Individualized, transdiagnostic approaches to complex presentations: a case study

Journal of Psychiatric and Mental Health Nursing, 2013, 20, 216–221

Individualized, transdiagnostic approaches to complex presentations: a case study J. BINNIE bsc (hons) dip/he rmn bsc (hons) Cognitive Behavioural Psychotherapist, King’s College London, London, UK

Keywords: cognitive and behavioural psychotherapy, common mental health problems, evidence-based practice Correspondence: J. Binnie King’s College London James Clerk Maxwell Building 57 Waterloo Road London SE1 8WA UK E-mail: [email protected] Accepted for publication: 24 January 2012 doi: 10.1111/j.1365-2850.2012.01881.x

Accessible summary

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Basing psychological treatment on diagnosis can work but not always. People are complicated and so are their problems. Being responsive and adapting treatment plans is important.

Abstract Cognitive behavioural therapy is an evidence-based approach to helping people resolve their mental distress. Cognitive behavioural therapy practitioners are often encouraged to adapt their interventions according to the person’s diagnosis. However, this approach can be too simplistic. This paper aimed to reflect on working with complex clinical presentations and to explore how transdiagnostic approaches can be effectively integrated into standard cognitive behavioural interventions. To achieve these aims, a case study of cognitive behavioural therapy assessment and treatment was presented. The interventions used are described in detail. The move away from a diagnostic-led intervention to a transdiagnostic perspective based on the individualized formulation is described. Reflections on the process are discussed and the overall approach used is evaluated with recommendations made to enhance future clinical practice.

Introduction This study aims to demonstrate how cognitive behavioural therapy (CBT) is applied with clinical cases with complicated presentations. Cognitive behavioural therapy can be described as a short-term, focused form of psychotherapy, with the basic premise that unhelpful styles of thinking can lead to unpleasant emotions and dysfunctional behaviours (Leahy & Holland 2000). Cognitive behavioural therapy is known to improve the mental health of various populations, for example, those with depression (Dobson 1989), anxiety (Butler et al. 1991) and growing evidence for schizophrenia (Cormac et al. 2002). Case study methodology is utilized, with assessment undertaken and cognitive behavioural treatment commenced in line with accepted protocols described in Roth & Pilling (2007). However, as treatment progressed it became apparent that disorder-specific protocols were not comprehensive enough to help alleviate distress. Therefore, a transdiagnostic, problem-focused approach was taken 216

with the individualized formulation being the key to successful therapy.

Clinical case presentation Summary of the assessment Frank1 was a 61-year-old man from London; he was referred with a diagnosis of obsessive compulsive disorder (OCD). Diagnostically, OCD is classed as a neurotic disorder with the essential features being distressing obsessive thoughts and related compulsive acts (World Health Organization 1992). Obsessive compulsive disorder is considered to be the fourth most common mental health disorder (First & Tasman 2004) and has been found to be associated with high co-morbidity, significant social and occupational impairment and high rates of alcohol dependence and attempted suicide (Torres et al. 2006). His 1

Name changed to assure confidentiality. Informed verbal consent obtained to be the subject of this assignment.

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CBT case study: formulation

general practitioner requested CBT to help with Frank’s problems with repeated ritualistic behaviours and associated drop in general functioning. At assessment Frank presented with compulsive rituals that took up most of his day. The rituals focused around his daily activities, with checking and cleaning behaviours dominating. Each ritual would also encompass a reliance on certain numbers, for example, the number 11 held particular significance. He would then feel he had to perform the ritual perfectly, if interrupted he would have to start from the beginning. He reported that he was unable to perform other more functional activities until his rituals were completed successfully. At assessment there were no distinct feared consequences; that is, there was nothing in particular that he feared would happen if the rituals were not performed. In regards to risk Frank reported that he occasionally had thoughts of ending his life but could dismiss them easily. No past suicide attempts. Some selfharm in the form of skin picking. No history of violence to others. Frank was born in London, the middle child of a working class family. He described a turbulent family atmosphere. His father had mental health problems and was violent towards his mother; his father sexualized Frank from a young age through having sexual intercourse in his presence and encouraging sexual activity with older girls. Frank had a difficult relationship with his older brother and was bullied. Frank attended school but left with no qualifications. He left home at 18 and began work in the construction industry. He married when he was 20 years old. Frank reports to have been happy for many years until he was 40. At this time he was having difficulties at work, was drinking heavily and struggling generally. His wife left him and he subsequently lost his job and his home. He went to his doctor and was diagnosed with OCD. He managed to build his life back together and met his current wife a few years later. Alcohol, however, remained an issue for many years with Frank describing himself as an alcoholic. From an early age Frank engaged in repetitive behaviours as a way of feeling in control. He first went to see a counsellor in the early 1990s; around this time he also had sessions of CBT at a specialist OCD clinic; this was unsuccessful due to Frank’s alcohol use. Five years ago Frank stopped drinking alcohol; he became abstinent. He was referred for more CBT and reported that this went well. However, a year later he continued to have disabling problems and was referred back. Again, he completed a course of CBT including sessions offered at his home; although partially successful, Frank’s rituals continued. At the time of assessment Frank worked as a handy man. He had been married for 14 years and had no © 2012 Blackwell Publishing

children. No contact with his wider family. Due to his problems Frank had little free time for outside interests or for socializing.

Measurement tools and goals for therapy During the first session Frank completed a generic measure of current mental health and a disorder-specific measure. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM; Evans et al. 2000) is a 34-item selfreport measure of global distress, subjective well-being, problems and symptoms, general functioning and risk. The measure is particularly useful for measuring response to psychological therapy (Evans et al. 2000). The Obsessive Compulsive Inventory (OCI; Foa et al. 1998) is a 42-item self-report measure of the frequency and distress of a range of obsessions and compulsions. With both measures results can be compared to clinical cut-offs, with higher scores indicating higher disability. Tables showing the completed measures can be found later in the study. Regarding goals for therapy, Frank stated that he wanted to reduce the amount of time taken up by his rituals by 50% and engage in more functional activities.

Initial formulation After the assessment it was assumed that Frank met the diagnostic criteria for OCD as he had obsessions and prominent related compulsions. Also, this had been his diagnosis for many years. Together, Frank and I went through how his behaviours, feelings and thoughts were all related to one another using Lang’s three systems model (Lang 1968). We discussed how Frank may have thoughts about safety, that something bad may happen, and this caused him to be anxious. Frank then did the compulsions to reduce the anxiety. As the behaviours reduce anxiety he was more likely to do them again due to operant conditioning through negative reinforcement (Gega 2004). Over time this cycle spiralled and resulted in Frank spending hours a day doing behaviours that stopped him living a more productive life.

Interventions Frank was seen for 12 CBT sessions over 4 months. Treatment began by investigating what had happened in his previous episodes of CBT; we concluded that Frank had received both behavioural and cognitive interventions. Behavioural treatments typically propose the use of Exposure and Response Prevention (ERP; Meyer 1966), a treatment based on behaviour therapy in which the patient confronts their fears and refrains from performing their 217

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rituals. The cognitive model of OCD, best put forward by Salkovskis (1985), highlights the role of the meaning given to the obsession; what the person fears happening is crucial to their reactions. By enabling the sufferer to perform experiments they can rationalize their thinking and therefore reduce the distress and the need to perform the rituals. Both previous CBT treatments had been conducted by experienced and proficient therapists. However, Frank continued to have disabling rituals. In line with standard, disorder-driven, manualized CBT programmes (e.g. Leahy & Holland 2000), the initial sessions were spent giving information about anxiety in general and OCD in particular. Goals were set and the formulation collaboratively discussed. Still, no feared consequences could be discovered and Frank seemed unable to justify why he did the rituals, he said he did them because he did them. To aid clarification Frank was encouraged to record his rituals using a diary for homework. Although not totally comprehensive the completed diaries were enough to get an idea of the nature and severity of his rituals. It became apparent that the vast majority of Frank’s day was spent conducting rituals; he had rituals for nearly every activity. However, from analysing the diary many inconsistencies were discovered. For example, he would only touch a drinking glass at home using a piece of tissue; however, when outside he would fix a car engine and then eat a sandwich without cleaning his hands. It was becoming clear that Frank really was unable to remember the reasons behind his rituals. The inconsistencies in his rituals casted doubt on whether his rituals were being driven by a fear of contamination or an over-inflated concern for safety. Without defining the obsessions cognitive work would be hard to implement. To help inform the formulation I asked Frank to stop one of his rituals and to see what happens. This was done as Frank had said that if he were to stop the rituals then he would become anxious. I wanted to discover if anxiety was the reason for continuing to perform the rituals. This experiment was necessary to help decide on a treatment approach. If anxiety was found then ERP could be utilized, in line with the Roth & Pilling (2007) recommendations. The experiment suggested that Frank was able to make changes to his rituals without any associated anxiety. At this point in the therapy following a prescribed disorder-specific treatment protocol was proving difficult. Anxiety was not a maintaining factor; therefore, it was unlikely that ERP would be successful. Also, Frank was unable to describe any particular feared consequences in relation to his rituals; this indicated that traditional cognitive strategies for OCD would also be unsuccessful. We therefore revisited the formulation. A move was made away from disorder-specific models to working 218

transdiagnostically. The transdiagnostic approach puts forward that psychological disorders share a range of processes; these processes should be the focus rather than the specific diagnosis (Mansell et al. 2009). Through discussing his difficulties and the exacting nature of his rituals we started to realize that many of his behaviours were driven by his rules and assumptions (Beck et al. 1979). Frank said that he wanted to be in control of all aspects of his life. We related this back to his earlier life experiences, in particular his relationship with his brother and also the critical events that happened when he was 40. These events had reinforced the need to have control in his life. However, rather than getting back on track he spent years dependant on alcohol. This again would reinforce the idea of control. We then made links from his rules in general to the rules he has for his rituals. These ritualistic rules, although linked to past experiences, still did not seem to make any logical sense due to the inconsistencies. These inconsistencies were presented to Frank and by examining them we began to see that the rituals could be seen as a habit. We discussed how originally there may have been reasons for his compulsions, for example, that he may have had previous concerns about getting ill therefore the desire to clean thoroughly. However, over time as the behaviours became habitual, he may have forgotten what the reasons were. He ended up performing the behaviours like he was on ‘auto pilot’. Once his problems were conceptualized differently habit reversal techniques (Azrin & Nunn 1973) could be applied. Frank was encouraged to monitor his rituals and then perform a competing response, such as clenching his fists. These techniques would help break the classically conditioned response between the trigger and behaviour. Classical conditioning is a form of basic learning in which one stimulus or event comes to predict the occurrence of another stimulus or event (Zimbardo et al. 1995). Frank understood the rationale behind the intervention and successfully applied it to some of his rituals. He then started to think differently about his difficulties and by seeing them as a habit or as a product of his past allowed him to act differently. At times he would perform a competing response, at others he would say to himself ‘I don’t need to do it’, and at others when finding it hard to resist the urge he would tell the urge to ‘F**K OFF!’ His idiosyncratic way of dealing with the rituals was encouraged and the distinctions were reinforced through conducting various behavioural experiments. Behavioural experiments (Beck et al. 1979, Bennett-Levy et al. 2004) are used to test specific beliefs and ideas. With Frank his ideas were tested both in the therapy room, such as touching his shoes and then licking his fingers, and at home by resisting the urge to perform the rituals to assess degree of anxiety. © 2012 Blackwell Publishing

CBT case study: formulation

Towards the end of therapy we reviewed what had worked and what had not. Frank reported that he had found disentangling his problems the most useful aspect. Being able to distinguish what was going on was important for him as it allowed him to make real changes. We then went over what to do if things became more difficult in the future using standard relapse prevention procedures (Beck 1995) and finally said our good byes.

Outcomes Clinical Outcomes in Routine Evaluation-Outcome Measure (Table 1) The above measure indicates that Frank’s well-being and functioning increased and his problems and symptoms reduced. Obsessive Compulsive Inventory (Table 2) The above measure indicates that all Frank’s symptoms reduced. Goals Frank stated that his time taken up by the rituals had reduced by over 75% and as a result he was able to develop new interests such as cycling. He also reported that the relationship with his wife was better and that his work was more productive.

Table 1 Clinical outcomes in routine evaluation-outcome measure Dimension

Beginning therapy

End

Clinical cut-off scores for men

Subjective well-being Problems or symptoms Functioning Risk Total minus risk

3.25 3 3.17 0 3.11

0 0.75 0.67 0 0.61

1.37 1.44 1.29 0.43 1.19

Discussion Frank’s case highlights the importance of a thorough problem-based assessment prior to deciding on a treatment pathway (Grant et al. 2008). The assessment was continual; it only neared completion when the experiment was conducted to see if anxiety was a pivotal factor. I believe that without this thorough assessment the treatment would not have been successful. Treatment would have adhered to a disorder-specific framework advocated by Roth & Pilling (2007) as had previous episodes of CBT. The experiment suggested that Frank did not have major issues with anxiety; perhaps, this indicated that he did not really have OCD as OCD is often considered an anxiety disorder. However, diagnostic systems place a different emphasize on the role of anxiety, for instance, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV TR) expressly states that anxiety and distress is an essential component of OCD (First & Tasman 2004), whereas the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) does not (World Health Organization 1992). This creates confusion if strictly following a disorder-specific protocol. This case study highlights the importance of understanding the presenting problem thoroughly in cognitive behavioural terms rather than in diagnostic categories. What followed with Frank was more of a transdiagnostic approach. Frank’s behaviours were investigated through experimentation. As no anxiety was found then the maintaining mechanism could not be based on operant conditioning via negative reinforcement. This would mean that any treatment such as ERP that is based on this assumption would fail. This level of examination was crucial as choosing the right behavioural technique for the right problem is fundamental in CBT (Gega 2004). The factors involved in maintaining the behaviours were then conceptualized as habitual and classically conditioned rather than anxietyreducing. Perhaps, years ago Frank did have a reduction in

Table 2 Obsessive compulsive inventory Beginning therapy

End therapy

Clinical cut-off scores

Dimension

Frequency

Distress

Frequency

Distress

Frequency

Distress

Washing Checking Doubting Ordering Obsessing Hoarding Mental neutralizing Total OCI

2.75 2.44 2 3.8 2.38 3 3.5 118

2.5 2.11 1.33 3.4 1.88 2 3 99

1.5 1.44 1 2.4 0.25 1.33 1.83 57

1.13 1 0.67 2 0.25 0.33 1.5 42

1.44 1.51 2.01 1.87 1.67 1.22 1.49 66.36

1.44 1.51 1.84 1.87 1.79 1.24 1.38 66.33

OCI, Obsessive Compulsive Inventory.

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anxiety when performing his rituals; then over the years the trigger became classically conditioned to the ritual to form a stimulus and response reaction without any anxiety present (Barlow & Mavissakalian 1981). With this alternative process in mind, a different treatment was envisioned, one that aimed to break associations that were classically conditioned. Allen (1998) put forward that habit reversal procedures could be effectively applied to any number of persistent self-control behaviour problems. Therefore, these interventions were utilized. Cognitive interventions were not primarily used as classically conditioned associations are not accessible to conscious experience (Brewin 1989). However, some time was spent with Frank discussing the development of his problems and his underlying beliefs concerning control. The habit reversal techniques were interwoven into an individualized, transdiagnostic formulation. Frank was enabled to understand his problems and where they may have arisen from; this was considered appropriate as it allowed Frank to distance himself from his rituals and engage in targeted strategies to facilitate change.

concerning the use of disorder-specific frameworks and transdiagnostic approaches. For the client in this case study the transdiagnostic approach was found to be more effective. These findings correspond to my previous clinical experiences with other clients with complex problems. I would put forward that cognitive behavioural treatment should always be based on an individualized problembased formulation. Then if this fits a diagnostic category then a disorder-specific protocol can be used as a guideline for treatment. If the diagnosis is not clear or the client has complex issues then transdiagnostic approaches should be implemented. At present the trend in the NHS towards disorder-specific protocols reverses this suggestion and fits individuals with individual issues into a manualized treatment based on diagnosis only. This presupposes that psychiatric diagnoses are valid and reliable and that academic research samples can be compared to clinical populations; there are many who suggest that this is not the case for example (Kutchins & Kirk 1999, Bentall 2003). Alternatively taking a problem-focused, individualized approach allows more therapeutic precision and also a greater degree of flexibility.

Conclusion A case study of cognitive behavioural assessment and treatment has been presented. Reflections have been made

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