Case Report – Assessing and Formulating Psychosis
The City and State
Case Report “Rita”
This case report focuses on the assessment and formulation of Rita’s psychosis condition. This report will be under the guidelines of Cognitive Behavior Therapy for psychosis (CBTp) formulation models refer to fundamental theoretical issues, key existing literature, and their links to actual practice. The formulation, which is the hypothesis in an individual’s challenges that will link theory to practice, will help develop the treatment plan and reflect on the lessons acquired. Notably, Rita is not the patient’s name but a pseudonym so that confidentiality can be maintained. Also, some information in the client’s medical context has been disguised. Still, the report balances the provision of minimum information to capture the pertinent issues while not depriving the reader of fundamental information required.
At the beginning of the therapy, the treatment duration had been agreed upon to be a minimum of 16 sessions as per the clinical recommendations given by the CBTp programme. The main objective of these sessions will be a reduction in distress and improved functioning. At the development of this case report, seven sessions had already been undertaken.
Client’s Biographical Data and Current Circumstances
Rita is a 26-year-old female of Black Caribbean origin. Rita was born and raised in London and is currently single. She left home at the age of 14. She has reported dealing with verbal and physical abuse from her mother, prompting her to move to her aunt’s place, where she lived for a year. Her aunty tried to cope with her behaviour prompting but could not do it any further; hence, Rita moved into a hostel. At the hostel, other girls would bully Rita. Rita did not meet with her biological father until the age of 16. She is the firstborn to four siblings from her mother’s side. She remains in contact with their family. Her relationship with her mother, conflicted. However, she has a good relationship with her aunt, who has remained supportive of her. Currently, she lives in a 24/hr supported placement and is unemployed. She was volunteering part-time, but since the placement of the lock does, she stopped.
Development of Problems.
Rita is well known to mental health services. She came into contact with services at the age of 16. She struggled with depression and anxiety for over 15 years. She has heard voices from childhood. She has experienced childhood sexuality. This research literature will draw causal links between childhood trauma and psychosis particularly the presence of comorbid depression (Garcia et al., 2016), anxiety disorder (Reiff et al., 2012, 2) and extensive auditory hallucinations (Reiff et al., 2012, 2).
Rita is under the care of a CMHT. She is under the Care Programme Approach receives care from a psychiatrist who reviews her every three months. She has a diagnosis of paranoid schizophrenia. She is prescribed Clozapine, and Aripripizole Rita referred for CBTp for her care coordinator’s voices and anxiety.
Previous Psychological Treatment
2015 – 6 talking therapy sessions on how to manage difficult situations.
2016– 16 sessions of CBT trauma-focused therapy.
Rita’s main presenting problems would like to get psychological help with difficulties related to managing hearing voices (interpreted by her as the devil) and anxiety. Rita also described experiencing low mood, feeling ’empty’ at times, lacking motivation, low energy and being exhausted. She experiences distressing voices which are derogatory and threatening in nature. Over the past few months, her voices have increased in frequency, duration, and intensity.
To cope with distressing emotions and ‘voices’, Rita described spending time at home and in bed, where she feels safer, avoiding family and friends, not going outside much, ‘ not doing some of the things she enjoyed doing. Rita described several more helpful coping strategies: listening to music, painting, self-care, writing poetry and going to church but is currently unable to attend church services.
Scores on Personalised Measures and Standardised Measures:
Cognitive-behavioural therapy (CBT) is an empirically supported approach that has gained widespread application in treating substance abuse disorders. The intervention uses standardised and personalised measures to assess the present health problem and measure the progress and effectiveness attained by the implemented interventions. Self-report standardised measures for voice interviews were used in the first stages of the Psychotic Symptom Rating Scales (PSYRATS). Thus would facilitate a beneficial discussion and gaining critical information in Rita’s experiences.
PSYRATS: Voice Hearing Scoring Sheet
1. Frequency 2
2. Duration. 3
3. Location. 3
4. Loudness 4
5. Beliefs Re: Origin. 3
6. Amount of negative content of voices. 3
7. Degree of negative content. 3
8. Amount of distress. 3
9. Intensity of distress. 3
10. Disruption to life caused by voices. 2
11. Controllability of voices. 4
PSYRATS: Haddock et al, 1999
It was explained that PSYRATS would provide a baseline and we would complete it again midway and at the end of therapy to measure and explore any changes. During the assessment process, we also discussed idiosyncratic and personalised measures, including conviction, belief in cognitions, pre-occupation, distress and mood. For example, Rita rated her anxiety of going out at 80% (with 0% being not anxious and 100% being the most anxious she had ever felt). She also rated low mood and fear at 90% using the same scale. She rated the belief in her voice ‘you are not good enough’ at 80% (with 0% not believing it at all, and 100% true).
Given the indicators of high levels of anxiety and depression being linked to hearing voices, Rita also completed two further standardised outcome measures, the Generalised Anxiety Disorder Questionnaire (GAD-7) (Spitzer et al. 2006); and the Patient Health Questionnaire (PHQ-9) (Kronenke et al. 2001). She scored 16 on the GAD-7, indicating severe anxiety, and 18 on the PHQ-9, indicating severe depression. These will also be repeated midway and at the end of therapy.
The risk was assessed as part of the assessment. Rita reported that she hears voices which she interprets as the devil’s voice saying negative and derogatory things about herself. At times the devil’s voice has been so intrusive that she has attempted to harm herself and end her life. In the past, she has attacked people due to the voices. No current plans or intent to act on them or to harm others. A safety plan was in place, and Rita said that she would seek help in a crisis. Risk and mood were reviewed at every session. Strong protective factors are her aunty and her Christian faith.
Rita identified, and we collaboratively agreed and prioritised the following goals. These were reviewed regularly and smartened as therapy progressed.
• To enhance strategies to distract and cope with voices.
• To enhance strategies to cope with anxiety and depression.
• To increase meaningful activity and improve social networks and relationships/connections with others. We made this goal more concrete as therapy progressed
• To cope with and distract voices better with meaningful activities e.g.
• Participating in art therapy x1 a week
• Reconnecting and seeing family members and a couple of old friends
• Joining in her church service online once a week.
• Daily exercise and increasing gradually.
In CBTp, the therapeutic process is conceptualised via a series of fundamental steps that will reduce Rita’s symptoms and disability through a change in beliefs about the symptoms. Fundamentally, a robust therapeutic alliance is developed for the treatment to be successful. The therapist is to adopt the “collaborative empiricism” strategy that entails working jointly with Rita to better understand her experiences, thoughts, feelings, and goals (Landa, 2017, 7). The therapist is expected to be empathetic and normalise engagement with Rita to understand the problem the same way the patient will understand it. Rita is to describe her experience, the process they take to making their conclusions, and the process taken in developing their individual beliefs. Engagement will be incorporated entirely through the therapeutic relationship despite it being categorised as the initial step in the therapeutic process (Landa, 2017, 7).
For each session, the CBTp’s structure will be essential for maximising predictability and reducing anxiety levels, increase Rita’s investment and involvement in the treatment process, helping to exercise memory, and developing meta-cognitive skills. In the initial minutes of the sessions: Rita and the therapist are to carry out several activities: a complete mood check, quantifying the severity of symptoms, setting up the session’s agenda, and setting up the order of topics for discussion. During the session, the therapist is to review any assignments given, assess Rita’s progress during the session and transitions, relate topics to previous discussions, and the whole treatment plan. After the session, issues to be handled include reviewing upcoming topics, making plans for the upcoming sessions, assessing Rita’s perception of the session, what is helpful and what was not helpful, finalising the mood check and reviewing any assignments.
The formulation development within CBTp will help Rita and her therapist gain a better understanding of the links between her early experiences, primary schema, obstructive thinking patterns, and maintaining the prevailing symptoms (Hardy, 2017, 3). Essentially, this stage will inform the intervention taken as it points out the changes that should be taken to handle the distressing symptoms.
The initial sessions focussed on Rita’s presenting problems: difficulties related to managing hearing voices that she interpreted to be the devil’s voice and anxiety. The ABC model was incorporated as the basic framework to understand and formulate the voices and delusional beliefs. Through the framework, the acronym “ABC” simplifies the cognitive process such that A represents the activating event that is particular observable experiences, B is the belief including the thoughts and beliefs of the mentioned events and C representing the consequences both emotional and behavioural consequences to the thoughts and beliefs (Landa, 2017, 6). The ABC model was hence taught to Rita so that she could construct her thoughts and beliefs.
Beliefs about experience
I went outside in the afternoon. My mood is low, anxious thinking about my past.
I hear the voices of 3 women and two men. Sometimes it can be three or 5 of them.
Sometimes they are loud and other times they are low.
I can hear them throughout the day night. They are mostly when I am alone and worse when I am stressed, low or anxious.
“Just give up “what is the point “just end it, end your life.
“you are not good enough *you are ugly and useless’ ‘no one likes you, “they think you are weird.
“stay in, don’t go out< it is not safe.”
“I will be ok, just carry on.
The voices are devil, tormenting me for the things I did in the past.
The voices are powerful. I have no control (belief 60%). I have to listen to them. I have no choice but to take the battering.
I can’t resist them; they just get louder and won’t stop.
The voices of the devil want me to give up and end my life. They are strong but not strong that I will follow through (65).
The voices are right. I am worthless, not good enough, incapable of believing this 70%.
They are right; they are right. I am weird and not normal.
I must do what the voices say and not go out and stay in bed. I will not be harmed. I am not open to judgement, hurt and pain.
It’s intolerable, distressing, painful and tiring. I can’t cope with it.
Sometimes I feel like giving up on life.
Stay in bed ruminating, and can’t sleep.
Give the voices my full attention. Listen to the voices and stop what I was doing ( “take the battering”).
The urge is to follow their instructions.
Stay at home.
Figure 1: ABC Formulation for Voices
While undertaking the ABC, Rita and the therapist were able to identify the most troublesome challenges, determine Rita’s thinking habits, consider how Rita behaves to them, and look at how unrealistic or unhelpful the thinking or behaviour habits were and look into opposite ways in which the habits could become more helpful to solve the challenges. Finally, these new ways were to be tried again and selecting the workable ones. The guiding principle in this therapy is that Rita’s emotional reactions result from their perception of distinct events as per Beck’s Model of Emotional difficulties (Lester, 2020). After this framework, Rita was able to relate to the entire process understanding how distinct events were triggering her distress, which was very unhelpful considering the reactions she made towards the triggers. Essentially, Rita identified that her challenges were mainly inherent such that the beliefs she had towards these voices were playing a huge part on how she was reacting towards them.
The information collected from the initial sessions was used to develop the formulation collaboratively. This meant having a maintenance formulation illustrating how Rita was interpreting the voices she heard and the impact of the interpretations in her feelings and behaviours. The maintenance formulation was the starting point for Rita’s CBTp as we helped identify the interventions for her thoughts and behaviours. The upcoming sessions could help in building up the formulation and even undertaking further symptoms and past experiences leading to yielding information to guide in a longitudinal formulation., the longitudinal formulation would draw from Rita’s early experiences to aid in understanding how particular beliefs were formed and the interpretations to the event. The therapist is hence able to better understand how Rita responds to particular situations and helps her identify and make better responses to thinking and behavioural patterns.
Notably, while the formulation is done together with Rita’s important input, the complex case formulation should be utilised as the main feature in team meetings to offer support to steam treatment planning, with respect to Rita, her childhood abuse from her mother and the bullying from other girls in the hostel affected the world and self-view. Rita’s primary beliefs included “I am not good enough, I am weird, I am not normal, I am incapable, I am worthless, people are cruel and cannot be trusted, even those close to me, other people are judgemental and can’t see weaknesses, people are dangerous, evil and the world is unsafe. Understandably, Rita gets to interpret the auditory hallucinations negatively and as threats.
According to Haggard (2017), citing the learned helpless model by Abramson in 1978, depression results from a depressive attributional style where the bad results are seen to originate personally.. Stable and global faults of character. In relation to Rita, her interpretations of the voices are attributed to her incapacities, such as not being normal, not being good enough, worthless, and even incapable. Lester (2020) indicated that the distorted and biased inferences arise from negative emotional states within clinical challenges. Rita’s cognitive processes and attributional biases demonstrate emotional reasoning that tends to relate the external events to herself and blame herself for all the wrong things. Rita also externalises bias through the voices where she sees them as an external cause (from the devil) and is powerful and in control.
In relation to Rita’s hallucinations, the therapist incorporated Socratic questioning to explore the connections made by Rita and determine that the primary hallucinations were causing her distress and making her not be in control of her thoughts (Sivec and Montesano, 2013, 460). The voices were powerful as Rita would comply with what they said that she would not even leave the house so that she does not meet the “evil people”, cause emotional stress as she feels anxious and scared and adversely impactful on her functioning as she chooses to stay in bed all day long. An assessment of Rita’s beliefs specifically on the origin of the voices, her triggers are mainly when she is alone and feeling stressed, she hears the voices of five individuals (three women and two men) that keep telling her to give up, she is ugly, useless and even not good enough. These voices control her as she chooses to stay alone even further and avoid her family and friends. An understanding of the nature of her triggers to the voices can be connected to child abuse, neglect, and lack of nurturing that she did not receive from her present mother and the absent father. Like other children, Rita did not grow in a normal family where parents are seen as protectors. Being sexually abused by her cousin and even being bullied by other girls in her hostel would reaffirm her that she was also not good for the outside world, which was also not treating her well enough.
In this case, the therapist recognises that Rita has lived a lonely life. It was time to normalise alternatives such as the possibility of experiencing voices and still live a normal, productive and happy life (Landa, 2017, 20). Normalising Rita’s experience entailed referring to famous and successful persons such as Anthony Hopkins to try and inspire hope and reassurance of better wellbeing in the future.
According to Reed et al. (2008), childhood trauma has been linked to several mental health challenges such as depression, anxiety and psychosis. The hallucinations and delusions are linked to childhood trauma in terms of the problematic thinking styles originated from abuse and other childhood disadvantages. The hallucinations have been seen to come from sourcing elucidating difficulty in accurately attributing experiences, specifically the inner thoughts to the internal or external sources.
Rita pointed out several traumatic experiences that could be linked to the development of psychosis and being cognitively vulnerable. In her childhood years, Rita stated that she experiences both verbal and physical abuse from her mother. She was neglected and never nurtured as a child should be. She also experienced bullying in primary school, secondary school and at the hostel too. At the age of 9, she was sexually abused by her cousin. Also, her biological father was not present in almost her entire childhood life as she met him at 16. These traumatic experiences demonstrate how Rita could develop negative beliefs about herself and believe them to be true. This is because neither her home nor school environment was conducive for her as a child. She, therefore, grew knowing that her environment is an unsafe place that cannot be trusted. This prompted her to run away from home and live with her auntie, which she could not do so for long due to her behaviour. While she now has a better relationship with her auntie, she now prefers living along as she believes that letting other individuals into her space will only be hurting her. Hence, the reason she left home at the age of 14 to live alone.
Rita also started using illegal drugs at the age of 10, and has been to prison on remand are other significant events that demonstrated rejections from the society. Individuals who engage in illegal drugs have always indicated that they lack the right guidance and support they require, especially in their depressive periods. This is evident in Rita’s life who has been living alone and unlived life since her childhood. The depressive symptoms and psychosis worsened when she went to prison as it is not an environment that is loving. The early events contributed to the development of fundamental predictors that are affiliated with developing psychosis. The emergence of later events would wholesomely cause a problematic emotional and interpersonal adaptation, higher sensitivity levels to interpersonal stress such as the emotional over-involvement, poor prosocial coping skills, withdrawal and an impoverished reflective function. These are the symptoms that Rita is dealing with, and with her feeling that she has no control over her emotions, thoughts and beliefs, she lives as if they are true.
Current Triggers and Modifiers
Rita indicated that her present triggers and modifying factors would increase in frequency, intensity, and duration whenever she is alone and when she is stressed, low or anxious. With the lockdown placed for the pandemic, Rita cannot engage in any volunteering, and she still has no job. This causes her a lot of stress which triggers the negative voices. Notably, Rita provided several helpful coping strategies that she could incorporate, such as listening to music, painting, self-care, writing poetry and going to church but currently unable to attend church services.
Rita’s maintaining factors included staying alone at home and in bed, avoiding family and friends or any interactions, and not engaging in things she enjoys doing. These are the safety behaviours which primarily entail being alone. Nonetheless, the loneliness meant that Rita would focus on her difficulties by giving the voices full attention, ruminating and worrying extensively. To this effect, Rita fails to do any functional things that would help her with the negative voices and the adverse impact.
Each of the triggering events for the voices that caused the childhood trauma led to increased fear and apprehension for Rita and would have the anomalous experiences of having the urge to listen to the voices and believe them. Rita appraising the emotional and cognitive changes was affected by the prevailing beliefs about herself and her world: “I am not good enough, I am ugly and useless, Stay in and don’t go out as it is not safe”. The positive symptoms’ maintenance processes created the hypothesis that Rita’s reasoning and attributional style, depression, anxiety. Using safety behaviours and incorporating coping strategies to suppress the voices appraised her to be suffering from psychosis.
Cognitive models have pointed out several cognitive and behavioural mechanisms attributed to the susceptibility to psychosis leading to traumatic experiences. One of them is the shared developmental and maintenance factors operating in psychosis cases and present in PTSD (Larkin and Read, 2008). The model is built upon the work by Morrison on the integrative cognitive approach to hallucinations and delusions. It states that hallucinations and delusions could be representative of distinct points on a spectrum of responses to trauma mediated by the shared mechanisms such as one’s attributional style or interpretations of voices, fundamental to this model is the concept that the traumatic experiences lead to negative beliefs about oneself, the world and others (Valmaggia et al., 2008). These held beliefs create distressing interpretations of even ambiguous situations, highly prevalent with psychotic patients. Research has indicated that these beliefs, especially those that arise as an adversarial impact of trauma, are affiliated with psychotic experiences (Smith et al., 2006, 163). Also, it has been suggested that transparency on the link between the traumatic event and the content and form of psychotic experiences will determine whether the individual is considered psychotic suffering from previous trauma impacts.
From the formulation diagram, Rita’s interpretations of the voices, the maintenance factors and safety behaviours offer guidelines on the CBTp treatment plan. The interventions incorporated will focus on handling Rita’s challenges and achieving her goals for the better quality of life and reduced distress. As illustrated below, the maintenance cycles for anxiety and depression to Rita;s case were drawn out to illustrate the vicious cycles that play out to maintain them. When Rita felt anxious, it made sense to do things that reduced the anxiety. She would try and reduce it by avoiding the feared situation entirely (Centers for Clinical interventions, n.d.). The avoidance instantly reduced the anxiety as one has not put themselves in a distressing situation. Nonetheless, the avoidance only reduces it in the short run and worsens it for the long run. The same cycle continues for the depression.
Figure 2 & 3: Maintenance Cycles Relating to Rita’s Depression and Anxiety
In the evolving formulation, the longitudinal formulation based model develop[ed by Morrison (2017) was utilized as it allowed a historical formulation yjay incorporating life experiences and beliefs created hence validating the experiences and creating an optimism for change to happen (7). Rita’s beliefs on the voices she was hearing demonstrated a close affiliation to the negative self attributes she developed and to her earlier experiences.
Figure 4: Morrison formulation diagram
Cognitive Behavioral Interventions In Progress and Being Considered for Rita’s Treatment
Care Programme Approach Under the care of Community Mental Health Team (CMHT) In this intervention, Rita receives psychiatric care for the diagnosis of paranoid schizophrenia. She undergoes care review after every three months. She is also taking medical prescriptions of Clozapine and Aripiprazole given by her care coordinator to deal with the voices and anxiety.
Empathic Exploration In this intervention, the therapy will be focussing on dealing with distress related to the delusions (Pinninti and Gogineni, 2016). Rita, the 26-year-old, believes that the voices she keeps hearing are the devil, tormenting her for the things she did in her past. In the case, the therapist will explain that he understands that it is scary for Rita whenever she is alone, and the voices start tormenting and talking negatively about her. This wants Rita to reduce her defensive position and open up on her distress (Pinninti and Gogineni, 2016). The follow-up steps will focus on bringing in new information on the orient coping strategies, such as how she has been dealing with the situations for the past few weeks. The therapist is trying to get useful information on the listing coping strategies that will be effective for Rita. Considering Rita’s conditions, enrolling Rita into groups engaging in art, constantly staying with family and close ones, and even a gym should reduce the time she spends alone.
The normalisation of Psychotic Symptoms This has been considered the antidote to stigma, and catastrophizing will need to be avoided entirely. Mental illnesses are common with at least one in every four persons experiencing it regardless of their age, gender, ethnicity or other traits (Hardy, 2017). Notably, each individual does have the capability to overcome the symptoms by positively viewing them. Normalisation in Rita’s case would involve informing her on the rate at which individuals are dealing with depression, anxiety and hallucinations. The main focus is to look into the links between her traumatic childhood experiences and her overall personal safety view. The process will be about normalising her experiences through providing success stories of persons that have gone through a similar journey. With her consent and an understanding that this will help her with her condition, Rita is also included in groups of people dealing with psychosis. In these interactions, Rita learns about the prevalence of the symptoms she is facing and helps her understand the journey she needs to take to deal with the issue.
Cognitive Restructuring The main objective of this intervention is to compassionately challenge and restructure the auditory hallucinations (Mankiewicz and Turner, 2014). It will begin with an evidential analysis of the content within the delusional beliefs. The next step is a reattribution of the beliefs about the voices. Here, Rita identifies the existence of repetitive negative internal dialogues that are happening in his thoughts. These dialogues precipitated the experiences she had with the auditory hallucinations, while the voices represented her fundamental worries about her life (Mankiewicz and Turner, 2014). In conjunction with the information gained from the normalisation discussions, Rita will be on the path to understand the functional affiliations between the voices, the derogatory beliefs, and the concerns she had towards her life. Over time, Rita is encouraged to practice identifying the internal thoughts daily and when they normally happen, which is evidently at her lonely times. Restructuring these unhelpful cognitive experiences would begin by implementing several better self-statements such as she is beautiful and not being punished for anything for she has not hurt anyone.
From that point, Rita will practice to reframe the negative appraisals of her experiences, identify the cognitions inducing depression and anxiety then replace them with proof and better self-statements (Mankiewicz and Turner, 2014).
This research on the assessment of psychosis would present fundamental lessons that I would not have gained if I did not take the entire process. One evident thing was that an assessment of psychosis is a complex process that needs to be done articulately to ensure that the desired objectives are attained. In this case, I understood the five stages incorporated into Cognitive Behavioral Therapy for psychosis (CBTp) and the importance of each one of them. These stages include engagement, assessment, formulation, goals, intervention and even relapse work. It became evident how a collaborative treatment alliance between the client and the therapist streamlines this complex process. Therefore, as a therapist, it is prudent that one builds their collaborative skills to improve the interactions’ quality. The process also ensured that I understood that mental health conditions could affect anyone and arise from anything. Therefore, the development of listening skills is fundamental to understanding the patient’s situation.
Notably, extensive research has been done on assessment and intervening on the psychotic issue. Therefore, it is the therapist’s responsibility to be conversant with the many interventions existing since they will need to find the best approaches that will work for their clients. A cohesive treatment plan will understand the patient entirely and recommend an effective approach after an analysis of all the effective ones existing.
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