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 )
Situation
At home with
step-mum
Cognitive
“what’s the point in
getting up?”
Physical
Tired, insomnia,
sleeping in the
day
Mood
Sad
Numb
Behaviour
Stay in bed, on
laptop or watch
TV
Hot cross bun
(Padesky & Mooney, 1990)
Situation
Meeting
someone new
Cognitive
“I want to be
someone different”
“I’m not normal”
Physical
Butterflies in
stomach, faster
hear rate
Mood
Anxious
Behaviour
Tell lots of jokes, say
“I sound weird” out
loud
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 experiences
Dad left when 9 years
Mum became neglectful at 11 years
Core Beliefs
I’m unlovable
I’m abnormal
Assumptions/Rules
I 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 strategies
Don’t let anyone get close
Tell someone everything about me that’s “abnormal” straight away
Use of humour to detract from the “real me”
Critical Incident
Broke up from first serious girlfriend
Moved in with Dad and Step-Mum
Trigger
Date doesn’t go well, reminder of ex
NATs
“It’s because there’s something wrong with me”
“I’ll be alone forever”
Emotion
Depressed, Lonely
Physical
Tired, tearful, low motivation
Behaviour
Stop 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
Cognitive Model of Low Self Esteem (Fennell,
1997)
Activation of Bottom Line
A first date
Depression
Predictions
“I’m abnormal, I
won’t be accepted if
I am myself”
Self critical thoughts
“there’s something
wrong with me, I’ll be
alone forever
Anxiety
Confirmation of Bottom Line
Maladaptive
Behaviour
Use of humour
Proposed Treatment Plan
Aim
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)
Situation
Aware 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”
Physical
Butterflies, heart rate
increased
Mood
Anxious
Behaviour
Avoided 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?
Plan
Use 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?