Outline the benefits and disadvantages of this CBT approach in relation to your interactions with your client.
According to Lazarus (2005) typically these modalities are to be assessed through a series of questions however the disadvantage of asking a series questions posed somewhat of a challenge as John remained focused on one particular issue “I feel tired all the time which my doctor tells me is due to my depression, I just want these depressive symptoms to stop controlling my life” Lazarus (2005) argues it is advisable to engage the client by focusing on the presenting issue , to redirect matters too prematurely onto other matters that seem more important is only inclined to make a client feel invalidated.
I noted that by addressing the presenting issues with John asking him to elaborate for example (“please tell me more about these depressive symptoms you are experiencing” “can you elaborate on them further?”
While attempting to have John elaborate on these issues with open ended questions I carefully documented specific modalities across the BASIC ID that were being discussed and which were being glossed over however I also noted that there were some avenues left unexplored.
The clinician needs to discuss and jointly agree with the patient how to priorities the target areas. (Explained exposure profile) This necessitates putting some of the problems to one side for the time being and then, having jointly identified a key area, together drawing up a plan of how to tackle the problem. Change will be difficult without this degree of focus and structure.
Planning and selecting which areas to try to change first is a crucial part of successfully moving forwards. By choosing a single problem area to focus on initially, you and your patient are actively choosing not to focus on other areas. Setting targets will help you and your patient to focus on how to make the changes needed to get better. To do this you will need to identify the following:
TABLES MUST BE USED IN APPENDIX ACCORDING TO UNI
After John the completion of Johns MLHI a treatment plan was devised including interventions in each modality.
JOHNS MULTIMODAL TREATMENT PLAN
Prefers to stay home, social withdrawl Activity scheduling
Increase time and contact time with others
AFFECT Depressed Explore triggers and associated thoughts
SENSATION Tiredness, low energy Graded task assignments to treat low energy
IMAGERY Rumination of critical comments by his father as a teenager, Confidence and coping imagery
COGNITION Thinks of himself as a failure (signs of irrational self talk) Cognitive restructuring methods and identify strengths
INTERPERSONAL Passive behavior
Avoids social contact Increase social skills
DRUGS/BIOLOGY Adherent with medication.
Drinks alcohol in within moderation at tomes when overwhelmed with feelings of depression
No physical exercise Monitor and reduce alcohol use
Increase physical activity.
The next stage, having summarized the problems, is to identify the first target area to tackle – the short-term target(s) with chosen interventions. The patient has also to be actively involved in agreeing the choice or he or she is likely to be unmotivated, showing poor compliance or failing to return to the clinic.
Modalities identified to be prioritized issues as per Johns assessment were as follows, Cognitions and sensations therefore the following CBT interventions were used to facilitate these issue which also correlated with johns agreed goals in his initial interview.
Cognitive restructuring refers to any methods which help people to think differently about a situation/event/thought/belief. Really, this could apply to anything done in (or outside of) a therapy session. Typical approaches to promote cognitive restructuring in therapy include:
• traditional CBT thought records which help clients to challenge unhelpful Negative Automatic Thoughts
• behavioral experiments which help clients to test beliefs which may be unhelpful
• Socratic questioning to explore a client’s beliefs
Cognitive–behavioural therapy (CBT) interventions in the language of the traditional and Five Areas models
Traditional CBT Five Areas assessment
Collaborative empiricism with guided discovery using Socratic questioning Aim to ask sequences of effective questions, and provide information that can help the person understand more about how he/she feels
Identify negative automatic thoughts and schemas using thought diaries Identify extreme and unhelpful thoughts using a thought investigation worksheet
Modify negative automatic thoughts, restructure core beliefs and schemas Use thought challenge worksheet to challenge extreme and unhelpful thoughts
Behavioural deficits – behavioural activation or pleasant event scheduling, graded task assignment, self-reward Identify the presence of the vicious circle of reduced activity
Graded exposure with or without response loop tapes, event rehearsal (for nightmares and post-traumatic stress disorder ) and stress inoculation Plan a step-by-step increase in activity Identify the vicious circle of unhelpful behaviours. Face up to fears in a planned step-by-step way
Problem-solving Practical problem-solving using a seven-step plan (seeWilliams, 2001b)
Relaxation, re-breathing, stimulus control, visualisation, worry periods and mindfulness meditation Use any evidence-based, short relaxation treatment, e.g. anxiety control training (Snaith, 1998)
Homework task ‘Putting into practice what you have learned’
A crucial part of CBT is a self-help approach that enables the patient to put into practice in everyday life what he or she has learned during treatment sessions. Equipping the patient with a set of skills to self-manage current problems is a central aim of CBT. For this reason a key component of each treatment session is to work with the patient in developing a specific action plan of how, between now and the next scheduled meeting, he or she is going to put into practice what was learned in the session. The term ‘putting into practice what you have learned’ is preferred to the traditional CBT term ‘homework’ as it avoids the potential negative associations of treatment being akin to school work that must be completed and is then marked by a teacher, or in this case the clinician. ‘Practice’ is negotiated collaboratively between patient and clinician and is seen as a time for active self-treatment. The inter-session practice encourages the patient to generalise skills learned in sessions to tackle problems encountered in everyday life. It is important that difficulty with this process is not viewed as a failure but simply as an opportunity for further learning. Success, on the other hand, can reinforce the patient’s sense of self-efficacy and give encouragement that future difficulties or relapses may be tackled in a similar manner. As a result, treatment outcome is enhanced for patients who complete such ‘homework’ assignments.
Compliance therapy Using medication effectively (Williams, 2001a)
Thus, in practicing MMT, one does not mindlessly apply the multimodal spectrum across the board, but instead, when indicated, the well-trained multimodal clinician has an imposing armamentarium of assessment and treatment strategies at his or her disposal. Recall that MMT is a clinical approach that rests on a social and cognitive learning theory, and is therefore not a unitary or closed system. Instead it uses technically eclectic and empirically supported procedures in an individualistic manner. Obviously, there is no one therapist who can be well versed in the entire gamut of methods and procedures that exist today. Therefore it should go without saying that if a problem or a specific client falls outside their sphere of expertise, the competent clinician will endeavor to effect a referral to an appropriate resource.
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