Florence Nightingale School of Nursing & Midwifery
Cognitive Behavioural
Assessment and Formulation
Cheryl Jordan
Objectives:
• Critically reflect on frameworks and approaches to
assessment in CBT
• Identify and discuss factors which are maintaining the
problem as proposed by CBT theory
• Understand the practicalities and process of the CBT
formulation
• Understand the role of measurement in CBT assessment and
practice
• Discuss the advantages and limitations of utilising this
framework in standard mental health nursing practice
Assessment
• What skills are required in assessment ?
• What do you think the differences might be
when undertaking a cognitive behavioural
assessment ?
Cognitive formulation (Beck 1976)
Early
Experience
Core Beliefs
Rules and
Assumptions
Critical
Incident
About self/others /world
Conditional statements
If………..then
I must…..
Situations or events where rules
are broken or assumptions activated
Emotion
Somatics
thoughts
Behaviour
These elements interact
in a vicious cycle
Structure of a therapy session
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Greetings and mood check
Agenda setting
Homework and review of previous session
Focused work for the session
Negotiation of homework linked to work in
session and formulation
• Elicitation of effectiveness of session and
feedback.
Process of Assessment
Gather Information
Analyse info using CBT theory
Decide what further
Info will help test
hypotheses
Develop hypotheses about important processes
initial ideas about formulation
Modify formulation
Discuss with client and modify as necessary
Agreed working formulation
Treatment plans
Note further info acquired
During treatment
Formulation
• Helps client and therapist understand the problem
• Bridge between CBT theory about problem
development and maintenance and clients
experience
• Shared rationale and guide for therapy
• Opens up new ways of thinking
• Helps therapist understand/predict difficulties in
therapy or therapeutic relationship
Current problem
What’s the problem?
Ask for a recent example
What?
Where?
When?
With Whom?
Why?
Critical
Incident
What does it mean to you?
What’s going through your mind
when you feel……..?
Thoughts
Affect
physical
What do you feel most ….
About ?
How frequent? how intense?
Duration?
Behaviour
Do you notice anything
happening in your body ?
What do you do or feel like doing when you feel..?
What’s the consequences of doing this?
Maintaining process: anxiety
Fear of a particular
situation /object
No change to fear beliefs
Client does not learn coping
Strategies or expose beliefs
to disconfirmation
Escape/avoidance
Maintaining processes: depression
Depression
Loss of positive rewards
Negative thoughts
( activity is seen as pointless)
Reduced activity
Video Clip
• Watch the clip
• Analyse the information elicited by the
therapist, use CBT theory to understand what
the problem is and what might be
maintaining it.
• Take note of the questions the therapist asks
to elicit the information and how the CBT
approach is introduced.
Core beliefs and assumptions
• Downward arrow technique.
If that where true what would that mean to you?
Rules/assumptions
Core beliefs
What does it mean to you if /when………….?
If that were true what would it mean to you/ about you?
History
Early
Experience
Medical/psych history
Previous experience of therapy
Family & relationships
Themes within the family
Cognitive formulation (Beck 1976)
Early
Experience
Core Beliefs
Rules and
Assumptions
Critical
Incident
About self/others /world
Conditional statements
If………..then
I must…..
Situations or events where rules
are broken or assumptions activated
Thoughts
Somatics
Affect
Behaviour
These elements interact
in a vicious cycle
Problems and Goals
• Problem: I feel X ( emotion) about X
( situation) and this leads to X
( behaviour)
• Overall goal:
I would like to feel X ( emotion) about X
( situation) and this would lead to X
( behaviour)
• Smart goals : set week to week
( Dryden W, 2001)
Role play exercise
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Divide into groups of 4
Cheryl to play patient
Plan your questions to elicit info on the following:
Group 1: thoughts
Group 2: emotions/physical sensation
Group 3:behaviour
Group 4: situation
Patients goals for therapy
1 person from each group to ask the questions
Others observe
Carry out assessment. In your small groups begin to construct a
formulation, need anymore info?
• Present formulation to Cheryl and the group.
• What could you do to test out whether the formulation is accurate?
Formulation
• Art or science?
• Do different therapists agree the exact same
formulation for the same client?
(Beiling & Kuyken 2003)
Is treatment based on formulation more effective ?
(Schulte et al 1992) ( Ghaderi, 2006)
Suitability
Inclusion:
1.
2.
3.
4.
5.
Can access thoughts and feelings
Accepts some responsibility for change
Understands a CBT rationale and basic formulation
Able to form a good enough relationship with therapist
A degree of optimism
Exclusion
1.
2.
3.
4.
Impaired cognitive functioning
Currently in crisis
Unwilling to let go of avoidance behaviours
Pronounced pessimism about therapy ( Wills F 2008)
Types of measurement
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Self-ratings (SUDs)
Diaries
Questionnaires / outcome measures
Physiological responses
Making good use of data
BDI scores
35
30
score
25
20
Series1
15
10
5
0
1 2 3 4 5 6 7 8 9 10 11 12
session number
Measurement scales
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BDi
PHQ9
BAI
GAD 7
HAD
Ybocs
Liebowitz social anxiety scale
Multi dimensional perfectionism scale
Dysfunctional assumption scale
BDI
1.Beck Depression Inventory is a series of questions
developed to measure the intensity, severity and
depth of depression in patients with psychiatric
diagnoses.
2.The BDI is a 21 item self-report rating inventory
measuring characteristic attitudes and symptoms of
depression (Beck et al., 1961)
3. It is not a diagnostic tool for depression.
4. It takes 5-10 minutes to complete.
Encyclopedia of Mental Disorders:http://www.minddisorders.com/A-Br/Beck-Depression-Inventory.html)
HISTORY OF BDI
• First developed by Aaron Beck in 1961.
• Adapted in 1969.
• Copyrighted in 1978.
• BDI-I was revised in 1996 -> BDI-II was published in
1996 in response to DSM-IV 1994.
HOW TO USE BDI-II?
• It has 21 self-rating questions.
• It takes 5-10 minutes to complete.
• It has to be subjective to the client, focusing on
feeling of past one week
• Designed for use by trained professionals.
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(Groth-Marnat,1990)
BDI-II - TWO FACTORS APPROACH
1. Somatic symptoms.
2. Cognitive symptoms.
Somatic symptoms consist of 13 items:
Sadness, lack of pleasure, tearfulness, agitation, loss of interest,
indecisiveness, loss of energy, change in sleep pattern,
irritability, poor appetite, poor concentration, tiredness and loss
of libido.
Cognitive symptoms consists of 8 items.
pessimism, past failures, feelings of guilt, punishment feelings, self
dislike, self critical, feelings of worthlessness and retardation.
HOW TO USE AND SCORE BDI-II?
• It has 21 assessment criteria.
• Each criteria has 4 statements and a score of 0-3 is
assigned for each statement.
• Eg: (0) I do not feel sad
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(1) I feel sad
(2)I am sad all the time and can’t snap out of it
(3) I am so bad or unhappy that I can’t stand it
Scoring of BDI-II
The standard cut-off point are as follows:
• 0-9 - indicates a person is not depressed
• 10-18 - mild-moderate depression
• 19-29 - moderate-severe depression
• 30-63 - signifies severe depression
The higher the score, the more severe the
depression.
Strengths
• It has two subscales which help determine the primary cause
of the depression.
• Its short and easy to use and subjective to clients’ own
feelings.
• It is an instrument widely used in research and CBT .
• Sensitive to changes for use in monitoring and evaluation
• It has helped develop other self rating scale,
• eg: Beck Anxiety Inventory, Beck Hopelessness Scale, Beck
Scale for Suicide Ideation.
• Available in many different languages
Weakness
• Score can be exaggerated or minimised by
client.
• Concomitant physical illness can inflate the
score rather than depression.
• Social expectation may elicit different
response (e.g. postal survey)
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(Bowling, A.2005)
PHQ – 9
Quick Depression Assessment
• Indication:
all new patients in primary care
also tested in clinical specialty areas
• Widely used - Adapted by England – IAPT
(IAPT, 2007) and commonly used in Primary
Care Settings
• Self-administered tool
• Sensitive to change (Lowe et al, 2004)
GAD 7
• This easy to use self-administered patient
questionnaire is used as a screening tool and
severity measure for generalised anxiety
disorder.
The GAD-7 score is calculated by assigning
scores of 0, 1, 2, and 3, to the response
categories of “not at all,” “several days,”
“more than half the days,” and “nearly every
day,” respectively, and adding together the
scores for the seven questions.
BAI
• Screen for anxiety with the Beck Anxiety
Inventory® (BAI®). Patients respond to 21
items rated on a scale from 0 to 3. Each item is
descriptive of subjective, somatic, or panicrelated symptoms of anxiety.
• Screen Anxiety
BAI has been found to discriminate well
between anxious and nonanxious diagnostic
groups in a variety of clinical populations.
Homework
• Recommend some reading
Eg, CBT for dummies
• Information gathering
• Getselfhelp.co.uk
Taking it forward
• Think about one of your own fears and
consider to what extent they are maintained
by the way you think about them and behave
in relation to them.
Cognitive behavioural strategies
• Two main methods
– Questioning unhelpful beliefs
– Devising behavioural tests
Cognitive behavioural strategies
• Two main methods
– Questioning unhelpful beliefs
– Devising behavioural tests
Types of question
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Evidence for questions
Evidence against questions
Alternative view questions
consequences of questions
Guided discovery
Principles :
• Ask a series of questions to uncover relevant information
outside of the client’s awareness
• Tease out :
• false assumptions,
• inconsistencies in belief,
• contradictory views
• Double standards
• Faulty conclusions
• Develop a way forward
Cognitive behavioural therapy
• Behavioural Experiments
• Involve testing predictions about physical, social or
psychological danger or gathering information
• Focus is on belief change through experience
• Experiment must have a clear hypothesis from client,
followed by a task that tests out that belief in an
appropriate setting
What is a good Socratic question?
• The client has the ability to answer or work
out an answer
• The answer reveals new perspectives
• ‘People are generally better persuaded by the
reasons which they themselves discovered,
than by those which have come into the
minds of others.’
(Pascal 17th Century French Philosopher)
Examples of socratic style
questioning
• Exercise:
• Socrates in action
• Clinical application
References
• Branch R, Dryden W, 2008, The cognitive behaviour counselling Primer.
Athenoeum Press, UK.
• Dryden W, 2001 Reason to change. Whurr. London
• Grant et al, 2008 Assessment and Case Formulation in Cognitive
Behavioural Therapy. SAGE Publications. London.
• Westbrook et al, 2011 An introduction to CBT. .Skills and applications.
Sage. London
• Wills F, 2008 Skills In Cognitive Behaviour Counselling & Psychotherapy.
Sage publications. London.