approach which is based on the concept in the way we conceived the world alters the way we behave. People are believed to experience emotional difficulties when they hold irrational beliefs about self and the environment. One of the key principles of CBT is that it focuses on the present rather than the past as it is in other perspectives as the psychodynamic, Individual with psychosis tends to be locked in unsupportive ways of thinking hence bias thoughts are distorted.
This formulation will look at the cognitive perspective in Cara’s case study. Cognitive behavioural therapy formulation will be used including the key ideas that underpin the approach to formulate Cara’s prescribed distressed referred by her psychiatrist.
Cognitive-behavioural therapy (CBT) is a successful system of distinguishing events of individual life, which is a well-organised approach using different types of treatment of psychiatric disorders for example depression, phobias, pain problems, anxiety, paranoia and hearing voices etc. Cognitive behavioural therapy has fundamental theoretical underlying principles that effect an individual’s behaviour, thinking and are mainly based on the way people structure their world (Beck, 1976).
Formulation is another way of understanding and obtaining information of an individual with psychosis and evaluating this. Formulation illustrates psychological theory and data which provide support for describing a problem, how it was created and how it is being retained (Division of clinical psychology, 2001). Case formulation has its own origins in the application of psychological science to clinical problems. Kanfer and Saslow (1965) explained the procedure of behaviour breakdown as another option to psychiatric diagnosis. Therefore, psychological formulation shows other ways of psychiatric diagnosis and medical models, through predictable treatment implication, (Ownes et al. 1982; Bissett et al. 1992).
In addition, to have knowledge of the characteristics of clinical disorder in particularly with anxiety and fear, drawn from empirical research are carried out. The “cognitive revolution” Meichenbaum, (1977): Wilson, (1978), increases by the work of (Beck, Rush, Shaw, and Emery, 1979) and others (Hawtom, Salkovskis, Kirk, and Clark, 1989) have highlighted the increase in the development of behaviour therapy. Cognitive behaviour therapy is involved with cognition which is beliefs, attributions, expectations, confidential unobvious events, added to formulations, and there has been a shift from environmental factors to internal cognitive process and content. The power of cognitive therapy with more attention toward investigative factors internal to the persons thinking which is not that interesting when given to a person’s environment, their social surrounding if it had been true historically and a lot of their behaviour tradition, (Hayes, 1992).
The formulation of cognitive-behavioural therapy’s key principles approach consist of the five P’s process structures which refers to the in depth practice of formulation that is used to explain Cara’s psychological experience. The key aim of cognitive-behavioural therapy is presenting problems which means description of the client’s current problem, such as thoughts, behaviour and emotion. Secondly, precipitating factors are external and internal issues which caused the existing issues. Thirdly, perpetuating factors is the feeling within and outward factors that maintain the current problems. Fourthly, predisposing factors is the origin external and internal reasons that enlarged the individual’s vulnerability to their present crisis. Finally, the protective factor shows the individual’s ability to recover from problems and their emotional strength that helps to maintain emotional health. This formulation process of cognitive-behavioural therapy helps to organise and accomplish formulation aims. All the five P’s have different types of in depth statements and conclusion which is drawn from evidence, and closes intervention planning on the five Ps (cited in Johnstone and Dallos, 2010).
Cara’s presenting issues were illustrated in her case study that she was experiencing different types of problems as at present, which she is feeling isolated and excluded by her friends. She has been experiencing problems that her friends, co-worker and believed teachers were laughing at her. Cara has also been described as paranoid since hearing voices telling her that all is well. Also as a result of her distress this has lead Cara to be accusing them of being racist conspiracy against her and she is feeling frustrated with them.
Formulation is very useful when undertaking therapeutic work with someone presenting delusional beliefs (Johnstone and Dallos, 2010). Mostly what Cara is thinking, is associated with her emotions and behaviour which are logically related. Furthermore, (Morrison 2001, Freeman and Garety 2004) stated that there is no clear accurate theory of psychotic symptoms to let somebody know the practice of CBT. In addition (Freeman and Garety 2003) has shown that there is evidence that people with delusions have greater reasoning of unfairness and more abnormal experiences than non-psychotic groups. Moreover, individuals with emotional disorder have a tendency to cling to their ideation with lower levels of conviction.
Cara’s precipitating factors (Ellis’s 1977 ABC model Burns, 1989; Trower et al., 1998. Trower et al 1998, p.3) according to this model what prompts these problems are internal and external which are inclined to the formulation of Cara presenting problems. Cara’s precipitating issues shows what led to events of her problem at present, which will give details of Cara’s response to her rage towards others. The ABC model in this circumstance refer A- activating event, B-beliefs and C-consequences, which will help to split out the starting point event of Cara’s problems, like her negative thoughts that makes her distressed.
Cara’s activating events which are her relationships with friends when she overhears them talking about how weird she is, she feels that they were laughing at her because of her different accent and background and that they were making rude gestures and mimicking her every move and she is sure they were particularly pointing at her hair. This led her to believe that her hair is falling out or it is hugely greasy and the consequence of this is that she is weary to talk to others, resentful of herself and isolating herself from everybody.
Her second activation was that when she thought her teacher gave her eye contact, this made her to belief that they share a special connection and the consequence of this is that she started attending class which was positive for Cara and hearing voice that she will be okay. Lastly, Cara is convinced that her co-workers are laughing at her, increasing distress and made her to lose inhibition at school. Her belief is that there is a wider conspiracy to preventing her from achieving, when she failed her AS level exams, as a result of this the consequence were that she left her part time job, having lower marks from school, she become very angry and started shouting Cited in (Johnstone & Dallos 2010) .
According to (Garety et al. 2001; Tarrier 2002) stated that individuals see themselves and their emotions as a response to their sickness and its outcome and impact on the individual’s life. All this could happen in the individual’s life in so many ways like their experience, uncommon perception; their thoughts may be complex and upholding psychopathology in the state of psychotic symptoms.
The way Cara is feeling according to Garety, this might lead to feelings of self-worthlessness and as an effect may cause feelings of depression, hopelessness and despair, which can be associated with suicidal ideation and behaviour. Individuals with suicidal tendencies usually suffering from schizophrenia with attributes of psychotic hallucinations and delusions (positive symptoms) which lead to cognitive and behavioural functioning (negative symptoms), it is a deep emotional and traumatic life event. This includes anxiety, irritability, restlessness and mood instability as in quasi-psychotic symptoms like delusional mood and supernatural thoughts (Caldwell & Gottesman, 1990). As for Cara she believes that she and her teacher are sharing a special connection friendship. Besides Cara shown that she has low self esteem on her case study of her feeling that her hair is falling out and the fact that her friends her laughing at her (Silverstone, 1991) made a statement that people who suffer from low self esteem is a continual of mental health problems which is mostly related with psychosis. (Tarrier, 2004) says that depression and suicidal ideation and behaviour are also interconnected with low esteem.
Cara perpetuating factors (what keeps the problem going) even when the ABC model is an excellent heuristic tool to recognize Cara’s emotional disorders (Greenberger & Padesky, 1995). Cara’s problems are her co-workers, teachers, and friends, internal feelings of isolation, hearing voices, her father leaving when she was much younger and her relationship with her mother is very disconnected. She was abused by her brother when she was a child which may have contributed to her illness, exclusion and disappointment in them all resulting in her failing of her GCSE exams. Her thought is that they were laughing at her which caused Cara to be angry, shouting and accusing them. This might have an effect on her thoughts and view of others. (Beck 1976; Beck et al 1985) stated that dysfunctional beliefs can trigger danger schemas may have made Cara vulnerable which activated those behaviours in mechanisms of maintenance. On the other hand one could say that this is an anxiety which Cara is having and it is persistent or social anxiety, which could be an underlying problem for maintains the problem.
In Cara’s case she is shouting and accusing everyone that they are against her doing well. Thus Ehlers et al. (1995) and Lyons, (1991) suggested that people who have survived trauma try to look for meaning and assess the event, predominantly the effect on their beliefs about themselves, others, and the world. Janoff-Bulman, (1985); Lyons, (1991); Joseph, Yule, and Williams (1993) recommended that other authors have looked and there is relation among how people explain and react in hearing voices, and they stated that belief about voices can provoke distress or help to maintain her voice hearing. Chadwick and Birchwood, (1994), Morrison, (1998), Romme and Escher, (1989), Maher (1974) have also added that delusional beliefs might be seeking for a sense of meaning activated by the existence of abnormal experiences linked with psychosis. Garety, Kuipers, Fowler, Freeman, and Bebbington (2001) have also suggested that there could be general psychological processes included in the increase and maintenance of both Post-traumatic stress disorder (PTSD) and psychosis. Carrigan and Randall (2003) argued that social isolation is from social phobia and it becomes secondary to depression, Stein et al (2001) stated that someone experiencing psychosis mostly have problems with awareness of the social world around them.
However Cara’s predisposing factors which are external issues that make Cara vulnerable, with perpetuating a crisis, it may still be unclear, what caused the problem in the first place. Naturally it could be predominantly a complicated stressful event or time in her life that made her behaviour (Johnstone & Dallos 2010).
To understand the beginning of Cara’s difficulties is to look at stress-vulnerability Neuchterlain and Dawson, (1984). Her father left when she was a very young, her early life was quite disrupted, no support from others, Cara mostly stayed at grandmothers and aunt’s house, her mother found it hard to care for four children by herself. She also feels confused and relatively disengaged from her mother, she has no one to sustain her internal and external, she feels rejected and let down by her brother because he sexually abused her and threaten her with violence, which is found to be very perplexing with that she could not tell nobody in the family.
Still she feels that her boyfriend is disloyal to her, the fact that he was white and he left her for a white girl and she is black. It was reported that patients experiencing psychosis reported themselves as being the victim of violence in the previous 12 months with one in six, Chapple et al. (2004), and spent childhood experiencing physical and sexual abuse. Greenfield et al. (1994); Mueser et al. (1998) reported a prevalence of 43% in patients with schizophrenia. Moeller and Bachmann (1993) conducted a study which showed that women, who were abused in early years of their life, are more likely to experience abuse as an adult in comparison to those who had not been abused in childhood. Read (1997) suggests that there might be relationships between childhood abuse and adult psychosis and in particular among childhood abuse and schizophrenia (p. 450)
Furthermore Cara’s protective factors help her to maintain her emotion in handling work, ambitions to go to university, going out, making new friends. These are strategies that she used to keep her psychotic experience or her emotional state maintained. Ehlers and Clark, (2000), cognitive model of persistent posttraumatic stress disorder (PTSD) noted that a key characteristic of constant PTSD is someone that could not pull through naturally display features of idiosyncratic negative assessment of the traumatic event or it could develop a sense of severe threat to themselves and others. The threat could be external e.g. people are dangerous or internal could be Cara can see her self able to do things and be acceptable about the achievement of life’s important goals. Cited in (Johnstone & Dallos 2010)
Integration: Systemic formulation
CBT draws on the five Ps which are the underlying principles of Cara’s problems; however it does not focus on Cara’s family issues and her past life events, Cited in Johnstone and Dallos (2010) thus systemic approach deals with the family or some part of families. Systemic formulation is not perceived as little things therapist does for the family rather is something that they do with the family. Systemic formulation practically looks at the issues of what is noticeable as the dilemma and the family effort trying to conquer the problem. Systemic approach sees the family as a system and individual distress as an expression of problems within that scheme. To some extent, instead of ‘blaming the families’ this widens the focus from any particular individual. Particularly the ways of communicating within families are especially associated with mental health problems. Family relationships and specific traumatic events are not the only factor in creating problematic life circumstances.
Social and economic factors also shape people’s life experiences. David Smail (2005) argues that these factors are actually more important in shaping our experiences in understanding the world as ‘self as centre’.
Cara lives with mother, older brother and younger sister, her father left in her early years in life. Her mother struggled to look after all her children by herself, Cara feels disconnected from her mother, which in a sense it could be she is feeling neglect, no communication with her mother, on communication within the family, she has moved from her other relative family member to make things even more dreadful for her. (Hobson et al, 2005) argued that difficult childhood experiences and attachment issues lead to difficulties in forming and maintaining relationships in adulthood (Tarrier, 2009). In addition, her brother had intercourse with her and threatens her with violence. According to systemic approach it might be regarded as shared beliefs between the women in the family. Proctor (1981) illustrates families that share different beliefs maintain the patterns of relationships in the family.
In conclusion, Cognitive Behavioural Therapy (CBT) is certainly famous and most practiced form of modern psychotherapy. CBT has produced collective dealings which arise on behaviour and cognitive theories to decrease emotional, anxiety and paranoia problems Beck, 1963; Ellis, 1962), with excellent effect (Mahoney, 1974).
However there is limited investigation into the effectiveness of these methods in the framework of behaviour change and little evidence of usefulness of CBT in changing health behaviours Hobbis and Sutton (2005). The ABC models is extremely useful as a solution tool, it has limitations when helping us understand emotional disorders Cited in Johnstone and Dallos, (2010). Others studies have shown that case formulation cannot single-handedly decrease conviction of strength for delusions or negative person evaluation Chadwick, Williams, Mackenzie, (2003). Horowitz (1997) study has shown that evidence that case formulation has little or no value, but participants that were interviewed stated that case formulation improved hope and understand their problem more (Johnstone and Dallos, 2010)
On the other hand the method was very useful in understanding the family and how the problem is being maintained within the family cycle. One could say that combining model together might be good. Weerasekera (1996) proposed that formulation can start with one model and move to another, that this might bring in new opportunities that the formulation can change as more material come out about the client’s life. It could be