This is a fictional case study that I compiled based on a broad range of experiences prior to qualifying as a Clinical Psychologist. It is hoped this case study will help aspiring psychologists who are currently undergoing training. The case material does not relate to anyone I have worked with and any similarities are purely coincidental (or because people in certain groups can sometimes have similar presentations/formulations).
Reason for Referral
Wilbur was a man in his eighties who was an informal patient on an inpatient ward specialising in older-adult mental health. He was referred to the on-site psychology service due to severe anxiety and depression.
Assessment
During our introductory meeting, Wilbur made little eye-contact, spoke very softly and appeared easily distracted. Wilbur said he was depressed and severely worried about his health, his family’s wellbeing, and what other people thought of him. When asked if he would be prepared to undergo psychological assessment in order to gain a better understanding of his difficulties, he said he would, “give it a go”.
I assessed him over the course of three sessions, on a one-to-one basis. My supervisor’s preferred approach was Cognitive Behavioural Therapy (CBT) and this seemed like a good framework to use as the model had been adapted for use with older adults (James, 2010) and there was some indication that Wilbur was open to exploring links between his thoughts, mood, behaviour and physical reactions, which are central components of the model (see Dobson & Dozois, 2009). My supervisor and I discussed the assessment of older adults from a CBT perspective and the relevance of factors such as cohort effects and role transitions. I decided to structure the assessment and preliminary formulation using the Comprehensive Conceptualisation Framework (Laidlaw, Thompson, & Gallagher-Thompson, 2004), as this included such factors.
Background
Wilbur was a former lawyer and seemed to value intelligence and social status which I suspected were values formed in early life. He described having a happy childhood and appeared keen to tell me how proud he was of his father. However, he also said his father was a strict disciplinarian who used corporal punishment. I suspected Wilbur was trying to demonstrate his own success and intelligence when he talked about past achievements and his impressive grasp on complex intellectual topics. However, he occasionally became very upset as he described the great sense of loss he felt because of feeling the best years of his life were behind him.
Prior to admission, Wilbur lived at home with his daughter. He expressed considerable affection towards her and was deeply troubled by the impact his difficulties were having on her wellbeing. Regarding friends, Wilbur told me he was popular and that he was severely worried about how other people would view his recent difficulties.
History of Presenting Problems
Wilbur reported he had suffered a brain injury approximately five years ago and I was mindful this might have resulted in some cognitive change. However, Wilbur was adamant neither he, nor his family, had noticed any such change after the event. However, he said in the past year he had found it harder to concentrate and had noticed a slowing of thought.
Current problems
There was variation in Wilbur’s presentation from one week to the next and he expressed various health concerns that appeared fairly transitory. The staff informed me he requested frequent medical investigations but that no physical health problems that explained his self-reported symptoms had been identified.
Wilbur also expressed concerns unrelated to health, such as financial concerns, concerns about others’ wellbeing and concerns about people talking about him. Wilbur reported he had never been a worrier, but now spent the majority of his time ruminating.
There were several instances during the assessment when Wilbur expressed beliefs similar to persecutory delusions. Throughout our sessions he displayed a cognitive style of jumping to conclusions, catastrophising, cognitive-rigidity and hyper-vigilance to threat. Wilbur expressed many self-critical thoughts and described himself as “shadow” of his former self.
Wilbur’s daughter questioned whether Wilbur’s difficulties might be related to traumatic events he was closely involved with during his time as a criminal lawyer. When I asked Wilbur about this, he described some very harrowing events, but the way he described them was in a detailed, linear, coherent manner, and his mood actually brightened to a degree when he recounted the process of “locking up scum”. He had conviction about the cases and, although there was little sign of compassion or empathy for the people who had committed the crimes, this was in keeping with his personality. Although Wilbur described thinking about the events he experienced occasionally, he did not experience intrusions or have any associated symptoms of hyperarousal or avoidance. This led me to conclude these stressful past events were unlikely to be of clinical relevance, based on conceptualisations by Horowitz, Wilner, and Alvarez (1979).
Risk
Although Wilbur expressed suicidal ideation, he was adamant he would never act on his thoughts. I discussed risk regularly in supervision and documented my assessment of risk at the end of every session, using the electronic note-keeping system. We completed a safety plan together in case his risks escalated.
Assessment Measures
On admission to the inpatient ward, Wilbur completed the GAD-7 (Spitzer, Kroenke, Williams, & Löwe, 2006) and scored in the moderately-severe anxiety range (a score of 10). He also completed the PHQ-9 (Kroenke, Spitzer, & Williams, 2001) and scored in the severe depression range (a score of 22). Early on in his admission he completed the Montreal Cognitive Assessment (MOCA; Nasreddine et al., 2005) and scored 28, which was above the recommended cut-off score for suspected dementia (Davis et al., 2015).
To further assess for dementia, Wilbur underwent a brain scan which showed small vessel ischemic changes in the left frontal lobe and right parietal lobe. Coupled with the self-reported cognitive changes Wilbur described, this led me to suspect Wilbur had a degree of executive difficulty. However, the Consultant Psychiatrist on the ward said Wilbur did not meet the criteria for a dementia diagnosis and felt strongly that his current difficulties were largely due to psychological factors.
Goals
Wilbur found it very difficult to identify any goals for therapeutic work as he said he could not make decisions (which potentially related to executive difficulty). There was also a degree of hopelessness about the future as Wilbur expressed thinking there was not much left to live for. With some scaffolding of the question about goals, Wilbur said he wanted to worry less and engage in more meaningful pursuits. We attempted to develop these into goals that were specific, measurable, achievable, relevant and timely. However, Wilbur had great difficulty with this and I felt I was becoming too directive.
At the conclusion of the assessment my impression was that Wilbur’s presenting problems were due to an interaction between biological, psychological and social factors and I will elaborate on these in my formulation.
Formulation
I structured my formulation using the Comprehensive Conceptualisation Framework (Laidlaw et al., 2004). This model combined a CBT maintenance cycle with information about early life experiences, core beliefs and factors especially relevant to work with older adults (e.g. role transitions). Therefore, it not only illustrated the factors maintaining Wilbur’s difficulties, but identified factors potentially important in their development. Wilbur was able to identify many of the links himself and confirm or disconfirm additional hypotheses I communicated. In this way the formulation was devised collaboratively. However, given Wilbur’s probable cognitive difficulties, I did not think the comprehensive diagrammatic formulation would be helpful to him. I thought it would be better to discuss the different links with him and provide simpler formulation diagrams at appropriate points during therapy. Therefore, the formulation was used primarily for case conceptualisation and identifying targets for intervention. With consent, it was shared it with other professionals involved in his care for the purpose of joined-up working.
I have presented the formulation as leading directly from the assessment information, preceding the intervention. Whilst this is an accurate reflection of the general process, each stage informed the others to a certain degree. However, given the complexity of the case, I felt the report would be more coherent if presented in a linear format.
Early Experiences
Wilbur’s core beliefs of being a bad person who deserved to be punished likely resulted from corporal punishment by his father. His father’s values also seem to have shaped his conditional belief that one must be intelligent, successful and have high social-standing in order to be loved and worthy.
Activating Event
When Wilbur’s physical health deteriorated, he withdrew from community activities and became socially-isolated and dependent on others. This transition in role investment seems to have had a significant impact on his mood and self-esteem. Furthermore, a decline in executive functioning likely impacted on his thinking style, leading to cognitive rigidity, catastrophising and a tendency to jump to conclusions (given his former career, it is unlikely these we traits he always held). Therefore, my working hypothesis was that biological, cognitive and social events interacted with each other, reinforcing negative core beliefs formed in childhood.
Maintenance Cycles
Wilbur had a severe intolerance of uncertainty. He expressed significant worry about his health, other people and the future which resulted in anxiety, social withdrawal and reassurance-seeking and checking behaviours. Persecutory beliefs exacerbated his anxiety and led to agitation. This resulted in him withdrawing to his bed, and in the absence of distraction, he focussed on his physical pain. Coupled with a hyper-vigilance to threat, this perpetuated his concern over his health and motivated further checking and reassurance-seeking behaviours.
Perceiving himself as a shadow of his former self, Wilbur experienced significant sadness and shame. The time he spent in bed likely exacerbated this and led to exhaustion which then increased the time he spent in bed, lowered his mood and potentially exacerbated his executive issues.
In line with the approach recommended by James (2010), I created two simple formulations to share with Wilbur and his daughter. The first had the purpose of highlighting Wilbur’s strengths and talents and demonstrated the positive impact on his mood when he kept his mind engaged on meaningful activities and spent more time socialising. The diagram contrasted this cycle with the impact of worrying. The second was introduced during therapy when Wilbur began spending an increasing amount of time in bed. We identified this behaviour as the primary maintaining factor in his difficulties.
Additional Factors
Wilbur had little hope for the future and believed the best years were behind him. He thought he could no longer contribute to society in a meaningful way and worried about how his difficulties would be perceived by the community. This lack of self-worth was exacerbated by a cohort belief that men should be independent and mentally sharp.
Targets for Intervention
Wilbur’s maintenance cycle centred on the intolerance of uncertainty. Although diagnostic conceptualisations are less important than idiosyncratic formulations, a cognitive-behavioural model of generalised anxiety disorder (GAD; Dugas & Robichaud, 2012) mapped onto Wilbur’s idiosyncratic formulation and represented a primary target for treatment. Additionally, Wilbur’s withdrawal from engaging in social activities and spending the majority of his time in bed likely exacerbated his low mood, mapping onto a behavioural model of depression (Veale, 2008). These behaviours represented another primary target for treatment.
Alternative Models
I considered a cognitive model of persecutory delusions (Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002). However, Wilbur’s worries about being punished seemed more like extreme versions of the other worries he had. My hypothesis was that they were underpinned by the same cognitive and behavioural processes and, therefore, were not necessary to differentiate. This was in line with the continuum model of psychosis advocated by the British Psychological Society (2014).
I also considered conceptualising Wilbur’s difficulties from the perspective of attachment theory (Ainsworth & Bowlby, 1991). This shall be discussed in the critique.
Evidence-Based Practice
Of relevance to Wilbur’s unique presentation, National Institute for Health and Care Excellence (NICE; 2011) guidelines stated that high-intensity psychological interventions for GAD should comprise CBT or applied relaxation, using a treatment manual tested in clinical trials. However, the guidelines also stated that in cases of GAD with comorbid depression, the primary disorder should be treated first.
Wilbur’s low mood and severe worry were intertwined and I did not feel comfortable subordinating one to the other. Furthermore, Wilbur was unable to identify which issue caused him the greater difficulty. Given the NICE (2009) guidelines for depression stated that behavioural activation was a viable treatment option for depression, I decided that to offer Wilbur a CBT-informed intervention based on a GAD treatment manual (Dugas & Robichaud, 2012) and behavioural activation for depression (Veale, 2008). This treatment mapped onto Wilbur’s broad goals of worrying less and engaging in more meaningful activities and Wilbur said he was happy to proceed with this approach.
Adaptations
I adapted the treatment protocols to Wilbur’s idiosyncratic presentation. I used the Two-Dimensional Framework (James, 2010) for this purpose, a model for adapting CBT to older adults. The model featured intersecting continuums of intellectual status and physical health status, and thus resulted in four quadrants. Using information gathered during assessment, I judged that Wilbur had a fairly high level of cognitive impairment and a moderate level of physical impairment. This placed him in the third quadrant of the model. By reviewing the research, James noted that effective interventions for people within this quadrant were often behavioural in nature and enlisted the support of caregivers, who were considered important “agents of change” (p.40). James also highlighted that working flexibility, exercising patience and using repetition might be useful.
Intervention
Prior to commencing treatment I obtained verbal consent from Wilbur and ensured he understood what the therapy would involve and the effort it would require. We contracted 16 sessions of treatment (one per week), which was in line with the protocol by Dugas and Robichaud (2012) and guidance from NICE (2009; 2011).
Sessions 1 -3
The first three sessions were conducted on the ward, on a one-to-one basis. I spent a lot of time socialising Wilbur to the CBT model and tried to check his understanding as we progressed. The first between-session task we agreed was to keep an activity record using a blank template from Greenberger, Padesky, and Beck (2016). However, Wilbur did not complete it and said he would prefer to keep a journal and, in doing so, successfully monitored his mood and activity most days. Wilbur was able to see that his mood (and pain) were worse after spending time in bed and were best after engaging in meaningful activities. Using his journal, Wilbur planned more meaningful activities and this had the desired effect of increasing his mood.
In addition to Wilbur’s self-reports, the staff on the ward documented an improvement in Wilbur’s presentation and granted overnight home leave.
Sessions 4 – 6
As he remained on leave, these sessions were conducted in the community clinic, with his daughter in attendance (at Wilbur’s request). We reviewed the progress we had made with behavioural activation and encouraged ongoing activity scheduling which had a positive effect.
We began the first module from the GAD treatment manual (Dugas & Robichaud, 2012) which was focussed on psycho-education and worry-awareness training. The second module focussed on behavioural exposure to uncertainty-provoking situations and we conducted a series of in vivo exposures. I encouraged Wilbur to resist using the checking and reassurance-seeking behaviours we had identified previously and, eventually, his self-reported anxiety reduced. Given the strength of the evoked cognitions, I thought repeated exposures would be most helpful for Wilbur if we maximised expectancy violation (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). Therefore, I suggested that Wilbur made a note of his predictions and anxious thoughts during similar behavioural exposures to uncertainty. In doing this, Wilbur learnt that his predictions were inaccurate.
Sessions 7 –9
At the request of Wilbur, the consultant psychiatrist discharged him from the ward. We had some difficult conversations about managing risk and this put a strain on our therapeutic relationship as Wilbur was adamant he would never act on his thoughts and did not like being asked.
Wilbur engaged in repeated behavioural exposures. He took a leading role in developing this work and made really good progress.
Sessions 10 – 16
Via his daily journal, Wilbur identified that on the days he could not get up he experienced increased tension and agitation and we introduced an applied relaxation technique (adapted from Brown, O’Leary, & Barlow, 2001). Although this deviated from our planned intervention, it was in line with Wilbur’s formulation and NICE (2011) recommendations. In order not to divert therapy time away from the planned treatment, I recorded the relaxation exercise on his phone and Wilbur listened to it regularly between sessions and reported finding it helpful.
Given Wilbur’s executive difficulties, he agreed to undergo formal neuropsychological testing. In addition to a carefully-managed ending and relapse prevention, the final session was an opportunity to review the formulation and to consider the potential that executive issues played a more dominant role than initially thought.
Outcome
As he had completed a PHQ-9 and GAD-7 on admission to the ward, I re-administered these post-therapy. On the PHQ-9, he scored 22 pre-therapy and 24 post-therapy. Therefore, this suggests his depression increased marginally. However, the questions on the PHQ-9 were not ideal for measuring Wilbur’s mood because his physical and cognitive difficulties will likely have impacted his ratings. For example, there was a question about difficulty with concentration which will have likely been impacted by his executive difficulties. I believe the most telling question was the one about suicidal ideation. Prior to therapy, Wilbur reported he had these thoughts nearly every. Post-therapy, he reported only having them on several days (in a two week period). The overall score on the GAD-7 did not change from pre- to post-therapy. However, there was some evidence the targeted intervention was effective as the scores for questions about worrying thoughts improved.
Qualitative feedback was the most useful measure of outcome in this case. Wilbur kept a daily diary throughout therapy and, although variable, his mood and anxiety seemed to improve considerably overall. On the weeks Wilbur spent more time out of bed and engaged in meaningful activities, he reported that he felt “fantastic” and expressed surprise that his pain had “vanished”. There was also a considerable change in his behaviour. Wilbur reported this was because he was able to tolerate not knowing if there was anything he should be concerned about.
Another positive outcome was that Wilbur was discharged from the inpatient ward to the community whilst I was working with him. Both he and his daughter reflected that our work was crucial in this process. However, at the conclusion of therapy, Wilbur still had days he was unable to get out of bed which led to a downward spiral. Therefore, I am not confident the gains made during therapy will be maintained in the long-term. As I finished my placement at the same time as I finished my work with Wilbur, I do not know the outcome of the neuropsychological assessment that Wilbur was undergoing. However, given the complexity of the case and the insights I had gained into Wilbur’s presentation, I sent a comprehensive account of our work to the professionals involved in his ongoing care.
Personal and Professional Development (PPD)
Given the focus of this case study, I have discussed PPD in the context of the supervision section below. However, one personal reflection I had was the role my optimism played in this case. On one hand I wonder whether my optimism encouraged unrealistic expectations about the progress Wilbur could make, and potentially exacerbated the strain on his relationship as his daughter tried to encourage him (sometimes forcefully) to engage in the behaviours most beneficial to his wellbeing (when they might have been out of his volitional control). However, I also think my optimism was beneficial because Wilbur made considerable progress, despite probable executive issues. Had I placed executive issues at the centre of his formulation at the assessment phase, I suspect our intervention would have been less demanding, but also less effective.
Diversity issues
There was a considerable age gap between Wilbur and I and I considered the impact of this in supervision and tried to imagine what our relationship was like from Wilbur’s perspective. Wilbur found it difficult to adjust to a recent transition in roles and I suspected I reminded him of the things he felt he had lost; potentially impacting on our relationship. As well as empathy, I felt sympathy for Wilbur and I felt sad after many of our sessions. However, I was mindful not to let this impact on my clinical work and considered it in supervision.
I did not understand some of the cultural references Wilbur made (and vice-versa) which occasionally created a communication barrier. We discussed these issues and, as our therapeutic alliance strengthened, they became less of a barrier.
I remained mindful of the power imbalance throughout our work together. Wilbur initially viewed me as a doctor; someone who would ask him some questions, diagnose him and then fix his problems. It took time for Wilbur to see us as equals, but we negotiated this together.
Supervision
I kept a supervision diary summarising the main themes discussed in each supervision session and any associated learning or action points. I learnt that conceptualising the function of each note as an aide-mémoire rather than a comprehensive record, allowed me to stay present and focussed in the supervision session, whilst ensuring I did not forget the important points discussed.
Relationship with Supervisor
The contracting process was essential in developing a strong working relationship as it helped clarify expectations, boundaries, roles and responsibilities. This created an atmosphere of containment and trust and I felt safe, secure and confident enough to deliver my clinical work effectively. Reflecting on this relationship in the context of attachment theory, I believe my supervisor represented a secure base (Bowlby, 2005).
PPD
I felt daunted by the complexity of the case initially and I wanted my supervisor to tell me what to do and how to do it. The integrated developmental model of supervision (Stoltenberg & McNeill, 1998) suggests that trainees progress through a series of qualitatively distinct stages in regard to awareness, motivation and autonomy. I believe I was in the first stage initially and sought concrete direction to reduce my anxiety. In the context of the model, it is likely I was initially less focussed on Wilbur and more focussed on myself. Had my supervisor been pulled into a directive role, I would not have progressed but, fortunately, he encouraged me to work autonomously. For example, rather than suggesting additions to my preliminary maintenance formulation, he encouraged me to consider socio-cultural and longitudinal factors that were relevant to working with older adults and recommended a book about adapting CBT to older adults. Whilst this raised my anxiety, it facilitated my transition to the next stage of the model, characterised by increased confidence and assertiveness when working autonomously. I believe this improved my clinical work by allowing me to become more focussed on Wilbur, and increased my empathy and my understanding of his worldview.
Models of Supervision
The primary model we agreed to use in supervision was the Inskipp and Proctor (1993) model of the function of supervision. I wanted to use this model because I had experienced very different types of supervision in the past and was somewhat unclear about the purpose(s) of supervision.
The model describes three, overarching functions of supervision. The normative function involves communicating (and monitor adherence to) the rules, regulations and guidelines of the employing organisation and any professional bodies the clinician is affiliated with. The formative function involves helping the supervisee to develop the required skills and knowledge to work effectively. Finally, the restorative function involves managing the emotional impact of the clinical work. During my work with Wilbur, I used supervision primarily for formative and restorative purposes because most normative aspects had been covered in supervision for clients I worked with prior to Wilbur.
The primary restorative theme I brought to supervision was feeling out of control and out of my depth. Related to this, I thought about the case outside of working hours and was anxious before sessions. What I learnt from supervision was to cultivate greater self-awareness and self-compassion to ensure my emotions did not impact on my clinical work and lead to boundary violations. This was particularly important when working with Wilbur as he frequently asked me a number of personal questions. I was encouraged to discuss our respective roles and set boundaries prior to engaging in therapy, which helped us form an effective, appropriate, therapeutic relationship.
The primary formative theme was adapting CBT to older adults. I was encouraged to take an idiosyncratic approach and to use a period of extended assessment to fully understand Wilbur’s difficulties before proceeding with treatment. Had I rushed into treatment I believe it would not have been effective as I would not have targeted the key factors maintaining his difficulties. I also used supervision to help identify targets for treatment, to assess whether elements of the formulation mapped onto diagnostic conceptualisations, and how to adapt the treatment to Wilbur’s needs.
Critique
On reflection, I am pleased with how I handled this complex case. I believe CBT was an appropriate model to use (as justified in the assessment section) and I believe the longitudinal formulation model (Laidlaw et al., 2004) was beneficial as it helped to consider the diverse factors relevant in Wilbur’s presentation.
The two main outcomes Wilbur reported were having greater tolerance for uncertainty and noticing an improvement in mood from engaging in meaningful activities. This maps onto Wilbur’s initial goals and the intervention. However, given the central role of the intolerance of uncertainty in Wilbur’s formulation, I was surprised initially that his improvement in this area did not result in better outcomes in mood and anxiety. On reflection, this was likely due to the maintaining role of executive issues, which became increasingly prominent as therapy progressed. Given this, I believe it was highly beneficial that I adapted the delivery of the interventions, as per the recommendations by James (2010). Had I not, I believe Wilbur would have become overwhelmed and frustrated by the treatment and would not have made the progress he did.
There are some aspects of the case I am less confident about. The presence of Wilbur’s daughter in some of the sessions as an agent of change (James, 2010) was beneficial in some respects (e.g. compliance with between-session tasks). However, it might have communicated to Wilbur that his role as an agent of change was less significant. I obviously attempted to encourage Wilbur’s sense of agency and both he and his daughter were keen for her to attend to the sessions.
It might also have been useful to focus more on Wilbur’s cognitive biases that were potentially maintaining his depression and to work on his core belief of being a bad person that was likely underpinning it (James, 2010). However, given Wilbur’s probable executive issues this would have been unlikely to be effective and, as James (2010) points out, core beliefs formed in early childhood are very difficult to change. In line with James’ recommendations, cognitive processes were addressed indirectly through behavioural approaches, although some modest attempts at cognitive intervention were conducted (unsuccessfully).
Related to Wilbur’s core beliefs, I suspected he had suffered emotional and physical abuse in his childhood, potentially from his father. He described one incident of physical abuse, but I sensed there were further significant experiences he was unwilling to disclose. As research (e.g. Ashcroft, Kingdon, & Chadwick, 2012) suggests a potential link between emotional abuse in childhood and persecutory delusions in adults, a greater understanding of the events of his childhood would have been beneficial. Similarly, research (e.g. Pickering, Simpson, & Bentall, 2008) suggests that insecure attachment predicts persecutory delusions. Given Wilbur’s presentation, it is plausible he developed an insecure attachment style from having a father who was punishing, emotionally unavailable and unpredictable and so he never developed a sense of security in the world, had difficulties forming and maintaining relationships and, in time of stress, had severe difficulties with emotion regulation (Ainsworth & Bell, 1970; Bowlby, 2005; Main & Solomon, 1986). This would appear to fit with Wilbur’s difficulties, potentially sheds light on the difficult relationships with his family he described, and suggests he might have benefited from an attachment-based intervention such as interpersonal psychotherapy (Miller & Reynolds III, 2007). However, as Wilbur was unwilling (or unable) to discuss his childhood in detail, this hypothesis remains tentative.
References
Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67. doi:http://dx.doi.org/10.2307/1127388
Ainsworth, M. D. S., & Bowlby, J. (1991). An ethological approach to personality development. American psychologist, 46, 333. doi:http://dx.doi.org/10.1037/0003-066X.46.4.333
Ashcroft, K., Kingdon, D. G., & Chadwick, P. (2012). Persecutory delusions and childhood emotional abuse in people with a diagnosis of schizophrenia. Psychosis, 4, 168-171. doi:http://dx.doi.org/10.1080/17522439.2011.619012
Bowlby, J. (2005). A secure base: Clinical applications of attachment theory. London, United Kingdom: Routledge.
British Psychological Society. (2014). Understanding psychosis and schizophrenia Retrieved from http://www.bps.org.uk/
Brown, T. A., O’Leary, T. A., & Barlow, D. H. (2001). Generalised anxiety disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders, third edition: A step-by-step treatment manual. New York, NY: The Guilford Press.
Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behav Res Ther, 58, 10-23. doi:http://dx.doi.org/10.1016/j.brat.2014.04.006
Davis, D. H. J., Creavin, S. T., Yip, J. L. Y., Noel-Storr, A. H., Brayne, C., & Cullum, S. (2015). Montreal Cognitive Assessment for the diagnosis of alzheimer’s disease and other dementias. Cochrane Database of Systematic Reviews(10). doi:http://dx.doi.org/10.1002/14651858.CD010775.pub2
Dobson, K. S., & Dozois, D. J. A. (2009). Historical and philosophical bases of the cogntive-behavioural therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies, third edition. London, United Kingdom: Guilford Publications.
Dugas, M. J., & Robichaud, M. (2012). Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice. New York, NY: Taylor & Francis.
Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive model of persecutory delusions. Br J Clin Psychol, 41, 331-347. doi:http://dx.doi.org/10.1348/014466502760387461
Greenberger, D., Padesky, C. A., & Beck, A. T. (2016). Mind over mood, second edition: Change how you feel by changing the way you think. New York, NY: The Guilford Press.
Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of event scale: A measure of subjective stress. Psychosom Med, 41, 209-218. Retrieved from https://ovidsp.ovid.com/
Inskipp, I., & Proctor, B. (1993). The art, craft and tasks of counselling supervision. Part 1: Making the most of supervision. London, United Kingdom: Cascade.
James, I. A. (2010). Cognitive behavioural therapy with older people: Interventions for those with and without dementia. London, United Kingdom: Jessica Kingsley Publishers.
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9. Journal of General Internal Medicine, 16, 606-613. doi:http://dx.doi.org/10.1046/j.1525-1497.2001.016009606.x
Laidlaw, K., Thompson, L. W., & Gallagher-Thompson, D. (2004). Comprehesive conceptualization of cognitive behaviour therapy for late life depression. Behavioural and Cognitive Psychotherapy, 32, 389-399. doi:http://dx.doi.org/10.1017/S1352465804001584
Main, M., & Solomon, J. (1986). Discovery of an insecure-disorganized/disoriented attachment pattern. In T. B. Brazelton & M. W. Yogman (Eds.), Affective development in infancy. Norwood, NJ: Ablex Publishing.
Miller, M. D., & Reynolds III, C. F. (2007). Expanding the usefulness of Interpersonal Psychotherapy (IPT) for depressed elders with co-morbid cognitive impairment. Int J Geriatr Psychiatry, 22, 101-105. doi:http://dx.doi.org/10.1002/gps.1699
Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., . . . Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53, 695-699. doi:http://dx.doi.org/10.1111/j.1532-5415.2005.53221.x
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Extracts from Supervision Diary
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Extract |
Notes from supervision diary |
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1 |
Expectations of supervisor: – I should come prepared to supervision, having critically reflected on my work to some degree. – I should show a genuine interest in working with older adults and demonstrate warmth, enthusiasm, curiosity and an eagerness to learn. – I am expected to use supervision effectively to ensure I can work autonomously, within the limits of my ability. – We should be honest and open with one another and be receptive to two-way feedback. If difficulties or ruptures occur, both should make a concerted effort to address the issue in supervision but, if unresolved, another psychologist working into the service can be requested, as well as my University tutor. – |
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2 |
Discussed hot cross bun formulation with supervisor. He asked me to consider the client’s upbringing and family background and to ask about any difficult early life experiences. He also asked me to consider cohort effects, sociocultural context, transitions in role investments and intergenerational linkages as these are relevant to this population. Action point: read Kenneth Laidlaw’s CBT for Older People: An Introduction (chapters on assessment and formulation). |
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3 |
Discussed feeling out of my depth with client – far most complex case than I anticipated. Advised this is normal for trainees to feel this way, especially with older adults as cases are highly complex involve interactions between physical health, dementia, complex trauma, grief, adjustment, social isolation etc. |
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4 |
Discussed pull to want to rescue client, how to manage personal questions and becoming too involved and anxious about progress i.e. thinking about it in car on way home. Advised not to plan sessions too rigidly – to work flexibly and respond to issues that arise in sessions. Action point: discuss boundaries with client (including the sharing of personal information and our respective roles- explain therapeutic relationship is very different to a friendship – more one-way). |
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5 |
Take time on assessment- don’t rush. Make sure formulation includes all key information communicated, even though hypotheses will be tentative (embryonic formulation). Can structure it using Laidlaw’s comprehensive conceptualisation model and then look at targets for treatment and diagnostic-specific models later. |
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6 |
Is formulation consistent with OCD or GAD model? Seems to be elements of both. Action point: briefly review the literature on OCD and GAD and reflect on whether client’s thoughts are more like worries or intrusive-thoughts and whether behaviour is similar to OCD compulsions or GAD-type checking. Assess potential utility of incorporating diagnostic model into formulation. Review Dugas treatment manual on GAD. |
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7 |
Tailor manual to client: use simplified explanations and go slowly with intervention. Explain the importance of intolerance of uncertainty and how client’s behaviour is an attempt to increase certainty. Focus on behavioural more than cognitive aspects initially. |
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8 |
Discussed additional targets for intervention. Action point: consider addressing cognitive distortions (jumping to conclusions, catastrophising) by weighing up evidence for and against and trying to find a balanced perspective. Potentially introduce a relaxation exercise to tackle agitation/tension. |