Case 2 Janet Laura McGraw and Alison Brabban

The main purpose of this chapter is to provide some insight into the impact that developing new ways of understanding and new skills has on the therapist and their clinical practice. This in itself may not seem particularly revolutionary, however, the transition from believing you know most things to realising you know very little can be both demanding and emotionally challenging (Salzberger-Wittenberg, Henry & Osborne, 1990). I will use a case study to illustrate this experience. In 15...

Assessment formal and informal and formulation

Jane and her parents were assessed formally using a number of psychometric tests (see Table 11.1) and informally through observation and interview. Four psychometric tools were used to assess Jane's parents the Relative Assessment Interview (Barrowclough & Tarrier, 1992), the Knowledge About Schizophrenia Interview, the General Health Questionnaire (Goldberg & Williams, 1988) and the Family Questionnaire (Barrowclough & Tarrier, 1992). Following the assessment of both parents the...

Background and history

She was chronically neglected by her parents, her father having been alcoholic and her mother cold. Her mother apparently had an affair when she was young, and Mary described having been sent to live with her aunts before she was 8 years old. They apparently did not want her, and sent her back to her mother. She then described having taken on many of the household chores throughout her childhood. When her parents separated at around this time, she and her...

Beliefs About People With Mental Illness

As noted above, the Cognitive Therapy Checklist is used to assess clinical skills. The general skills may also be used to structure some of the educational experience and provide some of the course content. However, the main model for individual work with patients and service users broadly follows the sequence outlined by Nelson (1997) and includes engagement, coping strategies, psycho-education and modification of beliefs. The teaching is timetabled and taught in the same order.

Delusional beliefs

One particular aspect of cognitive therapy that I found intriguing was asking the client to rate conviction in his or her delusional beliefs. I had always assumed that those with delusions were absolutely 100 convinced of their beliefs and it never occurred to me otherwise. Using this approach I found that Janet had some doubt about her implant, though she was 90 sure it existed and was controlling her. The next stage of my intervention was to explore the evidence that Janet was using to...

Delusions

Two factors appear important in delusion formation (Hemsley & Garety, 1986) prior expectation, i.e. what you expect affects what you believe and the current relevant information provided by the environment, i.e. the events occurring at the time and circumstances you find yourself in. Working with delusions involves establishing engagement, tracing the origins of the delusion, building a picture of the prodromal period, identifying significant life events and circumstances, identifying...

Development of illness

She became depressed with the birth of her daughter and presented within weeks after childbirth to her general practitioner, and thence for psychiatric assessment. The birth had been difficult but the pregnancy had been wanted. However, since the birth, she had developed suicidal feelings and ideas of worthlessness and had contemplated taking an overdose of an-tidepressants. Unfortunately her mother had also been seriously ill four months previously, removing one potential source of support....

Development of the problem

Mary's difficulties appeared to have started about a year before her presentation to the services. She initially painted a rather confused picture, involving her husband and his daughter. She had at some time believed that her husband was going to evict her from the house that they shared, which he had bought. She no longer believed this so strongly, but was convinced that the daughter would throw her out of the house if her father died. This, she reported, was because the daughter was...

Developmental and social history

Janet was 51 years old when I started this work. She had one older sister and a younger brother who now had successful careers and lived away from home. Her father had been a solicitor (though he was now dead) and her mother had worked as a teacher. The family had lived in a large detached house in a small economically deprived village. Janet had never associated with anyone from the village and described them as different from her. She received her primary education as a day pupil at a private...

Effectiveness of research in routine clinical practice

There are important effectiveness differences between research studies and practice, although the CBT studies have tried to allow for these as far as possible. Selection of patients for clinical trials is distorted by the essential need for patients to consent to participate in such a trial with the extra time and trouble for patients involved of meeting raters, the risk to them of receiving an ineffective control treatment, and an aversion, in principle, of involvement in research. It is...

Family history

She was eldest of four siblings she had three younger brothers. A female cousin spent several years in Knowle Hospital in the 1960s (reason unknown) and her father suffered from alcoholism. He died in 1984 aged 66 from stomach cancer, but the patient claimed I took no notice. He worked as a driver until retirement at 60. The patient did not feel close to her father even though she did not mind him. She later disclosed that he was drinking day and night, but denied that he was violent or had...

Formulation

The following formulation was shared with the multidisciplinary team, who were struggling with Helena's continuing impulses to commit suicide and the problems of working towards discharge. They found it particularly difficult to cope with her constant talk of her voices and the urge to commit suicide, and the team was split into those who advocated for her, and those who had essentially lost patience. The meeting, which took place five sessions into the weekly therapy, served to increase...

Further treatment

Future sessions will continue along current themes. Jane continues to work with her stressful events and confrontation and although finding it easier to apply the cognitive model she still requires time to deal with some of the more difficult issues. One area that appears to be dormant at present is the schema work surrounding her three early experiences. In particular, there is work to done with the name-calling and the cognitions and beliefs around that time. Jane continues to be aware that...

Initial contact and voices group

Helena's keyworker initially asked me to do some work with her, focused on her dependence on particular relationships. From that initial contact it was clear that Helena had the capacity to make good use of cognitive therapy, as she was well able to identify key cognitions. In a short session, we identified that she felt herself to be worthless, and only felt good when someone else was treating her as special. She was receptive to the idea that she needed to work on treating herself well and...

Intervention with positive symptoms

With the working assumption that auditory hallucinations can be conceptualised as misattributed inner-speech, Malcolm was asked to compare what his voice said with his current concerns (Birchwood & Iqbal, 1998). His comparisons highlighted themes of desire for freedom and promise of rescue, low self-esteem and being the chosen one, motivation to pursue powerful goals outside of secure psychiatric care, and that he was above containment by virtue of his status. This comparison process is...

Malcolm

Malcolm is a 34-year-old man with a diagnosis of paranoid schizophrenia. He was admitted into high secure psychiatric care as a transfer from medium secure psychiatric care following absconsions and hostage-taking. His admission to medium security had been made by Court Order following a conviction for attempted murder. Assessment revealed a complex persecutory belief system (Delusions Rating Scale (DRS) 18 Haddock et al., 1999) and a separate grandiose belief system (DRS 17). While Malcolm...

Medication

She was treated with a variety of medication at increasingly high doses. These included various antidepressants including the monoamine oxidase inhibitor, phenelzine, and antipsychotics, including newer atypical drugs. Unfortunately she also had serious physical problems, myocarditis (inflammation of the heart muscle) and hepatitis (inflammation of the liver), treated in a specialist unit in London. A cause for this was not found, although the possibility that it may have been medication...

Negative symptoms

There is evidence that CBT improves negative symptoms (Sensky et al., 2000). Techniques involve eliciting specific positive symptoms, especially ideas of reference, thought broadcasting and hallucinations, which may emerge under stress. Patients may become essentially agoraphobic or socially phobic because of a fear of reactivating distressing positive or panic symptoms. They may also require a convalescence period after an acute episode, and a reduction in pressure and the postponement of some...

Outcomes

Malcolm made no attempt to escape when the deadline for his rescue passed. He did feel disappointed about remaining in Rampton but commented that his Clinical Team had prepared him well for his non-event. He reported that since he had been the only person expecting him to leave, he was aware that something is not right in his thinking about his situation. He had used his self-help list for coping with disappointment on a regular basis and said that he had half expected not to be...

Outpatient care

As an outpatient, times were difficult with concerns about excessive noise from his TV, and occasional abusive debates with neighbours. He also continued to have problems with the police through minor incidents of theft. Although these went to court, conditions of treatment and probation had usually resulted. He was much less thought disordered and having much less medication. He tolerated discussions of his misdemeanours without leaving abruptly. He professed to be using cannabis occasionally...

Presenting problems

Jane was in hospital from July 1994 to September 1995, which was the last in a number of relapses (see personal history) that ended in a lengthy hospital stay. On admission Jane had been very paranoid generally to young children and football supporters and specifically to her parents. On discharge Jane was referred to the community psychiatric nurse (CPN) department, and was allocated to a keyworker. Although it was felt that Jane's improvement was being maintained by the medication, it was...

Provisional hypothesis and rationale for procedures used

When the above case was discussed it was felt that Jane's family would be suitable for family work as there was a high degree of contact between the patient and her parents (> 35 hours) and there appeared to be a certain amount of high expressed emotion. It was agreed that assessment should begin with a view to offering a number of family sessions on completion. Depending on the outcome of the assessment, differing amounts of education, stress management and goal-setting would be negotiated....

Psychological intervention

Initially, the psychiatrists managing her care thought that psychotherapy, especially for her feelings about the termination, was contraindicated. One entry in her notes says that this should not be attempted until 6 months stability on medication, providing she is motivated and can then be assessed. However, on consultation with a psychotherapist, it was agreed that such an approach was worth considering and was started relatively early in the course of her illness, initially using dynamic...

Session 5 How I see myself and others

As Kathy put on more weight she reached the point of leaving the house only if it was essential, could not be avoided or could not be done by someone else. The thoughts she remembered were of people laughing at her and thinking that she was ugly. We were able to look at how some of the beliefs she held had developed and again try to develop some alternative explanations for what people might think about her and why they might be laughing. PM Why do you think these people are laughing at you C...

Summary

Nicky presented with depressive symptoms and distressing hallucinations. Vulnerability factors included the termination of pregnancy in her teens and the distancing and difficulties with the relationship with her parents. Precipitation of her symptoms occurred when she gave birth and a perpetuating factor was the range of critical comments from her husband. We spent time understanding her symptoms, working on the negative statements that the voices made and her difficulties with assertiveness....

The formation of an appropriate family intervention treatment strategy

Following the above comprehensive assessment and the subsequent formulation, the family were invited to a feedback session to discuss the outcome of the session and the possibility of negotiating further sessions. Following discussion with both Jane and her parents it was decided that she would not be present at the initial sessions but would join the sessions at strategic points throughout the therapy. The family work would hence consist of patient-focused sessions, parent-focused sessions and...

The Role Of Supervision And Teaching

After years of self-study and supervision from more or less well-qualified supervisors I was fortunate enough to be accepted at the newly established Diploma Course in CBT at Southampton University year 2000-01. The course consisted of three teaching modules axis I disorders, personality disorders and finally psychotic disorders. I was at this stage doing my specialist registrar training in general adult psychiatry in the area and was therefore able to be granted one day's study leave each week...

Therapist time

How many therapists are needed Or, more specifically, what number of sessions of highly skilled therapist time is required for therapy, for training and for support and supervision Similarly, how much trained therapist time is required for therapy, for training and for support and supervision Finally, how can a basic cognitive behaviour approach to patients by all clinical staff be developed Most services develop incrementally, so that numbers of therapists needed becomes apparent as time...

Tracing antecedents of symptoms

Understanding the circumstances in which delusional ideas or hallucinations began, even when they may be 30 years previously, can be invaluable in finding out why particular beliefs have arisen. For example, paranoid delusions and hallucinations may have occurred for the first time during a drug-induced psychosis (bad trip) and need to be relabelled as originating with, although not currently caused by, that experience. Also, voices may relate to a specific traumatic event that is often...

Training In Cognitive Behaviour Approaches For Inpatients

The developments that have occurred in CBT over the past decade have been predominantly with outpatients (although many studies have enlisted patients while they have been acute inpatients). Developing therapeutic skills in inpatient staff is very important as so many patients spend weeks or months of their time in such settings when they are at the height of their illness. There has been major concern at the state of wards and that users express that they do not feel listened to. In 1999, John...

Using A Cognitive Behaviour Framework

Although the Thorn course does not aim to provide training in cognitive behaviour therapy, nonetheless it does draw extensively on this model. The principles of cognitive behaviour theory and therapy are taught on the course by practising therapists and follow the format described by Hawton and colleagues (1989). The course team was also aware that the study day provided a number of opportunities for modelling some of the skills. This enables a mirroring between the clinical and educational...

Using analogue exercises to maintain skills

Please read through the following exercise and think about what you could do to tackle the problems described. Make some notes for a discussion and make an appointment with one of your Ward Nurses to discuss and practise dealing with the situation. Imagine yourself feeling sad compared to usual. You've noticed yourself not wanting to get up in the morning and not talking with other Patients and Staff. You noticed Staff laughing in the office and think they were laughing at you. While you've...

Working with voices

Before delving into any therapeutic intervention with Janet's voices I felt it was important to find out more. Did she recognise the voices What were they saying to her Could their occurrence be predicted After completing a 'voice diary', I realised that Janet heard one male voice that was worse in the morning when she was alone in her bedroom. The voice, identified as her sister, was generally offensive, saying she was a waste of time and knew nothing. Her usual response was to get angry and...

Case 8 Sarah Pauline Callcott and Douglas Turkington

Kingdon and Turkington (1998) suggest four therapeutic subgroups relating to schizophrenia. They emphasise the complicated nature of the phenomenology and have therefore argued for the existence of separate syndromes within the schizophrenia spectrum. These subgroups not only provide a broad spectrum for understanding and normalising individual symptoms they also help to provide a framework for Cognitive Behaviour Therapy interventions. One of the subgroups relates to psychosis which occurs...

Paranoia and delusions Process and product

Thinking psychologically about psychotic symptoms, a useful distinction can be made between paranoid thinking (characterised by particular cognitive distortions) and delusional ideation. The former can be considered to be a perceptual process, involving attending to stimuli salient to the individual because they are threatening. Delusions are considered as the explanatory hypotheses developed by the individual to account for the strange perceptions. This conceptualisation is a development of...

Session 1 Engagement and developing alternative explanations

The first thing that I noticed upon entering Kathy's house was the number of cats that she possessed. There must have been at least half a dozen of different breeds roaming about the house. As I began the session, the cats began climbing all over me, trying to take the pen from my hand. This was becoming a distraction so I asked Kathy if it was possible to use a room where the cats would not disturb us. Unfortunately Kathy was unable to feel comfortable without the cats, so they became a...

David Kingdon and Jeremy Pelton

Supervision is fundamental to developing skills in CBT, especially for patients with psychoses because of the need to adjust techniques learned in training to the realities of everyday clinical practice and to a very variable group of patients. Its goal has been described as modifying in-therapy behaviours by support and training. It can particularly enable the therapists to step back and review and reflect on their practice to learn and prepare for the next session. It is complementary and at...

Normalising

For many people the experience of psychosis is worsened by the fear that they see themselves as mad, a lunatic, a nutter. They are subject to the media portrayal of mental illness and fear the arrival of the knife wielding maniac that lies dormant within them. Many people diagnosed as having schizophrenia have little idea of what this actually means, clutching onto beliefs that it has something to do with a split personality or two minds. Along with that belief is the fear of the implications...

Case 9 Carole Ronald Siddle

I was initially trained as a psychiatric nurse. I left school at 15 having just sat my GCE O levels and was persuaded by a friend to apply to the local psychiatric hospital as a cadet nurse. After two years of working in the various departments of the hospital I started training as a student nurse. Towards the end of the RMN training I applied for the shortened post-registration RGN course and was able to finish that training in about a year and a half. Swiftly returning to the safety of...

Psychosocial Intervention Courses

'Thorn' courses and other courses in psychosocial interventions (e.g. in Sheffield) are more available around the UK, but these have generally recruited nurses and occupational therapists rather than other professions. These courses were originally set up in the early 1990s with a remit that was initially case management and family work, but the original courses at London and Manchester began to include CBT in the early-1990s and courses established since (e.g. in Nottingham, Hackney,...

Psychometric assessment

Three psychometric tools were used to assess Jane. Firstly, the modified KGV Scale (Krawiecka, Goldberg & Vaughan, 1977) highlighted the severity of any psychological phenomena present. This is a 14-point assessment tool, six areas being elicited by questioning and eight by observation. Secondly, the Social Functioning Scale (SFS Birchwood et al., 1990) examined Jane's social capability and highlighted any areas of concern. Finally, the Liverpool University Neuroleptic Side Effect Rating...