Case Formulation of Patient with Child Trauma Emotional Neglect

Case Formulation

1. Introduction

The importance of the development of a case formulation has been highlighted by a number of theorists. According to Bieling and Kuyken (2003, p 53), case formulation (CF) is “a provisional map of a person’s presenting problems that describes the territory of the problems and explains the processes that caused and maintain the problems.” Boschen and Oei (2008) stress the necessity of a sound understanding of the client’s presentation and they believe it is a prerequisite for therapeutic treatment planning, with the alternative being an unstructured, ad hoc style of intervention.  Eells et al. (1998) claim that CFs from psychodynamic, cognitive, behavioral, and interpersonal therapies have three features in union. In the first instance, they make inferences concerning a client’s presenting issues that are supported by the client’s interactions in treatment. In the second instance, the inferences made in the CF process are reached on the basis of the treating clinician’s own knowledge and judgment, rather than the self-report of the client. In the third instance, CFs are ‘compartmentalized’(p 145) with an overall formulation being produced as the sum of a collection of smaller components. For Persons (1989) a case formulation helps the therapist understand how apparently diverse problems are related and develop an efficient treatment plan to address them. The case formulation translates the nomothetic (general) protocol into an idiographic (individualized) one for the case that is being presented. The idiographic formulations assist the clinician’s decision making process. Ingram (2006) developed an approach for integrating concepts from a comprehensive list of theoretically differentiated “core clinical hypotheses” to create a treatment plan that best suited for the client.

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With the specific instance of a client who believes that she suffered a trauma childhood emotional neglect, this assignment will outline a case formation along with the rationale for the theoretical framework and methodology presented.

Trauma and its consequences have been recognized as a high-priority public health risk (e.g., U.S. Department of Health & Human Services, 2003).

2. The Client

V. R (not her real initials) is a 32 year old female who arrived in England 18 months ago from a Scandinavian country. She came to England to read for a BA in music. She believes she suffers from the trauma of emotional childhood neglect which she stated has left her feeling anxious and unable some Google searches. She had one suicide attempt in her early 20’s when she took an overdose and has occasional suicidal ideation. She scored 21 on the GAD and 21 on the PQR.

V. R. believes she was emotionally neglected by her father in childhood. Two years ago she confronted her father about his emotional absence. Her father said that when V. R. was born he was over devoted to his work and felt he could not be emotionally available to her as he had not received emotional support from his parents. In her assessment, V. R. described having a warm relationship with her mother, with whom she said she can be emotional expressive. V. R. has one sister, with whom she has a distant relationship. V. R. had a warm relationship with her mother’s mother and a poor relationship with her father’s mother. All grandparents are now deceased.

She is in a loosely committed relationship for a year with a single man who is 23 years her senior. He is frequently away due to his work and V. R. is aware that she is partly in love with him because he reminds her of her father. She has been in a number of relationships before with men who were significantly older than her.

As a student, V. R.  qualifies for a reduced fee at the low cost counseling service where I practice. The length of time she can avail of counseling at the service is open ended.  She self-referred to the therapy centre.

3. Initial Meeting(s) and General Outline of the Case Formulation.

A belief I hold is that it is a courageous decision for a person to enter into the therapeutic process. After establishing if there are no emergency issues (Ignam, 2009), an aim I have for the opening session and initial sessions will be to provide space for the client to tell her story in her own words along the provision of broad outline of what therapy is, the various issues concerning confidentially and to let her know that she is in a safe place in which she has the freedom to share. The rationale for this process, especially for someone who has potentially suffered trauma, is to present a positive relational space where sensitive and personal issues can be explored in a safe environment. I will attempt to complete this by drawing on the Rogerian model (1957) of congruence, unconditional positive regard and empathy. By building on a strong therapeutic alliance, it is my intention to offer the client a space to delve deeply into the issues that she believes are hindering her reach her full potential. A number of theorists propose that the therapeutic relationship influences interpersonal schemas, early attachment problems, emotional processing, failures in validation and compassion (Gilbert, 1992; Safran, 1998; Safran and Muran, 2000; Greenberg, 2002; Leahy, 2001; Gilbert and Irons, 2005; Leahy, 2005; Bennett-Levy and Thwaites, 2007; Gilbert and Leahy, 2007). Wright & Davies (1994) believe that therapists need to be sensitive to both the general and idiosyncratic expectations of their patients, without compromising the necessary limits or boundaries of the relationship.

3. Genogram—- elements of patterns and family dynamics

Following the initial session(s), it is my intention to invite the client to undertake a genogram of her family to assertion roles and familial dynamics that are present in her family of origin. The rationale for charting the client’s genogram is to come to understand how roles and familial dynamics are currently influencing the operating functionality of the client. According to Stagoll and Lang (1998), genograms were invented by Murray Bowen in the 1970’s. I am aware that taking the client’s genogram may be a slow and a painful process for the client as in her assessment she referred to the relationship with her father as being the most negative and disruptive relationship in her life. During the taking of the genogram I will pay particular attention to the salient features of how the client expressing herself and her operating worldview.

4. Anxiety

Having explored the client’s family of origin from a systemic framework, it is my intention to move towards addressing the client’s high levels of anxiety. The client is not currently on medication for her anxiety and it is my hope that the client’s level of anxiety will decrease by the conclusion of therapy. Anxiety is experienced through a constellation of emotional, physiological, cognitive, and behavioral symptoms (APA, 2000; Barlow, 2000). Cognitive restructuring is a range of interventions intended to support the client in rational evaluation of their cognitions, and modification of these cognitions with the aim of reducing emotional distress (Beck, 1995). Cognitive restructuring is seen as the primary vehicle by which perceptions of danger are addressed.

A therapeutic resource I shall draw on is Beck’s Cognitive Triad (Beck, 1976) which provides a series of principles in which cognition is conceptualized along three levels, namely, core beliefs, dysfunctional assumptions and negative automatic thoughts.

Core beliefsare seen as fundamental, inflexible, absolute, and generalized beliefs that people hold about themselves, others, the world, and/or the future (Beck, 2011; Dobson, 2012). According to Wenzel (2012) core beliefs are considerably more difficult to elicit and modify in cognitive therapy sessions, relative to situational automatic thoughts and I am aware there may be a level of resistance from the client to give up her deeply ingrained core beliefs. Core beliefs normally develop from messages received during a person’s formative years and that is why I believe it appropriate for me to explore them with the client as she believes she suffered the trauma of emotional childhood neglect. Core beliefs are part of a construct which is part of a person’s schema. It is my hope to explore with the client, through the use of Socratic questioning, the origins of her core beliefs especially those which are causing her harm.

Dysfunctional assumptions arise from core beliefs and schemas and can involves areas on a person’s life concerning achievement, acceptance or control. To counter the dysfunctional assumptions I would propose to the client that we might collaboratively compare the advantages and disadvantages of these statements, asses their irrationality, develop a healthier and positive statement, and implement an action plan.  For the CBT method to be effective, a key component for both the therapist and the client is the identification of the client’s negative automatic thoughts (NATS). They surface without any obvious conscious process and are accepted as normal and are taken for granted. For recovery to occur, my task as therapist is to assist the client in reducing, modifying or eliminating the NATS and helping her to generate alternative ways of thinking to help the client to have a more realistic of themselves, others and the world. Possible ways of generating alternative ways of thinking include examining, exploring, exposing, expanding and experimenting (McManus, Van Doom, Yiend, 2008).

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For Fisher (in press), it is clear that a cognitive-behavioural case formulation (CBCFF) for anxiety disorders does not incorporate a holistic view of the client, but is centered on the issues for which they are seeking treatment. This is consistent with the ideas of preceding theorists who have emphasised that within the CBT model, the case formulation is a description of the presenting issue, rather than of the whole person (Bieling and Kuyken, 2003).

Contingent with cognitive outlooks of anxiety psychopathology (e.g. Beck and Clark, 1997), the CBCFF holds to the understanding that the perception of threat or danger, rather than the feared stimulus itself, elicits anxiety.

In the anxiety disorders CBCFF, anxiety-reducing behaviour is directly elicited by the experience of increased anxiety. Elevated anxiety serves as a discriminative stimulus to indicate to the individual that certain behaviours will be followed by anxiety reduction.

5. Childhood Emotional Abuse

After having engaged with the client on cognitive restructuring it is my intention to focus on the childhood emotional abuse which the client believes she suffered. According to Fisher (in press) a persons capacity for affect tolerance along with the incorporation of an integrated sense of self in later stages of development in life is contingent on self-regulatory abilities gained during infancy, both the ability for interactive regulation (to be soothed by others) and auto-regulation (soothing ourselves). In her assessment, client mentioned that she felt both her interactive regulation and auto-regulation capacities were inhibited and was having a negative capacity for her to fully function with her academic studies.

As dysregulated autonomic arousal inhibits activity in the prefrontal cortex (LeDoux, 2002), the child’s ability to learn, problem-solve, and verbally communicate is contingent on self-regulatory capacity and therefore on the quality of early attachment. Where interactive regulation from securely attached parents is lacking, small children must depend on their ability to alter consciousness when soothing is needed and on the body’s innate “fault lines” for compartmentalizing overwhelming experiences (Van der Hart, Nijenhuis & Steele, 2004; 2006). As the client believes this is true in her case, part of the treatment plan is to explore the early attachment styles and offer to the client the Adult Attachment Interview (AAI). I would also offer the client the Adverse Childhood Experience (ACE) Questionnaire. Depending on her results it will assist in the repairing of what the client may have felt she did not receive in terms of a secure attachment in her formative years.

Assessing brain development in children and adolescents, Teicher (2004) has noted a link between a history of abuse and/or neglect and under-development of the corpus collosum compared to normal controls which would also sustain the hypothesis that trauma is linked with structural dissociation of right and left brain-mediated parts of the personality. While this would be beyond my scope and competence as a psychotherapist, if the client wishes to explore this area further I believe it would be ethically responsible for me to make her aware of neuroscientist or psychologist who has a specialty in this area.

6. Transference and Counter-Transference

A central presenting issue for the client is the relationship she had with her father and how is has impacted the rest of her life. As there is a six year age difference between the client and me, while a moderate amount of time, it is still sufficient I believe, that the client may see me as a ‘father-like figure’. Other reasons why the client may see me as a ‘father-like figure’ include me being seen to her as a person in ‘authority’ or an ‘expert’. Part of my awareness for the potential of this particular transference is that I may intintile the client and there is the potential that the power dynamics that have been operative in her previous relationships, especially male relationships would come into force in the therapeutic relationship.   Sharing my awareness with the client of potential negative aspects of transference may generate resistance (King and O’Brien, 2011) from her or may be a function of my own intrapsychic processes that could confuse or alienate the client.

Along with being aware of possible transference I will also pay attention to areas of possible counter transference on my part (Wilson and Kniest, 1996). Examples of this could include where I would attempt to rescue the client or not let her express her emotions.

7. Conclusion

Case formulation is an approach to the development of treatment plans that fits well within the scientist practitioner model that dominates clinical psychology training and practice (Baker and Benjamin, 2000). The outline of this case formulation for V. R. was presented as schematic response to the particular and idiosyncratic needs that she presented in her assessment.  I approach her case formulation that it will need to be metamorphic with the ability evolve and adapt given the course of treatment with an awareness that she may respond to some aspects of the case formulation with eagerness and other elements of the case formulation with resistance.

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At the same time, I learned about the use of “core clinical hypotheses” in an article by Aaron Lazare (Lazare, 1976): “A core clinical hypothesis” is a single explanatory idea that helps to structure data about a given client in a way that leads to better understanding, decisionmaking, and treatment choice. Based on these educational experiences, the foundation of my future clinical work was the development of a case formulation for each client that involved clear specification of “problem titles,” and the selection of clinical hypotheses that best fit the data.


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