The second CBT session:
finishing the assessment and making a longitudinal formulation and diagnosis (part 2)
Hopefully, you now have a cup of coffee and a copy of the OCTC (2009) generic longitudinal formulation, available from: https://www.getselfhelp.co.uk/docs/basicformulation.pdf
The four part problem list box (in the centre of the formulation) helpfully specifies the problematic symptoms as
- Problematic thoughts
- Problematic emotional feelings
- Problematic physical symptoms
- Problematic behaviours
The rest of this session is essentially dedicated to systematically asking the client discovery questions, such that we can complete all the boxes in this longitudinal formulation.
Here is my script for explaining the formulation process to the client. For ease of reading, I have highlighted the script that has developed naturally for me in blue. The questions highlighted in pink are the ones that I consistently find particularly high yielding.
‘Let’s start to bring together what’s happened to you so you can understand it better and we can start to think about how to help you. I’ve got some views on it and you will have too, so we can share them and see if we get to something we both agree on. We will end up with what we call a formulation, which is a brief way of condensing the information so we can make sense of it.’
I begin with the vulnerability factors:
‘Vulnerability factors are things in your background that may have made it possible for your problems to arise. They may not cause a problem but it’s like the ground that can provide the soil in which a problem can grow. Do you have any ideas about what might have been important in your background?’
This question is a great open question for giving the client space to tell any outstanding historical facts/events that assessment has not revealed thus far.
Next I ask about the client's beliefs, rules and assumptions:
‘What ideas about yourself do you think developed from those experiences and that background?’
This is one of the most useful script questions in my whole kitbag! Exploring their own ideas quickly and reliably yields assumptions/rules for living and beliefs. To which we can add ones already elicited through the Mood Diary and the formulation of the current problems from session one.
We then identify and document the precipitant situation that either provoked onset of the client’s problem for the very first time, or caused significant worsening of a long-standing problem. This is usually the answer to the question:
‘What happened that finally made you come and see me for help?’
I find that it’s really helpful to establish at this early stage if the precipitant situation was the very first time that the client experienced their problem. If so, the precipitant situation may be acting as an unprocessed ‘trauma’, with implications for diagnosis and treatment (see later articles).
Next we elaborate the triggers and modifiers that may have become apparent in the first session, when describing and formulating the current problems.
Triggers are ‘the things that make the problem more or less likely to occur.’ They essentially ‘flip the switch on’ and can do so many times every day. (In contrast, precipitants happened in the past and often only as a single traumatising event).
Modifiers are ‘the things that make a difference to how bad the problem gets once it starts.’ To continue the light switch analogy above, modifiers are like a dimmer or brightness function on the switch.
Eliciting information about triggers and modifiers now is useful for later, when setting up behavioural experiments in the treatment phase of CBT, as they can point to a hierarchy of situations that create increasing distress. These can then be addressed through serial experimentation, starting with the least distressing.
Now we move to eliciting the maintaining processes. These are the psychological processes that keep a problem going. They are often in the form of vicious cycles in which the original thoughts, feelings and behaviours give rise to effects that ultimately feed back to the original symptom, keep it going or even making it worse. The major maintaining processes are usually behaviours in the widest sense, such as:
- Safety seeking behaviours – doing something you believe will prevent disaster from happening
- Avoidance of the feared situation/object – can be overt or subtle
- Escape from the feared situation/object
- Withdrawal from positively rewarding experiences
- Worrying
- Ruminating
- Hypervigilance – usually of physical sensations
- Catastrophic misinterpretation of physical sensations
- Behaviours that make prophecies about the self come true e.g. hostile behaviour towards others creating hostility to self; social withdrawal causing others to withdraw from self; worrying about performance causing actual performance to become impaired
- Fear of fear – when the symptoms of anxiety are perceived as so aversive that the client has anticipatory fear of becoming anxious
- Perfectionism – failing to achieve impossibly high standards causing standards to be raised even higher, with inevitable disappointment and distress
- Behaviour that has a short term reward – e.g. seeking reassurance, anger, aggression, substance abuse, some eating disorders
- Behaviours that result from cognitive biases e.g. self-criticism, procrastinating
Key questions that I ask to elicit maintaining processes include:
‘What keeps this problem going?’
‘What stops this problem from going away and keeps you stuck?’
‘How have those people who are important to you responded to your problems?’
‘What coping strategies have you tried and how successful have they been?’
The key maintaining processes are documented in the boxes immediately below the arrow cycles on the OCTC longitudinal formulation template. Most clients can usually see at this stage, albeit with some trepidation, that these maintaining processes are what they are going to have to disrupt, in order to break the cycle of distress. The targets for treatment fall out fairly logically from the above.
I cannot emphasise enough how revolutionary the concept of maintaining processes has become to how I ‘do CBT’. Looking out for patterns of thinking, feeling and behaving that keep the client ‘stuck’ in their distress – these are key to:
- Creating a framework upon which to structure the assessment sessions
- Creating a framework upon which to set the agenda for every session
- Selecting the most appropriate CBT interventions to use/teach the client in treatment sessions
- Devising an effective relapse prevention plan in the final session
The final aim for this session is to make and share the working diagnosis. Rarely, it’s simple, when the client has a specific phobia. Other times, I may have gathered enough information to be reasonably confident the client probably has Social Anxiety Disorder or OCD, for example. On other occasions, I might only be confident that the client has co-existing anxiety and depression, but not yet be clear whether it’s Generalised Anxiety Disorder with depressive features or Major Depression with anxious distress. Not infrequently, I get to the end of the formulation and think the client’s fundamental problem is low self-esteem, which is not a diagnostic category at all! However, the discipline of trying to make a diagnosis is invaluable, because it:
- Highlights gaps in my assessment to date
- Highlights where ambiguity exists in my mind about the precise thought or feeling that the client had, or the behaviour with which she responded – clarity around these can help swing me towards one diagnosis rather than another
- Makes me refer to the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). The Differential Diagnosis section under each disorder contains tips that help to decide the diagnosis between one disorder and another
- Helps me to select a disorder specific model to guide treatment and interventions
If I am not yet clear enough about the diagnosis, I will defer sharing a specific diagnostic category with the client at this stage and talk more generally about ‘depression’ or ‘anxiety state’. I then invariably set a Thought Diary for homework, in order to refine my hypotheses about the diagnosis during the next session.
I know that some therapists are wary or even critical of making a diagnosis at all. Personally I can’t see how I could otherwise claim that my interventions are truly evidence-based. I frequently explain to clients that this is the value of a diagnosis – it is not to simply categorise or reduce her unique experiences to a generality for the sake of it.
My experience is that all clients value the formulation for ‘making sense’ of their difficulties and their life experiences. The formulation gives a road-map for where CBT will take them and this sense of direction can be comforting and a relief at the end of the assessment process.
Summary points
Create a four part problem list
Vulnerability factors: are the things in your background that may have made it possible for your problems to arise. They may not cause a problem but it’s like the ground that can provide the soil in which a problem can grow. Do you have any ideas about what might have been important in your background?’
Assumptions and beliefs: ‘What ideas about yourself do you think developed from those experiences and that background?’
Precipitants, triggers and modifiers – the latter are helpful when setting up a hierarchy of stretching Behavioural Experiments
Maintaining processes are key to ‘doing CBT’. They can usually be captured in vicious cycle type mini-formulations
Make, share and explain the working diagnosis and what value it adds