A Case Analysis of CBT Application

Introduction

Cognitive behavior therapy (CBT) is used to treat patients that are experiencing various forms of anxiety or mood disorder. This paper will discuss what this therapy is and how it works. It will also include a case study in which the principles of the therapy are applied in an intervention setting. This paper is divided into three sections. The second section will discuss CBT in some detail, including how it is different from other psychotherapies. The third section will be the case study application of CBT treatment therapies to a patient in an intervention.

CBT Overview

CBT is a type of psychotherapy that is used to treat patients experiencing anxiety and mood disorders. It is contrasted with other types of mental health intervention. That is, CBT is focused around patient involvement and participation in reaching a resolution to the causes of the mood or anxiety disorders. It's also contrasted with other therapies in that it's much more goal-oriented in its approach to problem resolution. CBT can be used to teach patients important skills that can be used long after the therapy has ended. CBT is designed to confront distortions in thinking patterns, modify self-destructive belief systems, relate to individuals in their lives in more fulfilling ways, and transform debilitating behaviors ("What is," n.d.).

CBT Case Analysis

This case study will focus on Sharon, a patient of Dr. Jennifer Garrido, who appeared on the A&E reality television series, Obsessed (Pepin, 2010). Sharon is suffering from obsessive-compulsive disorder (OCD). This disorder appears to stem from two precipitating events in her life. The first was the suicide of a good friend of the patient. The second is her mother's ongoing battle with ovarian cancer. As the show begins, it's explained that Sharon's mother was in remission until recently when the ovarian cancer returned (Pepin, 2010).

Client's problem conceptualization. Automatic thoughts occur when some event occurs or something in our environment attracts our attention. These events trigger thoughts and these thoughts, in turn, cause the individual to experience certain emotions. These thoughts and their associated emotions may contain severely negative ideation. We tend to automatically believe these thoughts, hence the term automatic thoughts. Worse, sometimes these thoughts are repeated over and over again.

In Sharon's case her thoughts automatically concern her mother's cancer diagnosis. Sharon feels powerless amid this diagnosis and the realization of the seriousness of her mother's disease. For Sharon, her greatest desire is to protect her mother and her inability to do so is causing Sharon to experience severe mental dysfunction.

Client's behavioral responses. Compensatory strategies are used by the patient to work around the problems they have so that they can perform in life. But, these strategies are maladaptive behaviors that result in functional impairments. In Sharon's case these strategies include rituals surrounding light switches, parking her car, and a jar of peanut butter. Sharon becomes fixated and obsessive in her rituals regarding these tasks. Sharon reportedly engages these rituals a few times each week. If she performs them incorrectly she can experience panic attacks. Unfortunately, panic attacks can lead to severe neurological and cardiovascular problems.

Psychosocial history and stressors. Sharon describes her development from childhood as always needing to be in control and the "leader of the pack". Then one night she describes an experience of turning out the light and feeling that monsters were crawling all over her bed. She immediately gets up and turns the light back on. According to her mother, Sharon experienced this event very early in life, between the ages of 5 and 8. Sharon further describes this problem as getting progressively worse each night. She also begins adding new ritualistic elements. These new elements included setting a toothbrush down in a very specific pattern or spinning around in the shower. By the time Sharon reaches college, she describes the suicide of her friend and co-worker, Michael. This affected her OCD severely for about a week. Then came her mother's ovarian cancer diagnosis in 2008. Upon receiving this news, Sharon reports curling into a ball and experiencing one of her worst ever panic attacks. From that point on, Sharon describes her OCD as having been consistently "through the roof." There has likely been a period of two years since this event.

Additional cognitive interventions. I would integrate automatic thought records (ATR) into treatment. In using such records, Sharon would keep a notebook in which she would list items relevant to her psychopathology and treatment. These records can be used to generate rational alternatives for the client. She can then use the alternatives to de-catastrophize her mental state. The ATR would log the events in her day that are implicated in triggering her OCD episodes. She would then log her automatic thoughts that are associated with these events. A third item for her to log would be her feelings in these triggered mental states. A fourth and final option would be alternative explanations. More specifically, a triggering event relevant to Sharon would be parking her car. Thus, the automatic thought associated with this event is the need to park the car precisely or bad things will result. The third option, under feelings, Sharon would list her feelings of abject fear or panic at the consequences of failure. The fourth item to log is alternative explanations. Under this item Sharon would log the possibility that nothing bad will result if she doesn't park her car precisely. This last option is crucial for challenging the automatic thoughts and maladaptive behaviors Sharon habitually exhibits. These challenges, once performed repeatedly and with empirical evidence no tragedies ever result, can train Sharon to think much more positively. Indeed, the goal here is to make parking the car a routine task that requires little if any afterthought.

Additional behavioral intervention. One potentially behavior activation method useful in Sharon's case emphasizes the connectedness between actions and resultant emotions. To conduct this activation, Sharon would keep a chart monitoring her emotional state on an hourly basis. This intervention could be conducted on a weekly basis, after which the results would be reviewed. Sharon would rate changes in her mood on a scale as used in the documentary (from one to ten). By using this method, loops in Sharon's mood could be used to track the recurrence of dysfunctional coping responses. Sharon would then replace her usual maladaptive responses with alternative ones designed to break the cycle of loops.

Treatment obstacles and relapse. Sharon's belief that her incorrect performance of rituals is the cause of her mother's illness is extremely powerful. At the same, the need to be there for her mother during a time of crisis and to get on with her own life goals, are powerful counter-measures against her OCD. As such, Sharon's motivation to address psychological problems, she freely recognizes, means that the therapist was presented with few obstacles to treatment in this case.

CBT can be used to prevent relapse through the use of such techniques as ATR and behavioral activation. Indeed, once the patient has effectively used these methodologies during treatment, they are equipped to use them as tools on their own. This is true even after the treatment period has ceased. This is one of the benefits of CBT. It provides patients with crucial tools they can use throughout their life whenever a crisis sets off a relapse of maladaptive thoughts, actions, and behaviors.

As explained in the program, Sharon's OCD manifests itself in three major ways. The first is Sharon's obsessing over parking her vehicle correctly. If Sharon perceives that she has parked her car incorrectly, she can take up to 24 hours, repeating the same parking routines over and over until she perceives it is finally parked correctly. Her second reported obsession concerns light switches in the home. Sharon reports an intense fear of darkness. As a result, Sharon will engage in an intense ritual of procrastination over the simple act of turning a light switch off. The patient reported sleeping entire nights with all the lights on in her apartment because she is morbidly afraid of darkness. She will tap a switch as much as 12 times before actually turning it off. Tapping is also another obsession Sharon reports. She relates how removing a jar of peanut butter from the refrigerator is no simple task for her. She will intensely procrastinate over whether to open it. While doing so, she will tap repeatedly on the jar while contemplating this.

Sharon's OCD has physical manifestations as well. This is thought to be fairly common in patients suffering from anxiety and mood disorders (Cully & Teten, 2008). Sharon reports suffering from panic attacks when her anxiety reaches its peak. She also reports that her body becomes completely rigid. This is clearly in response to her experience of intense fright.

As noted above, Dr. Jennifer Garrido is treating Sharon. It's Dr. Garridos' assessment that Sharon's OCD symptoms are rooted in Sharon's obsessive need to control her environment. Sharon was particularly traumatized by her mother's ovarian cancer diagnosis. It's her belief that if she can only perform her set rituals correctly, that her mother won't die. Thus, Sharon appears to believe her precise ritual performance can control the physical well-being of her mother. This suggests Sharon is blaming herself for the tragedies in her life.

Sharon's OCD is causing considerable strain and distress in her life. This strain is evident in her relationship with her mother. Sharon's mother is experiencing a very serious health problem and could benefit from her daughter's support. However, this support is currently limited by Sharon's struggles with her own mental health. It's notable that Sharon's mother believes she may somehow have caused her daughter to develop OCD. At the same time, Sharon is suffering in her professional career. She reports an interest in photography as a career. But she has been unable to focus on this while she is suffering from OCD. Therefore, her goals in life are to be stronger for her mother and establish herself in a gainful career.

In order to treat Sharon, Dr. Garrido takes the approach that Sharon must confront her fears. The therapist's objective is to demonstrate to Sharon that her ritual routines have no impact on her mother's well-being. It is also to demonstrate how unreasonable it is for Sharon to believe so.

Dr. Garrido begins by instructing Sharon to park her car once and walk away from it. Sharon approaches this task with great anxiety and apprehension. However, after she performs this routine, Sharon experiences a gradual abatement in her anxiety symptoms. As she reflects on the consequences of her breaking her parking ritual, Sharon realizes they have no effect at all on her mother's well-being.

The next intervention concerns Sharon's apprehension in turning off light switches. It's notable for this intervention that Sharon's mother is sitting in the next room and is providing moral support. As instructed by Dr. Garrido, Sharon is turn off the light switch without procrastination. During the intervention, Sharon again experiences an almost debilitating onset of anxiety symptoms. They also to appear to peak as she is closest to carrying out the prescribed act. When Sharon switches the light off she realizes that her mother, sitting in the next room, is completely unaffected. As time progresses, Sharon's anxiety symptoms again abate and she is now aware that her fears of control were completely unrealistic.

The intervention is repeated a third time with the peanut butter jar and with similar results. Again, the pattern was of mounting anxiety symptoms as the routine was nearing its performance. This was followed by an abatement of symptoms as the OCD ritual was broken with no negative consequences to anyone. In each of these interventions, Dr. Garrido was present and it appears her stern but the reassuring presence was an important factor in the patient's recovery. Such a presence may be crucial to facilitate patient recovery in situations where he will act alone is powerful. Indeed, it's notable that Dr. Garrido does not coddle Sharon. Thus it is crucial, in order to achieve results in patient treatment, for the therapist to be empathetic without being overprotective (Cully & Teten, 2008).

During these interventions, Dr. Garrido advises Sharon, to act and not think. The longer Sharon thinks about performing a routine act, then the more likely it is she will relapse into a ritualized behavior. It was reported that thought provides fuel to Sharon's fear and this fear, in turn, creates stress that feeds the debilitative behaviors. At least, based on what was broadcast, there is not much more to add to Dr. Garrido's intervention. The discussion above provides much inferential information that the patient was asked to complete self-report symptom inventories, problem lists, cognitive assessments, and assessments involving both behaviors and precipitating events. These are all in line with standard CBT practice (Cully & Teten, 2008).

References

Cully, Jeffrey A. & Andra L. Teten. (2008). A Therapist's Guide to Brief Cognitive Behavioral Therapy. Houston, TX: Department of Veterans Affairs South Central MIRECC. Retrieved from http://www.mirecc.va.gov/visn16/docs/therapists_guide_to_brief_cbtmanual.pdf. Oct. 2013.

Pepin, Michael J. (Director). (2010). Sharon/Patricia. In Keith Guinto & Liz Kerrigan (Producers), Obsessed. Retrieved from http://www.aetv.com/classic/video/sharon-patricia-17143088. Oct. 2013.

What is CBT? (n.d.). Beckinstitute.org. Retrieved from http://www.beckinstitute.org/cognitive-behavioral-therapy. Oct. 2013.