Psychology: Case Study
Initial interview 4
Assessment formulation methods utilized 4
Assessment of John presenting problems and goals 5
Analysis and critique of MMT approach 6
Agreed goals 6
Treatment plan 6
CBT interventions 7
Intervention for cognitions-thoughts records 7
Benefits of the approach 7
Interventions for behavior- activity scheduling/diversion techniques 8
Benefits of the approach/ interaction 8
Interventions for imagery/interpersonal- imagery based exposure 8
Benefit of approach 9
Intervention for sensation- relaxation/ visualization 10
APPENDIX 1 13
Psychology: Case Study
A nurse - who works in a busy inpatient ward-, the writer argues how difficult it can be to undertake a thorough assessment when interviewing patients. It is also too easy to overlook relevant details if only cognitions or specific behaviors are being examined. Multimodal therapy (MMT) is the approach to psychotherapy based on the view that there are various modalities of each person that should be addressed when identifying or treating a psychological disorder. Each individual is affected in various ways and in different amounts depending on the dimensions of their personality and should be treated accordingly in order to facilitate remission of a client’s disorder named (2005).
The MMT framework comprises of seven modalities: behavior, sensation, affect, cognition, interpersonal, drugs and biology (Kerkhof & Akhnikh, 2010). This framework is known by the acronym BASIC ID and is utilized for the assessment of clients. This research will discuss John (acronym) a former patient at the writer’s place of employment that was briefly counseled. This paper will therefore discuss the following: the modalities utilizing the revised BASIC ID model, initial interview, assessment methods utilized, agreed goals of counseling, the use of some of the writers chosen CBT interventions with John. Finally, benefits and disadvantages of these CBT interventions in relation to the writer’s interactions with John will be discussed.
John Bio Psychosocial Profile
John, a 36 year old single male, diagnosed with adjustment disorder three months ago after being let go by his place of employment was admitted to a hospital X (acronym) for deterioration in mood over the past 6months. He is the only child raised by both parents in Melbourne. He is of a Catholic, Irish descent and this is Johns first admission to a psychiatric facility. There is no known family history of mental illness. John has a Bachelor’s degree in business management and has worked for a popular Communication Company for the last decade until he was terminated 6 months ago. John has no history of suicide or self-harmand denies any suicidal thoughts.
The interview took place in the interview room of hospital X. The aim of the initial interview was to create a therapeutic alliance between John and the writer;it also enabled the increase of any therapeutic techniques implemented in later sessions to be more effective due to a collaborative relationship (Loewenthal, 2010). The initial interview also fulfilled other functions in that the writer would get an idea of what problems John wanted help in solving and what he would like to achieve through counseling sessions.
Assessment formulation methods utilized
It was important for the writer that information was gathered in order to do a comprehensive evaluation in each of the BASIC ID modalities (Chigwedere, 2012). Assessment methods employed to gather info were: patient history, the Multimodal Life History Inventory questionnaire that John had to complete before the next session and a cognitive behavioral analysis through acronym FIDO and ARCS questioning.
Lazarus (2005) argues it is advisable to engage the client by focusing on the presenting issue, to redirect matters too prematurely onto other matters that seem more important is only inclined to make a client feel invalidated
FIDO and ARCS questioning are acronyms for questions relating to frequency, intensity, duration and occurrence of problems (FIDO) besides, Ant incidence, Response, Consequences, strengths (ARCS) questioning- provided a thorough cognitive analysis of John. During the assessment information gathered was documented across the BASIC ID modalities.
Being that John was diagnosed with adjustment disorder it was important that he understood the basic cause and nature of the disorder. Psycho education provided regarding CBT therapy and how treatment usually proceeds was provided as it was imperative that the process of therapy make sense to John and that it feels right for him.
Assessment of John presenting problems and goals
At the end of the initial interview, John was issued a copy of MLHI to complete at home and bring to our next session. A description of John’s problems as per his MLHI read that- since the loss of his job 6 months ago, he has found it difficult to cope with feelings of sadness, anger and anxiety. These feelings interfered with his everyday functioning and therefore he preferred to stay at home and not socialize with his family or friends. Furthermore, he had noticed negative self-talk to be major trigger towards his low moods and change in behaviors. John reports his coping strategies to be limited due to poor inadequate engagement to the outside world. Moreover, he employed emotional avoidance strategies and suppresses painful feelings from family and friends.
Analysis and critique of MMT approach
According to Lazarus (2005) MMT offer a distinct set of assessment procedure that that facilitate treatments outcome by shedding light on the interactive processes the presenting issues at play in the clients BASIC ID modalities. MMT pinpoints a selection of appropriate techniques and their best mode of implementation, it should also be argues that MMT offers whenever possible empirically supported treatments. However Lazarus (2005) argues that although the MMT approach offers a selection of appropriate and effective techniques for each individual there also exist several situations where multimodal one may choose not to work. For example clients with extreme depression may not be able to complete a MLHQ. Furthermore certain situations may call for immediate crisis intervention, on which interventions or methods would be more limited but intense.
Following the summary of John’s problems, it was collaboratively agreed on how to prioritize these target areas. This called for putting some problems to one side for the time being and then having jointly identified key areas, together drawing up a plan of strategies to tackle the problem- this provided focus and structure. John reported his main concerns where his cognitions, affect and sensations as stated in appendix 1. Johns agreed goals of counseling were as follows: challenge negative self-talk, create tension release techniques, participate in more social and non-social activities, and minimize rumination of intrusive painful memories.
With regard to initial assessment John’s treatment plan followed a pathway of CBT interventions in which each of Johns significant problems were attempted to be addressed wherever possible, by empirically supported approaches. Therefore a standard series of CBT intervention was embarked on refer to APPENDIX 1.
Intervention for cognitions-thoughts records
John was encourage the use of a thought record, this helped John, look for evidence that both supports and contradicts his negative thoughts, and furthermore it aimed to help John to develop a more balanced thought. For example John was struggling with the thought “why bother? I’m just a failure.” The thought record offered John evidence of the thought being true and example of it being untrue in his life. Benefits of this intervention were that John was able to identify different types of unhelpful thinking styles that perpetuate automatic negative thoughts (Miller 2003).The thought record helped John establish that he was over generalizing at times and making premature negative conclusions about events that hadn’t even occurred, thus discounting the positive and emphasizing on the negative (Ogden, J. 2010).
Figure 1 an idea of what John's initial formulation looked like.
Benefits of the approach
As the sessions continued, John confessed that the thought record, guided him to a new more balanced thought process, which also contributed to ease of feelings of anger, sadness and anxiety (Rhodes, J., & Jakes, S. 2009). John reported that instead of his initial thought that sounded like ‘Why bother I’m still a failure, John now tries to employ a more balanced thought similar to “even though I don’t do everything 100%, I’m still capable of doing most things pretty well.”In simple terms, the way John's therapy progressed to ensure the benefits was by speaking to the areas in which it was at ease to make changes. Clearly, it is not simple to change physicalor feelings states and it does takesome time to work on our negative thoughts and beliefs. On the other hand, it is possible to make changes very quickly in John’s behavior. Even small changes to what can be done have big effects on what we reason and how we feel. Each week, the benefits would come when John agreed to commit to homework. Sometimes this would simply keep a record of his negative thoughts and how he would respond to them. On other times, John would decide with his therapist that he would array to go out twice with supports, or go for a cycle ride in order to make sure that she planned properfoodsfor herself, and maybe bid someone different to eat with him. (Robertson, 2010).
Interventions for behavior- activity scheduling/diversion techniques
According Robertson(2010) pleasant activity scheduling and diversion techniques are effective Cognitive behavioral methods. John was asked to write down on a piece of paper starting with today to schedule one pleasant activity. This activity could be anything that he enjoyed that was not unhealthy or something that he normally would not do. Starting at a very simple level such as reading the newspaper, going to the library or going for a short walk through the park Seiler (2008).According to Robertson, D (2010), making behavioral experiments simple greatly increases the chance that they will be followed through with.
Benefits of the approach/ interaction
John acknowledged that participating in the activities diverted his attention temporarily from feelings of anxiety, anger and sadness. Furthermore he acknowledged his thinking was slightly more positive and less self-focused during these periods of time. John acknowledged that he did notice to be spending more time interacting with staff, co patients and visitors on the ward, which also was a distraction from persistent negative self-talk. John reported that when spending time with fellow co patients he was recommended to join an online forum called dailystrength.org in support of people who are unemployed. John revealed it was a place where personal stories could be shared; emotions could easily be expressed while feeling accepted and encouraged by others in the same situation.
Interventions for imagery/interpersonal- imagery based exposure
This CBT approach indulges a version of imagery exposure (Seiler, 2008). During our therapy session, John was advised to bring to mind a present memory that triggered strong emotions. He cooperated and gave an example of been given critical feedback from his boss at work. He was then asked to remember his boss’s tone of voice and what the room looked like at the time. He was also asked to accurately label the thoughts and emotions he experienced during the interaction and the emotions he felt Simmons & Griffiths, (2009).
John reported that he felt angry and humiliated- dejected. It was advised that John keep visualizing the image in detail until his level of distress reduced to about half of its initial level, say from 9/10 to 3/10. The goal was to counteract the ruminating thoughts because it aided to make intrusive painful thoughts less likely to trigger rumination. The aim of the method is to prepare client, eventually to work through their feelings in real life. For instance, imagery-based emotion exposure can prepare clients to better express their emotions to others. The less distressed an individual is the higher the probability of choosing healthier coping strategies Rymniak, & Kaplan (2002).
Benefit of approach
John reported that he felt that exposing himself to these feelings let them run their natural course. The key to reducing your avoidance of painful emotions is through imagery based therapy (Simmons & Griffiths, 2009).John reported that when he was visited by his friends’ and family, the fear of saying what he felt slightly reduced was because he was learning how to express and watch his feelings. During interaction with John, ‘John made a revelation that he likewise felt that the disgrace of revealing his inner self was to some extentstarting to fade as he was now learning to communicate to others how he was feeling, on the other hand he felt the online forum was easier to express emotion than it was to friends and family.
Although the memory was still there and quiet painful according to John the rumination frequency of the painful memory has reasonably decreased.
Intervention for sensation- relaxation/ visualization
Relaxation approaches are helpful in coping stress and since it quiets the mind and slows down the body. John reported he usually experienced physical tension in addition to his mental stress. Therefore I found it essential for John to learn relaxation skills to help him relieve some of these symptoms of tension and anxiety when they appeared. Intervention included making John aware of the four most effective relaxation techniques.
The first relaxation techniques taught was Progressive muscle relaxation. This involves tightening and releasing of particular muscle groups from toe to head within seven seconds with prominence on noticing the variation between the relaxed feeling and the tensed feeling Kerkhof, & Akhnikh (2010).
Secondly, the second relaxation technique was a / learning how to let go of tension without initially tensing the muscles. This is practiced by centering attention on the muscle and visualizing the tension dispensing Kerkhof & Akhnikh (2010).
Moving on, the third techniques was a cue- controlled relaxation where John was put up to speed on how to relax his body by uttering loosening up words such as ‘relax’ or ‘calm’ with very slow exhalation (Kerkhof & Akhnikh, 2010).
Finally, the fourth relaxation prowess is special-place visualizations. This prowess enlightens an individual to imagine an area of comfort and safety in his or her own vision/ imagination. The individual can head to a mental safe place when he or she feels the intensity of distressing feelings has increased immensely (Kerkhof & Akhnikh, 2010).
As John discharged date was approaching he was urged him to continue employing the cognitive behavioral skills that he had been taught during the treatment. John was discussed all his resources available, such as CBT web links, readings and online resources. John was also advised to keep implementing the new skills learnt in therapy and continue follow up with his GP and CBT therapist.
In conclusion, the Multimodal therapy facilitated in treating Johns specific problem areas by utilizing a variety of treatment strategies to bring about positive change. The BASIC ID multimodal assessment covered all attributes of John’s personality and provided a base framework that consisted of seven modalities: affect behavior, imagery, interpersonal, cognition, sensation and drugs / biology (Lazarus, (2005)
In conversation with his therapist, John gradually began to understand that all his safety-seeking, reassurance-seeking behaviors and avoidance were designed to assist in reducing his anxiety, some of which may well have come from his previous life experiences, which had left him feeling that he was one way or another accountable for warding off harm or disaster. John also started to see that, in actual fact, all these behaviors in the end continued his anxiety. Over the weeks, he undertook to keep a diary monitoring how his anxiety levels rose and fell as he gradually gave up his customs. It became stronger to him, once he comprehendedthat his anxiety was the enemy instead of any external set of circumstances, that it was impossible to have total control or cast-iron assurances in life about anything, and that his nervousness was worsened by focusing constantly on likely dangers. John’s therapist also heartened him to see the benefits of change, ways in which he could regain his pleasure of life
In the evaluation process various modalities were examined The writer argues that due to CBT being relatively short term, it relied heavily on the pinpointing of specific problems which were able to be identified through assessment methods such as the MLHQ and FIDO and ARCS questioning. Various CBT interventions implemented as per treatment plan such as activity scheduling, daily thought record and relaxation technique all proved effective in minimizing symptoms and bring about positive change.
John was spending more time out of his room and had joined an online support group of his own accord. Over the course of three weeks John’s participation in the activities proposed above gave him higher levels of positive emotions through the use of the dysfunctional thought record changing the way he thought about things aiding him in making his thinking more positive and self-focused. John’s social life was also noted to slowly start to improve in that he slowly started interacting with people. Overall the MMT proved effective in implementing treatment strategies in all seven interactive modalities of John’s personality. John was also provided all resources available and advised and to keep implementing the effective new strategies learnt in therapy.
JOHNS MULTIMODAL TREATMENT PLAN
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