Introduction
In spite of the main approach still being a medical one, formulations are starting to play a huge part in treating people living with mental distress. The purpose of formulations is to look at information gathered in the assessment of a distressed person. Formulations look at the life experiences of a distressed person and the meaning they make out of these experiences (Johnston & Dallos 2009).
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Formulations and how they could explain a problem can be done from many perspectives in psychology. The perspective this formulation will use, to analyse a case of a young lady, is Cognitive Behavioural Therapy (CBT). This approach is looking at people’s cognition and how it explains behaviour. It looks at thought patterns, how they have developed, and how they may be driving behaviour (Tarrier, Wells & Haddock 2008). CBT is a talking therapy that concentrates on present problems and difficulties in a client’s life. It breaks the problems into smaller parts, and this makes it easier for the client to see how these problems are linked and how they affect their life. Our emotions and behaviours are shaped by our perception of the world and our lives; if the perception is unhealthy, distress can be experienced (Bental 2004). The role of the therapist is therefore to change a client’s perceptions of their problems and help them to deal with difficult situations in their lives. CBT aims to break the unhealthy circle that affects the health, thinking, emotions and behaviour of a person (Clark & Fairburn 2005). The interaction between the therapist and the client plays an important role. In order for the treatment to be successful, the therapist has to gain a clients’ trust. For many people, to understand the difficulties that they are going through can be a way to a recovery.
A CBT formulation normally consists of a number of stages. Different therapists divide CBT formulations into different stages, depending on what they see fit according to the circumstances of the case. The structure this formulation is going to follow consists of five stages: presenting issues, precipitating, perpetuating, predisposing and protective factors (Johnstone & Dallos 2009). In the presenting issues stage the current problems are clarified, and goals are defined. In the second stage, the Precipitating factors stage is forming the understanding or the link between the external and internal factors that cause the problem. The stage of Perpetuating factors looks at factors that maintain and keep the problem manifesting. The fourth stage is the stage of Predisposing factors in which a longitudinal understanding of the problem is looked at. Finally the fifth stage is the Protective stage. This stage looks at the strengths of the client and how they can be used to prevent a relapse (Johnstone & Dallos 2009). These five stages are going to be followed to construct a psychological formulation of Cara’s case.
Formulation
Presenting issues
According to the provided material Cara is experiencing a number of problems. These problems include: a.) hearing voices (which are both positive and negative), b.) paranoia which makes her believe that people are talking about her and that there is a conspiracy against her, c.) obsession with cleanness of her hair.
From the CBT perspective the first important step or goal would be to engage Cara into the therapy. Through Cara’s engagement it would be possible to gain an understanding of her emotions, beliefs and experiences. It is important to build a good relationship between the therapist and Cara and for her to consider that there may be another explanation for her distress. Turkinton et al (cited in Tarrier 2009) argued that people with delusions that are prepared to consider another explanation for their problem are more likely to respond positively to the therapy. Therefore it is important for Cara first to believe that there may be an alternative explanation to her problems and beliefs.
Precipitating factors
Goals should be set for each problem and for each week according to what the therapy should achieve. The three problems may not be reduced at the same speed but the aim to reduce them should be maintained. This reduction is possible to make by going through possible explanations of problems and beliefs (Bentall 2004). People with paranoia process information the same way as people without paranoia, the only difference is that they jump into a conclusion without analysing the situation or other possible explanations (Johnston2009).
To understand the link between Cara’s external and internal distress, The ABC model (Activating events, Beliefs, Consequence) (sited in Johnstone 2009) is going to be used to link recent experiences to her behaviour and beliefs.
Starting with Cara’s belief that people are talking about her and laughing at her, the Activating event can be her moving into a new area, which is different to the one she is used to. But, at the same time, the link can go back to her splitting up with her boyfriend, where she learned that he is seeing a white girl and the fact that people used to make comments when they were together because of their colour difference. These activating events would lead to her beliefs being affected. According to Livingstone and Sembhi (2003) people from black or minority groups are more likely to suffer with schizophrenia. Because she is the only black girl in her class and because there are not that many black people in her new environment, she starts to think that people are talking about her behind her back. This could lead to the consequence of her being paranoid. People from a minor ethnicity combined with a social-economic depression, a family instability are more likely to have psychosis (Livinston & Sembhi 2003).
The second problem is Cara’s constant obsession with her hair and thinking that it is greasy and falling out. The activating event probably would be when she feels excluded from her new friends and feels different to them because they are from a different background. Her beliefs are that they are laughing at her hair and the consequences are her being obsessed with her hair. She therefore started to attend to it and wash it all the time. Obsession can be developed from trying to eliminate negative thoughts related to external influences (Tarrier et al. 2008).
The third problem Cara has is that she is hearing voices. The activating event would be around the time when she has isolated herself from everyone and made eye contact with her teacher in town to make her believe that they are communicating. The consequences would be her hearing the positive voices of her teacher at first, later negative voices and believe in conspiracy against her. Attributions are believed to play a role in conspiracy ideas. When external attributions (e.g.bad marks) are made instead of circumstantial attributions (e.g. not studying enough) paranoid ideas can develop (Bentall 2004).
Perpetuating factors
Once delusional ideas have been formed, attentional as well as perpetual processes are important in maintaining delusions (Bental 2004). Maintaining certain behaviour in people with psychosis can be viewed as the only way for them to avoid frustrating or upsetting experiences (Johnstone 2009). The present problems are maintained by Cara’s negative thinking and by her protecting herself from being hurt. People with paranoia are known to avoid situations which would cause them distress (Clark et al 2005), therefore Cara may be avoiding socialising with people to avoid being hurt. It has been reported that 90% of the population at some point experiences intrusive thoughts, or feel paranoid and feel that people are doing things on purpose to them (Rachman & de Silva 1978, Salkovskis & Harrison 1984, sited in Tarrier et al. 2008).
Hearing voices is believed to be maintained for the reason of not feeling lonely. Voices are companions for people who isolate themselves and have no one to turn to (Miller et al. Sited in Read 2004, Clark et al 2005). Cara over a period of time has isolated herself from her school friends, work friends and family what would lead her to see the voices as only companions.
Maintaining the paranoid, obsessive and delusional behaviour for the “paranoid schizophrenic” is important in order to survive and protect themselves (Bentall 2004). When it comes to her constant hair washing, by making sure that she has always clean hair she may hope not to give any reason to people to laugh at it. By performing the ritual of constantly washing her hair, Cara maintains prevention of distress thoughts or distress outcomes (Clark 2005). Kenneth Colby pointed out that paranoid individuals are highly sensitive to any threats to their self-esteem, therefore it is important to the individual to maintain the behaviour that they believe is protecting them from hurt to their self-esteem (sited in Bental 2004).
Predisposing factors
Predisposing events that lead to psychotic symptoms play an important part in finding a way out of psychosis. It is important to understand for the therapist and for the client the link between past experiences and present distress. Cara has been through a number of traumas in her life: not having a stable home, little attention from her mother, a sexual abuse, a bad break up and a new environment. As it was pointed out by Moe et al. (2007) there is only a certain amount of negative experiences that one can deal with in a short period of time before breaking down. Her disturbed childhood may have contributed to her psychosis. Read (2004) has pointed out that a disturbed child-parent attachment can contribute to the development of psychosis.
According to Read (2004) people with psychosis sexually or physically abused as children are more likely to experience hearing voices. The consequences are less severe if the abuse happens at a very early age; if it happens only once and if no further traumas are experienced. However, even though Cara was sexually abused only once, the important thing that may relate to her schizophrenic experiences later in life is that she was ten years old when it happened and that she has experienced further traumas in her life afterwards (Read 2004).
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Her self esteem may have been negatively affected by her boyfriend leaving her for a white girl and by the fact that her family is black and not as wealthy as most of the families in her new area. As pointed out by Freeman (sited in Bentall 2004), many people with paranoid delusions have a low self-esteem. This would lead to her obsession with her hair, since black people’s hair is different to white’s people hair.
Obsession with her hair would lead her to being paranoid that people are talking about it and laughing at her. Instead of trying to look for alternative explanations of why people are looking at her and if they are really looking at her, she jumps into negative conclusions. Beck (sited in Read 2004) suggests that the way we perceive events and experiences, influences our feelings and our behaviour. If the interpretations are influenced by negative thinking the result is negative behaviour. Our interpretations are influenced by our core beliefs and our core beliefs are influenced by our life experiences.
Cara isolates herself from everyone, which would therefore mean she doesn’t really have anyone to talk to about her problems. It would be a reasonable assumption that this could lead to her having imaginary conversations. In addition to this, the fact that her teacher makes eye contact with her at the time of her being isolated and in need of having someone who understands her, she starts believing that they have a special connection and a way of communicating which eventually leads to her hearing voices. Since she feels lonely voices are there to provide a companionship for her. Romme and Escher in 1989 (cited in Read 2004) proposed that people hear voices as a coping response to trauma. Auditory hallucinations are significantly higher in people that have been through a number of traumas in their life (Read 2004). Therefore, all the traumas that Cara has been through in her life may have built up and resulted in her hearing voices. Positive voices would give her strength at first but they then lead to hearing negative voices, which would have resulted from feeling disappointed in her teachers not supporting her as she was expecting since she believed that they had special connections (Howe 1997).
Protective factors
According to Read et. all (2004) it is important to reduce, as much as possible, stress and traumatic events for people recovering from Paranoid Schizophrenia, and start to get involved in social life as much as possible. However, one of the most important skills that they have to remember to perform is to analyse situations before jumping into conclusions.
Cara’s resilience and strength, such as academic achievements, are good potential factors that can help her to recover. It was suggested by Moe et al. (2007) that resilience to unhealthy behaviour or thinking can be strengthened if the person is surrounded by positive factors (hobbies, a nice home, a good friend/family etc.) rather than risk factors (problems at home/ school, bad friends). Therefore, the strengths of Cara’s environment should be used in a recovery procedure. It would give her the opportunity to be with other people and to learn to analyse situations and others’ behaviour giving her chance to recover and lead a healthy life.
Intergration (300)
A Systematic approach would add a valuable point to our formulation. This approach is looking at family relationships and the functioning of the family. The belief here is that problems in one’s life can be seen as a product of his/hers family relationships. The “symptoms” are seen as a problem in the interaction and the communication within the family rather than as a problem within the person (Scheid & Brown 2010). Having Cara’s family involved would most likely be of benefit to Cara’s recovery.
Educating family about psychosis and working with them to reduce some of Cara’s problems would hopefully prevent a relapse (Leff 1990 sighted in Kuipers et al. 2002). No judgement or criticism of any family member should be made and the emotions should be respected. Cara, despite her moving in and out of her family home, has always returned to her family home when things got better. This can be viewed as a positive aspect. Have the ability to stay together, despite the negative influences, conflicts and tension should be seen as strength of the family (Kuipers et al. 2002).
No every member of the family would take part, but the more family members participate the more beneficial it should be for all of them. The fact that Cara’s father has left at her early age gives the likelihood of him not taking part. As mentioned by Kuipers et al. (2002), fathers are the least likely to participate. Taking into consideration what Cara’s brother has done to her, he may not take part either. However, even if only a few members fully participate, the emotional support from them can be very beneficial to Cara. Having emotional support from a family has a significant benefit on person with psychosis and plays a major part in a recovery (Laing & Esterson 1970).
By supporting Cara emotionally, and providing her with family support and love, her stress level would be reduced and reduction in voice hearing, obsession and paranoia should be achieved. In the developing countries and the eastern world, where people with schizophrenia are looked after by their family and community, have high rates of recovery and small relapse rate (Jankins & Barrett, 2004).
Conclusion
Formulations of each individual have to be taken with care, since they are hypothesis and not statements of facts as pointed out by Butler (Jensen 2009). It would be difficult to say which formulation is correct, and if there is such a thing as a correct one, since everyone has an individual view of what is right or wrong. What has to be looked at in every formulation is if the particular formulation seems to be the right one and benefit for the person with the psychosis. It is believed that CBT receives government support and funding because it is cheap and quick, even though the empirical evidence for it is weak (Hussain 2009). CBT has been found to not be effective in schizophrenia (Lynch et al. 2009). According to Dr Oliver James (Hussain 2009) CBT is over praised; what CBT achieves any other therapy can achieve to. As mentioned earlier different therapists have a different structure of formulations in CBT, this can be seen as down side to the therapy since it doesn’t have a particular structure that everyone follows.
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