Case Studies in Clinical Psychology:
Bradshaw (1998): The Case of Carol
Journal of Cognitive Psychotherapy: An International Journal, 12, (1) 13-25, 1998
What does Bradshaw say about the use of CBT for schizophrenia and other clinical disorders?
CBT widely used; effectiveness established with numerous patient populations and problems (Beck, 1993). Limited in the treatment of schizophrenia; little research regarding its efficacy with this population. This may be due to dominance of drug treatments, decline of psychotherapy, the severity of the disorder, inadequacies of previous attempts to understand and manage schizophrenia with CBT.
What does Bradshaw say about causes of stress (stressors) that might lead to relapse?
Relapse is associated with stressful life events, stressful interactions with family members and overstimulating residential and treatment environments
What does Bradshaw say about problems with intensive rehabilitation in the first 6 months?
overly aggressive rehabilitation efforts/intensive rehabilitation can trigger relapse in first 6 months of treatment
What evidence is there in the paper that taking an ideographic approach might be very useful in terms of accessing the subjective experience of the person with schizophrenia’s experience of the condition?
Research focuings on the subjective experience of persons with schizophrenia is limited; Strauss (1989) highlights the need to focus on the interaction between the person and his disorder: how the person’s goals, feelings regarding illness and self and ways of managing affect the course of the disorder and vice versa. Also Estroff (1989) emphasizes that focusing on the impact on the self of the person with schizophrenia is critical for treatment of schizophrenia. Strauss (1989) states, “attention to life trajectories, personal goals, characteristic approaches to regulating one’s life… is essential”
How does Bradshaw think that CBT could be helpful to people with schizophrenia?
- Specific coping skills that help the client modify environmental stresses, change perceptions and interpretations of events, reducing physiological arousal and management of affect
- focus on the interaction of the illness and the person; enhancing the client’s ability to cope with stress and manage affect is essential to prevent relapse and improve functioning
What evidence is there that CBT has been effective in treating schizophrenia prior to this paper?
- Several studies describe positive results with the use of graded, non-confrontational examination of evidence and the development of alternative explanations to modify the strength of hallucinations and delusions and to increase control of these symptoms (e.g. Chadwick & Lowe, 1994)
- Others have described the use of CBT in residential and inpatient treatment settings; Kingdom and Turkington (1991, 1994) describe the use of a destigmatising, normalising rationale to explain symptom emergence and management to clients, resulting in reduced levels of symptomatology, hospitalisations and improved social adjustment
- Perris (1988, 1992) reports successful use of “cognitive milieu treatment” with patients living in group homes in Sweden.
- Bradshaw (1997) found that four clients with schizophrenia experienced considerable reduction in symptomatology, rehospitalisations and improvement in psychosocial functioning and attainment of treatment goals maintained at 1-year follow-up
- significant methodological problems:
- relatively brief periods of experimental treatment with brief follow-up
- lack of control over the delivery of other treatments clients maybe receiving in inpatient settings
- lack standardised measures of outcome
- limited posttreatment data
- little comprehensive application of CBT to the multiple problems of schizophrenic clients over the long-term course of the disorder.
Describe Carol and her family in as much detail as you can
- 26-year- old single white female; high school graduate; completed 1 year of college
- upper-middle- class family; academic/career success extremely important
- conservative Christian faith
- third of five children
- good student, hardworking, self-critical, shy but with several friends, dated occasionally
- she went to an out of state to college; passed the first year,
Describe Carol’s symptoms and diagnosis in as much detail as possible
- auditory persecutory hallucinations and delusions
- “I’m no good, “I can’t do anything”; “I’ll always be this way”
- flat affect
- anxiety related to interpersonal situations and tasks
- Anxiety about the hallucinations and delusions
- withdrawn and socially isolated
- inactive, unable to work or live independently (lives with parents)
- basic self-care severely limited
- bizarre behaviour;
- hospitalised aged 18 for 1 month; dropped out of college
- hospitalised 12 times in last 7 years
- discharged from a psychiatric hospital after 2 months of inpatient treatment
- diagnosis of schizophrenia, undifferentiated type, chronic
- referred by psychiatrist for ongoing psychotherapy (part of discharge plan to help her adapt to community life and manage her illness)
- Global Assessment of Functioning (GAF) at discharge was 30
- no family psychiatric history; family supportive financially
- increase in negative symptoms (apathy, avolition, anhedonia) to deal with stress also increased anxiety, negative cognitions and psychotic symptoms.
Describe the treatments she was receiving
- taking 500 mg of thorazine daily; medication compliant
What variables were measured in this case study?
- Symptomatology: Global Pathology Index (GPI) of the Hopkins Psychiatric Rating Scale (Derogatis, 1974): The GPI is an 8-point behaviourally anchored scale that describes severity of symptoms.
- Psychosocial functioning: Psychosocial functioning was measured by the Role Functioning Scale (RFS); RFS is made up of four subscales: work, social, family and independent living subscales. Each scale is a 7- point behaviourally anchored scale. The RFS and GPI are rater-based scales.
- Attainment of treatment goals: measured by Goal Attainment Scaling (GAS) ; behavioural descriptions of functioning for various levels of goal achievement are developed and scored with the client. A score ranging from -2 (regression in goal attainment) through 0 (attainment of goal) to +2 (exceeds standards) is given for each goal based on the client’s attainment
- Hospitalisations: measured by the number of times hospitalised and total days in hospital
- The GPI, RFS and hospitalisation data were independently obtained by the case manager on a quarterly basis throughout the 3-year treatment period and at 6 months and 1-year follow-up.
Give examples of quantitative data that was collected
- Rating scales scores (see above);
Describe the “rapport” between the therapist and Carol and ways that this was established
- Rapport took some time to develop (approximately 3 months) established by consistent use of the core conditions of genuineness, respect and accurate empathy
- The worker was directive, active, friendly and used feedback, containment of feelings, reality testing and self-disclosure
- Carol had enjoyed playing softball and had been an avid baseball fan; when the therapist shared that he had similar interests it became a regular point of conversation and strengthened their connection
- Self-disclosure was also used to normalise situations and promote discussion of real life difficulties.
Describe the “socialisation phase”
- 2 months: therapist actively educates the client about schizophrenia and the process of treatment.
- sessions determined by the client’s capacity ranged from 15 minutes to an hour or more
- therapist and client frequently went for walks during the sessions when Carol was agitated or lethargic
- goals –
i. develop the therapeutic alliance regarding the rationale of treatment
ii. facilitate understanding of the process of CBT
iii. agree on treatment goals
iv. explaining the biological vulnerability to stress of individuals with
schizophrenia and the importance of identifying stresses and
improving methods of coping with stress in order to minimise
disabilities associated with schizophrenia.
v. Explaining the cognitive view and process of treatment; issues
with daily life used to highlight the cognitive components of feeling
and behaviour, analysing events in terms of A. activating event and
C: emotional consequences and then discussing together possible
self- statements (B) that could have led to the emotional
vi. the therapist used personal examples relating to his life to help the relationship between a psychologist or psychotherapist and a patient, regarded as important for the outcome of psychological therapy
What happened in the “early phase” of treatment?
- 12 months focus on her inactivity and her difficulty managing stress and anxiety
- She would spend much of her time in bed, watching TV and smoking; when she would consider doing some activity or was requested by her parents to do something, she would become anxious and hallucinations and delusions would increase; she would think that the task was too much for her and would withdraw to her room; she coped with the stress of her symptoms by apathy and withdrawal
- The weekly activity schedule (Beck, 1984) was useful in helping her cope with the loss of structure she experienced after leaving the hospital and the symptoms she experienced
i. Using a blank calendar Carol recorded her activities in three time blocks: morning, afternoon and evening
ii. She and the therapist reviewed the activities to identify what things improved or exacerbated her condition and to help Carol understand her reactions to different events.
What practical strategies did the therapist use to help Carol build som structure back into her life and expand the range of activities which she participated in?
- Behavioral assignments using a graded hierarchy of small tasks were used to increase her activity level
- Initial focus was on daily living skills (self-care, cooking, cleaning, time management)
- Exploration of previous interests and the use of an interest inventory were helpful in stimulating her interests and expanding the range of her activities
- She had previous experience in arts and crafts and began to do paint by number paintings
- This was followed by learning macramé and adding other activities such as bowling that could be done with other people
- Mastery and pleasure ratings were later assigned to activities to evaluate the benefits of the activities and to identify cognitive distortions that minimised her sense of accomplishment and pleasure.
How did the therapist help Carol to improve her stress management?
Carol expressed an interest in meditation; the therapist taught her how to meditate and they practised meditation for short periods in each session
- gradually she began to meditate twice daily for 15 minutes
- the therapist helped her to identify personal signs of stress and symptoms of relapse; organised these into low, medium and high signs on her stress thermometer
- posted the thermometer on her door and recorded her “stress temperature” each day; as she recognised signs of stress she would meditate briefly as a coping response to stress.
- habitual stress situations were defined and meditation was used to cope with anticipated stressful events.
What does Bradshaw say was the cause of Carol’s problems (clue he refers to it as “the major cognitive theme”) ?
- Carol significantly underestimated or overestimated her ability to control others, events in the world and her own behaviour
- The process of faulty attributions resulted in ongoing negative beliefs regarding her own efficacy, e.g. “I can’t do it; nothing I do can change it; I have no control over things”; predominated in the early stages; major target of behavioural treatment using graded task assignment
- During this period Carol’s symptoms lessened and her functioning, especially independent living skills, improved; she moved into an apartment by herself. She also developed skills in identifying and coping with stress and had experienced some increased sense of self-efficacy.
Describe the “middle phase” of Carol’s treatment
- 16 months; emphasized identification of habitual stressful situations and cognitions and utilization of cognitive strategies to cope with them
- Three major areas of cognitive work emerged
i. dealing with social situations
1. she frequently had problems reading social cues and would
interpret them by overgeneralising, personalising, and
2. She was trained to "check it out" by identifying automatic
thoughts, evaluating evidence, exploring alternative
explanations and generating new coping self-statements to
replace the automatic thoughts
3. Social skills deficits specific to stressful social situations were
assessed by role-play with the therapist and social skills
training was provided to improve coping in interpersonal
ii. the impact of schizophrenia on Carol’s sense of self
iii. fears of relapse.
What social skills did Carol’s therapist help her to focus on?
- expressing feelings and assertiveness; specific and reoccurring stressful situations were identified and plans made for positive coping responses
- cognitive coping skills were developed by collaborative empiricism, guided discovery, cognitive modelling, rehearsal, role-play and homework assignments
- Carol took a class at the community college, began to go out weekly with a friend and worked 10 hours a week as a volunteer at a food shelf.
Increased exposure to other people increased Carol’s anxiety. How was this dealt with?
- planning activities in a way that ensured she had a sufficient balance of time alone and time with others
- use of planned regression in which Carol would take a day off in which she stayed in her apartment and had no contact with others.
How did the therapist deal with Carol’s fear of relapse?
- low level anxiety, fatigue or depression was interpreted as “I’m going crazy.”
- experience of vulnerability and issues of low frustration tolerance, overgeneralising and catastrophising contributed to this problem
- education about her illness and interpretation of her experiences as normal responses to stress helped her understand and normalise her experience
- reviewing her stress thermometer, schedule of activities, sleep patterns, exercise, diet and level of stimulation to protect against relapse
- fears examined using Socratic questioning, examining evidence and alternative explanations
Carol had a limited self-concept; “I’m just a mental patient”; how did the therapist help Carol to build her sense of self and her self esteem?
- Carol and the therapist examined evidence that supported other roles she currently was performing, e.g., student, friend, employee and exploring other areas of life interests including travel, skiing and her desire to get married
- Carol’s self-esteem was also impaired by frequent self-criticism and negative comparison to other non-ill individuals
- Selective perception and attributions of negatives to oneself and positives to others were common.
- a cognitive technique, PSOB, “pat self on back” was developed by the author to train clients to more positively appraise daily situations and themselves
- she was trained to identify three positive events in her life each day, no matter how minor the event may be; she then generated a list of positive words and qualities which described the event and identified positive qualities in themselves that were associated with the event; PSOB very useful daily exercise to promote positive self- appraisal and enhance self-esteem.
What were the goals of the “ending phase”?
- 3 months were spent ion two goals;
- dealing with thoughts and feelings regarding ending treatment
- developing plans to maintain treatment gains
- a review was done of stresses, signs of stress and effective coping strategies; these were written down on cue cards and reviewed each day by the client
- 3-month termination plan developed including emergency procedures, gradual reduction of sessions, planned phone contact and booster sessions
What evidence is there that her psychosocial functioning improved?
- improvement in psychosocial functioning, achievement of goals, reduction of symptomatology and number of hospitalisations that were maintained at 6 months and 1 year follow-up
- major improvements in work, independent living, social and family relations
- The subscale scores of the RFS provided an overall psychosocial functioning score; baseline was 6 (severely impaired functioning in all areas) 27 at end of study – major improvements in psychosocial functioning: relationships with family and friends, ability to independently manage personal and household tasks and performance of school, employment or household tasks
|1||2||3||6 months||1 year|
|Psychosocial Functioning (RFS)||6||11||19||27||27||27|
|Goal Attainment (GAS)||19.85||80.15||80.15|
*In the 3-month period prior to beginning CBT
What evidence is there that her symptoms were reduced?
- Symptomatology measured by GPI was reduced; baseline 7 (severe symptomatology including inappropriate mood, hallucinations and delusions, impaired judgement, disorganised conceptual processes, disabilities in volitional and motor areas and inability to care for self and risk to self) by the end of the study her GPI was 1 (only slight impairment) Few symptoms present, little self-reported distress; interpersonal functioning relatively unimpaired, affect and cognition within normal limits.
What evidence is there that Carol met her treatment goal (goal attainment)?
- On The Goal Attainment score (GAS score) a score of 50.00 represents the expected level of goal attainment; Carol’s pre-treatment score was 19.85; post-treatment GAS 80.15 (significant attainment of treatment goals beyond that expected)
- Examples of treatment goals accomplished include clinical and socially important tasks such as improved daily living skills, living independently, developing social support systems, returning to school and obtaining employment.
Carol had no further hospitalisations; how does this compare to national averages for people with schizophrenia?
- Carol had no psychiatric rehospitalisation in the 4-year study period
- Previously she had an extensive history of hospitalisation; national average rehospitalisation rate of 35%-50%