Assessment and Formulation Case Presentation

Natalie Davies

Alice

Referral information

•23 year old female

•History of depression and self harm whilst at university 3 years ago

•Depression had returned in the last 3 months, along with thoughts of self harm

•Living with father and step-mother, after being evicted from the family home along with her mother and sister

•Prescribed 50mg Lustral (Sertraline)

Presenting Issues

• Depressive symptoms improved however......on further exploration, still occasionally

experiencing:– Low motivation– Tiredness– Social withdrawal– Self-critical thoughts

• DSM –IV criteria

Assessment tools

• IAPT Minimum Data Set– PHQ9: 11 (Moderate)– GAD7: 5 (Mild)– WSAS: 20 (Significant impairment)– Phobia 1: 2– Phobia 2: 1– Phobia 3: 0

• Disorder specific measures

Other factors

• Medication– Sertraline 100mg 6 weeks prior to assessment

• Risk– No thoughts of self harm or suicide (score of 0 on

PHQ9 question 9)– No risk of neglect– No risk of harm to/from others

Hot cross bun (Padesky & Mooney, 1990 )

SituationAt home with

step-mum

Cognitive“what’s the point in

getting up?”Physical

Tired, insomnia, sleeping in the

day

MoodSad

Numb

BehaviourStay in bed, on laptop or watch

TV

Hot cross bun (Padesky & Mooney, 1990)

SituationMeeting

someone new

MoodAnxious

BehaviourTell lots of jokes, say “I sound weird” out

loud

PhysicalButterflies in

stomach, faster hear rate

Cognitive“I want to be

someone different” “I’m not normal”

Predisposing factors

• Father left at age 9

• Mother “stopped caring” at age 11– Home felt “unstable and unsafe”

• Mother harsh and critical towards Alice

Precipitating Events

• Evicted from home, went to live with father and step-mother– Step-mother critical

• First serious relationship ended

Goals Westbrook, Kennerley, & Kirk, 2007

“To feel better about myself and have more self belief “ (Long Term)

Refined in session 2:

•To accept compliments (Short Term)•To do a stand-up comedy gig in London (Medium Term)•To stick up for myself more when my step-mum shouts at me (Medium Term)•To be myself and be more relaxed on dates e.g. telling less jokes (Medium Term)

Longitudinal Formulation (Beck et al, 1979)

Early experiencesDad left when 9 years

Mum became neglectful at 11 years

Core BeliefsI’m unlovableI’m abnormal

Assumptions/RulesI can protect myself from the pain of rejection if I don’t let people get close

People only accept you if you’re normal In order to be accepted I must not show the real me

Compensatory strategiesDon’t let anyone get close

Tell someone everything about me that’s “abnormal” straight awayUse of humour to detract from the “real me”

Critical IncidentBroke up from first serious girlfriendMoved in with Dad and Step-Mum

TriggerDate doesn’t go well, reminder of ex

NATs“It’s because there’s something wrong with me”

“I’ll be alone forever”

Emotion Physical Depressed, Lonely Tired, tearful, low motivation

BehaviourStop going on dates, use humour more in interactions, withdraw from friends

Which model?• Beck et al’s (1979) cognitive model of

depression– identified assumptions and core beliefs– developed as a result of early experiences– rigid assumptions, resistant to change– NATs triggered, which lead to depressed mood

and social withdrawal

Low Self Esteem?– Schemas in cognitive model of depression (Beck et

al, 1979) similar to self esteem i.e. “they are a product of learning and, once in place, they in turn shape how a person perceives and makes sense of subsequent experiences” (Fennell, 1997, p. 2)

– Low self-esteem may i) represent an aspect of a presenting issue ii)be a consequence of a presenting issue or iii) represent a longstanding vulnerability factor, preceding the onset of presenting issues

Activation of Bottom Line A first date

Predictions“I’m abnormal, I won’t be accepted if I am myself”

Anxiety

Maladaptive BehaviourUse of humour

Self critical thoughts“there’s something wrong with me, I’ll be alone forever

Depression

Confirmation of Bottom Line

Cognitive Model of Low Self Esteem (Fennell, 1997)

Proposed Treatment PlanAim Method

Socialising Alice to the CBT model Completion of hot cross buns and cross-sectional formulation

Challenging Alice’s self critical thoughts

Completion of thought diaries

Testing Alice’s assumption that she has to behave how she thinks others want her to in order to be accepted or loved

Exploring consequence of belief, advantages and disadvantages, identify alternative rule, behavioural experiments

Test Alice’s belief that she is abnormal

Continuum work

Engagement and Therapeutic Alliance

• Engaged Well– Socialised to CBT model – Contributes to session

• Alliance very good from the start– Open, honest, friendly

• However, too many jokes?– Eliciting emotion- avoidant?

Experience & Observe (Kolb 1984 and Lewin 1946)

SituationAware of client making many

jokes in therapy session

Cognitive“If I raise this it will be really awkward” “I’ll come across

as really formal”

PhysicalButterflies, heart rate

increased

MoodAnxious

BehaviourAvoided bringing this up in

conversation

Reflection

–Assumptions related to valuing humour in sessions –I didn’t fully consider the potential impact on the

emotional expression in the session–There is a need to validate my clients experiences, even if

she isn’t?

PlanUse of humour is advantageous to the therapeutic alliance

where appropriate, but can become a barrier to eliciting emotions

Summary

• Presenting issue of mild-moderate depression, with a previous episode of depression 3 years ago

• Assumptions/rules led to compensatory behaviours which became self-perpetuating

• Treatment plan aimed at increasing confidence through reducing compensatory behaviours and testing assumptions

Questions?