Cognitive behavior therapy for schizo-affective disorder: A case study

Cognitive Behavior Therapy- A Case Study

Cognitive Behaviour Therapy (CBT) Case Study

Case report

K is a forty-eight-year female who referred to Midlothian's clinical psychology psychosis service. K has a twenty-year history of mental health conditions. She first decided to contact mental health services because of the episodes of paranoia and severe depression she had experienced. During her initial contact with the mental health services she was diagnosed with schizo-affective disorder in 1996. When she was first referred to the mental health services department she was a single. She told of having only two close relationships in her past life. She however also said that she found these relationships challenging when it came to intimate contact. She also generally described that she found it somewhat difficult to form friendships or to trust people in her life. Despite the mental health conditions her general physical well-being was good. K was prescribed with antipsychotic and antidepressant drugs. Before the prescription she had had no prior contact with any form of psychological therapies. In her description of her mental problems she described them as affecting her regularly and that they were greatly linked to her sense of inadequacy and failure. Her depressive episodes were lengthy, sometimes lasting for several days and they severely affected her vocational and social functioning. At times, in her depressive thoughts she could turn paranoid and believe that her sister had the ability to control her, a belief that was linked to unusual physical sensations in K's body. K also described a difficult childhood especially with regards to her relationship with her mother, which was not cordial at all; that her mother constantly belittled her leaving K with a sense of inadequacy. K had also been sexually abused when she was a child causing further disturbances to her sense of self. These childhood disruptions were later extended to her adult life in her relationship with her older sister, who treated her in the same manner as her mother, constantly deriding her and thus contributing further to K feeling that she was not good enough. In spite of her early difficulties, K gained an admission into a university and successfully completed her higher learning. Upon graduation, she held different temporary positions over the years such as waitressing and working as a receptionist and working at a bar. Most of these jobs were cut short due to her depression episodes. At the time of the psychological evaluation, she had not worked for quite a number of years and had only a handful of social contacts (Ponniah & Hollon, 2008; Harper, 2013; Morrison, 2007).

The belittling, neglect and abuse k suffered in her upbringing seems to have resulted in a negative self-schema associated with a sense of inadequacy and failure. She tended to view other people around her as superior, untrustworthy, and potentially harmful. The world was as an evil place to her. The time periods in her life in which negative schema were active led to experience of paranoia, depression and associated unusual experiences. Subsequently, K developed different coping strategies to prevent the activation of negative schema in her life, and thus, these ways of coping were understood as underlying assumptions (U.As). These underlying assumptions involve her being cold and avoiding any expression of emotion or emotional needs and her avoiding to open up or to trust those around her in fear of rejection. The resulting suppression of personal needs and social isolation were therefore just representations of negative schema. The main cognitive element of the problem was marked by self-criticism, leading to emotional issues such as frustrations, anger and depression. The above mentioned description of the problem and its progression was discussed after the first evaluation/assessment and K agreed that it was a logical explanation of the problems she was facing (Ponniah & Hollon, 2008; Harper, 2013).

Client's presenting problems impact CBT approach

It was important to agree that the problems that K experienced had been caused by childhood abuse and neglect and extrapolated through other difficult adult experiences. The rationale behind this explanation was that negative schemas and their associated dysfunctions emerge out of gaps in the primary nurturing experience right from early childhood and such schemas are made of a combination of the behavioural, cognitive, emotional and psychological affectations. Awareness of this fact allowed K to be less self-critical of herself, this is because she realised that her problems could be attributed to different factors instead of solely on herself. She also became aware that the active negative schemas were directly associated with her childhood experiences and thus her 'feeling like a girl', feeling emotionally overwhelmed or out of control were rational actions for her when the negative schemas were active (Harper, 2013).

According to Morrison (2007), a dysfunctional schema is a broad organizing principle that is used by one to make sense out his or her life experiences and that schemas are thought to be formed in the early stages of childhood and continues to be superimposed and elaborated upon with later experiences in life. Dysfunctional schemas can, be formed to help one understand problems in psychosis in this case (Harper, 2013) and have in several occasions been implicated in the formation and maintenance of psychotic experiences. And thus psychotic experiences can at times be thought as schemas. In our case (K's case), it was thought that a schema formulation and clinical intervention was needed because of her self-described negative self-sense that had persisted in her life since she was a child. Dysfunctional schemas were identified via Socratic dialogue and clinical questioning, through a procedure that was first proposed by Morrison (2007). Obviously, this may not be the best method for assessing the presence of dysfunctional schemas; however the schemas that were identified matched with what K had described and agreed with and thus provided a basis to form important heuristics that would allow the schema level work to continue. Harper (2013) schema level formulation was followed and therefore, the case-level formulation was broken down into two working formulations; one extending the negative self-formulation and the other developing the positive one.

Positive self-formulation was however much more difficult to form because the positive sense of self was much less experienced even though it was acknowledged to be present. And thus during therapy K was asked the question that which aspect or type of self did she feel closely resembled who she really was or liked to be. In response, K chose the positive sense of self and this step was regarded as crucial in encouraging her to continue being engaged in therapy. The negative and positive sense of self were then weighed and noted to be two real parts of self and that the negative self-dominated due to childhood experiences and other difficult adult life experiences building on that as described earlier. In the same setting, the idea of schema as prejudice, the negative sense of self was thought of a 'lens' through which K saw her life (Zayas, Drake & Jonson-Reid, 2011). Moreover, K was encouraged to see her negative sense of self-linked behaviours and beliefs as functional on the grounds that they only appeared to help her cope with negative self schema activation. Therefore, using the term that Drisko (2014) utilized, these associated beliefs and behaviours were supposed to be considered as 'good reasons'. This part of the discussion was to help K in reducing self-criticism.

The logic behind schema-based CBT was conceptualised and discussed in order to make more room to allow the experiencing of positive self and to form strategies to cope more effectively with negative sense of self. Negative beliefs are not likely to be adequate to cause emotional change, as emotional processing level that is linked to schematic beliefs is stored at different levels and not just in the cognitive domain. Therefore, for there to be any form of emotional change, clients need to change their way of 'being' and not merely their way of thinking. Discussions from ICS on the implications were thus thought to be the best way of motivating K to continue with her therapy work, particularly in behavioural experiments as the new ways of being would take somewhat longer to take root and in turn also longer to affect the linked schema level emotional states. The emotional change or implicational meaning was then discussed as a long-term objective of the therapy, while cognitive change was expected to occur more quickly. Discussing these issues motivated K to continue with behavioural experiments which at the initial stages provoked anxiety in her (Harper, 2013; Zayas et al., 2011).

Positive Self Data log

Another method that was utilized to bring about a positive sense of self was the incorporation of a positive self-log that followed the one proposed by Harper (2013). And again, the concept of schema as self-prejudice (Priyamvada, Kumari, Prakash & Chaudhury, 2009), and the function of the negative self as a 'lens' to see or experience life provided the reason for the use of a positive self-data log. The assignment was to document all positive experiences of self every day so as to create and develop a greater awareness of the positive self. Positive self-data logs were filled between the therapy sessions and reviewed during sessions.

Negative self-interventions

The justification used here was that the negative self is a real and legitimate experience of the self (Ponniah & Hollon, 2008) and that U.As and the behaviours associated with them had resulted due to 'good reasons' associated with them. And that they had also served a useful purpose over the years. The objective here was again to decrease self-criticism in terms of the negative self (self-criticism was conceptualised as a maintenance factor in the experience of negative self). The objective was to enable more awareness of the process of negative schema operation and resultant effects on functioning and or moods rather that to remove negative self-experiences. Also in this case, the cognitive work showed that negative self schema was caused by cases of childhood neglect and/or abuse and was therefore an experience of self instead of the experience of self (Priyamvada et al., 2009).

A schema flashcard showing the process of activation and operations of negative schema what steps should be taken when one was overwhelmed emotionally was created as a method of promoting negative self-schema decentred awareness. Via the promotion of decentred awareness, the objective was to decrease the attachment to negative self-schema activation and consequently reduce the associated length of distress. To create a mindful reaction to negative schema activation, the nature of decentred awareness was regarded as an initial phase of the process.

Effects of counter transference on dialogue, engagement, assessment, and intervention

The ways in which counter transference representations hinder or promote therapy process and results are known as effects. Most scholars have conceptualised counter transference as a hindrance rather than advantage to therapy and thus most literature material with regards to the matter focus on the negative aspects of counter transference. Counter transference can be portrayed as a therapist's attempts to meet his/her own needs rather than those of their clients.

The response of the therapist toward the client may meddle with objectivity. Not generally hindering to therapeutic objectivity and goals; can give imperative methods for comprehending your client's reality. Countertransference responses must be checked with the goal that they are utilized to advance comprehension of the client and the therapeutic process (Wachtel, 1993).

Since therapy is ideally geared towards meeting the needs of the client, counter transference can be perceived as being an obstacle to the therapy's fundamental aim. Similarly, MacLaren (2008), in his review of literature on counter transference, concluded that, when uncontrolled, it could have a negative effect on the outcome of therapy. He further stated that counter transference has a harmful effect on the techniques and the interventions of the therapist and that it also interferes with the patient's optimal understanding. Similarly, as argued by Nye (2006), the therapist's inner experiences often offer a useful pathway to understanding the patient's inner experiences. Moreover, careful sharing of these useful inner experiences with a patient can strengthen the working relationship and thus improve the therapy outcome (Graybeal, 2014).

Management factors in this case are the characteristics and the behaviours of the therapist that helps him or her to regulate and productively utilize his or her counter transference reactions. While on one hand, management factors may reduce the possibility of occurrence of detrimental counter transference reactions, they may on the other hand help therapists to productively utilize their counter transference reactions when they have occurred. Among the behaviours that are thought to promote counter transference management are; utilizing supervision, being in therapy, reflecting on sessions and fully meeting one's needs (Graybeal, 2014). Therapist characteristics or qualities that have been discovered to help in regulating counter transference are empathy, integration, conceptual skills, anxiety management and self-insight (DeJong & Berg, 1998; Morrison, 2007).

Counter transference brings about a revelatory process, once one has become aware of it and has effectively decoded it. It reveals to therapists the manner in which they are influencing therapy. For example, if the therapist likes old people because they had sweet grandparents, and convey this to elderly patients, then the patients feel accepted and highly valued. A good therapeutic relationship is quickly established. However, if on the other hand, therapists do not like the elderly because of their unpleasant grandparents, they are more inclined to concentrate even on the slightest forms of negativity from their elderly clients. As a result, their clients will feel rejected and devalued and the therapeutic relationship will be fragile at best. In the same way, if a therapist continues to associate elderly clients to their sweet but weak grandparents, they might not put them through the hard work needed for therapy thus negatively affected outcome (Graybeal, 2014; Nye, 2006).

If a therapist becomes aware of counter transference, it can reveal to him or her information on what is going on between their clients and them. This awareness also reveals to therapist information about how either they and or their patients are impacting the treatment process. Counter transference, thus, in a way, opens a door enabling visualization of the patient's life and the therapist's own life and the life that the two share in the treatment process. It enables a therapist to get a firsthand experience of what thoughts or feelings their clients are communicating unconsciously (Drisko, 2014; Zayas et al., 2011).

The manner in which a therapist feels that he or she is inclined to behave or to feel because of the patient's transference can be as significant as what the patient says, and at times even more so (Drisko, 2014). For example, a patient's posture of "what should I do?" can result in a therapist giving advice, helping the patient think through alternatives, or turning the question back to the patient, all reactions depending on whether the counter transferential response of the therapist is: one of pity, is he or she doesn't have the experience of being forced to act immediately; one of confidence if he or she desires to become more analytical or; one of impatience if he or she wants to stay dependent. In summary, therapists will have significant insight into the manner in which they need to organize their work with patients by decoding their own counter transference (Teresa, Andrae, Nicole & April, 2013; Graybeal, 2014).

Following this rationale, DeJong & Berg (1998) noted that counter transference was more instrumental to therapeutic work than transference itself. Counter transference is the most important research tool that a therapist has to imbibe into a client's sub-conscious.

Use of Personality

CBT practitioners utilize this approach because it speaks to them in certain ways (Teresa et al., 2013; Harper, 2013). Some clinicians unfortunately feel forced into taking up a CBT as their theoretical model because of managed care or other reasons. Subsequently, it can be argued that numerous therapy missteps that are blamed on CBT are actually a result of lack of real faith or any training prescribed in the model. While theoretically, CBT is very simple, it's competent application to difficult human problems in its theoretical complex is not that simple. CBT trainees are encouraged to solve their own issues both as a chance to practice the application of emotive, behavioural and cognitive techniques as also to enable them to better prepare in terms of being aware of and handling their feelings, behaviours and thoughts as clinicians (Priyamvada et al., 2009; Ponniah & Hollon, 2008).

Practicing techniques on their real life problem enables clinicians to experience them first hand and prepares them to use the model with their patients. With practice, CBT trainees and clinicians can create their own ways of applying the technique. The utilization of humour is encouraged in CBT but it must however be driven by the clinicians' evaluation of the kind of therapy style that is best suited for the client (Nye, 2006; MacLaren, 2008). Making fun of an aspect of the client's problem (not the client himself) can help shed light on the project and develop the clinician-client relationship (MacLaren, 2008).

Usually, if a clinician is well trained and experienced in an approach that he or she fully believes can help their client, then he or she possesses an awareness and is thus, operating within the limits of professional boundaries. It is then much easier for them to add their personality style appropriately in their utilization of self in the client-clinician therapeutic relationship.

Use of Belief System

CBT clinicians use a lot of energy discovering their own beliefs about themselves, others and the world towards being better agents of change (Graybeal, 2014). This self-knowledge or awareness enables clinicians to engage better and more clearly with patients. They then spend a significant amount of time in understanding and assisting a client to become aware of his or her belief systems. CBT respects a client's rights to his or her beliefs and the work of a CBT technician is just to help the client to assess their beliefs in terms of whether or not they are functional and to provide tools that facilitate change. The client's belief of his or her ability to change has been revealed to be an important factor in later therapeutic gains (Zayas et al., 2011; Drisko, 2014).

It seems that the relationship between a social worker and a client develops over hours, days, weeks or months. While the reality of the matter is that connections can extend after some time, there's nothing more needed than a couple of minutes or even seconds for client and provider to shape an introductory evaluation of each other. It most likely takes only three to 5 minutes to set up the essential parameters of a working organization together. In those opening minutes, it is basic to watch and adjust to clients' individual styles of connection; how they move, the nature of interaction, their dialect, their feeling of ease or distress, where they sit. The promptness of practice is reflected in parallels to improvisational theatre (Walter 2003).

Use of Relational Dynamics

Some of the components required from the clinician in a therapeutic relationship have been articulated as genuineness, unconditional positive regard, acceptance, warmth and empathy (Harper, 2013; Ponniah & Hollon, 2008). The strength of a therapeutic relationship is a consistent indicator of positive outcomes in the therapy. An effective CBT therapy requires a solid therapeutic relationship. Evidence reveals that many CBT clinicians are greatly involved in forming positive relationships with their clients, and that, thus, they are able to show support, empathy and acceptance (MacLaren, 2008).

From a relational perspective, the client and the therapist in CBT are equal in their therapeutic relationship. The client brings a lot of expertise for his or her life and the therapist has additional perspective in areas that are outside the experience of the client. In this relationship, the therapist is also knowledgeable at offering different possible proven interventions that can help the client (Graybeal, 2014). Therapists are therefore encouraged to work in collaboration with their clients as equal partners in the change process (Harper, 2013).

CBT is a problem-focused approach that encourages patients to tell clinicians what they would like to change and consequently the clinician assists the patient to the best of his or her ability. The CBT approach is then explained to the patient so that he or she can have an opportunity to discuss, ask questions and to eventually decide if CBT appears to be a good fit to them. In CBT, knowledge has to be obtained about what the patient has tried before in his or her attempts to change in order to avoid repeating something that was not effective and to build on any measure that proved useful in the past (MacLaren, 2008). The objective is to give the best support and intervention for this patient at this time given his or her stated objectives and the assessed problems.

CBT is frequently experiential. Its clinicians utilize different techniques such as teaching, modelling, role-reversal, role-playing and in-vivo desensitization to promote understanding and change within the client-clinician professional relationship (MacLaren, 2008). CBT clinicians also teach and practice mindfulness together with their clients for deeper experience and understanding (Priyamvada et al., 2009; Teresa et al., 2013; Drisko, 2014). CBT also provides a room for clients to learn and eventually practice emotional regulation and also social skills that they need so as to lead more satisfying lives (Teresa et al., 2013).

According to Nye (2006), CBT takes into cognizance that transference is the patient's response to a therapist based on generalized expectations and/or beliefs that they have about relationships rather than the manner in which the therapist actually behaves towards the patient. These beliefs and expectations are tackled in the initial session by helping the patient to understand that the client unconditionally accepts him or her and then they are used to help the therapist to understand the challenges that the client faces and to effect the changes that he or she desires (Ponniah & Hollon, 2008; Morrison, 2007).

Conclusion

Cognitive Behavioral Therapy perceives the significance of the therapeutic relationship and the therapist's utilization of self in effective therapy. A talented CBT clinician can detail issues, offer methods and make mediations in cognitive behavioural terms while interfacing with clients in a warm, certified manner. As a last note on CBT manuals it is critical to take note of that since CBT has demonstrated to have a high achievement rate with numerous issues manuals have been utilized outside of the examination world with fluctuating levels of progress to enlarge or supplant costlier and tedious formal preparing in CBT. Sadly, there is a supposition that the clinician will have what it takes and learning to adjust the material to the individual client which is by and large not the situation for clinicians who don't have fitting preparing or supervision (Huppert & Abramowitz, 2003). The adaptable utilization of CBT manualized treatment took into account particular people can be successful (Levitt et al., 2007) yet requires a social viewpoint for the clinician to have the capacity to utilize the manual discriminately.