The diagnostic model has been under severe scrutiny lately. Its main flaw involving placing all distress in confined categories, based on superficial and subjective ‘symptoms’ (Kleinman, 1988). Consequently, the mental health field have sparked a catalyst of attention towards a more holistic approach, in the form of a formulation. A formulation is a theoretically influenced conceptualisation explaining the development, maintenance and relation of the individual’s difficulties to one another (Corrie & Lane, 2010) based on a summary of the client’s core issues (Kennedy & Llewelyn, 2001).
This essay will therefore begin to unravel the multi-layered problems of Cara, an 18 year old who has recently been referred to a clinical psychologist, due to her medication (Olanzapine) not reducing her auditory hallucination and unusual beliefs. This will be done through the use of a cognitive-behavioural perspective. And more specifically by analysing the five P’s (Williams, 2001) and the influences they have on her behavioural and psychological dilemma (Dudley and Kuyken, 2006). This essay will also evaluate the perspective used, and include an integration of different perspective where cognitive-behaviourism may lack insight to further our understanding of Cara’s distress.
Cognitive Behavioural Perspective:
Cognitive behavioural perspective is best understood as a ‘family’ of related ideas from several methodologies. In fact, it primarily draws upon an unwieldy union of two previously deemed distinctive disciplines, known as cognition and behaviourism.
Behaviourism emerged in the early 19th century, as psychologist such as Watson (1930) increasingly felt that the restraint posed by studying the mind held back psychology’s looming scientific status. And so behaviourist primarily focussed on studying observable behaviour, and reduced all behaviours to a simple stimulus-response association, acquired only through conditioning processes. For example, operant conditioning increases or decreases behaviour to stimuli because of associations made between reinforcement and punishment (see Skinner, 1953). And classical conditioning, pioneered by (Pavlov, 1927) involves evoking a conditioned response on its own, by forming an association between naturally existing stimuli to an unconditioned stimuli.
However a cognitive theory, dating back to the 18th century parallel behaviourism as it highlights the importance of internal processes (Sternberg, 2003). Such as attention, memory, language, thought and perception (Gardner, 2006). Cognitivist state that one’s behaviour is subject to internal processes mediating between sensory and perceptual information (Neisser, 1967).
Until the 1970’s, both discipline remained on polar opposites, with the role of cognition remaining idiosyncratic of each independent discipline. However, a joint union established when cognitive psychologists showed interest in behaviourism, and vice versa (Kendal & Hollon, 1979). Ultimately, the union gave birth to a collective movement known as cognitive behaviourism. This movement claims cognition to influence responses to external stimuli independently, as behaviour occurs due to mediating internal processes.
Ellis (cited in Corey, 2009) whose theories of irrational beliefs underpin the CBT took that claim further. He states that it is not external stimulus that causes emotional distress. But rather an individual’s cognitive appraisal that evaluates the stimulus based on one’s previously developed belief, expectations, attitudes and assumptions that lie at the heart of distress. Highlighted in the ABC model, it is not the activating event (A) that causes the consequential behaviour (C), but our belief (B). And this belief is subject to individual differences, based on the context they interpret it in, as “”men are disturbed not by things but by the views they take of them” (Epictetus cited in Elis, 2002).
Beck (1967 cited in Beck, 2008) also identified ‘cognitive distortions’, these are inaccurate thoughts that fuel negativity, but are interpreted by the individual to be rational and just. An example of this could be “black and white” thinking, such as “I failed an exam, so I must be a complete failure”.
The frequency of cognitive distortions can lead to a stream of consciousness becoming activated, known as negative automatic thoughts. Those are situation specific and arise when individuals experiences emotional distress. It is these recurrent thoughts that can lead to behavioural, psychological and physiological dysfunction. Bedrosian & Beck (1980) even went as far to say, that depression is a behavioural response to feeling hopelessness, rather than a traditional symptom of depression.
Cognitive Behavioural Formulation
The clients’ presenting issues:-
Cara is described as suffering from auditory hallucinations and unusual beliefs, due to limited writing space a full detailed account of her issues can be found in Appendix I.
Precipitating external and internal triggers:-
The ABC model (see appendix II) reveals the impact Cara’s beliefs and emotions have on her current issues. The most notable issues are her unusual paranoid beliefs and her auditory hallucination. Firstly let’s delve into Cara’s hallucination. Auditory hallucinations are conceptualised as “internal mental events, such as cognitions, which are perceived by the individual to be of a nonself origin” (Stinson et al, 2009). Hence they are false sensory experiences that occur despite the absence of stimulation. Cara hallucinations take the form of one of her A-level teacher’s voice. Alongside Cara’s hallucinations, she also truly beliefs he communicates with her in classes and that the teachers are on her side. Thus her hallucination illustrates that her teachers encompass the role of a protector, and friend. Upon closer inspection of the ABC model, we see that the onset of Cara’s hallucination was triggered by feeling severely disconnected and isolated from her peers. And through the simple comfort she took from making eye-contact with one of her teachers. Cara hallucinations began and reassured her she that she would be fine.
Cognitive behaviourism would explain the auditory hallucination experienced by Cara, to be due to a failure in source monitoring. This is defined as the ability to distinguish the source of an experience, whether is from within oneself or from an external source (Garret & Silvia, 2003). It could be the positive nature of the hallucination and the reassuring and comfort Cara feels, would have conflicted with Cara’s negative schema content, if she believed them to be hers. This could have been the possible cause for source monitoring failure. Since extensive literature have demonstrated that these hallucinations are a result of misattributing internal voices as external (Allen et al, 2004). This theory would be plausible, had the voice not been so starkly different to Cara’s “inner” voice. As highlighted with critics of this theory, that most auditory hallucination come from an external source of an identifiable person (Ditman & Kuperberg, 2005).
Perhaps a better explanation would be found, by looking at the association between auditory hallucinations with the parahippocampal gyrus (PHG). The PHG main role involves memory recollection, and is used as a shortcut to the hippocampus for recognition. And recent studies have shown that the PHG becomes increasingly activated during auditory hallucinations (Escarti et al, 2010). However the PHG deactivates once the auditory hallucination has occurred (Diederen et al, 2010). This may be a sign of traumatic memories being recalled back into the consciousness in different forms, due to the hippocampus failing or incorrectly recognizes the relevant schema content. This may explain why Cara specifically hears a male’s voice and feels a “special bond”, as this is reminiscent of the university boyfriend she was in relations with aged fourteen.
Predisposing factors and perpetuating factors that maintain the client’s present issues:-
It is important to note any predisposing factors, as they influence Cara’s interpretation of precipitating triggers. For example, increasing literature suggests vulnerable dispositions increase the likelihood of psychosis (Morrison et al, 2003). Especially, in individuals who were raised in lower socio-economic status in derelict neighbourhoods (Kerkbride et al, 2008), or where abuse and long periods of neglect (Read et al, 2005) were common. It is also important to delve into the relationship of life events and her schematic content. As it is these two intertwined and our desperate need for confirmation bias can lead to cognitive interference with one’s perception, judgement, memory and attention.
Literature shows that behavioural/emotional disturbance is associated with predominance of negative schema content (Morris, 2007). Schemas are permanent reference points stored in the brain, gained from relevant developmental experiences. Due to classical conditioning, emotional responses are conditional as they are associated to past experiences stored in schemas (STUDY). Therefore it is not the external environment that causes distress, but from emotions associated to past experiences. The more negative a past experience was, the stronger the memory is and the greater the distress it could evoke.
Cara’s predisposition could stem from logical fallacies she made as a child leaking incorrect and negative content into to her schemas. These could have occurred during critical life events, such as her early life disruptions due to her mother’s neglect. It is demonstrated that parenting styles can highly influence Cara’s emotional and behavioural functioning. For example, Young (DATE!) identified five kinds of parenting; the one most applicable to Cara scenario would fall under “unpredictable and/or rejecting parent”. From a young age, her mother left Cara and her siblings at her aunts or grandmother’s home for long periods. Young suggested that extreme poverty or work commitments contribute to the parent’s severe stress and make them unpredictable and unable to display positive emotions (STUDY!). Also, Cara’s mother shows extreme self-interest when she and partner move the entire family to Southampton. Despite Cara going through her GCSE’s, also Cara’s mom tends to divide her time between her new partner and her work leaving no quality time for Cara. This could lead to faulty cognitions, such as Cara thinking she is unwanted or disliked. This is a type of black or white thinking, where Cara made an extreme conclusion even though she does not have all the facts. However, this cognitive distortion developed from a young age will exaggerate negative thoughts about Cara’s self-worth (STUDY).
Critical events that are so severe and traumatic, such as Cara being raped, aged 10 by her older brother. Could also influence Cara’s response to potential future triggers, and lead to personality, behavioural and emotional malfunctioning. Sexual abuse can have catastrophic impact on Cara’s cognition, especially being threatened if she told anyone. Could have led to personalisation, a type of logical error where an individual takes sole responsibility for an event.
From an evolutionary perspective (DATE + STUDY!!), Cara’s past negative experiences increases her tendencies to make logical errors. Her logical errors serve the purpose of exaggerating potential threats and keeping her safe (STUDY!). Cara displays catastrophisation, where an individual’s surpasses the facts in a negative way. A specific type is “Direr than justified”, where someone makes inaccurate conclusion of something being much worse than it really is. As well as, inappropriate abstraction, in which Cara draws a false or inappropriate abstract conclusion, through “overgeneralisation” where a minor negative example is applied to all scenarios, and people.
Protective factors that show the clients strength in maintaining their emotional health:-
Among Cara’s strengths are her ambitions to go the university and her excellent academic achievements despite the move during her GCSE. As well as her admirable work ethic, shown by the part-time job she used to have while also doing her A-levels. Despite the medication not reducing her delusions or hallucinations, the fact that she is taken them regularly is a feat worth noting.
Integration of Other Perspectives: (500 words)
Cognitive-behaviourism lacks insight when it comes to Cara’s relationship with a university student, and the fact that her auditory hallucination consist of an older male teacher’s voice. Along the hallucination, she also refers to an attraction to him by claiming she feels a “special bond”. The psychoanalytical perspective would deem this to be a classic Elektra Complex, where Cara has become fixated during the phallic stage. This might have been triggered when her father left at an early age, and by seeking older men Cara wants the father figure she never had (Scott, 2005). Cara’s lack of a father figure and her later traumatic sexual abuse experience contribute to her feeling inferior to men. And to regain superiority, she uses her sexual nature and extreme infatuations as a defence mechanic to diminish her ID-ego conflict (Berzoff & Flanagan, 2008) by asserting power over these men. And by feeling these grandiose bonds, she asserts power to herself by seeing herself as an equal to these men (STUDY!).
The social constructionist perspective sheds light on Cara’s unusual beliefs of the racist conspiracy against her. It is her minority status, and socio-economic status that made Cara belief she was different. It is through this label, that she started to fulfil her own prophecy of being potentially bullied due to her status. (REVISE + ADD STUDIES, CHANGE DOESN’T MAKE SENSE YET!
Evaluation and Conclusion:
Evaluation of CBT!