doing things properly and avoidance of mistake making. In the course of therapy these were formulated as: If I don’t do things properly I’ll be criticised and rejected. If I’m not in control I will be overwhelmed.

Early experiences that may have been relevant in the development of these themes are as follows. Jane recalled her mother as strict, setting high standards, with a tendency towards criticism and disapproval if such standards were not maintained. In addition, Jane often experienced her mother’s criticism as beyond her influence, i.e. nothing she did ever met her mother’s standards (implicit to this is a sense of helplessness and lack of control). The original critical incident that triggered Jane’s depression can be related back to the themes of helplessness and control over the situation where the senior partner was sexually harassing her and her inability to influence the situation. This mirrored a childhood incident where on three occasions when Jane was 11 an uncle visiting the family home made inappropriate sexual advances towards her. Similarly, in her second job, the boss with the exacting standards which Jane felt she never met also resonated with her early experiences with her mother.

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Session plan for contract of therapy The therapy contract was broken down into the following stages: • • • • •

Sessions 1–3: assessment Sessions 4–6: problem and target setting and formulation of relevant cognitive themes Sessions 6–16: formulation of maintenance model and activity scheduling and graded task assignment within a cognitive rationale (targeting problems 1 and 2 on the problem list) Sessions 17–25: working with active affect; modifying content-based cognition using behavioural experiments; formulation of conditional beliefs (targeting further problems 1 and 2 and beginning to tackle problem 3) Sessions 25–30: modifying conditional beliefs and relapse prevention.

Sessions 1–3: The assessment process Assessment consisted of three one-hour sessions. In session one, a detailed history of the presenting problem (how her depression affects her currently on a day to day basis). Homework following this session was completion of the Beck Depression Inventory (BDI; Beck at al., 1961). Session two consisted of using the data from the completed BDI to ask further questions about Jane’s experience of depression; assessment of the development and maintenance of her depression and the initial sharing of the treatment rationale. Homework at the end of this session was to read the treatment rationale handout; to keep a baseline activity schedule taking mastery and pleasure ratings (Beck et al., 1979; Fennell, 1989) and to make a list of problems Jane would like to work on in therapy and treatment goals. The final assessment session reviewed the homework and gathered relevant information that arose from this. In addition, assessment of social and environmental factors from childhood to the present day was undertaken, and a written formulation was shared with Jane of specific themes that seemed relevant in terms of maintenance of her difficulties. For a detailed description of the assessment process tailored to chronic and recurrent depression see Moore and Garland (2003). At assessment, Jane described a range of residual depressive symptoms, notably depressed mood, tiredness, lack of energy, lack of motivation, loss of pleasure and interest, irritability and reduced concentration and memory, which were impeding her ability to engage in the activities of daily living. She had been avoiding social situations for the past 12 months. Jane also described a tendency to ruminate both on current symptoms of depression and on painful memories from the past. Specifically these memories were two instances of being severely criticised by her mother, a memory of unwanted sexual attention from her uncle (which involved groping) when she was 11, and the sexual harassment she experienced at work. At assessment it became evident from her verbal dialogue that Jane had a tendency to be self-critical and blame herself when things went wrong. At assessment, Jane

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scored 50 on the Beck Depression Inventory (version I; Beck et al., 1961), indicating a severe depressive state. Sessions 4–5: Problem and target setting The following problem and target list was developed with Jane: Problems

•

• •

Depressed mood, tiredness, lack of energy, lack of motivation, loss of pleasure and interest, irritability and reduced concentration and memory, depressive rumination and negative biases in memory manifest on a daily basis which interferes with activities of daily living A sense of feeling out of control in terms of depression and life circumstances, which leads to a sense of feeling helpless and withdrawing, i.e. going to bed or avoiding certain situations Concern about making mistakes and a tendency toward self-criticism and self-blame which leads to avoidance in relation to personal, social and work-related activities.

Targets

•

To be able to identify actions I can take to influence depression and its symptoms and to find helpful ways of managing times when I cannot, and not beating myself up or expecting myself to ‘just get on with it regardless’ • To re-engage with activities of daily living (e.g. housework, shopping, cooking) • To re-engage with social activities 2–3 times per week (e.g. having friends round for a meal; visiting the cinema; going into town shopping) • To begin to be more tolerant of mistake-making in everyday situations (e.g. practical tasks) and to try out activities I am currently avoiding (e.g. sewing classes, gardening) • To recognise when I am being self-critical and/or blaming myself when something goes wrong and disengage from ruminating on my perceived shortcomings. Sessions 5–16: Cognitive therapy interventions targeting maintenance factors The cognitive therapy intervention used to treat Jane’s depression (described in Beck et al; 1979; Moore and Garland, 2003) was implemented in the usual order beginning with activity scheduling and graded task assignment used within a cognitive rationale, followed by working with NATS. A key difference here is that the use of behavioural experiments to modify NATS is used more frequently than the

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traditional Beckian method of disputation of NATS. However, where disputation is clinically indicated this is used where active affect is present and is followed up with a behavioural experiment to test out the results of the disputation. This is followed by working with conditional beliefs with behavioural experiments and relapse prevention. Usually, when working with chronic and recurrent depression it is necessary to formulate and work with conditional beliefs much earlier in the therapy process, as these can be implicated in the cognitive, affective and behavioural avoidance that characterises this type of clinical presentation. With regard to the memory biases that were pertinent to the maintenance of Jane’s depression, she exhibited the following: 1 2 3

Negatively biased, all-or-nothing, over-general processing of information Rumination on unpleasant memories from the past and on the symptoms of depression, their meaning and consequences and on the importance of controlling her depression Self-critical and self-blaming rumination regarding her perceived inability to influence depressed mood and meet standards.

These maintenance factors were shared with Jane using the maintenance cycle described in Figure 6.2. The initial target for treatment was the first two problems on the problem list. Interventions used in this phase of therapy are: •

•

Formulation of the maintenance factors in depression, taking into account both process of thinking (memory biases) and content of thinking (negative automatic thoughts) and conditional beliefs that impact upon activities of daily living that depressive symptoms make harder due to the resultant impaired functioning Activity scheduling and graded task assignment utilised with a cognitive rationale.

Revisiting the maintenance formulation The formulation presented in Figure 6.2 focuses specifically on an example of where Jane is criticising herself for not being able to concentrate on sewing and makes a mistake. Simultaneously, she is ruminating on why she cannot concentrate and is comparing her current level of functioning in relation to the activity of sewing to her past functioning and noting a chasm of difference which she cannot reconcile. She is i) ruminating on her symptoms of depression and berating herself for not being able to ‘make them go away’ by sheer effort of will and ii) experiencing concomitant NATS imbued with the negative bias that accompanies depressed mood. These are further enhanced by autobiographical memories of past upsetting experiences which recall both pictorial and emotional memories of past mistakes, not meeting standards and how significant others have responded to these which is

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with criticism and an admonishing tone to try harder. This also feeds into rumination and in turn gives rise to feelings of both anxiety and shame, which provides further fuel for rumination. As a consequence, unable to meet the demands of her conditional beliefs regarding doing things properly (in this instance, her sewing) and controlling her depression, Jane gives up and takes to her bed. She spends the next three hours lying there ruminating on her perception of herself as a helpless, useless failure. This is a frequent occurrence in the early stages of therapy. As the note beneath Figure 6.2 indicates, Jane’s conditional beliefs can clearly be seen in action in terms of how she makes sense of the reasons why she can’t concentrate Self-critical/self-blaming rumination ‘Why can’t I just concentrate?’ ‘Why does this always happen?’ ‘Why am I like this?’ ‘I never used to be this way’ ‘Look what I have become’ ‘It’s my fault, I’m lazy’

negative bias to thought content (NATS)

Emotions: Sadness; anxiety, anger shame Biological symptoms: poor concentration and memory; tiredness Physiological symptoms: butterflies; tremor; agitation

‘I m useless’ ‘I just need to try harder’ ‘Nothing I do ever goes right’ ‘It is pointless’ ‘I’ll never get better’

autobiographical memory bias/overgeneral recall emotional memories of being told off for mistake making and being told to try harder

Cognitive, affective and behavioural avoidance Thought suppression; Initially push self harder (to avoid affect) Eventually give up on activity And go to bed

Figure 6.2 Clinical example of the maintenance cycle of Jane’s depression. The conditional beliefs can be readily seen in action here as Jane strives to control her concentration (by focusing properly) for fear of criticism if she is not able to engage in the agreed homework assignment, sewing.

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(‘I am just not trying hard enough to concentrate properly’) and her perception that if she doesn’t get a grip on her depressive symptoms (i.e. take some control) then she will never overcome her depression and will be stuck in this interminable state of despair which is experienced as intolerable, uncontrollable and unremitting (and therefore potentially overwhelming). This is illustrated in Figure 6.2 and numerous examples of this maintenance cycle were generated in this phase of therapy. Using activity scheduling and graded task assignment with a cognitive rationale Beckian cognitive therapy uses activity scheduling and graded task assignment with a cognitive rationale. The first step of this is to use an activity schedule to take a baseline measure of activity levels and taking a rating of mastery and pleasure for each activity. Mastery in the Beckian model has a very specific meaning; it is defined as ‘how well you did the activity given how you are feeling’ (rated on a scale of 0–10). This statement, given how you are feeling, is a key element of the cognitive rationale for grading tasks. What the patient is being asked to do is make an allowance for their depressive symptoms. Most patients struggle with making this allowance, often because depressive symptoms interfere with most everyday activities that when not depressed can be completed with ease and without much consideration for how to go about them. Thus, to return to Jane, in the example in Figure 6.2 she is berating herself for not being able to sew as she used to prior to becoming depressed. Implicit in her reasoning is ‘this is something I used to do with ease and now I can’t, why? Because I’m useless’. At this point, it was put to Jane that the main reason that, at present, sewing was difficult was due to the symptoms of depression, specifically poor concentration and tiredness. Thus, not only will the task be harder but there is an increased likelihood of making a mistake, not due to her uselessness but due to fatigue. As is often the case, Jane was sceptical and met the therapist’s proposition with the comment ‘I think this is just me,’ (i.e. not symptoms of depression), followed by a barrage of self-criticism. A behavioural experiment was proposed using the classic ‘Theory A / Theory B’ method. Thus, in this example: Theory A: I should, by sheer effort of will, be able to push on and complete activities as I did prior to becoming depressed, and eventually I will overcome them. Theory B: These symptoms of depression are real; they significantly interfere with my ability to engage in everyday tasks. If I make an allowance for the symptoms by pacing myself and grading tasks then I may be able, over time, to do more. The first experiment involved approaching sewing from a different perspective. On day one, Jane was to test theory A by approaching sewing (she was attempting to embroider the Last Supper in embroidery silks) as she usually would with her

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‘keep going and push on through these symptoms’ approach. She was to try to sew for one hour (her usual goal) and to monitor her concentration and energy levels, thoughts and feelings and the point at which she made a mistake. She was then to summarise the overall outcome. The next day, Jane was to test theory B and try to make an allowance for depressive symptoms. This involved simplifying the task and planning to implement specific steps in a graded way, making an allowance for concentration and energy levels. Thus she chose the simplest embroidery possible, a small birthday card. Then we established at what time of day her concentration and energy levels were at their best and for how long these sustained themselves. From this we agreed her concentration span was about 15 minutes and was at its best between 11 a.m. and 1 p.m., and 5 p.m. and 6 p.m. On this basis, we planned two 10-minute periods of embroidery twice a day during the stipulated times. She was to set a timer to prompt her to stop after 10 minutes and she was to take a 15-minute active break in which she was to do something restorative, e.g. drink a cup of tea. Again Jane was to monitor her concentration and energy levels, thoughts and feelings, the point at which she made a mistake and summarise the overall outcome. The following week Jane had – by grading the activity – completed her small card. The Last Supper was now on hold. She had learned from the experiment that theory B possibly held some weight. She recognised that by grading and pacing she had completed more sewing, her concentration and energy levels, combined with taking regular breaks, had sustained themselves for longer. Also, not only had she not made a mistake and descended into self-criticism in relation to sewing, she had felt some pleasure and a sense of achievement. She had also persisted with the activity over the course of a week. As is often the case in chronic and recurrent depression Jane did not readily generalise this strategy and it took numerous repetitions of the process with different activities before she was able to maximise its benefits. Depending on the activity, the triggering of self-critical rumination varied. This difficulty with generalizability is likely to be related to over general recall particularly in relation to activities that require the person to draw on past memories of how they did things. By session 12 of treatment, Jane’s score on the BDI had reduced to 30 and she had experienced a 40% reduction in depressive symptoms. She had re-engaged with a number of activities of daily living, including her hobbies which included sewing and reading magazines, and she could now watch 30 minutes of television and focus on and retain the plot of the programme. Importantly, Jane had developed strategies to interrupt behavioural avoidance and self-critical/self-blaming rumination. This in turn impacted on reducing the number of negative automatic thoughts leaving the more recurrent NATS to be tackled in the next phase of therapy. Also, as her mood improved Jane was, through discussion, able to observe the frequency and intensity with which depressive intrusive memories re-intruded was reduced by 40%. This intervention began the process of enabling Jane to have a sense that she could influence depressive symptoms and that they waxed and waned. We used dips in mood to contrast the

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variance in the intensity and duration of rumination and intrusive memory recall with times when her mood was less depressed. The message to convey here is ‘this is how memory works when mood is low,’ that is it is a symptom of depression and not ‘a permanent irreversible change in who I am’. Sessions 17–25 The target of this phase of treatment was to further undermine the second problem on the problem list whilst also beginning to tackle the third. The interventions in this stage were: • • •

Working with active affect Identifying and modifying content-based cognition, i.e. negative automatic thoughts, using behavioural experiments Formulating conditional beliefs.

In Teasdale’s critique of Beckian cognitive therapy (Teasdale, 1993) he cites the limitations of modifying negative automatic thoughts (NATS), arguing that patients often see the logic of it but do not really believe it, i.e. ‘I know it in my head but don’t believe it in my heart.’ In reply to this, it is possible to argue that this depends on the way in which this intervention is utilised. In Beck’s original articulation of the intervention (Beck et al., 1979) there is a reliance on using disputation to appeal to logic and the goal in challenging negative thoughts is to try to help the patient see the error of their logic. In chronic and recurrent depression this approach is indeed unhelpful as it often serves to reinforce self-critical and self-blaming rumination. However, Padesky (1990) takes a different view of modifying NATS than this classical Beckian method. In her paper on Socratic Questioning (called ‘Changing Minds or Guided Discovery’) she puts forward the view that modifying thoughts is about experientially testing NATS by deliberately activating affect by using behavioural experiments. In this regard, it is unlikely there will be one all-purpose conclusion to reach when working with NATS but rather a range of perspectives that may hold weight depending on context. This position appeals to the ‘mindful experiencing mind in place’ in Teasdale’s model, which takes into consideration the necessity of activating affect in order to modify thought processes via experiential engagement. This is a point made by Bennett-Levy et al. (2004) in their book on behavioural experiments in cognitive therapy. Clinicians often observe how difficult it is to activate affect in patients with chronic and recurrent depression. As a supervisor and trainer, the author would observe that whilst practitioners of CBT are generally willing to use treatment interventions for anxiety that deliberately provoke anxiety, there is greater reluctance to deliberately provoke emotions such as sadness, guilt and shame, and work with these as active affect in session alongside concomitant cognitions. Thus, a central component of this phase of work with Jane was in-session activation of affect. Initially, behavioural experiments were conducted to test out what

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happens if affect is momentarily approached, how this experientially manifests itself and what cognitions emerge with this. A key aspect of Jane’s presentation was that emotion (as the formulation indicates) was not only experienced as out of control and potentially overwhelming, but emotions were also shameful, and she criticised herself for feeling sad, angry and anxious. Shame and avoidance go hand in hand and this requires intervention if progress is to be made. Gilbert (personal communication, 2012) observes that in childhoods characterised by emotional neglect and subjugation children often do not learn to identify, describe, label, experience and tolerate emotions and as a result have reduced capacity for self-soothing. He continues that as humans we don’t have one mind but many, thus often in an upsetting situation we can experience a range of often conflicting emotions. Therefore, key skills that may protect us against being overwhelmed are i) the ability to differentiate between and verbalise these different emotions, ii) to be able to recognise how each emotion manifests itself in our bodies, iii) to be able to identify and verbalise what is upsetting (i.e., identify our thoughts in relation to each feeling), iv) to identify relevant pictorial and emotional memories (early experiences) that inform current distress, v) to recognise the behaviours that emerge from these memories in the present and vi) to engage in all of these with acceptance and tolerance of self and experience without judgment (i.e. not beating yourself up for feeling and thinking in this way). Fundamental to this is Gilbert’s idea that emotions serve an evolutionary purpose and help us to survive. A key intervention on the part of the therapist is the validation and normalising of emotions and examining with the patient the adaptive purpose of them in their context. The process of validation is important as this begins to tackle the subjugated position inherent in emotionally abusive childhoods where children can implicitly learn that their thoughts and feelings are unimportant. This process was used with Jane over a period of eight sessions in conjunction with the Beckian intervention of identifying NATS and modifying these using behavioural experiments. This was applied initially to testing hypotheses about engaging with emotions and latterly to her predictions about mixing socially which were informed by her shame-based self-criticism about having depression. After this phase of treatment, Jane scored 22 on the BDI and reported an 85% improvement in depressive symptoms and a 95% improvement in intrusive depressive memories. Jane was still troubled by one specific memory of being publically criticised by her mother. She was engaged in working towards all of the goals set at the start of therapy. Sessions 25–30 These sessions were devoted to: • • •

Intrusive depressive memory work Modifying conditional beliefs Relapse prevention.

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In this phase of therapy, one session plus one homework assignment were used to address the one intrusive depressive memory that was still causing some distress. This was tackled using a historical log (Padesky and Greenberger, 1995) and identifying and working with the meaning enshrined in the memory. This allowed therapy to then move into using standard cognitive therapy interventions for modifying conditional beliefs associated with this memory and more broadly in Jane’s life around the themes of control and high standards. For an in-depth discussion of this see Kinsella and Garland (2008). In addition, a relapse prevention plan was developed. This incorporated a summary of skills developed in therapy, a process for identifying and tackling early warning signs of relapse, and a concrete and specific plan for continuing to work on her conditional beliefs. In cognitive therapy there is an implicit assumption that working with NATS has an impact on increasing the flexibility of conditional beliefs. The psychological vulnerability resides in the conditional beliefs and their role in generation of the maintenance cycle. Therefore, continued work on modifying conditional beliefs is required. At discharge Jane had achieved the therapy goals. Her BDI score was 16. Interestingly a score in the region of 11–18 is indicative of residual depressive symptoms. A clinical observation the author would make is that in chronic and recurrent depression this is a typical picture. Patients make an 80–95% recovery but residual symptoms stubbornly remain. These can serve as kindling for depressive relapse because they can become fuel for rumination. It is on this basis that MBCT is recommended as a relapse prevention strategy and not as a replacement for cognitive therapy (Williams, 2013).

Conclusion This chapter presents a cognitive maintenance model for chronic and recurrent depression. It aims to integrate the cognitive science of depression into the clinical cognitive therapy for depression (Fennell, 1989; Beck et al., 1979). This is illustrated using a clinical example. As Moore and Garland (2003) observe, depression is a heterogeneous disorder and as such, a range of theoretical models framed within the broad umbrella of CBT treatments can be found in the literature. For the clinician this can prove challenging. Often, in the face of complexity and non-response to standard cognitive and behavioural interventions clinicians are prone to ‘mix and match’ interventions without consideration of a coherent theoretical rationale for so doing. Hence a popular approach to chronic and recurrent depression currently is an eclectic mix of ‘behavioural activation’, ‘mindfulness’ and ‘compassion’–based interventions, with an apparent abandonment of potentially efficacious cognitive interventions. This eclecticism goes against the spirit of the scientist-practitioner model that lies at the heart of the behavioural and cognitive therapies. The scientist-practitioner model exhorts the clinician to develop competencies in generating, analysing and applying research data and using this in the treatment of patients. Thus, scientific methods and research underpin clinical practice with the aim of using scientific methodology to inform clinical

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decision-making. A further finding in the Newcastle-Cambridge trial (Scott et al., 2000) was that both the active treatment and TAU groups showed statistically significant changes in overall levels of depressive symptoms and social adjustment. Interestingly there were relatively few between-group differences in level of depressive symptom ratings. However, the active treatment group showed a statistically significant reduction in levels of hopelessness and pessimism and an improvement in self-esteem. This may suggest that cognitive therapy helps the patient to relate differently to depressive symptoms, resulting in lower levels of hopelessness about being able to influence the illness and its course. This in turn is likely to lead to a shift in perception regarding their capacity to influence depression and its symptoms and the tolerability and persistence of depressed mood. A final observation worthy of note in the current health care climate that demands ever shorter treatment protocols: in the case study outlined here, Jane received 30 sessions of treatment. This is more than that stipulated in the received wisdom of the evidence base on which current health care funding is based. However, the impact of memory biases in depression means that there are higher levels of hopelessness and helplessness as well as avoidance being a central feature in chronic and recurrent depression. Thus, engagement in treatment often takes longer and more time needs to be spent in enabling the patient to work with active affect as well as teaching the patient how to use cognitive therapy interventions to tackle depression, thus the number of sessions required is variable. In addition, the effects of chronic avoidance (cognitive, affective and behavioural) and hopelessness and helplessness can exert a negative impact on therapy itself and this needs to be proactively tackled in the early stages of treatment. In the author’s most recent study (Morriss et al., 2010), a very complex and chronic population of participants with depression were recruited and 12 months of treatment was offered (up to 46 sessions of cognitive therapy). It was only at 9 months and again at 12 months that a significant difference in treatment effect was seen between the active treatment arm (which combined cognitive therapy and pharmacotherapy) and treatment as usual (standard treatment in secondary care). As such, evidence now exists to suggest that in chronic and recurrent depression, six months of treatment is ineffective and some patients require proactive and extended treatment in order to maximise the opportunity for the illness to respond to a combined treatment intervention.

References Beck, A. T. (1996). Beyond belief: A theory of modes, personality and psychopathology. In P. M. Salkovskis (ed.) Frontiers of Cognitive Therapy. New York: Guilford Press. Beck, A. T. et al. (1961). An inventory for measuring depression. Archives of General Psychiatry 4: 561–71. Beck, A. T. et al. (1979). Cognitive Therapy for Depression: A Treatment Manual. New York: Guilford Press. Bennett-Levy, J. et al. (2004). Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: Oxford University Press.

140  Anne Garland Brewin, C. R. et al. (2009). Imagery re-scripting as a brief stand-alone treatment for depressed patients with intrusive memories. Behaviour, Research and Therapy 47: 569–76. Bunnell, S. L. and Greenhoot, A. F. (2012). When and why does abuse predict reduced autobiographical memory specificity? Memory 20: 121–37. Dunn, B. D. (2012). Helping depressed clients reconnect to positive emotion experience: Current insights and future directions. Clinical Psychology and Psychotherapy 1: 326–40. Evans, J. et al. (1992). Autobiographical memory and problem-solving strategies of parasuicide patients. Psychological Medicine 22: 399–405. Fennell, M. J. V. (1989). Depression. In K. Hawton, P. M. Salkovskis, J. Kirk and D. M. Clark (eds) Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford: Oxford University Press. Gilbert, P. (2005). Compassion: Conceptualisations, Research and Use in Psychotherapy. London: Routledge. Gilbert, P. and Procter, S. (2006). Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy 13: 353–79. Hamilton, M. (1960). A scale for rating depression. Journal of Neurological and Neurosurgical Psychiatry 23: 56–62. Harvey, A. et al. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford: Oxford University Press. Hayes, S. C. et al. (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behaviour Change. New York: Guilford Press. Henderson, D. et al. (2002). Autobiographical memory and emotion in a non-clinical sample of women with and without a reported history of childhood sexual abuse. British Journal of Clinical Psychology 41: 129–41. Jacobson, N. J. et al. (2001). Behavioural activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice 8: 255–70. Kinsella, P. and Garland, A. (2008). Cognitive Behaviour Therapy for Mental Health Workers: A Beginners Guide. Hove: Routledge. Kuyken, W. and Brewin, C. R. (1994). Intrusive memories of childhood abuse during depressive episodes. Behaviour Research and Therapy 32: 525–28. Kuyken, W. and Brewin, C. R. (1995). Autobiographical memory functioning in depression and reports of early abuse. Journal of Abnormal Psychology 104: 585–91. Longmore, R. J. and Worrell, M. (2007). Do we need to challenge thoughts in cognitive behaviour therapy? Clinical Psychology Review 27: 173–87. Lynch, D. et al. (2010). Cognitive behaviour therapy for major psychiatric disorder; does it really work? A meta-analytic review of well controlled trials. Psychological Medicine 40: 9–24. Ma, S. H. and Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology 72: 31–40. Moore, R. and Garland, A. (2003). Cognitive Therapy for Chronic and Recurrent Depression. Chichester: Wiley. Moorey, S. (2010). The six cycles maintenance model: Growing a ‘vicious flower’ for depression. Behavioural and Cognitive Psychology 38: 173–84.

Case formulation for depression  141 Morriss, R. et al. (2010). A randomised controlled trial of the clincal and cost effectiveness of a specialist team for managing refractory uniploar depressive disorder. BMC Psychiatiry 10: 100. Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive states. Journal of Abnormal Psychology 109: 504–11. Padesky, C. A. (1990, September 24). Socratic Questioning: Changing Minds of Guided Discovery. Keynote address delivered at the European Congress of Behavioural and Cognitive Therapies, London. Padesky, C. A. and Greenberger, D. (1995). A Clinicians Guide to Mind Over Mood. New York: Guilford Press. Padesky, C. A. and Mooney, K. A. (1990). Clinical tip: Presenting the cognitive model to the client. International Cognitive Therapy Newsletter 6.1. Papageorgiou, C. and Wells, A. (2000). Treatment of recurrent major depressive disorder with attentional training. Cognitive and Behavioural Practice 7: 407–13. Paykel, E. S. et al. (1999). Prevention of relapse in depression by cognitive therapy. Archives of General Psychiatry 56: 829–35. Paykel, E. S. et al. (2005). Duration of relapse prevention after cognitive therapy in residual depression: Follow up of a controlled trial. Psychological Medicine 35: 59–68. Persons, J. B. (2008). The Case Formulation Approach to Cognitive Behaviour Therapy. New York: Guilford Press. Salkovskis, P. M. et al. (1998). The devil is in the detail: Conceptualising and treating obsessional problems. In N. Tarrier, A. Wells and G. Haddock (eds) Treating Complex Cases: The Cognitive Behaviour Therapy Approach. Chichester: Wiley. Schotte, D. E. and Clum, G. A. (1987). Problem-solving skills in suicidal psychiatric patients. Journal of Consulting and Clinical Psychology 55: 49–54. Scott, J. et al. (2000). Effects of cognitive therapy on psychological symptoms and social functioning in residual depression. British Journal of Psychiatry 177: 440–46. Teasdale, J. D. (1993). Emotion and two kinds of meaning: Cognitive therapy and applied cognitive science. Behaviour, Research and Therapy 31: 339–54. Teasdale, J. D. et al. (2000). Prevention of relapse/recurrence in major depression by mindfulness based cognitive therapy. Journal of Consulting and Clinical Psychology 68: 615–23. Teasdale, J. D. et al. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology 70: 275–87. Ustun, T. B. and Chatterji, S. (2001). Global burden of depressive disorders and future projections. In A. Dawson and A. Tylee (eds) Depression: Social and Economic Time-Bomb Strategies for Quality Care Proceedings of an International Meeting. London: BMJ Books. Watkins, E. et al. (2000). Decentering and distraction reduce over general autobiographical memory in depression. Psychological Medicine 30: 911–20. Watkins, E. et al. (2007). Rumination-focused cognitive behaviour therapy for residual depression: A case series. Behaviour, Research and Therapy 45: 2144–54. Watkins, E. and Teasdale, J. D. (2001). Rumination and over general memory in depression: Effects of self-focus and analytic thinking. Journal of Abnormal Psychology 110: 353–57. Wenzlaff, R. M. et al. (2001). Beneath the veil of thought suppression: Attentional bias and depressive risk. Cognition and Emotion 15: 435–52. Wenzlaff, R. M. and Luxton, D. D. (2003). The role of thought suppression in depressive rumination. Cognitive Therapy and Research 27: 293–308.

142  Anne Garland Williams, J.M.G. (2013). State of the art of mindfulness based cognitive therapy (MBCT). Workshop held at the British Association of Behavioural and Cognitive Psychotherapies (BABCP) Annual Conference, London. Williams, J.M.G. and Broadbent, K. (1986). Autobiographical memory in suicide attempters. Journal of Abnormal Psychology 95: 144–49. Williams, J.M.G. and Scott, J. (1988). Autobiographical memory in depression. Psychological Medicine 18: 689–95.World Health Organization (1999). World Health Report 1999: Making a Difference. Geneva: World Health Organization. Williams, J.M.G. et al. (1997) Cognitive Psychology and Emotional Disorders (2nd ed.). Chichester: Wiley. Williams, J.M.G. et al. (2000). Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology 9: 150–55. Williams, J.M.G. et al. (2007). Autobiographical memory specificity and emotional disorder. Psychological Bulletin 133: 122–48. Young, J. E. et al. (2003). Schema-Therapy: A Practitioner’s Guide. New York: Guilford Press.

Chapter 7

Case conceptualisation in complex PTSD Integrating theory with practice Deborah Lee

Introduction The diagnosis of complex posttraumatic stress disorder (PTSD) has received much attention in recent years. It is not yet recognised as a formal diagnosis by the DSM-5 (APA, 2013) and we are yet to see if it will be included into ICD-11 (due for publication by WHO in 2015). This does not reflect the strength of belief held by many researchers and clinicians working in the field of trauma (see Cloitre et al., 2011, for a review of expert opinion) that PTSD alone does not adequately capture the clinical presentation and treatment needs of some individuals who have experienced repeated Type II trauma (Terr, 1991). For instance, those of us who work clinically with traumatised people recognise that PTSD is part of the picture but often not the whole clinical story. As well as recognisable symptoms of intrusions, avoidance and hyperarousal, we see difficulties with affect regulation, trust, interpersonal functioning, maintaining a cohesive sense of self and effective problem-solving abilities. Thus, case conceptualisation in complex PTSD presentations needs to capture the nature and maintenance of the memory disturbance, as well as the impact of repeated trauma on psychological and interpersonal functioning. There is now quite a body of evidence to suggest that phased-based treatment approaches are effective for complex PTSD (Cloitre et al., 2011) albeit the precise ingredients of the phases are still up for debate. What is consensus, is those who suffer from complex PTSD benefit from a period of stabilisation and skills development around affect regulation and interpersonal functioning before the trauma memory work (such as prolonged exposure, trauma-focused CBT or EMDR). The aforementioned techniques are well documented and researched as effective when working with PTSD arising from Type I trauma (NICE, 2005). Given the considerations outlined above, the topic of case conceptualisation in complex PTSD is complicated, not least by the fact that clinicians often use the terms PTSD and complex PTSD to mean different things. For instance, complex PTSD is sometimes used to convey the presentation of PTSD with complicated features. In order to address some of these issues in a way that will be useful to clinicians, this chapter considers case conceptualisation of PTSD and presents

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various issues that complicate the treatment of PTSD. The chapter then considers case formulation in complex PTSD and phased-based treatment implications. Post-traumatic stress disorder The characteristic feature of PTSD is continual reliving of a traumatic event from the past, with the same emotional intensity as the original experience. PTSD has three symptom clusters: intrusions, avoidance and hyperarousal. It is the most common psychiatric disorder in those who have experienced traumatic events (see Lee and Young, 2001, for a review). Since PTSD was first described in DSM-III (APA 1980), a variety of theories have been proposed to account for the disorder, including information processing theories (e.g. Brewin et al., 1996; Chemtob et al., 1988; Dalgleish and Power, 2004; Foa and Kozak, 1986), behavioural theories (e.g. Keane et al., 1985a, 1985b; Mowrer, 1960), socio-biological theories (Christopher, 2004; van der Kolk et al., 1996; Yehuda, 2001), socio-cognitive theories (Horowitz, 1986; Janoff-Bulman, 1992; Resick and Schnicke, 1992, 1993; Resick and Calhone, 2001) and the cognitive model of PTSD (Ehlers and Clark, 2000). All of these theories offer useful theoretical insights into the etiology and maintenance of PTSD in the aftermath of a traumatic event. Furthermore, all of these theories (with the exception of Dalgleish and Power, 2004) view the predominant emotional experience associated with trauma as fear. Interestingly, the DSM-5 (APA, 2013) has notably changed the diagnosis of PTSD, and fear is no longer the significant emotional response required to meet a diagnosis. It is likely now that we will see the emergence of new treatments that broaden the focus from fear-based symptoms to encompass the targeting of additional symptoms outlined in DSM-5. Information processing theories of PTSD Three major theories underpin contemporary CBT treatments of PTSD (NICE, 2005): (1) emotional processing theory (Foa and Kozak, 1986; Foa and Rothbaum, 1998), (2) the cognitive model of PTSD (Ehlers and Clark, 2000), and (3) dual representation theory (Brewin et al., 1996, Brewin et al., 2010). Together these theories offer a robust psychological framework for understanding and conceptualising PTSD. Although it is not possible to discuss these theories in depth given the parameters of this chapter, those readers who would like to expand their knowledge of these theories can see Holmes and Brewin’s (2003) excellent review paper. Emotional processing theory Emotional experiences are thought to be encoded in semantic fear networks (Foa and Kozak, 1986; Foa and Rothbaum, 1998). These contain sensory information about the stimulus (sights, sounds, smells, texture), the behavioural, physiological

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and cognitive responses (heart pounding, sweating) and the meaning of the event (vulnerability, near death; Lang, 1977, 1979). The model proposes that the fear network in trauma is coherent, stable and generalisable, is readily activated and brought to the conscious mind (Foa and Kozak, 1986). Many other stimuli present at the time of the event and/or stimuli that resemble the traumatising stimuli take on the capacity to activate the fear response. For example, a neutral stimulus, like a car of the same colour or model as that involved in a road traffic accident, may provoke a fear response in the victim of a road traffic accident. Given the size, complexity and easy accessibility of the fear network, activation alone does not lead to exposure (under optimum conditions), as not all aspects of the fear network are brought to the conscious mind. Thus, the individual is repeatedly exposed to the traumatic material under poor exposure conditions (Rachman, 1980), and this perpetuates the fear response by preventing habituation from taking place. Foa and Kozak (1986) suggest that the meaning element of the fear network needs to be re-evaluated for emotional processing to be complete. They propose a treatment approach using prolonged exposure, which activates the fear structure in its entirety. This involves taking the individual through the traumatic event in great detail, allowing for exposure to all aspects of the trauma network (sensory, physiological, behavioural and cognitive). This technique is the basis and origins of what is now commonly known as enhanced reliving. While the trauma network is activated the therapist helps the individual to introduce and accommodate new incompatible information, which changes the meaning element of the network. For example, in the case of a serious assault during which the individual thought he or she might die, exposure to the feared stimuli (memories of the assault) no longer means near death but survival. What is not clear from this theory is the answer to a rather perplexing question: why does the memory of a traumatic event give rise to such an intense experience of fear and belief that, as in the case above, one is in imminent danger of death, when in most cases the threat has been removed? Ehlers and Clark (2000) have noted this idiosyncrasy of PTSD, when compared to other anxiety disorders. Central to the maintenance of other anxiety disorders are fears about things that might happen in the future (for instance fear of contamination in OCD or fear of illness in health anxiety), whereas in PTSD, sufferers report fear in relation to an event that has already happened and is clearly in the past. The cognitive model of persistent PTSD This model offers a synthesis of ideas to explain the persistence of PTSD. Persistent PTSD occurs only if individuals process the traumatic event in a way that produces a sense of serious current threat to the physical or psychological sense self. As a consequence of the way in which the event is processed, the memories are: (a) experienced as if it were happening again, (b) frozen in time, (c) not contextually updated, (d) have no temporal context or meaning context and (e) are involuntarily recalled. Thus, traumatic memories are experienced by individuals

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as if they were literally happening again. Ehlers and Clark (2000) propose that two key processes lead to this: (1) that individuals with persistent PTSD are characterised by idiosyncratic negative appraisals of the traumatic event that have the common effect of creating a sense of current threat. Predominant emotional responses in persistent PTSD are dependent on the specific appraisals. For instance, an appraisal concerning one’s own sense of responsibility for causing the event may lead to guilt, whereas appraisal concerning one’s violation of internal standards may lead to shame, (2) that implicit trauma memories are characteristically encoded via data-driven processing systems. They note the discrepancy between difficulties in intentional recall of the traumatic memory and easily triggered re-experiencing of the event, and propose that this can be accounted for by poor elaboration and inadequate integration of the trauma memory into its context in time, place, subsequent and previous memories and other autobiographical memories. This explains problematic intentional recall, no context in time and hence the perception of current threat, the absence of links to subsequent information and the easy triggering by physically similar cues. The model proposes that easy triggering of traumatic memories and/or emotional responses by associated stimuli can be explained because the stimulus–stimulus (S–S) and the stimulus–response (S–R) connections are particularly strong for traumatic material (Charney et al., 1983; Foa et al., 1989; Keane et al., 1985a). Thus triggering of such memories is more likely given the large number of associated stimuli present at the time of trauma (Ehlers and Clark, 2000). A number of possible treatment interventions arise from Ehlers and Clark’s model. First, the sense of current threat – i.e. the meaning assigned at the time of trauma – requires updating and re-insertion into the trauma memory (as also suggested by Foa and Kozak, 1986, who discuss the need to introduce new incompatible information to change the meaning of the fear network). Second, they emphasise the need to address pre-existing beliefs (which may give rise to different emotional states in the aftermath of trauma), as they may need to be adapted before a new meaning can be discovered (Lee et al., 2001). Third, the model highlights the importance of assessing negative post-trauma appraisals and behaviours (such as avoidance), which play a role in maintenance strategies. The question of why trauma memories may be processed in a way that leads to a sense of current threat is more fully addressed by the third theory presented below. Dual representation theory Brewin et al. (1996) and Brewin et al. (2010) offer a synthesis of fear networks (Foa and Kozak, 1986) and socio-cognitive theory by proposing that there are two parts to the fear structure in their model – an unconscious part that they refer to as sensory memories known as S-reps and a more conscious contextual representations now known as C-reps. They postulate that part of the fear network generated by the traumatic event is not readily accessible to the conscious mind and is stored in S-reps. This storage is hypothesised to involve the amygdala.

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S-reps include information about the stimulus, its meaning and the person’s state of consciousness at the time of trauma (Brewin et al., 1996, 2010). S-reps are encoded via non-conscious processes and cannot be deliberately accessed. S-reps are associated with the conditioned emotional responses that were experienced at the time of the trauma (e.g. intense fear, anger). Hence, flashback memories with a dissociative quality or emotional arousal would be indicative of an S-rep memory. In contrast, C-reps can be conceptualised as the person’s conscious experience of the trauma – as a series of autobiographical memories encoded via conscious processes. These memories can be deliberately and progressively edited; are readily available for conscious inspection and are central to the process of accommodating incongruous information received from the traumatic event, appraising meaning and understanding causality. The hippocampus is thought to be involved in these cognitive functions. Attribution and appraisal processes are associated in turn with secondary emotions such as guilt, remorse and shame. Brewin et al. (1996) postulate that aspects of the trauma memories are stored in C-reps because, under extreme threat, the hypothalamus secretes stress hormones, which inhibit processing of information via the cortex (where C-reps, appraisal, attributional and meta-cognitive process are ascribed to events). Thus, under extreme threat, the mind ‘does not have time to think’ but needs to process information about threat in order to maximise the chance of survival. This can be viewed as a primitive and rapid process but because these memories are not available for cognitive inspection, they remain de-contextualised and, most importantly, when accessed in the form of flashbacks have the same meaning that was ascribed at the time of the event. Automatic reactivation of S-reps may be prevented by incorporating new information about the meaning into the original fear network (Foa and Kozak, 1986) or by creating new sensory representational memories that block access to the original one (Brewin, 1988). Successful emotional processing of the traumatic experience occurs when sufficient contextual representation are formed and accommodated into the individual’s belief system, which, in turn, inhibits the reactivation of sensory memory. The theory suggests that the new C-rep needs to contain all of the information stored in the sensory memory plus new novel information about meaning. This serves to make the new memories distinctive and more likely to be recalled under triggering circumstances. In order to achieve this, the framework of Brewin et al. (1996) proposes some key intervention routes. First, the activation of S-reps can be achieved via prolonged exposure or reliving and second, new meaning is introduced to update S-reps (which is essentially the paradigm suggested by both Foa and Kozak (1986) and Ehlers and Clark (2000). This can be done via a number of cognitive steps: (a) restructure meaning outside of reliving, (b) rehearse the new appraisal and (c) relive the whole event and bring in ‘new’ (and rehearsed) information to modify the cognition/meaning – this can be achieved either verbally or through imagery work. For a more detailed description of this technique see Grey et al. (2002).

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Integrating theory into case conceptualisation Conceptualising fear-based PTSD The momentum of research into evidence-based practice in PTSD has focused on fear-based Type I trauma experiences, e.g. a train crash (the label of Type I trauma has been used to describe unanticipated single event(s) whereby the full details of what happened are often ‘etched’ in memory and relived with the full intensity of the peritraumatic emotions). Essentially, the experience ‘stays alive’ and is repeatedly ‘relived’ with clear recollection via intrusions, flashbacks and nightmares. During their ordeal they experience intense fear, helplessness and/or horror and subsequently, due to the novel and overwhelming nature of the event, and/or the intensity of their emotional response, they are unable to integrate the experience into their autobiographical memory and develop intrusions/flashbacks relating to their experience. There may be a number of factors that make the presentation more challenging to formulate and work with clinically. We will look at these later on in the chapter. So, by drawing on the theories discussed above one might hypothesise the development of an elaborate fear memory (see informational processing theory; Foa and Kozak, 1986) which contained a vast amount of information about: (a) the actual train crash, including sights, sounds and smells; (b) the individual’s behaviour during the event and emotional and physical responses and (c) the meaning of the event ascribed at the time of the incident (‘I am going to die’). Due to the nature of the intense emotional experience, the memories were encoded via the amygdala’s threat perception system as sensory-based experiences (S-reps). There may have been a number of peak moments of distress (also known as hotspots) associated with intense fear experienced during their ordeal. Typically flashbacks and intrusions contain memories that relate to peak moments of distress (Holmes et al., 2005). In this case these hotspots were represented in flashbacks that developed in the aftermath of the event. These flashbacks were not readily integrated in the ‘here and now’ autobiographical as they conveyed a sense of imminent death (current threat; Ehlers and Clark, 2000) and were associated with intensely overwhelming fear. Due to the size and non-specificity of the stimuli present at the time of the trauma and original encoding of the memory, a number of internal (physiological) or external (sound, smell, colour, sight) stimuli readily trigger the flashbacks, which are experienced by the individual as if the event were happening again. The intensely aversive experience of these flashbacks motivates them to engage in a number of elaborate avoidance behaviours (such as avoiding trains, watching TV, or engaging in conversations about their experiences) to reduce the likelihood of flashbacks being triggered. Treatment implications In fear-based PTSD, treatment involves activation of the fear network in its entirety via a reliving paradigm, whereby as much detail as possible about the original event

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is retrieved and, at the peak moments of distress, where salient meaning can be identified (Grey et al., 2002), the therapist encourages the client to reframe the meaning using Socratic dialogue. For instance, in the case above: first, the therapist and client identify all flashbacks and intrusions relating to the event and their associated meaning (‘I am not going to get out alive,’ ‘I will be burnt to death’); second, they discuss the fact that, although at the time this was the meaning, in the aftermath of the trauma the client knows that they survived and were not burnt to death; third, the therapist uses the reliving paradigm to activate the fear network and flashbacks under controlled circumstances and fourth, at previously identified peak moments of distress, the therapist asks the client, ‘and what do you know now?’ which allows the client to say, ‘I survive this, I don’t burn to death.’ This technique, known as cognitive restructuring within reliving, facilitates the formation of a verbally accessible memory. This encodes the experience in the here and now, rather than as it was experienced at the time of the event (Ehlers and Clark, 2000). This type of presentation of fear-based PTSD is central to most theories of PTSD, which attempt to explain why the individual, in the aftermath of the trauma, remains in a heightened state of arousal and fear and continues to re-experience the event with the same intensity of emotions. A good working understanding of fear-based PTSD and its theoretical underpinning provides the first principles to build upon when dealing with increasingly complex presentations of PTSD. What makes PTSD more challenging to work with? Typically there is a fear-based trauma reaction in most complex case presentations of PTSD. However, a number of factors, either relating to the event itself or to the individual who experiences the event, affect the complexity of the presenting PTSD. Unpacking the meaning of the experience can provide the route to understanding the psychological reaction. The event characteristics Often, individuals have experienced overwhelming, horrific, violating and/or shocking events characterised by profound human suffering and violation of human rights. Such events may include experiences of physical, sexual and psychological torture, rape, deliberate mutilation and mass catastrophes to name but a few. Therapists are often overwhelmed by the extent to which the client has suffered and may experience a sense of ‘therapist paralysis’ and incomprehension at how they will help the client deal with/overcome things that they themselves find so shocking and sometimes, unbelievable. Clients with complex PTSD often present with multiple traumatic events and/or prolonged/repeated exposure to traumatic events over a period of months or years. This may include combat experience, kidnapping, imprisonment, domestic violence and/or multiple events such as two or three road traffic accidents as well as histories of childhood sexual abuse. Suffering post-trauma consequences such as

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permanent physical scars, pain, physical disability and losses such as job, status, mental well-being, loved ones and relationships are common as well. In cases where there are multiple traumatic events and/or prolonged exposure, the therapist can draw on the same principles that apply to single event trauma. Namely, it is important to identify all peak moments of distress and the content of flashbacks. In a trauma that lasted several months, there may have been key experiences that are represented in flashbacks, and there may be themes to emotional responses and meaning that can be identified and worked with in cognitive therapy. For instance, a client who has been repeatedly subjected to incidents of domestic violence and rape may have six or seven flashbacks with differing content, but which convey the same meaning (e.g. ‘I am worthless’) and trigger the same emotional response (e.g. shame). This same principle can be applied to multiple traumatic events, including childhood trauma. It is common in complex PTSD to find the personal meaning assigned to adult Type I trauma intrinsically linked to key childhood experiences, such as abuse. There may or may not be intrusions and flashbacks to these childhood events, but there is invariably a link or congruence of meaning between childhood and adult experiences in complex PTSD. For instance, a client who nearly died in childbirth assigned the meaning, ‘I don’t count, my life if not worth saving.’ One can only understand her meaning for this event if one examines pre-trauma factors. Her childhood was characterised by emotional neglect. She grew up believing that no-one cared for her. Consequently, her interpretation of her near-death experience was not fear but shame. Complex emotional responses Most people experience a range of emotions during and/or in the aftermath of trauma (Holmes et al., 2005). Not all clients with PTSD report feeling fearful. Research has shown that 45% of hotspot emotions (peak moments of distress) experienced during the trauma are not fear, helplessness or horror but include other cognitive themes such as revenge, self-criticism, feeling let down by others and confusion (Holmes et al., 2005). Shame and anger also have a major role in the disorder (Andrews et al., 2000). Yet shame and, to a lesser extent, anger are not adequately dealt with in theoretical conceptualisations of PTSD, empirical research and resultant treatment packages. This is in spite of the fact that shame and anger would appear to pose a barrier to effective exposure programs and to be associated with chronic presentations of PTSD (Brewin et al., 1996; Ehlers and Steil, 1995; Foa et al., 1995; Riggs et al., 1992). Given this, case conceptualisation in PTSD needs to identify all of the emotional responses associated with the event. Exploration of the cognitions/appraisals assigned to these (emotional) experiences often allows access to the core meaning. It is helpful to discover the source of the emotional response. Does it come from pre-existing core beliefs and is it associated with a pervasive/global emotional experience? Does it come from an appraisal made at the time of the event

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(peritraumatic) and is it associated with a circumscribed emotional state? Or is the emotional response associated with an appraisal made about the aftermath of the experience (posttraumatic appraisals)? The importance of this lies in understanding how to work with meaning, as exposure may not be helpful with pervasive shame (Lee, 2005) where the development of compassionate self-soothing may be more helpful in the first instance. Similarly, different techniques may be helpful to work with pervasive anger or circumscribed guilt based on hindsight (Chemtob et al., 1997; Kubany and Manke, 1995). Pervasive, pre-existing emotional states associated with negative core beliefs need to be addressed first in therapy before an update of meaning can be successfully achieved (Lee et al., 2001). Working with loss of meaning An individual’s perception of a traumatic event(s) may confirm or indeed activate dormant core beliefs. For instance, a woman’s experience of rape may confirm a salient, premorbid, cognitive theme that she is disgusting and not worth protecting (Lee et al., 2001). The experience may also challenge/shatter core beliefs. For instance, the belief that we live in a just and fair world where good things happen to good people and bad things happen to bad people (Lerner and Miller, 1978; Janoff-Bulman, 1992) is frequently challenged in the aftermath of trauma. Janoff-Bulman and Frantz (1997) noted that trauma survivors readily assume the world has meaning and then see the world as it really is, stripped of the meaning and order. Most people who experience ongoing trauma describe difficulties in ascribing a meaning to their experience either on an existential level and/or on a personal level. In the aftermath of trauma, there is typically an overwhelming need to ponder meaning-related concerns about comprehensibility (‘does this event make sense or fit my understanding of the world?’) and personal significance (‘does this event challenge my own sense of value and worth?’). We often see the client struggle with re-assigning meaning to their now meaningless world. Indeed, Janoff-Bulman and Frantz (1997) suggest that success in overcoming this existential crisis (meaningless world) is only achieved when individuals are able to shift their meaning concerns to a focus of significance and value in their own life. Thus, the task of therapy is to help the client to create a meaningful life when faced with living in a meaningless world. This task can be more difficult to achieve in complex PTSD, as the meaning of the event is rarely solely about threat to physical self (fear) but relates to psychological threat (‘why did this happen to me?’ ‘what does this event say about me?’). Hence, being able to identify the exact nature of the threat to psychological integrity is a crucial process in conceptualising the experience of trauma in these cases. Co-morbidity Co-morbidity may also present quite a challenge to the clinician, as there are high levels of co-morbidity between PTSD and other psychiatric disorders such

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as depression (Blanchard et al., 1998), substance abuse, panic and somatisation (Deering et al., 1996). Indeed, somewhere in the region of 78% of traumatised refugees present with both depression and PTSD. Excessive use of alcohol and/or recreational drugs, as a means of avoiding painful recollections of traumatic experiences, are also common features of complex PTSD presentations. Other behaviours such as self-harm, binge eating and dissociation may form part of an individual’s repertoire of avoidant behaviours. In case conceptualisation, it is important to identify the nature, maintenance and function of the co-morbid disorder and to identify core themes across the disorders. Sometimes other problems such as substance misuse or self-harm can be conceptualised as avoidance strategies and become part of important maintenance cycles. For instance, it is not uncommon for clients to use alcohol to ‘numb’ their emotional responses and ‘switch off’ their minds from intrusive images. In cases where shame is a problem, self-harm and dissociation are often included in the avoidance strategies and maintenance cycles. For instance, a client may have a tendency to dissociate when faced with overwhelming affect of shame, triggered by a flashback of rape. The client may have learned this strategy in childhood and/or may trigger dissociation by engaging in self-harm. It is important to conceptualise each of these strategies and identify unhelpful or negative beliefs that perpetuate the vicious cycles of maintenance. In a clinical setting, these behaviours may need to be targeted first using cognitive methods described elsewhere (Kennerley, 1996) before work on trauma memories can begin. Conceptualising complex PTSD Type II trauma refers to traumatic experiences that are long-standing and repeated ordeals. It is often associated with experiences such as childhood sexual abuse or physical and emotional abuse (Terr, 1991). As we mentioned earlier, Type II trauma is more likely to give rise to a pattern of symptoms commonly referred to as complex PTSD. Whereas there are clear treatment guidelines for treating PTSD, this is not the cases for complex PTSD. Successful treatment often requires clinical innovation informed by evidence-based practice. That said, there is an emerging evidence base for phased-based approaches (see Cloitre et al., 2011, for a comprehensive review of current research). Although the diagnosis is not agreed, what does appear prima facie to capture the clinical picture of complex PTSD are the symptoms of PTSD (intrusions relating to multiple events, high levels of avoidance, high levels of hyperarousal) plus clear ruptures in caregiving attachment relationships, giving rise to difficulties in affect regulation (frequently observed self-harm), other self-regulating capacities, disturbances in relational capacities (as seen in difficulties establishing and maintaining supporting, loving, trusting and meaningful relationships with others, alterations in attention and consciousness (including dissociation), adversely affected belief systems (including profound feelings of self-loathing and unworthiness) and somatic distress or disorganisation.

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What is clear to those clinicians working with complex PTSD is that those who suffer from it struggle to maintain a cohesive and coherent sense of self. Their often abusive experiences in childhood and multiple ruptures in caregiving attachment relationships leave them struggling to manage their inner and external worlds. McCann and Pearlman (1990) have written extensively about the impact of extreme trauma on attachment. In their writings they suggest that the human capabilities that emerge from experience of healthy attachment are as follows: 1 2 3 4

To maintain an inner sense of positive connection with others To maintain a sense of self as viable, benign and positive To experience, integrate and tolerate feelings Have experiences of internalised loving others. In contrast, what we see in complex PTSD is:

1 Difficulty with the connection with internalised others and difficulty with self-soothing; expression of profound isolation; experience of self as oddly different; hiding self from others; relationship problems 2 Difficulties with developing images of internal loving others 3 Significant underdevelopment of self-worth, as seen in self-denigrating statements, lack of self-care, substance abuse, isolation 4 Underdevelopment of affect tolerance as evidenced in dissociation, self-harm, aggressive behaviours, substance abuse, affective lability, numbing. The philosophy of phasing treatments for PTSD gains much credence from the impressive research into the ‘window of tolerance’ (WoT; Ogden, Minton and Pain, 2006). WoT is thought to be crafted by early attachment relationships. Window of tolerance is the ‘outcome’ of the sculpting of auto-regulation through childhood experiences. Auto regulation is the ability to calm down when arousal rises to upper limits (sympathetic activation) of window of tolerance or increase activity when arousal drops (parasympathetic activation). Affect intolerance is the response to under- or over-activity of the stress response system and we often see behaviours such as addictive behaviour, self-harm, discharges of emotion and dissociation associated with an inability to tolerate intense emotion, whereas low activation is associated with numbing, inertia and disengagement. WoT narrows as a consequence of repeated trauma and it influences emotion regulation abilities, relational capacities, capacity for attention and consciousness, which negatively affect influence belief systems and increase experiences of somatic distress or disorganisation. A phased-based treatment approach to complex PTSD There is now quite a body of evidence to suggest that phased-based treatment approaches are effective for Complex PTSD (Cloitre et al., 2011), albeit the precise

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Figure 7.1  Phased-based approach for treating complex PTSD.

ingredients of the phases are still up for debate. Most evidence-based practice suggests that phase 1 develops stabilisation, phase 2 develops psychological life skills such as skills development around affect regulation and interpersonal functioning and phase 3 attends to trauma memory work by using evidence-based interventions such as prolonged exposure, trauma focused CBT or EMDR (NICE, 2005). Figure 7.1 shows the phased-based approach and the development of window of tolerance used at the Berkshire Traumatic Stress Service, whereby stabilisation is achieved through the development of compassionate resilience using compassion focused therapy (Gilbert, 2010).

Case examples Two cases are presented, each with a different focus on complexity of the PTSD presentation. In order to aid discussion of these cases, the clinical material will be presented with reference to the diagrammatic formulation adapted from Ehlers and Clark’s (2000) cognitive model of PTSD and shown in Figure 7.2. The original formulation diagram has been modified for the purpose of this chapter. Case 1 This case highlights a number of complex issues. It is characterised by the experience of an overwhelming and prolonged index event, complex peritraumatic emotional reactions, negative core beliefs, co-morbidity and chronicity. Index event Amy’s presenting problems included PTSD, depression, binge eating, panic attacks and chronic fatigue. At the age of 18, Amy was brutally raped by three men. They broke into her home and systematically attacked her. The details of her

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1. Early experiences (Pre)

2. Nature of trauma memory

3. Negative beliefs or thoughts about self, world and others (Post)

4. Feeling of current and constant threat (flashbacks etc.) (Peri)

5. Coping behavior Physical and mental avoidance of trauma memory

Resilience

BASED ON COGNITIVE MODEL OF PTSD Ehlers & Clark, 2000 with thanks to BTSS PGCert

Figure 7.2  Case formulation of PTSD.

attack were horrific and shocking. Her ordeal lasted for eight hours and during that time she was repeatedly physically and sexually assaulted. She did not tell her family about the attack. In the aftermath of the attack, she tried to suppress its emotional impact by not talking about it and withdrawing from friends and family. She put on six stones in weight and developed a habit of binge eating. About 10 years after the event she began to develop chronic fatigue and eventually had to give up work because her condition had become so debilitating. Since the attack, Amy had suffered from flashbacks and fragmented images of the assault, which made her feel intense shame, humiliation and fear. She was highly avoidant of anything that brought back reminders of the attack and rarely went out as she feared being attacked again. Amy constantly ruminated about the attack and was plagued by thoughts such as: ‘how could I let this happen to me, I feel so degraded, why didn’t I fight them off? I feel so stupid, what is wrong with me that they would want to do this to me? It was my fault, I am no good, the way I looked caused me to be attacked.’ She was also constantly assailed by a range of emotions, such as intense shame, rage, humiliation and fear, when she was reminded about the attack. Amy sought treatment 22 years after the initial assault. She had tried to get help in the past, but had never discussed the details of the rape with her previous therapists.

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Salient premorbid features Until the attack, Amy had been functioning well in life. She was working hard at her job in the fashion industry and had plans to study fashion design at college. She described her childhood as idyllic. She was brought up in a small town in north Wales, where her family had settled in her early childhood. Although she enjoyed school, she struggled with her schoolwork and in her late teens she was diagnosed with dyslexia. She reported suffering mild verbal bullying and some racial abuse, as she was one of two black children at her school. However, at the time Amy felt unaffected by these experiences, as her parents had brought her up to believe that she was different and special. She was also able to gain status at school by excelling at athletics and being striking in appearance. She had always been proud of her looks and the attention she received. Further investigation of her premorbid beliefs revealed that she was brought up to have a strong sense of justice and believed, ‘you get what you deserve in life.’ She had a sound belief in herself but, with hindsight, she wondered whether she had been too cocky and arrogant. When discussing her prior beliefs about rape, Amy said that she had been brought up to believe that men wanted to marry virgins, ‘slutty’ women got raped and raped women were ‘damaged goods’. Case conceptualisation Central to understanding Amy’s reaction to her assault was unpacking the meaning of the event and how this placed her psychological integrity as well as her physical integrity under threat. In order to access meaning, and as part of the assessment process, we identified the content of all of Amy’s flashbacks and intrusive images, the associated emotional responses and the core cognition ascribed to the image (peritraumatic appraisals). Although Amy’s ordeal lasted some eight hours, there were five key images that repeatedly caused her distress: 1

Seeing herself tied to the bed and being beaten: this flashback was associated with intense fear and the thought, ‘I am going to die, why am I letting this happen to me?’ 2 Being urinated on: this was associated with feelings of shame and humiliation and the thought, ‘this is disgusting, I must be disgusting and worthless.’ 3 Being raped: this was associated with feelings of shame and humiliation and the thought, ‘they hate me, I am to blame for this.’ 4 Hiding under the bed after the attackers had left: this was associated with a feeling of intense shame and the thought, ‘I am disgusting and worthless.’ 5 Seeing herself losing consciousness: this was associated with intense fear and the thought, ‘I am going to die here.’ After identifying Amy’s prior beliefs it became clear that her experience of rape had both confirmed and challenged pre-existing beliefs about herself (Lee

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et al., 2001). Amy’s dormant beliefs about unworthiness and unacceptability had been activated and became the predominant mode of her thinking pattern. Interestingly, Amy’s prior beliefs about being special and different served to maintain her sense of shame, as one of the meanings she assigned to the event was, ‘I had my come-uppance.’ Amy believed she was attacked because she was arrogant and because of the way she looked – thus it was her fault and this made her feel both shame and humiliation. In the aftermath of the event, her post-trauma appraisals of herself were congruent with her pre-trauma beliefs about women who were raped – these men must have thought of her as a slut and deserving of her punishment. Furthermore, her dormant negative beliefs about herself as unworthy and unacceptable were incongruent with her dominant mode of thinking prior to the attack, yet because of her experience and her search to understand it based on her prior beliefs, she had concluded that she must be unworthy and unacceptable. In essence, the meaning of the trauma for Amy was that she deserved to be raped because of who she was – not special and different but unworthy and slutty. As well as maintaining her PTSD, the activation of these fundamental core beliefs of unworthiness/unacceptability was also at the root of her depression. Thus, in this case, a working hypothesis was that her PTSD and depression were maintained by core beliefs about unworthiness and the experience of intense shame. A functional analysis revealed that her binge eating was part of her avoidance of affect. However, this behaviour also made her feel ashamed and unworthy and was caught up in a vicious maintenance cycle. Her withdrawal from family, friends and work was maintained by her depression and her sense of shame but also served as a safety behaviour to avoid talking about reminders of the attack. Amy’s situationally accessible memories were encoded at the time of trauma with overwhelming emotions of shame, humiliation and fear. Her post-trauma appraisals (verbally accessible memories) were congruent with her peritraumatic appraisals, as, in the aftermath of the attack, dormant beliefs about herself as unworthy were activated and influenced her predominant thinking pattern about herself. Amy’s case conceptualisation is shown in Figure 7.3. Treatment plan Amy’s case highlights an important clinical issue relating to the question of when it is appropriate to do reliving. From the case conceptualisation, this technique would be indicated because Amy presented with fragmented, situationally accessible memories (experienced as both flashbacks and intrusions) associated with overwhelming affect such as shame, fear and humiliation. Yet, Amy’s case is characterised by activation of core beliefs (pre-trauma factors). As these are now the predominant mode of thinking and linked to her depression, Amy would not be able to access a different or more balanced meaning for her hotspots, other than meaning that is congruent with her negative self-beliefs. Consequently, attempting the reliving of the trauma under these circumstances

158  Deborah  Lee 1. Early experiences (Pre) Beliefs about being unworthy, 2nd class citizen, special aloof

2. Fragmented flashbacks

3. I was cocky arrogant, I deserved this, I was attacked because of who I am (Post)

4. Intense fear, shame, humiliation loss, current and constant threat (flashbacks etc.) (Peri)

5. Avoids going out, talking about it, overeats, avoids intimate relationships and friendships

Loving, supportive family

BASED ON COGNITIVE MODEL OF PTSD Ehlers & Clark, 2000 with thanks toBTSS PGCert

Figure 7.3  Amy’s case formulation of PTSD.

(when pervasive and global beliefs and affect are activated) could serve to perpetuate the disorder. Effectively, this could be considered re-traumatising if the individual is unable to assign another meaning to the event. In Amy’s case, therapy began with 18 months of schema-focused cognitive therapy using methods and techniques described by Padesky (1994). Once Amy was consistently rating her new beliefs at 60–70%, we returned to her experience of rape. Amy identified five key hotspots, which she experienced in flashbacks. For each one, Amy came up with a new meaning that was congruent with her new beliefs. Having substantially rehearsed these new thoughts, Amy agreed to relive the rape and, when cued by the therapist, inserted her new beliefs. For instance, at the point when she saw herself being raped, which had the previous meaning of ‘I’m to blame for this, they hate me,’ she inserted, ‘this attack is about their badness and not about who I am.’ The rest of Amy’s hotspots and the new updates are outlined in Figure 7.4. Amy was surprised that she was not overwhelmed by shame when she relived the rape, and that she had been able to assign a new evaluation of meaning in the context of her new adaptive core beliefs. During the reliving, which took place over five sessions, there was an increase in Amy’s compulsive eating behaviour; however, this returned to its usual levels at the end of the process. After 51 sessions, over a period of 20 months, Amy no longer suffered from flashbacks and intrusive imagery. Her mood was much improved. She did, however, still have

Case conceptualisation in complex PTSD  159 Situation

Thought

Emotion

Rate

Update

Being beaten and tied up

Why am I letting this happen to me I am dying

Fear

10/10

Being urinated on

I am so disgusting and worthless

Humiliation, shame

10/10

Being raped

They hate me – this is my fault

Shame

10/10

Hiding under bed Losing conscious

I deserve to die I am going to die here

Guilt, fear, shame Fear, hopelessness

10/10 10/10

I survive this; I can’t do anything to stop them I don’t deserve this; I am a decent person This is about them and not me – their cruel minds I deserve a life I survive this and recover

Figure 7.4  Amy’s hotspot update chart.

problems with compulsive eating and she was referred to a specialist eating disorders unit. Case 2 The case presented below captures a clinical picture of complex PTSD. Index trauma Lucy was a 37-year-old firefighter. As a child she suffered repeated childhood sexual abuse from a friend’s father. This went on for a number of years during her mid-childhood. She also endured emotional neglect in her attachment relationships with her parents. During her career as a firefighter she witnessed many traumatic events, but she developed PTSD in response to a major incident during which a colleague died. Lucy always thought she was to blame for this death. Salient premorbid features There are several important childhood experiences that help us understand Lucy’s psychological symptoms. Her mother was very emotional, cold and overtly critical of her. She cannot remember ever being cuddled or comforted, or made to feel special at home. She felt a disappointment to her parents, as they never praised her. She said ‘nothing was ever good enough.’ Her father was often absent as he travelled a lot and his parenting manner was authoritarian and distant. Lucy struggled at school. She was bullied and struggled to make friends. A key emotional experience Lucy expressed in therapy was, ‘no one cared, no one ever came to rescue me when I needed them, I felt so alone.’

160  Deborah  Lee

Case conceptualisation When Lucy came to the clinic for help she had been diagnosed with PTSD. She also had depression and had suffered a number of disabling episodes over the years. She was very angry and critical of others, paranoid, wary of others, hypervigilant to other people’s reactions and very sceptical of other people and their motives. She had a tendency to overwork. She had at times significantly misused alcohol to cope with her symptoms. In relationships, she struggled to be honest and relaxed and did not have close friends. She suffered from medically unexplained symptoms of pain. Below are the key areas of psychological difficulties for Lucy. We hypothesised that these difficulties arose from attachment ruptures and experiences of Type II trauma, as well as all the symptoms of PTSD both to her childhood abuse and to the incident as a firefighter: 1 2

3

4

Affect regulation. She did not know how to control her emotions and often had anger outbursts. Integrated sense of self. She had no real idea of who she was. She spent most of her time worrying about what others thought of her and trying to work out what she should do to fit in. She described herself as a chameleon who could change to suit the environment and needs of others. Interpersonal functioning. Lucy really struggled with relationships. She did not know how to trust people and did not feel she could be honest with people about who she was. She was very critical of others and very intolerant of less-than-perfect behaviour. Memory disorganisation. Her memories were fragmented and blurred. A lot of her childhood trauma experiences had merged into each other. Her 15-year career as a firefighter was associated with many fragmented trauma memories alongside clear memories relating to the incident when a colleague died. Lucy’s case conceptualisation is presented in Figure 7.5.

Treatment plan In this case, compassion focused therapy was used as the framework for skills development in a phased-based treatment approach and then trauma focused CBT for completion of trauma memory work. We used compassion focused therapy because the nature of Lucy’s difficulties (affect regulation, shame and interpersonal difficulties) are suitable for compassion focused work. For more details of compassion focused therapy, please refer to Paul Gilbert’s chapter in this book. In brief, the explicit goal is to develop, access and stimulate positive affect associated with self-soothing in the mind and body of the patient in order to promote an inner sense of psychological safeness (Gilbert and Irons, 2005). Gilbert (1989) suggests that the capacity to self-soothe and feel compassion for the self comes from the caregiving mentality and is learned in the context of the caregiving

Case conceptualisation in complex PTSD  161

Figure 7.5 Case formulation in Complex PTSD using an Ehlers & Clarke model of p­ ersistent PTSD.

relationship. Consequently, how we self-soothe as adults will be directly influenced by our experiences of being cared for as a child (Bowlby, 1969). The ability to self-soothe as an adult is an essential skill needed to promote psychological well-being, as it allows us to deal with external threats from our social world (what other people think of us, how they treat us) and also internal threat (our own self-criticism). Being compassionate to the self is a state of mind, just as feeling threatened is a state of mind, and states of mind are related to physiological responses that govern behaviours, thought processes and attention that are compatible with the needs and goals of the individual at that time. Working from an emotional perspective in the first instance to help people develop positive affect, self-soothing capabilities, warmth and kindness for themselves, can have a profound impact on traditional trauma-focused cognitive behavioural therapy (CBT). As part of Lucy’s phased-based treatment approach, we helped her increase her window of tolerance for emotional distress and develop her compassionate resilience, over a period of seven months. At the end of this time, Lucy was quite skilled in using her compassionate mind to problem-solve interpersonal stresses and she was able to use compassionate imagery exercises to regulate her affect, which in turn improved her affect regulation, interpersonal functioning, and problem solving (Lee, 2009, 2012). So, for example, Lucy’s shame-based trauma memories were highly distressing and disturbing for her.

162  Deborah  Lee

High levels of self-criticism appeared to maintain the sense of current psychological threat. The personal meaning conveyed in the fragmented images and flashbacks was often painful, condemning and shaming. Compassionate resilience enhanced her feelings of self-soothing and safeness in these memories and reduced self-critical maintenance cycles by developing compassionate self-talk. Thus, compassion focused therapy helps the development of the capacity to self soothe in those who feel deeply shamed about who they are and what they have been through. Once Lucy was able to develop and use self-soothing dialogues when she was self-critical, we were able to revisit the memories from childhood and adulthood. This was phase 3 trauma memory work, which was very similar to the work outlined in the case 1. Specifically, we aimed to re-evaluate the meaning of Lucy’s trauma experiences using Lucy’s compassionate part of her mind. Lucy was able to update her thoughts of ‘you are dirty and disgusting’ with a compassionate reframe – ‘this is so sad that you have suffered like this. You don’t deserve this, this is not your fault.’ She was able to tolerate the sadness she felt about being so alone in her childhood and feeling so uncared for. She was able to realise that none of this was her fault. These new updates became meaningful to Lucy because they triggered the congruent emotional response of soothing, compassion and safeness. We then revisited her flashback by using the technique of enhanced reliving. Lucy worked on updating the meaning of her experiences. We did this by asking Lucy ‘what do you know now’ while keeping the image of abuse in mind, to which Lucy responded ‘this is so sad that you have suffered like this. You don’t deserve this, this is not your fault.’ Lucy focused on the feelings of warmth, compassion and safeness, whilst still reliving the flashback. In spite of Lucy suffering from PTSD for many years, we revisited her trauma memory from the fire service only once. Her compassionate mind was able to hold a different perspective on the event and Lucy was able to get in touch with the great sadness of the event. She did not have further flashbacks as she held the event differently in her mind. Similarly, we revisited her experiences of childhood abuse in few sessions, each time allowing Lucy to experience the memories with feelings of care and comfort for herself, rather than shame, disgust and aloneness. Lucy reported that these memories had become much less troublesome for her. At the end of therapy, Lucy no longer had PTSD and she was no longer depressed. Her relationship with her partner and friends had improved significantly. She reported feeling ‘good and happy’ for the first time in her life, which was a bit of a shock for her and she was mistrusting of the progress she made. Nevertheless, she was still doing very well at a six-month follow up.

Conclusion This chapter has discussed case conceptualisation in PTSD and complex PTSD. A number of factors have been highlighted that may make PTSD complex and challenging to work with. Complex PTSD as defined in this chapter requires more

Case conceptualisation in complex PTSD  163

time and development of essential skills before the undertaking of trauma memory work. Developing tolerance of emotional arousal is essential and clinicians should take into account the window of tolerance. This needs to be increased before trauma memory work can proceed effectively. Phased-based treatments for complex PTSD have to reflect areas of deficits in psychological life skills such as affect dysregulation, dissociation coping strategies, traumatic memories, interpersonal functioning, sense of self and re-integration.

References American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (3rd ed.). Washington, DC: Author. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (5th ed.). Washington, DC: Author. Andrews, B. et al. (2000). Predicting PTSD in victims of violent crime: The role of shame, anger and sexual abuse. Journal of Abnormal Psychology 109: 40–48. Blanchard, E. B. et al. (1998). Post-traumatic stress disorder and comorbid major depression: Is the correlation an illusion? Journal of Anxiety Disorders 12: 21–37. Bowlby, J. (1969). Attachment and Loss: Vol. 1. Attachment. London: Hogarth Press. Brewin, C. R. (1988). Cognitive Foundations of Clinical Psychology. Hove: Lawrence Erlbaum. Brewin, C. R. et al. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review 103: 670–86. Brewin, C. R. et al. (2010). Intrusive images in psychological disorders: Characteristics, neural mechanisms, and treatment implications. Psychological Review 117: 210–32. Charney, D. et al. (1993). Psychobiological mechanisms of posttraumatic stress disorder. Archives of General Psychiatry 50: 294–305. Chemtob, C. M. et al. (1988). A cognitive action theory of post-traumatic stress disorder. Journal of Anxiety Disorders 2: 253–75. Chemtob, C. M. et al. (1997). Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 65: 184–89. Christopher, M. (2004). A broader view of trauma: A biopsychological-evolutionary view of the traumatic stress response in the emergence of pathology and/or growth. Clinical Psychology Review 24: 75–98. Cloitre, M. et al. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress 24: 615–27. Dalgleish, T. and Power, M. (2004). Emotion-specific and emotion non-specific components of PTSD: Implications for taxonomy of related psychopathology. Behaviour, Research and Therapy 42: 1069–88. Deering, C. G. et al. (1996). Unique patterns of comorbidity in posttraumatic stress disorder from different sources of trauma. Comprehensive Psychiatry 5: 336–46. Ehlers, A. and Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy 38: 319–45. Ehlers, A. and Steil, R. (1995). Maintenance of intrusive memories in posttraumatic stress disorder: A cognitive approach. Behavioural and Cognitive Psychotherapy 23: 217–49. Foa, E. B. et al. (1989). Behavioral/cognitive conceptualisation of post-traumatic stress disorder. Behavior Therapy 20: 155–76.

164  Deborah  Lee Foa, E. B. et al. (1995). The impact of fear activation and anger on the efficacy of treatment for posttraumatic stress disorder. Behaviour Therapy 26: 487–99. Foa, E. B. and Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin 99: 20–35. Foa, E. B. and Rothbaum, B. O. (1998). Treating the Trauma of Rape: Cognitive Behavioural Therapy for PTSD. New York: Guilford Press. Gilbert, P. (1989). Human Nature and Suffering. Hove: Lawrence Erlbaum. Gilbert, P. (2010). “An introduction to compassion focused therapy in cognitive behavior therapy”. International Journal of Cognitive Therapy 3(2): 97–112. Gilbert, P. and Irons, C. (2005). Focused therapies and compassionate mind training for shame and self-attacking. In P. Gilbert (ed.) Compassion and Psychotherapy: Theory, Research and Practice. London: Routledge. Grey, N. et al. (2002). Cognitive restructuring within reliving: A treatment for peri-traumatic emotional hotspots in PTSD. Behavioural and Cognitive Psychotherapy 30: 37–56. Holmes, E. A. et al. (2005). Intrusive images and ‘hotspots’ of trauma memories in posttraumatic stress disorder: An exploratory investigation of emotions and cognitive themes. Journal of Behaviour Therapy and Experimental Psychiatry 36: 3–17. Holmes, E. and Brewin, C. R. (2003). Psychological theories of PTSD. Clinical Psychology Review 23: 23–56. Horowitz, M. J. (1986). Stress Response Syndromes. Northvale, NJ: Jason Aronson. Janoff-Bulman, R. (1992). Shattered Assumptions: Towards a New Psychology of Trauma. New York: Free Press. Janoff-Bulman, R. and Frantz, C. M. (1997). The impact of trauma on meaning: From meaningless world to meaningful life. In M. Power and C. R. Brewin (eds) The Transformation of Meaning in Psychological Therapies: Integrating Theory and Practice. Chichester: John Wiley and Sons. Keane, T. M. et al. (1985a). A behavioral approach to assessing and treating Vietnam veterans. In C. R. Figley (ed.) Trauma and Its Wake: The Study and Treatment of Post-Traumatic Stress Disorder. New York: Brunner/Mazel. Keane, T. M. et al. (1985b). A behavioural formulation of post-traumatic stress disorder in Vietnam veterans. Behaviour Therapist 8: 9–12. Kennerley, H. (1996). Cognitive therapy of dissociative symptoms associated with trauma. British Journal of Clinical Psychology 35: 325–40. Kubany, E. S. and Manke, F. P. (1995). Cognitive therapy for trauma-related guilt: Conceptual bases and treatment outlines. Cognitive and Behavioral Practice 2: 27–61. Lang, P. J. (1977). Imagery in therapy: An information processing analysis of fear. Behavior Therapy 8: 862–86. Lang, P. J. (1979). A bio-informational theory on emotional imagery. Psychophysiology 16, 495–512. Lee, D. A. (2005). The perfect nurturer: A model to develop a compassionate mind within the context of cognitive therapy. In P. Gilbert (ed.) Compassion: Conceptualisations, Research and Use in Psychotherapy. London: Brunner-Routledge. Lee, D. (2009). Compassion-focused cognitive therapy for shame-based trauma memories and flashbacks in post-traumatic stress disorder. In N. Grey (ed.) A Casebook of Cognitive Therapy for Traumatic Stress Reactions. London: Routledge. Lee, D. (2012). The Compassionate Mind Approach to Recovering from Trauma Using Compassion Focused Therapy. London: Constable Robinson.

Case conceptualisation in complex PTSD  165 Lee, D. A. et al. (2001). The role of shame and guilt in reactions to traumatic events: A clinical formulation of shame-based and guilt-based PTSD. British Journal of Medical Psychology 74: 451–66. Lee, D. A. and Young, K. (2001). Post-traumatic stress disorder: Diagnostic issues and epidemiology in adult survivors of traumatic events. International Review of Psychiatry 13: 150–58. Lerner, M. J. and Miller, D. T. (1978). Just world research and attribution process: Looking back and ahead. Psychological Bulletin 85: 1030–51. McCann, L. and Pearlman, L. A. (1990). Psychological Trauma and the Adult Survivor: Theory, Therapy, and Transformation. London: Brunner-Routledge. Mowrer, O. H. (1960). Learning Theory and Behaviour. New York: Wiley. NICE Guidelines (2005). Post Traumatic Stress Disorder (PTSD), National Institute for Health and Care Excellence, HYPERLINK “http://www.nice.org.uk”www.nice.org.uk Ogden, P. et al. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: W. W Norton. Padesky, C. A. (1994). Schema change processes in cognitive therapy. Clinical Psychology and Psychotherapy 1: 267–78. Rachman, S. (1980). Emotional processing. Behaviour, Research and Therapy 18: 51–60. Resick, P. A. and Calhoun, K. S. (2001). Posttraumatic stress disorder. In D. H. Barlow (ed.) Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual (3rd ed., pp. 60–113). New York, NY: Guilford Press. Resick, P. A. and Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology 60: 748–56. Resick, P. A. and Schnicke, M. K. (1993). Cognitive Processing for Rape Victims. Newbury Park, CA: Sage. Riggs, D. S. et al. (1992). Anger and post-traumatic stress disorder in female crime victims. Journal of Traumatic Stress 5: 613–25. Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry 148: 10–20. Van der Kolk, B. A. et al. (eds) (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press. Yehuda, R. (2001). Biology of posttraumatic stress disorder. Journal of Clinical Psychiatry 62: 41–46.

Chapter 8

A cognitive behavioural case formulation approach to the treatment of psychosis Sandra Bucci and Nicholas Tarrier

Introduction The term ‘psychosis’ describes a broad range of experiences, including hallucinations, delusions and confused thinking. Schizophrenia, the most serious form of psychosis, affects 1 in 100 and is traditionally characterised as a loss of contact with reality. The symptoms of psychosis are classified as positive and negative. Positive symptoms include hallucinations, mainly auditory but also visual, tactile or olfactory, and disorders of thought, including delusions. Negative symptoms include cognitive dysfunction, loss of volition, anhedonia and poor self-care skills. Schizophrenia is frequently associated with impairment of cognition and emotion. Vocational and social functioning are often disrupted and the problem is associated with considerable social and economic burden to the individual, their carers and society as a whole. The mainstay of treatment has been anti-psychotic medication combined with case management delivered by multidisciplinary mental health services. However, the outcome is variable in spite of treatment. Typically, schizophrenia follows an episodic relapsing course with periods of remission, although recovery is often incomplete and residual hallucinations and delusions are common. Nevertheless, the range of outcomes is broad, with some making a complete recovery and others becoming resistant to conventional treatments. Until recently, schizophrenia was thought to be solely biologically determined, but there is now strong evidence that psychosocial determinants, such as childhood adversities (e.g. interpersonal trauma, loss, bullying and abuse) increase the risk of psychosis (Varese et al., 2012). Furthermore, schizophrenia was thought to be impervious to psychological treatment. However, over the last decade evidence has accrued that cognitive behaviour therapy (CBT) has good utility in treating schizophrenia, and psychosis more broadly, when added to standard psychiatric care (Cormac et al., 2004; Pilling et al., 2002; Tarrier, 2005; Tarrier and Wykes, 2004). Although the efficacy of CBT has been debated in recent times, there has been sufficient evidence for CBT to become a recommended treatment for schizophrenia in the UK, as determined by the National Institute for Health and Care Excellence (2003), the government body that recommends which treatments should be used in clinical practice.

A case formulation approach for psychosis  167

The nature of the problem Schizophrenia, as defined in the DSM-5 (APA, 2013), can differ widely in its clinical presentation, both between individuals and within the same individual at different times. A number of phases of the diagnosis are recognised during which the intensity and effects of symptoms may vary. The aims and nature of any CBT intervention will vary depending on the phase of the problem. The phases of the problem and treatment options are outlined in Table 8.1. Part of the formulation will require an assessment of the phase and associated treatment needs. There are a number of factors clinicians need to take into account, both in their clinical formulation and in developing a treatment plan, when working with Table 8.1 Treatment aims and methods in different phases of psychosis Phase

Description

Aim of a CBT Intervention

Treatment Method

Prodrome phase

Occurs before the development of an established psychosis. During this phase there is an increase in non-psychotic symptoms such as anxiety, irritability, insomnia and mood instability, and in quasi-psychotic or sub-threshold symptoms such as delusional mood and magical thinking.

Prevent transition to a full psychotic episode; reduce distress and symptom severity

Acute phase

Acute episode, during which the positive symptoms become apparent. The acute phase is followed either by remission or by a period of residual symptoms whereby positive symptoms persist but at a reduced intensity compared to the acute episode. Symptoms are stable and in remission.

Speed symptom resolution and recovery

CBT for early signals and prevention of symptom escalation (e.g. normalising cognitive appraisals of psychotic-like phenomena, generating and evaluating alternative explanations, de-catastrophising fears); CBT strategies for anxiety and/or depression (French and Morrison, 2004). CBT and coping training (usually in tandem with medication) CBT, coping training, self-esteem enhancement, improving quality of life and client empowerment CBT for staying well

Partially remitted residual symptoms Remission Relapse prodrome

Symptom reduction; recovery-oriented goals

Relapse prevention; prevent deterioration Prevent relapse

Early signs identification and relapse prevention

168  Sandra Bucci and Nicholas Tarrier

people with psychosis. Not only are the symptoms of psychosis themselves distressing, the person’s perceptions and their emotional reaction to their mental health problem and its consequences also impact on a person’s life and can serve to maintain psychotic symptoms (Garety et al., 2001; Tarrier, 2002). For example, psychosis can have a significant effect on the way in which a person perceives him/herself and upon feelings of self-worth. The person’s perceptions of their condition and its consequential effect on his/her life can result in feelings of depression, hopelessness and despair, which can be associated with suicidal ideation and behaviour. The risk of suicide in schizophrenia is particularly high (Caldwell and Gottesman, 1990). Thus, although schizophrenia is characterised by positive and negative psychotic symptoms, the clinician will need to take into account the emotional and potentially traumatic nature of the problem, the difficulties the person will experience in functioning in their social, educational and vocational roles, and the potential risk of self-harm, anxiety and depression. Aspects of psychosis and its psychological and social consequences are outlined in Table 8.2. Table 8.2 Aspects of psychosis that need to be assessed and possibly taken into consideration in CBT for psychosis Psychological •  Interference: disrupted or slowed thought processes •  Restricted attention •  Hypersensitivity to social stressors and social interactions •  Difficulty processing social stimuli and acting appropriately •  Social anxiety and avoidance •  Flat and restricted affect •  Elevated arousal or dysfunctional arousal regulation •  Hypersensitivity to stress and life events •  High risk of traumatisation and its consequences, including post-traumatic stress •  High risk of suicide and self-harm • Stigmatisation •  Risk of depression and hopelessness •  High risk of alcohol and other substance abuse •  Onset in late adolescence/early adulthood interferes with developmental processes Psychosocial •  Hypersensitive to family environments and social relationships •  Risk of perpetrating, or being the victim of, violence •  Poor engagement with mental health services •  Disruptive and potentially traumatising effect of hospitalisation Social •  Social deprivation •  Poor housing •  Downward social drift •  Unemployment and difficulty competing in the job market •  Restricted social network •  Poor utilisation of social resources

A case formulation approach for psychosis  169

Comorbidity and associated clinical conditions Further clinical problems associated with schizophrenia can be classified under the heading of comorbidity, although whether these are separate and distinct disorders rather than part of, or a consequence of, psychosis is unclear. For convenience, suicide risk and self-esteem have also been covered under this heading. Social anxiety Social anxiety is a common problem in psychosis (Cosoff and Hafner, 1998) and in itself may also result in further problems; for example, alcohol or substance abuse can be a strategy of self-medication in order to cope with social fears and self-consciousness (Carrigan and Randall, 2003). Individuals experiencing psychosis often have difficulty understanding the social world around them, which can lead to socially awkward behaviour as well as to the misinterpretation of the behaviour of others. As a result, people might develop social phobia: they are afraid of negative evaluation because of their diagnosis and the stigma it may evoke, or paranoid delusions may take the form of persistent fear of negative evaluation. Recent research has shown that people with comorbid psychosis and social anxiety demonstrate higher levels of self-blame, entrapment, shame and low self-esteem (Gumley et al., 2004), and they also have higher rates of psychosis relapse. Therefore, adjunctive treatment of social anxiety may have some potentially important therapeutic benefits. Trauma Individuals with experience of psychosis appear to have a greater exposure to traumatic events. Lifetime rates of childhood physical and sexual abuse far exceed rates in the general community (Mueser et al., 1998; Varese et al., 2012), and longitudinal research suggests that childhood adversity may play a casual role (Varese et al., 2012). One meta-analytic review found that the experience of childhood adversity and trauma substantially increased the risk of psychosis, with an odds ratio of 2.8 (Varese et al., 2012). Voice-hearing in particular has been associated with earlier experiences of abuse and trauma (Bentall et al., 2012), particularly sexual abuse (Kilcommons and Morrison, 2005). Elevated rates of PTSD have been noted in psychosis, with figures ranging between 43% and 53% in people diagnosed with a DSM-IV schizophrenia-related diagnosis (Mueser et al., 1998; Kilcommons and Morrison, 2005). There is evidence that the emergence of psychosis and its treatment (e.g. hospitalisation) can be severely traumatic (Frame and Morrison, 2001; Shaw et al., 2002), so much so that up to one in two people can report posttraumatic symptoms or disorder as a consequence (Shaw et al., 2002; Jackson et al., 2004; Tarrier et al., 2007). However, there is controversy regarding the accuracy and reliability of trauma reports and whether the experience of psychosis per se qualifies as a PTSD

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stressor (Seedat et al., 2003). Notwithstanding these problems, studies show that it is likely that posttraumatic stress reactions will complicate psychosis and its treatment. Surprisingly, little is currently known about how to treat comorbid trauma and psychosis, PTSD in psychosis or the complex posttraumatic stress response to psychosis itself and its consequences (e.g. involuntary hospitalisation), although research in these areas are underway. Depression Depression occurs in a large number of people with psychosis. Overall, the prevalence of depression in schizophrenia ranges from 22% to 75%, depending on the criteria used and the chronicity of the sample (Birchwood et al., 2005). There are a number of views as to the reason for this: (a) depression may be confused with negative symptoms; (b) depression may be a side-effect of anti-psychotic medication; (c) depression may be an integral part of psychosis or (d) depression may be related to insight and be a secondary response to the condition and its consequences (Gelder et al., 2001: 334). It is therefore important when assessing people with psychosis to identify any depressed mood and understand the potential determinants, which should be accommodated in any formulation and treatment plan. Self-esteem Low self-esteem is common in those with persistent mental health problems (Silverstone, 1991). It is frequently associated with psychosis, possibly in part due to the functional impairment related to psychosis, and the stigma associated with being diagnosed with a mental health problem. Low self-esteem is strongly associated with depression and suicidal ideation and behaviour (Tarrier et al., 2004). Self-esteem is a complex concept and there is evidence that there may be two distinct and independent dimensions: a positive evaluation of the self (which is associated with negative symptoms) and a negative evaluation of the self (which is associated with positive symptoms; Barrowclough et al., 2003). These two different aspects of self-esteem may require different treatment approaches, which may have an impact on different symptom clusters. Besides being related to various symptoms, low self-esteem is an important de-motivating factor and potentially compromises initial engagement or maintenance of benefits obtained through treatment. Suicide risk Lifetime prevalence of suicide for those with a diagnosis of schizophrenia is between 4.9% and 10% (Caldwell and Gottesman, 1990; Palmer et al., 2005). A substantial number of individuals will attempt suicide, and suicidal ideation is common in many more. Risk factors for suicide in psychosis are similar to those in the general population, including being young and male, depressed, experiencing

A case formulation approach for psychosis  171

a recent loss, previous suicide attempts, family history of suicide and drug misuse (Hor and Taylor, 2010; Hawton et al., 2005; Caldwell and Gottesman, 1990). However, other factors are associated with high suicide risk in schizophrenia, including a higher level of education, fear of further psychological deterioration, having a comorbid chronic physical illness, active hallucinations and delusions, the presence of insight, experiencing feelings of hopelessness in association with depression and poor treatment adherence (Hor and Taylor, 2010). It is important to be aware that suicide attempts are a very real possibility while working with individuals with psychosis. The presence of suicidal ideation needs to be assessed, as does whether any specific plans have been made or actions have been taken. It is necessary to be aware of potentially risk-elevating factors such as the erosion of self-esteem, an increased sense of hopelessness and despair, especially related to the person’s perception of their mental health problem and their recovery, disruptive family or social relationships and any changes in social circumstances or loss of supportive relationships (including changes in mental health staffing). Unfortunately, suicides in people with a diagnosis of schizophrenia are often impulsive; people tend to use lethal methods, such as jumping from heights, immolation or firearms. Particular symptoms, such as command hallucinations, may further increase risk.

Reasons for the development of cognitive-behavioural treatments There have been a number of reasons for the increased interest in developing effective psychological therapies in treating psychosis. In spite of improvements in anti-psychotic medication, a substantial group of clients, about 40%, show minimal or only partial improvement (Kane, 1996). There is emerging evidence showing an overestimation of the effectiveness of anti-psychotics and an underestimation of their toxicity (see Morrison et al., 2012a, for a review). Also, the over-reliance on anti-psychotic medication in the treatment of schizophrenia-related disorders often leads to poly-pharmacy with unpleasant and distressing side effects and little evidence of improved efficacy (Morrison et al., 2012b). In recent years, there has arisen an increasingly vocal user movement in mental health that has sought to increase user choice and preference in treatment for mental health problems. As such, there has been much greater emphasis on evidence-based health care and the implementation of treatment approaches, such as CBT. CBT approaches were initially developed to treat people who experienced chronic and persistent drug-resistant symptoms, and it is with this group of people that most evaluation has been carried out (Wykes et al., 2008). CBT has also been shown to be applicable to acutely ill clients, typically when they have been hospitalised for an acute psychotic episode (Lewis et al., 2002), in relapse prevention (Gumley et al., 2003), in the treatment of dual diagnosis (people diagnosed with both psychosis and alcohol or substance misuse; Barrowclough et al., 2001; Haddock et al., 2003; Baker et al., 2006) and in reducing transition in those at ultra-high risk for

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developing psychosis (Stafford et al., 2013). More recently, the benefits of CBT have been demonstrated in an open trial for people choosing not to take anti-psychotic medication (Morrison et al., 2012b). In line with recent evidence, it is important that clinicians reappraise the assumption that anti-psychotics should always be the first line of treatment in psychosis. Rather, a collaborative decision regarding treatment, including both pharmacological and psychological interventions, should be negotiated when working with people accessing services for psychosis.

Evidence for cognitive-behavioural treatments There is a considerable body of evidence that demonstrates the efficacy of CBT for schizophrenia, so much so that the UK National Institute for Health and Care Excellence (NICE) and the Schizophrenia Patient Outcomes Research Team (PORT; Lehman et al., 2003) guidelines recommend that CBT be offered routinely to individuals with stable symptoms of schizophrenia. Wykes et al. (2008) have conducted one of the most robust meta-analytic reviews of CBT trials for schizophrenia. They identified 34 CBT trials targeting people with a schizophrenia-related diagnosis across various countries. There were overall beneficial effects for the target symptom in 33 studies (effect size = 0.400; 95% CI = 0.25, 0.55) as well as significant effects for positive symptoms (32 studies), negative symptoms (23 studies), functioning (15 studies) and social anxiety (two studies), with effects ranging from 0.35 to 0.44. There was no effect on hopelessness. Overall, results from this meta-analysis indicate a ‘modest’ effect size in improving positive symptoms compared to standard psychiatric care (TAU). Jauhar et al. (2014) recently updated the Wykes et al. (2008) systematic review and meta-analysis of CBT for schizophrenia. The review examined the effect of CBT on the core symptoms of schizophrenia. Fifty-two studies from various countries were included in the meta-analysis. Pooled effect sizes were −0.33 (95% CI = −0.47 to −0.19) in 34 studies of overall symptoms, −0.25 (95% CI = −0.37 to −0.13)1 in 33 studies of positive symptoms and −0.13 (95% CI = −0.25 to −0.01) in 34 studies of negative symptoms. Masking significantly moderated effect size in the meta-analyses of overall symptoms and positive symptoms, but not for negative symptoms. The authors concluded that CBT has a small therapeutic effect on core schizophrenia symptoms. In summary, meta-analyses demonstrate small to moderate effects for CBT for psychosis. CBT appears to be more effective at reducing relapse when it is dedicated solely to keeping well or preventing relapse (Tarrier and Wykes, 2004). There is also encouraging evidence that CBT is effective for those choosing not to take anti-psychotic medication (Morrison et al., 2012b), as well as in reducing transition in those at high risk for developing psychosis (Morrison et al., 2012c). In order for CBT for psychosis to develop beyond an intervention that produces small to moderate effect sizes, CBT programmes will need to focus on specific symptoms in more targeted populations (Steele, 2008). Such programmes have indeed shown promising results (e.g. Birchwood et al., 2014).

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A clinical model CBT for psychosis (primarily focused on schizophrenia), although following a common theme and set of principles, has developed in a number of centres and has been informed by a number of theoretical and conceptual bases (Tarrier, 2005). Thus, different models have adopted different emphases (e.g. Garety et al., 2001; Morrison, 2001; Trower et al., 2004). The model described here has been developed by Tarrier, but bears many similarities to other models and has benefited from contact and discussion with other clinical researchers in the field. The basic tenet is the recovery model, where the therapist’s role is to aid the individual in facilitating the process of recovery in relation to their personal goals. The clinical model that guides our treatment is presented in Figure 8.1. It assumes that the experience of psychotic symptoms, including hallucinations and delusions, is a dynamic interaction between internal and external factors. Internal factors may be either biological or psychological and can be inherited or acquired. For example, genetic factors may influence the biochemical functioning of the brain and also cognitive capacity. Alternatively, biological and psychological dysfunction may be acquired, for example in the development of maladaptive attitudes and deficits in cognitive flexibility. Such internal factors increase an individual’s vulnerability to psychosis. External factors involve a variety of environmental stressors (e.g. trauma, excessively demanding interpersonal environment, loss) and serve to further increase the risk of psychotic symptoms. The interaction between internal and external factors is important, both in the origins of the disorder and also in maintaining symptoms. Dysfunction in the processing of information, such as source monitoring in hallucinations and probabilistic reasoning in delusions, in combination with dysfunctions in the arousal system and its regulation, will result in the disturbances of perception and thought that are characteristic of psychosis. Once a psychotic symptom is activated there is a process of primary and secondary appraisal in which the individual attempts to interpret and give meaning to these experiences and then react to their consequences. The immediate reaction to the psychotic experience will be multi-dimensional and include emotional, behavioural and cognitive elements. Secondary effects such as low mood, anxiety in social situations and the effect of trauma may further compound the situation. The important aspect of this model is that appraisal and the reaction to the psychotic experience will feed back through a number of possible routes and increase the probability of the psychotic experience being maintained. For example, panicking in response to hearing threatening voices may lead to anxiety or anger. Both these emotions include elevated levels of autonomic arousal which, acting either directly through sustained increased levels of arousal or indirectly through further disruption of information processing, will increase the likelihood of psychotic symptoms. Similarly, behavioural responses to psychotic symptoms (e.g. violent behaviour, social avoidance) may increase exposure to environmental stress or increase risk of trauma, which maintains psychotic symptoms. For example, social avoidance

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could result in confirmatory rumination and resentment with a lack of opportunity to disconfirm paranoid beliefs. Thus, psychotic experiences can lead to dysfunctional beliefs which the person acts upon, resulting in a confirmatory bias to collecting and evaluating evidence on which to base future judgments of reality.

Figure 8.1  A clinical model in the CBT treatment of psychosis.

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This can be termed the experience–belief–action–confirmation (EBAC) cycle. It is suggested that such cycles maintain psychotic experience through reinforcement of maladaptive beliefs and behaviour. The generic model outlined in Figure 8.1 provides an overarching picture of how individual’s problems develop and are maintained. Embedded within this model are the micro-elements of specific time-linked events such as the EBAC cycle (see Figure 8.2).

Figure 8.2 The experience–belief–action–confirmation (EBAC) cycle.

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Engagement and assessment Understandably, people who experience distressing voices and present with negative symptoms can be difficult to engage in therapy. To embark upon a too-detailed assessment or on treatment strategies before the person has understood and accepted the rationale risks him/her disengaging because they find the process too intrusive or without personal relevance. Thus, the early stages of therapy involve building a trusting and safe relationship and may consist of providing emotional or Table 8.3  Semi-structured interviews and self-report measures to assess psychotic symptoms Measure

Description

Antecedent and Coping Interview (ACI; Tarrier, 2002)

Can be used to form the basis of clinical assessment upon which a formulation can be made. The ACI asks about the nature of the person’s psychotic experience, the context in which this experience occurs, their cognitive, behavioural and emotional reactions, the consequences of the problem and their ability to cope with their experiences and consequences. Both measures provide more detailed information about specific symptoms and will help the clinician elicit some of the more defining features of an individual’s experience of voices. These measures can inform the formulation by facilitating both the clinician and client’s understanding of the complex interaction between thoughts, feelings, behaviours and physical sensations. Useful measure of psychotic or related symptoms which are not included on the client’s problem list and are not the goal of treatment. The QPR can assist in setting goals, evaluating these goals and promoting recovery from psychosis. This measure can be particularly helpful when quality of life and empowerment, two important aspects of recovery, are an individual’s priority for therapy. Used to assess dimensions of delusions and hallucinations. The auditory hallucinations subscale consists of 11 items for frequency, duration, controllability, loudness, location, severity and intensity of distress, amount and degree of negative content, beliefs about the origin of voices, and disruption. The delusions subscale consists of six items: duration and frequency of preoccupation, intensity of distress, amount of distressing content, conviction and disruption. This measure is helpful to gather more specific information about the positive symptoms of psychosis.

Beliefs About Voices Questionnaire-Revised (BAVQ-R) and the Cognitive Assessment of Voices Schedule (Chadwick et al., 2000)

Questionnaire about the Process of Recovery (QPR; Neil et al., 2009; Law et al., 2014)

The Psychotic Symptom Rating Scales (PSYRATS; Haddock et al., 1999)

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practical support or learning about the person and their interests so as to develop a therapeutic relationship. Assessment should then proceed in the spirit of collaborative empiricism in an attempt to understand the person’s experience and its determinants and context within the structure of the clinical model described. A range of semi-structured interviews and assessment measures has been developed to aid formulation. Examples of these are listed in Table 8.3. The interview schedule or assessment measures used will largely depend on the nature of the problem as well as the clinical issue/symptom the individual finds most distressing. Psychotic symptoms: nature and variation Each psychotic symptom needs to be elicited. The interviewer needs to enquire about all psychotic experiences; for example, the types and nature of hallucinations, the types of delusions, and the nature of any interference with thought processes. Once each symptom has been identified the interviewer should elicit the details: frequency, severity or intensity of hallucinations or delusional thought, the physical characteristics of the voices and so on. If someone hears voices, it is important to know their identity and understand their meaning and purpose, their level of power, control and omniscience, whether they are commanding, positive, negative, supportive, neutral or hostile, and if the person feels the need to comply with or resist the voice. Structured assessment instruments such as The Psychotic Symptom Rating Scales (PSYRATS; Haddock et al., 1999) can be used to assess symptomatology further. Emotions that accompany each psychotic symptom The interviewer should elicit the emotional reaction that accompanies each symptom or psychotic experience. Once the interviewer has elicited the emotional reactions to the symptom in global terms, such as anxiety, anger or distress, they should attempt to break down the emotion in more detail, including cognition, behaviour, physical reaction and affect. Antecedent stimuli and context The interviewer is searching for triggers or precipitators that determine the context for the symptoms. Some people may be very aware of these, others are ­unaware of any pattern but one does unfold with questioning and others, even with detailed questioning, are unable to identify any obvious context or pattern to their symptoms. People can be asked to monitor their symptoms and keep diaries to establish cues and patterns. The interviewer should ask whether there are any triggers, whether the symptom occurs in certain circumstances or whether the person knows a symptom is going to ‘come on’.

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Besides location and circumstances the interviewer should enquire about details such as the time of day and especially any social context. Once the interviewer has asked about potential external stimuli this should be followed up with questions about internal stimuli such as internal feelings or specific thought patterns. The interviewer should also enquire about potential links between internal and external stimuli. For example, being in the company of others may make a person aware of feeling tense and a throbbing sensation in the head, which the person may appraise as something that has been implanted in his head. Particular attention should be paid to chains of stimuli and responses, especially where these relate to misidentification or misattribution, such as misattribution of physical sensations or misidentification of noises or olfactory cues. For example, physical sensations of anxiety and stress can be misattributed to the effect of poison being administered by neighbours. In addition, the interviewer should ask about situations which the person finds stressful, including situations which are characterised by deficits or absence of purposeful behaviour such as periods of inactivity or insomnia. When staying well is the goal, details regarding prodromal symptoms of previous episodes should be investigated. Prodromal symptoms typically include non-specific symptoms, such as anxiety, low mood and insomnia, followed by a feeling of a loss of control and disruption to normal functioning. Although difficult to achieve, the interviewer should try to obtain the chronological progression of symptoms that makes up the individual’s prodrome. Scales to tap the specific characteristics of a prodrome are available and can be helpful in this assessment (e.g. Birchwood et al., 1989; Yung et al., 2005). Consequences The interviewer should enquire about the consequences of psychotic experiences. These can be areas of long-term behavioural change such as avoidance, social withdrawal, isolation and loneliness, as well as the consequences of persistent symptoms and their impact on impeding goal achievement, poor employment prospects, restricted social networks and deprivation. Enquiries should also be made about behaviour that protects/encourages particular types of thought/ attitudes, behaviour that would support delusional thinking, or behaviour that might reinforce negative self-esteem. Special attention should be given to feelings of depression in combination with hopelessness and the presence of suicidal ideation. These may occur in the context of a failure to be able to achieve previously held aspirations, hopes and goals, and may be accompanied by a strong sense of loss, low self-worth and inability to break out of what feels like a desperate situation. Suicidal thoughts frequently arise as a result of feeling trapped and hopeless, from which rescue and escape is perceived as improbable. The interviewer should also be aware of the consequences of childhood adversity (such as trauma and bullying) and life events (e.g.

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loss), as well as the potentially stigmatising effects of being labelled with a mental health problem, including the effects on a person’s self-esteem. There is also the opportunity here to establish reactions to the psychotic experience that may feed back and maintain the psychosis. This line of enquiry is particularly important and can include behaviour change that further exposes an individual to stressful or difficult situations, such as exposure to arguments or hostile social situations, increased inactivity or disengagement, and biased and confirmatory beliefs about their experience. Here it is useful to ask about how they interpret their experience and why it has happened, or what they make of the voices or how they think about themselves, particularly in terms of their own self-worth. Coping Having established a comprehensive picture of what an individual experiences and how it affects them, it is now important to find out about how they cope with the situation. What strategies are used to manage their psychotic experiences or the emotional consequences? The therapist should be aware of opportunities to implement positive coping skills, which are not utilised. For example, the EBAC cycle may maintain maladaptive beliefs about a psychotic experience but the opportunities to reality-test or disconfirm these beliefs may not be exploited. The therapist should be alerted to any feelings of hopelessness indicated by a failure to use previously successful coping strategies, or a sense of abandoning the effort to cope, as these signs could indicate increased despondency and suicide risk. The therapist should be alerted to such signs of giving up. It is also useful to evaluate how successful the coping method is by ranking the coping strategy on a 3-point scale: 0 = no or little use or moderately effective for a very short time, 1 = moderately effective for a reasonable time or very effective for a short time and 2 = very effective for an extended period of time. Based upon the information obtained through this interview, a formulation can be developed which builds a picture of how a person’s experiences are being maintained/exacerbated. This formulation is used collaboratively to develop a treatment strategy. It is important to conceptualise the formulation as an individualised assessment from which an individualised strategic plan is developed to bring about the agreed changes to the individual’s life.

Cognitive-behavioural intervention Due to the potential complexity of treating psychosis there is a general progression in the therapeutic process. Engagement is the key to successful therapy; it is important to establish a trusting relationship, which can be achieved through empathic listening and addressing any therapy-interfering engagement beliefs. For example, the person who fears they will be taken back to hospital if they talk about the content of their voices may benefit from an open discussion about

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the role of the therapist, as well as the privilege, and limits, of confidentiality. The formulation is a fundamental tool used by cognitive therapists in distilling the key aspects of an individual’s problems and psychotic experiences. In some cases, an individual might not be willing to collaborate in identifying problems, or they might hold such strong beliefs about a situation, that this itself impedes the development of a formulation. In these cases, a pragmatic solution is likely to be the most tenable; the therapist and client agree to target the distress associated with a particular belief/experience in order to achieve some resolution of the problem. Often a decrease in distress and arousal is accompanied by a decrease in symptoms and thus an opportunity to improve engagement and collaboration. There is a wide range of cognitive-behavioural techniques available during the development of an intervention strategy. These involve methods that can bring about benefit through a change in behaviour, and both top-down and bottom-up cognitive processes. It is probable that these intervention strategies are most effective when they are event-specific; that is, when they are linked to an undesirable or problematic experience, such as EBAC cycles. Interventions include strategies aimed at changing cognitive processes such as attention by means of attention switching or narrowing, strategies to redirect processing or behaviour through change in meta-cognitive process or self-instruction and strategies to change interpretation or appraisal through a process of re-evaluation, challenging cognitive content or hypothesis testing through behavioural experiments and reality testing. Given the frequent occurrence of hyperarousal, people can learn targeted methods to cope with, and reduce, high levels of arousal. The identification of EBAC cycles allows the therapist to help an individual examine their beliefs and behaviour in a strategic manner. They are made aware that unhelpful beliefs are reinforced and confirmed by their own actions, and that this cycle serves to maintain their psychotic experiences. For example, the woman who believes her neighbours are poisoning her with X-rays because she has strange and unpleasant feelings every time she sees them does not learn that this is the result of misattributed appraisals. She becomes stressed and anxious in their presence because of past conflicts and misinterprets her physical sensations of anxiety as the consequence of poisonous X-rays. Her perception of their reaction to her past belligerence is misattributed to malevolent intention on their part. Such maintenance cycles are common and the case formulation approach is a helpful method for identifying their occurrence. Therapists frequently face the choice of whether to try to modify the content of hallucinations or delusions or the attentional processes that these phenomena have captured. In practice, these two therapeutic tactics can work together. Initial modification of attentional processes, through attention switching for example, can decrease the emotional impact of the experience. With regard to hallucinations, attending to the physical characteristics of a voice rather than to the voice content can produce a similar effect. This distancing from the emotional impact allows a tolerance of experience to develop without the necessity to implement

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escape, avoidance or safety behaviours. This can in turn provide an opening to challenge the truth of the content of the voice or delusional thought, and also provide a sense of control over these experiences. Take, for example, a young man who is experiencing voices that say he is Russian and accuse him of having committed a murder. Initially, he can be taught to turn his attention away from the voices in a systematic way to reduce their emotional impact. This technique can be used to elicit a sense of control and to challenge the belief that the voices are all-powerful – a process of reappraisal. He can then evaluate the statement that he is Russian by examining the evidence for and against this statement, and he can be guided to the conclusion that as he is not Russian and that the voices are incorrect. Later he can challenge the content of the voices that accuse him of murder by investigating the objective evidence that a murder has been committed, rather than concluding that he must have committed a murder because he cannot remember not having done so. Furthermore, the untruthfulness of the voices in saying he is Russian can be used to challenge the veracity of the murder accusation; the voices had been wrong about one issue so they could be wrong about the other. Modification of cognitive process and content provides the therapist with two basic routes to intervention and the flexibility to move from one approach to the other. Furthermore, establishing and sustaining effective coping strategies ensure the maintenance of treatment benefits. Given the potential for reinforcement of negative views of the self from internal (e.g. depression, hopelessness and suicidal ideation) and external factors (e.g. critical and hostile interpersonal environment, stigma, impoverished social relationships), it is not surprising that self-esteem is affected and fails to improve if not specifically targeted in therapy. Hall and Tarrier (2003, 2004) and Tarrier (2002) have developed techniques to enhance positive aspects of self-esteem. For example, low self-esteem can be addressed by asking an individual to produce a list of 10 positive qualities or statements (two per session) about themselves and rate their belief that they possess these qualities on a scale of 0 to 100 (where 0 = not at all and 100 = absolute conviction). The therapist and client work through the list together and for each positive quality, the client is asked to generate evidence in the form of as many real examples as possible of them actually displaying this quality. Every effort is made to make these autobiographical memories as specific as possible by linking them to time and context and describing them in detail. The individual then mentally rehearses the event so as to strengthen the positive memories and then re-rates the strength of their belief that they possess the qualities identified. The principle that positive beliefs about oneself varies considerably depending on one’s focus of attention and elicitation of different types of memories is constantly reinforced. For homework, individuals monitor their behaviour over the following week and record any evidence to support the contention that they possess these qualities. Then, the individual provides feedback on examples of positive attributes and the therapist prompts the individual for further examples. The individual then re-rates the belief that they do possess these positive qualities. By working through this process, individuals become aware that keeping

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weaknesses in balance with strengths (attentional focus) greatly affects mood and self-esteem. Social psychology evidence (Crocker and Wolfe, 2001) indicates that people evaluate their self-worth based upon the domains in their life that are important to them. Although it appears counterintuitive, there is good evidence that it is possible to hold both positive and negative evaluations about oneself (Barrowclough et al., 2003). Methods to reduce negative evaluations are less clear but may involve evaluating the evidence for any extreme negative belief and using social comparisons to evaluate these negative attributes. People can be asked to describe all the characteristics of an extreme negative ‘archetype’ and then compare themselves to this archetype, looking for evidence for and against the accuracy of this comparison. For example, a person who described herself as a bad mother would be asked to define all the negative characteristics of a bad mother and then compare herself with this view, including both favourable and unfavourable evidence, so as to dispute the negative appraisal, which will in all probability be a biased exaggeration.

Recent developments in CBT for psychosis Many research groups across the world have attempted to improve the outcome of people with psychosis by tailoring CBT interventions to target specific symptoms of psychosis. Birchwood and colleagues in the UK are one group who have developed CBT to target one specific symptom of psychosis, command hallucinations, with promising results (Birchwood et al., 2014). Cognitive therapy for command hallucinations (CTCH) is described in detail by Meaden et al. (2013) and is grounded in both cognitive and social rank theory. CTCH aims to reduce voice-related distress by altering the power balance between voice-hearer and voice by raising the power of the individual and viewing the relationship between voice and voice-hearer as an interpersonal one. Also, there has been a general growth of therapeutic approaches that extend beyond original cognitive theory that include an eclectic combination of theoretical and philosophical influences (e.g. mindfulness, acceptance and commitment therapy, meta cognitive therapy, compassion focused therapy). Technology is also being used to deliver CBT-informed interventions in psychosis in order to overcome the barriers individuals face in accessing psychological treatment (e.g. Granholm et al., 2012; Ben-Zeev et al., in press). Further technological advances may well see the developments of intelligent systems which can collect data sets based upon underlying psychological mechanisms and real-time assessments to deliver individualised real-time interventions (Kelly et al., 2012).

Keeping well Lastly, treatment benefits need to be maintained and strategies worked out to deal with any deterioration or potential relapse in the future. Schizophrenia is often a relapsing condition; the aim may be to minimise the impact of the relapse rather

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than expect to avoid it completely. People can be taught to identify early signs of relapse through recall of the prodromal signs and symptoms that preceded past episodes (see Birchwood et al., 1992). These need to be described in detail and in chronological sequence and to be distinguished from naturally occurring mood fluctuations. One way in which this can be achieved is to ask someone to keep a diary of their mood fluctuations so that a regular pattern can be established; the prodrome will be a departure from this pattern. Once a picture has been built up, an action plan can be formulated for how an individual can deal with these situations should they arise. This may involve various coping techniques and behavioural responses, or seeking help from a forewarned professional who can embark upon a previously agreed intervention plan.

Conclusions Psychosis is a complex problem in which different symptomatology, different phases and associated problems can be clinically challenging. Cognitive models have offered much in the way of aiding our understanding of the development and maintenance of the core symptoms of psychosis, in particular schizophrenia. Currently, the effectiveness of CBT based on these models is small to moderate. There have been considerable advances in the development of CBT in the treatment of schizophrenia, but the considerable variability both between and within individual clients at different times, and the multifaceted nature of psychosis, means that treatments need to be individually designed. Recent developments in CBT, such as CTCH and cognitive treatments branded as third-wave approaches, highlight the benefits of targeting specific psychotic symptoms and developing alternative methods to change how individuals relate to thoughts and feelings (Tai and Turkington, 2009). As a result, the case formulation approach is important in understanding multi-faceted and individual circumstances.

Case Example: Julia Julia is in her early twenties and has had a history of psychosis since her late teens. She described an unhappy childhood characterised by emotional and sexual abuse and severe bullying. Her school attendance was poor and she had few friends. Julia first described hearing a voice when she was about 10, which she experienced as ‘comforting’. She started experimenting with cannabis when she was 13 years of age and continues to smoke on a weekly basis. She lives with her parents. Julia currently has very few friends as she worries that people gossip behind her back. Julia was particularly concerned that her mother was poisoning her food. Recently, she started to hear voices again, but rather than being a source of comfort, she experiences panic as the content of the voices are insulting, commanding (e.g. ‘jump in front of that car’/‘don’t eat that food’) and the voices warn her about the dangers of eating the family meal. (continued)

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During the initial assessment phase, Julia described hearing two voices that were extremely loud. Julia found that smoking cannabis was the only strategy that provided some reprieve from the voices (‘it zones me out’). She felt compelled to comply with the voices, as she feared their threatened punishment. At the outset of therapy, it was important to develop a collaborative, empathic, trusting relationship with Julia. This was achieved by visiting Julia at the family home and commencing therapy with a gentle, relaxed conversation about a topic of interest (social networking). Symptoms were only briefly mentioned in passing through normalising voice experiences and associated distress. The clinician also addressed Julia’s engagement beliefs that she would be taken to hospital if she talked about hearing voices by carefully explaining the privileges and limits to confidentiality. Any CBT intervention should be based on an idiosyncratic case formulation. Julia described hearing voices that she described as malevolent and commanding. Because a voice warned her that her mother was poisoning her food, Julia avoided eating family meals, eating take-away fast food at lunchtime only. By carrying out this safety behaviour, Julia believed that she was avoiding being poisoned by her mother; however, this in fact confirmed her belief that the voices saved her from danger. The EBAC cycle highlights this problem: Experience – voice tells Julia that her mother is poisoning her food Belief – she is in imminent danger of being poisoned Action – she avoids eating family meals and only eats take-away fast food Confirmation – she has avoided being poisoned and remained safe by listening to and acting upon what the voices tell her. Julia had previously been told that voices are a result of mental illness. However, this explanation did not reflect or explain her actual experience. Through the EBAC cycle, Julia was presented with an alternative explanation of her experiences, allowing her to not only collaborate with psychological treatment but also learn that unusual beliefs and experiences are reinforced and confirmed by their own behaviour, with this cycle serving to maintain psychotic experiences. Once the formulation was developed, cognitive and behavioural strategies described by Meaden et al. (2013) were implemented targeting voices and associated distress.

Note 1 Negative score favours CBT.

References American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author. Baker, A. et al. (2006). Cognitive-behavioural therapy for substance use disorders in people with psychotic disorders. British Journal of Psychiatry 188: 439–48.

A case formulation approach for psychosis  185 Barrowclough, C. et al. (2001). Randomised controlled trial of motivational interviewing and cognitive behavioural intervention for schizophrenia patients with associated drug or alcohol misuse. American Journal of Psychiatry 158: 1706–13. Barrowclough, C. et al. (2003). Self-esteem in schizophrenia: The relationships between self-evaluation, family attitudes and symptomatology. Journal of Abnormal Psychology 112: 92–97. Bentall, R. P. et al. (2012). Do specific early-life adversities lead to specific symptoms of psychosis? A study from the 2007 The Adult Psychiatric Morbidity Survey. Schizophrenia Bulletin 38: 734–40. Ben-Zeev, D. et al. (in press). Feasibility, acceptability, and preliminary efficacy of a smartphone intervention for schizophrenia. Schizophrenia Bulletin. Birchwood, M. et al. (1989). Predicting relapse in schizophrenia: The development and implementation of an early signs monitoring system using patients and families as observers. Psychological Medicine 19: 649–56. Birchwood, M. et al. (1992). Early intervention. In M. Birchwood and N. Tarrier (eds) Innovations in the Psychological Management of Schizophrenia: Assessment, Treatment and Services. Chichester: Wiley. Birchwood, M. et al. (2005). Psychological pathways to depression in schizophrenia. European Archives Psychiatry Clinical Neuroscience 255: 202–12. Birchwood, M. et al. (2014). Cognitive behaviour therapy to prevent harmful compliance with command hallucinations (COMMAND): A randomised controlled trial. Lancet Psychiatry 1: 23–33. Caldwell, C. B. and Gottesman, I. I. (1990). Schizophrenics kill themselves too: A review of risk factors for suicide. Schizophrenia Bulletin 16: 571–89. Carrigan, M. H. and Randall, C. L. (2003). Self-medication in social phobia: A review of the alcohol literature. Addictive Behaviors 28: 269–84. Chadwick, P. et al. (2000). The revised Beliefs About Voices Questionnaire (BAVQ-R). British Journal of Psychiatry 177: 229–32. Cormac, I. et al. (2004). Cognitive behaviour therapy for schizophrenia (Cochrane Review). In The Cochrane Library (Issue 2). Chichester: Wiley. Cosoff, S. J. and Hafner, R. J. (1998). The prevalence of comorbid anxiety in schizophrenia, schizoaffective disorder and bipolar disorder. Australian and New Zealand Journal of Psychiatry 32: 67–72. Crocker, J. and Wolfe, C. T. (2001). Contingencies of self-worth. Psychological Review 108: 593–623. Frame, L. and Morrison, A. P. (2001). Causes of posttraumatic disorder in psychotic patients. Archives of General Psychiatry 58: 305–6. French, P. and Morrison, A. P. (2004). Early Detection and Cognitive Therapy for People at High Risk of Developing Psychosis: A Treatment Approach. London: Wiley. Garety, P. A. et al. (2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine 31: 189–95. Gelder, M. et al. (2001). Shorter Oxford Textbook of Psychiatry (4th ed.). Oxford: Oxford University Press. Granholm, E. et al. (2012). Mobile assessment and treatment for schizophrenia (MATS): A pilot trial of an interactive text messaging intervention for medication adherence, socialization and auditory hallucinations. Schizophrenia Bulletin 38: 414–25. Gumley, A. et al. (2003). A randomised trial of targeted cognitive behavioural therapy in schizophrenia: Effects on relapse at 12 months. Psychological Medicine 33: 419–31.

186  Sandra Bucci and Nicholas Tarrier Gumley, A. et al. (2004). Negative beliefs about self and illness: a comparison of individuals with psychosis with or without comorbid social anxiety disorder. Australian and New Zealand Journal of Psychiatry 38: 960–64. Haddock, G. et al. (1999). Scales to measure dimensions of hallucinations and delusions: The Psychotic Symptom Rating Scales (PSYRATS). Psychological Medicine 29: 879–90. Haddock, G. et al. (2003). Randomised controlled trial of cognitive-behavior therapy and motivational intervention for schizophrenia and substance use: 18 month, carer and economic outcomes. British Journal of Psychiatry 183: 418–26. Hall, P. L. and Tarrier, N. (2003). The cognitive-behavioural treatment of low self-esteem in psychotic patients: A pilot study. Behaviour Research and Therapy 41: 317–32. Hall, P. L. and Tarrier, N. (2004). The durability of a cognitive behavioural intervention for self-esteem in psychosis: Effects from a pilot study at 12 month follow-up. Behavioural and Cognitive Psychotherapy 32: 117–21. Hawton, K. et al. (2005). Schizophrenia and suicide: Systematic review of risk factor. British Journal of Psychiatry 187: 9–20. Hor, K. and Taylor, M. (2010). Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of Psychopharmacology 24: 81–90. Jackson C. et al. (2004). The trauma of first episode psychosis: The role of cognitive mediation. Australian and New Zealand Journal of Psychiatry 38: 327–33. Jauhar, S. et al. (2014). Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. British Journal of Psychiatry 204: 20–29. Kane, J. (1996). Treatment resistant schizophrenic patients. Journal of Clinical Psychiatry 57 (suppl. 9): 35–40. Kelly, J. A. et al. (2012). Intelligent Real Time Therapy (iRTT): Harnessing the power of machine learning to optimise the delivery of momentary cognitive-behavioural interventions. Journal of Mental Health 21: 404–14. Kilcommons, A. and Morrison, A. P. (2005). Relationships between trauma and psychosis: an exploration of cognitive and dissociative factors. Acta Psychiatrica Scandinavica 112: 351–59. Law, H. et al. (2014). Psychometric properties of the Questionnaire about the Process of Recovery (QPR). Schizophrenia Research 156: 184–89. Lehman A. F. et al. (2003). The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations. Schizophrenia Bulletin 30: 193–217. Lewis, S. W. et al. (2002). Randomised controlled trial of cognitive-behaviour therapy in early schizophrenia: Acute phase outcomes. British Journal of Psychiatry 181 (suppl. 43): 91–97. Meaden, A. et al. (2013). Cognitive Therapy for Command Hallucinations. Routledge: London. Morrison A. P. (2001). The interpretation of intrusions in psychosis: An integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy 29: 257–76. Morrison, A. P. et al. (2012a). Antipsychotics: Is it time to introduce patient choice? British Journal of Psychiatry 201: 83–84. Morrison, A. P. et al. (2012b). Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial. Psychological Medicine 42: 1049–56. Morrison, A. P. et al. (2012c). Early detection and intervention evaluation for people at risk of psychosis: Multisite randomised controlled trial. British Medical Journal 344: e2233.

A case formulation approach for psychosis  187 Mueser, K. T. et al. (1998). Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology 66: 493–99. National Institute for Clinical Excellence (2003). Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. London: National Institute for Clinical Excellence. Neil, S. et al. (2009). The questionnaire about the process of recovery (QPR): A measurement tool developed in collaboration with service users. Psychosis: Psychological, Social and Integrative Approaches 1: 145–55. Palmer, B. A. et al. (2005). The lifetime risk of suicide in schizophrenia: A reexamination. Archives of General Psychiatry 62: 247–53. Pilling, S. et al. (2002). Psychological treatments in schizophrenia: I. Meta-analysis of family interventions and cognitive behaviour therapy. Psychological Medicine 32: 763–82. Seedat, S. et al. (2003). Linking posttraumatic stress disorder and psychosis. Journal of Nervous and Mental Disease 191: 675–81. Shaw, K. et al. (2002). The aetiology of post-traumatic reactions to psychotic illness. Journal of Traumatic Stress 15: 39–47. Silverstone, P. H. (1991). Low self-esteem in different psychiatric conditions. British Journal of Clinical Psychology 30: 185–88. Stafford, M. R. et al. (2013). Early interventions to prevent psychosis: Systematic review and meta-analysis. British Medical Journal 346: f185. Steele, C. (2008). Cognitive behaviour therapy for psychosis: Current evidence and future directions. Behavioural and Cognitive Psychotherapy 36: 705–12. Tai, S. and Turkington, D. (2009). The evolution of cognitive behavior therapy for schizophrenia: Current practice and recent developments. Schizophrenia Bulletin 35: 865–73. Tarrier, N. (2002). The use of coping strategies and self-regulation in the treatment of psychosis. In A. Morrison (ed.) A Casebook of Cognitive Therapy for Psychosis. Cambridge: Cambridge University Press. Tarrier, N. (2005). Cognitive-behaviour therapy for schizophrenia: A review of development, evidence and implementation. Psychotherapy and Psychosomatics 74: 136–44. Tarrier, N. et al. (2004). Suicide risk in recent onset schizophrenia: The influence of clinical, social, self-esteem and demographic factors. Social Psychiatry and Psychiatric Epidemiology 39: 927–37. Tarrier, N. et al. (2007). The subjective consequences of suffering a first episode psychosis: trauma and suicide behaviour. Social Psychiatry and Psychiatric Epidemiology 42: 29–35. Tarrier, N. and Wykes, T. (2004). Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia: A cautious or cautionary tale? Behaviour Research and Therapy 42: 1377–401. Trower, P. et al. (2004). Cognitive therapy for command hallucinations: results of a ­randomized controlled trial. British Journal of Psychiatry 184: 312–20. Varese, F. et al. (2012). Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin 38: 661–71. Wykes, T. et al. (2008). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models and methodological rigor. Schizophrenia Bulletin 34: 523–37. Yung, A. et al. (2005). Mapping the onset of psychosis: The comprehensive assessment of at-risk mental states. Australian and New Zealand Journal of Psychiatry 39: 964–71.

Chapter 9

Cognitive behavioural case formulation in bipolar disorder Elizabeth Tyler and Steven Jones

Prevalence and severity Bipolar disorder is a severe and chronic mental health problem characterised by recurrent episodes of depression and mania/hypomania. Lifetime prevalence estimates are 1.0% for bipolar disorder I and 1.1% bipolar disorder II (Merikangas et al., 2007). Bipolar disorder I involves periods of severe episodes of mania to depression. Bipolar disorder II involves a milder form of mood elevation (hypomania) with periods of severe depression. Whilst bipolar disorder is sometimes associated with achievement and artistic creativity (Goodwin and Jamison, 2007; Murray and Johnson, 2010), it is often associated with considerable burden for individuals, including elevated rates of anxiety, substance use, suicidality, disability and unemployment (Fajutrao et al., 2009). Bipolar disorder is now placed within the top 20 most disabling illnesses in the world (Vos et al., 2012) and approximately 20–25% of individuals will attempt suicide at some point in their lifetime (Merikangas et al., 2011). The estimated cost to the English economy is £5.2 billion per year (McCrone et al., 2008) and in the US Kleinman et al. (2003) estimated total annual costs were $45.2 billion (1991 values). Bipolar disorder represents a considerable financial burden to society, with many individuals unable to work due to inadequate treatment. It is only in the last 15–20 years that the importance of psychological, and particularly cognitive behavioural, treatment has been recognised for bipolar disorder (Lam et al., 2010; Basco and Rush, 2007; Johnson and Leahy, 2005; Newman et al., 2001). The assumption that bipolar disorder is primarily a genetic/biological illness, with a relatively benign presentation between episodes, had led to medication with lithium or a similar medication (Scott, 1995; Scott and Colom, 2005; Vieta and Colom, 2004) being seen as the mainstay of treatment for mood stabilisation. Consistent with this approach, there is clear evidence that Lithium is more effective than placebo in preventing relapse in bipolar disorder (Burgess et al., 2001) and that it is likely to be more effective than more recently investigated mood stabilisers such as carbamazepine and sodium valproate (Kessing et al., 2011; NICE, 2006).

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However, medication is not adequate on its own, and lithium is not always beneficial for individuals with bipolar disorder (Goodwin, 2009; Geddes et al., 2004; Cipriani et al., 2005). A 1990 National Institute of Mental Health (NIMH) report noted that 40% of individuals treated with lithium did not experience a significant improvement in clinical state or relapse risk (Prien and Potter, 1990). Furthermore, Denicoff et al. (1997) reported that over 30% of patients stopped taking either lithium or carbamazepine within a year due to lack of efficacy. Other reports have concurred that many individuals with bipolar disorder continue to relapse despite prophylactic lithium treatment (Geddes et al., 2004; Burgess et al., 2001). Since the publication of the NIMH report, which called for the development of effective psychosocial interventions for the treatment of bipolar disorder (Prien and Potter, 1990), there has been rapid development of psychological treatment approaches for this disorder, as will be described below. The National Institute for Health and Care Excellence (NICE) Bipolar Disorder Guideline recommends that individual structured psychological treatment is offered to individuals with a diagnosis of bipolar disorder (NICE, 2006). The growing recognition of the effectiveness of psychological therapies for bipolar disorder is also reflected in the recent launch of the Improving Access to Psychological Therapies (IAPT) for Severe Mental Illness (SMI) project. IAPT-SMI aims to increase public access to a range of NICE-approved psychological therapies for psychosis, bipolar disorder and personality disorders. This chapter will briefly describe the rationale for a psychological approach to bipolar disorder before introducing a clinical heuristic as a context within which to appreciate the clinical examples and case formulations that follow. Key features of the assessment and therapy process with bipolar clients will be described. Potential pitfalls in therapy will be noted and possible solutions identified.

Stress-vulnerability issues The stress-vulnerability approach to mental health problems assumes that the individual has an inherent vulnerability which is impacted upon by life events and other stressors. The extent of the vulnerability and the amount of stress interact to determine whether and when that individual experiences a period of illness. There is increasing evidence that psychological and social factors have an important impact on the onset and course of bipolar disorder. Numerous studies have now reported that life events are associated with onset, severity and duration of both manic and depressed episodes (Alloy et al., 2005; Johnson and Roberts, 1995; Johnson and Miller, 1997). There is also evidence to suggest that stressful life events may be a consequence of bipolar disorder (Hosang et al., 2012), highlighting the importance of developing adaptive coping strategies in response to these events. Furthermore, studies of family atmosphere have indicated that relapses of manic and depressive symptoms are associated with high levels of expressed emotion (Butzlaff and Hooley, 1998; Rosenfarb et al., 2001).

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In addition to psychosocial factors, there is evidence that bipolar episodes are also associated with disruptions of circadian functioning. Thus, sleep disruption has been noted as a factor in mania in particular (Leibenluft et al., 1996; Wehr et al., 1987), and numerous markers of circadian instability have been reported for individuals with bipolar disorder during episodes (Millar et al., 2004; Teicher, 1995; Wolff et al., 1985). There is also evidence that circadian disturbances are present outside periods of acute mood disturbance. Sleep circadian activity disruption has been observed in individuals who are remitted (Jones et al., 2005; Millar et al., 2004; Harvey et al., 2005) and individuals at risk for developing bipolar disorder (Jones et al., 2006; Ankers and Jones, 2009). Additionally, research highlights the importance of cognitive styles in bipolar disorder which can exacerbate the initial disruptions caused by life events or circadian disturbance (Jones et al., 2006; Johnson and Jones, 2009). Alloy et al. (2005) suggest that the cognitive styles of individuals with bipolar disorder are distinguished by features which are characteristic of high Behavioural Activation System (BAS) sensitivity, including increased goal striving, perfectionism, self-criticism and autonomy. Jones (2001) further suggests that self-dispositional appraisals of circadian disturbance can exacerbate initial symptoms of both mania and depression (discussed further below).

An instability heuristic for understanding bipolar disorder Instability has long been proposed as a key feature of bipolar disorder (Goodwin and Jamison, 2007). For the purposes of developing psychological treatment approaches, the issue of instability has been integrated into relatively simple vulnerability-stress models (e.g. Figure 9.1; Lam et al., 2010). This indicates that social routine, sleep and life events interact with biological vulnerability to cause circadian disruption. These in combination then trigger the early warning sign stage. The manner in which the individual deals with this early warning sign stage, whether or not an intervention is put in place, is a key determinant of whether or not an episode develops. The early warning sign stage can develop into a full blown episode or an individual can revert back to more stable mood, dependent on the person’s coping strategies. This model has been extended to consider more closely how the disruption of circadian functioning might lead to the observed symptoms of bipolar disorder (Jones, 2001). This extended model integrates circadian approaches with a multilevel model of emotion, based on the SPAARS (Schematic Propositional Associative and Analogical Representation Systems) model (Power and Dalgleish, 1997). A particular feature of this approach is that it suggests that the individual’s interpretation of circadian disruption, as much as the disruption itself, may be crucial in the development of episodes of mania and depression. Circadian rhythms are indicated by patterns of behavioural and physiological activity that cycle over an approximately 24-hour light/dark period. Disruption of such rhythms is deemed

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Figure 9.1 Vulnerability-stress model (following Lam et al., 2010).

to occur when these patterns become less strongly entrained to the 24-hour period. When such disturbances of circadian functioning occur the individual will initially tend to experience dysphoria, fatigue and possibly problems with attention and concentration. These are commonly recognised as features of jet lag following travel across different time zones. When circadian rhythm disruption is more severe the individual can experience feelings of increased arousal, energy and alertness. Under normal circumstances, changes of this type would be expected to be self-correcting. However, when the individual tends to make stable internal attributions for the initial physiological changes associated with circadian disruption there is a risk of early warning signs exacerbating. Specifically, there will be an increased tendency to engage with the initial changes in mood and behaviour and therefore increase the impact of the initial disruption. A multilevel model of emotion also encompasses other important clinical features of bipolar disorder. First, it identifies that there is more than one route to mood change. Thus, although cognition plays an important role, it is not the sole determinant of mood change. Another important route highlighted in SPAARS is associative. This level of processing is accessed by experience and salience rather than language. As this level is directly related to emotional outputs, it is likely to have a powerful effect on emotion. A multilevel model is also important as it captures the conflicting emotions which are a key feature of bipolar disorder – often the combination of ‘feeling’

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something is right and ‘knowing’ something is wrong. A heuristic to summarise the potential relevance of this approach in clinical terms is described in Figure 9.2. This indicates that the ways in which the individual with bipolar disorder responds to and interprets instability is crucial. A relationship is proposed between this process and a number of psychological and social factors associated with the disorder, all of which are based on available research evidence. The heuristic suggests that sensitivity to circadian disruption is associated with frequent physiological fluctuation, which is in itself associated initially with dysphoric mood. A further proposal is that internal attributions are made for the instability caused by these fluctuations (Jones et al., 2006; Ankers and Jones, 2009). This could be seen as leaving the person in a situation of uncertainty, both with respect to mood and physiology, and hence struggling to evaluate situations objectively. More specifically, the heuristic proposes specific reactions which have been noted clinically and for which some research evidence exists. Two coping styles are indicated in response to this instability: 1 An avoidant coping style, in which initial changes are ignored or colluded with until mood change is too significant to avoid and most likely to be associated with mania. This is consistent with research into early warning signs (Lam and Wong 1997; Lam et al., 2001) which reported substantial variability in individuals’ responses to early signs of mood change, including responses which could be defined as avoidant. This avoidant pattern has also been confirmed in studies of response styles in both high risk and bipolar groups (Thomas and Bentall, 2002; Thomas et al., 2007).

Dysphoria

Rumination

Depression Social cognition problems

Sensitivity to circadian disruption

Frequent physiological fluctuation

Internal attribution for instability

Concentration problems

Proneness to EE effects Avoidant coping style Symptoms ‘out of the blue’

Mania ‘Manic defense’

Figure 9.2  An instability heuristic for understanding bipolar disorder.

Unpredictable environment

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2 There is evidence for the contrasting ruminative style in affective disorders in general (Nolen-Hoeksema, 1991, 2000) and also in healthy but high risk individuals more strongly associated with depression (Thomas and Bentall, 2002). Furthermore, studies demonstrate that individuals with bipolar disorder ruminate in response to negative affect in depressive states (Johnson et al., 2008; van der Gucht et al., 2009). The pattern of uncertainty referred to above can be expected to impact on the processing of both social and non-social information. The former is indicated by evidence of social cognition deficits in bipolar individuals (Scott and Pope, 2003; Scott et al., 2000; Donohoe et al., 2012), while other researchers have identified deficits in information processing (Green et al., 1994; Neuchterlein et al., 1991; Serper, 1993). Instability, dysphoria and social cognition deficits would also be consistent with research findings which indicate vulnerability to family atmosphere, specifically high expressed emotion (Miklowitz et al., 1988; Hooley, 2007). This suggests, then, that the bipolar individual is presented with demands associated with an unpredictable environment, an unstable internal environment, fragile self-esteem, ready distraction from focal tasks and vulnerability to exacerbations of early mood change. This indicates the importance of a comprehensive approach to bipolar disorder which seeks to address both instability itself and also responses to this through work on thoughts, assumptions and coping strategies.

How does treating bipolar disorder differ from other disorders? For most disorders the rationale for therapy is self-evident to the client. A person who is depressed, anxious or worried will normally request therapeutic help to remove the core symptoms of their conditions which are interfering with their lives. Many bipolar clients will enter therapy when either remitted or mildly depressed. They will often say that they wish to have help with improving their mood and may well also want to avoid having episodes which lead to hospitalisation. However, as Post et al. (2003) among others has demonstrated, the majority of people with bipolar disorder spend relatively short periods in mania (compared with depression) during their illness course. Similarly, in a study of 146 individuals with bipolar I disorder, Judd et al. (2002) found that participants showed depressive symptoms 31.9% of the weeks throughout an average of 12.8 years, compared to 8.9% of weeks spent in mania or hypomania. Many clients wish not only to address depression but also to achieve stable hypomania which does not tip into mania. This is understandable since many clients may have experienced positive aspects of their mood experiences which they do not want to lose, such as increased energy, optimism, creativity, sociability, faster thinking and often objective improvement in functioning in the initial stages of hypomania (Murray and Johnson, 2010; Lobban et al., 2012). Unfortunately, such mood states are often associated with an ascent into mania with significant consequences to work,

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family and social life both at the time and once mood has stabilised. Until this pattern is clear to the individual client, it is reasonable to expect ambivalence towards therapy. It is therefore crucial that the therapist is open to the client’s perspective regarding their mood experiences and that the therapy makes sense in terms of this, weighing up both the costs and benefits of elevated mood. Ambivalence towards treatment is common for people with bipolar disorder (Leahy, 2007). It has been argued that this should be recognised as important information to integrate into therapy rather than being dismissed as unhelpful resistance to therapeutic suggestions. As Lobban et al. (2012) reported, some people highly valued their bipolar experiences across elevated, depressed and euthymic mood states and were resistant to the idea of losing these. Recently Liebert (2013) critically reviewed the stance that ambivalence is a barrier to treatment adherence, arguing that instead, clinicians should regard ambivalence as a source of insight and expertise to help identify the client’s diagnostic and treatment preferences. Diagnosis Understanding the client’s route to diagnosis is important to take into account when first working with bipolar individuals. The average duration from onset to correct diagnosis is over 10 years (Hirschfield et al., 2000; Russell and Browne, 2005). A missed diagnosis can lead to serious consequences and the client may have spent long periods of time receiving inadequate and poor-quality care. This may have fostered mistrust in services, and work may be needed to rebuild this trust. Exploring the meaning of the client’s diagnosis is also an important factor. Diagnosis may be helpful for some individuals to explain and validate their mood experiences. However, for others it may have encompassed a loss of identity and stigma, resulting in a damaging experience. The therapeutic approaches here are applicable to mood instability and do not require that the client specifically endorse a bipolar diagnosis for them to be clinically beneficial. Flexibility As mentioned above, there may be many individuals whose approach to psychological and psychiatric intervention is ambivalent. Studies of cognitive style in individuals meeting criteria for bipolar disorder indicate the importance of autonomy and achievement. In therapy this can translate to a desire to retain control of the therapeutic encounter and to focus on personally relevant issues, which may or may not appear to be directly relevant to clinically defined problems. Maintaining a flexible approach to therapy is crucial for working with individuals with bipolar disorder. At times, engagement may be challenging. This may be due to prior negative experiences of services or residual psychotic symptoms. In other cases it may be due to low mood and associated motivational difficulties or conversely subsyndromal mood elevations. Some clients will attend therapy ready to engage in approaches to address their difficulties; however, for others patterns

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of alliance and motivation will fluctuate in tandem with their mood state. Their individual preferences may well vary over time, there may be weeks when they are fully engaged in homework tasks and then the following session appear to have lost all interest.

Research evidence for CBT Research has focused primarily on relapse prevention in individuals with an established course of bipolar disorder who enter therapy whilst euthymic. The most effective versions of CBT seem to be individual interventions focused on providing a comprehensive approach to understanding and coping effectively with mood fluctuation. A number of randomised controlled trials of individual CBT have been published (Perry et al., 1999; Lam et al., 2000, 2003, 2005; Zaretsky et al., 1999; Scott et al., 2001; Ball et al., 2006; Miklowitz et al., 2007; Meyer and Hautzinger, 2012). In all the studies reported, psychological interventions have been delivered in conjunction with pharmacotherapy. To date traditional CBT has been most effective in reducing depressive symptoms and preventing episodes in participants out of an acute episode (Lam et al., 2010). Structured psychological therapies are now recommended in the NICE guidelines for bipolar disorders (for reviews see Jones, 2004; Morriss et al., 2007; Miklowitz et al., 2008). Recovery focused CBT The studies described above have primarily focused on CBT and psychoeducational approaches designed to reduce relapse risk but with little explicit focus on functional outcomes including personal recovery. This is a limitation as recovery-informed interventions are now recommended by the UK government (Department of Health, 2009, 2011). An RCT study from our group is in the process of evaluating a recovery-focused CBT intervention (RfCBT) with a particular emphasis on individualised functional or symptomatic goals rather than primarily relapse prevention for individuals with early bipolar disorder (Jones et al., 2012).

Therapy structure Cognitive therapy extends from 16–24 sessions over a period of approximately six months to accommodate its clinical complexity and to offer the clinician the opportunity to help the client apply skills learnt across different mood states. Cognitive therapy is usually offered as an addition to psychopharmacological interventions, but it is not a ‘medication compliance’ intervention. The importance of developing greater stability in terms of both mood and activity may appear self-evident to the therapist at an early stage in therapy, but this will often not be a view shared by the client. Therapists need to be aware that their ‘sensible’ therapeutic suggestions can readily be viewed by clients as seeking merely to reduce

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their freedom and spontaneity. As indicated below, the time taken to ensure that client and therapist have a shared rationale for change will be crucial for both engagement and effective clinical and functional outcomes.

General treatment strategy There are many components to the formulation-driven cognitive behavioural treatment of bipolar disorder. In summarising a general treatment strategy, however, there are essentially four key areas: 1 Psycho-educational model: clients are provided with information about a vulnerability-stress approach to bipolar experiences. 2 Cognitive behavioural skills to cope with early warning signs: clients identify changes in mood and behaviour which represent early warning signs for depression or mania. Once such signs are identified, the client and therapist develop a programme of strategies to intervene to prevent progression into full clinical episodes. 3 Importance of routine and sleep: it is an important aspect of therapy to work with the client to improve stability in both of these areas where necessary. 4 Dealing with long-term vulnerabilities: particular themes for bipolar clients include a high need for autonomy and extreme achievement-driven behaviour. Later sessions can be used to explore these issues and to test out less-rigid beliefs. The majority of clients will enter therapy in remission or suffering from subsyndromal symptoms. The basic structure above will apply to clients of this type. The evidence base for cognitive therapy for clients who are acutely ill at entry into therapy is limited. It appears that acute depression responds well to cognitive behavioural therapy (Zaretsky et al., 1999; Miklowitz et al., 2007). Virgil’s (2010) review provides evidence from existing trials that supports a small but significant impact on manic symptoms (even though the studies were not designed to address this). There is a need for research studies that specifically target individuals during the acute stages of mania. However, the instability inherent in bipolar disorder means that most clients will experience significant changes in mood state during intervention. When it is clear that mood is heading towards depression or mania, then treatment priorities will be different. If the client does experience an exacerbation of symptoms during therapy, the utilisation of effective coping strategies during this early warning sign stage can be a useful way to consolidate treatment.

Assessment and formulation Given the complexity of bipolar disorder, a number of factors need to be borne in mind during the initial assessment and engagement process. First, the assessment (and subsequent therapy) must be carried out in a spirit of guided discovery. It is

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also important to collaborate in identifying therapy goals, while also respecting the client’s need for autonomy. Beck (1983) proposed that bipolar disorder might be characterised by oscillations between sociotropy and autonomy as people move from depressed to manic states. Clinically, however, the autonomy element appears to predominate in the remitted phase of the illness (Lam et al., 2010). Research has also reported that elevated behavioural activation system activity is found in both bipolar individuals and those at high risk (Alloy et al., 2008; Urosevic et al., 2008; Johnson, 2005). These findings concur with clinical observations reported elsewhere (Lam et al., 2010) that many individuals with bipolar disorder presenting for treatment aspire to an autonomous, perfectionistic, striving approach to life. Such individuals therefore need to establish that important issues for therapy come from their own experience and make sense in terms of their own priorities. Our clinical experience indicates that the presence of any sort of didactic approach early in therapy will lead to failure to engage. A clinical example will illustrate some of the features typical of many individuals with bipolar disorder (Box 9.1).

Box 9.1 Laura is a 41-year-old woman with a diagnosis of bipolar I disorder who has experienced several episodes of mania and depression. She was diagnosed in her second year of university at the age of 20. Laura was an only child and was close to both her parents; however, her mother had struggled over the years with anxiety and low mood and this was often a cause of arguments between her parents. Family life was unstable and appeared to fluctuate in tandem with her mother’s mood states. Despite this, Laura did well at school, achieving straight A grades in her A-Levels, and went to university. The move to university was an exciting time in Laura’s life. She made friends easily and like other students took full advantage of the social aspects of university life. Laura began drinking on a regular basis and started experimenting with ecstasy and cocaine at the weekends when she went clubbing. Laura had taken on a part-time job with the student union and was part of a team that was organising a large university social event. It was during this time that Laura became unwell and was hospitalised for a manic episode, after which she had to leave university and move back home to her parents. Over the subsequent years, she had another admission to hospital for a manic episode which was triggered by starting a new job. Following this last admission she met her husband John, and felt that this gave her a new focus. When Laura arrived at therapy she already had a great deal of insight into her condition. However, she felt there were elements of her mood experiences that were impacting on her relationship, social and work life and she often experienced periods of low mood. Laura had worked very hard to understand her bipolar disorder, particularly her manic experiences, and over the years she appeared to have put a lot of restrictions in place as she sought to maintain a stable mood. Her social life was limited and she felt very lonely at times. She often thought back to her time at (continued)

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university when she was the ‘life and soul of the party’ and was keen to build up a more fulfilling social life. She worked as a care assistant but avoided new responsibilities and applying for higher positions, in case this led to an episode. This had led to her feeling unfulfilled and often when her mood was low she ruminated about ‘the things she could have done with her life’. Her relationship with her husband was good but a frequent cause of tension was when she felt that he over-reacted to changes in her mood. When Laura experienced any symptoms of elevated mood, he would get anxious and think that she was going to become unwell again. Laura’s use of restriction was explored, including how it had been helpful at times in the past to prevent her from becoming unwell. However, over time it had held her back, preventing her from taking up on social and work opportunities, leading her to feel like a failure in these areas of her life. Laura’s goals for therapy were both functional and symptom-focused. She wanted to build up a social life, apply for a new job and for her husband to have more understanding of her condition. She wanted to build a relapse prevention plan where she felt confident to self-manage her mood fluctuations without both herself and her husband becoming fearful in response to changes in her mood.

For many people with bipolar disorder, it will often be the first time that they have managed to develop an integrated, chronological account of their experiences. Many patients recall events with regard to illness history in terms of their emotional salience. Although this makes some sense in psychological terms it can often leave the individual with vivid memories of apparently unconnected intense experiences. This process can then serve to reinforce their perception of life as being chaotic and of illness episodes as coming ‘out of the blue’. The development of a life chart can provide a useful summary of key episodes. They can help the individual to look for patterns of illness, stresses, occupational and educational achievements. An initial life chart for Laura is presented below. This illustrates how mood variability was a characteristic prior to the onset of her first manic episode. It also indicates how mood fluctuation appears to be associated with relationship issues, and success and failure experiences. Additional formal assessment measures are often helpful to provide information on the following areas: Current mood state

• • •

Beck Depression Inventory (Second Edition; BDI-II; Beck et al., 1996) The Altman Self Rating Mania Scale (ASRM; Altman et al., 1997) The Beck Hopelessness Scale (BHS; Beck and Steer, 1988)

Bipolar symptomatology

•

The Internal States Scale (ISS; Bauer et al., 1991)

Case formulation in bipolar disorder  199 Start university, lots of socialising, routine changes, experimenting with drugs M o o d s e l f r a t i n g

Start new job

+10

Get married

Meet John

+5

10

15

20

25

30

35

40

-5 Home life difficult -10

Met first End of boyfriend relationship Move back home

Leave job due to pressure

Age (Years)

Figure 9.3  Initial life chart for Laura showing self-rated mood over time. * Values between −5 and +5 are regarded as normal. Higher or lower values than this signify clinical mood disturbance.

Cognitive style

•

The Hypomania Interpretations Questionnaire (HIQ; Jones et al., 2006

Recovery

•

The Bipolar Recovery Questionnaire (BRQ; Jones et al., 2013)

Quality of life

• The Brief Quality of Life in Bipolar Disorder (QoL.BD; Michalak and Murray, 2010) Early Warning signs and coping skills

• •

Early Warning Signs Checklists (Lobban et al., 2011) The Coping with Prodromes Interview (Lam et al., 2001)

A small battery of tests can usefully be employed at the beginning and end of therapy. These would normally include the BRQ, QoLBD and the BHS. The BDI and ISS may be employed on a sessional basis to obtain crucial clinical information in an efficient manner. Information from symptom and life histories and formal measures will form the basis for working with clients to develop both a goal list and an initial formulation.

200  Elizabeth Tyler and Steven Jones

Many clients will generate a goal list which includes a combination of functional and symptom-related goals. The process of generating the formulation provides the clinician with the opportunity to work with the client to identify relationships between both functional and symptom issues, which leads to enhanced engagement. The formulation is also used to individualise the treatment protocol and to assess the relative importance of the different elements that it might contain. At times, presenting large, detailed formulations can feel overwhelming for the client. In this case, it can be helpful to begin with simple maintenance formulations that can be elaborated as the therapy progresses as proposed by Kinderman and Lobban (2000). A simple formulation was developed for Laura (see Figure 9.4a), based on the vulnerability-stress model (Lam et al., 2010) presented at the beginning of the chapter (see Figure 9.1). This formulation is based on the manic episode experienced before meeting her husband John. Laura had started a new job and, keen to impress, had taken on additional responsibilities. In order to complete these extra tasks she often stayed late at work and had also began socialising with new work colleagues. The combination of a marked change in social and sleep routine, interacting with her underlying biological vulnerability (to cause circadian

TRIGGER UNDERLYING BIOLOGICAL VULNERABILITY

New job Take on new responsibilities Socialising with work friends Change in routine

Circadian rhythm instability

STIGMA/ RELATIONSHIP PROBLEMS Quit job Split up with boyfriend PRODROMAL STAGE

MANIC EPISODE No sleep Racing thoughts Attending church daily Heavy alcohol use Hospitalisation

POOR COPING STRATEGIES Lack of awareness of change in mood Continued disruption to sleep, social and work life

Sleep disrupted More talkative More energy Ideas flowing fast Taking on additional responsibilities

Figure 9.4a  Formulation for Laura based on the Lam et al. (2010) vulnerability-stress model.

Case formulation in bipolar disorder  201 PRODROMAL STAGE

MANIC EPISODE

No sleep Racing thoughts Attending church daily Heavy alcohol use Hospitalisation

Back to work the following week

POOR COPING STRATEGIES

Lack of awareness of change in mood Continued disruption to sleep, social and work life

Reduction in hypomanic symptoms

Relaxed and slept Cancelled going out with friends

Sleep disrupted More talkative More energy Ideas flowing fast Taking on additional responsibilities

POSITIVE COPING

Spoke to Mum Took few days off work

Figure 9.4b  Formulation for Laura with positive coping example.

disruption), triggered the early warning sign stage. As Laura was unaware that she was experiencing a change in her mood, she continued to engage in activities which further disrupted her sleep, social and work routine, leading to a full-blown manic episode. A formulation of this type allows the individual to see how successful intervention during the early warning sign stage can prevent the escalation of a full blown episode. Generating a formulation can sometimes have a negative as well as a positive effect on clients. Highlighting the significant negative features of a person’s life can serve to confirm beliefs about their ‘flawed’ character rather than motivate change. It is important to identify examples of positive coping where possible so that positive formulations can be presented alongside problem formulations. This balanced approach can greatly enhance clients’ engagement and also their motivation for change as they are being provided with evidence from their own lives that such change is within their grasp. In the case of Laura, it was important to identify times in the past when she had coped in a positive way in response to her mood fluctuations. This information should be included in the formulation (see Figure 9.4b).

Key features of intervention As noted above, CBT for bipolar disorder is best delivered on the basis of an individual formulation. However, the research conducted to date has indicated that a number of features of therapy are likely to be important in reducing instability and relapse risk. These are outlined below.

202  Elizabeth Tyler and Steven Jones

Initial sessions Information/development of therapeutic alliance This provides the client with an introduction to a diathesis-stress model of bipolar disorder, often of the type outlined above (Lam et al., 2010). The role of thoughts and behaviour will be introduced at this stage and referred to throughout the therapy. Individual symptom history will also be collected during initial sessions and the importance of early signs highlighted with respect to previous episodes. This then forms the basis for work in later sessions on identifying early warning signs for relapse prevention. Another important aspect of early sessions is normalisation. Many individuals see themselves as having a fundamental flaw which separates them from ‘normal’ people. Clearly this can impede therapy and needs to be challenged at an early stage. The process of anchoring episodes in social and psychological contexts can be very important in this process. Additionally, identification of the experiences of others and the prevalence of mood episodes in the general population can also be relevant to this process. Socialising to therapy/goal setting As noted above, goals need to be individualised to the client. Laura’s goals were both functional (she wanted to build up a social life, apply for a different job and for her husband to have more understanding of her condition) and symptom-focused (self-manage mood fluctuations). However, these initial goals were very broad. Once the life and symptom history information is agreed, it is then helpful to try to work with the client to elaborate and clarify their goals for therapy. In Laura’s case, this involved working through each goal and setting realistic targets. She wanted to build up a social life but wasn’t sure how to approach this. We brainstormed a number of ideas and she decided that she wanted to join some local community groups where she would hopefully meet people with similar interests. Laura wanted to apply for a different job and this transpired as wanting more responsibility. We spent time thinking through the options and then the steps involved in finding a new role. Laura also wanted her husband to have more insight into her condition. This involved him understanding the patterns of her episodes and not over-reacting to small shifts in her mood. We decided it would be a good idea for him to attend a few sessions toward the end when we developed a relapse prevention plan. Intermediate sessions Cognitive techniques are taught, discussed and applied during this stage of therapy.

Case formulation in bipolar disorder  203

Mood monitoring For individuals with bipolar disorder, mood fluctuations have often previously been associated with distress. Therefore, people can become anxious and fearful in relation to what would be typically considered as normal mood fluctuation. As a result, individuals may present at therapy with fairly rigid and unrealistic views regarding their mood fluctuations which can often be reinforcing their difficulties. It can be helpful at the beginning of each session to ask them to rate their mood on a −10 to +10 scale. On this scale, +10 marks the most extreme positive mood ever experienced and −10 the most extreme low mood. A range of −5 to +5 is assumed to indicate the region within which normal fluctuations of mood occur. In the case of Laura, before we were able to engage in her functional related goals, we spent time exploring her mood states. Each session I asked Laura to rate her mood on a Likert scale ranging from −10 to +10. At the beginning of therapy, Laura was adamant that her rating ‘should’ always be 0, however it was often between −5 and +5, which would leave her feeling fearful that her mood may escalate. As a result, Laura had restricted her activities and treated any fluctuation in mood as pathological. We spent time understanding her mood fluctuations with the view that it would be impossible and unhealthy for anyone’s mood to remain at 0 consistently. Laura needed to discover where she felt comfortable on the scale and in time that would build her confidence in her ability to self-manage her mood fluctuations. Over time we mapped out Laura’s mood on the scale and identified her idiosyncratic early warning signs that were associated with her ratings, see Figure 9.5. This was then used later on in our relapse prevention sessions to help develop a set of coping strategies. The shaded areas demonstrate where Laura felt she needed to take action. As Laura began to feel more confident in the management of her mood we were able to develop a plan where she felt supported to achieve her long-term goals. Understanding the relationship between mood and activity The National Institute for Clinical Excellence Clinical Guidelines for Bipolar Disorder and the American Psychiatric Association Practice Guideline for the Treatment of Patients with Bipolar Disorder (APA, 2002; NICE, 2006) both recommend regular social and sleep routine as part of promotion of a healthy lifestyle. The completion of mood and activity sheets is a key feature of cognitive therapy with individuals with bipolar disorder. This will often begin early in therapy and continue throughout the active intervention. Many clients, although clearly very intelligent individuals, will struggle to appreciate the connections between what they do, the experiences they have and their mood. This fits with the heuristic outlined above, in which an internal attribution bias is proposed. If individuals are attributing change to features of themselves, they will not be alert to other possible explanations of mood change. It is therefore important that the therapist employs a repeated approach to guided discovery

+ 10

+8

Going to church, auditory hallucinations, no sleep at all, drinking alcohol every day

Racing thoughts, can’t sit still, wanting to go to church, getting in contact with old friends/ relatives, can’t get off to sleep

+6

Ideas flowing fast, difficulty concentrating, stronger interest in sex, difficulty sleeping, spending money more freely

+4

More talkative, feeling more creative, more energy, more optimistic

+2

Slight increase in energy

0

Energy levels feel normal

-2

Occasional negative thought, but easily distracted from them

-4

Feeling tired, less talkative than usual

-6

Loss of interest in activities but still continuing with them, difficulty concentrating, wanting to be alone, ideas slowed down, lots of negative and self critical thoughts

-8

Sleeping too much, wanting to be alone, feeling very anxious, struggling to get up in the morning

-10

Staying in bed all day sleeping, thinking about suicide / death

Figure 9.5  Idiosyncratic mood monitoring and early warning signs.

Case formulation in bipolar disorder  205

of mood–activity relationships. Single demonstrations of such patterns will be insufficient. The forms used are adapted from standard activity scheduling forms. They differ in two main respects: First, they make provision for the recording of activity throughout a 24-hour period rather than assuming that people will be active during the day and asleep at night; second, clients record a summary assessment of mood for each day. This is rated on a −10 to +10 scale (see mood monitoring for explanation of scale). See Figure 9.6 for an example of the times between 6 p.m. and 6 a.m.

Box 9.2 The person illustrated here is Bill, who is a 40-year-old artist with a 20-year history of bipolar disorder. He had recently been discharged from hospital after a six-month admission following a period of severe depression. He was preoccupied with the time he had lost in hospital and was very keen to catch up now that he was back in the community. When he brought this record to therapy the following week, his mood had decreased back down to +5 from a peak of +9 after exhaustion had led him to spend two days in bed. He was very disturbed about his previous elevated mood and felt that it came ‘out of the blue’. By working through the information in his record it was clear that there was pattern of overwork and loss of sleep clearly associated with mood change. Once Bill was able to appreciate this association, he was amenable to discussing how he might aim for targets around sustaining long-term creative output by being alert to overdoing it in the short term. In the absence of such a personally relevant illustration of this relationship, the risk would be that Bill would merely see any such target as being restrictive and inappropriate given the importance of his work.

Challenging positive thoughts The issue of addressing negative thinking and beliefs has been dealt with extensively elsewhere. Most bipolar individuals, even when euthymic, will present at times with patterns of negative thinking which can be addressed in the normal way, through thought records and evidence gathering. A more complex problem can be that of dealing with positive thoughts. In the first instance, the clinician needs to have a picture of when positive thoughts are associated with mood elevation and when they are merely a function of good mood. This is best done proactively when the client is not in a period of elevated mood. Reviewing periods of mood elevation, it is possible to encourage the client to identify retrospectively the thoughts associated with these periods and to use evidence to challenge them. This process can also be used to work with the client to identify the differences between thoughts during these periods and normally positive thoughts. Hypomanic positive thoughts are usually characterised by their rigidity and lack of relationship to external inputs – the evidence base for such thoughts is usually the individual’s feelings rather than concrete

Friend visits – leaves so can work

Ideas for new project Work

As above

Ring John re: new idea – long chat

List out ideas

As above

Search web for more Coffee and work ideas

As above

As above

Bed

Asleep

Asleep

Jim home

Tea then work

Finish picture

Look at picture

Ideas for exhibition

As above

As above

Bed – thinking

As above

Asleep

Asleep

Asleep

6–7 p.m.

7–8 p.m.

8–9 p.m.

9–10 p.m.

10–11 p.m.

11–12 p.m.

12–1 a.m.

1–2 a.m.

2–3 a.m.

3–4 a.m.

4–5 a.m.

5–6 a.m.

Figure 9.6  Example activity and mood record for Bill.

Work

Painting

Asleep

Fitful sleep

Awake

Bed

Argument

Friday

+9

Work

Ring Bill then Sam re: ideas

Walked dogs

Argument with Jim

Miss hospital

Asleep

Asleep

Bed

Get up – TV

Awake

Bed

Awake

Asleep

Asleep

Asleep

+9

Asleep

Asleep

Supper

Work

Work

Asleep

Asleep

Work

Asleep

Asleep

Awake

Asleep

Fitful sleep Asleep

Argument Asleep

Asleep

Awake

Argument – bed 11.30

Pub

Work

Work

Watched TV

Work

Dozed

Saturday Sunday

+8

Bed – fitful sleep Asleep

Internet

Internet

Argue with Jim

Work

Work

Went home TV

Pub with Jim

Buy materials for Work work

Thursday

+7

Email contacts re: Work project

Argument with Jim

As above

Watched TV – more ideas

Cancel mum for Thurs too busy

John visits – seems impressed

Wednesday

Tuesday

Monday

5–6 p.m.

+8

Date

+6

+5

10 to +10

Mood rating

Case formulation in bipolar disorder  207

outcomes or feedback from others. It is also usual in this process to work out with the client at what level of mood elevation these thoughts would normally occur. This can then lead to a joint agreement between therapist and client to use challenges developed by the client when and if such thoughts recur. The client can be asked to give advance permission for the therapist or a trusted relative to raise this matter if mood change above the specified threshold occurs. The important issue is that the client’s own words with respect to these thoughts are used at that point rather than those of the therapist or worried relatives. Working with unrealistic positive ideas Sometimes positive thoughts and associated mood elevation occur before it has been possible to identify strategies for challenging these. During periods of elevated mood people can over-estimate their personal abilities and attributes, become very optimistic about the world and find it hard to conceive of any negative consequences for their actions. This has traditionally been referred to as ‘grandiose’; however, we feel that this has acquired some negative connotations, therefore we will refer instead to unrealistically positive ideas. Reframing One way of managing unrealistically positive ideas is to help clients reframe them as indicators of elevating mood. This can be a difficult task to perform ‘in the moment’, therefore it can often be helpful to ask the client to practice this retrospectively when they have a relatively stable mood. The therapist should ask the client to recall a recent episode of mania or hypomania. Using careful questioning, the therapist should elicit any changes in thinking which occurred before the unrealistic positive thoughts, the content of the unrealistic positive thoughts and the consequences of these. The client is then asked to evaluate whether these thoughts were a good idea and reframe any subsequent ideas as indicators of elevating mood, termed as early warning signs, and a decision should be made regarding how they would like to respond to these in the future. It is important to differentiate between ideas that are inherently unrealistic, e.g. ‘I want to be a platinum-selling pop star,’ and positive thoughts that are unrealistic within the current context when perhaps the client is still unwell and has little financial support, e.g. ‘I want to open a new restaurant within the next six months.’ The latter may (or may not) be positive or realistic when the client is more stable, therefore it is important that the therapist does not inadvertently give the message that all positive planning should be banned. Delaying tactic Another strategy for managing unrealistically positive ideas is to set up mechanisms which allow clients to delay acting on these ideas for a certain period of

208  Elizabeth Tyler and Steven Jones

time. This was initially proposed by Basco and Rush (1996), and has proved to be an effective intervention. Time delay rules can be set up where the client agrees to not act upon ideas when they are in either an elevating or high mood. During the ‘delay’ period the client can utilise a range of cognitive strategies to enable them to step back and evaluate their ideas in more detail. It can often be helpful to develop a set of pre-defined questions where the client can ask themselves to assess why delaying may be a good idea and the quality of the idea itself. The questions should use the client’s own words as far as possible, as they have a much higher chance of resonating when they are in an elevated mood and perhaps reluctant to hear another point of view. The questions should be highly personally relevant and based on past experiences, e.g. ‘remember how gutted you were when you maxed out your credit card on X? You can spend your money on Y next week when you get paid, but you can’t get your money back on your credit card once you’ve spent it, worn the clothes and then changed your mind?’ Examples of the types of questions it can be helpful for clients to ask themselves are as follows: • • • • •

Would you lose anything by delaying? Could you gain anything from waiting? What would your friend/partner say? What would you say to your friend/partner if they had this idea? What would it be useful to do before taking action to make sure you are making the right decision?

A key advantage of such a rule is that there is no presumption that the clinician knows best. If the idea is actually a good one, by engaging with this process people can prove it to those around them. Final sessions Coping with early warning signs Early warning signs (previously termed as ‘prodromes’) are early signs of mood episodes, not symptoms of being in a full episode. A prodrome has been defined as the interval from first recognition of symptoms to the time of maximum symptom severity (Molnar et al., 1988), which in a vulnerability-stress model of bipolar disorder is when an important opportunity for relapse prevention occurs. By this phase of therapy, the client will have skills in identifying mood fluctuations and relating these to behaviours and thoughts, including examples where early warning signs have been experienced. They will also normally have some experience of the impact that they can have on their mood with changes which they make in thinking or in activity. This is therefore the appropriate stage at which to bring together all this information with the client to identify early warning signs

Case formulation in bipolar disorder  209

for both mania and depression. In general, individuals tend to find that mania signs are easier to identify, as many of the symptoms are clearer changes from ‘normal’ functioning. Identifying early, middle and late early warning signs Helping the client to detect early warning signs is best done with open-ended questioning to elicit both symptoms and the idiosyncratic responses which the individual associates with mood change. It is crucial that the client brainstorms as many signs as possible. It is helpful to prompt the client to consider mood, behaviour and thoughts when considering signs of mood change. It is also important that such changes are anchored in the social context: Issues concerned with social interaction and also the responses of others should be considered. Often the early warning signs reported will be a combination of changes which the client picks up and those which are reported to them by trusted friends or relatives. Some clients may struggle to identify idiosyncratic signs; in this case there are a number of lists of commonly endorsed signs that can be used as a starting point (e.g. Smith and Tarrer, 1992; Lobban et al., 2011). Once a list of early warning signs has been identified then the card sort technique reported by Perry et al. (1999) is an efficient method for organising early warning signs. Each symptom is written separately on a card. The client then sorts the cards into early and late symptoms, allocating middle stage symptoms by default. Once these stages have been identified the client then estimates the approximate duration of each stage. Once this has been agreed, an early warning signs list is drawn up. Figure 9.7 shows Laura’s three stages for mania (early, middle and late signs). In her case, the entire period lasts approximately 10 days. Pairing early warning signs with coping skills Once early, middle and late signs have been identified, the next task is to identify what coping approaches might best be applied at each stage. In doing this the therapist will review in some detail the coping approaches which the client has used in the past, as well as the skills developed during therapy. It is often the case that clients have previously addressed some early symptoms, but either have not systematised this response or have failed to employ it because the significance of a particular symptom has been missed. When they are drawn together in this way it becomes more obvious why a coping response might be needed. It can be helpful here to ask the client to review previous early warning signs and to visualise how they think particular approaches might have impacted on their symptoms had they applied them. When considering coping skills and early, middle and late signs, a crucial aspect of the rationale is to help the client to maintain choice and control. Many clients will have experienced these signs leading to episodes in which they have experienced admission to hospital, including involuntary admissions under the

210  Elizabeth Tyler and Steven Jones Early warning sign

Coping strategy

Early stage (2–3 days from onset) More talkative Creativity More energy Optimistic about future Sleep disrupted

Coping in early stage Cut down caffeine Try to stick to normal sleep routine Gentle gym classes – yoga, body balance Defer planning Slow down and pace self

Middle stage (4–5 days from onset) Ideas flowing fast Difficulty concentrating Stronger interest in sex Difficulty sleeping Spending money more freely Texting old friends

Coping in middle stage Withdraw self from stimulating environments Talk to husband Challenge positive thoughts Sleep medication Remove alcohol from house

Late stage (swings into full blown mania within a day or two) Racing thoughts Can’t get off to sleep Going to church Auditory hallucinations Drinking alcohol every day

Coping in late stage See psychiatrist Change in medication Time off from work

Figure 9.7  Early warning signs and coping strategies for Laura.

Mental Health Act. Even prior to this, many clients will recall having reached a stage when others were making decisions for them. This can be experienced as stressful and upsetting by the client, even if the actions were taken with the best of intentions. When the client understands that early detection of mood changes is associated with having choice and control over what happens, engagement with early warning sign work is enhanced. Long-term issues Final sessions should allow time to consider issues that are relevant to many people with a mental health history. Shame and guilt are commonly reported by individuals with bipolar disorder. Guilt is most common during the depressive and inter-episode phase of bipolar disorder and is commonly focused on actions that occurred during a manic episode. This can be related to behaviours engaged in when unwell, such as running up large debts or behaving in a sexually disinhibited manner. It can also be associated with having a label of mental illness and the reactions of others to this. Clinically, we have found that the process of working in a CBT manner with individuals is helpful in addressing some of these issues. It can be helpful to review problem-solving approaches to the different difficulties associated with their own experiences, to see these issues in a balanced

Case formulation in bipolar disorder  211

way. The important work that Paul Gilbert (2009) has been doing with shame and self-criticism can also be useful when working with individuals with bipolar disorder. Stigma is another issue which can be helped by considering mental health problems from a CBT perspective. It cannot, of course, deal with the stigmatising beliefs of others, but it can help individual clients avoid adding to this problem by stigmatising themselves.

Life span issues and bipolar disorder The family and bipolar disorder When engaging individuals with bipolar disorder in psychological therapy it is important to explore the role and context of the family. Research indicates that people in families with high expressed emotion attitudes (including criticism, hostility or emotional over-involvement) are 2–3 times more likely to relapse in the nine months post hospital admission than people in low expressed emotion families (Miklowitz, 2004; 2007). In parallel, the caring role can place considerable pressure upon carers, with approximately 90% of family members reporting high levels of burden attributed to caring for someone with bipolar disorder (Perlick et al., 2007). This can impair their ability to care for the individual resulting in poorer clinical symptom and medication outcomes for service user and higher levels of burden and distress in the relative (Ostacher et al., 2008; Perlick et al., 2004). Research has demonstrated that family focused treatment can improve relapse rates for individuals with bipolar disorder (Miklowitz et al., 2003; Reinares et al., 2006). It can be helpful to ask a relative to attend one or more sessions which focus on the development of an early warning and coping plan. This will help the relative develop a better understanding of the client’s mood experiences and agreements can be put in place as to when they can become involved if they are worried that their mood is escalating. Older age and bipolar disorder Bipolar disorder is present throughout adulthood (Goodwin and Jamison, 2007; Kennedy et al., 2005); however, there is very little research or service development for older adults with BD (Charney et al., 2003). The NICE guidelines (2006) highlight significant limitations to the evidence base for the treatment of individuals with BD who are over the age of 65. However, there is good evidence to suggest that cognitive therapy can be successfully adapted to meet the needs of older people with mental health problems. A Cochrane review (Wilson et al., 2008) supported the efficacy of CBT for depression in later life (Breckenridge, 1985; Scogin, 1987, 1989; Arean, 1993; Floyd, 1999). There is also an evidence base for the effectiveness of CBT in the treatment of anxiety disorders (Barrowclough et al., 2001; Stanley et al., 2003).

212  Elizabeth Tyler and Steven Jones

There is no reason to believe that the therapeutic approaches described throughout this chapter will not be effective for older individuals with BD. However, there are a number of issues that should be taken into consideration when working with individuals in the later stages of their life. There may be age-related changes in cognitions, such as a decline in working memory or cognitive speed and it is important that appropriate adaptations are made. This may include the way that the information is presented, slowing the pace of the sessions with frequent repetitions and summaries. Information may be presented both visually and orally and a trusted friend or relative may attend sessions so that they are familiar with the CBT strategies. There are other common life stages that should be taken into account, such as physical illness, retirement and job loss, loss of societal and financial status and changes in interpersonal relationships due to illness or death (Sajatovic, 2002).

Conclusions Bipolar disorder has only recently been studied from a psychological perspective. There is now increasing evidence for the importance of cognitive behavioural therapy in improving functioning and reducing risk of relapse. The adaptation of traditional CBT to target functional outcomes, including recovery (Jones et al., 2012), may offer promising results which corresponds with current UK government recommendations. This chapter has identified a number of key aspects of cognitive therapy as applied to bipolar disorder. The targets of therapy include helping the client to stabilise routines and to deal more adaptively with mood fluctuations, although this is only effective when the client is properly engaged. The likelihood of engagement is increased by taking the time to do a full psychological assessment, which includes developing a shared account of the client’s symptom and life history. This information is then configured into a formulation which is used to help guide therapy. Client and therapist work together to establish how making changes consistent with a CBT approach will help achieve important functional and symptom goals. The use of detailed mood and activity records is important in identifying mood variation and its relationship to external events. Identification of early warning signs and the development of coping strategies are important aspects of CBT for bipolar disorder and apply to both mania and depression. Successful completion of CBT will include work on longer-term issues which, if left untreated, might leave the client at risk of further relapse.

References Alloy, L. B. et al. (2005). The psychosocial context of bipolar disorder: Environmental, cognitive, and developmental risk factors. Clinical Psychology Review 8: 1043–75. Alloy, L. B. et al. (2008). Behavioral approach system and behavioral inhibition system sensitivities and bipolar spectrum disorders: Prospective prediction of bipolar mood episodes. Bipolar Disorders 10: 310–22.

Case formulation in bipolar disorder  213 Altman, E. G. et al. (1997). The Altman Self-Rating Mania Scale. Biological Psychiatry 42: 948–55. American Psychiatric Association (2002). Practice guideline for the treatment of patients with bipolar disorder (revision). American Journal of Psychiatry 159: 1–50. Ankers, D. and Jones, S. H. (2009). Objective assessment of circadian activity and sleep patterns in individuals at behavioural risk of hypomania. Journal of Clinical Psychology 65: 1071–86. Arean, P. A. et al. (1993). Comparative effectiveness of social problem-solving therapy and reminiscence therapy as a treatment for depression in older adults. Journal of Consulting and Clinical Psychology 61: 1003–10. Ball, J. R. et al. (2006). A randomised controlled trial of cognitive therapy for bipolar disorder: Focus on long term change. Journal of Clinical Psychiatry 67: 277–86. Barrowclough, C. et al. (2001). A randomized trial of the effectiveness of cognitive– behavioural therapy and supportive counselling for anxiety symptoms in older adults. Journal of Consulting and Clinical Psychology 69: 756–62. Basco, M. R. and Rush, A. J. (1996). Cognitive-Behavioral Therapy for Bipolar Disorder. New York: Guilford Press. Basco, M. R. and Rush, A. J. (2007). Cognitive-Behavioral Therapy for Bipolar Disorder (2nd ed.). New York: Guilford Press. Bauer, M. S. et al. (1991). Independent assessment of manic and depressive symptoms by self-rating: Scale characteristics and implications for the study of mania. Archives of General Psychiatry 48: 807–12. Beck, A. T. (1983). Cognitive therapy of depression: New perspectives. In P. J. Clayton and J. E. Barrett (eds) Treatment of Depression: Old Controversies and New Approaches. New York: Raven. Beck, A. T. et al. (1996). Comparison of Beck Depression Inventories –IA and –II in psychiatric outpatients. Journal of Personality Assessment 67(3): 588–97. Beck, A. T. and Steer, R. A. (1988). Beck Hopelessness Scale. San Antonio, TX: Psychological Corporation. Breckenridge, J. S. et al. (1985). Solicitation of elderly depressives for treatment outcome research: A comparison of referral sources. Journal of Consulting and Clinical Psychology 53: 552–54. Burgess, S. et al. (2001). Lithium for maintenance treatment of mood disorders. Cochrane Database of Systematic Reviews 3: CD003013. Butzlaff, R. L. and Hooley, J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry 55: 547–52. Charney, D. S. et al. (2003). Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Archives of General Psychiatry 60: 664–72. Cipriani, A. et al. (2005). Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: A systematic review of randomized trials. American Journal of Psychiatry 162: 1805–19. Denicoff, K. D. et al. (1997). Comparative prophylactic efficacy of lithium, carbamazepine, and the combination in bipolar disorder. Journal of Clinical Psychiatry 58: 470–78. Department of Health (2009). New Horizons: A Shared Vision for Mental Health. London: Author. Department of Health (2011). No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy. London: Author.

214  Elizabeth Tyler and Steven Jones Donohoe, G. et al. (2012). Social cognition in bipolar disorder versus schizophrenia: Comparability in mental state decoding deficits. Bipolar Disorders 14: 743–48. Fajutrao, L. et al. (2009). A systematic review of the evidence of the burden of bipolar disorder in Europe. Clinical Practice and Epidemiology in Mental Health 5: 3. Floyd M. R. (1999). Cognitive therapy for depression: A comparison of individual psychotherapy and bibliotherapy for depressed older adults. Dissertation Abstracts International 58(9-B): 5081. Geddes, J. R. et al. (2004). Long-term lithium therapy for bipolar disorder: Systematic review and meta-analysis of randomized controlled trials. American Journal of Psychiatry 161: 217–22. Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment 15: 199–208. Goodwin, F. K. and Jamison, K. (2007). Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression (Vol. 2). New York: Oxford University Press. Goodwin, G. M. (2009). Evidence-based guidelines for treating bipolar disorder: Revised second edition – Recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 23: 346–88. Green, M. F. et al. (1994). Backward masking in schizophrenia and mania. Specifying a mechanism. Archives of General Psychiatry 51: 939–44. Harvey, A. G. et al. (2005). Sleep-related functioning in euthymic patients with bipolar disorder, patients with insomnia, and subjects without sleep problems. American Journal of Psychiatry 162: 50–57. Hirschfeld, R. M. et al. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry 157: 1873–75. Hooley, J. M. (2007). Expressed emotion and relapse of psychopathology. Annual Review of Clinical Psychology 3: 329–52. Hosang, G. M. et al. (2012). Life-event specificity: Bipolar disorder compared with unipolar depression. British Journal of Psychiatry 201: 458–65. Johnson, S. L. (2005). Mania and dysregulation in goal pursuit: A review. Clinical Psychology Review 25: 241–62. Johnson, S. et al. (2008). Life events as predictors of mania and depression in bipolar I disorder. Journal of Abnormal Psychology 117: 268–77. Johnson, S. and Jones, S. H. (2009). Cognitive correlates of mania risk: Distinct or overlapping? Journal of Clinical Psychology 65: 891–905. Johnson, S. L. and Leahy, R. L. (2005). Psychological Treatment of Bipolar Disorder. New York: Guilford Press. Johnson, S. L. and Miller, I. (1997). Negative life events and time to recovery from episodes of bipolar disorder. Journal of Abnormal Psychology 106: 449–57. Johnson, S. L. and Roberts, J. E. (1995). Life events and bipolar disorder: Implications from biological theories. Psychological Bulletin 117: 434–49. Jones, S. (2004). Psychotherapy of bipolar disorder. Journal of Affective Disorders 80: 101–14. Jones, S. H. (2001). Circadian rhythms, multilevel models of emotion and bipolar disorder: An initial step towards integration? Clinical Psychology Review 21: 1193–209. Jones, S. H. et al. (2005). Actigraphic assessment of circadian activity and sleep patterns in bipolar disorder. Bipolar Disorders 7: 176–86.

Case formulation in bipolar disorder  215 Jones, S. H. et al. (2006). Appraisal of hypomania relevant events: Development of a questionnaire to assess positive self-dispositional appraisals in bipolar and behavioural high risk samples. Journal of Affective Disorders 93: 19–28. Jones, S. et al. (2012). A randomised controlled trial of recovery focused CBT for individuals with early bipolar disorder. BMC Psychiatry 12: 204. Jones, S. et al. (2013). The bipolar recovery questionnaire: Psychometric properties of a quantitative measure of recovery experiences in bipolar disorder. Journal of Affective Disorders 147: 34–43. Judd, L. L. et al. (2002). The long-term natural history of the weekly symptomatic status of bipolar I disorder. JAMA Psychiatry 59: 530–37. Kennedy, N. et al. (2005). Gender differences in incidence and age at onset of mania and bipolar disorder over a 35-year period in Camberwell, England. American Journal of Psychiatry 162: 257–62. Kessing, L. V. et al. (2011). Valproate v. lithium in the treatment of bipolar disorder in clinical practice: Observational nationwide register-based cohort study. British Journal of Psychiatry 199: 57–63. Kinderman, P. and Lobban, F. (2000). Evolving formulations; sharing complex information with clients. Behavioural and Cognitive Psychotherapy 28: 307–10. Kleinman, L. et al. (2003). Costs of bipolar disorder. Pharmacoeconomics 21: 601–22. Lam, D. et al. (2000). Cognitive therapy for bipolar illness: A pilot study of relapse prevention. Cognitive Therapy and Research 24: 503–20. Lam, D. et al. (2001). Prodromes, coping strategies and course of illness in bipolar affective disorder: A naturalistic study. Psychological Medicine 31: 1397–402. Lam, D. H. et al. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Archives of General Psychiatry 60: 145–52. Lam, D. H. et al. (2005). Cost-effectiveness of relapse-prevention cognitive therapy for bipolar disorder: 30-month study. British Journal of Psychiatry 186: 500–506. Lam, D. H. et al. (2010). Cognitive Therapy for Bipolar Disorder: A Therapist’s Guide to Concepts, Methods and Practice. Chichester: Wiley. Lam, D. and Wong, G. (1997). Prodromes, coping strategies, insight and social functioning in bipolar affective disorders. Psychological Medicine 27: 1091–100. Leahy, R. L. (2007). Bipolar disorder: Causes, contexts, and treatments. Journal of Clinical Psychology 63: 417–24. Leibenluft, E. et al. (1996). Relationship between sleep and mood in patients with rapid-cycling bipolar disorder. Psychiatry Research 63: 161–68. Liebert, R. J. (2013). A re-view of ambivalence in bipolar disorder research. Ethical Human Psychology and Psychiatry 15: 180–94. Lobban, F. et al. (2011). Early warning signs checklists for bipolar depression and mania: Utility, reliability and validity. Journal of Affective Disorders 133: 413–22. Lobban, F. et al. (2012). Bipolar Disorder is a two-edged sword: a qualitative study to understand the positive edge. Journal of Affective Disorders 141: 204–12. McCrone, P. et al. (2008). Paying the Price: The Cost of Mental Health Care in England to 2026. London: King’s Fund. Merikangas, K. R et al. (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the national comorbidity survey replication. Archives of General Psychiatry 64: 543–52.

216  Elizabeth Tyler and Steven Jones Merikangas, K. R. et al. (2011). Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Archives of General Psychiatry 68: 241–51. Meyer, T. D. and Hautzinger, M. (2012). Cognitive behaviour therapy and supportive therapy for bipolar disorders: Relapse rates for treatment period and 2-year follow-up. Psychological Medicine 42: 1429–39. Michalak, E. E. and Murray, G. (2010). Development of the QoL.BD: A disorder-specific scale to assess quality of life in bipolar disorder. Bipolar Disorders 12: 727–40. Miklowitz, D. et al. (2008). Common and specific elements of psychosocial treatments for bipolar disorder: A survey of clinicians participating in randomized trials. Journal of Psychiatry Practice 14: 77–85. Miklowitz, D. J. (2004). The role of family systems in severe and recurrent psychiatric disorders: A developmental psychopathology view. Development and Psychopathology 16: 667–88. Miklowitz, D. J. (2007). The role of the family in the course and treatment of bipolar disorder. Current Directions in Psychological Science 16:192–96. Miklowitz, D. J. et al. (1988). Family factors and the course of bipolar affective disorder. Archives of General Psychiatry 45: 225–31. Miklowitz, D. J. et al. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry 60: 904–12. Miklowitz, D. J. O. et al. (2007). Psychosocial treatments for bipolar depression: A 1-year randomized trial from the systematic treatment enhancement program. Archives of General Psychiatry 64: 419–27. Millar, A. et al. (2004). The sleep of remitted bipolar outpatients: A controlled naturalistic study using actigraphy. Journal of Affective Disorders 80: 145–53. Molnar, G. et al. (1988). Duration and symptoms of bipolar prodromes. American Journal of Psychiatry 145: 1576–78. Morriss, R. K. et al. (2007). Interventions for helping people recognise early signs of recurrence in bipolar disorder. Cochrane Database of Systematic Reviews 1: CD004854. Murray, G. and Johnson, S. L. (2010). The clinical significance of creativity in bipolar disorder. Clinical Psychology Review 30: 721–32. Neuchterlein, K. H. et al. (1991). Information-processing anomalies in the early course of schizophrenia and bipolar disorder. Schizophrenia Research 5: 195–96. Newman, C. F. et al. (2001). Bipolar Disorder: A Cognitive Therapy Approach. Washington, DC: American Psychological Association. NICE (2006). The management of bipolar disorder in adults, children and adolescents, in primary and secondary care: Clinical Guidelines CG38. Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressed mood. Journal of Abnormal Psychology 100: 569–82. Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology 109: 504–11. Ostacher, M. J. et al. (2008). Correlates of subjective and objective burden among caregivers of patients with bipolar disorder. Acta Psychiatrica Scandinavica 118: 49–56. Perlick, D. A. et al. (2004). Medication non-adherence in bipolar disorder: A patient centered review of research findings. Clinical Approach Bipolar Disorder 3: 59–70. Perlick, D. A. et al. (2007). Prevalence and correlates of burden among caregivers of patients with bipolar disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder. Bipolar Disorders 9: 262–73.

Case formulation in bipolar disorder  217 Perry, A. et al. (1999). Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal 318: 149–53. Post, R. M. et al. (2003). Morbidity in 258 bipolar outpatients followed for 1 year with daily prospective ratings on the NIMH life chart method. Journal of Clinical Psychiatry 64: 680–90. Power, M. J. and Dalgleish, T. (1997). Cognition and Emotion: From Order to Disorder. Hove: Psychology Press. Prien, R. F. and Potter, W. Z. (1990). N.I.M.H. workshop report on treatment of bipolar disorder. Psychopharmacology Bulletin 26: 409–27. Reinares, M. et al. (2006). What really matters to bipolar patients caregivers: Sources of family burden. Journal of Affective Disorders 94: 157–63. Rosenfarb, I. S. et al. (2001). Family transactions and relapse in bipolar disorder. Family Processes 40: 5–14. Russell, S. J. and Browne, J. L. (2005). Staying well with bipolar disorder. Australian and New Zealand Journal of Psychiatry 39: 187–93. Sajatovic, M. (2002). Treatment of bipolar disorder in older adults. International Journal of Geriatric Psychiatry 17(9): 865–73. Scogin, F. et al. (1987). Bilbliotherapy of depressed older adults: A self-help alternative. Gerontologist 27: 383–87. Scogin, F. et al. (1989). Comparative efficacy of cognitive and behavioural bibliotherapy for mildly and moderately depressed older adults. Journal of Consulting and Clinical Psychology 57: 403–7. Scott, J. (1995). Psychotherapy for bipolar disorder. British Journal of Psychiatry 167: 581–88. Scott, J. and Colom, F. (2005). Psychosocial treatments for bipolar disorders. Psychiatric Clinics of North America 28: 371–84. Scott, J. et al. (2000). Cognitive vulnerability in patients with bipolar disorder. Psychological Medicine 30: 467–72. Scott, J. et al. (2001). A pilot study of cognitive therapy in bipolar disorders. Psychological Medicine 31: 459–67. Scott, J. and Pope, M. (2003). Cognitive styles in individuals with bipolar disorders. Psychological Medicine 33: 1081–88. Serper, M. R. (1993). Visual controlled information processing resources and formal thought disorder in schizophrenia and mania. Schizophrenia Research 9: 59–66. Smith, J. A. and Tarrier, N. (1992). Prodromal symptoms in manic depressive psychosis. Social Psychiatry and Psychiatric Epidemiology 27: 245–48. Stanley, M. A. et al. (2003). Cognitive–behavioural treatment of late-life generalized anxiety disorder. Journal of Consulting and Clinical Psychology 71: 309–19. Teicher, M. H. (1995). Actigraphy and motion analysis: New tools for psychiatry. Harvard Review of Psychiatry 3: 18–35. Thomas, J. and Bentall, R. P. (2002). Hypomanic traits and response styles to depression. British Journal of Clinical Psychology 41: 309–13. Thomas, J. et al. (2007). Response styles to depressed mood in bipolar affective disorder. Journal of Affective Disorders 100: 249–52. Urosevic, S. et al. (2008). Dysregulation of the behavioral approach system (BAS) in bipolar spectrum disorders: Review of theory and evidence. Clinical Psychology Review 28: 1188–1205.

218  Elizabeth Tyler and Steven Jones Van der Gucht, E. et al. (2009). Psychological processes in bipolar affective disorder: Negative cognitive style and reward processing. British Journal of Psychiatry 194: 146–51. Vieta, E. and Colom, F. (2004). Psychological interventions in bipolar disorder: From wishful thinking to an evidence-based approach. Acta Psychiatrica Scandinavica Supplementum 422: 34–38. Virgil, G. L. (2010). Cognitive-behavioral therapy for depression in bipolar disorder: A meta-analysis. Journal of Evidence-Based Social Work 7: 269–79. Vos, T. et al. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2163–96. Wehr, T. et al. (1987). Sleep production as a final common pathway in the genesis of mania. American Journal of Psychiatry 144: 201–4. Wilson, K. C. et al. (2008). Psychotherapeutic treatments for older depressed people. Cochrane Database of Systematic Reviews 1: CD004853. Wolff, E. A. et al. (1985). Motor activity and affective illness: The relationship of amplitude and temporal distribution to changes in affective state. Archives of General Psychiatry 42: 288–94. Zaretsky, A. et al. (1999). Cognitive therapy for bipolar depression: A pilot study. Canadian Journal of Psychiatry 44: 491–94.

Chapter 10

Cognitive behavioural formulation for personality problems Henck van Bilsen and Simone Lindsey

Introduction A search of ‘personality disorders’ on Amazon.com comes up with almost 24,000 titles (January, 2014). But what exactly is personality disorder (PD)? The International Classification of Mental and Behavioural Disorders (ICD-10, World Health Organization, 1992), defines a personality disorder as ‘a severe disturbance in the characterlogical condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’. In this chapter we really want to take the phenomenon described as ‘personality disorder’ very seriously. Without any doubt, people with a diagnosis of personality disorder often make their own lives and the lives of those close to them very difficult. They also pose significant difficulties for clinicians trying to assist them. We want to take these problems very seriously by focusing on an idiosyncratic approach to clients with a diagnosis of personality disorder as opposed to a categorical approach. The development, maintenance and functionality of the client’s problem presentation needs to be understood using the underpinning theory and practice of cognitive behaviour therapy (CBT), as giving a person a label or attributing a diagnostic category to them does not add any value in our experience. We will also postulate that CBT for personality disorders is ‘just CBT and nothing special’; like driving a big car on a long, narrow and winding road is similar to driving a small car on a straight and very wide road, both are driving, but the style of driving in the larger car may be different: VERY SLOW AND VERY CAREFUL (van Bilsen and Thomson, 2011).

The problem with the diagnosis: Personality disorder Stigma Commons stereotypes of PD include: they are untreatable, they are difficult to work with, they are manipulative, attention seeking, team splitting and the general

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‘heart sink’ patient. The stigma associated with a diagnosis of PD can work in many ways. It freezes some therapists into a kind of threat mode, and thanks to the compassion literature (Gilbert, 2009) we know now that when in threat mode we do not produce our best work. Clinicians can turn away from people with a personality disorder diagnosis or they start the work with infectious doses of therapeutic pessimism, with an overriding sense of hopelessness. Moreover, people with a ‘label’ of personality disorder can often adopt this therapeutic pessimism (Bockian and Villagran, 2011; Dahl, 1993) and do not believe that change is possible for them. Diagnostic unreliability Studies indicate a prevalence of 10–13% of personality problems in the adult population in the community (APA, 2000). Often a heterogenic group of people is captured under the umbrella of personality disorder. This means that when someone presents to you with a diagnosis of PD, there are over 100 different combinations of symptoms/traits which could be present. Therefore it is of little wonder that there are strong moves to focus more on a dimensional model of personality disorder as opposed to the current dichotomous model (Widiger and Trull, 2007). As Tyrer (2013) eloquently puts it, the diagnostic categories of PD lead to a ‘Great Clinical Switch Off’ (p. 1). We are in effect in the same stage of development regarding personality disorders now as we were half a century ago with respect to anxiety disorders (Wolpe, 1958, 1964): we know some things work sometimes, with some patients in certain circumstances but we are in no position to proclaim the existence of effective evidence-based interventions for patients with a diagnosis of personality disorders.

Some evidence inspired contemplations The evidence for the effectiveness of the treatment for personality disorders is not hope-inspiring. Bateman and Tyrer (2004) suggest four criteria that need to be fulfilled for a treatment to be considered effective: 1 2 3 4

Demonstrate efficacy in randomised controlled trials over control treatments when used for a pure form of the personality disorder Similar outcomes in pragmatic randomised controlled trials Consistency in efficacy across settings when used with appropriate treatment fidelity Maintenance of outcomes over time (preferably more than 1 year).

They concluded in 2004 that there are no treatments that have passed this test. There has been more charisma then ‘real’ evidence in discussions about CBT-based treatments for personality disorders. A recent RCT which looked at the effectiveness of CBT for BPD, the UK BOSCOT sample, found that self-harm

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changes the most and mood changes the least, and that this is maintained over a 6-year follow up (Davidson, 2007). There have been a number of other variations of CBT which have been developed specifically for PD, including dialectical behaviour therapy (DBT; Linehan, 1993), systems training for emotional predictability and problem solving (STEPPS, Blum et al., 2008), schema focused therapy (Young 1990) and compassion focused therapy (CFT, Gilbert, 2009). The answer for now may be with Bateman and Fonagy’s (2000) suggestions. After reviewing the literature they suggest a range of generic (read a-theoretical) guidelines. Treatment should be: 1 2 3 4 5 6 7

Well structured Devote considerable effort to enhancing compliance Clear in focus (focused on problems and goals) Theoretically coherent to both therapist and client Relatively long term Invest in the therapeutic relationship Well integrated with other services available.

The NICE guidelines for borderline personality disorder (2009) support similar treatment.

The answer to the problems of stigma, diagnostic unreliability and lacking evidence Good old CBT (unified treatment model) As previously stated (van Bilsen and Thomson, 2011), the treatment of people with personality problems or disordered personalities does not require any special treatment, it merely needs well conducted cognitive behaviour therapy. In this chapter, we would like to make the case that when working with people for personality disorder there is a call for ‘full blown, good old-fashioned CBT’. In essence, CBT treatment should involve: 1) designing idiosyncratic formulations based on learning theory and the cognitive model of emotions, 2) basing treatment interventions on a formulation, 3) investing in engagement and building therapeutic rapport and 4) accepting that achieving meaningful and lasting change takes time. Based on this last point, therapy needs to be relatively long term and it’s important for therapists to be open and honest with clients about this, as sadly there is no quick fix. Treatment-interventions based on learning theory and the cognitive model of emotions As stated before, we do not see the cognitive behavioural treatment of people with a diagnosis of personality disorder as significantly distinctive to the treatment

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of people with common mental health problems such as depression or anxiety disorders. For us, then, a good starting point is the guidelines from Bateman and Fonagy (2000), mentioned earlier. Recently Barlow and colleagues (2004) suggested a unified treatment model for emotional disorders. Instead of creating a multitude of disorder-specific treatment approaches, the suggestion is to set up idiosyncratic treatments following a limited set of parameters: psycho-education, altering antecedent cognitive appraisal, emotion-driven behaviours and emotional avoidance. Psycho-education The client needs to develop an understanding of their specific problems and needs to become a gifted amateur in CBT. In CBT it is customary to start the treatment process with an assessment that culminates in a formulation about the emergence and maintenance of the problems (and this is really so much more than a diagnosis). Practically this means that therapists have to invest time in explaining their assessment and formulation results to the client in a manner that makes sense to the client. It is also essential that the client learns that: • • •

Problems are the result of an often long learning process Problems are influenced by unhelpful/irrational thinking The brain sometimes learns to have a mind of its own.

Socialising the client to the CBT model is an ongoing process whereby the therapist provides brief explanations, but mainly utilises the client’s own narrative of their problems as opportunities to highlight the workings of the CBT model. Socialising to the CBT model is therefore an integral part of the treatment process. Altering antecedent cognitive appraisals Many psychological problems are facilitated through the person’s unhelpful (irrational) thinking. A component of the cognitive behavioural treatment of people with a diagnosis of personality disorders therefore needs to include: • • •

Teaching the person about the concept of rational and irrational thinking Teaching the person to apply this to their personal problem behaviours and emotions Teaching people to replace irrational thinking with more balanced thinking, which requires more effort with this client group due to the entrenched nature of the thinking patterns.

Within CBT there is a whole range of techniques that can be used to achieve this including:

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• • •

Socratic dialogue Daily thought records (DTR) Behavioural experiments Below is an example of reviewing DTR in therapy:

C: Right, the trigger was a patient shouting and screaming at me and threatening to hit me in the café, which was packed full of people. T: Okay, so the situation was that a patient was shouting and screaming at you over at the café. C: And threatening to hit me in front of a whole packed café T: That sounds like a difficult situation. And what was going through your mind when this was happening? C: One: she’s trying to make me look stupid, which I believed to be true at 80 out of 100. Two: she’s got something against me, 80. Three: she’s targeting me, 80. T: Okay, so the thoughts there that you’ve picked out, that you’ve rated really high, were: she’s trying to make me look stupid, she’s got something against me and she’s targeting me. Okay, and what were the emotions that you felt during this situation? C: Embarrassed, which I rated as feeling 100%, and angry, 100. T: Okay, so some really strong emotions there; embarrassed is at 100% and anger is at 100%. Did you notice any changes in your body at this time? C: Yeah, my cheeks felt hot, I felt tense and could feel my jaw clenching and my fists clenching; my heart was beating fast. T: Right, okay, so you noticed physiological changes such as your heart beating faster, tension in your muscles and your cheeks felt hot. C: Yeah. T: Okay, and what was the self-defeating behaviour that you engaged in? C: I shouted at her to shut up and put my hand up like that [demonstrates holding hand in front of other person’s face]. T: Okay, so putting your hand up in front of her. C: She became more aggressive and started to shout at me louder and tried to hit my hand away. But she left me alone after that and she was asked to leave and had to be escorted back to the ward. I then went through using the form, disputing each of the thoughts. So, is this thought true? No. Is it helpful? No. T: Okay, so you’ve then gone through and disputed each one, you’ve started with the first one and you’ve said, ‘no, that’s not true and not helpful.’ Okay, great. C: I’ve done it ‘No’ for all of them. T: Okay, so you’ve looked through all of them and established that none of them are factual and none of them are helpful. Fantastic, okay. C: So, rational thoughts. One, she’s probably having a bad day, 100; two, it could have been anyone, 100; three, usually we’re so close and you take things out

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T: C:

T: C:

T:

C: T: C:

on the ones closest to you. And the outcome was that I don’t believe them [referring to NATs], I was just so angry and embarrassed at the time but she said sorry and said I could have been anyone. Now we’re fine. Okay, that’s good to hear, and the new behaviour, what would you do differently next time? . . . If that situation happened again, I’d say ‘look Lucy, please tell me if there is something bothering you.’ I’d say ‘is there something bothering you? I don’t want a fight with you or an argument with you. Is there something I can help you with?’ It sounds like this time you’d say, ‘look Lucy, what’s wrong? I can see something’s bothering you.’ So trying to have a conversation about it. Yeah, because she probably would have cried in my arms and then she would have probably told me what was bothering her, if I’d have done it that way, but I was just so embarrassed and angry with it at the time that I wasn’t thinking in that way. So, you’ve recognised that because you felt so embarrassed and angry, the emotions were so strong, the negative thoughts were really there and that lead you to carrying out ‘shut up, just stop it’ kind of behaviour . . . Yeah. So, if you were in that situation again and you were able to think these things here [points to RATS]. Would that enable you to do the different behaviours you just said? Yeah, because the anger would be less.

Modifying emotion-driven behaviours Emotions are the driving forces behind our actions. We do things to get (or get more of) positive feelings and we do things to get rid of, or get less of, negative feelings. Most problem behaviours are fuelled by the desire to reduce negative feelings or to increase positive feelings. Emotion-driven behaviours (EDBs) are often referred to as ‘action tendencies’ in the literature of emotion science (Barlow et al., 2004). EDBs can serve an adaptive purpose in specific situational demands (e.g. running away in response to a snarling dog with bared teeth) but become maladaptive and contribute to emotional problems when the behaviours occur at inappropriate times (e.g. running away from a public place – with no danger in sight – in response to one’s anxiety). EDBs are initially reinforcing as they reduce the intensity of a negative emotion or result in an increase of a positive feeling but they will be ultimately maladaptive. For example, drinking alcohol to reduce anxiety in response to fear of rejection is not a good long-term strategy to manage interpersonal relationships. Patients have to learn to recognise their habitual EDBs and the medium- to long-term self-defeating quality of them. They will also learn new and more adaptive responses to these emotional states. In CBT there is again a number of strategies that can assist the person to move away from emotion-driven behaviour:

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• Exposure and response prevention (van den Hout et al., 1988) • Communication skills training (Linehan, 1993; Verheul, 2003; Dixon et al., 2001) • Problem-solving skills training (D’Zurilla and Nezu, 2007). • Self-management training (Giesen-Bloo, 2006; Linehan, 1993; Hopko et al., 2003; Feldhege, 1979; van Bilsen and Whitehead, 1994; Cook et al., 2009). Below is an example of communication skills training with a client with a diagnosis of borderline personality disorder: T: Okay, so you felt really angry when she kept asking you to look at the magazine and you told her to shut up. C: Yeah, I mean she just kept bugging me and I was really busy completing a piece of homework for my CBT group and was trying to concentrate. And in the end I just shouted at her ‘leave me alone, go away.’ T: Okay, and how did Jane respond? C: She went away for about five minutes but then just came back and was poking me trying to get my attention. T: Okay, so she was poking you and trying to get your attention, but you were busy and trying to do something which was really important to you. So understandably you felt frustrated and as a result of that feeling and the appraisal that she was doing it on purpose to annoy you, you shouted at her to leave you alone. C: Yeah. T: Okay, how do you think Jane feels when you tell her to go away? C: Upset, I mean, I would if someone spoke to me in that way. T: Okay, so if someone spoke to you in that way you would feel upset. Can you clarify what you mean by upset? C: Yeah, like a bit sad and a bit pissed off. T: Okay, and why would that make you feel a bit sad and pissed off? C: Erm . . . because I would be annoyed that they didn’t ask me nicely and I would feel hurt that they didn’t want to hear what I had to say. T: Right, okay, so . . . C: I guess that’s how Jane might feel when I tell her to go away. T: Okay, so maybe that’s the way Jane feels when you tell her to go away . . . C: . . . Yeah, which explains why she keeps coming back, she probably doesn’t really get how much it upsets me. T: Right, okay, so maybe part of the difficulty here is that Jane doesn’t realise how you feel when she asks for your attention and you’re busy doing something. Okay, so how do you think we might overcome that? C: Well I could tell her that, you know, say ‘when you keep asking me to look at your magazine and I’m busy trying to concentrate, it makes me feel annoyed.’ T: Okay, and what would you like Jane to do differently?

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C: Stop. T: Okay, and what do you think would be a good way to make this request? Could we practice here now what you might say? C: Yeah, okay. T: Okay, so I’ll pretend to be Jane and I’ve been poking you and asking you to look at my magazine . . . C: Look, Jane, I’m really sorry but when you keep asking me to look at the magazine it makes me feel cross because I’m busy doing something really important. T: . . . Okay, I’ll come back in a minute then . . . C: No . . . I mean, actually . . . would you mind giving me 30 minutes until you come back? Please? T: Okay, great, well done Claire, so you managed to express a negative emotion there and put across a positive request. How did it feel doing that? C: It felt weird, but also I felt a bit nicer, and like I was getting my point across without upsetting her.

Preventing emotional avoidance Whereas EDBs are used to reduce or escape from negative feelings (or gain access to positive feelings), emotional avoidance is used to prevent the actual experience of the negative emotion in the first place. There are several forms of emotional avoidance. Subtle behavioural avoidance typically occurs when a person encounters a situation he or she associates with strong negative feelings. If many situations and people have become associated with strong negative feelings, then the person ‘has no place to go’ and we might see acting out behaviour in the form of violence to others or self (as is often observed in people with a diagnosis of borderline personality disorder). In ‘emotional avoidance’ the essential element is that the person deploys strategies to prevent the emotion from occurring. This is not escaping from a negative emotion but deploying strategies to prevent it from happening at all. This poses a challenge for the therapist and for the client alike as the client is responding in the absence of a negative feeling. Frequently, the process is so overlearned that the strategies to avoid the emotion are deployed before the real awareness of the negative emotion to be avoided has set in. The ‘avoidance strategies’ subsequently create their own emotional turmoil which overshadows the first subtle hint of awareness of the ‘negative emotion to be avoided’. The following CBT strategies work to teach people to go against emotional avoidance: • Behavioural activation • Exposure and response prevention • Mindfulness.

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Formulation based Well-conducted cognitive behaviour therapy needs to be formulation based. As stated earlier (van Bilsen and Thomson, 2011; van Bilsen, 2012), composing a formulation consists of four steps: 1 2 3 4

Understanding how the problem occurs ‘in the here and now’: topographical analysis Understanding the function of a problem behaviour: functional analysis Understanding how the person learned THESE problem behaviours: historical analysis Combining various functional analyses and the historical analysis in a narrative that explains the emergence of the problems and how they currently are maintained: the formulation.

Topographical analysis: The SORC maintenance cycle The SORC maintenance cycle is a helpful system to understand how reinforcement and other learning theory paradigms play a role in the maintenance of problems (Goldfried, 2003; Nezu et al., 2004; Eells, 2006; Sturmey, 2007). It involves getting a detailed overview of exactly what happened in a specific problem situation, involving details surrounding the situation, organism, responses and consequences. Talking with clients about many situations in which they encountered problems or engaged in the problem behaviour is essential for effective work with people with persistent and chronic problems. They have so often engaged in the same pattern of problems that their personal awareness of all the relevant elements is very low. Careful detailed questioning is essential. Situation This involves a description of the situation that triggers the problem or the situation in which the problem occurs. This would involve issues like places, times, people. Organism This involves the client’s internal reaction to the situation or trigger: Cognitions, feelings and physiology. Of course these three elements may ‘fire’ in a certain sequence, which is also important to note. This firing will occur in an idiosyncratic sequence; for some, in some situations the cognitions ‘fire’ first; while for others the physical sensations are the first to ‘fire’. Responses These are the behaviours the client engages in as a result of the ‘O’ reaction. We often see that what happens in ‘O’ is perceived by the client as unpleasant and

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they see the behaviour they engage in as the only option to escape the unpleasantness. We also often see here cognitions emerge that give ‘permission’ to engage in unhelpful behaviour. It is important to recognise that the ‘emotions–cognitions– physiology’ cycle can go round several times before the client engages in the problem behaviour. Consequences Here the actual result of the behaviour is described and interpreted from a learning theory perspective. What is the result of the behaviour and is it a reinforcing or punishing consequence? As a general rule, problem behaviours that continue to happen ‘need’ reinforcement otherwise they would be extinguished. Often clients find it difficult to understand the validity of consequences (e.g. is the consequence rewarding or not) and that is because they have a time frame that is too long. For the maintenance cycle, we really are interested in the consequences closest to the problem behaviour, not what happened after one hour, but what happened after one minute! Immediate consequences are far more important in influencing the behaviours that follow than longer-term consequences. From TA to FA: From SORC to SORCC To compose a functional analysis we can use the same format: SORC, but with an added C for ‘contingency’. Contingencies The elements of the SORCC paradigm occur in a certain chronology: The situation, the person’s internal reaction, the behavioural response and the consequences that follow the behaviour. ‘Contingencies’ does not refer to a specific element, but to the relationship between the various elements. From a learning perspective this relationship is extremely important. A consequence that occurs 100% of the time in the presence of the behaviour and never when the behaviour is NOT present, will be very effective in getting the behaviour established in the person’s repertoire for as long as the 100% connection occurs. Behaviour–consequences connections of the 100% kind are, however, not very resistant against ‘unlearning’ the behaviour. When used to 100% connection, the behaviour will be rapidly terminated when the connection no longer occurs. The story is very different for a more intermittent and variable link between behaviour and consequence. Here, the person has learned that there is a chance the consequence may occur, so if it does not materialise for several occurrences of the behaviour, the person will still persist. This is what gamblers do and this is what has hooked us on watching television. In both cases if you persist long enough you will win or watch something good on TV!

Formulation for personality problems  229 Table 10.1  Functional analysis Antecedent

Belief

Consequence

Someone says something critical to me

I am worthless; I deserve it

I feel angry, so I hit them and I feel better – negative reinforcement. However, in the long term I lose my leave and this hinders my progress, and I feel depressed.

A functional analysis aims to uncover the purpose or function of the problem behaviour. Functions can be defined as enabling someone to achieve something desirable or avoid something undesirable. The function of problem behaviours can be understood by carefully examining – through several topographical analyses – what triggers the behaviour and what is the result of the behaviour. An example of a functional analysis can be seen in Table 10.1. Problem behaviour history Part of the assessment is to put the problem behaviour in a historical context. The following questions may need answering: • • • • •

When did the client start engaging in the problem behaviour? Which rules and regulations are connected to the problem behaviour? Which models did the client have regarding the behaviour? When did the behaviour become problematic? Are there problematic circumstances connected with the period in which the behaviour became problematic?

It also may be helpful to make a chronological timeline of the behaviour and to make a retrospective overview of the last couple of years regarding the problem behaviour. With clients who have long-standing problems, it may be especially important to go beyond the problem history and aim for a comprehensive historical analysis. Formulation: SORCC-s A functional analysis focuses on one problem area, while a formulation is a holistic theory about the emergence and maintenance of all problem behaviours. A functional analysis from a SORC perspective puts the ‘problem behaviour’ in the centre and analyses its occurrence under a variety of circumstances. By doing this, it finds the idiosyncratic function that the problem behaviour has for this person. In a formulation, the therapist links the various problems and defines their

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relationships. A formulation comprises of the main problems that make life difficult and explains how they are linked together. It helps to understand which problem issues are more or less central, e.g. which problems are causing the others and which are more peripheral. A formulation links the various functional analyses together in a coherent narrative. In this narrative it is important to address to what extent the person ‘buys’ into a psychological model for their problems (or in other words, how much psycho-education still needs to be done). It is also important to identify to what extent irrational thinking plays a role in the emergence and maintenance of the problems; which emotional driven behaviours are instrumental in keeping the problems going and which emotional avoidance is pivotal.

Example of a formulation Understanding the client Although we say in technical terms that the aim of the assessment is to develop a pocket-sized theory on the emergence and maintenance of the problem, the real goal is to really understand the client. We need to understand why this person, with this learning history, has developed these problems. A good and detailed assessment resulting in an individualised formulation and treatment plan will pay off. It may seem like quite a bit of time is spent on this before actually offering treatment to the client, but it is really time very well spent. It is a bit like making a route-plan before embarking on a journey. If it is a very familiar journey, then the planning may not take that long, but if it is a complex journey that we are not familiar with, the planning will take longer and that will be useful when we are confronted with unexpected situations during the journey. It is very rare that a client will present with a simple problem, leading to a clear-cut problem definition, indicating that it could be treated by strictly adhering to one of the existing treatment protocols. We have found that when working with complex clients, it is very important to use the disorder-specific models and treatment protocols as inspiration and NOT as cookbooks that need to be followed like cordon-bleu recipes. SMART problems and goals A formulation needs to result in the identification of problems which the client and therapist will focus on and each of these problems needs to be linked with one or more ‘SMART’ (specific, measurable, achievable, relevant, time-bound) goals. It is very important to move from complaints and symptoms to specific problems. Complaints like ‘I feel tired all the time,’ ‘no one likes me’ and ‘I can’t stop self-harming’ need to be ‘translated’ into problems, e.g. the question needs to be asked ‘why is this issue a problem for the client?’ A problem definition often includes behavioural and emotional elements, for example: ‘I feel tired all the time, so I can’t do the things I really want to do (behaviour) and that makes me

Past Experiences Physical and verbal abuse from family, key memories of being hit and of brothers doing things such as leaving me alone in the dark streets when I was eight years old. Being shouted at for having TV volume turned up loud because I was deaf. Dad was an alcoholic.

Core Beliefs – about myself, others and the world I am alone, worthless, vulnerable, unlovable, bad/evil, others don’t care about me, the world is lonely, there’s nothing out there for me, I should be perfect. Strengths–having the courage to set such high standards for myself Maladaptive Assumptions 1. If I am perfect people will love me. If I am not perfect then I am bad and people will leave me. 2. I must do something to prevent people from leaving. 3. If I trust someone, they will let me down/hurt me. Current Problem I feel depressed, I think that I am worthless and I feel angry. Strengths–Hope, sociable and enjoy a variety of activities What triggers the problem now? Noise, violent images that play in my mind and people making fun of me What maintains the problem now? Thoughts No one cares I don’t know why this is happening to me It’s not fair There is no point, fighting a lost cause No one cares I'm an ‘animal’ People should understand me Everything should be perfect and it’s wrong Physical Sensations Tearful Butterflies in stomach Knot in stomach Heart pounding Breathing fast Tension in forehead

Emotions Shame Anxious Depressed Angry Behaviours Self harm Withdraw don’t talk Physical and verbal aggression towards others Ruminate Drink alcohol/take drugs (past) Too much/too little sleep

Figure 10.1  Generic linear formulation (from Beck, 1976) with maintenance cycle.

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angry (emotion).’ With clients whose lives often are chaotic and have been chronically unfulfilling, it is especially important to identify problems as specific as possible. Therapists should resist the urge to go along with vague problem definitions as ‘I just don’t feel myself’ or ‘everything sucks.’ Vague problem definitions lead to unstructured therapy and seldom result in the attainment of meaningful goals. Identifying meaningful SMART goals follows on from the problem selection. Each problem needs to be linked with one or more meaningful SMART goals. It is important to select goals that – when achieved – will disrupt the maintenance cycle that kept the problems going. Some guidelines for the selection of meaningful goals are: • • • • • • •

Are the consequences of the problem behaviour perceived as negative by the client? What is the likelihood that the target behaviour is amenable to change with the available methods and within the limits of the clinician’s competence, the resources of the client and the tolerance of the social environment? To what extent and in what way would the client’s present life improve if the treatment goal were attained? Are there any negative side effects of selecting this target for the client or others? Is the proposed change in the target behaviour or situation consistent with the client’s goals and values? To what extent is the client motivated toward attainment of this goal in relation to other goals? Will the goal be maintained by the client or the natural environment for long post-therapy effectiveness? (van Bilsen, 2012)

Invest in engagement People with personality problems are often not very motivated to work towards change. This could be because their problem behaviours result in too many rewards or because of the familiarity of the current situation or it may be connected with being afraid of the unknown that change will bring. These clients are a challenge for psychological therapists. If there is anything that makes treatment of people with personality problems different it is this apparent lack of engagement with treatment. The Stages of Change model (Prochaska and DiClemente, 1986) is a model that is helpful in developing an understanding about this lack of engagement and offering strategies what can be done about it. They postulate that humans change by going through a set series of steps (stages), as follows: 1. Pre-contemplation During this stage, people are not aware they have problems and therefore don’t think of change; there is a lack of integrated and accepted personal knowledge of

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the problems. If a person in pre-contemplation wanted to change anything, this would not be their own behaviour but the behaviour of others. 2. Contemplation In this stage, the client realises there could be personal problems. He/she starts thinking about possible ways to get rid of the problems but has not yet made the decision to change. 3. Determination/decision This is the transition from contemplation to active change. It is also possible to decide not to change by dropping out of the circle of change by way of exit one. The main obstacle that will prevent clients from reaching a decision is a lack of knowledge regarding change methods, not being aware of change method that fit clients’ preferences. This is the crux of motivational interviewing: getting the client involved in wise decision-making. Too often we make decisions based on our beliefs and not on the available facts. 4. Active change In this stage, people alter their overt behaviour and this is where traditional change-directed psychological therapy comes in with all its strategies. 5. Maintenance The client tries to stabilise the changes he/she has made. He/she tries to prevent a relapse into the old unwanted behaviour (for instance, drinking too much alcohol). Clients may seek professional help in this stage too, because they are afraid of a relapse. 6. Relapse Relapsing means returning to the old problematic ways of doing life. A relapse mostly results in going back to the stage of contemplation. Clients will become increasingly sceptical about the possibilities of change after experiencing relapses. Cognitive Dissonance The aim of all engagement strategies is to create ‘cognitive dissonance’ (Festinger, 1957). A state of cognitive dissonance is experienced as unpleasant by clients and therefore most people try to avoid it, or once in it try to escape from it. Cognitive dissonance creates an uncomfortable feeling by leading the individual to

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hold two contradictory ideas simultaneously. The theory of cognitive dissonance proposes that people have a motivational drive to reduce dissonance (because if feels unpleasant) by changing one or more of the following: attitudes, beliefs and behaviours. Dissonance occurs when people perceive a logical inconsistency in their beliefs, when one idea implies the opposite of another. The emotional consequence of the dissonance might be guilt, anger, frustration or embarrassment. Examples of opposing ideas in practice are: • • •

I want to be a healthy person / My drinking has cause irreparable damage I am a very important person / People treat me as just anyone I am an honest person / I have told lies and stolen to cover up personal mistakes. Ways to resolve cognitive dissonance are

• •

Behaviour change: stop drinking; stop being dishonest. Attitudinal change: being healthy is widely overrated, let’s have fun; what other people think is unimportant; I am not honest.

Investing in engagement strategies Let’s go back for a moment to the characteristics that are typical for people with personality difficulties: rigid and inflexible patterns of behaviour and thinking; negative consequences of behaviour are often ignored; the ‘instinctive’ reaction is that improvement can come through the change of others. This means that the psychological therapist who works with clients with personality difficulties has to be prepared to apply specific strategies to get these clients ready for therapy, ready for change and motivated to work towards change. It sometimes feels a bit like trying to sell something to people who do not want to buy anything! We suggest that there is a distinct set of techniques that can be used to this effect: motivational interviewing (van Bilsen, 1985a, 1985b, 1986, 1991, 1995; van Bilsen and van Emst, 1986; Denisen and van Bilsen, 1987; van Bilsen and Wilke, 1998).

Motivational interviewing (MI) MI is a set of techniques of talking to people about difficult topics without alienating them. Therapists working with personality disorders are after all often talking to people who do not want to change and who might feel quite antagonistic against the therapist and everything he/she represents. So the first port of call is to talk to clients without increasing the client’s antagonism. Motivation for change is based on knowledge, concern, self-appreciation, felt competence and trust in the change process. MI makes these elements of motivation a target and is exclusively focused on enhancing these within the client. In other words, MI is specifically focused on creating cognitive dissonance.

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Traditionally (Hettema et al., 2005; Miller and Rollnick, 2002), the perspective was that in order to motivate people the best strategies were to tell people what to think and do and to threaten people with negative consequences. Unfortunately these traditional motivational strategies only seem to work in a very limited way and then only with people who are ready to change (e.g. are in the stage of ACTION). These strategies trigger resistance and opposition in clients in other stages. Imposing insight on people will result in them starting a debate; giving people knowledge will result in that knowledge being disputed; try to teach skills to people in the stage of contemplation and you will have very reluctant participants. Reflections on engagement strategies MI is not a panacea for all sceptical and unmotivated clients. It is a tool to assist clinicians to talk to sceptical clients without getting into unproductive arguments and it is furthermore a set of techniques aimed at gradually building motivation for change. MI is proposed as an engagement strategy for sceptical clients. Many clients with a diagnosis of personality disorder who are referred for psychological therapy may fall in the sceptical category. The model we can use to assess the level of their scepticism is the stages of change model. This will provide a roadmap for the motivation enhancement work that needs to be done. Specific and detailed motivational interventions are described, however it is once again important to outline that they are no panacea for all challenging clients. Taking time Given today’s high demand for psychological interventions as well as the economic climate, treatment interventions need to be time limited. For example, care pathways for people with complex needs are defined in terms of limited time periods (18 months to 2 years). These time limits are often based on the average time frame that other clients within that population have needed for treatment to be deemed effective. Although this provides us with a guide as to what should time frame a treatment should be expected to take, this does in no way mean that this is always going to be the case. To hammer a nail into a piece of wood may take an average of 10 blows of a hammer but depending on the material you are using, the hammer and the force, it could take far fewer or far more attempts. In working with people with complex problems like personality problems we may be tempted to adopt a one-size-fits-all strategy. However, in our experience – and most clinicians who have worked with people with complex difficulties would probably agree – it is far better to take an individualised approach to treatment. Thus, returning to our cookbook analogy, we would recommend that clinicians use the basic recipe as a guide. Much like baking bread, you need the basic core ingredients such as flour and yeast, but you can choose to add in a whole range of ingredients such as fruit,

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nuts, herbs and spices dependent on what the baker is trying to achieve. Thus, clinicians can follow the basic recipes for working with anxiety or depression or personality disorder but can tailor these plans to the client’s own goals and needs. Clinicians, like any good cooks or bakers, need to be flexible and adapt to problems that may arise (I’m baking for someone who is wheat intolerant so I need to find a gluten-free substitute for my flour, rather than say ‘no, sorry that’s all we have’). Like with cooking, we can be creative but also we can draw on advice and guidance from people far more experienced or knowledgeable than ourselves. An amateur cook like myself might look for support and guidance from Jamie Oliver or Gordon Ramsay, and we need to utilise people in our field who have similar expertise when working with certain client groups and draw on them for information. But not just experts, other clinicians, peers and supervisors etc., because everyone has something to contribute and to suggest and a good clinician is able to collate this information and decide with the client the best course of action. After all, there is no need to reinvent the wheel – we need to learn and adapt from what others have learned and continue to build and develop from that.

Conclusion We wanted to make a case for using CBT for people with a diagnosis of personality disorder. We stated that well-trained cognitive behaviour therapists will be able to make an assessment of the person’s difficulties and convert these assessment results into a formulation that explains how the person’s difficulties started and how they are maintained. Based on this formulation, specific problems that will become the focus of treatment need to be identified and with each problem various SMART goals are selected. Subsequently, the therapist needs to design an idiosyncratic intervention plan whereby learning theory and the cognitive model of emotions are used as guides, as well as evidence-based CBT interventions.

References American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (4th ed., text rev.). Washington, DC: Author. Barlow, D. H. et al. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy 35: 205–30. Bateman, A. W. and Fonagy, P. (2000). Effectiveness of psychotherapeutic treatment of personality disorder. British Journal of Psychiatry 177: 138–43. Bateman, A. W. and Tyrer, P. (2004). Psychological treatment for personality disorders. Advances in Psychiatric Treatment 10: 378–88. Beck, A. T. (1976). Cognitive Therapy and the Emotional Disorders. New York: International Universities Press. Blum, N. et al. (2008). Systems training for emotional predictability and problem solving in women offenders with borderline personality disorder: A randomized controlled trial and 1-year follow-up. American Journal of Psychiatry 165: 468–78.

Formulation for personality problems  237 Bockian, N. R. and Villagran, N. E. (2011). New Hope for People With Borderline Personality Disorder: Your Friendly, Authoritative Guide to the Latest in Traditional and Complementary Solutions. New York: Random House. Cook, J. et al. (2009). Initial outcomes of a mental illness self-management program based on wellness recovery action planning. Psychiatric Services 60: 246–49. Dahl, M. (1993, January). The role of the media in promoting images of disability-disability as metaphor: The evil crip. Canadian Journal of Communication 18. Davidson, K. (2007). Cognitive Therapy for Personality Disorders: A Guide for Clinicians. Hove: Routledge. Denissen, K. and Van Bilsen, H. (1987). Motivationele milieu therapie [Motivational milieu therapy]. Tijdschrift voor Psychotherapie 13: 128–38. Dixon, L. et al. (2001). Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services 52: 903–91. D’Zurilla, T. J. and Nezu, A. M. (2007). Problem-Solving Therapy: A Positive Approach to Clinical Intervention. New York: Springer. Eells, T. D. (2006). Handbook of Psychotherapy Case Formulation. New York: Guilford Press. Feldhege, F. (1979). Selbstkontrolle bei Raushmittelabhangingen Klienten. Munich: Springer. Festinger, L. (1957). A Theory of Cognitive Dissonance. Stanford: Stanford University Press. Giesen-Bloo, J. et al. (2006). Outpatient psychotherapy for borderline personality disorder: A randomized trial of schema focused therapy versus transference focused therapy. Archives of General Psychiatry 63: 649–58. Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment 15: 199–208. Goldfried, M. R. (2003). Cognitive-behavior therapy: Reflections on the evolution of a therapeutic orientation. Cognitive Therapy and Research 27: 53–69. Hettema, J. et al. (2005). Motivational interviewing. Annual Review of Clinical Psychology 1: 91–111. Hopko, D. R. et al. (2003). Contemporary behavioral activation treatments for depression: Procedures, principles, and progress. Clinical Psychology Review 23: 699–717. Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Miller, W. R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. New York: Guilford Press. Nezu, A. M. et al. (2004). Cognitive-Behavioral Case Formulation and Treatment Design: A Problem-Solving Approach. New York: Springer. NICE (2009). Borderline Personality Disorder: Treatment and Management (Clinical Guideline 78). London: Author. Prochaska, J. O. and DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller and N. Heather (eds) Treating Addictive Behaviours: Processes of Change (pp. 3–27). New York: Plenum Press. Sturmey, P. (2007). Functional Analysis in Clinical Treatment. New York: Academic Press. Tyrer, P. (2013). The classification of personality disorders in ICD-11: Implications for forensic psychiatry. Criminal Behaviour and Mental Health 23: 1–5. Van Bilsen, H. (1986). Moraliseren of normaliseren: Een psychologische visie op de hulpverlening aan zogenaamd ongemotiveerde heroïneverslaafden in methadonprogramma’s

238  Henck van Bilsen and Simone Lindsey [Moralization or normalization: A psychological view of the treatment of so-called unmotivated heroin addicts in methadone programs]. Tijdschrift voor Alcohol, Drugs en Andere Psychotrope Stoffen 12: 182–89. Van Bilsen, H. (2012). Cognitive Behaviour Therapy in the Real World: Back to Basics. London: Karnac Books. Van Bilsen, H. and Thomson, B. (2011). CBT for Personality Disorders. London: Sage. Van Bilsen, H. P. (1985a). Praktische problemen in de ambulante gedragstherapie bij heroïneverslaafden [Practical problems in the ambulatory behavior therapy among heroin addicts]. Gedragstherapie 18: 77–86. Van Bilsen, H. P. (1985b). Valkuilen voor de therapeut: Verslavingsproblemen [Pitfalls for the therapist: Addiction problems]. Tijdschrift voor Psychotherapie 11: 192–95. Van Bilsen, H. P. (1986). Heroin addiction: Morals revisited. Journal of Substance Abuse Treatment 3: 279–84. Van Bilsen, H. P. (1991). Motivational interviewing: Perspectives from the Netherlands, with particular emphasis on heroin dependent clients. In W. R. Miller and S. Rollnick (eds) Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: Guilford Press. Van Bilsen, H. P. et al. (eds) (1995). Behavioral Approaches for Children and Adolescents: Challenges for the Next Century. New York: Plenum Press. Van Bilsen, H. P. and Van Ernst, A. J. (1986). Heroin addiction and motivational milieu therapy. Substance Use and Misuse 21: 707–13. Van Bilsen, H. P. and Whitehead, B. (1994). Learning controlled drugs use: A case study. Behavioural and Cognitive Psychotherapy 22: 87–95. Van Bilsen, H. and Wilke, M. (1998). Drug and alcohol abuse in young people. In G. Jeremy (ed.) Cognitive-Behaviour Therapy for Children and Families. New York: Cambridge University Press. Van den Hout, M. et al. (1988). Behavioral treatment of obsessive-compulsives: Inpatient vs outpatient. Behaviour Research and Therapy 26: 331–32. Verheul, R. et al. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month randomised clinical trial in the Netherlands. British Journal of Psychiatry 182: 135–40. Widiger, T. A. and Trull, T. J. (2007). Plate tectonics in the classification of personality disorder: Shifting to a dimensional model. American Psychologist 62: 71–83. Wolpe, J. (1958). Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford University Press. Wolpe, J. (1964). The Conditioning Therapies: The Challenge in Psychotherapy. New York: Holt, Rinehart and Winston. World Health Organization. (1992). International Statistical Classification of Disease and Related Health Problems, Tenth Revision (ICD-10). Geneva: Author. Young, J. E. (1990). Cognitive Therapy for Personality Disorders: A Schema-Focused Approach. Sarasota, FL: Professional Resource Exchange.

Chapter 11

Cognitive behavioural case formulation in complex eating disorder Helen Startup, Victoria Mountford, Anna Lavender and Ulrike Schmidt

Introduction and overview Despite a notable burgeoning of empirical research over the last decade, eating disorders (ED) remain notoriously difficult to treat. Where treatment gains do occur, initial optimism often fades and ‘revolving door’ patients can become the mainstay of specialist services. Patients typically present with a heterogeneous array of cognitive, behavioural, emotional, physiological and interpersonal maintenance factors. They can generate high anxiety in carers and clinicians desperate to offer support but often finding themselves overwhelmed and paralysed by the demands of the illness. Anorexia nervosa (AN) remains the ever elusive condition which, due to the effects of starvation, yields high mortality rates yet from the perspective of the sufferer is considered a ‘valued’ part of their identity (Serpell et al., 2003; 2004). Individuals with AN are often brought to services by worried loved ones but in themselves report low motivation to change with a ‘pull’ to ‘hold onto’ their illness (Treasure and Schmidt, 2001). Bulimia nervosa (BN) has shown relative promise in responding moderately well to cognitive behavioural treatments (CBT). However, presentations are often complicated by comorbidity (Hudson et al., 2007), risky weight control strategies requiring medical monitoring and intervention and links to obesity (Darby et al., 2009; Schmidt, 2000), all of which represent challenges to clinicians. Most clinicians working in ED acknowledge that this is a tricky and at times anxiety-provoking area of clinical work. Therapists have to show patience and endurance, along with a genuine curiosity for the factors that maintain the ED in that person’s life at that time. One must look out for any ‘threads’ of potential change for that individual, and have sufficient clinical skill and optimism to maximise this potential. In this chapter, we present a cognitive-behavioural case formulation approach to the conceptualisation and treatment of complex EDs, which represents an update on our previous chapter in the first edition of this book. This chapter will begin with updates regarding the classification and nature of EDs. We then move on to review available evidence regarding treatments for EDs. It will be evident that, in the case of AN in particular, there is ‘no front runner’

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regarding treatment efficacy. CBT shows some promise for those with AN and so we will use this model as a basis whilst drawing on available evidence to weave in other more ‘novel’ ways of working with this group. We also review work on the importance of carers in helping those with EDs to recover, and we explore some emerging research on the role of emotions in EDs, where we discuss the potential for a greater focus on emotion in future treatment packages for EDs. Finally, we ‘pull together’ these strands to present three case studies that demonstrate the formulation of such cases as used to guide treatment. Classification In DSM-5 (APA, 2013) the criteria for AN and BN are broadly similar to those in DSM-IV (APA, 1994), with AN being subdivided into a binge-purging subtype and restricting subtype and BN being subdivided into a purging and non-purging subtype. The workgroup responsible for DSM-5 describe a move to reduce ‘catch-all’ diagnostic categories, so as to provide patients with a clear description of their symptoms and behaviours which connect up with clear treatment paths. With this in mind, amenorrhea is no longer required as a criterion for AN, due to its lack of relevance for males, for those who are pre-menarchal or post-menopausal and those taking oral contraceptives. In the case of BN, DSM-5 criteria reduce the frequency of binge eating and compensatory behaviours that people with bulimia nervosa must exhibit, to once a week from twice weekly as specified in DSM-IV. BED is now considered a diagnostic category in its own right.

Cognitive-behavioural models of and therapy for eating disorders Bulimia nervosa: CBT models and treatment guide Bulimia nervosa (BN) is a common and disabling condition that can affect both sexes and often emerges during the sensitive period of adolescence (Treasure et al., 2010). Population prevalence of bulimic presentations in 2005 was reported as 7.2% for binge eating, 1.5% for purging and 4.6% for strict dieting (Hay et al., 2008). Alongside the physiological effects of restriction and strict dietary rules, it has been suggested that a central feature of BN is an inability to tolerate and regulate emotion; consequentially the typical BN behaviours serve to promote this avoidance of emotion. Readers working with this type of presentation are directed to the CBT models of Fairburn (2008) and Waller and colleagues (2007b) which give clear guidance on treatment delivery. However, BN can be complicated by many factors: its association with obesity and overlap with binge eating disorder (Darby et al., 2009; Schmidt, 2000), its co-occurrence with other axis-one presentations (such as anxiety disorders and depression) and with personality disorders (most notably borderline personality disorder).

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Bulimia nervosa: CBT treatment and the available evidence For BN, various meta-analyses, clinical trials and effectiveness studies suggest that CBT remains the treatment of choice (Hay, 2013; Hay et al., 2009; Poulsen et al., 2014; Waller et al., 2014). However, even with ‘gold standard’ CBT and relatively straightforward presentations, only 30–50% of individuals with BN-type presentations are symptom free at the end of treatment, with gains maintained at follow-up. Thus a significant proportion of sufferers remain clinically symptomatic after treatment and drop-out rates – even under optimal clinical trial conditions – can be high (Agras et al., 2000). Fairburn and colleagues updated their original treatment (CBT-BN; Fairburn et al., 1993) to an ‘enhanced’ version of CBT (CBT-E; Fairburn et al., 2003; Fairburn, 2008). They describe two forms of this treatment – ‘focused’ and ‘broad’. The focused form (CBT-Ef) targets ED pathology exclusively, whereas the broad form (CBT-Eb) addresses additional problems that may maintain the ED or impede treatment, such as low self-esteem, clinical perfectionism, mood intolerance and interpersonal difficulties (Fairburn et al., 2009). In a transdiagnostic trial (of bulimic patients across the weight spectrum) there was no difference overall in outcome between these two forms of CBT-E, but those with comorbidities responded better to the broad form, whereas the converse was true for those without (Fairburn et al., 2009). A recent RCT comparing a course of two years of psychoanalytic psychotherapy with 20 sessions over five months of focused CBT-E suggested markedly superior and faster improvements for the CBT-E group (Poulsen et al., 2014). Anorexia nervosa: CBT models, adaptations, alternatives and treatment guide Anorexia nervosa (AN) has traditionally been considered a ‘difficult to treat’ condition characterised by self-starvation, weight loss, hyperactivity and extreme concerns about weight, shape and eating. No single leading cognitive model of AN exists, and evidence for effective treatments of AN, cognitive behavioural or otherwise, remains slim. As described above, Fairburn and colleagues have developed an ‘enhanced’ CBT model for ED presentations (Fairburn, 2008). When applied to AN this involves three phases: increasing the patient’s motivation to change, working to directly enhance weight gain whilst tackling ED pathology including concerns about weight and shape and finally preparing for setbacks so as to maintain any gains. Moreover, Waller and colleagues (2007b) present a comprehensive CBT treatment model and plan for working across the EDs, including for those with AN, that can be a useful resource for guiding CBT interventions with this group. Furthermore, since publication of these CBT models, emergent research has suggested that various additional maintenance factors warrant accommodation within treatment packages; difficulties recognising and managing emotion (Oldershaw et al., 2011; Oldershaw et al., 2014) and complexities

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in the relationships of sufferers of AN (Schmidt and Treasure, 2006; Treasure and Schmidt, 2013). Finally, CBT has also been adapted for individuals with a severe and enduring eating disorder (SEED; Bamford and Mountford, 2012). Such individuals are likely to experience numerous adverse physical, psychological and social consequences of illness and the active nature of CBT may not match the entrenched psychopathology and possible ambivalence. The authors highlight the importance of developing a therapeutic alliance, working at a mutually agreed pace, and agreeing goals that encompass all areas of life. Anorexia nervosa: CBT treatment and available evidence Two recent uncontrolled studies suggested that CBT-E for AN may be effective in improving core ED symptoms in adults (Fairburn et al., 2013) and in adolescents with AN (Dalle Grave et al., 2013a). However, a small RCT which compared the two different forms of CBT-E (focused and broad) in inpatients with AN found no significant differences in outcomes between groups (Dalle Grave et al., 2013b). Finally, in a very large and well-conducted RCT comparing CBT-E with focal psychodynamic therapy and ‘optimised treatment as usual’, there were no differences across groups in regard to clinical outcome (Zipfel et al., 2013). Overall, in contrast to BN, there is currently no evidence to suggest that CBT-E has any advantage over other therapies in the treatment of AN. Using a different form of CBT (Pike et al., 2003) modified for ‘severe and enduring’ AN, a recent multi-site RCT suggested that although the CBT group showed some treatment gains, it was no more effective than a control condition mimicking a routine care style of treatment: Specialist Supportive Clinical Management (SSCM; Touyz et al., 2013). One benefit of the CBT arm was that those with long illness duration did show improvement and this ‘active’ treatment was conducive with a positive therapeutic alliance that was associated with treatment gains (Stiles-Shields et al., 2013). However, an alternative proposition in this connection is that positive therapeutic alliance may be brought about via treatment gains rather than result in them (Brown et al., 2013a; Brown et al., 2013b). What to extrapolate regarding the value of SSCM is also far from straightforward. An early RCT found SSCM to be superior to CBT and interpersonal therapy (IPT) and this obviously raised questions regarding the necessary components and focus for treatment of AN (McIntosh et al., 2005). However, when researchers followed up patients 7 years later, there were no longer any significant differences between any of the treatments (Carter et al., 2011). Thus, placing too much hope within this ‘routine care’ style of treatment may also be premature. Overall, it seems evident that the empirical research teasing out the maintenance factors of AN is more advanced and sophisticated than the data translating this into clinical intervention. Highlighting the factors that prevent this translation seems critical. It is clear that AN is quite a unique psychiatric disorder in regard to the deleterious effects of prolonged starvation on any potential ‘reversal’ of known maintenance

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factors. One potential way forward may be to take a ‘step back’ and to tease out what is meant by good quality ‘routine clinical care’. This could offer useful insights into core therapeutic ingredients. Such core ingredients could then form the framework for more targeted treatment packages that are easily trainable and deliverable and potentially supplemented with well-chosen components of CBT. Furthermore, there are indicators that a greater focus on the emotional and relational aspects of this illness could be important, but again how these factors are targeted and delivered needs careful consideration (Schmidt and Treasure, 2006; Treasure and Schmidt, 2013; Schmidt et al., 2014). In summary, there is some evidence that a targeted form of CBT for AN presentations may be useful for some individuals. However, optimism is tainted by the fact that there is no evidence for the superiority of CBT compared to alternative forms of psychotherapy or more routine styles of clinical care. Furthermore, it is unclear which components of these CBT packages are ‘core’ or even necessary and sufficient. Finally, the CBT required is relatively lengthy (40 sessions or more) and costly, and follow up periods vary. Where CBT treatments are struggling to comprehensively address severe AN presentations, alternatives have emerged. MANTRA (The Maudsley Model of Anorexia Nervosa Treatment in Adults) is a manualised cognitive-interpersonal treatment for adults with AN informed by a psycho-biological maintenance model of AN (Schmidt and Treasure, 2006, 2013; Schmidt et al., 2014). Given the issue of low motivation often encountered when working with this patient group, early modules incorporate motivational interviewing techniques to assess and work with issues of motivation. At the heart of the treatment manual is an individualised formulation depicted as a ‘vicious flower’ which maps out the ‘petals’ or factors that maintain an individual’s illness. The treatment change techniques are then divided into four core modules, each of which targets a factor known to maintain the disorder (Schmidt and Treasure, 2006). These are positive beliefs about the illness, one’s dominant thinking style, difficulties managing emotions and relationships, and the response of others to the illness. At the end of treatment, individuals are encouraged to depict progress via a ‘virtuous’ flower of factors that promote and maintain positive health and well-being. So far, one pilot study (Wade et al., 2011) and an RCT (Schmidt et al., 2012) comparing MANTRA with a routine care style of treatment (SSCM) for AN have yielded promising results. Patients showed improvement in their core ED symptoms and although overall there were no differences between the treatment conditions, there were indicators that MANTRA may be particularly beneficial for presentations at the more complex end of the spectrum. Two large multi-site trials of this treatment are in progress (e.g. Schmidt et al., 2013). Integrating working with carers within a CBT framework Carers of individuals with eating disorders often feel paralysed and overwhelmed by the demands of the illness. They report a strong wish to support the sufferer

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coupled with a sense of powerlessness and confusion in how to do this. Caring for someone with an eating disorder is in itself stressful and is associated with poor mental and physical health and lowered quality of life (Treasure et al., 2008). First-degree relatives of those with ED have higher levels of obsessive compulsive personality disorders, anxiety traits and eating disorders themselves. These shared family traits/disorders will shape the family’s initial reaction to the development of an ED and constrain their ongoing reactions to the challenges of the disorder in ways that may maintain the illness. Treasure and colleagues (2008) describe the processes involved in families inadvertently maintaining EDs, and techniques for formulating and working with these are integrated into the MANTRA model (Schmidt and Treasure, 2006). Group-based carers’ skills workshops based on these principles are found to be effective in that they reduce carer distress, high expressed emotion (EE), and care-giving burden associated with the ED symptoms (Sepulveda et al., 2008) and they have various positive effects for the sufferer (Hoyle et al., 2013). There is evidence that these packages can be delivered effectively in relatively accessible and low-cost ways, such as via books, DVDs and the internet (Goddard et al., 2011; Grover et al., 2011a, 2011b; Hoyle et al., 2013). Summary CBT clearly is the treatment of choice for individuals with BN, with evidence-based adaptations to treatment for complex patients. In the case of AN, CBT is as good as, but no better than, comparison treatments. However, with suitable adaptations, CBT for AN offers some promise, including for those with long-standing AN. However, we also argue for a position of ‘open mindedness’, creativity and flexibility in working with those with complex AN because a ‘one size fits all’ approach is not in evidence. In the case studies we present for complex BN, we will draw almost entirely on CBT formulation and intervention. In the case of AN, we will draw primarily on CBT with the modifications for complexity outlined by Bamford and Mountford (2012) and with some of the targeted and more relational components integrated in the model of Schmidt and Treasure (2006). We will also highlight ways to weave in the valuable input of carers when treating individuals across the eating disorders.

Risk factors for eating disorders A patient’s temperament, physical constitution, early experiences and family environment may be important in understanding his or her illness. The backgrounds of people with eating disorders have been studied extensively; here we will highlight several key themes in these findings that may influence the development and maintenance of the disorder. An initial review of risk factors for the development of AN and BN was reported by Jacobi and colleagues (Jacobi et al., 2004; Jacobi and Fittig, 2010).

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The earlier review found that the only two high potency risk factors for AN were being female and exercising before onset. Early feeding difficulties, picky eating, gastrointestinal problems, problems with sleeping and over-involved, anxious parenting were medium potency risk factors as were childhood perfectionism, obsessive-compulsive personality disorder and negative evaluation of self. Preterm birth, perinatal complications and birth trauma were specific risk factors for AN, as was obsessive-compulsive disorder. In a proportion of cases, sexual experimentation is delayed (Schmidt et al., 1995), and sexual development is experienced as negative (Karwautz et al., 2001). In approximately 25% of AN cases, a life event of a sexual nature (such as being confronted with premature or forbidden sexuality) is the trigger for the disorder (Schmidt et al., 1997a). This can be understood in the context of the high moral standards that are typically part of the obsessive-compulsive personality traits found in anorexia nervosa. Taken together, this evidence suggests that there are several developmental trajectories into AN. First, there may be major continuities in terms of parental preoccupation with a rather small, fragile child, with concerns round feeding and abdominal complaints and physical ill-health being an early theme. Refusing to eat can then become a way of eliciting care or nurturance. A second developmental theme commonly encountered is that of negative self-comparison to others and rigid competitive striving in conjunction with perfectionist standards for the self. Rigid control over food intake can become a way of winning the competition. A third developmental theme is that of sexuality being shameful and a resultant reluctance to grow up into a woman. These themes are not mutually exclusive and can co-occur. For BN, being female and dieting were the only high potency risk factors and negative self-evaluation the only medium potency risk factor (Jacobi et al., 2004). Maternal pregnancy complications, parental obesity and weight/shape-related criticism were specific risk factors for bulimia nervosa. In addition, just as in other psychiatric disorders such as depression, these patients typically have high levels of other childhood environment risk factors, including parental neglect and abuse (e.g. Schmidt et al., 1997b). Taken together, this evidence suggests that in terms of a developmental trajectory into BN, those predisposed to obesity or plumpness who experience childhood adversity and develop low self-esteem may resort to dieting in response to weight/shape-related criticism by their families or others. Incorporating the more recent data (Jacobi and Fittig, 2010), the authors conclude that almost all of the risk factors identified were confirmed with the most potent and best replicated risk factors for BN and – to a lesser extent AN – being gender (being female), weight and shape concerns and a cluster of variables around negative affect, neuroticism and general psychiatric morbidity. The authors highlight that the newer studies do not include broader psychopathological outcomes than EDs; therefore, it is unclear whether well-replicated risk factors are predictors of EDs or of general psychopathology. This of course means that how we interpret these risk factors in light of the proposed trajectory of ED

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development and maintenance is rather speculative. We still cannot be sure why ED develops specifically rather than another axis-one presentation. Furthermore, little is known about the interaction of risk factors over time.

The CBT model Core beliefs: The self, the world and others Within cognitive conceptualisations of eating disorders, temperamental features and early experiences, such as those above are hypothesised to interact with and to lead to the development of a set of core negative schematic beliefs concerning the self, world and others. These are not specifically eating disorder–related, but form an underlying system that acts as fertile ground within which an eating disorder may develop. Core belief content appears to be broadly similar across anorexia and bulimia (Leung et al., 1999; Waller et al., 2000). Core beliefs about the self typically involve themes of powerlessness, lack of self-efficacy, defectiveness, failure, worthlessness and lack of identity (Vitousek and Hollon, 1990; Woolrich et al., 2005). A recent meta-analysis synthesising all studies reporting on emotion variables in AN outlines the schemata most commonly reported by individuals with AN (Oldershaw et al., 2014). Unsurprisingly, individuals with AN score highly across the board of schemata; however, their scores are most pronounced for defectiveness/shame, subjugation, social isolation and dependence/incompetence. These highlight a mix of low self-esteem beliefs, coupled with a tendency to retreat and withdraw in the face of difficulties. Intermediate beliefs: Conditional assumptions, rules and attitudes Holding negative schematic beliefs such as these is immensely emotionally distressing. Thus, to avoid their activation and the affect that accompanies them, and to compensate for them, an individual may develop a set of attitudes, conditional assumptions, and ‘rules for living’, constructed to keep the beliefs at bay. Intermediate beliefs relate directly to the core beliefs/schemata they are developed to compensate for. Thus, for eating disordered individuals they are often around the need for control to compensate for core beliefs around powerlessness and lack of self-efficacy; and around success, achievement, specialness and lovability, in order to compensate for self-beliefs around defectiveness, failure, worthlessness, and lack of identity. Subjugation and shame typically stifle the individual from articulating their true needs and feelings. A typical example of beliefs at this level may include the attitude ‘it is terrible if anyone realises I am bad and doesn’t like me,’ the assumption ‘if I please others all the time, people might think I’m ok; if I don’t, they will realise I’m bad and reject me’ and the rule, ‘I should try to do what others want and expect from me all the time.’

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An additional intermediate belief domain important for many eating-disordered individuals is around the experience, control and expression of emotions. An individual’s early experiences and temperament may mean that she develops attitudes around, for example, the unacceptability of experiencing negative emotions, assumptions about her inability to cope with them, and rules about their regulation and expression. A key experience may be the non-recognition of the emotional state of the child by the parent and a subsequent response of criticism or ignoring. These experiences have been defined as an invalidating childhood environment (e.g. Mountford et al., 2007). Such early experiences can lead to a number of related manifestations, including emotional inhibition, distress tolerance and alexithymia (Waller et al., 2007a). Indeed, one study found links between emotional invalidation and vomiting and excessive exercise amongst individuals with anorexia and bulimia nervosa (Haslam et al., 2008). It is thus unsurprising that there is now abundant evidence to indicate that individuals with AN (in particular) struggle to recognise and tolerate emotions and their default management strategy is to supress emotions at all costs (Hambrook et al., 2011; Oldershaw et al., 2011, 2012; Oldershaw et al., 2014). Triggers: Why an eating disorder specifically? A meshing of self and weight or eating control–related beliefs and the triggering of an eating disorder may happen for a number of reasons. With anorexia, particularly presentations for which restraint or control of eating per se, rather than a desire for thinness is central, factors such as early onset obsessive-compulsive personality traits, or a childhood history of feeding difficulties, may be important to take into consideration. With BN and presentations of AN in which a drive for thinness is central, culturally based factors that predispose towards the development of links between thinness and self-esteem may be more important. For these individuals, experiences such as being part of a family for whom weight and food have always been contentious issues, or being bullied about being overweight at school may be important. Sometimes it is not possible to identify specific triggers or vulnerability factors; the meshing of beliefs about the self and weight can be a gradual process that becomes progressively self-reinforcing as an eating disorder establishes itself and begins to meet a patient’s needs to an increasing degree. This leads us to thinking about the next step in conceptualising eating disorders, which involves identifying how the illness functions for and is maintained within a patient. What functions does the eating disorder serve? One useful way of thinking about an eating disorder is as a perceived solution that an individual has found to underlying problems that are a product of her experiences and underlying schematic system (Serpell et al., 1999, 2002, 2003, 2004). The ED performs important functions as a perceived solution, and it is essential to identify these in formulation.

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There are numerous potential functions to the ED that can be teased out during a thorough formulation. Some recurring functions we have encountered include: Control: rigid control of eating to counter a sense of powerlessness and vulnerability; • Achievement and specialness: an ED may also function as a way to help an individual who has a strong perception of herself as useless or ‘a nothing’ feel special and more confident; • Avoidance of responsibility, maturity and intimacy: as a result of intermediatelevel beliefs designed to compensate for core beliefs around worthlessness or powerlessness, individuals with EDs tend to have high standards for themselves. They demand a great deal of themselves, and can have difficulty saying ‘no’ to others’ demands so that they may take on responsibilities that feel highly demanding for them. Sometimes, particularly with people with AN, they have taken on very responsible roles, such as caring for other family members, early in life. • Emotional avoidance: individuals with EDs often feel enormously threatened by the possibility of experiencing emotions and have a strong drive to avoid or escape from them (cf. Oldershaw et al., 2014; Corstorphine et al., 2007). Emotions relevant to eating disorders are those typically aroused by threat to rank such as shame, guilt or jealousy (Gilbert, 2001). •

Perhaps of greater note than the content of emotions across eating disorders, is the ED sufferers’ relationship with their emotions. In their review of the literature, Oldershaw and colleagues note that these patients block emotions at every stage. They struggle to spot the early signs of emotion, they are then unable to articulate these emotions and fail to express them. They thus have profound deficits at all stages of emotion recognition and management. Restrictive eating behaviour can function as a very effective way to avoid the activation of emotions at a primary level, and bingeing and purging behaviour can function as powerful ways to escape from emotion once it has been activated. ‘Beating the system’ In BN, a sense of literally being able to ‘have your cake and eat it’ is a common function of binging and purging behaviour. A person’s meshed core- and weight-related beliefs make thinness seem imperative for her. However, dieting to achieve this leaves her vulnerable to bingeing, which in itself may serve important functions for her. Purging to compensate for bingeing can give an individual who feels powerless and worthless a sense that she can ‘beat the system’. While others suffer the consequences (as she sees it) of eating, she has a way around this.

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Interpersonal functions: How an eating disorder works in relation to others Eating disorders can have important interpersonal functions. These are particularly but not exclusively relevant for anorexic individuals, principally because AN is visible to others, while BN tends to be hidden by the sufferer. It is worth noting that some of these interpersonal functions may also be very important within therapeutic interactions. Compliments and care, anger and distance A person with AN stands out from the crowd in a very visible sense. She may initially be complimented on her weight loss and receive admiring comments from others (Branch and Eurman, 1980), which is likely to boost her self-esteem and confidence. Gradually, as her weight loss continues, others’ admiration turns to worry and she may receive much-craved for attention and care from parents, friends, partners, peers and health care professionals. Alternatively or in addition to this, others, such as family members and health care professionals, may become increasingly frustrated and angry as attempts to help are repelled and seem to lead to ever-increasing determination by an individual to stick to her rigid diet and lose more weight (for a review see Schmidt and Treasure, 2006). For the person with anorexia who may have pre-existing perceptions of others as threatening and untrustworthy, this can serve the function of increasing her rationale for keeping others at a ‘safe’ distance and withdrawing further into her illness. Similarly, for an individual who feels powerless in relation to others, anorexia can function as a way to assert control and redress perceived imbalances in power within interpersonal relationships. This is often an important function of the illness within the family and sometimes therapeutic context. Others may also be kept at a distance when, as sometimes occurs, a person with anorexia seems happier, more full of energy and confidence than ever before. In this situation, the seeming wellness of an individual lulls others into a lack of concern, leaving her to pursue her weight loss goals in relative peace. Communication Individuals with EDs often have difficulty in communicating their thoughts, emotions and needs to others. This may result from a family environment where parents had difficulty with communication, or discouraged the expression of emotion. Because of its very visible nature, AN can be a powerful tool for communication. It gives a clear signal to others that all is not well, and that the person is not coping effectively with life’s demands. This can be an important function of

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the illness for a patient, as it may feel like her only means of letting others know about her emotional needs. Other maintenance factors Biological and starvation effects One prominent biological model of eating disorders hypothesises that during the early stages of an ED, eating little is maintained intra-personally by positive reinforcement from a temporary improvement in mood and well-being (Kaye et al., 1999, 2003). This may be moderated by an unknown biological vulnerability. This early stage has been summarised by Casper (1998) who noted that AN patients initially typically are cheerful, content, euphoric with high levels of energy despite a low caloric intake and continued weight loss suggesting that they feel mentally alert and physically active. In addition, the physical, cognitive, emotional and social effects of starvation conspire to maintain the eating disorders. Our knowledge about these effects comes from the famous Minnesota starvation experiment conducted in the 1940s, where healthy normal-weight volunteers were made to lose about 15% of body weight, and then were gradually refed (Keys et al., 1950). In brief, this study found that in the starved state study participants constantly thought about food and eating. They developed rituals around eating, and other obsessive-compulsive symptoms. Mood disturbance and social withdrawal were common. For some, their desire for food became so overwhelming that they gorged themselves on food, analogous to the bingeing in BN. With increasing starvation, eating aroused unpleasant physical sensations (such as feeling bloated, nauseous and overfull). Both biological and cognitive factors may have played a role in this. For example, delayed gastric emptying increases the sense of fullness and reduces appetite, and delayed gut transit times lead to constipation, bloating and discomfort (Treasure and Szmukler, 1995). For some, the prospect of having to eat may have become a threat associated with these aversive consequences. The learnt expectation that certain foods, such as those high in fat, cause particular physical sensations may exacerbate such physical symptoms (Feinle-Bisset et al., 2003). The maintenance of bingeing and purging behaviour Thus far we have presented an approach to the cognitive modelling of eating disorders that has considered anorexic and bulimic disorders together as far as possible, while highlighting important differences when needed. However, the development and maintenance of bingeing and purging behaviour, occurring in BN and binge-purge subtype AN, do require a specific note and it is pivotal to treatment to draw up a maintenance cycle of the mechanisms involved. Readers are directed

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to primary texts wherein relevant maintenance processes for binge-purge cycles are well articulated within the core CBT models of BN (cf. Waller et al., 2014).

Clinical case examples A comprehensive formulation is important for all clinical work but is essential when working with more complex presentations. In these cases, the formulation can highlight areas to target and potential areas of difficulty, for example within the delivery of treatment, barriers to change and the therapeutic relationship. When the working formulation is in place, this in conjunction with the overarching principles of CBT enables the therapist to be optimally creative, whilst being mindful of parsimony. This may incorporate the inclusion of the use of imagery (Mountford and Waller, 2006; Tatham, 2011), focus on emotions (Oldershaw et al., 2014; Corstorphine et al., 2007; Waller et al., 2007b) and relational aspects of the illness (Schmidt and Treasure, 2006; Treasure and Schmidt, 2013; Schmidt et al., 2014). Jodie: A young woman with restricting anorexia nervosa Presentation Jodie is a young woman with AN, restrictive subtype. She has recently been discharged from an inpatient eating disorders unit back to the community and weekly outpatient therapy. Previously, Jodie has had two admissions for life-threatening AN, one to an adolescent unit and one to the recent unit. Although Jodie stayed on the inpatient unit for four months, she gained a modest amount of weight and is currently at a body mass index (BMI) of 17.5 kg/m2. It appears that Jodie feels it is inevitable that she will need another admission. Jodie has one sister who is two years younger than her. Jodie’s mother had postnatal depression following the birth of her sister. During this time, Mum struggled to manage or care for the children. Jodie described how her mother tended to be a ‘worrier’, concerned with the possibility of catastrophe. Jodie’s father is described as strict, with Jodie experiencing a pressure to achieve academically and to behave ‘in the right way’. Jodie experienced her upbringing as split – her mother did not hold any boundaries whilst her father was controlling. The family relocated on three occasions due to her father’s job whilst Jodie was growing up and she reported finding these transitions difficult to manage, particularly the final time, when she was 12. Shortly after this, he was made redundant and the family was under considerable financial strain. Jodie remembers this time as often being told she could not have something but not fully understanding why. Prior to the recent admission, Jodie had been attending university some distance from home. She had been studying geography and wishes to become a teacher. Her parents became concerned as she began to avoid telephone calls and attempts

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to visit her. At university, she was monitored by the university GP and a counsellor, who also became concerned. Treatment At the beginning of treatment, Jodie and her therapist prioritised two goals. The first of these was to collaboratively develop the cognitive behavioural formulation, in order to understand what maintaining factors might have led to the previous relapse and re-admissions, and the second was to build Jodie’s self-belief that she can use therapy to recover and avoid a further admission. The formulation demonstrates how Jodie’s early experiences, in particular her mother experiencing depression and the frequent moves, led her to develop core beliefs about being defective and undeserving. Jodie attempted to compensate for these beliefs by developing rules about achieving, denying pleasurable events and using anorectic behaviours as a means of punishing herself and avoiding ‘real’ life. In addition to this, Jodie and her therapist developed a meal plan with the initial goal of maintaining a stable weight (NB: for a patient with a less complex or chronic history, an earlier focus on weight gain is recommended). Using the formulation enabled Jodie and her therapist to predict and discuss in advance the possible triggers to future difficulties in therapy or relapse, such as feeling that life is going ‘too well’ or feeling anxious about making decisions. Motivational letters (e.g. Schmidt and Treasure, 2006; Waller et al., 2007b) explored the pros and cons of recovery and made more explicit Jodie’s fears of managing ‘everyday life’. From the beginning of treatment, Jodie kept weekly food/thought/emotion diaries which were discussed and she was weighed weekly. As therapy continued, Jodie gave consent for her parents to be invited to sessions. Thus a family-based intervention was interwoven with the individualised CBT. Initially, Jodie shared what she felt comfortable with from her formulation, to enable her parents to understand some of the factors maintaining AN. The therapist’s stance was that family work is not about blame, but discovering strengths within the family that would help Jodie’s recovery. The ‘animal’ metaphors of care were introduced to discuss different styles of managing AN (Treasure et al., 2008). The family identified Dad’s style as that of a ‘rhino’ (i.e. directly ‘attacking’ the problem with criticism, arguing with logic) and Mum’s as that of a ‘jellyfish’ (i.e. being overly emotional without helpful action). Later sessions focused on enabling the parents to develop shared, consistent boundaries and expectations regarding Jodie’s behaviour. In total, there were four sessions with the family. Although Jodie was initially reluctant to involve her parents, she later acknowledged that this had been beneficial. As treatment entered the middle phase (session 10 onwards), it was evident that with some effort, Jodie was managing to maintain her weight. The therapist broached the subject of setting an interim target goal weight and developing behavioural experiments to increase food intake. Jodie reluctantly agreed to this.

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Initially, the food increase that Jodie agreed to was so small that her weight did not change significantly; this gave her the confidence to gradually increase her food intake further. In addition, Jodie conducted behavioural experiments around decision making and doing things ‘wrong’ to challenge her beliefs about not being able to manage everyday life. By this point, Jodie was a BMI of 18.5 kg/m2; the therapist encouraged her to seek a part-time job and she arranged voluntary work in a nearby school. This progress enabled Jodie to question some of her assumptions and rules for living, both about herself as an individual and her control over eating, shape and weight. Therapy began to address Jodie’s core beliefs. First, a historical review of evidence supporting Jodie’s beliefs was developed. Jodie shared some of this at home with her parents and was surprised to hear how differently they recalled these events. She was able to hear how Mum’s postnatal depression had impeded her ability to care for both children, rather than Jodie being ‘undeserving’ of Mum’s love and care. Therapy continued to build on these explorations, developing alternative beliefs such as ‘I’m not perfect, but I’m OK.’ In tandem, Jodie set up challenging behavioural experiments that allowed her to have her favourite foods, whilst tolerating the guilt and negative automatic thoughts ‘You don’t deserve that – how could you?’ Finally, therapy addressed Jodie’s body image dissatisfaction (see Waller et al., 2007b) and developed a relapse plan. Ending letters (as in MANTRA; Schmidt and Treasure, 2006; Schmidt et al., 2014; Waller et al., 2007b) were used to reflect on the gains in therapy and acknowledge ambivalence and sadness about ending. Jodie decided to transfer to a local university and restart the academic year. She continued her voluntary work on a reduced basis. After 40 sessions, her BMI was 19.5 kg/m2 and she was following a regular eating pattern. Jodie reported decreased anxiety and preoccupation with food. Importantly, improved family relationships, her role at work and restarting her degree supported her in continuing to modify her core beliefs. Jodie had a further four follow-up sessions over the next six months to consolidate her progress and manage the ending appropriately. Jodie’s cognitive behavioural formulation is presented in Table 11.1. Morag: A woman with severe and enduring anorexia nervosa Presentation Morag’s history and presentation is in many ways very different to that of Jodie. She is in her late 40s and has had AN since she was 15. In this time, she has only been admitted for treatment once, at the age of 16, near the onset of her eating disorder. Morag works long hours as a lawyer in a city law firm. Morag presented as ambivalent about treatment at her assessment, but stated that approaching a significant birthday had made her re-consider her life, although she admitted that she did not feel optimistic that treatment would help. Morag acknowledged that she felt ‘stuck’, feeling she had little in life except work and anorexia.

254  Helen Startup et al. Table 11.1  Jodie’s cognitive behavioural formulation • • • • • •

Early experiences and predisposing factors Perfectionist with high moral standards Mum had postnatal depression following the birth of younger sister Family frequently moved house and Jodie often had to start new schools High academic expectations within family and pressure to behave correctly Family tend to ‘sweep emotions under the carpet’ Dad made redundant when Jodie was 13, leading to financial strain

Core beliefs/schemas • I am undeserving • I am defective; I can’t manage everyday life • Others see me as a failure Intermediate beliefs: Attitudes, rules and assumptions General: • If I put all my effort into my work and succeed, then I might be OK • If other people saw the ‘real’ me, they would be disgusted • I don’t deserve to have a good life • I must ‘cope’ and not ask others for help or advice – I must not burden others AN specific • If I have my AN, then I don’t have to face adult life • If I’m thin, then I will be more acceptable (onset) • If I don’t gain weight, then I’m disappointing others (now) • I must not eat food that I might enjoy Triggers: Why anorexia? • Began to skip lunch at new school to save money and initial weight loss seemed a good way of ‘fitting in’ • Family stressed about financial difficulties Functions of my anorexia and my beliefs about it • Anorexia means I abdicate decision making • Anorexia makes me feel safe and in control • Anorexia gives me a reason not to ‘cope’ Behaviours • Restrict my food, follow my rules exactly • Keep emotions to myself and don’t get close to others • Have to do everything perfectly Other factors that maintain my anorexia • Starvation factors – I feel bloated when I eat • The longer I am ill, the more evidence I have that I have failed and am undeserving (e.g. worrying my family, not completing degree)

Morag reported a rigid and restrictive eating pattern. She often skipped lunch, using work as the reason. She tends to keep very little food at home, relying on her staple foods. Her weight had been stable at a BMI of 15 kg/m2 for many years. Morag is aware that she is very underweight and attempts to disguise this by wearing several layers of clothing. Morag began to binge and purge in her early

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30s and this happens approximately 1–2 times per week, often after she has drunk alcohol. Morag drinks about a bottle of wine a night, which she reports is to relax after a stressful day at work and to help her sleep at night. Morag has only sporadic contact with her family and has not had an intimate relationship for many years. She has a couple of friends from law school whom she remains in touch with, but she is aware that they have their own families now. Despite her difficulties, Morag appears to be successful at work and well regarded by her colleagues. She highlighted how challenging she finds the requirement to attend social events at work, particularly as they often involve food and drink. Treatment The therapist assigned to Morag was an experienced female clinician in her mid-30s. It was evident, however, that Morag felt very uncomfortable in the position of ‘patient’ and she was initially rather dismissive of the therapist. The therapist sought to explore Morag’s experiences of attending for therapy. Gradually, Morag was able to express how difficult it was to talk about her emotions and how fearful she was of being judged by the (younger) therapist. The formulation highlighted how Morag’s early experiences had contributed to her core beliefs. However, given the duration of illness, it was also vital to consider the function and maintaining factors of Morag’s anorexia. Morag reported two significant maintaining factors. First, because she had been ill for so long but still managing a demanding career, Morag struggled to recognise the severity of her illness. Second, when Morag contemplated the losses arising from her illness, she thought ‘my anorexia is the one thing I do have, I can’t give it up.’ Using the formulation, Morag was able to develop goals for treatment; to improve her physical health, to stop bingeing and purging, reduce her alcohol intake and to improve her quality of life. Treatment included appropriate adaptations to CBT for those with long-standing AN (Bamford and Mountford, 2012), including time to reflect on losses and focusing on expanding Morag’s interests and social network as well as addressing core eating-disorder symptomatology. Monitoring, structuring of time and distress tolerance techniques were used to gradually reduce bingeing, purging and alcohol use. In addition, elements of the Identity and Social Mind modules of MANTRA were used within the CBT framework to increase sense of self and social relationships (to enhance overall quality of life). Using a Socratic style, Morag’s values and their compatibility with her AN were explored. Morag acknowledged how her values of integrity, honesty and success were compromised by AN. Therapy explored how her sense of identity had shifted over the years of her illness. Morag disclosed that she had been an excellent cellist and a gradual plan was developed for her to start playing again. Unpicking Morag’s limited social network was highly painful. Morag had never cried before in therapy (as this was a sign of weakness and being out of control when she did); the therapist validated and welcomed this expression of her emotion, challenging Morag’s belief that emotions are overwhelming or uncontrollable.

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As Morag progressed through therapy and slowly built an alliance with the therapist, she began to openly reflect on her thoughts at the beginning of therapy, including her hopelessness about change and her concerns about the therapist. The therapist engaged in this discussion in a validating and reflective manner. They explored how Morag’s experience of seeking help had differed from her expectations. Tentatively Morag expressed thoughts of gaining a small amount of weight to increase her health. Therapy continued as outlined by Bamford and Mountford (2012). By the end of therapy, Morag had gained a small amount of weight, significantly reduced bingeing and purging and stopped her excessive alcohol consumption. She had contacted a friend she used to play the cello with and they attended small concerts together on a monthly basis. She began to very gradually increase contact with her family, particularly her brother’s young children. Morag described herself as recognising that she was not recovered but feeling that she would be able to gradually continue the changes she had made. She thanked the therapist for introducing the possibility that life could be different. The ending to the therapy was hugely important and worked through in the latter third of treatment. In working with patients with severe and enduring eating disorders, therapists may take a modified approach. This may include setting smaller goals which centre on quality of life and expecting more gradual progress towards these (e.g. beginning to play the cello again, rather than immediately joining an orchestra). Weight-focused goals may arise as a consequence of other quality of life–focused goals. Finally, always important, the therapeutic relationship is crucial here. Patients need to feel safe and respected. The therapist may be the main or a significant weekly contact – thus many interpersonal issues may be played out within the session (e.g. a validating, encouraging response to emotional expression will contradict previous early experiences and beliefs). Morag’s cognitive behavioural formulation is presented in Table 11.2. Maya: A young woman with bulimia nervosa Presentation Maya is a 25-year-old woman with diagnoses of BN and borderline personality disorder. Maya binges and purges on a daily basis, often in cycles which last until the early hours. Following a binge, Maya will intensify her food restriction. She rarely eats regular meals. She reports extreme body image dissatisfaction and finds her body disgusting. Maya also self-harms, cutting her upper thighs. This can be triggered by intense emotions such as guilt, shame, loneliness or disgust at her body. On three previous occasions she has taken a significant overdose. Maya experiences difficulties in emotion regulation and although she craves closeness with others, struggles to maintain relationships. Maya has a history of short, volatile relationships and at times engages in risky sexual behaviour. Maya currently works part-time in a coffee shop and is trying to develop a singing career.

Table 11.2  Morag’s cognitive behavioural formulation Early experiences and predisposing factors • Preterm birth, tendency to be anxious from a young age • Mother had undiagnosed eating disorder and food was closely monitored and controlled. Mother often commented on shape/size. • Family culture of emotional invalidation and being told to ‘pull yourself together’ • Parents had tendency to be critical rather than encouraging • Gained scholarship to public school at 11 but felt she didn’t fit in Core beliefs/schemas • I must always achieve • I must control my emotions • Others will criticise and judge me and find me wanting Intermediate beliefs: attitudes, rules and assumptions General: • If I let my emotions out, they will overwhelm me • If I ask for help, others will see me as weak or needy and will criticise me • I should be able to achieve the highest standards, if I don’t it’s proof I am a failure AN specific • If I eat normally, then I will gain weight and become fat • If I am fat, this means I am lazy and a slob • Without anorexia, I don’t know who I am • If I’m ill, it hides the fact that I’m not good enough Triggers: why anorexia? • Put on weight when puberty started • Popular girls at school were dieting • Early messages about the importance of being in control of eating and shape Functions of my anorexia and my beliefs about it • Low weight helps me keep my emotions numb • It helps me feel in control (emotions, weight, needs) • It gives me a sense of mastery Behaviours • Following a rigid and restrictive eating pattern • Bingeing and purging • Excessive alcohol use Other factors that maintain my anorexia • I have missed out on so much of life (partner, family, enjoyable events), my anorexia is the only thing I have • My life isn’t so bad really, I hold down a good job, change will be hard and uncomfortable

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Maya had been overweight as a child and subject to bullying by peers at primary school. Her grandmother was also critical of her size and would make comments whilst she was eating. Otherwise, Maya described a generally happy childhood. She was particularly close to her father, whom she idolised. When Maya was 10, her father was killed in an industrial accident. Maya and her mother were both devastated by the loss and her mother began to drink heavily and neglect Maya. Maya was not able to discuss her grief with anyone and focused on being a ‘good girl’ for her mother. Maya was often responsible for feeding herself. Maya’s mother began a new relationship with the man who was to become Maya’s stepfather. He began to sexually abuse Maya when she was 12. Treatment Maya’s attendance during early sessions was inconsistent. She would forget appointments or oversleep due to late-night bingeing. Her presentation was also variable, switching from open and engaged to vulnerable and childlike or to a more hostile, avoidant style. She was quick to perceive her therapist as critical. The therapist used these early sessions to gather a detailed account of Maya’s life, responding in a validating and empathic manner. This formed the top of the formulation and enabled exploration of Maya’s core beliefs and subsequent rules for living. Using this, the therapist was able to gently explore Maya’s inconsistent engagement, making sense of it within the context of her beliefs about others. Maya acknowledged how this served to ‘sabotage’ her attempts to recover and the therapist was able to sensitively reinforce treatment boundaries. Maya and her therapist agreed that the formulation highlighted the need to address the overwhelming emotions Maya experienced. First, the therapist discussed the concept of invalidation with Maya and how this might contribute to emotional dysregulation. Treatment followed a cognitive-behavioural-emotional model (Corstorphine et al., 2007) including psycho-education on recognising and identifying emotions and monitoring and experiential exercises to increase awareness of emotions. Maya tested alternative strategies to manage emotions without the need to binge and purge or self-harm. Cognitive restructuring was used to explore and modify Maya’s beliefs about emotion. Conventional aspects of CBT including food diaries, regular weighing, implementation of regular eating and behavioural experiments continued alongside. Towards the end of treatment, Maya’s weight chart reflected a stabilisation in weight within the healthy range, compared to significant fluctuations when her bingeing and purging was at the extreme. Maya continued to express extreme body image dissatisfaction, a clear risk for relapse. Maya and the therapist developed a body image–specific formulation, which they linked to the core beliefs in her general formulation. Maya disclosed how a number of her beliefs about her body related to her stepfather’s remarks about her shape and size. Addressing these cognitively did not produce a substantial or sustained change. Maya and her therapist agreed that using imagery rescripting to access the emotional content associated

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with these memories may help. Imagery was used to re-examine Maya’s experiences from the point of view of bystander. Maya chose for her father to intervene in the image, protecting her from her stepfather and comforting her. The imagery rescripting triggered a rapid shift and further work on body image continued (see Waller et al., 2007b). Throughout treatment, the therapist was mindful of Maya’s fear of being abandoned. The ending of therapy was discussed on a regular basis and the therapist took care to facilitate Maya’s ability to become her ‘own therapist’. Although all behaviours improved over the course of therapy, many of Maya’s emotional and interpersonal difficulties were ongoing. Maya was referred on to a service for individuals with emotional and interpersonal difficulties and close liaison ensured a successful transition. Maya’s cognitive behavioural formulation is presented in Table 11.3.

Table 11.3  Maya’s cognitive behavioural formulation Early experiences and predisposing factors • Overweight as a child and bullied by peers, negative comments from grandmother and stepfather • Father died in industrial accident when Maya was 10 • Mother drank heavily following this and was neglectful and verbally abusive to Maya • Stepfather began to sexually abuse Maya when she was 12 • Emotionally invalidating environment • Talented singer • • • •

Core beliefs/schemas I’m unlovable I’m weak, powerless and vulnerable Others will abuse/mistreat me Others will abandon me

Intermediate beliefs: attitudes, rules and assumptions General: • If I let people treat me how they want, they might not leave me • I’m too weak and vulnerable to cope with my emotions, if I experience them, I have to escape BN specific • If I’m thin, people might like me • I need to look ‘right’ otherwise I won’t make it as a singer • I don’t have any control over my eating or my life • My body is disgusting, I need to make it as small as possible Triggers: why bulimia/self-harm? • History of being overweight as a child • Neglect meant food at home was not reliable • Bingeing and purging / self-harm as ways to block out abuse

260  Helen Startup et al. Table 11.3  (Continued ) Functions of my bulimia and my beliefs about it • Escape: this is the only way I have to block out the pain and manage my emotions • This is the way to keep myself thin and succeed at singing (although I know it damages my voice) Behaviours • Bingeing and purging • Self-harm – cut or burn myself or take an overdose • Engage in risky sexual behaviour in an attempt to feel loved Other factors that maintain my bulimia • If I gain weight, I will be even more unlovable • If I stop bingeing, I’m scared my self-harm might get even worse • By not eating regular meals, I’m more prone to bingeing due to hunger • Fear of expressing emotions or losing another relationship mean I am prone to ‘sabotage’ therapy

Discussion We have attempted to outline a framework for the cognitive-behavioural formulation of patients presenting with complex EDs. Throughout, we have sought to emphasise the importance of using these ideas flexibly and adapting them to individual patients. An important aspect of this approach is the need to think more widely than about the importance of weight and shape concerns. Although these areas are relevant to varying degrees with many eating-disordered patients, for a significant proportion, other issues and factors are equally or even more significant in understanding their ED. One further aspect deserves mentioning. Patients with complex BN often present the therapist with lots of material, i.e. complicated, dramatic and epic stories. Every session new events will unfold that add further layers of complexity and detail. Yet the week after, these events will be replaced by another event or crisis which is even more urgent and the previous one will have paled into insignificance. Thus, it is easy for the therapist to feel overwhelmed by the stories and intense emotions attached to them and derailed by being tempted to follow new leads. A diagrammatic formulation as the one shown above helps to focus on themes and issues which are central to all the different stories and problems and thus helps patient and therapist stick to task. In contrast, patients with AN often give away relatively little and their account of themselves may seem somewhat bland and lacking in emotional detail. Thus, the emotional significance of particular events or beliefs can only be inferred or guessed at by the therapist. Diagrammatic formulations because of their ‘short-hand nature’ make it easy to stay somewhat distant from and avoid the emotional impact of this. We often give patients with AN their case formulation

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written as a personal letter from the therapist to the patient, in addition to a diagrammatic presentation. Letters, more than diagrams, speak to the person’s emotions. These letters ideally should build on and incorporate what is contained in the diagrammatic presentation. As much as possible, the patient’s own words and expressions are used. The practice of writing formulation letters derives from cognitive analytical therapy (Ryle, 1995), where the patient is typically presented both with a diagrammatic formulation and a formulation letter. In our experience, patients value these letters highly, many report feeling very validated by the therapist’s effort on their behalf and feeling very understood. We believe that these two very different ways of presenting the patient with their formulation, whilst somewhat more work for the therapist, can usefully complement each other.

References Agras, W. S. et al. (2000). A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry 57: 459–66. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author. Bamford, B. and Mountford, V. A. (2012). Cognitive behavioural therapy for individuals with long standing anorexia nervosa: Adaptations, clinician survival and system issue. European Eating Disorders Review 20: 49–59. Branch, C. and Eurman, L. J. (1980). Social attitudes toward patients with anorexia nervosa. American Journal of Psychiatry 137: 631–32. Brown, A. et al. (2013a). Is the therapeutic alliance overvalued in eating disorders? International Journal of Eating Disorders 46: 779–82. Brown, A. et al. (2013b). Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa. Behaviour Research and Therapy 51: 216–20. Carter, F. A. et al. (2011). The long-term efficacy of three psychotherapies for anorexia nervosa: A randomized, controlled trial. International Journal of Eating Disorders 44: 647–54. Casper, R. C. (1998). Behavioural activation and lack of concern, core symptoms of anorexia nervosa? International Journal of Eating Disorders 24: 381–93. Corstorphine, E. et al. (2007). Distress tolerance in the eating disorders. Eating Behaviours 8: 91–97. Dalle Grave, R. et al. (2013a). Enhanced cognitive behavioural therapy for adolescents with anorexia nervosa: An alternative to family therapy? Behaviour Research and Therapy 51: R9–R12. Dalle Grave, R. et al. (2013b). Inpatient cognitive behaviour therapy for anorexia nervosa: A randomized controlled trial. Psychotherapy and Psychosomatics 82: 390–98. Darby, A. et al. (2009). The rising prevalence of comorbid obesity and eating disorder behaviours from 1995 to 2005. International Journal of Eating Disorders 42: 104–8. Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press.

262  Helen Startup et al. Fairburn, C. G. et al. (1993). Psychotherapy and bulimia nervosa. Longer-term effects of interpersonal psychotherapy, behaviour therapy, and cognitive behavior therapy. Archives of General Psychiatry 50: 419–28. Fairburn, C. G. et al. (2003). Cognitive behaviour therapy for eating disorders: A ‘transdiagnostic’ theory and treatment. Behaviour Research and Therapy 41: 509–28. Fairburn C. G. et al. (2009). Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up. American Journal of Psychiatry 166: 311–19. Fairburn, C. G. et al. (2013). Enhanced cognitive behavioural therapy for adults with anorexia nervosa: A UK-Italy study. Behaviour Research and Therapy 51: R2–R8. Feinle-Bisset, C. et al. (2003). Role of cognitive factors in symptom induction following high and low fat meals in patients with functional dyspepsia. Gut 52: 1414–18. Gilbert, P. (2001). Evolutionary approaches to psychopathology: The role of natural defences. Australian and New Zealand Journal of Psychiatry 35: 17–27. Goddard, E. et al. (2011). Cognitive interpersonal maintenance model of eating disorders: Intervention for carers. British Journal of Psychiatry 199: 225–31. Grover, M. et al. (2011a). An off-line pilot evaluation of web-based systemic cognitive-behavioural intervention for carers of people with anorexia nervosa. International Journal of Eating Disorders 44: 708–15. Grover, M. et al. (2011b). A randomized controlled trial of an Internet-based cognitive-behavioural skills package for carers of people with anorexia nervosa. Psychological Medicine 41: 2581–91. Hambrook, D. et al. (2011). Emotional expression, self-silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome. British Journal of Clinical Psychology 50: 310–25. Haslam, M. et al. (2008). Invalidating childhood environments in anorexia and bulimia nervosa. Eating Behaviours 9: 313–18. Hay, P. (2013). A systematic review of evidence for psychological treatments in eating disorders: 2005–2012. International Journal of Eating Disorders 46: 462–69. Hay, P. et al. (2008). Eating disorder behaviours are increasing: Findings from two sequential community surveys in South Australia. PLOS ONE 3: e1514. Hay, P. et al. (2009). Psychological treatments for bulimia nervosa and binge eating. Cochrane Database Systematic Review 4: CD000562. Hoyle, D. et al. (2013). Evaluation of a web-based skills intervention for carers of people with anorexia nervosa: A randomized controlled trial. International Journal of Eating Disorders 46: 634–38. Hudson, J. I. et al. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry 61: 348–58. Jacobi, C. et al. (2004). Coming to terms with risk factors for eating disorders: Application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin 130: 19–65. Jacobi, C. and Fittig, E. (2010). Psychosocial risk factors for eating disorders. In W. S. Agras (ed.) The Oxford Handbook of Eating Disorders. New York: Oxford University Press. Karwautz, A. et al. (2001). Individual-specific risk factors for anorexia nervosa: A pilot study using a discordant sister-pair design. Psychological Medicine 31: 317–29. Kaye, W. et al. (1999). New directions in treatment research of anorexia and bulimia nervosa. Biological Psychiatry 45: 1285–92.

Case formulation in complex eating disorder  263 Kaye, W. H. et al. (2003). Anxiolytic effects of acute tryptophan depletion in anorexia nervosa. International Journal of Eating Disorders 33: 257–67. Keys, A. et al. (1950). The Biology of Human Starvation. Minneapolis: University of Minnesota Press. Leung, N. et al. (1999). Core beliefs in anorexic and bulimic women. Journal of Nervous and Mental Disorders 187: 736–41. McIntosh V. V. et al. (2005). Three psychotherapies for anorexia nervosa: A randomized, controlled trial. American Journal of Psychiatry 162:741–47. Mountford, V. et al. (2007). Development of a measure to assess invalidating childhood environments in the eating disorders. Eating Behaviours 8: 48–58. Mountford, V. and Waller, G. (2006). Using imagery in cognitive-behavioural treatment for eating disorders: Tackling the restrictive mode. International Journal of Eating Disorders 39: 533–43. Oldershaw, A. et al. (2011). The socio-emotional processing stream in anorexia nervosa. Neuroscience and Biobehavioral Reviews 35: 970–88. Oldershaw, A. et al. (2012). Emotional processing following recovery from anorexia nervosa. European Eating Disorders Review 20: 502–9. Oldershaw, A. et al. (2014). Emotional processing in anorexia nervosa: A systematic review. In preparation. Pike, K. M. et al. (2003). Cognitive behaviour therapy in the post hospitalization treatment of anorexia nervosa. American Journal of Psychiatry 160: 2046–49. Poulsen, S. et al. (2014). A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioural therapy for bulimia nervosa. American Journal of Psychiatry 171: 109–16. Ryle, A. (1995). Cognitive Analytic Therapy: Developments in Theory and Practice. Chichester: Wiley. Schmidt, U. (2000). Binge eating and binge eating disorder. European Eating Disorders Review 8: 340–43. Schmidt, U. et al. (1995). Puberty, sexual milestones and childhood sexual abuse: How are they related in eating disorder patients? Psychological Medicine 25: 413–17. Schmidt, U. et al. (1997a). Is there a specific trauma precipitating anorexia nervosa? Psychological Medicine 27: 523–30. Schmidt, U. et al. (1997b). Childhood experiences of care and abuse in eating disorders: Clinical and research implications. European Review of Eating Disorders 5: 184–207. Schmidt, U. et al. (2012). Out-patient psychological therapies for adults with anorexia nervosa: Randomised controlled trial. British Journal of Psychiatry 201: 392–99. Schmidt, U. et al. (2013). The MOSAIC study – comparison of the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified, anorexia nervosa type: Study protocol for a randomized controlled trial. Trials 14: 160. Schmidt, U. et al. (2014). The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA): Development, key features and preliminary evidence. Journal of Cognitive Psychotherapy 28: 48–71. Schmidt, U. and Treasure, J. (2006). Anorexia nervosa: Valued and visible. A cognitiveinterpersonal maintenance model and its implications for research and practice. British Journal of Clinical Psychology 45: 343–66.

264  Helen Startup et al. Sepulveda, A. R. et al. (2008). An examination of the impact of the ‘Maudsley eating disorder collaborative care skills workshops’ on the well-being of carers: A pilot study. Social Psychiatry and Psychiatric Epidemiology 437: 584–91. Serpell, L. et al. (1999). Anorexia nervosa: Friend or foe? International Journal of Eating Disorders 25: 177–86. Serpell, L. et al. (2003). The use of the Pros and Cons of Anorexia Nervosa (P-CAN) scale with children and adolescents. Journal of Psychosomatic Research 54: 567–71. Serpell, L. et al. (2004). The development of the P-CAN: A scale to operationalize the pros and cons of AN. International Journal of Eating Disorders 36: 416–33. Serpell, L. and Treasure, J. (2002). Bulimia nervosa: Friend or foe? The pros and cons of bulimia nervosa. International Journal of Eating Disorders 32: 164–70. Stiles-Shields C. et al. (2013). Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. International Journal of Eating Disorders 46: 783–89. Tatham, M. J. (2011). The role of imagery-based techniques in cognitive-behavioural therapy for adults with eating disorders. Clinical Psychology Review 31: 1101–9. Touyz, S. et al. (2013). Treating severe and enduring anorexia nervosa: A randomized controlled trial – Corrigendum. Psychological Medicine 43: 12. Treasure, J. et al. (2008). The assessment of the family of people with eating disorders. European Eating Disorders Review 16: 247–55. Treasure, J. et al. (2010). Eating disorders. Lancet 375: 583–593. Treasure, J. and Schmidt, U. (2001). Ready, willing and able to change: Motivational aspects of the assessment and treatment of eating disorders. European Eating Disorders Review 9: 1–15. Treasure, J. and Schmidt, U. (2013). The cognitive-interpersonal maintenance model of anorexia nervosa revisited: A summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders 1:13. Treasure, J. and Szmukler, G. (1995). Medical complications of chronic anorexia nervosa. In G. Szmukler, C. Dare and J. Treasure (eds) Handbook of Eating Disorders. Chichester: Wiley. Vitousek, K. B. and Hollon, S. D. (1990). The investigation of schematic content and processing in eating disorders. Cognitive Therapy and Research 14: 191–214. Wade, T. D. et al. (2011). A case series evaluation of the Maudsley Model for treatment of adults with anorexia nervosa. European Eating Disorders Review 19: 382–89. Waller, G. et al. (2000). Cognitive content among bulimic women: the role of core beliefs. International Journal of Eating Disorders, 28, 235–241. Waller, G. et al. (2007a). The role of emotional abuse in the eating disorders and its implications for treatment. Eating Disorders: The Journal of Treatment and Prevention 15: 317–31. Waller, G. et al. (2007b). Cognitive Behavioral Therapy for Eating Disorders: A Comprehensive Treatment Guide. Cambridge: Cambridge University Press. Waller, G. et al. (2014). Cognitive behavioural therapy for bulimia nervosa and atypical bulimia nervosa: Effectiveness in clinical settings. International Journal of Eating Disorders 47: 13–17. Woolrich, R. et al. (2005, April). Negative self-beliefs in anorexia nervosa: A detailed exploration of their content, origin and link to behaviour. Paper presented at the Academy of Eating Disorders Meeting, Montreal. Zipfel, S. et al. (2013). Focal psychodynamic therapy, cognitive behavioural therapy, and optimised treatment as usual in outpatients with anorexia nervosa: A randomised controlled trial. Lancet 383: 127–37.

Chapter 12

Case formulation in suicidal behaviour Daniel Pratt, Patricia Gooding, James Kelly, Judith Johnson and Nicholas Tarrier

Introduction Suicide is one of the leading causes of preventable death across the world (DeLeo et al., 2002), with approximately 6,000 people completing suicide in the UK and over 30,000 people in the United States each year, with suicide rates varying significantly across nations (Nock et al., 2008). The World Health Organization (WHO) estimate approximately one million suicide deaths each year, with attempted suicides up to 20 times more frequent than completed suicides. Put another way, a person dies from suicide every 40 seconds and an attempt is made every 3 seconds. WHO reported that suicide accounts for the largest share of the intentional injury burden (Mathers et al., 2003), with estimates indicating that, by 2020, suicide will constitute more than 2% of the total disease burden across the world (Murray and Lopez, 1996; Bertolote and Fleischmann, 2009). These figures are likely to be significant underestimates since official statistics tend to rely upon presentations to emergency departments and accurate recording of the individuals’ suicidal intent (Horrocks et al., 2003). Nevertheless, suicidal ideation and behaviour is more common than one might expect. International surveys and meta-analyses report a lifetime prevalence of suicide attempts of approximately 1–5% (Bebbington et al., 2010; Bertolote et al., 2005; Nicholson et al., 2009; Kessler, Borges and Walters, 1999; Weissman et al., 1999) with rates of suicide planning (1–15%) and suicidal ideation (2–25%) even more common (Bertolote et al., 2005; Casey et al., 2008; Weissman et al., 1999). Of course, not all individuals who engage in suicidal ideation and/or behaviour will eventually take their own lives, but all aspects located along the suicidal behaviour continuum are accompanied with significant, distressing, disruptive and undesirable psychological states worthy of therapeutic intervention. Suicidal behaviour is not an act where the effect is limited to the individual. Family, friends, colleagues and acquaintances experience grief, distress, trauma, regret, shame and many other devastating difficulties following a suicidal death. Questioning of the self over ‘was it my fault in some way?’ and ‘could I have done anything to stop them?’ can be common. Clinicians are not immune to these sequelae.

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For more than 50 years, the predominant focus in the study of suicide has been on the identification and cataloguing of various socio-demographic and clinical correlates of suicidal behaviour. This epidemiological approach has helped generate a profile of the typical ‘high-risk individual’. In the UK, this profile would be of a young male who is less ‘integrated’ within his community, so more likely to be single or divorced with no children and unemployed. He has an almost 90% chance of experiencing a diagnosable mental disorder, most likely depression, substance use, personality disorder and/or psychosis (Arsenault et al., 2004) and, compared to his general population peers, this man is 35 times more likely to have previously engaged in suicidal behaviour (Cooper et al., 2005; Harris and Barraclough, 1997). In recent years, this biomedical framework has been called into question for three reasons. First, the identification of a range of correlates lacks specificity with many of the correlated variables too common to accurately and efficiently identify ‘high-risk’ individuals (Bolton et al., 2007; Paris, 2006). A second criticism is the absence of a theory to explain the resulting suicidal behaviour. Risk profiling describes who is more likely to die from suicide, but can offer no explanation as to why. An empirically testable model that explains suicidal behaviour is required to allow the clinician to helpfully and meaningfully intervene (O’Connor and Sheehy, 2000). And third, the majority of the socio-demographic factors identified to be associated with an increased risk of suicide are hard, if not impossible, to change; i.e. a young, divorced, unemployed male. Such an approach is therefore of limited use to the clinician who carries the responsibility for facilitating behaviour change away from suicide (Tarrier et al., 2013). Rather, an individualised case formulation approach is required when working with suicidal individuals. Such a formulation has to comprise a description of the suicidal behaviour itself and, importantly, an explanation of the purpose and function of the behaviour and the meaning the person attributes to this. In this chapter, suicidal behaviour will be used to refer to a cognitive-behavioural continuum from thoughts about death, wishing to die, suicidal ideation, intention and planning through to action in the forms of attempted and completed suicide. It is assumed that completed suicides can be prevented by intervening at earlier stages along the continuum.

Contemporary models of suicidal behaviour Several cognitive-behavioural theories have attempted to explain how the various psychological correlates of suicide coalesce at the individual level to lead to a decision about suicide. The ‘cry of pain’ model Williams (1997, 2001) suggested suicidal behaviour should be explained as a ‘cry of pain’ (CoP). A chain of events are triggered by an individual’s perceived failure

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to meet expectations set for themselves. These failures are attributed internally, thus making self-awareness painful and providing motivation to escape from the self. Drawing upon the phenomenon of ‘arrested flight’, the model proposes suicidal behaviour is reactive (‘the cry’) to a situation that has three components: defeat, no escape / entrapment and no rescue. The initial stress or triggering event(s) include situations in which individuals feel they have suffered a defeat central to their life. In order to escape from this painful situation, individuals then have to make a judgement as to whether they believe there is a chance of escape or they are trapped in the situation. Furthermore, the individual’s judgement of the presence of rescue factors, i.e. whether they believe they may be saved or rescued from the situation by other people or circumstances, attenuates the effect of entrapment to reduce suicide risk. The interpersonal-psychological theory of suicide Another key psychological theory of suicidal ideation and behaviour has been developed and tested by Joiner and colleagues (Joiner, 2005; van Orden et al., 2010). Joiner’s interpersonal-psychology theory (IPT) proposes suicidal desire leads from the coming together of two interpersonal constructs – thwarted belongingness and perceived burdensomeness. The first construct, thwarted belongingness, refers to the failure to meet one of the fundamental human psychological needs – the ‘need to belong’ (Baumeister and Leary, 1995). The second construct identifies perceptions that one is a burden upon family members and significant others likely to have developed as a result of negative life events, such as family conflict, unemployment or illness. For the individual to further their suicidal desire towards actual behaviour, a third construct must be present – acquired capability. According to Joiner (2005), the capability for suicide can be acquired as a result of an increased physical pain tolerance and a reduced fear of death, achieved through habituation as a result of repeated practice and exposure. Only when all three main constructs are in place would an individual engage in a suicidal act. The integrated motivational-volitional model O’Connor (2011) attempted to incorporate key components of the CoP and IPT into a new model. The Integrated Motivational-Volitional (IMV) model focuses upon explaining how those who think about suicide (ideators) can be distinguished from those who engage in suicidal behaviour (attempters). Importantly, the IMV proposes three categories of moderating factors (threat to self, motivational and volitional) that influence key transitions from states of defeat or humiliation, resulting from an acute stressor, through entrapment towards suicidal ideation and eventually to suicidal behaviour. Interventions tailored towards minimising the impact of each moderator is hoped will divert the individual from progressing along this suicidal trajectory.

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The schematic appraisals model of suicide The Schematic Appraisals Model of Suicide (SAMS; Johnson et al., 2008) attempted to provide a framework from which to understand the development of psychological mechanisms that drive suicidal thoughts and behaviours, with a view to directly informing how case formulations can be developed when working with suicidal individuals. The SAMS attempts to extend the focus within the CoP model upon concepts of defeat, entrapment and ‘no rescue’ by specifying the key underlying cognitive and behavioural processes associated with suicidal behaviour. Consequently, the case conceptualisation can offer a description of the individual’s experience of suicidality and also an explanation of the function of the behaviour, thus providing direction for intervention plans. Three key components are proposed: negative information-processing biases, the presence of a suicide schema and a four-stage appraisal process (current, historical, future, self). A heuristic summary of the SAMS is shown in Figure 12.1. The SAMS model assumes the presence of a precipitating event. The range of triggers can include external events, such as an argument with a friend, or internal events, such as recall of an unpleasant memory. In the presence of such a potentially threatening event, attention becomes preferentially focused upon the threat (Dalgleish and Watts, 1990). Information processing biases Common information processing biases include a failure to inhibit processing of negative stimuli, better recall of negative information, negative interpretational style of ambiguous information, reasoning biases with decisions made on insufficient information, and a bias towards external attributions of the cause of the triggering event (see Cisler and Koster, 2010). Such biases can affect the information that becomes encoded into memory, subsequently resulting in a negatively skewed range of balanced material available for recall at a later date. For instance, triggering events that are perceived to be potentially suicide-relevant are more likely to be successfully encoded, including the emotionally laden mental images associated with the trigger. A consequence of such biases is that they influence and ‘aid’ the development and elaboration of the suicide schema. Suicide schema In the presence of a triggering event, threat-focused attention leads to the activation of the suicide schema. The ‘suicide schema’ can be seen as an example of a loose network of interconnecting stimulus, response and emotional stored information pertaining to suicide that can become activated at any point of the network. When activated, the schema will trigger beliefs

Case formulation in suicidal behaviour  269 TRIGGERING EVENT Internal o thoughts o memories

External o stressors o interactions

THREAT FOCUSSED ATTENTION Attention biases Memory biases Reasoning biases Problem solving biases

ACTIVATES SUICIDE SCHEMA Memory scripts If...then... rules Beliefs about suicide (positive and negative)

SELF-APPRAISALS Self-esteem Personal agency Rescue factors Evaluation of cognitive abilities

SITUATIONAL APPRAISALS Current situation Historical context Future expectations: o Solution generation o Solution content o Solution evaluation TIPPING POINT SUICIDAL BEHAVIOUR

Figure 12.1 A clinical heuristic for the Schematic Appraisal Model of Suicide (following Johnson et al., 2008).

about suicidal behaviour, such as ‘suicide is an escape from my intolerable emotional pain’ or ‘suicide is the only solution to my problems.’ The activation of the suicide schema inhibits the activation of other schema containing less damaging escapes or more appropriate goal-directed cognition or behaviour (Tarrier et al., 2007).

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Appraisal system The SAMS model specifically identifies three types of appraisal: appraisal of the current situation, appraisal of historical factors and appraisal of the future. Each of these three types of appraisal are informed and influenced by a fourth, self-appraisal in terms of self-esteem, personal agency and the perceived presence/absence of rescue by others. The perception and appraisal of the current situation is an important contributor to suicidal risk especially when experiencing psychological distress. Unsurprisingly, negative appraisal of historical factors is more likely if the individual has experienced traumatic events in their past, and one of the strongest predictors of suicidal behaviour is a personal or familial history of suicide (Hawton et al., 2005). In terms of appraisals of the future, three subcomponents are considered – the ability to generate solutions to current difficulties, the content of the solutions generated, and the appraisals made by the individual of these solutions. Continued engagement in negative situational appraisals serves to strengthen the individual’s perceived need to monitor for further confirmatory evidence thus maintaining threat-focused attention. Appraisals of the self will influence each of the other appraisal components, with negative self-perception, expectations of others and a lack of emotional resilience of particular importance (Johnson et al., 2008). Suicidal behaviour At a certain point, the individual draws a conclusion that he or she cannot continue within this distressing situation any further and a ‘tipping point’ is reached. Tipping points vary across individuals according to their previous history of engaging in suicidal behaviour, significant life events and perceived coping ability. With few, if any, rescue factors, suicidal ideation can progress to more detailed consideration of suicidal behaviour as a realistic possibility. Ambivalence about the decision to end his or her own life is removed as the individual progresses further along the suicidal continuum from passive suicidal ideation to active planning of an attempt. Engagement in such planning, and any subsequent suicidal behaviour, then becomes incorporated into the suicide schema which, in turn, elevates the likelihood of suicidal behaviour to be more easily triggered in future suicidal crises.

Empirical basis for cognitive therapy for suicidal behaviour There is some empirical evidence to suggest that cognitive behavioural therapies can have a significant preventative effect upon suicidal ideation and behaviour. Tarrier et al. (2008) reviewed cognitive behavioural interventions for suicidal behaviour and identified 25 studies reporting measures of suicidality. The meta-analysis revealed an overall effect size indicating CBT interventions to be effective at reducing thoughts and behaviours related to suicide. Subsequent to the review, in a

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sample of 90 adults and adolescents presenting to a local medical centre following an episode of self-harm / suicidal behaviour, Slee et al. (2008) found that those participants who were randomly allocated to receive up to 12 sessions of CBT reported significantly reduced levels of suicidal cognitions, improved problem-solving ability and improved self-esteem, compared to those who had received standard treatment alone. From this evidence, it can be concluded that the CBT intervention approach is successful in the prevention of suicidal ideation and behaviour, although larger, multi-site studies are required to strengthen support for this conclusion.

Generating a formulation of suicidal behaviour The rationale behind the assessment sessions are threefold: (i) to assess the patient’s current level of risk to inform risk management; (ii) to collect information about factors that may contribute to the patient’s vulnerability to suicidal behaviour and (iii) to identify factors that may be harnessed to reduce vulnerability to suicidal behaviour and improve resilience. A comprehensive assessment would look to draw upon as broad a range of sources of information as possible. In addition to the patient’s self-report, and with appropriate consent, the therapist should seek to gather information from the significant others involved in the patient’s ongoing care and support, e.g. family, spouse/partner, care team etc. Views and observations could be elicited of the patient’s previous episodes of suicidal behaviour or attempts that required their support. Speaking with family may also provide an indication of the level of expressed emotion within the patient’s home environment and the potential availability of support from others. Family and friends may also be able to provide examples of situations that either exacerbated or reduced the patient’s suicidal distress. Risk assessment A thorough and detailed assessment of risk is warranted when working with people at increased risk of suicidal behaviour. Informed by the literature that has highlighted several key risk factors common amongst completed suicides, key areas of assessment would include: •

• •

Previous suicidal behaviour – has the client previously attempted to kill themselves? What was their preferred method? How often have they engaged in this behaviour? What are the patient’s reflections on the previous attempts – regret, shame, relief? Psychiatric diagnoses – has the patient any diagnosable mental disorder? How do they experience this disorder and what does having such a disorder mean to the patient? Current stressors – is the suicidal behaviour attributable to current personal circumstances, e.g. unemployment, homelessness, relationship problems, financial difficulties? How can these be resolved?

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• • •

• •

Life events – how are previous life events (e.g. trauma, loss, illness) impacting upon the patient’s current experience? Suicidal ideation – what thoughts, images, emotions has the patient recently experienced when ‘suicidal’? What interpretations does the patient make about their suicidal ideation? Suicidal intent – what is the patient’s current motivation to act? What further stress would lead to the patient engaging in suicidal behaviour? What is the likelihood of this happening? What precautions could be made to prevent a suicidal act? Suicidal plans – has the patient developed a plan for their suicidal behaviour? How detailed, specific and feasible is the plan? Has the patient planned for what will happen after their death? Access to means – can the patient arrange access to the means they intend to use within their plan, e.g. stockpile of medicines, motorway bridge etc.)?

Vulnerability to suicidal behaviour Informed by the SAMS model of suicidal behaviour (Johnson et al., 2008), the focus of this part of the assessment is to elicit the role of attentional processes and information processing biases, the patient’s appraisals of distressing situations and their response to the situation and the underlying assumptions and beliefs related to suicide held by the patient, including the function of suicidal behaviour for them. Often, engaging the patient in the recalling of recent episodes of suicidal ideation or behaviour can provide the therapist with most of this information. Such conversation can also support the patient to develop confidence in their ability to talk about such material and also help to counterevidence any beliefs that talking about suicide makes a person more suicidal. Since this material is often highly distressing and personal to the patient, the therapist must be attuned to the patient’s tolerance to the assessment, with breaks during sessions or shortened sessions offered. Within the discussion of recent episodes, the therapist should seek to identify the following key factors: • •

• •

Triggers – was the situation triggered by an external or internal event? Attentional processes – how much did the patient focus their attention on internal experiences such as worrisome thoughts, distressing images, feelings? Was it difficult for the patient to move their attention away from the triggering event? Appraisals of current situation – how did the person make sense of the triggering event? What was difficult about this situation? How does this link with appraisals of defeat, entrapment and absence of rescue? Appraisals of the past – how does the current situation remind the patient of their previous experiences? How did these common memories influence how the patient saw the current situation?

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• • • • •

•

Appraisals of the future – what does the patient think will happen in the future as a consequence of the current situation? What is the patient looking forward to? Problem-solving appraisals – can the patient think of different ways of solving this problem? How confident is the patient in their solutions to overcome the current situation? Defeat and Entrapment appraisals – what was it about the current situation that made the patient feel they couldn’t cope or see a way out? Can they describe what led them to feel overcome or beaten by this situation? Behavioural responses – what did the patient do (or not do) in response to the current situation? What did the patient want to do (or not do)? How much control do they have over this response? Suicide Schema – what does suicidal ideation and behaviour mean to the patient, both positive and negative beliefs? How could a suicide attempt help them in the current situation? What subsequent problems would suicidal behaviour cause the patient, their family, the world around them? Function of Suicidal behaviour – what did the patient hope to gain from the suicide attempt? What was their motivation for this behaviour? Was it . . . • • • •

the only escape from intolerable pain? an expression of distress for others to see? a method used to influence the behaviour of others? a form of self-punishment?

Protective and resilience factors In addition to the assessment of vulnerabilities, the therapist should also seek to identify the patient’s strengths and available resources that have helped to keep them alive. Discussion of recent episodes when the patient resisted engaging in suicidal behaviour can be used as examples of successful coping and examined in detail to identify the protective or resilience factors that enabled this success. When reviewing previous suicidal episodes, the therapist can extend the timeline to also include the period subsequent to the suicidal experience and, if possible, through to the time when the patient no longer felt ‘suicidal’. Through such discussion, the therapist and patient can collaboratively uncover the supportive responses and behaviours that were helpful to the patient’s recovery from the suicidal episode. This aspect of the assessment can help to engage the patient in a dialogue that engenders hope and belief in a more positive future, thus facilitating the patient’s access to alternative schemas as opposed to the suicide schema and related appraisals. Furthermore, the patient’s sense of personal agency and control over situations previously seen as defeating and overwhelming can begin to be developed.

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Developing motivation for therapy and successful engagement (‘can we talk about suicide?’) Patients with recent suicidal behaviour can often find engaging in conversation about suicide to be a difficult and challenging experience, which may explain why attendance rates at outpatient appointments following suicide attempts can be as low as 40% down to 10% (Kessler et al., 2005; Lizardi and Stanley, 2010; Rudd, 2006). The patient may hold stigmatising beliefs about their previous suicidal behaviour and feel too ashamed or embarrassed to describe these events, and they may harbour an intense fear of the dangers of talking about suicide. When working with a suicidal patient, the therapist will want to discuss some of the most difficult times in the patient’s life. From the outset, it is important that a collaborative, trusting and open relationship be developed between the patient and therapist. By adopting a non-judgemental and empathic approach, the therapist can express a genuine curiosity into the patient’s experiences of suicidal behaviour. The patient can be encouraged to decide upon an initial level of disclosure they feel most comfortable with. For some clients, an assessment of their previous suicidal ideation or behaviour can be too threatening and emotionally arousing. In such instances, the emphasis must be placed more so upon the development of the trusting, therapeutic alliance with the need to gather information met at a later point. The therapist could follow the patient’s lead with the initial conversation to ensure this takes place on comfortable ground. Talking about ‘talking about suicide’ can often help clients recognise their unhelpful beliefs and feared consequences of such a conversation, e.g. ‘talking about suicide will make me suicidal again.’ Normalising experiences and distress, as well as the difficulties of entering into a new relationship with the therapist, can assist clients in feeling understood and diffuse fear or angst associated with therapy (Tarrier et al., 2013). When the client is no longer in a suicidal crisis it can seem less important, or even irrelevant, to engage in a suicide prevention therapy. A metaphor that may help facilitate engagement in these instances can be taken from a quote from President J. F. Kennedy: The time to repair the roof is when the sun is shining. Clients are encouraged to consider the pros and cons of trying to ‘repair’ a particular problem, i.e. suicidal behaviour, when they are not currently experiencing distress related to that problem. It is proposed to the client that a period of relative stability may offer them a window of opportunity to engage in a constructive programme of therapy that aims to systematically understand previous difficulties and improve ways of overcoming such problems if they arise in the future. Clients can also be asked to reflect upon the potential advantages and disadvantages of attempting to develop resources and a prevention plan when they are in a crisis, i.e. ‘fixing the roof in the rain’.

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Treatment A treatment strategy driven by the cognitive behavioural formulation of a patient’s suicidality is based on the basic principles of agenda setting, use of Socratic questioning to help patients evaluate the validity of underlying beliefs and functions of suicidal behaviour and collaborative empiricism in the implementation and review of potential intervention techniques. Following the assessment and conceptualisation of the patient’s suicidal experiences, a treatment plan usually comprises of five key areas. Attentional control At times of a suicidal crisis, patients can find themselves ‘locked-in’ to a pattern of suicide ideation that they can feel is difficult to control. Therefore, one of the first techniques used within the intervention should aim to increase the patient’s attentional control, such as Wells’s (1990) attention training technique (ATT). Through the use of the ATT technique, patients learn how to overcome ‘attentional fixation’ by switching their attention onto non-self-relevant aspects of their environment, e.g. sounds from various spatial locations. Through practice, patients also develop a greater sense of control over whether or not to engage with any interfering cognitions. The ATT technique can then be extended to include attention to neutral imagery and any associated sensations such as sound, touch, smell. This technique is then further extended into the Broad Minded Affective Coping (BMAC) technique (Tarrier, 2010), where the patient is asked to visualise an image related to a positive event from their past, typically a family event, birthday party or wedding day. The patient is supported to savour the positive emotions associated with the details of the memory, to bring these emotions back to life in the present-moment, to identify the meaning attached to this emotion and the implications for their sense of control over their emotions. Appraisal restructuring According to the SAMS model, a number of key appraisals are maintained by the suicidal client, which the therapist and client need to work together to identify and challenge through traditional cognitive behavioural methods. More helpful, and rational, appraisals can be developed through psycho-education work with the client to increase their awareness of common thinking biases, e.g. ‘negative mental filter’, catastrophising and jumping to conclusions. Once aware of such thinking habits, the client can monitor occurrences which can then be used as opportunities for a new way of thinking, thus maintaining a sense of hope for the future. The accuracy of the client’s appraisals can also be questioned by evaluating the evidence supporting the appraisal and also disputed through consideration of contrary evidence. Furthermore, behavioural experiments can often be helpful to encourage the client to seek out and uncover disconfirmatory evidence directly.

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Problem-solving skills training Since deficits in problem-solving are associated with suicidality (Pollock and Williams, 1998), a structured technique to developing skills in solving problems should be considered. The conventional method of problem-solving is as follows (Tarrier et al., 2013): 1 2 3 4 5 6

List clearly the problem(s) to be resolved Select a problem and clearly and simply define it Brainstorm as many solutions as possible List the advantages and disadvantages of each possible solution Select and implement a solution Evaluate the effectiveness of the selected solution. If ineffective, select and implement an alternative solution, and repeat.

It can be initially helpful for patients to learn the steps of this technique on a hypothetical, everyday problem, e.g. ‘you have run out of milk but want a cup of tea.’ The patient can then begin to apply the technique onto previous problems related to suicidal distress to demonstrate how the technique could help them to consider alternative responses. Furthermore, the patient can then predict potential future problems and work through the above steps to develop plans of how to resolve the problem should this actually occur. Self-reflections on the patient’s use of the problem-solving technique can then inform the development of more positive appraisals of coping in future situations. Behavioural techniques A common behavioural technique to introduce early within an intervention when working with a suicidal patient is activity monitoring and scheduling. Increasing the frequency of activities found to be associated with an increased sense of pleasure and/or achievement can be achieved through timetabling into the patient’s daily or weekly schedule. The resulting increase in time spent accessing pleasurable and/or achievement activities has the potential to elevate the patient’s engagement with their external environment, such as family and friends, and ensure routine access to positive, alternative schema. This improved sense of meaning in the patient’s life and increased connection with their social network serves to undermine the potential ‘no rescue’ appraisals of ‘I’m alone and no one will help me.’ Another technique often employed involves practical support from the therapist to improve the patient’s sense of connectedness with their social support network. The therapist can ask the patient to list all the people they know who could offer them help and support when they need it. Patients can often find this activity challenging due to the common assumptions of ‘I’m alone’ and ‘no-one cares about me’ stemming from ‘no rescue’ appraisals. In many instances, patients are

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pleasantly surprised to find a list of several people who they could turn to for help if they needed to. To strengthen this technique, the patient should then be encouraged to discuss the help they may need from each person listed prior to the time of a crisis, so that suitable plans can be put in and agreed upon. Additionally, for those patients who wish to expand their ‘help list’, new sources of support (e.g. community groups, phone lines, Samaritans) can be contacted to find out about the potential help that would be available to the patient at a time of need. The therapist can facilitate joint sessions, held with the patient and family members, where a ‘safety plan’ can be agreed with all parties. Schema-focused work The aim for this final phase of a client’s treatment plan is to deactivate, inhibit and/ or change the suicide-related schema through the adoption of new and appropriate schematic beliefs about the client’s circumstances, self and future (Tarrier et al., 2013). Reduced activation of the suicide schema is achieved through the enhancement of more positive schemas with associated links with more adaptive problem solving responses. Methods are used which help to promote positive self-worth, i.e. the client is supported to draw up a list of 10 positive qualities about themselves, each of these qualities are then rated as to how much the client believes they are actually true. The client is invited to recollect specific examples of when they demonstrated each quality, with detailed memories then used as examples for BMAC practices between sessions to emphasise and bolster this experience within the client’s memory. Re-ratings of the client’s belief in each of the positive qualities can then be used to emphasise to the client that their beliefs can change depending upon what evidence they focus their attention to. Similar to the activity scheduling technique, the client can then be encouraged to monitor and then plan events where they will engage in a positive quality, with belief ratings taken before and after each event to provide further evidence of the client’s improvement and hope for a preferred future.

Case example – Steve Steve was a 42-year-old white British male who was referred by a consultant psychiatrist for psychological therapy following a deliberate drug overdose and inpatient admission. As an only child, Steve lived with his parents until aged 3 years, but was then placed in local authority care for his own protection following significant neglect by his parents, who were heavy substance abusers. In the subsequent years, Steve was relocated several times between various foster placements. Steve did not enjoy his childhood and never felt at home in any of his placements since he was always aware of the potential to be moved on again. Since leaving school, aged 15 years with no formal qualifications, Steve had had numerous low paid jobs but never worked in one place for more than a year or so. Steve had a limited social network with a few friends he had made at his local

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pub. The only relationship of significance to Steve was with Barbara, whom he married nine years ago. Initially, Steve and Barbara enjoyed a good relationship and had two children. However, the relationship broke down when Barbara had an affair. Barbara left Steve four years ago and took the two children with her to live with her new partner. In response to this breakup, Steve began to fall into a deep depression and withdrew from the world. Steve was convinced that he had lost his only real chance of finding happiness and he would now be left to live a long and lonely life with no one to care for him. After several months of feeling low and depressed, Steve attempted to take his own life by overdosing on paracetamol. He was later found by a friend who noticed he was missing from the pub for a few weeks. Steve was admitted to the local hospital and eventually made a full physical recovery. A year or so after his suicide attempt, Steve was working in a local factory and met Sandra. Steve and Sandra became very close over subsequent months and decided to move in together 15 months ago. Although the relationship has been testing at times for Steve, he seemed happy to be living with Sandra. Approximately one month before the initial appointment with the therapist, Steve and Sandra had had an argument which led to Sandra leaving the house to stay at her friend’s overnight. Sandra’s leaving immediately triggered a second suicidal episode for Steve which led to him taking another overdose of paracetamol and an inpatient admission to the local mental health ward. Formulation By working through Steve’s recent suicidal episode, a formulation was collaboratively developed. Steve identified significant feelings of abandonment by his parents for placing him into care as a young child. He felt he was vulnerable and needed their love and support at this time, and yet he perceived his parents to have prioritised their own needs above his own. Steve internalised these experiences as evidence that he was unlovable and therefore a failure as a human being. Steve began to see others as unreliable and rejecting towards him. However, his core beliefs were changed during his relationship with Barbara, who offered him the love and care he had not received before. When Barbara left him, Steve quickly became engulfed in feelings of abandonment reminiscent of what he thought he must have felt as a young boy being placed into care. Steve viewed himself as a ‘nobody’ if he had nobody to love him. These thoughts and feelings arose again when Sandra ‘stormed out’ of their house as a result of an argument between them. Steve immediately began to believe that Sandra had left him and that he was all alone again. Steve became frightened by the idea of being alone again and saw himself as unable to cope on his own. Steve became convinced that he could only cope with the help from his partner and without this help there would be no reason to live. These thoughts and accompanying feelings quickly established themselves straight after the argument with Sandra, during which time Steve spiralled into a withdrawn state, engaging in little activity, preferring to spend his

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time in bed. He would also drink several cans of lager in the evening to ‘numb the pain’. For most of this time, Steve would engage in self-critical thinking by blaming himself for the perceived relationship breakdown with Sandra, which led to defeating appraisals of ‘No point in carrying on’ and ‘no-one would notice if I was dead.’ In this state, Steve recognised that suicide would offer him the only solution to his current situation, as it would remove his loneliness, the need to worry about the future and it would end his pain. Steve considered himself to be trapped in a defeating circumstance with no hope for the future to be any better. Nevertheless, with significant support from the therapist, Steve was able to recognise that there were certain parts of his life that he would miss if he was no longer alive. To facilitate engagement and to promote motivation for the therapy, Steve was supported to identify a short list of reasons for living. Steve considered that he would miss seeing his children grow up, get married and have children of their own, and he would miss being part of this family. Steve also become aware of the impact his death would have upon his family and the hurt this would cause them. Through considering previous difficult circumstances, Steve was also able to see that these difficulties, no matter how challenging and distressing at the time, did not last. The possibility that ‘things might change’ gave Steve a glimmer of hope for a better future. Through discussing previous difficulties, Steve also reflected upon his memory of being able to cope with relationship breakups before. He had eventually come to terms with losing Barbara and was able to find happiness again with Sandra. It therefore seemed logically possible to Steve that, despite his current problems, he may find another partner again in the future (see Figure 12.2). The main goals of therapy were agreed to be: • •

to develop a better understanding of depression and suicidality, and how these problems specifically affect Steve to develop ways of coping with depression and suicidal thoughts and feelings.

Intervention The psychological intervention for Steve commenced with the attention training technique to help him to gain attentional control. Practice involved paying attention to the sounds in the environment to assist Steve to learn how to deliberately move his attention to whatever he wanted to focus upon. This proved to be helpful when he felt his head was full of racing thoughts and he wanted to feel more relaxed. By identifying a few positive memories from his past, Steve was then able to extend his attention training into the Broad Minded Affective Coping technique. Steve recalled the memory of the birth of his first child and how excited this made him feel to belong to his own family. By focusing in on these memories, Steve became able to remember more and more details of what was happening, who he was with at the time, how this made him feel and what this memory meant to him.

280  Daniel Pratt et al. TRIGGERING EVENT Argu ment with Sandra Sandra ‘storms out’ of house Steve is left alone

THREAT FOCUSSED ATTENTION Catastrophising Negative mental filter Mind-reading Jumping to conclusions

ACTIVATES SUICIDE SCHEMA Memories of previous abandonments If I am not loved by someone, I am a nobody Suicide is an escape from these intolerable feelings

SELF -APPRAISALS I don’t know how to cope on my own I need others to help me but no-one wants to help I need to get rid of this hurt I can’t stop all these thoughts whizzing round my head

SITUATIONAL APPRAISALS It’s all my fault that she’s left me Once again, I’m all alone Things will never be good for me again There’s no point in carrying on like this No-one would notice if I wasn’t here TIPPING POINT

SUICIDAL BEHAVIOUR

Figure 12.2  Formulation for Steve.

The second aspect of the intervention was to help Steve challenge unhelpful thoughts. Steve identified thoughts about his relationship problems as particularly distressing with the underlying belief of being ‘unlovable’ resting behind much of his distress. By examining the evidence that supported this belief and any evidence against this belief, Steve was able to come to a more balanced alternative belief that relationships can be difficult and challenging at times but given time and effort can also be rewarding. Several sessions then focused upon problem-solving training which enabled Steve to feel more in control of difficult situations through learning how to think of realistic and practical solutions. Initial sessions drew upon examples of previous problems before then imagining future potential problems and devising

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solution plans. This approach not only served to help Steve learn the steps of the technique, but also improved Steve’s confidence in his ability to solve problems and self-efficacy appraisals. The final stage of the intervention was to reflect upon the achievements made during the course of therapy. Through looking back on the work completed within the therapy, Steve was able to identify the key elements of the intervention that proved to be most useful to him going forward. These learning points were documented in a ‘maintaining progress’ plan for Steve to refer back to when encountering a problem in the future, with setbacks reframed as chances for Steve to practice his new coping strategies to prevent things getting any worse.

References Arsenault-Lapierre, G., Kim, C., and Turecki, G. (2004). Psychiatric diagnoses in 3,275 suicides: A meta-analysis. BMC Psychiatry 4: 37. doi:10.1186/1471-244X-4-37 Bebbington, P. E., Minot, S., Cooper, C., Dennis, M., Meltzer, H., Jenkins, R., and Brugha, T. (2010). Suicidal ideation, self-harm and attempted suicide: Results from the British Psychiatric Morbidity Survey 2000. European Psychiatry 25: 427–31. Bertolote, J. M. and Fleischmann, A. (2009). A global perspective on the magnitude of suicide mortality. In D. Wasserman and C. Wasserman (eds) Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. Oxford: Oxford University Press. Bertolote, J. M., Fleischmann, A., De Leo, D., Bolhari, J., Botega, N., De Silva, D., Tran Thi Thanh, H., Philips, M., Schlebusch, L., Värnik, A., Vijayakumar, L. and Wasserman, D. (2005). Suicide attempts, plans, and ideation in culturally diverse sites: The WHO SUPRE-MISS community survey. Psychological Medicine 35: 1457–65. Bolton, C., Gooding, P., Kapur, N., Barrowclough, C., and Tarrier, N. (2007). Developing psychological perspectives of suicidal behaviour and risk in people with a diagnosis of schizophrenia: We know they kill themselves but do we understand why? Clinical Psychology Review 27(4): 511–36. Casey, P., Dunn, G., Kelly, B. D., Lehtinen, V., Dalgard, O. S., Dowrick, C., and Ayuso-Mateos, J. L. (2008). The prevalence of suicidal ideation in the general population: Results from the Outcome of Depression International Network (ODIN) study. Social Psychiatry and Psychiatric Epidemiology 43: 299–304. Cisler, J. M. and Koster, E.H.W. (2010). Mechanisms of attentional biases towards threat in the anxiety disorders: An integrative review. Clinical Psychology Review 30: 203–16. Cooper, J., Kapur, N., Webb, R., Lawlor, M., Guthrie, E., Mackway-Jones, K., and Appleby, L. (2005) Suicide after deliberate self-harm: A 4-year cohort study. American Journal of Psychiatry 162: 297–303. Dalgleish, T. and Watts, F. N. (1990). Biases of attention and memory in disorders of anxiety and depression, Clinical Psychology Review 10: 589–604. De Leo, D., Bertolote, J., and Lester, D. (2002). Self-directed violence. In E. G. Krug, J. A. Mercy, L. L. Dahlberg, and A. B. Zwi (eds), World Report on Violence and Health. Geneva, Switzerland: World Health Organization. Harris, E. C., and Barraclough, B. (1997). Suicide as an outcome for mental disorders: A meta-analysis. British Journal of Psychiatry 170: 205–28.

282  Daniel Pratt et al. Hawton, K., Sutton, L., Haw, C., Sinclair, J., and Deeks, J. J. (2005). Schizophrenia and suicide: systematic review of risk factors. British Journal of Psychiatry 187: 9–20. Horrocks, J., Price, S., House, A., and Owens, D. (2003). Self-injury attendances in the accident and emergency department clinical database study. British Journal of Psychiatry 183: 34–39. Johnson, J., Gooding, P. and Tarrier, N. (2008). Suicide risk in schizophrenia: Explanatory models and clinical implications, the Schematic Appraisal Model of Suicide (SAMS). Psychology and Psychotherapy: Theory, Research and Practice 81: 55–77. Joiner, T. (2005). Why People Die by Suicide. Cambridge, MA: Harvard University Press. Kessler, R. C., Berglund, P., Borges, G., Nock, M., and Wang, P. S. (2005). Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. Journal of the American Medical Association 293: 2487–95. Kessler, R. C., Borges, G., and Walters, E. E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry 56: 617–26. Lizardi, D. and Stanley, B. (2010). Treatment engagement: a neglected aspect in the psychiatric care of suicidal patients. Psychiatric Services 61: 1183–91. Mathers, C. D., Bernard, C., Iburg, K. M., Inoue, M., Ma Fat, D., Shibuya, K., and Xu, H. (2003). Global burden of disease in 2002: data sources, methods and results. Global Programme on Evidence for Health Policy Discussion Paper No. 54. Geneva: World Health Organization. Murray, C. L. and Lopez, A. D. (eds) (1996). The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard University Press. Nicholson, S., Jenkins, R., and Meltzer, H. (2009). Suicidal thoughts, suicidal attempts and self-harm. In S. McManus, H. Meltzer, T. Brugha, P. Bebbington, and R. Jenkins (eds), Adult Psychiatric Morbidity in England, 2007. London: Information Centre for Health and Social Care. Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., and Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews 30: 133–54. O’Connor, R. C. (2011). Toward an integrated motivational-volitional model of suicidal behaviour. In R. C. O’Connor et al. (eds), International Handbook of Suicide Prevention: Research, Policy and Practice. Chichester: Wiley Blackwell. O’Connor, R. C. and Sheehy, N. P. (2000). Understanding Suicidal Behaviour. Leicester: British Psychological Society. Paris, J. (2006). Predicting and preventing suicide: Do we know enough to do either? Harvard Review of Psychiatry 14: 233–40. Pollock, L. R., and Williams, J.M.G. (1998). Problem solving and suicidal behavior. Suicide and Life-Threatening Behavior 28: 375–87. Rudd, M. D. (2004a). Cognitive therapy for suicidality: An integrative, comprehensive, and practical approach to conceptualisation. Journal of Contemporary Psychotherapy 34: 59–72. Rudd, M. D. (2004b). Fluid vulnerability theory: A cognitive approach to understanding the process of acute and chronic suicide risk. In T. E. Ellis (ed.), Cognition and Suicide: Theory, Research and Therapy. Washington, DC: American Psychological Association. Rudd, M. D. (2006). The Assessment and Management of Suicidality. Sarasota, FL: Professional Resource Press.

Case formulation in suicidal behaviour  283 Slee, N., Garnefski, N., van der Leeden, R., Arensman, E., and Spinhoven, P. (2008). Cognitive-behavioural intervention for self-harm: randomised controlled trial. British Journal of Psychiatry 192: 202–11. Tarrier, N. (2010). Broad minded affective coping (BMAC): A ‘positive’ CBT approach to facilitating positive emotions. International Journal of Cognitive Therapy 3: 64–76. Tarrier, N., Gooding, P., Gregg, L., Johnson, J., and Drake, R. (2007). Suicide schema in schizophrenia: The effect of emotional reactivity, negative symptoms and schema elaboration. Behaviour Research and Therapy 45: 2090–97. Tarrier, N., Gooding, P., Pratt, D., Kelly, J., Maxwell, J. and Awenat, Y. (2013). Cognitive Behavioural Prevention of Suicide in Psychosis: A Treatment Manual. London: Routledge. Tarrier, N., Taylor, K., and Gooding, P. (2008). Cognitive-behavioural interventions to reduce suicide behaviour: a systematic review and meta-analysis. Behavior Modification 32: 77–108. Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., and Joiner, T. E. (2010). The interpersonal theory of suicide. Psychological Review 117: 575–600. Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H. G., Joyce, P. R., and Yeh, E. K. (1999). Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine 29: 9–17. Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy 21: 273–280. Williams, J.M.G. (1997). Cry of Pain. Harmondsworth: Penguin. Williams, J.M.G. (2001). Suicide and Attempted Suicide. Understanding the Cry of Pain. Harmondsworth: Penguin.

Chapter 13

Physical health problems A framework and checklist for case formulation Craig A. White

Introduction In recent years there has been a proliferation of research and academic material published in relation to clinical health psychology and cognitive-behavioural factors in adjustment to physical health problems (Helder et al., 2002; Mohr and Cox, 2001; Stanton et al., 2007). There are also cognitive-behavioural models of psychological concepts such as loneliness that can be applied usefully when formulating presenting problems in this area (Badoux-Levy et al., 2004; Heinrich and Gullone, 2006). It is this potential to ensure linkage of other empirical data (from clinical health psychology work most often) through the cognitive-behavioural formulation that is a considerable strength and appeal of this approach. Although this provides therapists and clinicians with an expanded source of reference material to inform their assessment and intervention plans, it is not always clear how to integrate this with established cognitive-behavioural models and frameworks that are commonly used for formulating the origins, maintenance and contributors to various presenting problems associated with physical health concerns. This chapter proposes a framework within which a wide range of presentations can be considered. Widespread application of cognitive therapy Cognitive therapy (CT) has been shown to be beneficial in a wide range of medical outpatient individual and group settings and specific medical scenarios, such as irritable bowel syndrome (Toner et al., 1998), cancer (Hopko et al., 2008), HIV (Seedat, 2012), inflammatory bowel disease (Bennebroek et al., 2012), heart disease (Hambridge et al., 2009; Lewin et al., 2009, Turner et al., 2013), pain (Thorn, 2004; Lamb et al., 2010), hepatitis C (Evon et al., 2013) and diabetes (Lustman et al., 1998). Behavioural treatment components such as relaxation may be useful in patients with long-term medical illnesses (Cottraux, 1993). Computerised programmes are also being evaluated (Sharp et al., 2013). The cognitive model is particularly well suited to working with individuals with physical health problems, given observations that progression or severity of

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physical illness are not synonymous with increased psychological morbidity or distress. Prospective studies of advanced cancer patients show that rates of mental disorders or existential distress do not increase as death approaches. Similarly, depression does not increase over time in late-stage amyotrophic lateral sclerosis as patients move towards ventilatory dependence and eventual death (Zhang et al., 2012). Depression is not predicted by whether patients undergo more arduous allogeneic stem cell transplants as compared to lesser autologous transplants; high medical comorbidity/risk also does not increase the rate of depression when compared to a low comorbidity/risk group (Syrjala et al., 2004). Additionally, it is well established that breast cancer stage and other medical variables are not associated with worse depression and anxiety (Bardwell et al., 2006; Kissane et al., 2004). Levin et al. (2013a) proposed that formulation provides a model for understanding and drawing together medical, psychological and social problems, against the greater backdrop of a person’s life. Cognitive-behavioural formulation of psychological components of physical health problems can be challenging – usually because of the multiple interactions between physical and psychological dimensions of problems, mediators and the general interacting nature of common presenting symptoms and problems. It is essential to ‘stay true’ to the relatively simplistic principles – principles that provide a framework for intervention and for wider multi-disciplinary team engagement with care planning (Levin et al., 2013b). This chapter outlines how these principles when applied within established cognitive behavioural models can assist with the development of formulations for complex presentations (including people with multiple psychological and physical health problems). As with cognitive-behavioural formulation more generally, conceptualisation of cases should always be informed by hypotheses that are generated from review of relevant literature, where this exists.

Cognitive behavioural assessment is universally applicable The information emerging from assessment information and the monitoring that someone has completed (which includes observations made by others in the wider multi-disciplinary team, which includes members of the patient’s family) should also be a central element of the construction of a formulation (Livsey, 1972; Li and Loke, 2013). Clinicians who are familiar with and competent in cognitive-behavioural case and problem formulation usually find that most of their skills are applicable to the emotional, behavioural and cognitive aspects of long-standing physical health problems. However, it can be more difficult to formulate elements that have not been studied comprehensively from a psychological perspective or where there is not an established cognitive-behavioural model for the experiences described. Everything can be assessed from a cognitive-behavioural perspective using a Beckian approach (Beck, 1995).

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It is also important that therapists consider how the principles of formulation can be applied in a manner that reflects the transdiagnostic focus often required in clinical health psychology practice settings (Dudley et al., 2011). Kuyken et al. (2011) emphasise the move from descriptive levels of conceptualisation, moving to explanations of triggers and maintenance, and then considering factors that predispose people to and protect them from presenting concerns. This serves as a useful reminder of the importance of first beginning with a descriptive focus that will then allow for possible linkages across situations and, finally, the possibility of extending ‘back’ into life experiences that identify the development of cognitive structures, processes and interactions. It is vital therefore that work on conceptualisation is seen as an ‘ever-evolving formulation’, one of Beck’s (1995) 10 key principles of cognitive therapy. Kuyken et al.’s (2011) descriptive, cross-sectional and longitudinal elements to case formulation will be used to structure this chapter. Formulation structure A descriptive level formulation is focused on cognitive-behavioural descriptors of the presenting problems, usually in superficial or associative terms (thought A leads to emotion B and behaviour C). Explanation for triggers and factors that maintain the presence of problems across situations are typically the focus of the cross-sectional formulation, moving finally then to longitudinal focus that ‘pieces everything together’. This outlines how predisposing factors, protective factors and all of the interactions between medical, psychological and social factors are linked in a comprehensive description of the origins, maintenance and contributors to the presenting problems, understood through the lens of their developmental history, which includes the role of physical illness. Formulation process The following steps reflect the process elements that should inform case formulation at each of the levels required, moving from descriptive, cross-sectional to longitudinal levels. • • •

Determine a problem list of all current physical, psychological, social and interpersonal problems – outline these in cognitive-behavioural terms. (Descriptive level) Explore the emotional, cognitive, behavioural, situational and interpersonal antecedents, moderators and consequences (through assessment, observation, monitoring and self-report from a range of sources). (Cross-sectional) Take each presenting problem and, through linkage of information available and hypotheses outline an explanation for the genesis, maintenance and experience of symptoms and problems. (Cross-sectional)

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•

Outline at the level of the case the factors that contribute to the nature of the problems, symptoms and their interaction with historical and psychological process factors (including strengths). (Longitudinal)

The common elements across each level will now be outlined, followed by a checklist that can be used for reference when developing and reviewing case formulations. Descriptive level This level focuses on the identification of thoughts, behaviours, emotions and physical reactions – with a specific emphasis on recent situations and experiences. This helps with socialisation of the patient to the cognitive-behavioural model and provides a platform for gathering more information as the basis for assessment and symptom monitoring. The descriptive level focus is represented diagrammatically in Figure 13.1, which is taken from Levin et al (2013a), based on Beck (1995).

Situation

Automatic

Thought

CT scan

I’m a burden family

to my

Reaction

Emotion

Sad Behaviour

Misses

dinner

Physiological

Heaviness in abdomen

Figure 13.1 The relationship among acute medical situations, automatic thoughts and subsequent emotional, behavioural, or physiological reactions (Levin et al., 2013a, reproduced with permission).

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Comprehensively describe all dimensions to capture experiences During the early stages of assessment, patients will provide information about recent examples where they have been distressed or problems have caused them difficulty. These difficulties can usually be described in terms of the patterns of thoughts, feelings and/or behaviours that are considered in mainstream CBT. As with other presenting problems, the formulation when working in physical health settings can be thought of as the framework that is applied to understanding what it is that makes the occurrence of symptoms problematic – at the descriptive level the aim is to explain how thoughts, emotions and behaviour co-exist and are responsible for mediating and moderating all of the problems (including the physical symptoms) on the problem list. Verbatim quotes are often more illustrative of thought content and less susceptible to misunderstanding – they should therefore always be preferred for inclusion in written notes and materials when working at the descriptive levels of a case formulation. This helps with initial engagement with the formulation and captures individual meaning from cognitive elements. It can also assist with socialising other clinicians to the cognitive-behavioural model, explaining how phrases they may have heard people saying are illustrations of the application of the cognitive behavioural model. This is often essential in acute medical and surgical settings. Isolate and describe all avoidance A patient’s perception of the severity and course of their illness has a crucial role in determining their psychological responses to all aspects of their attendance at hospital and interactions with staff regarding their illness (Rutter and Rutter, 2007; Ashley et al., 2013; Baines and Wittkowski, 2013). Just as with adult mental health practice, the core of most adjustment, anxiety and mood disorders relates to personal threat, danger, loss and an inability to cope with such threatening or dangerous situations. Being physically ill often threatens well-being and requires that people draw upon coping resources to respond to these threats. Episodes of anxiety symptoms are also often accompanied by cognitive and behavioural efforts to minimise anxiety, some of which might be supported by the advice that has been given by medical staff. This avoidance can be necessary to regulate the demands of living with physical symptoms – do not assume that all avoidance is dysfunctional. However, these avoidance tactics often have paradoxical effects in that instead of minimising negative moods, they only serve to maintain it. Comprehensive descriptive accounts of thoughts and behaviours linked with avoidance (including cognitive and emotional avoidance) should be captured, as these often directly inform initial interventions. The main difference in this area of practice comes in relation to the contextual reinforcement that can occur as a result of collusion from others (e.g. nursing staff saying that

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it is understandable that someone will not want to become too upset or focus on problems). Realistic negative automatic thoughts When one considers the automatic thoughts of people who are physically ill, there is often a grain of truth behind their automatic thoughts. Consider a dying patient who worries that ‘my family is avoiding me’ and feels depressed. This could be included in a formulation as distorted and, in time, related to be the consequence of an ‘abandonment core belief’ – but in reality, family members who are overwhelmed in the face of likely death may really be avoiding the patient. Thus, there is often a grain of truth to these thoughts. They should be included in the formulation in order that the primary emotions associated with them can be considered (describing them is often sufficient to validate patient experience). Secondary emotions derivative of the meaning of the realistic automatic thoughts should be included in the descriptive formulation (Moorey, 1996). ‘Realistic’ automatic thoughts often trigger other secondary automatic thoughts (e.g. ‘I can’t go on with this sadness any more’) and it is these secondary automatic thoughts that are contributors to the secondary emotion. Monitor physical and psychological dimensions simultaneously Patients should be asked about the presence, nature and frequency of all physical and psychological symptoms – detailed information that can be obtained from review of recent problem episodes. Diary monitoring of a combination of physical and psychological symptoms is essential – as this will give details on the key cognitive and emotional factors that are associated with all symptom experiences. This often results in a more comprehensive descriptive account of symptoms and allows the generation of hypothesis about cross-situational factors. This ability to explain to people that there could be factors that render several symptoms or experiences understandable often acts as a strong positive factor supporting engagement in therapy (particularly when someone is struggling to make sense of their emotional reactions to a diverse range of physical health problems and impact). Clinical procedures Cognitions may relate specifically to the idiosyncratic elements of a clinical procedure (e.g. implantable defibrillator intervention; Irvine et al., 2010) that has been or will be carried out (e.g. a patient with distressing imagery of her heart being stopped during bypass graft surgery). If not volunteered, any recent examples about clinical procedures need to be elicited as these often provide clues to themes relating to primary psychological problems and cross-situational themes.

290  Craig A. White

Self-doubt and tendency towards suspicion may give rise to automatic thoughts that question the reliability and functioning of medical devices. Imagery Imaginal association with physical symptoms (Gillanders et al., 2012) or representation within imagery of personally salient cognitive themes (Gosden et al., 2014) often feature in descriptive level formulations and should be assessed if not spontaneously offered. Imagery can be a vital process element – for example, it can serve to create the illusion that feared events are actually happening, which inflates estimates of likelihood. Inclusion within a formulation is essential as it can then be linked with imaginal-based intervention techniques (Serra et al., 2012). Summary of descriptive-level focus Descriptive-level formulations should feature everything that is spontaneously offered by the patient as a concern. Other elements not disclosed should be screened, taking account of illness specific factors. In summary, a descriptive cognitive-behavioural formulation of a physical health problem should be comprehensive in coverage and, in addition to being used to appreciate generic cognitive-behavioural principles, provides a focus for how specific physical health dimensions are problematic – something that should be clearly appreciable from review of the descriptive content. When this phase has been concluded there should be: • • • • •

A problem list in cognitive-behavioural terms Details of physical symptoms if not reflected in the problem list Description of disease course and reactions in cognitive-behavioural terms Clinical treatments and procedural aspects, expressed in cognitive-behavioural terms All of the preceding elements presented diagrammatically in a format such as Figure 13.1.

Cross-sectional Contextual triggers and setting conditions Given the nature of the problems reported in this area of practice (i.e. a combination of physical and psychological issues), this may mean formulating some symptoms with reference to biological, genetic or pharmacological factors – which although not cognitive-behavioural in content, this element is highly relevant in contextualising the relationship of all variables across situations. A formulation should also specify the extent to which the environment has an influence on physical

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symptoms, whether this is a direct influence or acts as a setting condition for the influence of another variable. Cross-sectional focus also needs to ensure that the inter-relationships of medical co-morbidity, past medical history, medications and prior experience with investigations are considered and integrated appropriately. Use of medication such as steroids, medical presentations linked with process such as hypoxia or arrhythmias, serotonin syndrome and delirium may manifest primarily with psychological symptoms. Formulations should avoid confounding symptoms attributable to medical pathology with a psychological problem; a thorough understanding of possible biological contributors must inform the formulation. Clinicians who are not medically qualified should ensure that they have a basic knowledge of psychopharmacology and internal medicine and they can access specialist supervision/guidance as required. Exacerbating and ameliorating factors Symptoms fluctuate in intensity from moment to moment and hour to hour and it is helpful to measure this variation. A cross-sectional focus in formulation should account for the factors that seem to influence the changes in symptom frequency and intensity. This can provide a good opportunity to determine tolerance thresholds for the experience of key symptoms (such as times when the same symptom experience is experienced differently from a psychological perspective). Using descriptive examples from different times can engage people in understanding the importance of cross-sectional principles. Past psychological problems When patients have had past psychological problems that resurface or are exacerbated by physical health problems, cognitive-behavioural formulations should seek to determine whether it is these same mediators that relate to the present episode. Reviewing prior case notes, records and clinical correspondence or tests is vital in support of this. ‘Thought experiments’ that take new insights and apply them to recollections of historical events (e.g. ‘if you had known before that this is often associated with thoughts of failure, what impact do you think that would have had?’) can also be useful in identifying factors responsible for fluctuations in symptom frequency and intensity. Impact of illness Patients who have become preoccupied by illness and its impact often report that their lives are ‘ruled’ by it. This can then lead to the establishment of links with prior beliefs or thoughts that determine current behaviours. Prospective monitoring over a range of situations can begin to unpack the basis for beliefs with the potential for pervasive impact.

292  Craig A. White

Cross-situational ‘self ’ appraisals Core beliefs such as, ‘I am unlovable,’ ‘no-one wants me now,’ and ‘I can’t do anything right,’ can fuel depressive symptoms. Cognitions linked with themes of stigma (Joachim and Acorn, 2000), self-efficacy (O’Leary, 1985), appearance, desirability, shame or disgust are commonly present among people living with changes in body functioning or with invasive treatments. They can offer explanations for the situations that will become distressing and begin to link discrete problem areas with generic psychologically significant themes across all problems for an individual. Beliefs about being ‘incomplete’ are generally signs of a need for cross-situational focus on core beliefs about self and links with longitudinal aspects of experience. Interpersonal functioning, family and social support Interpersonal factors that relate to interactions with and relationships to professional caregivers should be considered. Family functioning should be assessed by examining cohesion, teamwork, openness of communication and conflict resolution (Merz and Consedine, 2009). This is important in CT because family interactions are often increased during episodes of physical ill health and may therefore buffer or precipitate crises (Rosland and Piette, 2010). Family members are often accessed as support during the care provided in acute medical settings. Deficient social support is a well-established risk factor for negative health outcomes (including mortality) and vulnerability to psychological distress (Cohens and Wills, 1985). This is generally consistent across situations and is most easily included in the cross-sectional formulation. When this phase of formulation has been completed there should be: • Description of contextual, environmental and non-psychological factors influencing problem occurrence • Explanation of factors contributory to variation in symptoms across situations • Impact of all problems and symptoms on quality of life functioning. Longitudinal Pre-illness factors and psychological vulnerabilities The nature of pre-existing psychological vulnerabilities to psychosocial morbidity should be outlined within cross-sectional elements of a formulation. Pre-existing fatalistic, pessimistic or optimistic beliefs can moderate the impact of the daily demands of coping with physical ill health. In some cases it is possible to trace problems with adherence to treatment recommendations to long-standing beliefs about an inability to cope or low self-confidence (e.g. I am helpless; I cannot manage things on my own). This provides a clear demonstration for people that their

Physical health problems: A framework  293

adjustment to illness is being influenced by factors that have been present before the illness was a present factor in their lives. This can be a very helpful ‘in’ to therapy and therefore, formulation descriptors and diagrams should include beliefs and assumptions present before physical health problems began to negatively influence psychological functioning or quality of life. In some cases, it is possible to determine salient beliefs by asking directly (e.g. ‘when you found out that the liver disease could not be cured, did you find that some of the things you always thought instantly came into sharper focus in your mind?’). More commonly, details of the beliefs and assumptions that have been shattered by experiences of physical illness emerge from themes within other elements of the formulation. The links between descriptive, cross-sectional and longitudinal elements of a case formulation is outlined at Figure 13.2, a conceptualisation diagram based on Beckian principles. Early illness experiences are important as beliefs/assumptions may have been formed directly and are now activated, contributing directly to distress. For example, one patient delayed curative surgery because, as a child, he was traumatised by an appendectomy performed under anaesthetic at a time when his mother was unavailable. The fear of choking (experienced during the original episode) was intolerable, as were lingering abandonment cognitions of the sort experienced as a child. Similarly, many intermediate beliefs such as, ‘you must eat,’ ‘you must rest,’ and ‘you must listen to the doctor’ originate from experience with childhood illnesses and influence the response to illness. Global family coping beliefs, mottos and attitudes are also passed on from one generation to the next. These may include attitudes regarding autonomy which impact on adherence, e.g., ‘I don’t like taking tablets.’ All cross-sectional elements provide the building blocks for the narrative that will eventually feature in the longitudinal formulation. Figure 13.3 provides a worked example of these important linkages, highlighting how a pre-illness factor (divorce) and early illness trajectory experience (misdiagnosis) contributed to the development of core beliefs ‘no-one can be trusted’ and ‘I am unlovable.’ These in turn resulted in the formation of the intermediate belief ‘if I don’t let anyone know the real me then I can’t be let down again.’ The cross-sectional influence of these beliefs in outpatient appointments, when at home and in respect of illness-specific communications, can be seen through the

Factors Influencing Activation of Core Beliefs

Core Beliefs

Intermediate Beliefs

Situation 1

Automatic Thought

Reaction

Situation 2

Automatic Thought

Reaction

Situation 3

Automatic Thought

Reaction

Figure 13.2 The cognitive conceptualisation diagram for acute medical settings (adapted from Levin et al., 2013a with permission).

294  Craig A. White

Misdiagnosis of initial symptoms Divorce

No-one can be trusted I am unlovable

If I don't let anyone know the real me then I can't be let down again

Outpatient visit

She isn't interested in what matters to me

Sad, withdrawn

TV on future technology

Everything goes wrong for me and lets me down

Depressed, crying

Letter received re scan date

I won't be able to stand the waiting

Apprehensive, stomach churning

Figure 13.3  Sample cognitive conceptualisation diagram.

influence of automatic thoughts (e.g. ‘she isn’t interested in what matters to me’) on emotional and behavioural reactions. Personal values Research and clinical experience with behavioural activation has confirmed the benefit of considering values within formulation and treatment plans, identifying the way in which these influence meaning, belief and interpretation as related to everyday functioning, adjustment and ultimately to interventional focus (Ryba et al., 2014). Core and intermediate beliefs linked with values should be explored and explicitly outlined in the formulation. Care system influence and interaction Care systems and the way in which care processes are organised or applied need to be considered in respect of psychological variables that might interact with this (Taufen, 2013). The way in which the early investigation and diagnosis of symptoms was handled can be a significant determinant of psychosocial adjustment and result in an interactional pattern which is repeated and generalised to all patient and staff interactions. An example of this might be a patient who believed that the consultant who informed her of her diagnosis did not care about the impact on her. She believed that all staff in the unit were uncaring and tended to be rude to them when she was in their company. Illness-specific cognitions Patients may have unhelpful beliefs about the origins of their illness, something that should be included as this often influences the ways that patients respond to illness-related events. Cognitions throughout the various phases of the illness ‘story’ should be elicited. The role of cognitions relating to critical events in an illness trajectory such as missed/delayed diagnosis, losses (e.g. family deaths, illness that has forced retirement) or inter-current stresses (e.g. loss of employment, family strain or marital discord) often provide clues to intermediate beliefs that should be considered.

Physical health problems: A framework  295

Thoughts and beliefs regarding genetic susceptibility and familial history of illness should be considered (Fantini-Hauwel et al., 2011). A person whose father died from a myocardial infarction aged 54 may perceive his fate to be identical, ignoring potentially modifiable risk factors such as hyperlipidemia and smoking. A cancer patient whose grandfather died at 94 may feel short-changed because he did not meet the perceived expectation of longevity. Shared family variables (genetic and environmental) can have multiple legacies that impact on current biopsychosocial functioning. Prior abuse and trauma Childhood sexual, physical and/or psychological abuse and abandonment experiences often impact upon adjustment to physical illness (Romans and Cohen, 2008). These frequently result in the presence of thoughts about parental figures such as clinical staff – often focused on themes of trust, control and personal safety. These can be reactivated in hospital care settings, something that should be borne in mind when formulating these presenting problems. When this phase of formulation has been completed there should be: • Details of how pre-illness psychological vulnerabilities influence current presentation • Core beliefs and personal values that link descriptive and cross-sectional elements of the formulation (including illness specific cognitions) • Interaction of personal factors in formulation with care system dimensions • Specific descriptors of prior abuse and trauma in relation to presenting problems. When descriptive, cross-sectional and longitudinal core information has been elicited through observation, assessment and monitoring – synthesis of experiences through the application of psychological processes will have both explanatory power and therapeutic relevance in support of the most appropriate elements to commence intervention. Common process focus in formulation Mental models Cognitive processing models focus on the assimilation of new information about the self or the world to provide a framework to begin to conceptualise the way in which events are being understood and processed. This can often provide the bridge between thinking styles and cross-section impact. A formulation needs to take account of the extent to which that stimuli relating to physical health experiences are approached or engaged with in relation to the times that avoidance based tactics are used. This can usually be determined through review and discussion of several descriptions of recent examples and where cross-sectional

296  Craig A. White

and longitudinal elements include intrusions (thoughts or memories) and avoidance symptoms. The integration of physical illness into pre-existing mental models of personal health and well-being should promote psychological adjustment. Intrusions are markers of incomplete information processing and should prompt focus on explaining how descriptive levels, cross-sectional and longitudinal elements are linked. The occurrence of intrusive memories is often related to the reactivation of traumatic memories which have been incompletely processed and, as such, this element of a formulation needs to be linked to elements that outline the nature of the hypothesised problems with the assimilation or accommodation of illness-related experiences to existing schema/beliefs about illness, self, mortality, the regulation of emotion or other personally salient schemata. Cognitive processing therapy concepts are useful for this (Resicke et al., 2007). Formulations when there are self-esteem problems should determine whether physical illness is hypothesised to influence self-esteem directly (as in the case of a patient who believes illness is a further example of her long-standing worthlessness) or indirectly (via diminished social support, disrupted social roles or low perceived control). Longitudinal-level formulations should try to explain the process by which a patient’s experience of illness has been integrated (or not) with pre-existing mental models and make links with any intrusive thoughts or memories that might have been included at initial descriptive levels. Catastrophising Thinking styles such as catastrophising (Borsbo et al., 2010; Nieto et al., 2011; Robson et al., 2012; Rodero et al., 2012; Horsham and Chung, 2013) or a looming threat–processing style (Riskind et al., 2006), where the velocity of potential threats is overestimated, has been found to have widespread application and should be considered where presenting problems are related to anxiety and panic. The interactions with self-efficacy, symptoms and quality of life underline the importance of including this when it is noted. The presence of worry often requires linkages in a formulation with other moods and thinking styles (Davey et al., 2007). Identifying and addressing catastrophising in a formulation can influence the success of intervention (Verhagen et al., 2010). Problem solving, decision-making and attentional focus Negative emotions are disruptive to rational problem-solving and complex collaborative endeavours such as shared decision-making. Problem solving and decision-making are both essential elements of adjustment to physical health problems and should feature as key explanatory processes, particularly for the maintenance of problems. Extraneous environmental detail tends to be excluded as a result of the attentional narrowing that is so often a feature of intense emotion. A formulation should

Physical health problems: A framework  297

include the central impact of attentional factors, present by virtue of the emotional impact of a condition or the impact of a physical symptom burden on attention. Automatic thoughts relating to themes of acceptance and non-acceptance of illness, the course of the disease and opinions on medical advice are often related to problem emotions and behaviours. Patients may find it difficult to accept that recommended treatments do not ‘solve’ or prevent all health-related problems. Acceptance-related thoughts can often therefore mediate many of the features at different levels of a formulation. Formulation can highlight how a patient may have thoughts that, although unrelated to physical illness, are identical to the predominant themes in their thinking about their physical health more generally. Here the incomplete processing of personally meaningful information can be shown to be influencing the reactions to a wider range of areas that might be within awareness. Avoidance Cognitive, emotional and behavioural avoidance prevents confrontation with emotionally significant stimuli and, importantly, denies access to disconfirmatory information. People often report that it is their avoidance that is protecting them from the outcomes they fear. People with depressive symptoms often report that their avoidance is protecting them from feeling emotions that they find uncontrollable. These avoidant patterns of coping can often be worsened by the culture within many physical health clinics and teams, where emotional and psychological dimensions of illness are minimised. Health care professionals working predominantly in physical health care settings can sometimes promote and collude with avoidant responses. The cognitive model of panic outlines how patients tend to catastrophically misinterpret benign physical sensations as evidence of an impending catastrophic mental or physical event. Safety behaviours, attentional deployment, imagery, emotional reasoning, memory processes and the way in which threat is represented can also be relevant in understanding other emotions. These processes should be outlined in all formulations when relevant, with a specific emphasis on an explanation of how they all link to explain the origins and maintenance of the predominant reaction to physical ill health. Safety behaviours and psychophysiological links Mainstream conceptualisations of anxiety disorders have rightly emphasised the role of safety behaviours as key maintaining factors. These behaviours may be subtle and, with physical health presentations, are usually best identified by determining the function of behavioural changes which have developed to control or manage physical symptoms (e.g. ‘what things do you do in response to your symptoms that you did not do before?’). The role of safety behaviours can be especially problematic when they serve to increase symptoms through activation

298  Craig A. White

of psychophysiological mechanisms. For example, someone with urinary symptoms might restrict fluids, paradoxically increasing the chance of urinary urgency. The direct psychophysiological effect of stress and negative emotions should also be considered, e.g. muscle tension, respiration or mood (Selhub, 2002; Lutgendorf and Costanzo, 2003; Steptoe et al., 2009). This should be a central element in a formulation, representing as it does a potential vulnerability to other problems (Wilhelm et al., 2011). Checking behaviours that are designed to identify physical symptoms often result in increased anxiety as patients develop hypervigilance for a range of physical sensations. In some instances the checking can itself cause physical symptoms. In many cases, patient perceptions of symptoms are accurate and reflect what they have been told by staff. It is crucial, though, to triangulate information if there is any doubt that the person’s account of their symptoms, diagnosis or prognosis might be subject to bias in information processing or recall. Coping The predominant coping pattern preferred by the patient should be outlined in the overall formulation. It may be that there is a restricted pattern of coping where patients rely on one strategy for all problems, as opposed to varying strategy depending upon the demands of the situation. The role of coping style is now well established and provides a firm foundation for inclusion when present (Myers, 2010). Escape-avoidance coping has been consistently shown to be associated with distress. Cognitive contributors to stress usually relate to a perceived coping incapacity that (even among patients who have acceptable coping strategies) may paradoxically result in self-management problems which then reinforce perceptions of poor coping. The cognitive coping model defines coping as a ‘process’ of what people think (cognitive) and do (behavioural) to manage specific external and/or internal demands that are appraised as taxing or exceeding a person’s resources (Garnerski and Kraaji, 2010; Garnefski and Kraaij, 2012). Coping is viewed as a mediator of the emotional response. Ways that people cope include positive reappraisal, planful-problem solving, seeking social support, accepting responsibility, escape avoidance, distancing, self-control, meaning-making and confrontative coping. Emotional coping is used where the outcome is less likely to change while problem-focused coping, a more desirable style, is used in potentially malleable circumstances. A formulation needs to outline the cognitions and behaviours that serve to promote coping and adaptation and those that are working against this overall goal. Causal attributions Asking people, ‘What do you think may have caused . . .?’ is often a high yield exercise that can elicit surprising cognitions that prove to be central to the

Physical health problems: A framework  299

formulation and subsequent intervention (Luszczynska and Schwarzer, 2005). Illness attributions are pivotal as people attempt to make sense of the seeming random nature of illness (O’Hea et al., 2009). Dietary attributions may lead to radical changes in diets. Prior treatments may be attributed to the current illness. Personal experience, family adversity, culture, science, religion and the popular press may all influence illness attributions.

Assets and strengths There has been increasing recognition of the importance of strengths as an essential element of formulation. Kuyken et al. (2011) have included this within their model. People have often had periods of time where they have coped with their medical condition or symptoms, before psychological impact becomes troublesome. This time period can be used as a way of exploring strengths that could be moderating factors on the frequency or impact. Clinicians are often deficit-focused. Focusing on strengths, assets and new possibilities within the context of prior positive coping or strengths serves to provide a balance within the formulation. A problem may not have generalised to other life domains, meaning that it is relatively straightforward to understand, and that strengths from other domains can be used to buffer or moderate the impact of the problems overall. Consideration of engagement with life domains outside of those most directly related to physical ill health will usually help with the identification of assets and strengths. When this phase of formulation has been completed there should be: • • •

Details of the way in which cross-sectional elements reflect any discrepancy or discordant elements of premorbid and personal characteristics Description of how, over time, cognitive processing, causal attributions, psychophysiology and coping (including avoidance) influence presentation Assets and strengths with specific linkages to the elements of the formulation where there is potential to focus changes.

Conclusion This chapter has outlined an approach that moves from descriptive, through cross-sectional to longitudinal elements – ensuring that process linkages take account of cognitive processing, avoidance, psychophysiology, attribution, assets and strengths. The checklist outlined in Table 13.1 can be used to guide and inform this process, which will ultimately be the product of the unique interaction between clinician and patient, informed by prevailing and relevant research literature.

300  Craig A. White Table 13.1  Cognitive behavioural therapy in physical health – conceptualisation checklist Descriptive

Cross-Sectional

Longitudinal

•  Problem list • Cognitive behavioural description of every problem •  Avoidance descriptions • Realistic negative thoughts and secondary thoughts/emotions • Physical and psychological symptom links • Clinical procedures and treatments • Imagery

• Biological, genetic and pharmacological context (past and present) • Ameliorating and exacerbating factors across situations •  Past psychological issues •  Impact of illness • Cross-situation beliefs regarding the self • Interpersonal, family and social support

•  Pre-illness factors • Pivotal early life experiences regarding ill health • Personal values and wider core beliefs •  Care system influence • Illness-specific beliefs development over time • Any prior trauma or abuse

•  Process focus •  Explain how information processed over time (using intrusions as clues) • Catastrophising •  Attentional, problem-solving and decision-making styles •  Avoidance and safety-seeking processes •  Psychophysiological interactions •  Coping profile •  Causal attributions and reactions •  Assets and strengths

References Ashley, L. et al. (2013). Psychometric evaluation of the Revised Illness Perception Questionnaire (IPQ-R) in cancer patients: Confirmatory factor analysis and Rasch analysis. Journal of Psychosomatic Research 75: 556–62. Badoux-Levy, A. et al. (2004). Psychological and social factors predictive of loneliness: a cognitive and behavioral approach. Encephale 30: 16–23. Baines, T. and Wittowski, A. (2013). A systematic review of the literature exploring illness perceptions in mental health utilising the self-regulation model. Journal of Clinical Psychology in Medical Settings 20: 263–74. Bardwell, W. et al. (2006). Objective cancer-related variables are not associated with depressive symptoms in women treated for early-stage breast cancer. Journal of Clinical Oncology 24: 2420–27. Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford Press. Bennebroek Evertsz, F. et al. (2012). The effectiveness of cognitive behavioral therapy on the quality of life of patients with inflammatory bowel disease: Multi-center design and study protocol (KL!C- study). BMC Psychiatry 12: 227. Borsbo, B. et al. (2010). Impact of the interaction between self-efficacy, symptoms and catastrophising on disability, quality of life and health in with chronic pain patients. Disability and Rehabilitation 32: 1387–96.

Physical health problems: A framework  301 Cohen, S. and Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin 98: 310–57. Cottraux, J. (1993). Behavioral psychotherapy applications in the medically ill. Psychotherapy & Psychosomatics 60: 116–28. Davey, G. C. et al. (2007). What ends a worry bout? An analysis of changes in mood and stop rule use across the catastrophising interview task. Behaviour Research and Therapy 45: 1231–43. Dudley, R. et al. (2011). Disorder specific and trans-diagnostic case conceptualisation. Clinical Psychology Review 31: 213–24. Evon, D. M. et al. (2013). Chronic hepatitis C and antiviral treatment regimens: Where can psychology contribute? Journal of Consulting and Clinical Psychology 81: 361–74. Fantini-Hauwel, C. (2011). Genetic testing for hereditary cancer: Effects of alexithymia and coping strategies on variations in anxiety before and after result disclosure. Psychology and Health 26: 855–73. Garnekski, N. and Kraaij, V. (2010). Do cognitive coping and goal adjustment strategies used shortly after myocardial infarction predict depressive outcomes 1 year later? Journal of Cardiovascular Nursing 25: 383–89. Garnekski, N. and Kraaij, V. (2012). Cognitive coping and goal adjustment are associated with symptoms of depression and anxiety in people with acquired hearing loss. International Journal of Audiology 51: 545–50. Gillanders, D. et al. (2012). Pain related-visual imagery is associated with distress in chronic pain sufferers. Behavioural and Cognitive Psychotherapy 40: 577–89. Gosden, T. et al. (2014). Mental imagery in chronic pain: Prevalence and characteristics. European Journal of Pain 18: 721–28. Hambridge, J. A. et al. (2009). BraveHeart begins: Pilot results of group cognitive behaviour therapy for depression and anxiety in cardiac patients. Australian and New Zealand Journal of Psychiatry 43: 1171–77. Heinrich, L. M. and Gullone, E. (2006). The clinical significance of loneliness: A literature review. Clinical Psychology Review 26: 695–718. Helder, D. I. et al. (2002). Living with Huntington’s disease: Illness perceptions, coping mechanisms, and spouses’ quality of life. International Journal of Behavioral Medicine 9: 37–52. Hopko, D. R. et al. (2008). Cognitive-behavior therapy for depressed cancer patients in a medical care setting. Behavioural Therapy 39: 126–36. Horsham, S. and Chung, M. C. (2013). Investigation of the relationship between trauma and pain catastrophising: The roles of emotional processing and altered self-capacity. Psychiatry Research 208: 274–84. Irvine, J. et al. (2010). Acceptability of a cognitive behavior therapy intervention to implantable cardioverter defibrillator recipients. Journal of Cognitive Psychotherapy 24: 246–64. Joachim, G. and Acorn, S. (2000). Living with chronic illness: The interface of stigma and normalization. Canadian Journal of Nursing Research 32: 37–48. Kissane, D. W. et al. (2004). Psychiatric disorder in women with early stage and advanced breast cancer: A comparative analysis. Australian and New Zealand Journal of Psychiatry 38: 320–26. Kuyken, W. et al. (2011). Collaborative Case Conceptualization: Working Effectively With Clients in Cognitive-Behavioral Therapy. New York: Guilford Press.

302  Craig A. White Lamb, S. E. et al. (2010). A multicentred randomised controlled trial of a primary care-based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial. Health Technology Assessment 14: 1–253. Levin, T. T. et al. (2013a). A review of cognitive therapy in acute medical settings. Part II: strategies and complexities. Palliative and Supportive Care 11: 253–66. Levin, T. T. et al. (2013b). A review of cognitive therapy in acute medical settings. Part I: therapy model and assessment. Palliative and Supportive Care 11: 141–53. Lewin, R. J. et al. (2009). A brief cognitive behavioural preimplantation and rehabilitation programme for patients receiving an implantable cardioverter-defibrillator improves physical health and reduces psychological morbidity and unplanned readmissions. Heart 95: 63–69. Li, Q. and Loke, A. Y. (2013). A spectrum of hidden morbidities among spousal caregivers for patients with cancer, and differences between the genders: A review of the literature. European Journal of Oncology Nursing 17: 578–87. Livsey, C. G. (1972). Physical illness and family dynamics. Advances in Psychosomatic Medicine 8: 237–51. Lustman, P. J. et al. (1998). Predicting response to cognitive behavior therapy of depression in type 2 diabetes. General Hospital Psychiatry 20: 302–6. Luszczynska, A. and Schwarzer, R. (2005). Multidimensional health locus of control: comments on the construct and its measurement. Journal of Health Psychology 10: 633–42. Lutgendorf, S. K. and Costanzo, E. S. (2003). Psychoneuroimmunology and health psychology: An integrative model. Brain, Behavior, and Immunity 17: 225–32. Merz, E. M. and Consedine, N. S. (2009). The association of family support and wellbeing in later life depends on adult attachment style. Attachment and Human Development 11: 203–21. Mohr, D. C. and Cox, D. (2001). Multiple sclerosis: Empirical literature for the clinical health psychologist. Journal of Clinical Psychology 57: 479–99. Moorey, S. (1996). When bad things happen to rational people: Cognitive therapy in adverse life circumstances. In P. Salkovskis (ed.) Frontiers of Cognitive Therapy. New York: Guilford Press. Myers, L. B. (2010). The importance of the repressive coping style: Findings from 30 years of research. Anxiety, Stress and Coping 23: 3–17. Nieto, R. et al. (2011). Are coping and catastrophising independently related to disability and depression in patients with whiplash associated disorders? Disability and Rehabilitation 33: 389–98. O’Hea, E. L. et al. (2009). The interaction of locus of control, self-efficacy, and outcome expectancy in relation to HbA1c in medically underserved individuals with type 2 diabetes. Journal of Behavioral Medicine 32: 106–17. O’Leary, A. (1985). Self-efficacy and health. Behaviour Research and Therapy 23: 437–51. Resick P. A. et al. (2007). Cognitive Processing Therapy: Veteran/Military Version. Washington, DC: Department of Veterans’ Affairs. Riskind, J. H. et al. (2006). The looming cognitive style: A cognitive vulnerability for anxiety disorders. Journal of Social and Clinical Psychology 25: 779. Robson, C. et al. (2012). Catastrophising and normalising in patient’s accounts of their seizure experiences. Seizure 21: 795–801. Rodero, B. et al. (2012). Perceived injustice in fibromyalgia: psychometric characteristics of the Injustice Experience Questionnaire and relationship with pain catastrophising and pain acceptance. Journal of Psychosomatic Research 73: 86–91.

Physical health problems: A framework  303 Romans, S. and Cohen, M. (2008). Unexplained and underpowered: The relationship between psychosomatic disorders and interpersonal abuse – a critical review. Harvard Review of Psychiatry 16: 35–54. Rosland, A. M. and Piette, J. D. (2010). Emerging models for mobilizing family support for chronic disease management: A structured review. Chronic Illness 6: 7–21. Rutter, C. L. and Rutter, D. R. (2007). Longitudinal analysis of the illness representation model in patients with irritable bowel syndrome (IBS). Journal of Health Psychology 12: 141–48. Ryba, M. M. et al. (2014). Behavioral activation for depressed breast cancer patients: The impact of therapeutic compliance and quantity of activities completed on symptom reduction. Journal of Consulting and Clinical Psychology 82: 325–35. Seedat, S. (2012). Interventions to improve psychological functioning and health outcomes of HIV-infected individuals with a history of trauma or PTSD. Current HIV/AIDS Reports 9: 344–50. Selhub, E. M. (2002). Stress and distress in clinical practice: A mind-body approach. Nutrition in Clinical Care 5: 182–90. Serra, D. et al. (2012). Outcomes of guided imagery in patients receiving radiation therapy for breast cancer. Clinical Journal of Oncology Nursing 16: 617–23. Sharp, J. et al. (2013). Computerized cognitive behaviour therapy for depression in people with a chronic physical illness. British Journal of Health Psychology 18: 729–44. Snyder, D. K. and Whisman, M. A. (2004). Treating distressed couples with coexisting mental and physical disorders: Directions for clinical training and practice. Journal of Marital and Family Therapy 30: 1–12. Stanton, A. L. et al. (2007). Health psychology: Psychological adjustment to chronic disease. Annual Review of Psychology 58: 565–92. Steptoe, A. et al. (2009). Positive affect and psychobiological processes relevant to health. Journal of Personality 77: 1747–76. Syrjala K. L. et al. (2004). Recovery and long-term function after hematopoietic cell transplantation for leukemia or lymphoma. JAMA 291: 2335–43. Taufen, A. (2013). Mind game: Integrating behavioral health improves patient outcomes. Mgma Connexion/Medical Group Management Association 13: 51. Thoolen, B. J. (2009). Beyond good intentions: The role of proactive coping in achieving sustained behavioural change in the context of diabetes management. Psychology and Health 24: 237–54. Thorn, B. E. (2004). Cognitive Therapy for Chronic Pain: A Step-by-Step Guide. New York: Guilford Press. Toner, B. B. et al. (1998). Cognitive-behavioral group therapy for patients with irritable bowel syndrome. International Journal of Group Psychotherapy 48: 215–43. Turner, A. et al. (2013). Randomised controlled trial of group cognitive behaviour therapy versus brief intervention for depression in cardiac patients. Australian and New Zealand Journal of Psychiatry 47: 235–43. Verhagen, A. P. et al. (2010). Pain severity and catastrophising modify treatment success in neck pain patients in primary care. Manual Therapy 15: 267–72. Wilhelm, F. H. et al. (2011). Bridging the gap between the laboratory and the real world: Integrative ambulatory psychophysiology. In M. Conner (ed.) Handbook of Research Methods for Studying Daily Life. New York: Guilford Press. Zhang, J. et al. (2012). Effects of psychological interventions for patients with systemic lupus erythematosus: A systematic review and meta-analysis. Lupus 21: 1077–87.

Chapter 14

Formulating collaboratively with carers Katherine Berry and Fiona Lobban

Introduction In this chapter we will outline a rationale for formulating with carers. We will present the evidence to support developing shared formulations and describe a clinical approach to achieve this, which will be illustrated with a case example to demonstrate its practical application. The case example focuses on a range of issues that are present in working in many different settings, but here we specifically focus on developing shared formulations with professional caregivers working with an inpatient with a diagnosis of psychosis. Many of the themes are also applicable when working with informal carers such as family members and with other client groups, and we draw on this literature where relevant. We define carers as both professional and informal caregivers who have accepted or been given the role of supporting a person or people with mental health needs.

Why develop shared formulations with carers? Carers have the potential to play a significant role in supporting people with mental health problems. They are often people who spend a lot of time with the individual and know him or her very well. They are often family or friends who care about what happens to the person and so are very motivated to invest time and energy in supporting them. Even in the case of paid carers, an emotional attachment is often formed, driving a motivation to understand and offer support. People with psychosis often find it difficult to form relationships with others and wider social networks can diminish, with parents and mental health professionals playing a more central role than peers (Berry et al., 2007; MacDonald et al., 2005; Schomerus et al., 2007). A number of behaviours of both informal and formal carers may potentially be involved in the maintenance of service users’ problems, including over or under protection, critical, hostile or abusive behaviour, reassurance seeking and anxious behaviour and lack of limits or over indulgence. Key cognitions or cognitive processes which may drive some of these behaviours and problem maintenance include selective attention to negative behaviours, high expectations and

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unrealistic standards and service user blaming attributions for negative events, self-blame and hopelessness. Equally, the behaviour and underlying cognitions of carers can be significant predictors of positive outcome and recovery. Family environments characterised by positive affect and high levels of warmth have been shown to be protective factors for adolescents at risk of psychosis (O’Brien et al., 2006; Schlosser et al., 2010) and following a first episode of psychosis (Lee et al., 2013). The majority of empirical studies into the role of carers in maintaining problems have focused on the concept of Expressed Emotion (EE). EE refers to affective attitudes and behaviours towards patients, with high EE being characterised by critical comments, hostility and emotional over-involvement (Leff and Vaughn, 1985). High EE has been shown to be a key factor in influencing relapse and recovery across a range of different mental and physical health problems (Wearden et al., 2000). A substantial body of this research has been carried out with people with a diagnosis of schizophrenia and their family members and there is strong evidence that those living in high EE environments have a much higher risk of relapse than those living in low EE environments (Butzlaff and Hooley, 1998). The association between high EE and relapse is an important finding as it suggests that reducing EE and facilitating supportive relationships would reduce rates of relapse. This may also be true of formal carers such as mental health workers. Research in this area provides evidence of high EE in dyads of staff and patients. However, high EE ratings in staff–patient studies are almost exclusively based on the presence of critical comments with infrequent hostility and very little evidence of emotional over involvement. These differences may be associated with the fact that staff members may have less emotional attachments to patients and less frequent and intensive contacts. Associations between EE and relapse are also less robust in staff–patient studies and the evidence suggests that the absence of a positive relationship may be a more sensitive indicator of relationship quality in staff-patient relationships than criticism, hostility or emotional over involvement (Berry et al., 2011). Given the potential importance of the quality of relationships with both informal and formal carers in determining outcomes, researchers have sought to identify factors that influence relationship quality. One factor that has perhaps received the most attention in the literature is the attributions that carers make for service users’ problems. For example, symptoms and problems that are perceived to be within the service user’s control tend to be associated with more hostility and criticism in relatives than those attributed to uncontrollable factors (Barrowclough and Hooley, 2003). High EE carers tend to make more of these personal and controllable attributions, whereas low EE carers tend to be characterised by a more ‘survivor appraisal style’ in which the service user is seen as less responsible for negative events than high EE critical relatives, but more responsible for positive events (Grice et al., 2009). Research involving people with a diagnosis of schizophrenia has shown associations between staff perceptions of problem behaviours as being stable and under the patient’s control and poor staff-patient relationships

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(Barrowclough et al., 2001; Berry et al., 2012). Similar findings are also evident in relation to patients with learning disabilities and dementia (Dagnan et al., 2004; Dagnan et al., 1998; Stanley and Standen, 2000). We propose that collaborative case formulation is a way of enabling carers to develop more helpful attributions for service users’ difficulties, on the basis that these attributions could promote more positive responses to service users’ distress or problems. The process of developing shared formulations provides richer conceptualisations of the service users’ social context and leads to more creative treatment strategies which draw on wider resources. It helps ensure a more consistent way of working with service users’ problems over time, and across family or staff members. Furthermore, developing formulations with carers can be useful when service users themselves are unable or unwilling to actively engage in therapy. Importantly, the process of formulating may also provide an opportunity for carers to reflect on and receive emotional support in relation to difficulties that arise in their day-to-day interactions with service users. Models of sharing formulations and the evidence base Developing shared conceptualisations with carers is a key component of family interventions for people with a diagnosis of schizophrenia (e.g. Barrowclough and Tarrier, 1992; Stanbridge and Burbach, 2007) and using simple case conceptualisation has been proposed as a useful way of helping relatives to understand the experiences of people with mental health problems (Charlesworth and Reichelt, 2004). There has also been a growth in the practice of developing case formulations with staff teams and team formulations are recommended by the British Psychological Society as a particularly effective way of achieving cultural change and promoting a more psychosocial perspective (British Psychological Society, Division of Clinical Psychology, 2011). Team formulation is not unique to any one theoretical orientation and numerous different models of shared formulation have been presented in the literature in a variety of different settings with wide range of client groups, including psychiatric rehabilitation (Berry et al., 2009; Davenport, 2002; Meaden and Hacker, 2011; Summers, 2006; Hewitt, 2008; Newman et al., 2012), acute inpatient wards (Kennedy, 2009), learning disability (Ingham, 2011) and dementia care homes (James, 2011). Despite the recognition of the importance of developing shared formulations with others, there is actually a limited evidence base to support the use of shared formulation as an intervention in its own right. The majority of models for shared formulation are described as examples of innovative practice and are published in practitioner journals such as Clinical Psychology Forum (Jackman, 2013). Evaluations of this work have primarily involved qualitative interviews or service evaluation of the team members’ experiences. These studies largely suggest that mental health professionals value shared formulation in terms of bringing together staff with different viewpoints and encouraging more creative thinking, but they suggest that in order for formulations to impact on patient outcomes, there needs to be clear links to patient

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care planning (Kennedy et al., 2003; Summers, 2006; Hewitt, 2008). There is also some preliminary evidence from case studies and pre- and post-measure designed studies that shared formulation can change staff attributions and attitudes towards service users (Berry et al., 2009; Janes and Shirley, 2008; Meaden and Hacker, 2011) and reduce challenging behaviours (Ingham, 2011; Janes and Shirley, 2008; Newman-Taylor and Sambrook, 2012). The lack of evidence base for formulation might help explain the findings of a recent study by Christofides et al. (2012). In this study, psychologists working in both inpatient and community settings were interviewed about their use of formulations with multidisciplinary teams. Psychologists reported that formulations were shared mostly through informal means, such as ideas during a team discussion, and they were often wary of formalising formulation processes with staff due to concerns about staff viewing them as unwelcome experts. In order to address this gap in the literature, our recent work has involved assessing the feasibility and acceptability of a cognitive interpersonal model of shared formulation first described in an earlier study (Berry et al., 2009). Our model of formulation, which is summarised is Table 14.1 also draws on good practice guidelines on the use of psychological formulation developed by the DCP (2011). It relates most closely to person-level formulations described by Meaden and Hacker (2011) which provide a historical and developmental interpersonal context for understanding the person’s difficulties and highlight broad treatment targets that can be implemented by non-psychologists. Key principles of cognitive behavioural therapy are used such as Socratic questioning and guided discovery, as well as collaborative empiricism to test out ideas jointly. Rather than providing staff with a prepared formulation, a collaborative non-expert approach is taken where the carers are experts in bringing information about the service user and the psychological therapists brings together information about psychological processes and evidence-based interventions. However, in addition to deriving interventions an important element of shared formulation is generating a more compassionate understanding of the service user’s current behaviours; thus the formulation is an intervention in itself. A total of 85 staff and 51 patients across 10 psychiatric rehabilitation units in Greater Manchester participated in the study (Berry et al., 2015). We used a cluster randomised design with 5 of the units receiving the intervention over 24 weekly one-hour sessions and the other 5 units receiving treatment as usual. We developed a shared formulation for all patients on the unit and depending on the number of patients in the service these were reviewed more than once. An average of five members of staff (range 1–12) attended each formulation meeting and staff attended a median of four meetings (range 0–11) over the course of the intervention. Staff attendance was slightly lower than anticipated and the reason for non-attendance was primarily associated with shift working which meant that staff were not always rotated to work on the day of the formulation meeting. We assessed a number of outcomes including staff–patient relationships, patient symptoms and functioning and staff burnout at baseline, post-treatment and six-month

The therapist explains that the purpose of the meeting is to help develop a better understanding of the service user and his or her needs. Example questions to elicit needs: What behaviours or aspects of the person’s presentation do you find challenging? What behaviours would you like to try to understand better? What are your beliefs about the causes of these behaviours? How easy/difficult is the person to engage? How easy/difficult is the person to motivate? What approaches have the team used that haven’t worked? What are the triggers for the person’s difficulties?

The therapist elicits the service user’s strengths and resources including both personal and environmental resources. Example questions to elicit strengths and resources: What are the person’s strengths? What is the person good at? What do you like about him/her? What do other people like about him/her? When have they been able to cope successfully? What is going well at the moment? How have they coped with adversity/psychosis? What resources are available in the person’s environment, e.g. family, friends, services?

The therapist elicits the service user’s goals and values. Example questions to elicit goals and values: What are the person’s goals/hopes/aspirations? Short and long-term? What does the person value/belief is important?

The therapist elicits key events in the service user’s life which can be supplemented with information recorded from the medical notes or the therapist’s own interviews with the service user. Both positive and negative experiences are identified. Example questions to elicit significant life events: What was it like for the person growing up? Relationships with parents and earlier family? Parental mental and physical health? Emotional abuse, physical abuse, sexual abuse and neglect? Supportive relationships past and current? Experiences of friendships and romantic relationships? Bullying or abuse in peer relationships? Experiences in education and work? Leisure, hobbies, relaxation? Learning difficulties/cognitive problems? Position in society? Gender, race, sexuality, cultural beliefs? Moral, political, religious and spiritual influences? Experience of prison or police? Position in society? Finances? Experience of authority figures? Physical health? Substance use? Experiences of mental health problems and mental health services? Significant events within the team? Team responses to person? Nature of care plans? How does the person experience the team? What are your interactions like with the person?

The therapist explains that life experiences can influence beliefs about self, others, world in general and the future and provides examples for those unfamiliar with the cognitive model. (e.g. if you are criticised a lot by significant others, you may believe you are useless and expect other people to be critical, if you have frequently been the victim of violence you may believe you are vulnerable, other people are aggressive and the world is a dangerous place).

Needs

Strengths and resources

Goals and values

Significant life events

Beliefs

Table 14.1  Cognitive interpersonal model of shared case formulation

Using Socratic dialogue, the therapist asks the group to think about how the hypothesised beliefs are likely to affect how the service user interacts with others (including team) and copes with stress and life in general (e.g. if a person believes that other people can’t be trusted, he is likely to avoid putting trust in people, may avoid close relationships with others or may be hostile towards others; similarly if a person believes he is a failure he is likely to avoid new challenges). The therapist emphasises that strategies may be short-term solutions to managing distress, or they might have been useful at a different stage of the person’s life when no other means of coping were available to him/her (e.g. overdependence – person good at getting help and hypervigilance to risk is an evolutionary advantage). Where possible, the therapist backs up any ideas generated by the staff with evidence from psychological research, but emphasises that the ideas generated are only hypotheses.

Using Socratic dialogue, the therapist asks the group how to think about the possible impact of the service user’s interactional styles and methods of coping. In particular, the therapist focuses on how the styles are likely to maintain the service user’s problems (e.g. if a person avoids close relationships, he will be deprived of opportunities to learn that people can be trusted, similarly if a person avoids new challenges he will be deprived of opportunities to learn that he can succeed). The therapist emphasises how the person makes the team feel, think and respond (e.g. an aggressive patient may lead staff to back off and disengage and a patient with limited skills and a child-like presentation may draw staff into doing things for him/her). Where possible the therapist backs up any ideas generated by the staff with evidence from psychological research, but emphasises that the ideas generated are only hypotheses/best guesses.

Using Socratic dialogue, the therapist asks the group to think about ways of engaging the service user or interventions that might help break maintenance cycles. It is also useful to think about the service user’s goals and values as a way of motivating them. The therapist should emphasise that this might include things the person or other people in his/her life are currently doing and specifically ask staff to think about what has worked well for this person or other people they have worked with in the past

Ways of coping

Consequences

Implications for support planning

Using Socratic dialogue, the therapist then asks the group to generate possible beliefs the service user may have about himself, other people (including team) and the world in general, including both positive and negative beliefs. Where possible the therapist backs ups any ideas generated by the staff with evidence from psychological research, but emphasises that the ideas generated are only hypotheses/best guesses.

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follow-up. Compared with treatment as usual, patients in the intervention arm felt less criticised by their keyworkers and reported improvements in ward atmosphere following the intervention. Staff in the intervention arm also reported lower levels of depersonalisation post-intervention. This study was a pilot study and as such was not large enough to detect statistically significant improvements in longer term patient outcome, but differences in patient outcomes were in the direction suggesting a more positive change for those on wards receiving the intervention. More in-depth interviews suggested that staff valued the intervention in terms of improving understanding of patients’ needs and developing new ways of working with patients. Patients also described actual changes in staff members’ behaviour towards them with staff members being more proactive in approaching patients. Barriers and facilitators to implementing the intervention were identified through the interviews and were consistent with previous research about implementing psychological interventions in routine practice (Berry and Haddock, 2008). Key barriers included competing demands on staff members’ time and staff anxieties about or resistance towards their practice being challenged by a psychologist. Key facilitators were managerial support including ring fencing time for the intervention and promoting staff attendance, and the fact that the intervention focused on drawing out the team members’ own strengths in working with service users. The next stage of our research programme will involve trialling the intervention on a larger scale and exploring the effects on longer-term patient outcomes. The remainder of this chapter will describe the process of developing shared formulations with a staff team and use a case example to illustrate the approach.

Formulation framework: Case example Background Andrew was 27 years old and had been on the hospital-based psychiatric rehabilitation ward for a period of eight months. The ward provides support for a period of around 18–24 months to service users who have typically disengaged from mainstream services in the community and who are frequently admitted to acute inpatient wards due to relapses in their mental health and consequent increases in risk. In addition to medication, patients typically have an individualised weekly activity plan focused on skill acquisition vital to functioning in the community (e.g. self-care, budgeting, cooking) and increasing engagement in social activities on the ward and in the community. The psychological therapist initially met with Andrew’s key nurse to establish what specific issues the staff were struggling with in relation to their work with him. Andrew’s keyworker described him as ‘pleasant’ but ‘hard to get to know’. Andrew had told ward staff and his psychiatrist that he does not need to be in hospital and he does not experience any symptoms of psychosis. Ward staff had observed Andrew talking to himself and they suspected he was responding to voices, but when questioned, Andrew did not acknowledge this behaviour.

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Andrew’s key nurse described him as having poor self-care and limited skills in activities of daily living but that he would not engage in supported rehabilitation activities. Andrew did not have any friends outside of hospital and did not mix with other patients on the ward. The keyworker reported that Andrew’s mother visited him to bring him food, but she did not stop to spend time with Andrew and the keyworker felt that she made ‘excuses’ not to attend review meetings about Andrew. Andrew would spend long periods of time in his room on his own. Andrew’s key nurse and other staff felt frustrated in their work with Andrew as he would initially agree to engage in rehabilitation programmes and social activities but then would change his mind at the last minute by saying that he is too tired. Andrew had told staff that he wanted to be a scientist and that as soon as he was discharged he planned to apply for a degree course. Andrew had resisted staff efforts to help him work towards this or any other goal. Following the meeting with Andrew’s keyworker, the therapist arranged a team formulation meeting on the ward to discuss Andrew’s needs and support plans. Prior to the team meeting the therapist also reviewed Andrew’s medical notes to gather some information about his personal history both prior to and following his contact with services. Although all ward staff were permitted access to Andrew’s medical notes, all staff did not routinely read all of the patients’ records due to time constraints. Andrew did not want direct contact with the therapist. However, the decision was made to develop a formulation without his involvement as the process may indirectly benefit Andrew by improving the quality of the care that the staff provided to him. As with other patients on the ward, the process of developing a formulation was described to Andrew by his keyworker with the help of a written information sheet and he agreed for the therapist to meet with staff to develop a shared formulation of his needs. Andrew grew up with his mother and younger brother. Andrew’s parents separated when he was 2 years old. The notes stated that Andrew had not seen his dad since the separation and his whereabouts were unknown. Following the separation, Andrew’s mother was in a long-term relationship with a man who was physically and emotionally abusive towards her in front of Andrew and his brother. This relationship ended around the time that Andrew was first admitted to hospital. The notes stated that Andrew achieved good GCSE results and started A-levels at college. He was reported to have been in a relationship with a girl and moved into a house with her due to arguments at home. The house was owned by the housing association. The girl ended the relationship after about 18 months. Andrew was reported to have become increasingly withdrawn following the end of the relationship and he stopped going to college. He spent long periods of time on his own playing video games and smoking cannabis. Andrew’s mother and neighbours became increasingly concerned about his mental health. He was not paying his bills and there was evidence of significant self-neglect. He was also heard shouting very loudly by the neighbours throughout the night threatening to kill people if they did not leave him alone. Andrew’s neighbours eventually reported Andrew to the police, who broke down the door and took him to hospital. The notes stated

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that the police had to use force and handcuffs to get him into the police van and then onto the ward. When Andrew was first admitted he told ward staff that he was being admitted as part of a government conspiracy which was attempting to prevent him from saving the world from corrupt forces, but ‘denied’ the need to be in hospital. He was prescribed medication and discharged to another flat with follow up from the community team. The notes stated that Andrew’s mother was reluctant for him to live with her as she was experiencing mental health problems herself and felt that she could not cope with Andrew’s behaviour. Prior to his current admission, the previous five years of Andrew’s life were characterised by a series of acute inpatient admissions and ‘failed’ discharges back to his flat. Following a discharge from hospital, Andrew would stop taking his medication, disengage from his community support team, become socially isolated and spend his time smoking cannabis on his own. He would then be readmitted due to concerns expressed by his mother and the community team about self-neglect. Team meeting The therapist began the meeting by outlining that the aim of the session was to try to understand Andrew better and use this information to review existing support plans. The therapist emphasised that she would not be telling the staff what they should be doing; the ideas would come from the team as they had the most expertise in working with Andrew and had a lot of experience to draw on from their work with other service users. The therapist explained that her role was to facilitate the meeting and if relevant share any ideas from her own experiences and psychological theories. The therapist reminded staff that the ideas discussed at the meeting were only a ‘best guess’ about what might be going on for Andrew and ideas would need to be tested out over time. The therapist then outlined a proposed structure of the meeting which included eight key themes written on flip chart paper: 1) what Andrew is like to work with and what are his needs, 2) strengths and resources, 3) goals and values, 4) significant life events, 5) beliefs, 6) ways of coping, 7) consequences and 8) support plans. The therapist engaged with the staff using a collaborative and Socratic dialogue. Key ideas were jotted down on the flip chart so that everyone in the meeting could keep track of the issues discussed. See Figure 14.1 for a diagrammatic representation of these ideas. Andrew’s needs and staff emotional responses to them were elicited by asking staff to think about what Andrew was like to work with and specifically what aspects of his presentation they found challenging. In line with Andrew’s keyworker, staff described Andrew as superficially pleasant but difficult to get to know as he avoided discussing his mental health and emotional issues. Staff also reported that Andrew can be overly compliant, for example, he would agree to all his support plans and to take medication, but he would not engage when activities were arranged and would not take medication when discharged. Staff reported feeling stuck and hopeless about the potential to make progress with Andrew due

Formulating collaboratively with carers  313 Diagrammatic formulation

Absent father Abusive step-father

Limited resources for coping with distress

Mother’s subsequent distress and difficultly in meeting Andrew’s emotional needs Cannabis used by peers

Cannabis use Trauma of first admission Negative view of services

Beliefs: Others are abusive and unsupportive; I have no control; I can’t protect those close to me

Development of psychosis Beliefs about being a powerful protector in charge of preventing a conspiracy

Doesn’t engage with treatments

Doesn’t make progress in relation to rehab programmes or normal social goals

Insecure avoidant attachment style. Lack of awareness of feelings and diff iculty expressing feelings to others

Relationship ends

Enhance selfesteem and sense of control Negative impact on self-esteem

Mother expects staff to criticise or blame her and avoids ward

Compares self to successful peers

Don’t talk to staff about beliefs and mental health Fades into background on busy ward, needs are missed and beliefs aren’t challenged

Figure 14.1  Diagrammatic formulation.

to barriers they were facing with engagement. They felt frustrated that they had not been able to make progress with Andrew despite the fact that he had been on the ward for eight months. Some staff expressed the view that Andrew should not be on the ward as he was ‘taking up a place’ that someone who was more willing to engage might benefit from. Others believed that Andrew had good potential to achieve ‘normal’ social goals and felt upset and frustrated that his lack of engagement was preventing him from achieving these goals.

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In order to counterbalance this initial negativity within the team, the therapist asked staff to think about Andrew’s strengths and resources by asking them what Andrew was good at, what they liked about him and what was going well for him at the moment. Staff were also asked explicitly about Andrew’s goals and values. Staff described Andrew as intelligent and they felt that he had good social skills when he did interact with others. Staff also identified that the fact that Andrew’s mother visited him and brought him food may have suggested that she cared about him. Staff reported that Andrew had said that he would like to go to university and be able to live more independently. Following the discussion of Andrew’s strengths, the therapist asked the team what they knew about Andrew’s history both pre- and post-diagnosis. For example, the staff were asked if they knew what it was like for Andrew growing up, any experiences of abuse or neglect he might have experienced, his experiences of peer relationships including any experiences of bullying, his academic performance in school and any work history and experiences of mental health problems and mental health services. The therapist also added to this discussion by sharing information from case notes. For example, staff present at the meeting were not aware that Andrew had obtained good GCSE results and had started a college course and were not aware of his mother’s relationship history. Some staff also knew things about Andrew and his family that were not documented in his notes. For example, Andrew had told one member of staff that his brother was studying for a degree and that many of his former school friends had gone to university. He had also told another member of staff that he worked in a music shop while at college. Interestingly, during a meeting with his keyworker Andrew had told her about his first admission to hospital and described it as a scary experience during which he thought he and has family might be harmed, although following this meeting, he was reluctant to talk any further about his experiences of services. In line with the cognitive model, the therapist then explained the way in which life experiences influence beliefs about self, others, the world in general and the future. The therapist started by giving some examples to illustrate this point. For example, she explained that if you are criticised a lot by significant others, you may believe you are useless and expect other people to be critical, or if you have frequently been the victim of violence you may believe you are vulnerable, other people are aggressive and the world is a dangerous place. Using Socratic dialogue, the therapist then asked the staff team to think about beliefs that Andrew may have had about himself, other people (including the team) and the world in general. This was followed by a discussion about how hypothesised beliefs were likely to affect how Andrew interacted with others and coped with stress. Again the therapist gave the staff examples prior to eliciting their thoughts about Andrew’s interactional style and methods of coping. The therapist helped the staff to reconceptualise problems, for example, lack of engagement was reconceptualised as one of Andrew’s coping strategies. It was emphasised that these types of strategies may have been short-term solutions to managing distress, or they might have been

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useful at a different stage of Andrew’s life when no other means of coping were available to him. The therapist asked the group to think about the possible impact of Andrew’s interactional styles and methods of coping and how these were likely to maintain Andrew’s problems. In developing maintenance cycles, the therapist explicitly asked the staff to focus on how Andrew made them feel, think and respond. Where possible, the therapist backed up any ideas generated by the staff at the meeting with evidence from psychological research, but emphasised that the ideas generated were only hypotheses. The therapist and staff talked about Andrew’s earlier relationships, including the absence of his father and the difficulties faced by his mother. The team thought he may have had little control over his mother’s partner’s abuse and as a child may have lacked the capacity to protect his mother. The staff and therapist talked about Andrew’s relationship with his mother and the stress that his mother must have been under when he was growing up. The therapist explained how this stress may have affected Andrew’s mother’s capacity to develop an ‘emotionally attuned’ relationship with her son. The therapist explained that traumatic experiences in childhood coupled with these earlier difficulties in attachment relationships can lead people to develop insecure attachment styles. She explained that Andrew may have an ‘insecure avoidant attachment’ style and that this meant that he may lack awareness of his own psychological distress, find it difficult to talk to others about his feelings and expect other people to be unsupportive. She went on to explain that this avoidant attachment style may be functional and protective for individuals, but may ‘break down’ under periods of more extreme psychological distress. The fact that Andrew’s first psychotic episode had followed the breakdown of his relationship with his long-term partner and that this experience may have been very distressing for Andrew was also discussed. The therapist and staff then talked about Andrew’s beliefs possible around a conspiracy and how within this delusional system, he might be the powerful protector of others. The therapist and staff agreed that Andrew’s possible delusional beliefs may enhance his self-esteem and give him a feeling of control. The therapist hypothesised that if Andrew still held any beliefs about a conspiracy and his role in saving the world, he may be motivated to maintain this belief system and resistant to any attempts to challenge it. The staff and therapist talked about how Andrew may be reluctant to talk about his beliefs if he believes others including mental health staff are part of a conspiracy that might prevent him from achieving a mission to save others. Staff also wondered if Andrew may be reluctant to talk to others about his beliefs as talking and thinking about his beliefs might lead them to be challenged. Although functional in some respects, the therapist and staff felt that Andrew’s psychosis may prevent him from investing in and consequently achieving ‘normal’ social goals. In a vicious cycle, lack of achievement in relation to ‘normal’ social goals may result in a loss of self-esteem and therefore increase his investment in any delusional thinking. The therapist drew the staff’s attention to the fact that Andrew’s brother and peers had achieved ‘normal’ social goals and that Andrew might compare himself to them.

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Staff highlighted the potentially important role of cannabis in maintaining Andrew’s difficulties with motivation and any psychotic symptoms he may be experiencing. Although Andrew had relatively less access to cannabis on the ward due to restrictions on his leave, staff felt cannabis and non-adherence to medication might play a key role in triggering relapses following previous discharges from hospital. The therapist asked staff to think about possible reasons why Andrew might use cannabis. Staff suggested that Andrew might not see a problem with using cannabis if his friends had used it and that Andrew might smoke cannabis as he doesn’t have other activities to stimulate him or fill his time. The therapist also suggested Andrew might use cannabis to help him to cope with difficult emotions if he hadn’t learn other ways to cope when he was growing up. The therapist reflected that Andrew might not see the point in taking medication if he does not share his team’s view about his problems. The therapist highlighted the possibility that Andrew may ‘fade into the background’ on the ward as he does not proactively seek help and is he not a management problem. Staff felt that this is more likely to happen when they were busy and when there were other more ‘vocal’ patients. The therapist further suggested that Andrew may be overly compliant and pleasant in his interactions with others in order to please people and prevent them from challenging him. Staff acknowledged that it felt harder for them to push Andrew to talk about his beliefs about his psychosis or challenge his denial if he is pleasant. Rather than confronting Andrew, staff felt that they could get drawn into the ‘trap’ of not engaging with Andrew around his beliefs. The staff and therapist agreed that if Andrew did not challenge or talk to others about his delusional beliefs, they were unlikely to change. The therapist also asked staff to reflect on Andrew’s comment that he had been scared during this first admission and the potential trauma he may have experienced by being admitted forcibly by the police. The staff wondered if this distressing experience might have led him to view the psychiatric systems and staff as controlling and abusive. The therapist suggested that such perceptions of mental health services might be a further reason why Andrew found it difficult to trust staff and engage in their rehabilitation programmes or take the medication that they prescribed. Finally, the therapist and the staff discussed Andrew’s mother’s potential reluctance to spend time with Andrew on the ward. Staff wondered if she had previously had negative experiences of psychiatric staff during Andrew’s previous admissions which made her feel uncomfortable being on the ward. Staff wondered if Andrew’s mother expected staff to criticise her not being able to cope with Andrew in her own home or if she felt that they blamed her for Andrews’s problems. Following the formulation the therapist then asked the group to think about ways of engaging Andrew or interventions that might help break maintenance cycles. In order to help staff feel optimistic about the potential for change, the therapist encouraged them to start by thinking about what has worked well for Andrew or other people they have worked with in the past.

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The staff and therapist agreed that it was important to try to engage Andrew in anything that would give him feelings of self-confidence and control, so that he would not have to rely on possible delusional beliefs to experience these feelings. The therapist and staff talked about the fact that Andrew’s delusional beliefs were very functional for him and the therapist pointed out that if he started to challenge them he may experience distress. She therefore suggested helping him to develop alternative ways of coping with difficult feelings and also suggested that the team monitor signs of low mood or anxiety. The staff and therapist agreed that given Andrew’s difficulty in acknowledging his mental health needs, the most helpful interventions would be those which normalised mental health problems and the effects of stress. Staff suggested talking to Andrew about examples of successful people who have developed mental health problems, the high incidence of mental health problems in the population and staff members’ personal experiences of stress. The therapist highlighted that this work may need to be carried out over a long period of time and although Andrew may not respond immediately, continued work in this area may be helpful in the longer term. The therapist suggested that in order to help Andrew develop skills in recognising his emotional needs and communicating these to others, it would be helpful to reflect back and empathise with any emotional reactions he was able to describe. She explained that these experiences would signal to Andrew that it was acceptable to talk about emotions and that others would not react negatively. She suggested that Andrew may initially find these conversations difficult and back off, but that this should not deter staff from having similar conversations with him in the future. The therapist talked about the importance of finding a balance between giving him space and encouraging him to open up about his experiences. She highlighted the importance of Andrew needing to feel safe with staff before he would be able to discuss any feelings with them. The therapist highlighted how Andrew’s goals and values were a potential way of motivating him. As some staff were unclear about Andrew’s current goals and values she recommended asking him to go through a list of goals and values that people might or might not believe are important to them and ask Andrew to reflect on which were most important to him. Staff also suggested the possibility of working with Andrew towards his longer term goals of living more independently and returning to studying. Staff felt that this work may be important for his self-esteem, as it may communicate to him that staff feel that this is a possibility. At the same time, the staff and therapist agreed that it was important to emphasise that people are more likely to succeed in achieving their goals if they carry out smaller steps within structured and graded rehabilitation programmes. Staff highlighted that it was important to make clear links between rehabilitation programmes and his longer term goals and to emphasise that he could start making these steps now. Staff also suggested that it would be helpful to make more of an effort to engage with Andrew’s mother to demonstrate that they were not critical of her and did not blame her for Andrew’s difficulties. For example, the staff suggested that they might try to communicate to her that they could learn from her

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expertise in supporting Andrew and normalise how difficult It can be coping with psychosis. Feeding back Following the meeting, the therapist typed up a report of the meeting detailing the formulation and agreed plan of action. The therapist then met with the keyworker to share the report, review current support plans and identify any changes that needed to be made to these in light of the formulation meeting. The therapist also helped the keyworker to identify any barriers to implementation and potential ways to overcome these. Service user involvement There are pros and cons to involving service users themselves in the process of formulation. Although service user participation in the process of developing psychological formulations is the ideal, it is not always possible because service users may not be willing, ready or able to participate. We would also argue that, at times, it is also important for both formal and informal carers themselves to have space to reflect on their own experiences of interacting with the service users and receive emotional support for negative reactions that service users may elicit in those who care for them. When service users do not actively participate in the construction of a formulation, we advocate that it is important to inform them of meetings to develop the formulation and its function. It may not, however, be helpful for service users to be presented with a full formulation developed in their absence or part of a formulation that contains strong negative reactions towards the service user. Given Andrew’s difficulties in discussing his mental health needs, it was agreed feeding back the full content of the report would not be helpful to him. In this instance, Andrew’s keyworker met with him to give him feedback on his strengths that were discussed at the meeting. She told him that as a result of the meeting the staff team would like to talk to Andrew more about his goals and values in order to try to understand and work with him better. She also told him that the staff team would like to get to know his mother better. Andrew was given an opportunity to give his reflections on the keyworker’s feedback.

Implementing shared formulations in clinical practice The constantly changing nature of service users’ circumstances and the potential for carers to revert to previous ways of working (as well as the changing nature of ward environments in the case of formal carers) necessitates that formulations are frequently reviewed and updated. In terms of implementing shared formulations into routine practice, we have found, as is the case with other forms of intervention, that the process of developing shared formulations is also only likely to be

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adopted when the organisation is ready for that change. We have found that having senior managers on board maximises the uptake of formulation based interventions and a non-expert stance which recognises team strengths is key to engaging staff in sessions. Much of the focus of this chapter has been on paid caregivers. We acknowledge that the vast majority of carers of people with a diagnosis of psychosis and other mental health problems are unpaid and require support in this role. The shared formulation case example provided in this chapter has many parallels to work that might be done with unpaid carers as part of a structured Family intervention (Barrowclough and Tarrier, 1992; Falloon et al., 1984; Kuipers et al., 1992; Lobban and Barrowclough, 2009; McFarlane, 1983). Family interventions also aim to facilitate a compassionate understanding of service users’ behaviour and generate ideas about how best to support their recovery. Where multiple family members are involved, a shared formulation can help to reduce conflict between family members and provide more consistent coping strategies throughout the family. In common with team formulations, decisions about whether to work with the service user present or not is guided by the needs of family members, and the likely impact of this process on each person. Two important differences are worth highlighting. First, the mental health of the relatives needs to be carefully assessed and the formulation and care plan should aim to facilitate recovery for relatives as well as for service users, as unpaid caring is associated with significant psychological distress in carers (Gallagher and Mechanic, 1996). Second, it may not be possible to work with more than one member of the family system for a number of reasons including practical constraints. However, a shared formulation approach can still be used in which the family member present is encouraged to elicit the views of other family members to inform the formulation and to share the knowledge gleaned from the process throughout the family system as appropriate.

Conclusion In summary, both informal and formal carers can play key roles in the lives of people with mental health problems and as such may benefit from the interventions which help them to develop formulations about service users’ needs. An important aspect of this process of formulating should include exploring how carers themselves might be maintaining difficulties, in addition to recognising their own strengths and expertise. Whilst a formulation can be an intervention in its own right to improve carer understanding and empathy, we also believe that formulations are most helpful when they generate ideas about how carers can relate to service users in ways that support and maximise opportunities for recovery.

Acknowledgments We would like to thank James Tomlin for his ideas in relation to the case formulation example.

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References Barrowclough, C. et al. (2001). Staff expressed emotion and causal attributions for client problems on a low security unit: An exploratory study. Schizophrenia Bulletin 27: 517–26. Barrowclough, C. and Hooley, J. M. (2003). Attributions and expressed emotion: a review. Clinical Psychology Review 23: 849–80. Barrowclough, C. and Tarrier, N. (1992). Families of Schizophrenic Patients: Cognitive Behavioural Intervention. Boca Raton, FL: Chapman and Hall/CRC. Berry, K. et al. (2007). Adult attachment styles and psychosis: An investigation of associations between general attachment styles and attachment relationships with specific others. Social Psychiatry and Psychiatric Epidemiology 42: 972–76. Berry, K. et al. (2009). A pilot study investigating the use of psychological formulations to modify psychiatric staff perceptions of service users with psychosis. Behavioural and Cognitive Psychotherapy 37: 39–48. Berry, K. et al. (2011). The role of expressed emotion in relationships between psychiatric staff and people with a diagnosis of psychosis: A review of the literature. Schizophrenia Bulletin 37: 958–72. Berry, K. et al. (2012). Staff–patient relationships and outcomes in schizophrenia: The role of staff attributions. Behaviour Research and Therapy 50: 210–14. Berry, K. et al. (2015). The feasibility of a ward-based intervention to improve staff and patient relationships in psychiatric rehabilitation settings. British Journal of Psychology. Berry, K. and Haddock, G. (2008). The implementation of the NICE guidelines for schizophrenia: Barriers to the implementation of psychological interventions and recommendations for the future. Psychology and Psychotherapy-Theory Research and Practice 81: 419–36. British Psychological Society, Division of Clinical Psychology (2011). Good Practice Guidelines on the Use of Psychological Formulation. Leicester: Author. Butzlaff, R. L. and Hooley, J. M. (1998). Expressed emotion and psychiatric relapse – A meta-analysis. Archives of General Psychiatry 55: 547–52. Charlesworth, G. M. and Reichelt, F. K. (2004). Keeping conceptualizations simple: Examples with family carers of people with dementia. Behavioural and Cognitive Psychotherapy 32: 401–9. Christofides, S. et al. (2012). Chipping in: Clinical psychologists’ descriptions of their use of formulation in multi-disciplinary team working. Psychology and Psychotherapy: Theory, Research and Practice 85: 424–35. Dagnan, D. et al. (1998). Care staff responses to people with learning disabilities and challenging behaviour: A cognitive emotional analysis. British Journal of Clinical Psychology 42: 189–203. Dagnan, D. et al. (2004). Understanding challenging behaviour in older people; the development of the Controllability Beliefs Scale. Behavioural and Cognitive Psychotherapy 32: 1–6. Davenport, S. (2002). Acute wards: problems and solutions. A rehabilitation approach to in-patient care. Psychiatric Bulletin 26: 385–88. Falloon, I. R. H. et al. (1984). Family Care of Schizophrenia. New York: Guilford Press. Gallagher, S. K. and Mechanic, D. (1996). Living with the mentally ill: Effects on the health and functioning of other household members. Social Science and Medicine 42: 1691–1701. Grice, S. J. et al. (2009). Carers’ attributions about positive events in psychosis relate to expressed emotion. Behaviour Research and Therapy 47: 783–89. Hewitt, M. (2008). Using psychological formulations as a means of intervention in a psychiatric rehabilitation setting. International Journal of Psychosocial Rehabilitation 12: 8–17.

Formulating collaboratively with carers  321 Ingham, B. (2011). Collaborative psychosocial case formulation development workshops: A case study with direct care staff. Advances in Mental Health and Intellectual Disabilities 5: 9–15. Jackman, L. (2013). When, how and why does indirect formulation work? Proposing a ‘shared formulation’ framework. Clinical Psychology Forum 245: 25–31. James, I. A. (2011). Understanding Behaviour in Dementia That Challenges; A Guide to Assessment and Treatment. London: Jessica Kingsley. Janes, E. and Shirley, L. (2008). Acknowledging the man, not the behaviour. Journal of Dementia Care 16: 20–24. Kennedy, F. (2009). The use of formulation in inpatient settings. In I. Clarke and H. Wilson (eds) Cognitive Behaviour Therapy for Acute Inpatient Mental Health Units: Working With Clients, Staff and the Milieu. Hove: Routledge. Kennedy, F. et al. (2003). Clinical psychology for inpatient settings: Principles for development and practice. Clinical Psychology 30: 21–24. Kuipers, E. et al. (1992). Family Work for Schizophrenia: A Practical Guide. London: Gaskell. Lee, G. et al. (2013). Positive affect in the family environment protects against relapse in first-episode psychosis. Social Psychiatry and Psychiatric Epidemiology 49: 367–76. Leff, J. and Vaughn, C. (1985). Expressed Emotion in Families: Its Significance for Mental Illness. New York: Guilford Press. Lobban, F. and Barrowclough, C. (eds) (2009). A Casebook of Family Interventions for Psychosis. Chichester: Wiley. Macdonald, E. et al. (2005). What happens to social relationships in early psychosis? A phenomenological study of young people’s experiences. Journal of Mental Health 14: 129–43. McFarlane, W. R. (1983). Family Therapy in Schizophrenia. New York: Guilford Press. Meaden, A. and Hacker, D. (eds) (2011). Problematic and Risk Behaviours in Psychosis. A Shared Formulation Approach. Hove: Routledge. Newman-Taylor, K. and Sambrook, S. (2012). CBT for culture change: formulating teams to improve patient care. Behavioural and Cognitive Psychotherapy 40: 496–503. O’Brien, M. P. et al. (2006). Positive family environment predicts improvement in symptoms and social functioning among adolescents at imminent risk for onset of psychosis. Schizophrenia Research 81: 269–75. Schlosser, D. A. et al. (2010). Predicting the longitudinal effects of the family environment on prodromal symptoms and functioning in patients at-risk for psychosis. Schizophrenia Research 118: 69–75. Schomerus, G. et al. (2007). Residential area and social contacts in schizophrenia. Social Psychiatry and Psychiatric Epidemiology 42: 617–22. Stanbridge, R. and Burbach, F. (2007). Developing family-inclusive mainstream mental health services. Journal of Family Therapy 29: 21–43. Stanley, B. and Standen, P. J. (2000). Carers’ attributions for challenging behaviour. British Journal of Clinical Psychology 39: 157–68. Summers, A. (2006). Psychological formulations in psychiatric care: Staff views on their impact. Psychiatric Bulletin 30: 341–43. Wearden, A. J. et al. (2000). A review of expressed emotion research in health care. Clinical Psychology Review 20: 633–66.

Chapter 15

Working with people seeking asylum Jake Bowley and Colsom Bashir

Introduction This chapter examines issues related to working with people seeking asylum using cognitive behavioural therapies (CBT) with a focus on engagement, assessment, case formulation and intervention. It hopes to raise awareness of the needs and rights of this population to psychological interventions and the advantages of using case formulation in CBT within a human rights context. Grouping ‘asylum seekers’ together is misleading; indeed, it is hard to find a more heterogeneous population. This chapter prompts practitioners to consider a number of ways to respond to often diverse and challenging presentations. It suggests that using approaches that address contextual, transitional, management and recovery processes can enable therapists to tailor formulations that can lead to effective interventions for this client group.

Seeking asylum in the United Kingdom The complex immigration and asylum system in the United Kingdom (UK) and the type of media coverage it receives indicate that this is a major contextual factor, requiring introduction. The frequency of legal and political changes does mean this information will become outdated quickly. Readers should access up-to-date material from web-based resources such as Asylum Aid (2014) or the Refugee Council (2013, 2014). The legal context The UK has had an international obligation to offer a safe haven to refugees since it signed the United Nations Convention on the Rights of Refugees in 1951. A refugee is a person who . . . owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country. (United Nations 1951: 16)

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On entry to the UK, individuals make an application for asylum to the Home Office, UK Visas and Immigration Section. Applications are based on the Refugee Convention or are human rights claims. Figure 15.1 summarises the initial process of seeking asylum. The substantive interview forms the basis of the initial claim. The Home Office closely questions interviewees, often over a number of hours, to establish their identity and the reasons for their application. The credibility of the account is judged and the majority of cases are initially refused. Applicants then enter appeal processes that allow their claim to be intensively examined. This involves obtaining further legal support (usually Legal Aid funded) to pull together a coherent case for reconsideration. The evidence will include medical and psychological documentation of torture. Appeals rights and processes result in delays with some applicants waiting years for a decision. At the end of June 2013, 14,589 of the applications received since April 2006 were pending a decision (Home Office, 2013). During this process claimants are called ‘asylum seekers’ and are dispersed by the National Asylum Support Service (NASS, now known as Asylum Support) to live across the UK. Claimants are required to report regularly at a Home Office reporting centre. Local councils or private landlords are contracted to provide people with predetermined low-cost accommodation; usually shared with others of different nationalities. The two biggest suppliers are currently G4S and Serco (UKBA, 2013). Housing is usually in districts with high indices of social deprivation, with already pressured statutory services, and where there are higher than average crime rates and poor local facilities. ‘Asylum Seekers’ are entitled to all aspects of health and social care but are not permitted to work and must manage on 54–69% of income support levels depending on their age (£36.62 a week for an individual) to pay for extra utilities, food, clothing and transport. A Children’s Society briefing highlighted how people struggle to feed and clothe themselves adequately and that children and families are in effect forced to live below the poverty line (Children’s Society Briefing, 2012). If a claimant’s case is allowed they have been accepted as a refugee and are legally entitled to the same housing, social and economic rights as UK citizens. ‘Refused’ applicants whose legal right to appeal has been exhausted are obliged to leave the country and await removal orders. They are subject to detention or become homeless and destitute. Whilst still entitled to immediate and urgent health care they have little or no recourse to public funds including benefits and housing.

Asylum seeking demographics People flee their own countries to reach a place of safety from ongoing conflicts, human rights abuses and repressive regimes. Refugees arrive in the UK for a number of reasons including the presence of family and friends, having a shared

Figure 15.1  Overview of the asylum process (adapted with permission: Hermione McEwen, Freedom from Torture Training Materials North West Centre 2012, reviewed May 2014).

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language and the existence of a perceived affinity, but often they have no control over their destination and merely follow agents’ directions. The UK is not seen as an ‘easy target’, despite the myths propounded in the media, and most people are unaware of the benefit systems or work prospects in the UK or across Europe (Crawley, 2010). UK asylum figures have been stable since 2006 (Home Office, 2013) and as of 2012 still represented less than 0.5% of the world’s refugees (UNHCR, 2013). About three quarters of applicants are male, and mostly aged 18–34. There are also applications from families, and in 2012 they brought with them over 6,000 dependants (Home Office, 2013). Significant numbers of children arrive alone; in the first half of 2013, 528 unaccompanied asylum-seeking children arrived. People arrive from many countries; Figure 15.2 illustrates the origins of recent applicants (Home Office, 2013). Applicants come from widely ranging backgrounds, from highly educated, politically active dissidents to uneducated agricultural workers. Levels of English and/ or literacy in all languages can therefore be equally diverse. Experiences of health and statutory services range from better-funded services than the UK to none at all. Seeking asylum and well-being The majority of people arriving compare favourably in terms of physical health to the general and minority populations in the UK and their countries of origin (British Medical Association, 2002; Szczepura et al., 2004; Johnson, 2006). Most people are relieved and optimistic at having managed to get to a place of safety in what they expect will be a safe and democratic country. Pakistan Iran Sri Lanka Syria Albania India Bangladesh Afghanistan Nigeria China Figure 15.2 Top ten asylum applicant–producing countries – first quarter 2013.

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However, psychological distress is ubiquitous, and adult rates of ‘psychological disorders’ such as depression, anxiety and posttraumatic stress disorder (PTSD) are much higher than in the general UK population (e.g. Fazel et al., 2005; Lavik et al., 1996; Tribe, 1999, 2002; Turner and Gorst-Unsworth, 1990; van der Veer, 1998). Studies have found that refugee children have up to three times the rate of significant psychological problems when compared to the general UK child population (Fazel and Stein, 2003). In their review of over 7,000 cases, Fazel et al. (2005) indicate that refugees based in Western countries could be 10 times more likely than the age-matched general population to have PTSD. This is unsurprising given the extensive preand post-flight adversity, loss, change and transition experiences of people seeking asylum. It is common for people to have experienced specific traumas such as detention, beatings, torture, humiliation, rape, sexual assault or being forced to witness the torture and murder of others. Other persecutions include long-term political repression, the deprivation of human rights and repeated harassment (Summerfield, 1996). A German study (Heeren et al., 2012) examining prevalence rates in asylum seeking populations showed high psychiatric morbidity in the first two years with no indication of a decrease in mental distress over time. Four out of 10 participants met diagnostic criteria for at least one DSM-IV disorder, with major depression (31.4%) and PTSD (23.3%) diagnosed most frequently. The number of traumatic events experienced was highly correlated with psychiatric morbidity. People seeking asylum have usually escaped war and/or conflict, and/or experienced prolonged, repeated and multiple traumatic events that manifest within the context of ongoing threat or stress. They might present for therapy in a UK context where they could still be awaiting a decision or have been refused asylum. In the UK context there is evidence that mental and physical well-being deteriorate over the extended asylum application process (BMA, 2002). This reflects factors inherent to the asylum process, such as poor accommodation, lack of personal control, financial hardships, the inability to work, language and cultural barriers resulting in social isolation, general uncertainty and ongoing legal problems (Lavik et al., 1996). Another important factor affecting people’s well-being in the UK is the high level of threat and antipathy from the local population. Racism is a common experience for people seen as ‘asylum seekers’, and the British media have been criticised for the ‘climate of verification of asylum seekers that has taken hold in the UK’ (UNHCR, 2001). A MIND report in 2009 confirmed how the marginalising effects of this hostility along with restrictive health and welfare policies cause or intensify mental health problems when seeking asylum and impact on prospects for integration. One protective factor for the well-being of people seeking asylum has been found to be social support, to the extent that a lack of support is more predictive of problems than pre-existing trauma (Gorst-Unsworth and Goldenberg, 1998). In the context of dispersal, this means that people placed in areas without existing populations might have higher rates of psychological problems as a consequence

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of isolation. Refugees and people seeking asylum are referred through the usual pathways, and statutory services have obligations to provide appropriate interventions. Access to therapy is both a right as emphasised in the Mental Health National Service Framework (Department of Health, 2000) and strongly argued for in the literature (Mahtani, 2003). However, access can be difficult and people often do not receive support or continue to be denied services due to misunderstandings. People refused asylum who do not have the ability (financial or otherwise) to return home are disadvantaged by destitution and street homelessness as well as poor access to health care. They do not have access to public funds, can become part of the informal economy and might be exploited or subjected to other human rights abuses. A report by the Health for Undocumented Migrants and Asylum Seekers Network (2009) across Europe demonstrated little or no access to basic health care and standards of living for this group as laid down by international human rights instruments.

Cognitive behaviour therapies and seeking asylum Whilst the literature showing increased psychological difficulties associated with seeking asylum is growing, there is less research focusing on the efficacy of interventions. Despite the range of therapies on offer, research with both ethnic minority clients and this client group have, for a host of methodological and cultural reasons, been limited (see Bhui and Morgan, 2007; Nickerson et al., 2011), particularly in relation to randomised controlled studies (Horrell, 2008). Existing studies have mostly focused on working with refugees where a threat of repatriation has been removed. They have tended to examine treatments for PTSD in isolation, or lack the sophistication or methodology to evaluate the comparative efficacy of interventions (Basoglu, 1993). Studies assessing CBT with torture survivors experiencing PTSD have looked at the application of both behavioural exposure and cognitive approaches (Basoglu, 1992; Basoglu et al., 2004; Paunovic and Öst, 2001). In a review of the therapy literature with refugees, Regel and Berliner, 2007 demonstrated the applicability and flexibility of the CBT model in different cultural contexts, despite perceived cultural limitations. Basoglu et al. (2005a) found that single-session exposure treatments designed to enhance control over trauma-related fear and distress in earthquake survivors were highly effective in a controlled study which resulted in reducing PTSD and depression in over 85% of cases. This approach showed efficacy in female survivors of war trauma and gang rape in a series of case studies (Salcioglu and Basoglu, 2011). One other study focused on developing coping skills strategies in refugees with PTSD (Snodgrass et al., 1993). A promising approach to refugee trauma is that of narrative exposure therapy (NET; Schauer et al., 2011) which has shown efficacy in the context of ongoing threat. NET owes its origins to the narrative and political elements of testimony therapy (TT) as well as CBT. TT originated from the collation of human rights testimony to document the atrocities committed during the Pinochet dictatorship. The

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evident secondary psychological benefits were attributed to the contextualising and collectivising of individual suffering as well as the public and political uses made of testimonies (Cienfuegos and Monelli, 1983). The therapist’s ethical standpoint as a witness is central and TT has been used for over 20 years in a range of contexts (Raghuvanshi and Agger, 2008). NET is based on neurocognitive memory theory. This predicts that powerfully elicited sensory, cognitive, emotional and physiological elements of overwhelming trauma and internalised threat are encoded as fragments of information that are not contextualised in autobiographical memory. These sensory perceptual fragments are then associated into networks that result in connections between multiple traumatic events to form generalised ‘fear networks.’ The contextualising of these fear networks to an autobiographical memory narrative is the main agent of change in NET (Neuner et al., 2008). There are a number of processes in TT and NET that align with traditional CBT models. The emphasis on ‘politicising’ the act and experience of torture offers survivors a framework in which to reappraise their identity and experiences, with resemblances to the examination of trauma-related meanings and appraisals in CBT. The drawing up of a complete and precise testimony contains elements of exposure. The role of integrating fragmented narratives to form a coherent inclusive account, and linking the affective to the previously dissociated cognitive aspects of trauma, is paramount in treating PTSD (Brewin, 2007). Mueller (2009) writes that NET facilitates firstly habituation through prolonged exposure to traumatic hotspots, as well as using testimony to pursue justice for clients. Results from treatment trials with adults and children often in refugee camps, demonstrated the superiority of NET in reducing PTSD symptoms compared with other therapeutic approaches. Changes were sustained at follow up even within the context of ongoing threat or insecurity (Neuner et al., 2010; Robjant and Fazel, 2010). Therefore, a brief structured trauma module is considered one essential component of a multi-disciplinary approach to the care of people seeking asylum. Limitations of cognitive models The fact that published accounts focus mainly on relatively straightforward interventions based on cognitive behavioural models of PTSD is not particularly useful for therapists working with this population. Reducing an individual’s difficulty to a formulation guided by a simple disorder model runs the risk of ‘treating an illness which the refugee does not have’ (Eisenbruch, 1991: 25). Moreover, the very meanings such models attach to ‘symptoms’ are based on a view that they are a disordered process, which can be very different from both the client and therapist view. Cognitive models of PTSD assume that both the intrusive phenomena and distorted appraisals of risk and danger are a result of insufficiently processed sensory memories (Ehlers and Clark, 2000, Brewin, 2007, Neuner et al., 2010). However, for people who remain at risk of being returned to the dangers from which they fled, intrusive and anxious appraisals will be an entirely appropriate response.

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Further, such models do not address treatment issues for people who remain at risk, whose trauma is ongoing or continuously triggered by processes outside of their control. These kinds of presentations are more likely to meet the criteria for acute stress reactions (American Psychiatric Association, 2013), Complex PTSD (Herman, 1992) or CTS, continuing traumatic stress in the context of ongoing threat (Eagle and Kaminer, 2013). In the same way, depression and more general anxiety, rather than pathology, are seen as clear sequelae of the ongoing environmental stressors people encounter. The cognitive biases seen in generalised anxiety, where the self is seen as vulnerable, the world as dangerous and the future unpredictable (Blackburn and Davidson, 1990) do not seem so biased when seen in the asylum seeking context. Anxiety about such stressors is palpable and intense, and will be passed on to therapists, especially if they hold beliefs about curing clients or face service pressures for outcomes. In summary, the evidence for interventions is limited, and restricted mainly to PTSD, which is only part of the intervention package for this client group. Clients in the asylum process continue to present with complex comorbid problems in difficult ongoing circumstances. Therapists are therefore required to adapt the theoretical underpinnings of CBT, with both its general cognitive understanding and focused models of specific disorders.

Formulating with people seeking asylum Uses of narrative and testimony interventions are aimed at PTSD specific formulations which are extensively covered in the literature (e.g. Ehlers and Clark, 2000). However, the complexity and high number of client needs and difficulties, in contexts of ongoing uncertainty, threat and powerlessness, make using straightforward disorder-specific models difficult. Clients’ presentations could be made sense of for example, as simultaneously depressed, anxious, traumatised and grieving, resulting in formulations that are unwieldy and unusable for therapist and client alike. We argue that transdiagnostic formulation should be driven by the context of refugee experiences to understand how trauma, migration, transition, loss and psychological well-being interact. Approaches that are helpful to guide clinicians include • • • •

The phased approach to recovery outlined by Judith Herman (1997). Stirling Moorey’s work around adjustment (Moorey, 1996). Resilience models (e.g. Amering and Schmolke, 2009). Trans-diagnostic models (e.g. Mansell et al., 2009).

Phased recovery formulations Judith Herman provides a framework to guide psychotherapy with the common patterns of distress associated with atrocities whether they are domestic violence,

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physical or sexual assault or political terror. This captures the primary tasks associated with the ongoing process of healing and recovery, perhaps comparable to an adjustment process. Herman (1997) identifies three stages: • • •

Safety, where the restoration of control and establishment of safety are vital. Reconstruction, where traumas are explored and transformed. Reconnection, involving developing activity and relationships.

She argues that establishing safety and control is always the first task of recovery, as well as a guiding principle. This sense of control and safety covers all features of an individual’s experience, from physical and psychological health (including destabilising intrusions to self-destructive or risky behaviours), and outward into environmental, financial and social situations. Key tasks include anchoring oneself in a safe present and developing autonomy, usually removed in victims of trauma and people seeking asylum. The second stage (‘the transforming process of reconstruction’), comparable to therapeutic interventions for PTSD, is seen as part of an ongoing remembrance and mourning. The retelling of the trauma and the facilitating of emotional expression are means by which individuals regain control of their experiences, and in doing so ameliorate the intrusive and uncontrollable nature of associated distress. Finally, individuals work towards reconnecting with wider social and interpersonal worlds. Taking control of one’s life and actions, and then developing a future, are all part of the final and enduring process of recovery. Adjustment formulations Working with people in adverse life circumstances such as serious or terminal illness holds similarities to working with people seeking asylum. Their situations are both extremely difficult, and their feelings of helplessness and powerlessness reflect real difficulties in many areas of their lives. Stirling Moorey has written about the role of cognitive therapy with cancer patients whose situations are objectively difficult, and whose anxiety or depression are rational responses to an appalling situation. He has argued that when ‘bad things happen to rational people’, formulating their difficulties as one of ‘adjustment’ is a productive and effective approach (Moorey, 1996: 450; Moorey, 2010). Adjustment involves ‘the processing of the cognitive and emotional significance of adverse life events’ (Moorey, 1996: 755), and as such it applies to a range of processes of grief, trauma and/or adjusting to major aversive life changes. Therefore keeping adjustment in mind can help manage and draw together formulations. It allows client and therapist to accept the distress experienced and to explore feelings rather than see them as symptoms of disorder. CBT formulations help clients to identify their immediate thoughts, appraisals and feelings, as

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well as understanding the environmental factors that maintain distress. Standard techniques are used to develop appropriate coping strategies within clients’ capacity and competence (Moorey, 1996, 2010), and help address blocks to managing transition. Resilience formulations As the field of positive psychology progresses, attention has been drawn to those components of personality and social psychology that contribute to well-being and strengths. Seligman (2011) provides the acronym PERMA to connote the five measurable elements of well-being, which are: • Positive emotion • Engagement • Relationships • Meaning and purpose • Accomplishment. Furthermore, prevalence rates indicate that PTSD is not an inevitable consequence of trauma. The factors that maintain resilience in the face of abnormally adverse life events such as torture, trauma and displacement are especially relevant here. Disorder-specific models are inherently pathologising, fail to account for multiple, prolonged and complex trauma, or pathologise non-Western or collectivist coping styles. These models might lead us to fail to ask the question of what a ‘normal’ or ordinary response might be to the extensive range of stressors, losses and transitions in a refugee’s life. Amering and Schmolke (2009) in a comprehensive sourcebook on this subject, argue that it is a clinical responsibility to incorporate resilience as a dynamic recovery factor. Resilience is described as the ability to resist and regain mental stability following a stressful event or period. Thus, it is not understood in terms of a biological invulnerability but as a flexible psychological competency involving processes of ‘protection, repair, regeneration’ (p. 27). Most asylum seekers have already survived extensive threats at the level of individual, family, community, culture and country. The overarching aim of a resilience approach is not necessarily just to enable clients to focus on the present but also to begin to confront and integrate the impact of adverse life events, trauma, torture, loss and transition. This potentially provides clinicians with a range of resources and strengths to consider in their collaborative formulations. Resilience based formulations especially in relation to the migration and trauma trajectory might aim to enable clients to: • Recount pre-existing resources (e.g. positive history of attachments, self-agency/esteem, self-efficacy, active coping, socio-economic resources, political activism, spirituality, locus of control).

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•

•

•

Consider new mechanisms that are a necessary part of migration and resettlement in a new culture and country (e.g. knowledge of health/social care structures, familiarity with the culture, adjusting to an individualistic vs collectivist culture, developing new social networks, appropriate engagement and participation, renewed activism). Consider how pre-, peri- and post-traumatic and migration social, political and psychological processes continue to deplete pre-existing protective factors and resources (e.g. loss of identity, class, role, self-esteem, family, access to culture and language, reduction in personal agency as a consequence of restrictions during the asylum process or of reduced quality of life). Consider how these pre-, peri- and post-traumatic and migration processes present barriers to developing new resources and attachments.

Resilience-based formulations offer opportunities to consider posttraumatic growth (PTG, Calhoun and Tedeschi, 2013) and adversity-activated development (AAD, Papdopoulous, 2007) as responses to trauma and adversity. Whilst PTG examines positive developments following trauma, AAD assumes adverse experiences will influence the trajectory of individual development in positive, neutral and negative ways. Transdiagnostic formulations ‘Third wave’ or transdiagnostic CBT refer to emerging trends in cognitive therapies over the last two decades which have led to a spectrum of models with varying degrees of empirical support for particular conditions or client groups (David and Hofman, 2013). Such models offer a unifying approach which target cognitive and behavioural processes that are shared across disorders and contribute to the development or maintenance of symptoms. Whilst heterogeneous, transdiagnostic CBTs reflect a trend away from cognitive content and towards metacognitive processes. This is helpful given the multifaceted nature of clients’ difficulties. Key themes evident in third-wave therapies include: • • • • • • •

The approach/relationship of the individual to cognition/experience – which is relevant to diverse cultural understandings of the mind Psychological flexibility – particularly relevant to the multiple adaptation processes required of people seeking asylum Linguistic, narrative and social constructions of experience – which are often culturally bound and understood Learning processes – which are dependent on social, environmental, linguistic and cultural variables and help build effective interventions Thinking, reasoning and information processing which is relevant to how experience is understood and processed across presenting difficulties Memory formation – particularly relevant to PTSD Renewed interest in the role of emotions – appraisals of which are influenced by social and cultural values

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• • •

Role of positive affect – relevant for self-soothing strategies or to address shame, guilt or anger underpinning trauma, loss and transition The role of biological mechanisms (e.g. the body, the brain) in maintaining disturbance – relevant in most psychological presentations especially trauma, anxiety and depression Socio-cultural, environmental and familial factors which influence causal attributions, locus of control, attitudes to and opportunities for change.

Hinton et al. (2012) address some of these points in one protocol for culturally adapted CBT (CA-CBT) for trauma in refugees. They detail how a culturally bound therapy like CBT must be led by clients’ cultural understandings to be accessible and effective. For example, culturally held beliefs about knowledge, experience, the mind, the body and change will influence clients’ causal attributions as well as their engagement and recovery. Evidence increasingly demonstrates the effectiveness of transdiagnostic therapies particularly for people who have failed to benefit from conventional approaches. A full description is beyond the capacity of this chapter. The intention is to encourage practitioners to consider the extent to which the underlying theory and principles of such approaches can provide us with helpful insights for refugee clients. In the next section we aim to integrate the recommendations of these models to build practice guidelines that are culturally acceptable, de-pathologising, resilience-oriented and collaborative.

Practice Psychologists as human rights practitioners Refugees can experience a range of human rights violations in both their pre- and post-exile contexts. A psychological perspective would lead us to hypothesise how this may affect well-being, reduce resilience and increase a sense of powerlessness. We may implement a needs analysis to identify who or what the individual requires to recover. A human rights standpoint, however, forces practitioners to consider the individual beyond their needs and begin to take action with regard to their rights as a human being. Respect for universal human dignity underpins human rights law (e.g. The Human Rights Act, 1998; The Children’s Act, 1989; The Immigration and Asylum Act, 1999). A human rights standpoint moves us from arbitrary conjecture about who might be enlisted to meet client needs to identifying the ‘duty bearers’ who hold the responsibility to ensure refugee rights are honoured. Psychological professionals working in statutory contexts themselves might be duty bearers or enlisted to gain access to those who are. Furthermore the duties of those in the clinical sector will be not only to provide the right to rehabilitation for, for example, torture survivors, but also to bear witness, document and advocate for their clients, including to provide medical and psychological documentation for legal, housing or forensic purposes.

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Reflexive practice Practitioners should consider what they are doing and why they adopt one course of action over another and constantly reflect on how they can improve the services they provide. Emanating from systemic theory is the idea of reflexivity in practice (Dallos and Stedmon, 2009). The reflective practitioner model is an adjunct to the scientist practitioner model. A reflective practitioner is one who uses careful mental reflection to consider their practice. A reflexive practitioner, on the other hand, is one who considers from moment to moment how his/her own interest, position, standpoint, reactions and assumptions influence what is happening at any given point in his/her practice and uses this to reflexively improve practice in the moment and afterwards. This ability to notice and understand is used ‘reflexively’ in and out of session to build formulations, interventions and care plans that embed a right to redress within a human rights framework alongside the key psychological components of the intervention. Working with interpreters Sometimes people seeking asylum will need to use interpreters for therapy to occur. This can be new to a therapist and raise anxieties. A study by d’Ardenne et al. (2007), compared clinical outcomes of three groups of PTSD patients receiving CBT (refugees who required interpreters, refugees who did not require an interpreter, and English-speaking non-refugees) and concluded that interpreter use was highly feasible and could be used with positive outcome. This is echoed in our own experience. There are useful resources for clinicians who want to consider working with interpreters in more depth and training is usually available within the refugee sector. Tribe and Ravel’s (2003) Working with Interpreters in Mental Health is an ideal primer for therapist and service alike. However, the ongoing effective use of interpreters involves regular use of supervision to consider not just the direction of the intervention but also the impact of the three-way dynamic. The expectation for effective service provision is that interpreters are fully trained and qualified and hold a diploma in public service interpreting (DPSI). However, the reality of practice is that interpreters will come from various backgrounds, abilities and levels of training. A full briefing with written guidelines is indispensable at the outset of every new interpreting contract to set out expectations and to socialise the interpreter to the psychological domain. After this, shorter conversations to brief and debrief the interpreter at the start and end of each session are considered the minimum standard (full briefing guidelines available at Bashir and Bowley, 2014). Key issues when working with interpreters are those associated with confidentiality and trust. Clients appear to have few concerns about the trustworthiness or professionalism of therapists but can be very concerned about the interpreter. At one extreme, political, religious and ethnic differences mean that interpreters from the same country as a client are often

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viewed as being part of the oppressive or persecutory groups they are trying to flee. Alternatively, and more commonly in small refugee communities, the use of interpreters who are well known by clients, their relatives and even their community, has implications for therapy (Tribe and Ravel, 2003). Another consideration is that of mental health concepts and categorisation. Terms and models may not have equivalents in different cultures, and working with an interpreter to decipher these differences is especially important. Working across cultures can seem broad and complicated but the fundamental CBT practices of working in collaboration with client concerns and developing shared formulations are a firm foundation on which to approach this work. Engagement Engagement falls into Herman’s (1997) safety stage, and is about ‘establishing safety in the relationship and with the goals of the relationship’. Table 15.1 outlines the important tasks to consider when engaging clients. The issue of trust is paramount with this client group and should be addressed at the outset. Establishing your helping role and explaining confidentiality is key, especially when working with interpreters, as their commitment to confidentiality needs to be explicitly discussed. Informing clients that you are not connected to the Home Office is useful, and many therapists choose to make their commitment to human rights explicit. Clients may not be familiar with therapy or have very idiosyncratic views as to the reason for the session. Explaining the reason for the appointment and rationale for therapy is extremely important. Explaining the limits of one’s role is useful (i.e. one’s relationship to prescribing medication or involvement in processes such as benefits and accommodation). For some, the idea of therapy is threatening, or associated with ill health or weakness. Being able to give positive normalising rationales for your role is invaluable. Allowing time for the development of trust and the establishment of a working alliance is vital. The message of concern for the client’s safety and autonomy needs to be constantly reiterated. People need to know that they do not have to meet, do not have to talk and that you are aware of how difficult this is. Assessment People seeking asylum present with many difficulties and this can be a challenge to therapists needing to assess and formulate quickly. It is important not to rush through engagement or to determine model-driven formulations, but instead to follow the initial case formulation task of collaboratively developing a problem list (Persons, 1989). This process would be part of Herman’s initial safety stage. The most pressing concerns may not be psychological, but problems for example with medication, other health concerns, accommodation, racism or legal difficulties. These are often overwhelming in number and complexity. Working

Table 15.1  Key tasks during engagement Topic

Meet, contract and brief interpreter before meeting with the client and clarify their role Initial contract and outline for the continuing assessment process Introduce interpreter and their confidentiality obligations. Introductions Briefly, introduce self, human rights or other standpoint, separating your service from Home Office. If relevant, discuss how interpreting will work, e.g. using short sentences, and the importance of client feedback when interpreting/interpreter difficulties arise. Contextualise Determine clients understanding and rationale for the appointment. the service Explain the route of referral and contextualise your service in relation to the client’s health care. Elicit and acknowledge differences to their home country experience of accessing and using health care. Introduce the Explain the assessment process in simple terms e.g. ‘Today I will be asking about what you would like help with in relation assessment to some of the problems you have talked to your GP about process and and talk to you about how we might be able to work with parameters you on those issues.’ Explain confidentiality and its limits, e.g. risk and safeguarding issues. Obtain consent. Explain regularity and length of meetings. Socialisation to Determine client understanding about therapies and your role. Psychological therapy Explain what therapy/psychology is and what its aims are in relation to their care. When/if client is able, acknowledge the therapy as a Western construct. Discuss evidence that indicates why it could be helpful. Allow space to discuss. Explain the limits of psychological therapy, e.g. how psychological models differ from the medical model. Therapy is not a magic solution to problems or is not used like medication is used to treat physical disease. Ways in which working with the mind is different from disease processes. Emphasise the role of the relationship and three-way dynamic in helping client feel safe enough to talk openly about what they would like help with. Explain who is responsible for reviewing psychiatric medication and its role in well-being. Explain what the client’s responsibilities are, e.g. effort, punctuality, cancellation policies, participation between session tasks. Provide contact details. Interpreter

Herman’s stage 1: Safety

Suggested Pointers

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together to develop a problem list is valuable for developing a shared and controllable understanding of the difficulties faced by your client. Assessment of the client’s current situation should include their legal situation, as their stage in the asylum process will influence possible interventions. Although the focus of cognitive therapy is appropriately on the psychological factors associated with a client’s difficulties, with people seeking asylum, active and practical assistance is also warranted in the context of continuing stress. This challenges a therapist’s boundaries but, practically, there are rarely alternative sources of support. The help required is short term and highly effective in developing engagement, and the option of doing nothing may seem impossible. The assessment of well-being is similar to standard non-refugee populations, but the intensity of distress and sense of crisis people present with will make it less straightforward. Although fears and anxieties are clear, they could have an intensity that seems delusional but remain consistent with an individual’s experience. When clients report suicidal ideation, therapists need to be prepared to assess risk. It is common for people to say, ‘I’ll kill myself rather than be sent back,’ and there are cases where individuals have committed suicide rather than be removed. Fear of removal triggers PTSD, which results in threat-focused cognitive impairment, influencing decision making. If a client has had a refusal or become ‘appeal rights exhausted’, risk should become an imminent concern. In assessing ideation, it is not uncommon for clients to non-disclose due to personal religious reasons or the cultural unacceptability of suicide. Presenting a normalising rationale and challenging personal responsibility for such intrusive thoughts is helpful, especially as feelings of guilt around such experiences will worsen distress. An important feature of assessing symptomatology is to elicit the meaning of those symptoms. Clients may see problems as culturally normal so assumptions of pathology will not apply. Similarly, clients might view experiences common in the West as aversive. Sometimes with victims of political violence, remembering is viewed as a powerful act of self-integrity and forgetting seen as the perpetrator winning. Prior expectations of torture are a protective factor for posttraumatic symptomatology in torture victims (Basoglu et al., 1997). Working with this client group can involve exploring the wider political meaning of their experiences. Assessing different socio-cultural interpretations of well-being is useful, not only in eliciting beliefs about the cause and nature of problems, but in socialising clients to the CBT model. When socialising clients to the model, use straightforward examples and imagery, and/or metaphors that are relevant to the client’s current frame of reference. Asking clients about the traditional or local name of a problem, of its signs, causes and how it was addressed help in the engagement process and in the development of a shared goal. When working with people seeking asylum, it is important to be sensitive when assessing their history, especially when their coping strategies focus on avoidance. A possible pitfall during the assessment is to elicit memories, thoughts, and feelings that clients have been suppressing or lead to unmanageable levels of

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affect. It is important to identify the degree to which clients have talked about their experiences, their strategies for managing affect, and even their view of the result of talking. Clients may hold the belief that talking makes things immediately better, when in practice an increase in negative affect will result. If unprepared, they could opt out of therapy, feeling overwhelmed and afraid. Gaining an understanding of a client’s history can seem difficult when they have long and complicated life histories. It is helpful to conceptualise clients’ histories in three stages: • • •

Pre exile: childhood, and the time leading up to fleeing the country Flight: experiences of fleeing to the UK, arrival, asylum application Exile: experiences in the UK including dispersal.

It is useful to gain an understanding of clients’ countries of origin. Information is available on websites such as Human Rights Watch (2014) or Amnesty International (2014), who provide brief but detailed summaries of most relevant countries. This is also useful in identifying languages and religious contexts. Developing and sharing formulations Assessment and formulation is still part of the safety stage of Herman’s conceptualisation, with the goals of normalising reactions, validating experiences and developing a respectful therapeutic relationship. Assessing and formulating are not separate processes, and through identifying the client’s concerns and understanding, and providing a rationale for support and joint working, many of the safety and trust issues key to Herman’s first recovery stage can be developed. Prompt presentation of a general normalising recovery formulation with explicit trust and safety requirements is helpful in supporting clients in the early stages of work. This is particularly useful to help prevent clients going into early detailed descriptions of trauma that result in excessive distress. Supporting clients’ basic health and safety, assisting with environmental problems and engaging with effective social support all help establish safety and trust. Explicitly giving control to clients is vital, as is clear discussion of the difficulties, risks and challenges associated with therapy. Establishing safety and control is difficult for people who face the threat of repatriation and whose lives are controlled by powerful legal, financial and social constraints. Restoring control is clearly a goal of developing shared formulation and in normalising and accepting symptoms. Clients may attend because of the sense that they should not be in distress. Using an adjustment model, distress could be seen as an appropriate part of the individual’s emotional processing and does not mean they need formal support. In these cases, a normalising rationale can alter appraisals, reduce anxieties, and allow individuals to continue on the process of recovery without formal assistance.

Table 15.2  Key tasks during assessment Topic

Consent form to contact relevant agencies e.g. solicitor and social worker where clinically indicated. Initial contract and outline for the continuing assessment process Gather information relevant to their legal issues, e.g. Collect general relevant information stage of asylum process, details of solicitor. Regularity and impact of asylum reporting arrangements Current living arrangements e.g. street homelessness, homelessness, Asylum Support accommodation, council housing, living with friends/relatives, temporary/ private rented housing Current friends, networks and activities Access to education, literacy levels in all languages (relevant for giving homework tasks, self-help materials, psychometric measures) Financial circumstances, e.g. destitution, awaiting benefits decisions and so forth Explain what CBT is in simple terms, e.g. the links Introduction to the between how we perceive ourselves, others and our model lives and how this might impact on how we feel and how we behave. Ability to concentrate/understand you and interpreter History, problems, protective factors and Begin to gather the client’s problem list in their words. resilience Consider using loss, transition and journey into exile as categories to organise the problem list. Encourage clients to pace themselves and not launch into descriptions of traumatic events by suggesting the time and space to do this slowly will be available. Determine what is going well. Determine client’s understanding of psychological difficulties (e.g. cultural understandings, stigma as well as fears of ‘going mad’). Physical health related concerns Appetite and sleep difficulties including nightmares Risk and safeguarding issues Chronology to include resilience and pre-morbid resources (e.g. flowers and stones lifeline as in NET) Attention, concentration and mental flexibility Trans-diagnostic processes and changes Memory and imagery since adverse life Understanding of the mind, brain and its functioning events or transition Thoughts and understanding of thinking Reasoning and understanding of emotions Behaviour, safety behaviours, avoidance Expectations and attributions about well-being Contracting

Herman’s stage 1: Safety and start of stage 2: Reconstruction

Suggested Pointers

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For some, however, where the level of distress or the existence of maladaptive beliefs or coping strategies prevent recovery, cognitive formulations, psycho-education and interventions aimed at symptom management strategies are useful. The tasks for psycho-education (Table 15.3) are seen in part as preparation for the reconstruction phase. For those clients whose problems closely match specific models of psychological disorder (e.g. panic) sharing the formulations of these problems is entirely appropriate. Interventions Using Herman’s concept of a process of recovery, therapists can order their interventions around the three stages: safety, transformation and reconnection. The Traumatic Stress Clinic in London used and developed this three-phase model (Robertson, 2003; Grey and Young, 2008). In practice, clients’ needs are not static, they move between these phases. Interventions then act at different levels on various problems over time. Initial stage interventions focus on developing safety, control and trust, and include those already mentioned (Tables 15.1–15.3) during engagement, assessment and psycho-education. The decision on which intervention to use should reflect the formulation; however, the legal situation and the level of English language or interpreter skills often mean that simple behavioural approaches are the initial choice. These interventions have a marked effect on levels of distress and in regaining self-control. Due to the uncertainty of appealing for refugee status, many people feel unable to continue beyond the initial stages of engagement, assessment and psycho-education. Clients have awareness of their limits and often return for more specific therapy after gaining refugee status or becoming more established. When working with asylum seekers whose appeals rights are exhausted, who are detained or awaiting removal, therapists need to assess carefully whether continued work will benefit or be likely to cause harm. Furthermore, a reinforcement of earlier anxiety management and grounding interventions are more likely to be supportive here. The construct of CTS places significance upon regulation of anticipatory anxiety in the context of realistic threat and may also be a helpful formulation (Eagle and Kaminer, 2013; Murray et al., 2013). Stage two interventions correspond to Herman’s stage of reconstruction of experiences. These centre on the transformation of clients’ experiences, and in practice closely match the active therapeutic components of transdiagnostic cognitive processes in PTSD and depression, and for emotional problems of guilt and shame. This is especially true if clients’ difficulties are discrete and reflect specific traumas or losses. However, people may have had a lifetime of trauma and in these cases, the adoption of specific interventions is augmented by consideration of the human rights testimony approach or NET, which reinforce the notion of bearing witness to clients’ experiences. The degree to which stage two interventions bring about observable reductions in distress is variable. Many are able to move forward despite the anxieties

Table 15.3 Tasks for psycho-education Topic

Suggested Pointers

Referral to community-based refugee and asylum services including legal aid solicitors, drop-ins, destitution and rights based projects Normalising and empathising: loss of culture, language, family, community and familiarity as understandably overwhelming or stultifying Loss, transition Normalising how limited opportunities in current setting might worsen and adjustment presentation Accepting that there is not one way to overcome such adversity or bridge such transition; rationale for why this is a joint endeavour Body’s normal response to mild and extreme stress Memory formation and threat (a simple way of explaining this is to indicate that some parts of the brain perform harder and others recede resulting in fragmented sensory memories) Role of the brain and hormones The anxiety cycle The flight, fight and freeze response in the context of stressful events or memories Reasons for symptoms such as dizziness, feeling hot or cold, sweating, blurred vision, shaking, muscle tension Role of thinking/attention in maintaining stress response Rationale for why trauma memories might persist Exploring and understanding the motivation for torture or persecution (see Grey and Young, 2008) A rationale for nightmares, dreams and flashbacks Hyperarousal and hypervigilance Trauma and Rationale for insomnia and poor sleep flashbacks Avoidance and maintenance factors including asylum context and role of ongoing threat Grounding techniques and re-establishing safety Reducing hyperarousal, reducing threat – cognitive, metacognitive and behavioural (e.g. breathing, relaxation and mindfulness techniques) Recovery and resilience: rationale for developing new coping strategies in new environments Reasons why previous strategies might be less effective (e.g. loss of The role nexus, ongoing loss and bereavement) of thinking, Therapy as having a role of developing resilience in the face of emotion and continued adversity coping strategies Short and long term benefits of self-control and self-soothing strategies Protective factors in well-being (e.g. activity, spirituality, absorption, education, stimulation, diet and sleep) Reducing Breathing, relaxation and mindfulness techniques hyperarousal Explain specific focus of therapy model and its rationale, e.g. NET is to help reconstruct a trauma narrative. Specific model Explain rationale for present oriented coping strategies. of therapy to Obtain informed consent for trauma-focused work. be used Self-help or information in first language if literate (see Royal College of Psychiatrists (2014) website for resources) Signposting

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associated with not being assured of refuge, and this is a powerful experience for client and therapist. However, therapists must always be aware of and therefore assure their clients of the ‘rational’ nature of their distress; and normalise the appropriateness of them managing the adversity of their situation. Stage three interventions, the reconnection stage, focus on moving from the past into an active present, and future. Here the focus of work is on supporting clients to engage with the world. Stage three interventions present difficulty as people are unable to work, usually financially restricted, and through migration and dispersal isolated from communities or friends. Education and volunteering are two areas that are open to asylum seekers, providing their claims are still ongoing. Learning English is a powerful, though challenging, task, while many find the act of helping others an immensely powerful emotional support. Linking with colleges and voluntary agencies is a major role of therapy in this stage. As in stage two, however, for many people the goals of reconnection are extremely difficult given the temporary nature of their accommodation and social networks. In this context, the development of relationships, including in therapy, is something else to lose and care needs to be taken in exploring such steps. Ending therapy Ending therapy is a particularly difficult process for therapist and client alike. Most statutory services are unable to offer ongoing support, so therapy ends while an individual remains in an uncertain situation or is still experiencing symptoms. The decision to end therapy should be arrived at collaboratively and with clear rationales. Reasons include that basic coping strategy work has been completed, work on building resilience has come to an end or even that further work is contraindicated or not required. Given that people will have experienced multitudes of losses, unplanned and unwanted endings, it is important that the therapeutic ending be as different an experience as possible. Endings need to be talked about from the start of therapy, and clearly, as part of the contracting process, but maintaining a shared awareness of the stage of therapy is especially important. What constitutes a positive ending will differ between clients, but exploring this, raising awareness of difficulties that may raise and asking clients to design their own ending strategy promotes ending as a powerful intervention in itself. Self-care Working therapeutically with people seeking asylum can significantly impact on therapists, and self-care is especially important. The act of listening alone to people’s experiences of persecution, horror, injustice and suffering has been shown to have an impact on both mental and physiological health, but the role of therapist is particularly prone to negative effects (Pennebaker, 1990). Terms such as ‘vicarious traumatisation’ (McCann and Pearlman, 1990) and ‘burnout’ (Maslach, 1982) have been used to describe this impact, and it is a

Herman’s Stage 1

Table 15.4  Possible tasks during the intervention phase Key Area

Suggested Pointers

Managing risk

Managing hopelessness and suicide risk Strategies at points where risk could increase e.g. reporting, dispersal, appeals, refusal, acceptance, detention or removal Writing regularly to GP Assertive referrals to health and support services Behavioural interventions for insomnia or erratic sleep Imagery re-scripting or management of nightmares Managing worry or terminating intrusive thoughts Indicated therapies for depression or transdiagnostic models focusing on social isolation and avoidance Psycho-education, grounding techniques (Table 15.3) Managing intrusions and dissociation Imagery re-scripting for nightmares Bearing witness, validating and holding the client’s experience Re-contextualising trauma memories by developing a coherent and detailed narrative of experience focusing on resources and resilience Helping clients explore and develop the personal meaning of these events Exploring/reframing feelings of shame and guilt Confronting extreme affect e.g. despair and anger Exploring the shattered beliefs and assumptions of ruptured belief systems Focused therapeutic work aimed at altering traumatic memories Referral and rationale for pain management interventions Allowing grief and mourning for multiple losses Managing ambiguous loss for the missing or lost Loss of role, identity, culture and language Long term strategies to manage grief Identifying factors preventing connection and reconnection Exploration of trust and interpersonal difficulties and long term management strategies Encouraging clients to resume everyday activities Helping clients establish new relationships or re-establish old relationships and family bonds Helping clients rebuild a new life in a new country, developing goals and aspirations Helping clients rebuild beliefs, and religious and political convictions

Sleep Depression

Herman’s Stage 2

Trauma

Loss and grief

Herman’s Stage 3

Re-connection

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material fact of this work. People seeking asylum are almost always coping with high levels of adversity, they often present with extreme emotional intensity and histories of horrific ‘inhuman’ experiences, while their situations appear hopeless. This is especially so if therapists have entered work with a notion of cure – with a belief that ameliorating distress is a given. This work can challenge therapists’ sense of competence and skill. Professional boundaries are tested and the political nature of the work can affect a therapist’s sense of justice and faith. Although a lot of change is possible, an adjustment, resilience or recovery process philosophy possibly offers more protection for client and therapist. The issue of self-care should be addressed in part at an organisational level, through supervision and caseload management, but it also needs to be taken as a personal responsibility. There is no easy solution to managing this work, and therapists need to monitor and be self-aware of the impact it has on them.

Case example Claudine was a 55-year-old from a rural African background. Tribal conflict resulted in her witnessing the brutal murder of her husband as well as the kidnap and probable murder of her four teenage children. Her land was seized and she eventually found her way to a refugee camp. She was relocated as a refugee to a town in the UK. She was treated by psychiatric services because she expressed a wish to die and because she was neglecting her health as a means of self-harm. She was prescribed anti-depressants and her mood stabilised but she was constantly anxious. She still did not believe she had anything to live for, although she was not actively suicidal. She was referred for psychological therapy. Stage 1: Safety Engagement Initial attunement during the introductions to Claudine’s obvious emotional distress (noticing and expressing concern about agitation and reticence) helped her to build therapeutic rapport and manage her agitation symptoms. Claudine’s reticence was later assessed to be related to her lack of exposure to the culture of psychological therapy or UK health care providers. Her anticipatory anxiety (of having to relate her traumatic history) exacerbated hyperarousal symptoms. Detailed explanations were necessary to engage Claudine in the process as an active participant. At this stage, the role of psychology, the interpreter and confidentiality were explained. This ensured the context and purpose of the assessment were clear. The trajectory of therapy, especially the ending, was marked from the outset and at regular intervals throughout therapy. The novelty of the culture and context for Claudine along with impaired concentration indicated that

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initial explanations had to be limited to those aspects that enabled her to provide informed consent. Assessment Claudine was unfamiliar with therapy and psychological concepts. Her first language was not English and she could not read in any language. Thus far she had only been treated using medication. An initial problem list was obtained. Claudine described being overwhelmed by nightmares and visions of people who had died, particularly her 14-year-old daughter. She also described poor sleep, poor memory, lack of motivation, fear of people especially crowds, palpitations, sweats, feeling frightened all the time, often losing a sense of where she was, what she was doing and where she was going and losing a sense of time and place at the time of the ‘visions’ or when waking from nightmares. She attributed her inability to focus and learn in English classes to poor memory and concentration. She did not understand what was happening to her and believed she was ‘going mad’, leading to feelings of shame and dread. Claudine’s appraisal of her difficulties was that she was being haunted by spirits of the dead; an omen that she too would soon die. She explained this was a widely culturally held belief, which the interpreter confirmed in the debriefing. Thus, seeing her dead daughter was threatening not only because it was a reminder of the multiple traumas she had experienced but also as a direct threat of death. The assessment identified that Claudine’s ‘vision’ was the last memory of her daughter calling to her as she was being kidnapped. Claudine explained that since the civil conflict she was watchful of people who shared facial features of the opposing tribe. This prompted the therapist to check the appropriateness of the interpreter. A regular and consistent interpreter was deemed essential to enable Claudine to establish a sense of safety and engage with therapy. A standard trauma-based formulation explained most of Claudine’s symptomatology. A longitudinal CBT formulation capturing her pre-exile, exile and post-exile beliefs, assumptions and thoughts enabled a fuller appreciation of her trauma, grief, loss and transition processes as well as her resilience. Psycho-education Psycho-education was a significant aspect of the intervention. A detailed diagram was drawn up showing the symptoms of anxiety and their relation to overwhelming trauma. Transdiagnostic symptoms (memory, sleep, nightmares, concentration, anxiety, intrusive memories) were normalised within a Western psychological model of trauma, loss and migration. This was presented as another explanation (with reference to the research with refugees in this area) alongside her own appraisal of her experiences. Claudine found the narrative of trauma as a normal reaction to abnormal events affirming, and was reassured by how well the

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formulation explained her symptoms. The role of avoidance in the maintenance of threat, low mood and poor motivation was essential. The need to ground oneself in a safe present was taught as a strategy in extensive detail with a full rationale. Good sleep hygiene was explained and strategies to manage night-time waking, fear and worrying were addressed using a range of well-established cognitive and behavioural techniques. Claudine showed marked improvements in functioning after this initial work. Stage 2: Reconstruction During this stage, (which overlapped with the assessment phase) a chronology using stones and flowers placed along a rope (representing the lifeline) was co-constructed to include positive events, resilience factors and resources (flowers) as well as difficult (stones) life events (NET, Schauer et al., 2012). Bearing witness to her experiences across the lifespan and pausing at the particularly traumatising events enabled a rich account to develop which weaved in and out of narratives of survival and loss. Claudine’s own experiences as a daughter and woman had shaped a strong attachment to her daughter and had since become fused with the stories that she heard about how her daughter might have been violated and killed. Psycho-education about fragmented memories in posttraumatic stress disorder, along with standard CBT trauma exposure work in relation to the murder of her husband and children and pre-exile sexual assaults, enabled Claudine to manage and begin the process of living with the immeasurable losses she had experienced. Stage 3: Reconnection Reconnection was challenging for Claudine, given her history and age. She believed she would have been reaping the rewards of a lifetime of hard work raising a family, in her culture. Quality of life and how to hope again as an older woman on her own in a new culture was a significant theme in the work. Bearing witness included a formulation of those factors that had contributed to Claudine’s resilience in the face of overwhelming adversity, throughout her life. Old inner resources were refreshed in the context of present challenges and new skills necessary for optimal adjustment were goals during and after therapy. Managing challenges that depleted Claudine’s resilience was key. This included learning how to identify and manage experiences of racism by neighbours. For Claudine, this initially mirrored the hostility of tribal conflict, a matching trigger for trauma memories. Using a problem-solving approach enabled Claudine to consider her options. An obvious solution was to file a criminal report for harassment but she opted to enlist mediation and develop her rapport with her neighbours as she thought this was the most helpful solution. Claudine was able to reconnect with community-based groups with the help of referral to a community worker.

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At the end of 16 weeks of 90-minute therapy sessions, Claudine was ready to be discharged. Ending was emotionally charged but positive because of the resonances with endings in her own life. Difficulties had been somewhat pre-empted by reference to endings throughout therapy and by allowing emotional resonances to past losses and endings to emerge. Relapse prevention included predicting times where loss, grief and trauma symptoms might re-emerge and what internal and external resources were available to Claudine to self-soothe, continue with her recovery and when to seek help.

Conclusion Working with people seeking asylum presents cognitive therapists with many challenges, yet the collaborative goal-focused approach, with its use of individual, shared formulations and tailored interventions, means that it is highly suitable for this client group and the problems they experience. This chapter suggests that working both with a model of adjustment, ‘coping with adversity’ and using a staged recovery model approach to trauma, cognitive therapists can develop formulations that can effectively guide their interventions and support both their clients and themselves.

References American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author. Amering, M., and Schmolke, M. (2009). Recovery in Mental Illness: Reshaping Scientific and Clinical Responsibilities. Chichester: John Wiley. Amnesty International. (2014). Human Rights by Country. Retrieved June 24, 2014, from http://www.amnesty.org/en/human-rights/human-rights-by-country Asylum Aid. (2014). The Asylum Process Made Simple. Retrieved June 24, 2014, from http://www.asylumaid.org.uk/the-asylum-process-made-simple Bashir, C. and Bowley, J. (2014). Briefing Guidelines for Interpreters in Psychotherapeutic Settings. Retrieved June 17, 2014, from https://www.academia.edu/7301736/ BRIEFING_GUIDELINES_FOR_INTERPRETERS_IN_PSYCHOTHERAPEUTIC_ SETTINGS Basoglu, M. (1992). Torture and Its Consequences: Current Treatment Approaches. Cambridge: Cambridge University Press. Basoglu, M. (1993). Prevention of torture and care of survivors: An integrated approach. Journal of the American Medical Association 270: 606–11. Basoglu, M. et al. (1997). Psychological preparedness for trauma as a protective factor in survivors of torture. Psychological Medicine 27: 1421–33. Basoglu, M. et al. (2004). Cognitive-behavioral treatment of tortured asylum seekers: A case study. Journal of Anxiety Disorders 18: 357–69. Basoglu, M. et al. (2005). Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: A randomized waiting list controlled trial. Journal of Traumatic Stress 18: 1–11.

348  Jake Bowley and Colsom Bashir Bhui, K. and Morgan, N. (2007). Effective psychotherapy in a racially and culturally diverse society. Advances in Psychiatric Treatment 13: 187–93. Blackburn, I. M. and Davidson, K. M. (1990). Cognitive Therapy for Depression and Anxiety: A Practitioner’s Guide. Oxford: Blackwell. Brewin, C. R. (2007). Autobiographical memory for trauma: Update on four controversies. Memory 15: 227–48. British Medical Association. (2002). Asylum Seekers: Meeting their Healthcare Needs. London: BMA. Calhoun, L. G. and Tedeschi, R. G. (2013). Post-Traumatic Growth in Clinical Practice. New York: Routledge. Children’s Society Briefing. (2012). A Briefing From the Children’s Society: Highlighting the Gap Between Asylum Support and Mainstream Benefits. Retrieved November 16, 2013, from http://www.childrenssociety.org.uk/ Cienfuegos, A. and Monelli, C. (1983). The testimony of political repression as a therapeutic instrument. American Journal of Orthopsychiatry 53: 43–51. Crawley, H. (2010). Chance or Choice? Why Asylum Seekers Come to the UK. Swansea: Refugee Council. d’Ardenne, P. et al. (2007). Does Interpreter-Mediated CBT with Traumatized Refugee People Work? A Comparison of Patient Outcomes in East London. Behavioural and Cognitive Psychotherapy 35: 1–9. Dallos, R. and Stedmon, J. (2009). Flying over the swampy lowlands: Reflective and reflexive practice. In J. Stedmon and R. Dallos (eds) Reflective Practice in Psychotherapy and Counselling. New York: McGraw Hill. David, D. and Hofman, S. G. (2013). Another error of Descartes? Implications for the ‘THIRD WAVE’ of cognitive behaviour therapy. Journal of Cognitive and Behavioral Psychotherapies 13: 115–24. Department of Health. (2000). National Service Framework for Mental Health: Modern Standards and Service Models. London: Author. Eagle, G. and Kaminer, D. (2013). Continuous traumatic stress: Expanding the lexicon of traumatic stress. Peace and Conflict: Journal of Peace Psychology 19: 85–99. Ehlers, A. and Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behavioural Research and Therapy 38: 319–45. Eisenbruch, M. (1991). From post-traumatic stress disorder to cultural bereavement: Diagnosis of south east Asian refugees. Social Science and Medicine 30: 637–80. Fazel, M. et al. (2005). Prevalence of serious mental disorder in 7,000 refugees resettled in Western countries. Lancet 365 (9467): 1309–14. Fazel, M. and Stein, A. (2003). Mental health of refugee children: Comparative study. British Medical Journal 327: 134. Freedom from Torture. (2014). Freedom From Torture. Retrieved June 24, 2014, from http://www.freedomfromtorture.org Gorst-Unsworth, C. and Goldenberg, E. (1998). Psychological sequelae of torture and organised violence suffered by refugees from Iraq. British Journal of Psychiatry 172: 90–94. Grey, N. and Young, K. (2008). Cognitive behaviour therapy with refugees and asylum seekers experiencing traumatic stress symptoms. Behavioural and Cognitive Psychotherapy 36: 3–19. Health for Undocumented Migrants and Asylum Seekers Network. (2009). Access to Healthcare for Undocumented Migrants and Asylum Seekers in 10 EU Countries: Law

Working with people seeking asylum  349 and Practice. Retrieved December 2013 from www.episouth.org/doc/r_documents/ Rapport_huma-network.pdf Heeren, M. et al. (2012). Mental health of asylum seekers: a cross-sectional study of psychiatric disorders. BMC Psychiatry 12: 114. Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress 5: 377–91. Herman, J. L. (1997). Trauma and Recovery: From Domestic Abuse to Political Terror. London: Pandora. Hinton, D. et al. (2012). Adapting CBT for traumatized refugees and ethnic minority patients: Examples from culturally adapted CBT (CA-CBT). Transcultural Psychiatry 49: 340–65. Home Office. (2013). Immigration Statistics April to June 2013. Retrieved November 16, 2013, from https://www.gov.uk/government/publications/immigration-statistics-aprilto-june-2013/immigration-statistics-april-to-june-2013#asylum-1 Horrell, S. V. (2008). Effectiveness of cognitive–behavioral therapy with adult ethnic minority clients: A review. Professional Psychology: Research and Practice 38: 160–68. Human Rights Watch. (2014). Browse by Country. Retrieved June 24, 2014, from http:// www.hrw.org/browse_by_country Johnson, M. (2006). Integration of new migrants: Health. In S. Spencer (ed.) Refugees and Other New Migrants: A Review of the Evidence on Successful Approaches to Integration. Oxford: Centre of Migration: Policy and Society. Lavik, N. J. et al. (1996). Mental disorder among refugees and the impact of persecution and exile: Some findings from an outpatient population. British Journal of Psychiatry 169: 726–32. Mahtani, A. (2003). The right of refugee clients to an appropriate and ethical psychological service. International Journal of Human Rights 7: 40–57. Mansell, W. et al. (2009). Conceptual foundations of the transdiagnostic approach to CBT. Journal of Cognitive Psychotherapy: An International Quarterly 23: 6–19. Maslach, C. (1982). Burnout: The Cost of Caring. New York: Prentice Hall. McCann, I. L. and Pearlman, L. A. (1990). Psychological Trauma and the Adult Survivor: Theory, Therapy and Transformation. New York: Brunner/Mazel. MIND. (2009). A Civilised Society: Mental Health Provision for Refugees and Asylum Seekers in England and Wales. www.mind.org.uk/media/273472/a-civilised-society.pdf Moorey, S. (1996). When bad things happen to rational people: Cognitive therapy in adverse life conditions. In P. M. Salkovskis (ed.) Frontiers of Cognitive Therapy. New York: Guilford Press. Moorey, S. (2010). Cognitive therapy. In J. Holland et al. (eds) Psycho-Oncology (2nd ed.). Oxford: Oxford University Press. Mueller, M. (2009). The role of narrative exposure therapy in cognitive therapy for traumatised refugees and asylum-seekers. In N. Grey (ed.) Casebook of Cognitive Therapy for Traumatic Stress Reactions. London: Routledge. Murray, L. K. et al. (2013). Trauma-focused cognitive behavioral therapy for youth who experience continuous traumatic exposure. Peace and Conflict: Journal of Peace Psychology 19: 180–95. Neuner, F. et al. (2008). Narrative exposure therapy for the treatment of traumatized children and adolescents (KidNET): From neurocognitive theory to field intervention. Child and Adolescent Psychiatric Clinics of North America 17: 641–64.

350  Jake Bowley and Colsom Bashir Neuner, F. et al. (2010). Can asylum-seekers with posttraumatic stress disorder be successfully treated? A randomized controlled pilot study. Cognitive Behaviour Therapy 39: 81–91. Nickerson, A. et al. (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review 31: 399–417. Papdopoulous, R. K. (2007). Refugees, trauma and adversity activated development. European Journal of Psychotherapy and Counselling 9: 301–12. Paunovic, N. and Öst, L-G. (2001). Cognitive-behavior therapy vs. exposure therapy in the treatment of PTSD in refugees. Behaviour Research and Therapy 39: 1183–97. Pennebaker, J. W. (1990). Opening Up: The Healing Power of Expressing Emotions. London: Guilford Press. Persons, J. B. (1989). Cognitive Therapy in Practice: A Case Formulation Approach. London: W. W. Norton. Raghuvanshi, L. and Agger, I. (2008). Giving Voice: Using Testimony as a Brief Therapy Intervention in Psychosocial Community Work. Retrieved January 4, 2014, from doc. rct.dk/doc/ART17267.pdf Refugee Council. (2013). Asylum Statistics May 2013. Retrieved November 2013 from http://www.refugeecouncil.org.uk/assets/0002/7887/Asylum_Statistics_May_2013.pdf Refugee Council. (2014). Refugee Council. Retrieved June 24, 2014, from http://www. refugeecouncil.org.uk/english Regel, S. and Berliner, P. (2007). Current perspectives on assessment and therapy with survivors of torture: The use of a cognitive behavioural approach. European Journal of Psychotherapy and Counselling 9: 289–99. Robertson, M. (2003). The Traumatic Stress Clinic’s Phased Model of Intervention. Paper presented at the Mental Health Needs of Refugees Conference, London. Robjant, K. and Fazel, M. (2010). The emerging evidence for Narrative Exposure Therapy: A review. Clinical Psychology Review 30: 1030–39. Royal College of Psychiatrists. (2014). Translations. Retrieved June 24, 2014, from http:// www.rcpsych.ac.uk/healthadvice/translations.aspx Salcioglu, E. and Basoglu, M. (2011). Control-focused behavioural treatment of female war survivors with torture and gang rape experience: Four case studies. European Journal of Traumatology 2: S192. Schauer, M. et al. (2011). Narrative Exposure Therapy: A Short Term Treatment for Traumatic Stress Disorders (2nd rev. & exp. ed.). Gottingen: Hogrefe. Schauer, M. et al. (2012). Narrative Exposure Therapy: A Short Term Treatment for Traumatic Stress Disorders (2nd ed.). Cambridge, MA: Hogrefe and Huber. Seligman, M. (2011). Flourish: A Visionary New Understanding of Happiness and Well-Being. New York: Simon and Schuster. Snodgrass, L. L. et al. (1993). Vietnamese refugees with PTSD symptomatology: Intervention via a coping skills model. Journal of Traumatic Stress 6: 569–75. Summerfield, D. (1996). The Impact of War and Atrocity on Civilian Populations: Basic Principles of NGO Interventions and a Critique of Psycho-social Trauma Projects. London: Relief and Rehabilitation Network Overseas Development Institute. Szczepura, A. et al. (2004). Review of the Occupational Health and Safety of Britain’s Ethic Minorities. Retrieved November 16, 2013, from http://www.hse.gov.uk/research/ rrpdf/rr221.pdf Tribe, R. (1999). Therapeutic work with refugees living in exile: Observations on clinical practice. Counselling Psychology Quarterly 12: 233–43.

Working with people seeking asylum  351 Tribe, R. (2002). Mental health of refugees and asylum-seekers. Advances in Psychiatric Treatment 8: 240–47. Tribe, R. and Ravel, H. (2003). Working with Interpreters in Mental Health. Hove: Brunner-Routledge. Turner, S. and Gorst-Unsworth, C. (1990). Psychological sequelae of torture: A descriptive model. British Journal of Psychiatry 157: 475–80. UKBA. (2013). Compass Programme. Retrieved November 2013 from http://www.ukba. homeoffice.gov.uk/aboutus/workingwithus/workingwithasylum/compassprogramme/ United Nations. (1951). Convention Relating to the Status of Refugees. Geneva: Office of the United Nations High Commissioner for Refugees. United Nations High Commission for Human Rights. (2001, August 10). Press briefing given by Spokesman Kris Janowski at the Palais des Nations, Geneva. United Nations High Commission for Human Rights. (2013). Displacement: The New 21st Century Challenge. UNHCR Global Trends 2012. United Nations High Commissioner for Refugees. http://www.unhcr.org.uk/fileadmin/user_upload/pdf/UNHCR_Global_ Trends_2012.pdf Van der Veer, G. (1998). Counselling and Therapy with Refugees and Victims of Trauma: Psychological Problems of Victims of War, Torture and Repression (2nd ed.). Chichester: Wiley.

Chapter 16

Clinical supervision Helen Beinart and Sue Clohessy

Introduction Clinical supervision (CS) is seen as a crucial professional activity by applied psychologists and psychological therapists working in practice settings. There is broad agreement that good supervision is a prerequisite for competent practice (Bernard and Goodyear, 2014; Falender and Shafranske, 2004). Indeed, Falender and Shafranske (2012) argue that supervision is so important that it should be construed as a distinct professional competency requiring systematic education and training in its own right. Supervision is also essential to the development and maintenance of skills in cognitive behaviour therapy (CBT; Armstrong and Freeston, 2006) and therapists accredited by the British Association of Behavioural and Cognitive Psychotherapies (BABCP) are required to receive monthly supervision as a minimum standard. Additionally, CS is a significant component of the Improving Access to Psychological Therapies (IAPT) programme in the UK and several competency frameworks have been developed for supervision (e.g. Falender and Shafranske, 2004, 2012; Roth and Pilling, 2008a; Turpin and Wheeler, 2011). Current work is being undertaken to develop an international competency framework that operationalises the knowledge, skills and attitudes required to provide clinical supervision (Olds and Hawkins, 2014). CS is defined as ‘the formal provision, by approved supervisors, of a relationshipbased education and training that is work focused and which manages, supports, develops and evaluates the work of colleague/s’ (Milne, 2009: 15). Supervisory tasks include collaborative goal-setting, teaching, modelling, formulation, support, feedback, evaluation and consultation (Hawkins and Shohet, 2013; Milne, 2009). These different supervisory functions have been termed normative (quality monitoring), restorative (support) and formative (learning and development) and can sometimes conflict with one another (e.g. the normative and restorative functions). The aims of supervision are thus multi-faceted and although improved client outcomes are of primary importance, supervisee learning and development, improved practice for the service and overall improvement in workforce quality are also significant. Indeed, improved access and delivery of CS is one of the recommendations made by the recent Francis report (2013) in the UK for improving patient care and staff performance in the National Health Service.

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The supervisory relationship (SR) has been found to be a central component in the development of effective supervision (Beinart and Clohessy, 2009; Watkins, 2014), in particular, the development of a safe and supportive relationship has been shown to facilitate supervisee learning and development. Effective SRs require both an ethical stance and a respectfulness and sensitivity to difference and diversity in order to create a supervisory environment in which the supervisee can disclose their struggles and dilemmas. This can be a challenging requirement for supervisees who may feel anxious about their work being under scrutiny. It is inevitable that despite best intentions, SRs do not always work well, and at worst can be damaging. It is in this context that formulation, the tried and tested tool of psychology in making sense of complexity, can be applied to supervision itself. In order to apply formulation, some knowledge of models, evidence base and contextual influences on CS must be explored in order to have the tools to generate hypotheses and formulate in a way that is useful and meaningful within the supervisory context. Tarrier and Calam (2002) suggest that conceptualisation of the broader system including maintenance factors, historical and epidemiological background and interpersonal and social contexts should be added to traditional case formulation. These broader contextual and relational factors are seen as particularly significant in the formulation of difficulties within CS. This chapter will provide a summary of what is known about effective supervision by reviewing selected models, evidence and competencies. The key tasks of contracting, agenda setting, information sharing, feedback and formulation involved in the delivery of effective CS are described followed by a clinical example of formulation in supervision and some guidelines for effective practice.

Overview of effective supervision In recent years, an emerging evidence base in the field of clinical supervision has developed (Milne, 2009; Bernard and Goodyear, 2014). Given that supervision is so pivotal to clinical trainings, practice and indeed, treatment fidelity in clinical trials, it is surprising that it has lagged so far behind psychological therapies as a field worthy of study in its own right. It has been argued that the tendency to assume that supervision and therapy are similar and hence apply therapy models to CS has hindered the development of supervision theory and research (Bernard and Goodyear, 2014). Supervision is understood as a primarily educational activity (which may involve the learning of specific therapies such as CBT). In training, it is often involuntary and evaluative (Palomo et al., 2010) with the dual tasks of improving the quality of service provided to clients and supporting the learning and development of supervisees. Research in clinical supervision has also been held back by the lack of robust outcome measures, although there have been recent attempts to address this (e.g. Palomo et al., 2010; Pearce et al., 2013; Wheeler et al., 2011). The consensus in the field is that the SR is central to effective supervision, regardless of the model used. For example, in a recent summary of the research, Watkins argues that

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the supervisor–supervisee alliance has increasingly emerged as a variable of preeminent importance in the conceptualisation and conduct of supervision . . . it is widely embraced as the very heart and soul of supervision . . . but what do we really know about the supervision alliance? (Watkins, 2014: 19) The next section will summarise the literature and attempt to provide some answers to this question. The supervisory relationship: Theory and evidence Safran and Muran (2001) argue that as supervision takes place within a relational context, it must be understood within this context. However, despite numerous models of supervision (see Hess, 2008; Beinart, 2012) there are surprisingly few definitions and models of the SR itself. This presents a challenge to our understanding. This section will cover some examples of models that have been developed to specifically explain the SR. Bordin (1983) developed one of the few models of the SR, termed the Supervisory Working Alliance, which comprises goals, tasks and bonds. Supervisors and supervisors mutually agree on the goals and tasks of supervision and relational bonds develop through the mutual enterprise of working together in a collaborative manner. This model has been criticised, as it is a direct translation from a therapeutic working alliance model and thus does not attend to the educational and normative aspects of CS. Holloway (1995) developed a systemic model of supervision that places the SR as central to the negotiation of power and involvement in supervision. She describes a developing pattern of relationships, from hierarchical and role bound to more collaborative and involved as the supervisory dyad develops. More recently, Beinart (2012) developed a model of the SR (based on qualitative research with supervisees) that proposes a framework of relational characteristics (e.g. boundaries, collaboration and support) that need to be established to facilitate effective focus on the tasks of supervision (e.g. education and evaluation/monitoring). This model has been tested and refined by the development of two measures, the Supervisory Relationship Questionnaire (SRQ; Palomo et al., 2010) and the Short-SRQ (S-SRQ; Cliffe, 2013). Clohessy (2008) conducted qualitative research with supervisors to establish a model of the SR from their perspective. She found some overlap with Beinart’s model, particularly with regard to core relational characteristics (e.g. emotional tone; trust) but also some differences such as the importance of context and supervisee’s relationships with the wider clinical team. The model proposes a cycle of influence between supervisor and supervisee termed the ‘flow of supervision’ and proposes that supervisors invest more effort and time if the supervisee is open to learning, works well and is productive in the clinical context. The flow of supervision is proposed to influence the development of the core relational factors of the SR (namely, safety,

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honesty, a sense of connection and the emotional tone of the relationship), which in turn influences the supervisor’s investment and supervisee’s openness to learning. This model is supported by a robust measure of the SR from the supervisor’s perspective, the Supervisory Relationship Measure (SRM, Pearce et al., 2013) and is summarised in Figure 16.1. The research generated from these models and measures suggests that both supervisees and supervisors view a safe supervisory base as essential to effective supervision in order to provide a context for new learning. However, each side of the supervisory dyad has a slightly different slant with supervisees stressing the importance of emotional and practical support, feeling valued and respected, whilst supervisors emphasise workplace relationships and productivity. Bordin’s (1983) model of the supervisory working alliance has been widely researched using a questionnaire developed for this purpose (Bahrick, 1990). Findings suggest that the supervisory working alliance is related to supervisee satisfaction (Inman, 2006; Ladany et al., 1999), supervisee role-conflict (Ladany and Friedlander, 1995), supervisor evaluation and feedback (Lehrman-Waterman and Ladany, 2001), supervisor self-disclosure (Ladany and Lehrman-Waterman, 1999), supervisor interpersonal sensitivity (Ladany et al., 2001), supervisors’ ethical behaviour (Ladany et al., 2001) and supervisor multicultural competence (Inman, 2006).

Figure 16.1  Quality of the SR: Supervisors’ perspectives (© Copyright Sue Clohessy).

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Positive client outcome is the most important purpose of effective supervision and there is some promising early research in this area (e.g. Bambling et al., 2006; Bradshaw, 2007). However, given the widespread use of supervision both during training and for qualified staff, there is remarkably little evidence that shows robust client outcomes through supervision. Although widely applied, it is often not adequately measured in clinical research trials. In a review of 27 randomised clinical trials, Roth and colleagues (2010) noted that the training and supervision of therapists had not been consistently or systematically reported. The learning and professional development of the supervisee is another important outcome of CS. Indeed, supervision has been identified as the most important mechanism for developing competencies for therapists in training (Callahan et al., 2009). There is a growing body of evidence to support the role of the SR in supervisee satisfaction (e.g. Ladany et al., 1999; O’Donovan and Kavanagh, 2014), perceived effectiveness (e.g. Palomo et al., 2010) and skills development (e.g. Ellis and Ladany, 1997; Bambling, 2014). CBT supervision: Theory and evidence Early models of CBT supervision (e.g. Liese and Beck, 1997; Padesky, 1996) proposed parallels between the underlying principles, features and structure of supervision and therapy sessions. These include a collaborative approach, use of CBT methods such as Socratic questioning and providing a clear session structure e.g. checking in, providing a bridge between sessions, agenda setting, prioritising and use of homework. Pretorius (2006) suggests that the main goals of CBT supervision are to enable the therapist to adopt the philosophy of CBT as an approach to therapeutic change and to learn specific CBT skills. The CBT supervision literature has several helpful guidelines and models to inform supervision (e.g. Armstrong and Freeston, 2006; Gordon, 2012; Milne et al., 2008). The focus of CBT supervision can be wide-ranging. Padesky (1996) suggests a supervision options grid that provides a number of foci including mastering specific CBT skills (e.g. designing behavioural experiments, agenda setting), conceptualisation, the therapeutic relationship, therapist reactions and the supervisory process. Supervisors may also need to attend to their supervisee’s negative thoughts and assumptions as they relate to/interfere with therapy (e.g. Liese and Beck, 1997). For example, therapists who hold the belief that they are entirely responsible for their client’s progress in therapy or those who believe that they should never make mistakes will find the work of therapy challenging. Another important feature of CBT supervision is the emphasis on direct observation or recordings, and experiential methods of learning such as role-play. Using such methods gives the supervisor an opportunity to assess the supervisee’s learning needs and current skills, rather than relying on retrospective recall. Safran and Muran (2001) suggest experiential methods are also important in avoiding reliance on conceptual learning, and enabling the supervisee

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to attend to their interpersonal responses in therapy. Use of standardised rating scales such as the Cognitive Therapy Scale-Revised (Blackburn et al., 2001) are a useful means of assessing competence in CBT skills and providing feedback to the supervisee (Reiser and Milne, 2012). Although there is wide agreement in the literature that active learning methods (such as role play) should be utilised, there is evidence to suggest that in practice they are less frequently used (e.g. Townend et al., 2002). In addition to drawing on cognitive-behavioural theory, some authors (e.g. James et al., 2006) draw on theories from the educational and training literature, such as Kolb’s experiential learning cycle, and Vygotsky’s (1978) zone of proximal development. Kolb (1984) proposes that effective learning results from progression through four stages of learning – concrete experience, reflective observation, abstract conceptualisation and active experimentation. He suggests that individuals may have preferences for particular learning styles and that supervisors should be aware of this and encourage supervisees to progress through the learning cycle (using experiential methods such as role play, for example, in addition to reflective observation methods such as case discussion). As James et al. (2006) note, this may make supervision uncomfortable and challenging at times. Vygotsky’s Zone of Proximal Development (1978) can be useful in supervision when considering appropriate goal setting, and support needed from the supervisor in achieving these goals (James et al., 2006). The development of the competency movement within CS, in general, has also impacted on CBT supervision. As with other therapy models, the reliance on a model based on cognitive therapy obscures some of the unique features of CS including the SR, aspects of ethical and professional development, evaluative and gate-keeping functions and attention to organisational context. Newman (2010) developed a competency-based CBT supervision model based on Rodolfa et al.’s (2005) cube model, addressing foundational, developmental and functional dimensions of supervision. Newman emphasised the ethical, relational and cultural elements as foundational competencies in supervisory practice. Roth and Pilling (2007; 2008a) have developed competency based frameworks for CS initially commissioned by the IAPT programme in the UK. These are available for download (http://www.ucl.ac.uk/clinical-psychology/CORE/ competence_frameworks.htm). The framework defines levels of supervisory competence including generic (applicable to all supervision), specific supervision competencies (for all therapeutic models) and model specific competencies for a range of models, including CBT, which characterise the specific and unique competencies of that theoretical approach. These are underpinned by a set of meta-competencies, not dissimilar to the foundational competencies reflected in Newman’s model, such as ethical decision-making and clinical reasoning skills. The development of an evidence base for CBT supervision has been hampered by the complexity of assessing the multiple outcomes of supervision, lack of robust assessment measures and perhaps an unquestioned assumption about the implicit benefit of supervision (Roth and Pilling, 2008b). Additionally, supervision and

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training of therapists in clinical trials of CBT are often not detailed in the outcome literature, making these potentially important elements of effective therapy packages in research trials ‘invisible’. Milne et al. (2008) documented poor fidelity between guidelines for effective CBT supervision and actual practice where supervisors did not follow best practice in areas such as agenda setting, structuring, review of tapes and eliciting feedback. He suggests that the lack of a methodologically robust literature is particularly problematic for CBT, which prides itself on its underpinning empiricism. There are, however, a few studies which explore the impact of CBT supervision. Mannix et al. (2006) reviewed the impact of training in CBT skills and subsequent supervision on a small group of palliative care practitioners. All participants had 12 days of training in CBT and skills-focused supervision over six months, and all were judged to have shown significant gains in their CBT skills. Half of the group then discontinued supervision for six months. Their CBT skills decreased as did their reported confidence in delivering CBT, whereas those who carried on receiving supervision continued to develop their skills and maintained their confidence. In a systematic review of effective CBT supervision, Milne and James (2000) examined 28 studies that explored the impact of supervision on various aspects of the ‘educational pyramid’ (the impact of supervision on the supervisee, the client, etc.). From these studies (mostly in the area of intellectual disabilities), the authors highlighted particular supervision activities which were helpful, including close monitoring of the supervisee, modelling competence, providing specific instructions, goal setting and providing feedback on skills. Roth and colleagues (2010) stress the importance of direct monitoring of therapist skills through the use of recordings and standardised measures of competence. Additionally, there have also been efforts to develop standardised supervision training, based on best evidence in the form of manualised guidelines (Milne and Dunkerley, 2010). Similar to the general supervision literature, the evidence base for CBT supervision has been somewhat neglected and further research is much needed in this area. However, despite this, there is strong professional consensus regarding the value of supervision and it is viewed as an integral part of effective and ethical practice in CBT.

Key tasks in clinical supervision In this section some of the tasks for effective CS (drawn from both general and CBT supervision literature) will be described in more depth, followed by a clinical vignette that demonstrates the use of formulation in CS. The key tasks in CS include establishing a collaborative SR, contracting, agenda and goal setting, sharing information (using multiple methods), providing and inviting feedback and formulating particularly when difficulties occur. This is in the context of foundational or meta-competencies such as ethical and science informed practice (Falender and Shafranske, 2012).

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Contracting The supervision contract is a way of negotiating the goals and tasks of supervision and a useful way to establish the SR and encourage an atmosphere of collaboration and openness. The contract should be seen as a developing process and be regularly reviewed (Scaife, 2009). Contracting should include a discussion about mutual expectations, the supervisee’s learning needs and preferred learning style (e.g. through the use of Kolb’s (1984) experiential learning cycle) and helpful/unhelpful aspects of supervisees’ previous supervision experiences. Supervisors can model collaborative working by being clear about their expectations and share and explore assumptions based, for example, on culture, gender or beliefs about psychological change. These discussions can begin to create an atmosphere of trust and give permission for later discussions in relation to clients or service issues. During contracting, it is useful to approach the issue of feedback (or evaluation). It is important to clarify that feedback is a two-way process and that both parties may have preferences in the way it is given and received. The specific arrangements for supervision such as frequency, length of sessions, venue, supervisor availability and managing interrupted or missed sessions should be clarified. Contracting also involves discussion of ethical issues such as informed consent, management of confidentiality, professional conduct and fitness to practice, boundaries and boundary infringements and, if applicable, the relationship of managerial, clinical and professional supervision. In a training context it will additionally cover the professional competencies required by the professional training or registration body. Additionally, it is helpful to clarify roles and responsibilities, for example, expectations regarding the supervision agenda, note-keeping and communication. Finally, agreement of goals and tasks, that is, the function of supervision is a key aspect of contracting, particularly in CBT supervision where clarifying explicit learning goals or the supervision question are central. Agenda setting Agenda setting is a helpful way to structure individual CS sessions (regardless of therapeutic orientation) and may cover a broad range of areas such as clinical cases, therapy techniques, professional development and organisational issues. For example, reflective practice, team issues or a review of supervision may be part of a supervision agenda. In CBT supervision, a clear and well defined agenda has been a feature over several decades (Liese and Beck, 1997). The agenda is linked to goal setting and the structure of the supervision session. Supervisee’s preparation for supervision is seen as important, with the formulation of a specific supervision question key (e.g. Gordon, 2012) ensuring that the supervision agenda is focused and aimed at the learning needs of the supervisee, rather than reliant on generic case discussion. Interestingly, in a recent review of experienced

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CBT supervisors, only 60% reported that they used agenda setting in supervision (Townend et al., 2007). Information sharing One of the unique features of CS is its educational function and this is embedded in most definitions of CS. When new or experienced practitioners enter an unfamiliar clinical context, the supervisor has a role to impart as much information as possible to support their learning. This is likely to include ethical guidance, information about clinical arrangements such as record keeping systems, clinical and organisational policies (e.g. management of risk), as well as specific clinical techniques. Good communication is essential between supervisor and supervisee in order to support the open sharing of information (and building the SR). Use of multiple methods such as direct teaching, guided reading, enquiry, observation and modelling, use of recordings, consultation, reflection, role-play and creative methods are considered good practice in CS. Feedback Providing and inviting feedback in a sensitive manner that is targeted to the needs of the supervisee is another key supervision skill. Hoffman and colleagues (2005) define feedback as information that supervisors give supervisees about their skills, attitudes, and behaviour that may influence their performance with clients or affect the SR. Effective supervisors also regularly elicit feedback from their supervisees. Feedback is generally understood to be most helpful in the context of a supportive and trusting relationship (Scaife, 2009). Feedback is a significant aspect of supervision and features in many definitions; for example, Milne (2007) refers to ‘ “corrective feedback’, which implies a discrepancy between expected and actual performance in relation to agreed goals. Indeed, feedback (including praise and constructive criticism) is reported as the most common supervision method used (81%) in systematic reviews of supervision (Milne, 2009). The limited research into supervisee preferences for feedback suggest that balanced, timely, objective, consistent, clear and credible feedback in the context of a supportive relationship is experienced as most effective (Heckman-Stone, 2004). At its best, feedback is an integrated and mutual process within supervision (Hughes, 2012). Effective feedback should be given regularly in a manner that is respectful, clear, specific and unambiguous, so that the supervisee knows the issue to be addressed and how to go about this, owned by the person giving feedback (as their perspective) and balanced, including both positive and negative aspects. Recent competency frameworks (Roth and Pilling, 2007) stress the importance of directly observing supervisee practice and giving specific feedback on observed performance. Feedback can be provided on direct observations, recordings or experiential exercises such as role-play. However, much supervision occurs by

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the supervisee reporting verbally to the supervisor and thus relies on supervisees being able to share all aspects of their work and its personal impact (Webb and Wheeler, 1998) including difficulties and clinical mistakes (Ronnestad and ­Skovholt, 1993). In order to facilitate openness and honesty a safe SR has been found to be paramount (Ladany et al., 2001). Scaife (2009) suggests that supervisees are encouraged to self-evaluate alongside their supervisor and agree goals for their learning and development. This has the advantage of providing shared, clear and realistic expectations of change. It is helpful to clarify how supervisees prefer to receive feedback and whether feedback has been given and received in the preferred manner (and if not, how the supervisors could improve their performance). This provides an opportunity to reflect together on the process of giving and receiving feedback and creates an atmosphere of collaboration. Some supervisees find providing feedback to their supervisor difficult. Asking about responses to feedback is one way of facilitating this process. Research into supervisors’ perspectives about giving feedback, suggest that they prefer to give feedback about clinical issues, such as clinical skills, and may avoid providing feedback about supervisee personality, professional behaviour (e.g. self-presentation), or the SR (Hoffman et al., 2005). The strength of SR played an important role in whether feedback was given and how it was received and used. Ladany et al. (1999) suggest that supervisors avoid giving feedback for a number of reasons, including avoiding confrontations or having a negative impact, a belief that supervisees will discover the issues themselves and fearing boundary infringements between supervision and therapy. Measures of supervision are a useful method for giving and receiving feedback. Used in a clinical setting, these can provide a starting point for discussions about the SR from both perspectives. For example, supervisors can use the SRQ (Palomo et al., 2010) or S-SRQ (Cliffe, 2013) to gather feedback from supervisees. The SRM (Pearce et al., 2013) provides the opportunity for the supervisor to provide feedback to supervisees and a session-by-session measure, the LASS (Wainwright, 2010), provides a quick measure for regular review. Use of measures such as the Cognitive Therapy Scale-Revised (Blackburn et al., 2001) are a useful means of assessing competence in CBT skills and providing feedback to the supervisee (Reiser and Milne, 2012). Additionally, several authors have drawn on relevant literature to develop instruments to assess the quality of CBT supervision (e.g. SAGE; Milne et al., 2011; SCS; Kennerley et al., 2010). Formulation in supervision Johnstone and Dallos (2013) describe the essential features of a formulation as defining the core problems and how they relate to one another by drawing on psychological theories and principles, explaining the development and maintenance of the problems and indicating a plan for intervention based on the psychological processes identified. Formulation is a key therapeutic skill in CBT, and knowledge

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of formulation and relevant cognitive and behavioural processes is identified as a specific content area for CBT supervision (Roth and Pilling, 2008a). Dobson and Shaw (1993) identify it as one of three main activities in both Cognitive Therapy and CBT supervision, and Townend et al. (2002) found that formulation was the most frequently discussed topic in CBT supervision. Formulation in CS is a discrete activity that can be distinguished from clinical formulation in that it needs to take into account both supervisee learning and practice issues. Supervisors need to conceptualise at a number of levels. In addition to the formulation of the client’s presenting problems, the supervisor also needs to conceptualise the supervisee’s learning, any difficulties within therapy (Liese and Alford, 1998) and challenges within the SR. Questions that can help inform a supervisory formulation include: what is the supervisee’s preferred learning style (reflective, experiential, conceptual, active), and how can the supervisor best facilitate the supervisee’s use of the full learning cycle? What are appropriate learning goals for the supervisee that fall within their zone of proximal development? What is hampering their work with their clients? Do they hold particular beliefs and assumptions which impact on their work as a therapist? Is the SR working well and is the supervisee able to bring difficult issues or dilemmas to supervision? There may be problems that arise in the SR which need to be attended to (Safran and Muran, 2001). Such problems are common and can have negative consequences, so attending to and formulating any strains in the SR is important. Negative events in supervision most commonly reported concern the SR (e.g. personality conflicts, poor communication, a critical and judgmental supervisor; Ramos-Sanchez et al., 2002). Research indicates that supervisees prefer their supervisors to take responsibility for identifying and addressing any difficulties in the SR (Gray et al., 2001, Borsay, 2012). The evidence suggests that if supervisors ignore or mishandle conflict in the SR, this can lead to harmful and negative events in supervision (Gray et al., 2001, Nelson and Friedlander, 2001). Grant et al. (2012) found that experienced supervisors mainly used strategies such as empathy and reflection to manage difficulties. These interventions involved conceptualising and understanding various processes in the SR and monitoring what was happening. In a grounded theory study of supervisors who had experienced problems in their SRs with supervisees in training, Clohessy (2008) reported that after supervisors noticed a problem, they gathered more information about the issue (e.g. through checking things out tentatively with the supervisee, reflecting on the problem in their own supervision). Formulating and making sense of the difficulties was an essential part of the process of resolving problems. As these were training relationships, time was also important – noticing problems early so that they could be resolved before the SR ended. Supervisor’s continued investment in the SR, the supervisee’s openness to learning and collaboration were highlighted as important aspects of successful resolution of difficulties. Problems in these SRs were difficult to resolve if a supervisor became aware of a strain in the relationship, but was unable to gather additional information to formulate this (e.g. if the supervisee was not open about personal stressors). Additionally, if supervisors’ attempts at intervention were unsuccessful and the supervisee was

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Figure 16.2  Resolving problems in the SR.

perceived not to be open to feedback and learning, supervisors tended to stop investing in the SR. This process is summarised in Figure 16.2. The following example demonstrates how formulation at multiple levels can help make sense of a supervision dilemma.

Formulation in supervision: Vignette Anne (supervisor) is an experienced clinician who is new to supervision. She has positive experiences of being supervised herself, and as a result of this has expectations about what it means to be a good supervisor. She works in a busy trauma service, with a long waiting list and pressure to see clients within a set timeframe. Jane (supervisee) is a CBT therapist looking to build her CBT skills in a trauma service. She has limited experience in this area and is somewhat anxious. She experienced her previous supervisor as somewhat critical with high expectations. Jane’s client is a woman in her 40s who recently started a new relationship after a 10-year history of domestic violence. She is experiencing symptoms of PTSD and depression, is highly avoidant of emotions and finds it difficult to trust others. Jane is worried about exploring her client’s experiences of trauma in case she makes things worse for her. She has been unable to be open with her supervisor about this. Jane and Anne had a brief discussion during their first supervision session about the practicalities of supervision (frequency, duration, etc.), but spent little time on their mutual expectations such as how they would give each other feedback, Jane’s goals or their past experiences of supervision. Fairly quickly in their initial meeting, Jane began to talk about her clinical work. During the subsequent 2–3 supervision

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sessions, a pattern emerged whereby Jane described each of her clinical sessions in detail. She was unable to pinpoint any supervision questions, and despite repeated requests from Anne, did not bring along any therapy tapes. Supervision was ­unfocused and it became apparent that Jane was feeling anxious and overwhelmed. Anne started to feel frustrated in her supervision sessions with Jane. She felt that she had an insufficient grasp of the client’s difficulties and little in the way of a formulation. She was concerned that her supervision was not good enough as she saw little improvement in Jane’s anxiety. She was also aware of the pressures on the service and was concerned that Jane’s sessions were not progressing as she would have expected. Anne used her own supervision to explore these issues. She explored her responses to Jane and identified some of her beliefs, particularly ‘in order to supervise well, I must have all the answers.’ She reflected that her experience of ‘good’ supervision related to her supervisor’s ability to create a safe SR where she felt supported to bring any concerns. She hypothesised that the SR may not feel safe enough for Jane to share her clinical work, making it difficult to develop a clinical formulation. Her reflections in her own supervision allowed her to consider how she might raise these issues with Jane the next time they met. In their next supervision, Anne suggested that they allocate some time to reviewing supervision. She invited Jane to consider how she’d found supervision, whether she had been getting what she needed, as well as to reflect on her experience of trauma work in general. Jane was able to say that she was finding the work very difficult and was overwhelmed by her client’s multiple traumas and the difficulty in establishing trust in the therapeutic relationship. Jane was able to share that she had found it difficult to assess her client because she didn’t want to upset her. Anne also explored Jane’s feelings about bringing tapes to supervision and they were able to discuss this. Anne had the opportunity to reassure Jane and encouraged her to bring her concerns to supervision so that she could be supported in her learning. They were able to have a conversation about Jane’s preferred learning style, as well as her previous experiences in supervision, and the impact this had had on Jane’s confidence as a therapist and a supervisee. This enabled them to set specific goals for Jane’s identified learning needs ‘to build her CBT skills in trauma’. These included: To familiarise herself with the cognitive model of PTSD, and to use this in formulating her client’s difficulties, to increase her skills and confidence in talking about her client’s experiences of trauma, to regularly share her work on tape in supervision and to prepare for supervision by bringing a specific question. They discussed how and when they might review this new approach to supervision. Anne continued to attend to her SR with Jane to monitor its quality, and to regularly check in with her that their supervision was on the right track. Commentary Anne formulated at a number of levels and drew on models of supervision and the SR as well as CBT. Her ability to raise her concerns safely within her own supervision enabled her to do this.

Clinical supervision  365

Anne’s past experiences of supervision influenced the development of high standards for herself as a supervisor, and particular beliefs about what a good supervisor should be (‘I must provide all the answers’). Her work context and pressures on the service also influenced her experience in supervision. These contextual factors influenced how she felt in her supervision with Jane, and her ability to invest effectively in the SR (by, for example, spending time developing a supervision contract and assessing Jane’s learning needs). Jane was also influenced by her past experiences, which led to her developing beliefs about herself as a supervisee and therapist (‘if I share my work with my supervisor, I will be criticised. If my client is upset in session I am a bad therapist’). This had an impact on her ability to be open and honest about her work, and her ability to be productive in a busy service. The characteristics of her client and the difficulties in the therapeutic relationship also played a part in the problems she experienced in supervision. These multiple contextual factors influenced the development of an SR that was characterised by a lack of safety, openness and a mutual feeling of anxiety and being overwhelmed. Anne used her own supervision to gather more information, and to consider the various influences on the difficulties in supervision with Jane. The process of formulation was important. Anne hypothesised that the mutual high expectations within the SR increased anxiety and a sense that neither felt quite good enough and, as a result of this, both set unachievable standards for their work. These hypotheses were clarified by inviting Jane to reflect on her experience of supervision, some of the beliefs she held about herself as a therapist and the impact of her past experience as a supervisee. Formulating in this way enabled Anne to be empathic towards Jane and increased collaboration within the SR. These conversations enabled Ann and Jane to establish a meaningful supervision contract that allowed them to clarify mutual expectations, invite and give each other feedback and review supervision so that concerns could be raised. Consequently, they were able to create a safe space for discussion of clinical and supervision dilemmas.

Conclusion This chapter has provided an overview of CS and reviewed current literature. It is clear that the research on the training and supervision of psychological therapists has lagged behind the evidence on psychological interventions. This is concerning, as all psychological therapists receive CS as part of their initial training and ongoing professional development and it is endemic to clinical research trials, but not carefully measured or reported. There is still not sufficient evidence to categorically state that CS has an impact on clinical outcomes (although there are some promising indications of this). However, there is evidence to suggest that the SR has an impact on supervisee learning and both supervisee and supervisor experiences of, and satisfaction with, supervision. The best available evidence from the general and specific CBT supervision literature suggests that the key skills of effective supervision include relationship building, contracting, agenda setting, information sharing, feedback and formulation. Supervisors formulate at a number of levels – to understand the supervisee’s learning needs and how best

366  Helen Beinart and Sue Clohessy

to facilitate this learning, to enable the supervisee to formulate their client’s problems, as well as any difficulties encountered in therapy. Formulation skills are equally relevant to supervision dilemmas, and supervisors can helpfully apply them to problems in the SR so that such problems can be understood and resolved successfully. Models of supervision, the SR and adult learning can helpfully be applied to supervision to support supervisee learning and development, enhance the SR and provide an improved clinical service.

References Armstrong, P. V. and Freeston, M. H. (2006). Conceptualising and formulating cognitive therapy supervision. In N. Tarrier (ed.) Case Formulation in Cognitive Behaviour Therapy: The Treatment of Challenging and Complex Cases. London: Routledge. Bahrick, A. (1990). Role induction for counsellor trainees: Effects on the supervisory working alliance. Dissertation Abstracts International 51: 1484B. Bambling, M. (2014). Creating positive outcomes in clinical supervision. In E. Watkins and D. Milne (eds) The Wiley International Handbook of Clinical Supervision. Oxford: Wiley-Blackwell. Bambling, M. et al. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research 16: 317–31. Beinart, H. (2012). Models of supervision and the supervisory relationship. In I. Fleming and L. Steen (eds) Supervision and Clinical Psychology: Theory, Practice and Perspectives. Hove: Routledge. Beinart, H. and Clohessy, S. (2009). Supervision. In H. Beinart et al. (eds) Clinical Psychology in Practice. Oxford: British Psychological Society and Blackwell. Bernard, J. M. and Goodyear, R. K. (2014). Fundamentals of Clinical Supervision (5th ed.). Upper Saddle River, NJ: Pearson. Blackburn, I.-M. et al. (2001). The revised cognitive therapy scale (CTS-R) psychometric properties. Behavioural and Cognitive Psychotherapy 29: 431–46. Bordin, E. S. (1983). A working alliance model of supervision. Counselling Psychologist 11: 35–42. Borsay, C. (2012). Understanding the Supervisory Relationship and What Happens When Difficulties Occur. Unpublished doctoral thesis, University of Oxford. Bradshaw, T. et al. (2007). Does structured clinical supervision during psychosocial intervention education enhance outcome for mental health nurses and the service users they work with? Journal of Psychiatric and Mental Health Nursing 14: 4–12. Callahan, J. et al. (2009). Exploring the contribution of supervisors to intervention outcomes. Training and Education in Professional Psychology 3: 72–77. Cliffe, T. (2013). Development and Validation of a Short-Version of the Supervisory Relationship Questionnaire (S-SRQ). Unpublished doctoral thesis, University of Oxford. Clohessy, S. (2008). Supervisors’ Perspectives on Their Supervisory Relationships: A Qualitative Study. Unpublished doctoral thesis, University of Hull. Dobson, K. S. and Shaw, B. F. (1993). The training of cognitive therapists: What have we learned from treatment manuals? Psychotherapy 30: 673–80. Ellis, M. and Ladany, N. (1997). Inferences concerning supervisees and clients in clinical supervision: An integrative review. In C. E. Watkins (ed.) Handbook of Psychotherapy Supervision. New York: Wiley.

Clinical supervision  367 Falender, C. and Shafranske, E. (2004). Clinical Supervision: A Competency-Based Approach. Washington: American Psychological Association. Falender, C. and Shafranske, E. (2012). Getting the Most Out of Clinical Supervision: A Guide for Practicum Students and Interns. Washington: American Psychological Association. Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Gordon, P. K. (2012). Ten steps to cognitive behaviour supervision. Cognitive Behaviour Therapist 5: 71–82. Grant, J. and Schofield, M. J. (2012). Managing difficulties in supervision: Supervisors’ perspectives. Journal of Counseling Psychology 59: 528–41. Gray, L. et al. (2001). Psychotherapy trainees’ experience of counter-productive events in supervision. Journal of Counseling Psychology 48: 371–83. Hawkins, P. and Shohet, R. (2013). Supervision in the Helping Professions (3rd ed.). Buckingham: Open University Press. Heckman-Stone, C. (2004). Trainee preferences for feedback and evaluation in clinical supervision. Clinical Supervisor 22: 21–33. Hess, A. K. (2008). Psychotherapy supervision: A conceptual review. In A. K. Hess et al. (eds) Psychotherapy Supervision: Theory, Research and Practice (2nd ed.). New York: Wiley. Hoffman, M. A. et al. (2005). Supervisor perspective on the process and outcome of giving easy, difficult, or no feedback to supervisees. Journal of Counseling Psychology 52: 3–13. Holloway, E. L. (1995). Clinical Supervision: A Systems Approach. Thousand Oaks, CA: Sage. Hughes, J. (2012). Practical aspects of supervision: All you ever wanted to know but were too afraid to ask. In I. Fleming and L. Steen (eds) Supervision and Clinical Psychology: Theory, Practice and Perspectives. Hove: Routledge. Inman, A. (2006). Supervisor multicultural competence and its relation to supervisory process and outcome. Journal of Marital and Family Therapy 32: 73–85. James, I. A. et al. (2006). Conducting successful supervision: Novel elements towards an integrative approach. Behavioural and Cognitive Psychotherapy 35: 191–200. Johnstone, L. and Dallos, R. (eds) (2013). Formulation in Psychology and Psychotherapy: Making Sense of Peoples’ Problems (2nd ed.). London: Routledge. Kennerley, H. et al. (2010). Supervisor Competence Scale. In M. Mueller et al. (eds) Oxford Guide to Surviving as a CBT Therapist (Oxford Guides to Cognitive Behavioural Therapy). Oxford: Oxford University Press. Kolb, D. (1984). Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall. Ladany, N. et al. (1999). The supervisory working alliance, trainee self-efficacy and satisfaction. Journal of Counseling and Development 77: 447–55. Ladany, N. et al. (2001). Supervisory style: Its relation to the supervisory working alliance and supervisor self-disclosure. Counselor Education and Supervision 40: 263–75. Ladany, N. and Friedlander, M. L. (1995). The relationship between the supervisory working alliance and trainees’ experience of role conflict and role ambiguity. Counselor Education and Supervision 34: 220–31. Ladany, N. and Lehrman-Waterman, D. (1999). The content and frequency of supervisor self-disclosure and the relationship to supervisory working alliance and satisfaction with supervision. Counselor Education and Supervision 38: 143–60. Lehrman-Waterman, D. and Ladany, N. (2001). Development and validation of the evaluation process within supervision inventory. Journal of Counseling Psychology 48: 168–77.

368  Helen Beinart and Sue Clohessy Liese, B. S. and Alford, B. A. (1998). Recent advances in cognitive therapy supervision. Journal of Cognitive Therapy: An International Quarterly 12: 91–94. Liese, B. S. and Beck, J. S. (1997). Cognitive therapy supervision. In C. E. Watkins (ed.) Handbook of Psychotherapy Supervision. New York: Wiley. Mannix, K. A. et al. (2006). Effectiveness of brief training in cognitive behaviour therapy techniques for palliative care practitioners. Palliative Medicine 20: 579–84. Milne, D. L. (2007). An empirical definition of clinical supervision. British Journal of Clinical Psychology 46: 437–47. Milne, D. L. (2009). Evidence-Based Clinical Supervision. Chichester: BPS Blackwell. Milne, D. L. and Dunkerley, C. (2010). Evidence-based supervision guidelines. Unpublished manuscript. Milne, D. L. et al. (2008). Zooming in on clinical supervision. Behavioural and Cognitive Psychotherapy 36: 619–24. Milne, D. L. et al. (2011). SAGE: Preliminary evaluation of an instrument for evaluating CBT supervision. Cognitive Behaviour Therapist 4: 123–38. Milne, D. L. and James, I. (2000). A systematic review of effective cognitive-behavioural supervision. British Journal of Clinical Psychology 39: 111–27. Nelson, M. L. and Friedlander, M. L. (2001). A close look at conflictual supervisory relationships: The trainee’s perspective. Journal of Counseling Psychology 48: 384–95. Newman, C. F. (2010). Competency in conducting cognitive-behavioural therapy: Foundational, functional and supervisory aspects. Professional Psychology: Research and Practice 47: 12–19. O’Donovan, A. and Kavanagh, D. (2014). Measuring competence in supervisees and supervisors: Satisfaction and related reactions in supervision. In E. Watkins and D. Milne (eds) The Wiley International Handbook of Clinical Supervision. Oxford: Wiley-Blackwell. Olds, K. and Hawkins, R. (2014). Precursors to measuring outcomes in clinical supervision. Training and education in professional psychology 8: 158–64. Padesky, C.A. (1996). Developing cognitive therapist competency: Teaching and supervision models. In P. M. Salkovskis (ed.) Frontiers of Cognitive Therapy. London: Guilford Press. Palomo, M. et al. (2010). Development and validation of the supervisory relationship questionnaire (SRQ) in UK trainee clinical psychologists. British Journal of Clinical Psychology 49: 131–49. Pearce, N. et al. (2013). Development and validation of the Supervisory Relationship Measure: A self-report questionnaire for use with supervisors. British Journal of Clinical Psychology 52: 249–68. Pretorius, W. M. (2006). Cognitive behavioural therapy supervision: Recommended practice. Behavioural and Cognitive Psychotherapy 34: 413–20. Ramos-Sanchez, L. et al. (2002). Negative supervisory events: Effects on supervision satisfaction and supervisory alliance. Professional Psychology: Research and Practice 33: 197–202. Reiser, R. and Milne, D. L. (2012). Supervising cognitive behavioural psychotherapy: Pressing needs, impressing possibilities. Journal of Contemporary Psychotherapy 42: 161–71. Rodolfa, E. et al. (2005). A cube model for competency development: Implications for psychology educators and regulators. Professional Psychology: Research and Practice 36: 347–54. Rønnestad, M. H. and Skovholt, T. M. (1993). Supervision of beginning and advanced graduate students of counseling and psychotherapy. Journal of Counseling and Development 71: 396–405.

Clinical supervision  369 Roth, A. et al. (2010). Therapist training and supervision in CBT in major trials for depression and anxiety. Behavioural and Cognitive Psychotherapy 38: 291–302. Roth, A. and Pilling, S. (2007). The Competencies Required to Deliver Effective Cognitive and Behavioural Therapy for People With Depression and Anxiety Disorders. London: Department of Health. Roth, A. and Pilling, S. (2008a). The Competence Framework for the Supervision of Psychological Therapies. Retrieved from http://www.ucl.ac.uk/clinical-psychology/CORE/ supervision_framework.htm Roth, A. and Pilling, S. (2008b). Using an evidence-based methodology to identify the competencies required to deliver effective cognitive behaviour therapy for depression and anxiety disorders. Behavioural and Cognitive Psychotherapy 36: 129–47. Safran, J. D. and Muran, J. C. (2001). A relational approach to training and supervision in cognitive psychotherapy. Journal of Cognitive Psychotherapy 15: 3–15. Scaife, J. (2009). Supervision in Clinical Practice: A Practitioner’s Guide (2nd ed.). London: Routledge. Tarrier, N. and Calam, R. (2002). New developments in cognitive behavioural formulation: epidemiological, systemic and behavioural context. Behavioural and Cognitive Psychotherapy 30: 311–28. Townend, T. et al. (2002). Clinical supervision in practice: a survey of UK cognitive behavioural psychotherapists accredited by the BABCP. Behavioural and Cognitive Psychotherapy 30: 485–500. Townend, T. et al. (2007, July 11–14). Supervision Practices of UK Cognitive-Behavioural Psychotherapists 2001 and 2006. Paper presented at the 5th World Congress of Behavioural and Cognitive Therapies, Barcelona. Turpin, G. and Wheeler, S. (2011). IAPT Supervision Guidance. Retrieved from http:// www.iapt.nhs.uk/silo/files/iapt-supervision-guidance-revised-march-2011.pdf Vygotsky, L. S. (1978). Mind in Society: The Development of Higher Psychological Processes. Cambridge, MA: Harvard University Press. Wainwright, N. (2010). The Development of the Leeds Alliance in Supervision Scale (LASS): A Brief Sessional Measure of the Supervisory Alliance. Unpublished doctoral thesis, University of Leeds. Watkins, C. E. (2014). The supervisory alliance: A half century of theory, practice and research in critical perspective. American Journal of Psychotherapy 68: 19–55. Webb, A. and Wheeler, S. (1998). How honest do counsellors dare to be in the supervisory relationship? An exploratory study. British Journal of Guidance and Counselling 26: 509–24. Wheeler, S. et al. (2011). Practice-based supervision research: A network of researchers using a common toolkit. Counselling and Psychotherapy Research 11: 88–96.

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Index

abandonment experiences 278, 293, 295 abuse, childhood 67, 125, 149 – 50, 152, 160, 162, 166, 169, 245, 295; emotional 152; history of 57; human rights 324, 327; physical 152, 169, 231, 295; psychological 295; racial 156; verbal 231; see also sexual abuse; substance abuse Acceptance and Commitment Therapy (ACT) 26, 29, 43 – 4, 119; acceptance 46 – 7; being present 47 – 8; and clear values 45 – 6; self as context 46; use of cognitive defusion 48; use of valued action 48 – 9 action: action tendencies 224; committed 44; coordinating 59; creative 42; effective 43; plan for 183, 318; thoughts becoming 116; valued 48 – 9; see also EBAC cycle; thought action fusion active learning methods 357 adversity: and asylum seekers 332, 334, 346 – 7; childhood 169, 178, 245, 326; family 299; see also trauma adversity-activated development (AAD) 332 affect: absence/suppression of 123; active 127, 130, 132, 136; avoidance of 157; (in)tolerance of 153; managing 338; negative 67, 121, 125, 338; positive 65 – 6, 121, 125, 333; regulation of 64, 68, 72, 123, 125, 143, 152, 154, 160; “soothing-contentment” positive 66 affiliative relating 68 – 9, 77, 82 affiliative-soothing system 67 – 8 African Americans, in therapy 24 – 5 agenda setting, in clinical supervision 359 – 60

aggression 19, 64, 231 alcohol abuse/dependence treatment 19 – 21 allogenic stem cell transplants 285 Altman Self Rating Mania Scale (ASRM) 198 altruism 57, 59 American Psychiatric Association Practice Guideline for the Treatment of Patients with Bipolar Disorder 203 amygdala 68, 125, 146 amyotrophic lateral sclerosis (ALS) 285 analysis: behavioural 1, 5, 18, 43; developmental 2; evolutionary functional 53 – 4; functional 2, 17, 20 – 1, 23 – 4, 28, 52, 157, 227 – 9; historical 227; levels of 4; meta- 21, 172, 246, 270; needs 333; motivational 2, 62; of problem situation 2, 3, 18; systemic 7; topographical 227 – 8 anchoring heuristic 2 – 3 anhedonia 65 anorexia nervosa (AN) 239; CBT models 241; DSM classification of 240; risk factors for 245; “severe and enduring” 242; subtypes of 240; see also eating disorders anorexia nervosa treatment: adaptations 241 – 2; alternatives for 241 – 2; CBT as 241 – 4; CBT and available evidence 242 – 3; focal psychodynamic therapy 242; guide to 241 – 2; integrating working with carers 243; interpersonal therapy (IPT) 242; Maudsley Model of Anorexia Nervosa in Adults (MANTRA) 243 – 4, 255; patient’s lack of emotion and detail 260; Specialist

372  Index Supportive Clinical Management (SSCM) 242, 243 ANOVA testing 18 antecedents 5, 7, 39, 40, 42, 176 – 7, 222, 229, 286 anti-psychotic medications 171 – 2; resistance to 171; side effects of 171 anxiety 52, 67, 69, 244, 285, 288; in asylum seekers 329; see also anxiety disorders anxiety disorder models 93 – 4; panic disorder 94 – 105 anxiety disorders 222, 297; behavioural assessment tests for 114; and bulimia nervosa 240; case formulations for 117; CBT treatment for 211; fears of 145; formulation for 90 – 1; general schema model of 91; see also anxiety; anxiety disorder treatments Anxiety Disorders Interview Schedule 92 anxiety disorder treatments 114 – 15; CBT 115; cognitive and metacognitive 115; modification treatment 115; trials 19; verbal re-attribution strategies 115, 116; worry postponement experiment 116 anxiety sensitivity 18, 25 – 7, 28 anxiolytic substance dependence 18 assessment: of anxiety presentation 93; of asylum seekers 335 – 8, 345; behavioural tests (BATs) 114; of bipolar disorder 189, 196 – 8, 205, 212; cognitive behavioural 285 – 8; idiographic 15; of psychotic symptoms 176 – 9, 182; risk 271; in standardised protocol therapy 15; of suicidal behaviour 272, 274 – 5; by therapist/clinician 14 – 15, 17, 19 – 21, 28, 39 – 40, 127, 129 – 30, 156, 167, 222, 229 – 30, 236, 253, 271, 284, 295; use of technology for 10; of vulnerabilities 273 Asylum Aid 322 asylum seekers: and the asylum-seeking process 323; demographics of 324 – 5; formulations for 328 – 33; histories of 337 – 8; legal context 322, 324; psychological distress of 325; social support for 325 – 6; in the United Kingdom 322 – 7; use of cognitive behaviour therapies with 322, 327 – 9 asylum seeker treatment/interventions: and assessment 335 – 8, 345; case example “Claudine” 344 – 7; ending therapy 342; and engagement 335 – 6, 344 – 5; Herman’s process of recovery 336,

339 – 40, 342 – 3; psycho-education 340, 341, 345 – 6; psychologists as human rights practitioners 333; reconnection 346 – 7; reflexive practice 334; working with interpreters 334 – 5 attachment: anxious-ambivalent 71; avoidant-dismissive 71; disorganised 70, 71; insecure 67; and PTSD 152; and safeness 67 – 9; theory of 56 attention deficit disorder treatment trials 19 attention training technique (ATT) 275, 279 attentional control training 119 attentional focus 296 – 7 attentional processes, and suicidal behaviour 272 attributions, causal 333 autism spectrum disorders 56 automatic thoughts 3, 15, 52, 287, 290, 293 – 4, 297; negative 90, 99, 100, 101, 120, 126, 128, 132, 135, 136, 253, 289 autonomy 61, 190, 194, 196 – 7, 293, 330, 335 availability heuristic 2 – 3 avoidance 40, 143, 144, 288, 297, 346; cognitive, affective and behavioural 122 – 3; experiential 29, 82; experiments in 38 – 9 Beck Anxiety Inventory 22 Beck Depression Inventory (BDI; BDI-II) 16, 22, 23, 42, 130, 135, 198 Beck Hopelessness Scale (BHS) 198 Beckian cognitive therapy for depression 15, 98, 120, 121, 123, 127 – 8, 134, 136, 285 behaviour(s) 4, 40; analysis of 1, 5; with cognition and mood 7; emotion-driven 224 – 6; interpersonal and social 7; prosocial 57; violent 173, 226; see also behavioural activation; behavioural formulation behavioural activation (BA) 119; as treatment for depression 120 Behavioural Activation System (BAS) sensitivity 190 behavioural assessment tests (BATs) 114 behavioural avoidance 123 behavioural experiments 3 behavioural formulation 40 – 1; and the ACT model 43 – 50; and contextualism 41 – 3 behavioural responses 273

Index  373 being present 47 – 8 beliefs: cultural 345; negative 102, 105 – 6; positive vs. negative 91 bias(es): attentional 69, 269; attribution 203; autobiographical memory 121, 123; catastrophising 275; cognitive 3, 81, 329; confirmatory 3, 174, 179; content 127; hindsight 2; information processing 121, 268, 272; memory 125, 127, 132, 139, 269; negativity/negative 65, 73, 79, 121 – 3, 131, 275; problem solving 269; reasoning 269 binge eating 152, 240, 248, 250 – 1, 258 biological equipment 2 biological mechanisms 333 biopsychosocial approach 52 – 3; model of 75 – 6; see also evolutionary approach bipolar disorder(s) 10; and ambivalence toward treatment 193 – 4; assessment and formulation 196 – 201; and circadian rhythm disruption 190 – 1; clinical example “Bill” 205; clinical example “Laura” 197 – 8; and cognitive behavioural therapy 212; coping skills 199, 209 – 10; coping styles 192; diagnosis of 194; early warning signs 199; emotions and 191 – 2; and the family 189, 193, 211; flexible approach to therapy 194 – 5; general treatment strategy 196; instability heuristic for understanding 190 – 3; key features of intervention 201 – 11; life span issues 211 – 12; and mood changes 201; in older age 211 – 12; prevalence and severity 188 – 9; psychosocial factors 189 – 90; research in CBT treatment 195; and sleep routines 190 – 1, 196, 203; stress-vulnerability issues 189 – 91; therapy structure for 195; Type I vs. Type II 188 Bipolar Disorder Guideline (published by NICE) 189 bipolar disorder treatment/interventions: challenging positive thoughts 205, 207; coping with early warning signs (prodromes) 208 – 9; delaying tactic 207 – 8; differing from other disorders 193 – 5; final sessions 208 – 11; identifying early, middle and late early warning signs 209; information/ development of therapeutic alliance 202; initial sessions 202; intermediate sessions 202 – 8; long-term issues

210 – 11; medications as 188 – 9; mood monitoring 203; pairing early warning signs with coping skills 209; reframing 207; socialising to therapy/goal setting 202; therapy structure 195 – 6; understanding the relationship between mood and activity 203 – 4; working with unrealistic positive ideas 207 Bipolar Recovery Questionnaire (BRQ) 199 borderline personality disorder 68; and bulimia nervosa 240, 256; communication skills training example 225; treatment for 221; and violent behaviour 226; see also personality disorder(s); personality disorder treatment Boulder model of training 1 breast cancer 285 Brief Problem Checklist 20 Brief Quality of Life in Bipolar Disorder (QoL.BD) 199 British Association of Behavioural and Cognitive Psychotherapies (BABCP) 352 British Psychological Society 306 Broad Minded Affective Coping (BMAC) technique 275, 277, 279 bulimia nervosa (BN) 239; cognitive behaviour therapy models 240; DSM classification of 240; risk factors for 245; subtypes of 240; treatment guide 240; see also eating disorders bulimia nervosa treatment: CBT and available evidence 241; CBT-Ef and CBT-Eb 241; patient’s stories and emotions 260; trials 17 burnout 342 cancer 284 – 5 cancer patients 330 cannabis use 183 – 4, 311 – 12, 314, 316 carbamazepine 188 care giving mentalities 57 – 9 carers: negative behaviours of 304 – 5; positive behaviours of 305; see also formulations with carers care seeking mentalities 57 – 8 care system, influence and interactions 294; see also carers; formulations with carers case conceptualisation for complex PTSD 152 – 3; case 1 (rape experience)

374  Index 154 – 7; case 2 (death of colleague) 159; case conceptualisation 160, 161; case examples 154 – 5; conclusions 162 – 3; phased-based treatment approach 153 – 4, 161; salient premorbid features 156, 159; treatment plan 157 – 9, 160 – 2 case conceptualisation for fear-based PTSD 148; challenges for treatment 149 – 50; co-morbidity 151 – 2; complex emotional responses 150 – 1; event characteristics 149 – 50; treatment implications 148 – 9; working with loss of meaning 151 case formulation: advantages of 9 – 10; based on diagnosis or symptoms 16 – 17; based on psychological mechanisms 17 – 19; as collaborative 5 – 6, 10, 14; defined 4; for generalised anxiety disorder 111 – 14; influence on treatment 25; information necessary for 14; models for 28; for panic disorder 96 – 8; process of 5 – 6; for social anxiety 107 – 9; social context of 9; for social phobia 101 – 4; for suicidal individuals 266; utility of 6 case formulation-driven treatment: advantages of 28 – 9; changing formulation 31 – 2; implementation of 29 – 33; including feedback 19 – 21; single case studies 32 case formulation for depression: (sessions 1 – 3) the assessment process 130 – 1; (sessions 17 – 25) interventions 136 – 7; (sessions 25 – 30) memory work, conditional beliefs, relapse prevention 137 – 8; (sessions 4 – 5) problem and target setting 131; (sessions 5 – 16) CT interventions targeting maintenance factors 131 – 2; Jane’s case 128 – 9; maintenance formulation 132 – 3; relapse prevention plan 138; relevant cognitive themes 129; session plan for therapy contract 130; time needed for 139; using activity scheduling and graded task assignment 134 – 6 catastrophising 275, 296, 300 causal attributions 298 – 300, 333 CBT see Cognitive Behaviour Therapy Child Behavior Checklist (CBCL) 20 children: abuse of 67, 125, 149 – 50, 152, 160, 162, 166, 169, 245, 295; adversity in childhood 178; of refugees 325; school-refusing 23

Children’s Act (1989) 333 circadian rhythms, disruption in 190 – 1 classical conditioning 38, 41, 69 classification systems 2 – 4 clinical health psychology, and physical health problems 284 clinical supervision (CS) 352; and agenda setting 359 – 60; in CBT 356; collaboration in 359; competency movement in 357; and contracting 359; feedback in 360 – 1; formulation in 361 – 3; information sharing in 360; key tasks 358 – 63, 366; management of difficulties 362 – 3; see also supervision; supervisory relationship cognition(s): with behavior and mood 7; distorted 29; as level of analysis 4; and metacognition 97 – 8; see also metacognition cognitive behavioural assessment 285 – 6; clinical procedures 289 – 90; comprehensive description of all dimensions 288; cross-sectional 290 – 1; descriptive level 287; formulation process 286 – 7; formulation structure 286; imagery 290; isolate and describe all avoidance 288; longitudinal 292 – 5; monitoring physical and psychological dimensions simultaneously 289; realistic negative automatic thoughts 289; summary of descriptive-level focus 290 cognitive-behavioural factors, and physical health problems 284 Cognitive Behaviour Therapy: for asylum seekers 327 – 9; case-formulation driven 14 – 15; clinical supervision in 352; controlled trials comparing formulationguided and protocol-guided 15 – 21; enhanced broad form (CBT-Eb) 241; enhanced focused form (CBT-Ef) 241; enhanced variations of (CBT-E) 241, 242; guided by a standard protocol 15; implications for research, training, and clinical practice 27 – 33; increased use of 10; perspective on panic 92 – 3; in physical health, conceptualisation checklist 300; predictors, moderators and mediators 24 – 6; and shared formulations 307; single case studies 23 – 4; transdiagnostic (“third wave”) 332 – 3; trauma-focused 143, 161; uncontrolled trials 22 – 3; see also cognitive therapy

Index  375 cognitive behaviour therapy supervision: studies of 358; theory and evidence 356 – 8 cognitive behaviour treatments: for anorexia nervosa 241 – 2, 244; for anxiety disorders 22, 117, 211; based on hypotheses 4; for bipolar disorders 195, 212; for bulimia nervosa 241, 244; for depression 22, 136, 138; for eating disorders 239 – 40, 246 – 51; evidence for use of 172; formulationguided 15 – 19; formulation-guided with feedback 19 – 21; for personality disorder 219, 221; for psychosis 173 – 5, 179 – 83; for psychosis, case example 183 – 4; randomised control trials 15 – 21; reasons for development of 171; for schizophrenia with 166; standardised protocol 15; uncontrolled trials 22 – 3 cognitive competencies 56 cognitive defusion 48 cognitive dissonance 233 – 4 cognitive model of persistent PTSC 145 – 6 cognitive revolution 4 cognitive therapy (CT): for bipolar disorders 195 – 6; and family interactions 292; in interventions for depression 125; rumination-focused 119; for suicidal behaviour 270 – 1; use to treat depression 119; widespread application of 284 – 8; see also Beckian cognitive therapy for depression; Cognitive Behaviour Therapy cognitive therapy for command hallucinations (CTCH) 182 Cognitive Therapy in Practice: A Case Formulation Approach (Persons) 5 Cognitive Therapy Scale-Revised 357 collaboration: in clinical supervision 354, 359, 361 – 2, 365; with patients/clients 120, 180, 335 command hallucinations 171, 182 communication: in clinical supervision 360; and eating disorders 249 – 50 comorbidities: multiple 29 – 30; with PTSD 151 – 2; with schizophrenia 169 – 71 compassion focused therapy 78, 119, 160, 221 competencies: in clinical supervision 353, 356 – 7, 359; cognitive 72 – 4; meta- 358; in research 139; social mentality 55 – 6, 59; for soothing 77 competitive mentalities 58, 60 – 1

complex posttraumatic stress disorder (PTSD) 162 – 3, 329; conceptualisation in 143, 148, 150, 152, 156, 157, 160, 162; distinguishing features of 152 – 3; phased-based treatment for 143; see also posttraumatic stress disorder conceptualisation: alternative 2; of anxiety disorders 297; with asylum seekers 338; with carers 306; case 77; in clinical supervision 353 – 4, 356 – 7; in complex PTSD 143, 148, 150, 152, 156, 157, 160, 162; of dysfunctional system 7; in eating disorders 239, 246; medical 1; in physical health problems 285 – 6, 293 – 4, 300; positive 9; in suicidal behaviour 268, 275 conditioning, operant and classical 38 conduct disorder treatment trials 19 conduct problems, treatment for 19 conflicts 60 – 1; motivational 61 consultation, as supervisory task 352 contextualism 41 – 3 contracting, in clinical supervision 359 Control Enhancement Training, Primary and Secondary 19 cooperative mentalities 58 – 9 coping: with adversity 344, 347; with anxiety disorders 91, 94, 95, 109 – 10; with early warning signs 196, 199, 208 – 11; with emotions 64, 77; with mood fluctuation 183, 190, 195; not coping 62, 111, 249; by patients 309, 312 – 15, 317, 319; with physical ill health 292 – 3, 297 – 9; with psychosis 179; with suicidal thoughts and feelings 270, 273, 275 – 6, 279; training for 167; see also Broad Minded Affective Coping (BMAC) technique; coping strategies, skills and techniques Coping Cat 19 coping strategies, skills and techniques: active 331; adaptive 21, 181; avoidant 122, 125, 192, 299; for bipolar disorder 209 – 10, 212; confrontative 298; dissociation 163; effective 181; emotional 298; escape-avoidance 298; external and internal 82; individual 7; positive 179, 201; problem-focused 298; for refugees 327, 331, 337, 340 – 2, 344; ruminative 193; successful 179, 273 Coping with Prodromes Interview 199 cry of pain (CoP) suicide model 266 – 7 cultural change 306

376  Index culturally adapted cognitive behaviour therapy (CA-CBT) 333 culture, and psychiatric diagnoses 14, 32, 52 – 3, 63 – 4, 75, 335, 337 current situation, appraisals of 272 decentering 126 decision-making 20, 139, 233, 296 – 7, 337; and anorexia 253, 254; clinical 2 – 3, 31 – 2 defeat states 65 defences, activating or deactivating 65 Defiant Children 19 delusions and delusional thinking 166, 173, 177 – 8, 180 – 1, 315 – 17, 337 dementia 306 depersonalisation 26, 310 depression: in ALS patients 285; and anxiety, treatment for 22; among asylum seekers 326 – 7, 329 – 30, 333, 340, 343; and bipolar disorder 188, 190, 192 – 3, 196 – 7, 205, 209, 212; and bulimia nervosa 240; case study “Jane” 128 – 9; case study “Sally” 79; CBT treatment for 16 – 17, 19, 211, 222; chronic and recurrent 119 – 23, 125, 127 – 8, 136, 138 – 9; cognitive science of 120, 121, 123 – 6; cognitive therapy interventions for 15, 125; comorbidity with eating disorders 240, 245, 251 – 3; comorbidity with PTSD 152, 154, 157, 160; diagnosis of 52; maintenance model of 120 – 3, 128 – 9, 133; measures of 22, 25, 42; mindfulness-based cognitive therapy for 43; and physical illness 285; and psychosis 168 – 71; randomised control trials on use of cognitive therapy (CT) for treatment 119; recurrence of 119 – 20; risk factors for 266; and schizophrenia 170; and self-esteem 181; and suicide 178, 266; symptoms of 18, 60, 63, 65, 66 – 7, 121 – 2; treatment for 22, 236, 279, 363; treatment trials 16 – 17; in women 23; see also Beckian cognitive therapy for depression; case formulation for depression depressive rumination 121, 123 – 6, 131 – 2 despair states 65 destabilisation 7 – 9 desynchrony 4 diabetes 52, 54, 76, 284 diagnoses: of anxiety disorders 22, 25, 92 – 3; of bipolar disorder/schizophrenia

167, 169 – 72, 189, 194, 305 – 6; of complex PTSD 152; differential 93; vs. formulation 52; as identification 92; of personality disorder 219 – 22, 225 – 6, 235; of physical health problems 294, 298; psychiatric 1 – 2, 4, 15 – 16, 20, 22; of psychosis 304, 319; of PTSD 143 – 4 dialectical behaviour therapy (DBT) 221 diploma in public service interpreting (DPSI) 334 disorganisation 152 – 3, 160 dissociation 62, 64, 70, 152 – 3, 163, 343 distorted cognitions 29 distress tolerance 59, 247, 255 domestic violence 53, 149 – 50, 329, 363 dorsal vagal parasympathetic nervous system 65 dropout rate, of African Americans 24 – 5 dual representation theory 144, 146 – 7 dysfunction(s): biological 52; cognitive 155; psychological 4, 173 dysfunctional beliefs, assumptions and metacognitions 4, 90 – 1, 105, 174 dysfunctional systems 7 – 8 dysphoria 191 – 3 Early Warning Signs Checklist 199 eating disorders (ED): biological and starvation effects 250; classification of 240; clinical case examples “Jodie” 251 – 3; clinical case examples “Morag” 253 – 6; clinical case examples “Maya” 256 – 60; and core beliefs 246; difficulty treating 239; function of 247 – 8; and intermediate beliefs 246 – 7; and interpersonal functions 249 – 5; options for treatment 239 – 40; risk factors for 244 – 6; as shared family trait 244; triggers for 247; see also anorexia nervosa; bulimia nervosa eating disorder treatment: CBT 252, 255; family-based interventions 252 EBAC (experience-belief-actionconfirmation) cycle 175, 179, 180, 183 e-CBT approaches 10 – 11 ecological conditions, and formulation 75 – 6 e-health services 11 email therapy 17 EMDR 143 emotion(s): avoidance of 240, 248, 266; and bipolar disorder 191 – 3; categories for understanding 63 – 4; control and

Index  377 expression of 247; difficulty recognising and managing 241; and emotional fusion 69 – 70; and emotional memories 79, 81; expressed (EE) 244, 271; in formulation 63 – 4; frequency, duration and intensity of 63; pleasurable 65 – 6; role of 332; safeness 66 – 7; threat 64 – 5; and trauma 70 – 1; types and functions of 64 – 6 emotional disorders, treatment model for 222; see also anxiety disorders; bipolar disorder(s); personality disorder(s) emotional fusion 69 – 70 emotional processing theory 144 – 5 emotion-driven behaviours (EDBs) 224 – 6 empathy 56, 59, 319, 362 endorphins 68 engagement 232 – 5; with asylum seekers 335 – 6, 344 – 5; and well-being 331 environmental factors 333 epidemiological factors 7 escape-avoidance coping 298 ethnic minority clients, dropout rate among 24 – 5 ethnicity, as predictor and moderator 24 – 5, 28 evaluation: empirical 1; negative 60, 93, 169 – 70, 182, 245; positive 170, 182; as supervisory task 352, 354, 355, 359 evidence-based practice (evidence-based health care) 1 evolutionary approach: and emotional fusion 69 – 70; emotions in formulation 63 – 4; evolutionary function analysis 53 – 7; to formulation 83 – 4; functions of social goals 61 – 3; and the nonconscious mind 74 – 5; and the nonlogical mind 72 – 4; and safeness 66 – 9; social mentalities 54 – 7; and trauma 70 – 1; types and functions of emotions 64 – 6 experiential learning cycle 357 Expressed Emotion (EE) 244, 305 facial expressions 69 family: atmosphere 189, 193, 211; and bipolar disorder 211; as carers 304; and expressed emotion 271; familial factors 333; interventions 219; involvement of 271, 285; support from 292 fatigue 191 faulty contingencies 29 fear(s): in anxiety disorders 92 – 4, 98, 100, 111, 114 – 15; in asylum seekers

322, 324, 327 – 8, 337, 345 – 6; in bipolar disorder 203; in depression 125; in eating disorders 252, 255, 259, 260; environmental causes of 39 – 41, 54 – 5; evolutionary perspective 54 – 5, 57 – 8, 60 – 2, 65, 69 – 70, 73 – 4, 77, 80 – 3; of failure 61 – 2; influence of on decisions 47 – 8, 57; in personality problems 224; in psychosis 169, 171, 179; and PTSD 144 – 51, 157 – 9; in suicidal behaviour 267, 274 feedback: in case-formulation-driven treatment 21 – 4, 30 – 1, 33; in CBT supervision 357; in clinical supervision 360 – 1; corrective 360; cycles/loops 94 – 5; effect on outcomes 20 – 1; as essential element of treatment 30 – 1; positive 101, 181, 318; in social interaction 55, 207; as supervisory task 352 – 3, 355, 357 – 61, 363 – 6; in therapy 14 – 16, 18 – 19, 27; video 115 fight/flight defences 65 flashbacks 147, 148, 158 flexibility, psychological 44, 332 flowcharts 19 focal psychodynamic therapy 242 food seeking 53 formulation(s): adjustment 330 – 1; biopsychosocial and evolutionary approach to 52 – 3 (see also evolutionary approach); and the biopsychosocial model 75 – 6, 84; for bipolar disorders 200 – 1; case example “Sally” 78 – 83; in CBT supervision 361 – 3; clarifying emotional memories 79, 81; in clinical supervision 361 – 3; with clinical utility for depression 120; cognitive and metacognitive 90; as collaborative effort 7; components of 90; contextual 50; and diagnosis 52; environmental factors in 52 – 3; evolutionary approach to 83 – 4; example of 230 – 2; function and scope of 229 – 30; and the interaction of brain systems 75 – 6; and the non-conscious mind 74 – 5; in psychological therapies 52; and schema theory 90 – 1; for social phobia 101; in supervision (vignette) 363 – 5; as supervisory task 352; in treatment of psychosis 180 formulation of physical illness: assets and strengths 299; avoidance 297; catastrophising 296; causal attributions 298 – 9; common process

378  Index focus in 295 – 9; coping 298; mental models 295 – 6; problem solving, decision-making and attentional focus 296 – 7; safety behaviours and psychophysiological links 297 – 8 formulation of suicidal behaviour 271; and access to means 272; case example 278 – 9; and current stressors 271; developing motivation for therapy and successful engagement 274; life events 272; and previous suicidal behaviour 271; protective and resilience factors 273; and psychiatric diagnoses 271; risk assessment 271 – 2; and suicidal ideation, intent and plans 272; treatment 275 – 81; vulnerability to suicidal behaviour 272 – 3 formulations for asylum seekers 328 – 33; adjustment formulations 330 – 1; developing and sharing 338 – 40; phased recovery formulations 329 – 30; resilience formulations 331 – 2; transdiagnostic (“third wave”) 332 – 3 formulations with carers: case example “Andrew” 310 – 18; in clinical practice 318 – 19; cognitive interpersonal model of 307 – 10; feedback 318; as intervention 306 – 7; models of and evidence base 306 – 10; rationale for 304 – 6; service user involvement 318; team meetings 312 – 18 functional 2, 17, 20 – 1, 23 – 4, 28, 52, 157, 227 – 9 future, appraisals of 273 generalised anxiety disorder (GAD): case formulation interview 111 – 12; compared to PTSD 93; formulation for 111; illustrative dialogue 112 – 14; metacognitive model of 109 – 11; symptoms of 109; treatment for 116 Generalized Anxiety Disorder Scale 114 genotypes 54 Gilbert, Paul 125 goals: of assessment 230; of asylum seekers 335, 337, 338, 342 – 3, 346 – 7; of CBT 242; of CS 352, 354, 356 – 62, 364; of patients 14, 82, 84, 161, 199 – 200, 203, 212, 249, 252, 255 – 6, 314, 317 – 18; personal 62 – 3, 173; in shared case formulation 308 – 9; SMART 230, 232, 236; social 8, 59, 61 – 3, 313, 315;

of therapy 15, 30 – 1, 45, 48 – 9, 98, 115, 130, 138, 160, 178, 197, 221, 279, 298 goal-setting 202: in clinical supervision 359; collaborative 352 goal striving 190 group therapy 59 growth seeking, vs. validation seeking 61 guilt 210, 256, 337 hallucinations 166, 171, 173, 180 – 2 Hamilton Rating Scale for Depression 119 Hayes, Steven 43 Health for Undocumented Migrants and Asylum Seekers Network 327 heart disease 52, 284 helpless states 65 hepatitis C 284 Herman, Judith 329 Herman’s process of recovery 340; stage I 336, 339, 340, 343; stage II 339, 340, 343; stage III 342, 343 heuristics 4, 74 Hexaflex 43, 46 hindsight bias 2 – 3 HIV/AIDS 284 homeostasis 7 hopelessness 181 hospital admissions 209 human rights abuses 324, 327 Human Rights Act (1998) 333 human rights law 333 hybridisation 93 hyperarousal 143, 144 hypersensitivity to threat 72 hypomania 65, 188, 193, 199, 207; see also mania/hypomania Hypomania Interpretations Questionnaire (HIQ) 199 hypothalamus 147 hypotheses: case formulations as 30 – 2; generation of 3 identity: in anorexia nervosa 239; of asylum seekers 324, 328, 332, 343; compassion 76; loss/lack of 194, 246; self- 62, 68, 74, 82; sense of 255; of voices 177 imagery 147, 158, 161, 251, 258, 260, 275, 289, 290, 297, 300, 337 imagination 73 Immigration and Asylum Act (1999) 333

Index  379 Improving Access to Psychological Therapies (IAPT) programme 10, 352; for Severe Mental Illness (SMI) 189 impulsive sensation seeking 18 impulsivity 68 inferiority 60, 61 inflammatory bowel disease 284 inflexibility, psychological 44 information processing 332; and bipolar disorder 193; dysfunction in 173 information processing theories of PTSD: cognitive model of persistent PTSD 145 – 6; dual representation theory 146 – 7; emotional processing theory 144 – 5 information sharing, in clinical supervision 360 inpatient wards, acute 306 instability 68, 167, 190 – 4, 196, 201 Integrated Motivational-Volitional (IMV) model 267 Internal States Scale (ISS) 198 International Classification of Mental and Behavioural Disorders (ICD-10) 219 interpersonal relationships 160, 241, 292 interpersonal therapy (IPT) 242 interpersonal-psychology theory (IPT) 267 interpreters 334 – 5 interventions: with asylum seekers 322, 327 – 30, 332, 334, 337, 340 – 2, 346, 347; case examples 279 – 81, 316 – 17; clinical 242; cognitive 10 – 11, 32, 120 – 1, 236, 241, 244, 270 – 1, 275 – 6, 284 – 5, 288, 307, 361 – 3; family 306, 319; idiosyncratic 236; imaginal-based 290; motivational 235; nomothetic 30; psychological 235, 310, 322, 365; studies 310; therapeutic 54, 56, 265, 267 – 8; for weight control 239 intolerance of uncertainty 29 introversion-hopelessness 18 intrusions 77, 93, 105 – 7, 111, 116, 143, 144, 148 – 50, 152, 157, 296, 300, 330, 343 in vivo exposure 18 involuntary admissions 209 irrational cognitions 23 irritable bowel syndrome 284 jet lag 191 “just being” mode 66

Kabat-Zinn, John 126 Kanfer, F. H. 1 – 2, 4 – 5 Lambert’s OQ-45 21 language, and non-contingent learning 42 LASS 361 learning: active methods of 357; noncontingent 42; stages of 357 learning disabilities 306 learning processes 222, 332 life events 178; and suicidal behaviour 272 lithium treatments 188 – 9 locus of control 331, 333 looming threat-processing 296 low motivation to change see motivation to change major depressive disorders 119; see also depression mania/hypomania: and bipolar disorder 188, 193 – 4, 212; and positive thoughts 205, 207; and sleep disruption 190 – 1 MANOVA assessment 18 marital therapy trials 16 – 17 Maudsley Model of Anorexia Nervosa in Adults (MANTRA) 243 – 4, 255 mediators 24 – 7 medications: anti-psychotic 171; for bipolar disorder 188 – 9, 195 meditation 66 memories: autobiographical 123 – 6, 132, 148, 181; disorganisation of 160; extended 124; formation of 332; intrusive 296; over-general 121, 123 – 6; traumatic 145 – 7 memory bias, autobiographical 121, 123 – 4, 132, 139 Mental Health Act 209 mentalising 56, 69, 81 mentalities: care giving 57 – 9, 160; care seeking 57 – 8; competitive 58, 60 – 1; sexual 55 – 6; social 54 – 63, 65, 68, 77 metacognition: and cognition 97 – 8; and panic 98; and social phobia 104 – 5; see also cognition(s) metacognitive therapy (MCT) 90 – 1; and anxiety disorders 117 mindfulness-based cognitive therapy (MBCT) 119 – 20, 126 Minnesota starvation experiment 250 mobile-based treatment systems 11 mobile devices, used for treatment 10

380  Index modelling as supervisory task 352, 360 moderators 24 – 7 Mood and Anxiety Symptom Questionnaire 26 moods and mood states: and bipolar disorder 203 – 6; with cognition and behavior 7; disturbances in 190; intolerance of 241; as level of analysis 4; monitoring of 203 – 6; stabilisers for 188; treatment for problems with 19 Moorey, Stirling 330 motivational analysis 2, 62 motivation to change 14, 15, 25, 27 – 30, 239, 241 multidisciplinary teams 307 myelinated vagus nerve 68 narrative exposure therapy (NET) 327 – 8, 329 National Asylum Support Service (NASS; Asylum Support) 324 National Institute for Clinical Excellence Clinical Guidelines for Bipolar Disorder 203 National Institute for Health and Care Excellence (NICE) 166, 172, 189, 195 National Institute of Mental Health (NIMH) 189 National Registry of Evidence-based Programs and Practices (NREPP) 21 negative affect regulation 125 negative automatic thoughts (NATS) 126, 135, 136 – 7; and negative bias to thought content 122, 131 – 2 negative beliefs 102, 105 – 6 negative recall, and depression 123 negativity bias 65, 73 neuroplasticity 54 Newcastle-Cambridge RCT 119, 125 – 6, 139 non-conscious mind 74 – 5 non-impulsive sensation seeking 18 non-logical mind 72 – 4 nurturance 57 – 9 obesity 239, 240 obsessive-compulsive disorder (OCD): case formulation interview 107; compared to PTSD and GAD 93; illustrative dialogue 108 – 9; maintenance model for 121; metacognitive model 105 – 7; as risk factor for eating disorders 245; treatment for 116

obsessive compulsive personality disorders 244; see also obsessive-compulsive disorder operant conditioning 38, 41 opioid dependence 18 overconfidence 2 – 3 overestimation of threat 26, 28, 29 oxytocin 68, 71 pain 150, 160, 266 – 7, 269, 273, 279, 284 panic: cognitive approach to 97 – 8; cognitive model of 95; metacognitive approach to 98; and PTSD 152 panic attacks 94 – 5 panic disorder: case formulation interview 96 – 7; cognitive models of 95; diagnosis of 92, 94 – 5; illustrative dialogue 97; treatment for 115 panic formulation, idiosyncratic 99 Panic Rating Scale 114 paranoid tendencies 59 Partners for Change Outcomes Monitoring System (PCOMS) 21 past, appraisals of 272 patients: background influences of 77; contextualisation of 76 – 8; core concerns, fears and unmet needs of 77; life experiences of 77; safety strategies of 77; and unintended and undesirable consequences 78 perfectionism 29, 62, 190, 241 PERMA (measurable elements of wellbeing) 331 personality disorder(s) (PD) 10, 219; and bulimia nervosa 240; criteria for effective treatment 220; problem with diagnosis 219 – 20; and suicide 266 personality disorder treatment: altering antecedent cognitive appraisals 222 – 4; behavioural experiments 223; cognitive dissonance 233 – 4; compassion focused therapy 221; daily thought records (DTR) 223 – 4; dialectical behaviour therapy (DBT) 221; engagement 232 – 5; formulation 229 – 32; formulation based 227; functional analysis 228 – 9; modifying emotion-driven behaviours (EDBs) 224 – 6; motivational interviewing (MI) 234 – 5; need for time 235 – 6; options for 221; preventing emotional avoidance 226; psycho-education 222; Socratic dialogue 223; Stages of Change model

Index  381 232 – 3; systems training for emotional predictability and problem solving (STEPPS) 221; topographical analysis, SORC maintenance cycle 227 – 30; use of CBT 236 personality profiles 18 pharmacotherapy 22; for bipolar disorders 188 – 9, 195; for psychosis 171 phased recovery formulations 329 – 30 phenotypes 54 phobia, treatment trials for 18; see also social phobia physical health problems: assessment for 76; and care system influence and interaction 294; and clinical health psychology 284; and cognitivebehavioural factors 284; contextual triggers and setting conditions 290 – 1; cross-situational “self ” appraisals 292; exacerbating and ameliorating factors 291; illness-specific cognitions 294 – 5; impact of illness 291; interpersonal functioning, family and social support 292; and past psychological problems 291; and personal values 294; pre-illness factors 292 – 4; prior abuse and trauma 295; psychological components of 285; psychological vulnerabilities 292 – 4 political terror and violence 330, 337 poly-pharmacy 171 positive emotions, and well-being 331 posttraumatic growth (PTG) 332 posttraumatic stress disorder (PTSD) 71 – 2, 93, 104; in asylum seekers 325, 327, 328 – 9, 337, 340; characteristic features of 144; information processing theories of 144 – 7; and psychosis 169 – 70; resulting from trauma 331; theories proposed to account for 144; see also case conceptualisation for complex PTSD; case conceptualisation for fearbased PTSD; complex posttraumatic stress disorder practitioners: as human rights advocates 333; need for self-care among 342, 344; and reflexive practice 334; working with interpreters 334 predictors 24 – 7 Primary Control Enhancement Training 19 problem solving 276, 296 – 7 prodromes 199, 208 – 9 prosocial behaviour 57 proximity seeking 72

psychiatric classification 4 psychiatric diagnosis see diagnoses psychiatric rehabilitation 306 psycho-education 127; for asylum seekers 340, 341, 345 – 6; and bipolar disorders 195, 196; for personality disorders 222 psychological abuse 295 psychological flexibility/inflexibility 44 psychologists: clinical supervision by 352; as human rights practitioners 333; see also therapists psychopathologies 57 psychophysiological links 297 – 8 psychosis 6, 10, 52, 166; antecedent stimuli and context 177 – 8; aspects needing assessment 168; clinical model of CBT for 173 – 5; cognitivebehavioural intervention for 179 – 82; cognitive models of 183; consequences of 178 – 9; coping with 179; and emotions accompanying symptoms 177; engagement and assessment 176 – 9; internal vs. external factors 173 – 4; maintaining treatment for 182 – 3; nature and variation of symptoms 177; and PTSD 169 – 70; suicide 266; symptoms of 166; use of CBT in treating 172 psychotherapy, analysis of motivation in 62 psychotic episodes, acute 171 psychotic experiences 173 purging 240, 248, 250 – 1, 258 racism, and asylum seekers 325, 335 randomised control trials (RCT): on anorexia nervosa and CBT-E 242; on bipolar disorder treatment 195; of bulimia nervosa and CBT-E 241; on cognitive therapy (CT) for treating depression 119; on personality disorder treatment 220 – 1 rational system 74 readiness to change 25, 28 recovery-focused CBT intervention (RfCBT) 195 reflective practitioner model 334 reflexive practice 334 reframing 207, 343 Refugee Council 322 refugees see asylum seekers reinforcement 38 – 9, 65, 175, 181, 227 – 9, 250, 288, 340 reinforcers 2, 38 – 9

382  Index relapse, related to Expressed Emotion 305 relationships: with carers 305 – 6; importance of 8 – 9; negative effect of 9; social 2, 59; therapeutic 6, 177, 221, 242, 251, 256, 338, 356, 364 – 5; and well-being 331; see also supervisory relationship relaxation techniques 284 representative heuristic 2 – 3 re-scripting 81; of depressive intrusive memories 119 resilience 7; in asylum seekers 346; compassionate 162; and recovery 331; and suicide 273 resilience formulations 331 response patterns 8 risk and risk factors: assessment of 271; of bipolar disorder 190 – 3, 197; of disorders 8, 10; of eating disorders 244 – 6; in the lives of asylum seekers 328 – 9, 337, 338; management of 343, 360; for negative health outcomes 292, 295; of psychosis 166, 172 – 3, 305; of relapse 119, 189, 195, 201, 212, 258; of suicide 168 – 71, 179, 266 – 7, 270 – 1, 337; of trauma 173 role play 357, 360 rumination 63, 91, 98, 104, 138, 192; confirmatory 174; depressive 121, 123 – 6, 131 – 2; self-critical and selfblaming 121 – 2, 132 – 3, 135 – 6; socially focused 61 rumination-focused cognitive therapy 119 safeness 66 – 7; and attachment theory 67 – 9 safety behaviours 94, 100 – 1, 297 – 8 SAMS model 275 Saslow, G. 1 – 2, 4 – 5 schema-focused work 277 schemas/beliefs: about illness 296; personal 73; primary and secondary 120; and social phobia 98; suicide 273; treatment of 29 schema theory 90 – 1 Schematic Appraisals Model of Suicide (SAMS) 268; appraisal system 270; clinical heuristic 269; information processing biases 268; suicidal behaviour 270; suicide schema 268 – 9 Schematic Propositional Associative and Analogical Representation Systems (SPAARS) 190 – 1

schizophrenia: and anti-psychotic medications 171 – 2; biological determinants of 166; clinical model of CBT for 173 – 5; development of CB treatments for 171 – 2; effectiveness of CB treatments for 172; effect of Expressed Emotion on 305; environmental determinants of 166; family interventions for 306; nature of the problem 167; phases of diagnosis 168; prevalence of 166; relapses of 182 – 3; see also psychosis school-refusing child 23 scientist practitioner models 1, 334 search strategies, biased 2 – 3 Secondary Control Enhancement Training 19 Segal, Zindel 126 self: as context 35; integrated sense of 160; negative views of 181 self-appraisals, cross-situational 292 self-blame 131, 169, 305 self-control, analysis of 2, 298, 340, 341 self-correction 8 self-criticism 60, 67, 74, 80, 82, 83, 131, 134, 137, 150, 161, 162, 190, 211 self-efficacy 26, 246, 281, 292, 296, 331 self-esteem 59 – 60, 139, 167, 169, 179, 181 – 2, 247, 249, 270 – 1, 296, 315, 317, 332; fragile 193; low 170, 181, 241, 245 – 6; negative 178; and schizophrenia 170 self-harm and self-harming 68, 79, 82, 152 – 3, 168, 220, 230, 256, 258 – 9, 271, 344; see also self-injurious behaviour self-help treatment 11, 16, 17, 339, 341 self-identity 62, 68, 74, 82 self-image 100, 101, 114 – 15 self-injurious behaviour (SIB) 23, 40; see also self-harm and self-harming self-loathing 152 self-monitoring 73 – 4, 98 self-processing 99, 104 – 5 self-recognition 73 self-regulation 152 self-soothing 137, 151, 153, 160 – 2, 333, 341 self-validation 82 self-verbalisations 18 Session Assignment and Feedback Scale (SAFF) 30 severe and enduring eating disorder (SEED) 242

Index  383 sexual abuse 70, 125, 149, 152, 159, 169, 183, 258 – 9, 295 sexual assault 330 shame 72, 74, 169, 210, 246, 256, 292 Sidman, Murray 42 single case studies 23 – 4 Skinner, B. F. 42 – 3 sleep routines 190 – 1, 196, 201, 203, 346 SMART problems and goals 230 social anxiety 59; metacognitive formulation of 104 – 5; and schizophrenia 169 social avoidance 173 social cognition 9; deficits in, and bipolar disorder 193 social contexts, of emotions 63 – 4 social-cultural-physical environment 2 social isolation 17 social mentalities 56, 61, 68; care providing/giving 57 – 9, 160; care seeking/eliciting 57 – 8; competitive 58, 60; cooperative 58 – 9; sexual 58, 60 – 1 social mentality theory 56 – 7 social networks 304 social perception skills 19 social phobia 169; case formulation interview 101 – 2; cognitive model of 98 – 101; illustrative dialogue 102 – 4; treatment for 115 – 16 Social Phobia Rating Scale 114 social psychology 182 social rank 60 – 1 social relationships 2, 59 social skills: deficits in 23; training for 19 social support 7, 9, 292; and asylum seekers 325 socialisation 8 socio-cultural experience 2 socio-cultural factors 333 Socratic questioning 307, 309, 356 sodium valproate 188 somatic distress 152 somatisation 152 SORCC paradigm 228 – 30; contingencies 228 – 9 SORC maintenance cycle: consequences 228; organism 227; responses 227 – 8; situation 227 Specialist Supportive Clinical Management (SSCM) 242, 243 Stages of Change model 232 – 3 stigma 211, 292; associated with personality disorder 219 – 20

stress: acute reactions to 329; among asylum seekers 329, 331, 337, 339, 340; and bipolar disorder 189 – 91; levels of 7; and safeness 66; and suicidal behaviour 271; traumatic 329 stress hormones 147 stress levels 7 subjugation 246 substance abuse 17, 24, 153, 168 – 9, 277; alcohol abuse 19; and suicide 266 substance abuse treatment trials 17 – 18 suffering 43, 76 – 7, 84, 149, 328, 342 suicidal behaviour 265 – 6; appraisal restructuring 275; attentional control 275, 279; and attentional process 272; behavioural techniques 276 – 7; case example “Steve” 277 – 8; contemporary models of 266 – 70; empirical basis for cognitive therapy 270 – 1; formulation of 271 – 7; function of 273; problemsolving skills training 276; schemafocused work 277; socio-demographic and clinical correlates of 266 suicidal ideation 171, 178, 181, 265, 266, 272; among refugees 337 suicidal intent 265, 272 suicide: attempted 265; effect on circle of friends and relatives 265; ideators vs. attempters 267; plans for 272; risk of 179 suicide models: “cry of pain” 266 – 7; Integrated Motivational-Volitional (IMV) model 267; interpersonalpsychological theory 267; Schematic Appraisals Model of Suicide (SAMS) 268 – 70 suicide risk, and schizophrenia 168, 170 – 1 supervision: cognitive behaviour therapy 356 – 8; educational nature of 353; international competency framework for 352; tasks involved in 352; see also clinical supervision; supervisory relationship supervisory relationship (SR) 353 – 4; core relational factors of 354; quality of 355; theory and evidence 354 – 6 Supervisory Relationship Measure (SRM) 355, 361 Supervisory Relationship Questionnaire (SRQ) 354, 361 Supervisory Working Alliance 354 – 5; see also supervisory relationship support, as supervisory task 352

384  Index sympathy 59 synchrony 4 systems training for emotional predictability and problem solving (STEPPS) 221 taxonomy, psychologically based system of 4 teaching as supervisory task 352 Teasdale, J. D. 125 – 6 technologies, for assessment and treatment 10 testimony therapy (TT) 327 – 8, 329 therapeutic relationships 6, 177, 221, 242, 251, 256, 338, 356, 364 – 5 therapist paralysis 149 therapists: behavioural 52; clinical supervision by 352; cognitive 52; evolutionary 84; psychodynamic 52; psychological 352; systemic 52; working with individuals 76 – 84; see also psychologists thought action fusion (TAF) 105 thought event fusion (TEF) 105 thought object fusion (TOF) 106 threat emotions 64 – 5 threat system 65, 69, 72, 73, 82, 125 threats: hypersensitivity to 72; overestimation of 25 – 6; processing of 68; reappraisal of 26; response to 53 – 4, 55 tipping points 270 topographical analysis (TA) 227 – 8 Top Problems Assessment 20 transdiagnostic mechanisms 28 trauma: effects of 70 – 1; experienced by asylum seekers 325, 327; responses to 332; and schizophrenia 169 – 70; Type I 143, 148; Type II 143, 152, 160 trauma-focused cognitive behaviour therapy (CBT) 143, 161 traumatisation, vicarious 342 treatment: decisions regarding 14; development of 28; mediators of 24 – 7; moderators of 24 – 7; modular 19, 29; predictors of success 24 – 7;

protocol-driven 10; strategies for 3; strategy for developing 31; types of treatment utility 32; see also anorexia nervosa treatment; anxiety disorder treatment; asylum seeker treatment/ interventions; bipolar disorder treatment/ interventions; bulimia nervosa treatment; case formulation-driven treatment; cognitive behaviour treatments; personality disorder treatment triggers: contextual 290; for emotions 63; for psychosis 177 – 8; for suicidal behaviour 268 – 9, 272 uncontrolled trials 22 – 3 United Kingdom, asylum seekers in 322 United Nations Convention on the Rights of Refugees (1951) 322, 324 US Substance Abuse and Mental Health Services Administration (SAMHSA), 21 vagal parasympathetic tone 68 validation seeking, vs. growth seeking 61 values: clear 45 – 6; personal 62, 75, 294 – 5, 300 vicarious traumatisation 342 ‘vicious flower’ metaphor 121, 243 violence, domestic 50, 149 – 50, 329, 363 vulnerability(ies) 7 – 10, 21; and bipolar disorder 189 – 91, 196; and depression 138; psychological 292 – 4 well-being: accomplishment and 331; cultural interpretations of 337; measurable elements of 331 Williams, Mark 126 women, depressed 23 Working with Interpreters in Mental Health (Tribe & Ravel) 334 World Health Organization (WHO) 11, 265 Youth Self Report (YSR) 20 Zone of Proximal Development (ZPD) 357