Case Formulation
Santiago Adam, a 21-year-old Latino, is the client for this practicum. Recently, Adam has been experiencing perceptual disturbance and severe paranoid thoughts. When he was fifteen, he had recurrent depressive feelings, but the condition relapsed after several medications. Adam was diagnosed with intense depression, which resulted in diet restriction and a loss of fifteen pounds. He was subjected to depression pills which significantly improved his functioning and mood. Two weeks ago, he was admitted to an intensive psychiatric program due to suicidal ideation, anxiety and intense hallucination. At admission, he was oriented and alert and denied thoughts of homicidal thoughts. A critical examination of Adam’s case revealed that he had not slept for three consecutive days before admission, and the patient experienced endless insomnia.
Adam’s sister, with whom he lived, alleged she had noticed strange behavior in him, such as severe confusion, increased aggression towards children and persecutory delusions. Adam was presented with a broad range of effects that prompted the doctors to question his mental health status. He is often depressed, disorganized in speech with the tangential thought process, and talkative with a flight of ideas. Adams lacked awareness of his condition and distrusted everyone without the ability to discern the reality of processing information from fictional intrusive thoughts. His family medical history revealed that the grandmother was a victim of psychosis disorder.
Decision-Making Process
Cognitive Behavioral Therapy (CBT) was chosen as the mode of clinical intervention in Adam’s case. His mental health is characterized by psychotic disorder, evidenced by underlying symptoms such as hallucinations and delusion. The patient’s family history of psychotic illness underpins the puzzle of aetiology. Close observation and interaction with Adam link the patient’s mental status to cannabis-induced psychosis. However, his family history and collateral information posed more answers to the aetiology puzzle. Hence, on decision making to use CBT, through informed guesses, it was suggested that Adams’ case is of early onset of psychosis or schizophrenia outlasting a period of acute intoxication. The specialists handling the case speculated that cognitive behavioral therapy could reduce occurrences of such psychotic signs.
Moreover, the alteration could limit the depression and distress associated with such symptoms and the degree to which they affect Adam’s functioning and mood. Cognitive behavioral therapy can also monitor and identify the feelings and thoughts that come with psychotic illness in particular scenarios and correct and evaluate these thoughts against actual circumstances and objective external evidence. Doctors anticipated that CBT could reduce Adam’s anxiety and guide him towards thoughtful, informed decisions that can encourage his personal growth.
The depressive symptoms, Adam enhanced the medical team to project the client’s condition. Adam could be dealing with a psychosis-induced trauma or a complicated case of delayed grieving. Therefore, cognitive behavioral therapy would give Adam insight into adjusting negative patterns, which can help him reframe his thoughts during heightened panic or anxiety. Based on the clinical evidence, Batterbee (2020) posits that cognitive behavioral therapy can make a psychotic individual develop new coping skills, such as journaling and meditation, that can curb the struggles of depression. Responsible doctors handling the case objected to applying the same concept to Adam’s primary psychotic disorder. The team alleged that early intervention could prevent the development of secondary psychotic conditions aligned with Adam based on his current health situation. Adam’s paranoid thoughts must have escalated, affecting others in the unit. The condition was highlighted as evidence of his aggressiveness and anger towards children. As a result, health experts suggested that CBT could help Adam’s social problem-solving skills, regulate his frustrations, and provide him with assertive behaviours that are useful during conflicts instead of aggression.
Cognitive Behavioral Therapy
CBT is a form of psychotherapeutic treatment that has been effective in helping individuals learn how to identify and monitor disturbing and destructive thought patterns that negatively influence their mood, behavior, and emotions. CBT has been demonstrated to be safe and effective in reducing the severity of psychotic symptoms and, in some cases, preventing the occurrences (Kazantzis et al., 2018). The clinical intervention combines behavior and cognitive therapy by identifying maladaptive patterns of emotions, behavior, responses or thoughts and replacing them with more positive habits. Rawlings et al. (2019) illustrated that cognitive behavioral therapy is related to improved therapeutic relationships, changes in reasoning styles and beliefs about others, and improved functioning. This approach is time-limited, structured, and a goal-based treatment modality that can be delivered to individuals or groups modalities.
The therapeutic model for this clinical intervention is conceptualized through a series of essential steps and a solid therapeutic alliance to achieve its success. It is an intensive short-term practice with about six to twenty sessions in a problem-oriented approach. CBT is a collective of research and clinical-based in-session and out-session exercises that help patients to develop coping skills and practice for various mental problems (Batterbee, 2020). Indeed, ample scientific evidence exists in this approach in which the methods developed produced change. CBT’s unique features and steps make it different from other psychological treatment options. CBT has been recommended as the frontline psychotherapeutic option in the treatment guideline of psychosis published by the National Institute for Health and Care Excellence, the Patient Outcome Research Team, and The American Psychiatric Association.
Intervention
Cognitive behavioral therapy is goal-oriented and structured. The context and techniques in CBT are supportive and paired with a collective therapeutic stance. Introducing CBT to Adam involved a focused discussion of the rationale for the therapy in treating his condition, how the program will be structured, and the time-limited nature of the treatment. The emphasis was placed on the research basis of Cognitive behavioral therapy and with evidence that it is empirically supported psychotherapeutic treatment. Adam had little exposure to psychotherapy, and providing him with an understanding of the therapeutic program made him more active and insightful in his role in the therapy process. Awareness of this program enhanced the collaborative nature of this therapy. Adam had concrete thoughts about this; it was necessary to give him many examples and initially focus on behaviours, not his cognitions.
The alterations of Adam’s mental illness began with an orientation program that familiarized the patient with his emotions, thoughts, and feelings. While discussing Cognitive behavioral therapy with Adam, a pamphlet with the context of what the program entailed was handed to him to read. While it was anticipated that the step alone would be ineffective, he was assisted in going over the model using simple examples of his case to demonstrate how situations, feelings, behaviours and thoughts connect up. The entire discourse of the first step entailed; a discussion of the program underlying Cognitive Behavioral Therapy, a discussion of how present psychotic problems can be conceptualized and treated with the CBT approach, and a description of the format, structure, and therapy expectations. It was brought to Adam’s attention that the CBT model is a theoretical paradigm for demonstrating the association between feelings, thoughts and behaviours.
Adam often believed that situations gave rise to his emotions. It was explained to him that the CBT approach challenges this subject of his experience, which, instead, was his thoughts about situations giving rise to his emotions. Adam’s depression and anxiety displayed a pattern of dysfunction and false expectation about this approach. He had to be assured that he would be trained in specific skills to help him change and improve his behavior by modifying his thoughts about the situations. His thought record was key in examining and identifying his association between thoughts and feelings to this program.
Negotiating the amount of time Adam will spend in this program was critical to the treatment plan. It was addressed to him that he will typically attend a weekly session of three to seven weeks. The amount of time per therapy session and the number of daily attendances in a week was to be periodically reassessed and adjusted to meet Adam’s need. Adam’s feedback about the program was imperatively significant. A collaborative component of Cognitive behavioral therapy involves asking patients for session feedback. Encouraging Adam to give his input on his feelings about the treatment plan strengthened the rapport and trust that would make the sessions effective. It indicated that he could be an active member of the therapeutic process. It was also a platform to show that care is given to his thoughts and feelings about the program. Adam’s feedback resolved the misunderstandings about the cognitive model that would occur within the treatment process.
Steps of Clinical Intervention
The step-to-step interventions, in this case, operated on the principle that Adam’s emotional reactions are determined by how he perceives events. The ABC model of cognitive behavioral therapy was used in Adam’s case. The model worked by; a) Collaboratively assessing problems that Adam finds troublesome, b) assessing how Adam tends to think about the problems, c) looking at how he reacts to them, basically his behaving patterns, d) identifying whether it is unhelpful or unrealistic, and deciding possible ways to solve the problem, and e) ultimately engaging the new ways of practicing thoughts and habit that could correct the situation.
Identifying the Relationship Between Mood, Thoughts and Behavior
Interviews were the primary technique used in this step. Applying assessment and diagnostic skills was vital to expand the understating of Adam’s situation. Discussing Adam’s recent upsetting situation was the first step towards identifying cognitive distortion and automatic thoughts in problematic situations. This discussion helped me learn the relationship between Adam’s moods, ideas, and behavior. Adam was asked a few sets of questions for this step. He was asked to think of any situation in the past week that might upset him. He responded that he was sitting in the subway and noticed a man driving a Lamborghini. He was asked about his feeling when he saw the man going. He replied that he felt sad and hungry.
The patient was further asked what he thought when angry and sad. Adam said everyone seems to have a desirable destiny except him. That was unjust and fair to him. The client was later asked what he did when he had such thoughts and feelings, and Adam responded that he could not withstand such feelings. Instead, he went home to bed, started thinking about all that had happened and decided to have suicidal thoughts. From the interview questions, it was understood that Adam has no car, which seems fair and unjust, and he thinks he might not have any desirable destiny.
Identifying Cognitive Distortions
Cognitive restructuring and reframing were the technique used in this step. It entails assessing thought processes in confronting or upsetting situations to identify negative patterns. Identifying Adam’s automatic thoughts related to his emotions also encompasses learning to identify errors in his thoughts as he recalls troublesome situations. It was noticed that his mistakes in thinking were likely to occur when he felt distressed. Kuru et al. (2018) showed that emotional distress could wear down an individual and create defeating thoughts in minds, making people more reliant on simplistic thinking. It was noticed that Adam sees things as either black or white with no grey in between. Adam tends to disqualify the positive.
The patient discounts positive experiences and is likely to count the negative ones. For instance, Adam always helps his younger brother do homework and school assignments and spends as much time as possible with him every Saturday. Recently, his college work kept him away from home. Adam concluded that he was a lousy brother. It was as well noticed that Adam liked overgeneralizing things. He sees single events as things that will never end. For example, he felt anxious about helping his brother and now concludes that he will never be able to interact with him comfortably.
Targeting Beliefs and Assumptions for Change
As the therapy progressed, another cognitive strategy and homework worksheet was introduced to target Adam’s underlying core beliefs and assumptions. One approach to assess his core beliefs was through thought records that identified specific situations that caused emotional distress and how often they recurred. Adam was helped to evaluate and question this assumption to generate alternative viewpoints and less pain as they occur in upsetting situations. Another approach that can target assumptions and beliefs for change in this program is journaling opposing solid opinions, such as stressing moments on one page and journaling strong positive thoughts on the other (Chan & Sun, 2020). The approach was fundamental in giving Adam his correct belief insights in this case. He was asked to keep track of his daily experiences each week, identifying situations where positive and negative beliefs seemed supportive. The cases were reviewed carefully for contrary and supporting evidence to give a more balanced perspective.
Approach for Behavioral Change
The approaches selected for Adam’s case were based on his goals and case formulation. Adam’s case highlighted several intervention approaches, such as working with him to identify, monitor and reduce triggers. He was also helped to gather evidence against his belief patterns. The solutions included; creating awareness and providing education on cognitive errors, teaching reasoning skills, setting up behavioral experiments and reality testing, and working on Adam’s core beliefs and automatic thoughts. These approaches were applied within the subject of the therapeutic relationship and at Adam’s comfort and pace. Though the program was structured, the therapy was flexible and assisted Adam with non-related therapy programs that can collaborate with the client’s goals to improve and improve the quality of life. Such activities were more than completing an application for housing programs or writing a CV.
Self-monitoring
When Adam was asked to keep track of his problems as they occur daily. He became more aware of specific situations that tend to trigger his distress. The monitoring approach in this program was tuned into a particular type of trigger that could rise to more confronting situations. He could be more aware of situations that activate feelings such as sadness, anger, anxiety, disappointment or hurt. Monitoring forms in CBT can be imperative in creating awareness of intensity and mood. Such an approach helped Adam know if certain events could lead to low anxiety or extreme stress levels.
Evaluation
Outcome and Barriers
Cognitive behavioral therapy was geared towards alleviating Adam’s condition. The approach was to modify His cognitive content and process and realign his thoughts with reality. The therapeutic approach was to identify, monitor and correct difficulties that arose in Adam’s thinking, dysfunctional beliefs, faulting learning and misperceptions. Barriers to this program were evident and posed challenges during the treatment plan. Adam’s anxiety and depression were reduced. One of the principal objectives of this program was to identify and address how Adam’s feelings and behaviors are associated with creating anxiety. Psychoeducational intervention in this program was essential in breaking down events or scenes that would make Adam feel scared and anxious.
Patients with cognitive and behavioral disorders lean on CBT for effective healing processes. CBT fundamentally uses the tool of question and not assertion, which influences the subject’s answers to give self-stability, causing both behavioral and cognitive changes (Muir et al., 2021). The opportunity given to him to ask questions was impactful in helping Adam release the energy of misconception and exaggerated fears despite being a complicated patient. CBT counselling was an art of making Adam think through the questions for him to take deemed appropriate for his health. The program made his problems more manageable and helped him change his negative thoughts and patterns about confronting situations. Additionally, CBT had instruments of a great utility program that became practical tools of communication to help Adam make decisions and facilitate the expression of his fears and change in behavior.
CBT changed Adam’s distorted thinking, and he responded more positively to his behavior. Cognitive behavioral therapy was a collective effort to change his thinking pattern and help Adam better understand his mental state and motivation of self. From the talk therapy, Adam could identify interruptive and unhealthy thinking patterns. Naeem (2019) echoes that CBT is essential in helping psychologically challenged patients to recognize their distorted thinking patterns. Adam’s case was not an exception, the client was subjected to CBT therapy to allow him eevaluate his problems with the objective of reducing the depressive symptoms. The interventions incorporated in this program reduced Adam’s emotional burden with distorted thinking patterns; hence, he could control disease symptoms and better understand his mental health. Change in his thinking patterns enhanced self-efficacy and self-control, which promoted a solid adherence to therapy, decreased its side effects while increasing its effectiveness, and improved his mental regulation. His journaling of thoughts created a positive impact on his intrapersonal characteristics and self-growth.
CBT was essential in reducing delusion and hallucination experiences. Adam’s constant experiences of ideas that are not true and hearing things that do not exist changed how he thinks and responds to such incidents. Notably, this therapeutic approach applied to treat delusion and hallucination did not focus on reducing the experience of the voice but dissociating the perceived energy of voices that could harm him and motivate compliance. Indeed, the fundamental importance of this program was to challenge Adam’s critical beliefs about the power of commanding voices. Adam showed a lower level of compliance and appeasement behaviours. He as well showed increased resistance to the representatives of hallucination. The CBT framework created acceptance of voices of hallucination and delusions by cultivating his capacity to recognize and associate thoughts instead of perceiving them as truth and acting on them. Psychoeducational intervention made Adam understand all skills, psychological techniques, and knowledge vital to solve organic complications with hallucination and delusion. The education also encouraged hope and positivism on the psychotic delusional and hallucination disorders.
Despite the successful outcomes of CBT, barriers to this program were encountered and posed some challenges in treatment implementation. The potential barrier included multiple comorbidities and psychosocial stressors, such as Adam’s family’s financial instability influencing disruptive behavioral disorders during therapy. The general population’s youth are always anxious when presenting with multiple comorbid diagnoses, backgrounds from a more disadvantaged neighborhood, and lower social and economic status (Rawlings et al., 2019). Adam’s perception of this given comorbidity increases anxiety, disrupting the treatment plan. This barrier was solved by creating an environment of awareness and understanding with Adam Additionally, Adam had a belief about Cognitive Behavioral therapy that is not supported by any empirical evidence. Such conviction included; CBT is not suitable or harmful to specific types of patients with no comorbidity challenges, and depression and anxiety disorders are not central to his psychopathology and hence not essential to treat.
Moreover, cognitive-based therapy is the most scientifically and psychologically supported treatment, yet Adam lacked awareness. With his anxiety, he could not make empowered mental health decisions due to a lack of knowledge of evidence-based therapeutic psychological therapies. This barrier was addressed by educating Adam more on CBT. Furthermore, Adam’s traditional knowledge suggested that he did not find deliberate exposure to feared stimuli. Hence, given a choice, he preferred meditation over CBT to deal with his anxiety and depression problems. He also predominantly chose medication over his anxiety and depression rather than psychological treatment; hence convincing him about CBT therapeutic approach was tedious.
Cultural Adaptations
Proverbs, Analogies and stories served as good cultural adaptive techniques to facilitate Adam’s recovery. Sayings and stories represented cognitive sets that helped Adam interpret ideal situations that can serve as primers to adaptive functioning and promote positive affect. The rationale behind using proverbs and analogies is that they can function as emotional regulators and essential elements in teaching CBT information. Furthermore, proverbs and stories are essential promoters of cultural and social self-esteem, which gives the patient a sense of how his culture is full of rich and vital traditional knowledge. This can further reduce negative affect (Rawlings et al., 2019). The following was an essential frequent proverb in his Latino language; No se ahoge en un vaso de agua (do not drown in a glass of water), with a therapeutic meaning: avoid ruminating problems or issues to the degree they can cause distress (Rawlings et al., 2019). Culturally appropriate analogies and traditional proverbs improved the therapeutic alliance with Adam, making her feel his cultural background was well understood and appreciated.
Adam was instructed to perform important traditional rituals that would quicken his recovery. Hernandez et al. (2020) suggested that if the culture has transitional rights of purification, such as steam bath rituals, patients are advised to perform such requests at the end of treatments as it creates a positive transformation and a sense of closure. The patient was inspired to undergo a steaming ritual at the end of treatment as it was imperative in inducing a somatic state analogous to anxiety, such as shortness of breath and flushing. Fragrant substances are often part of steaming rituals and symbolic objects associated with bodily sensations. The rationale behind incorporating traditional practices as part of the treatment was to create a positive image of transformation, memories cosmology, and a positive world image.
Termination Plan
As Adam’s therapy draws to a close, the termination will be a time to review his achievement and decide whether to end the therapy program or reinforce other measures. First, reviewing gains made in the treatment will be a fundamental step of the termination plan. Many therapy sessions gradually foster changes without being noticed (Batterbee, 2020). Reviewing Adam’s progress at termination will highlight these positive changes. Things to look for in this case will include decreased symptoms severity, improved relationships, a positive future outlook, and more positive body language. Second, an assessment will be reviewed to highlight the mood and functioning trends. If the evaluation makes sense as the therapy ends, the results may be graphed to highlight the trends further. Third, Adam will be asked to review any changes he has noticed, if he has seen any improvement outside the therapy, or what has been noticeably helpful. This is a good indicator of whether the treatment will be terminated or other measures reinforced.
Managing this case has been instrumental in enlightening and giving more profound insights into the protocol for professionally managing psychotic patients. I have also gained a broad understanding of delivering a successful cognitive behavioral therapy program to psychotic or mentally ill patients. I will apply my abilities, knowledge, and skills in my future clinical profession if such instances arise.
References
Batterbee, R. A. (2020). The inclusion of cognitive behavioral therapeutic components in the undergraduate nursing curriculum. A systematic integrative review of the evidence. Nurse Education Today, 94(11), 104–567. Web.
Chan, H. W. Q., & Sun, C. F. R. (2020). Irrational beliefs, depression, anxiety, and stress among university students in Hong Kong. Journal of American College Health, 69(8), 827–841. Web.
Hernandez, M., E., Waller, G., & Hardy, G. (2020). Cultural adaptations of cognitive behavioral therapy for Latin American patients: unexpected findings from a systematic review. The Cognitive Behavior Therapist, 13(4), 67–94. Web.
Kazantzis, N., Luong, H. K., Usatoff, A. S., Impala, T., Yew, R. Y., & Hofmann, S. G. (2018). The Processes of Cognitive Behavioral Therapy: A review of meta-analyses. Cognitive Therapy and Research, 42(4), 349–357. Web.
Kuru, E., Safak, Y., Özdemir, I., Tulacı, R. G., Özdel, K., Özkula, N. G., & Örsel, S. (2018). Cognitive distortions in patients with social anxiety disorder: Comparison of a clinical group and healthy controls. The European Journal of Psychiatry, 32(2), 97–104. Web.
Muir, H. J., Constantino, M. J., Coyne, A. E., Westra, H. A., & Antony, M. M. (2021). Integrating responsive motivational interviewing with cognitive–behavioral therapy (CBT) for generalized anxiety disorder: Direct and indirect effects on interpersonal outcomes. Journal of Psychotherapy Integration, 31(1), 54–69. Web.
Naeem, F. (2019). Cultural adaptations of CBT: A summary and discussion of the Special Issue on Cultural Adaptation of CBT. The Cognitive Behavior Therapist, 12(4), 133–169. Web.
Rawlings, G. H., Perdue, I., Goldstein, L. H., Carson, A. J., Stone, J., & Reuber, M. (2019). Neurologists’ experiences of participating in the CODES study-A multi-center randomized controlled trial comparing cognitive behavioral therapy vs standardized medical care for dissociative seizures. Seizure, 71(12), 8–12. Web.