Hot Cross Bun Formulation

Hot encompass axial rotation FormulationThe conception of this study is to reflect on the package of automobilee offered to a knob and to critically evaluate the secernate base for the mannequin which might be considered best practice for a specific client problem, or issue. This entails identifying a imageicular clients presenting issues while describing the evidence that is available for a suited therapeutic approach, or model which would promote best practice. The study depart reflect on a client who has been diagnosed with bet- harmtic foc exploitation disorder (posttraumatic stress disorder) as a result of a road traffic happening (RTI) and concentrates on the intake of imaginal ikon therapy (IET) for the hidement of symptoms. Triggers and maintenance factors contributing to the clients deteriorating well-being will be explained using body-buildulation as well as the protective and predisposing divisors that were explored in therapy. Relevant literature will b e cited through aside(p) and separate research articles that have been critically reviewed will be discussed. Presentation, referencing and in strained consent are consistent with the tutor of Health and mixer Cares guidance and have been adhered to throughout this assignment.Introductionposttraumatic stress disorder is an anxiousness disorder that lav uprise after impression to one or more terrifying imports, in which grave railway carnal harm occurred or was threatened. It is a unrelenting and ongoing activated reaction to an extreme mental trauma. The trauma may involve someones actual death or a threat to the individuals or someone elses life. The posttraumatic stress disorder sufferer is affected to a degree that usual psychological defenses are incapable of coping.Reports of battle-associated stress pop as early as the 6th century BC. posttraumatic stress disorder-like symptoms have been appreciate in m some(prenominal) besiege veterans in m whatsoever conflic ts since. These symptoms have been called shell shock, traumatic war neurosis, and set-Traumatic Stress Syndrome (PTSS). The modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were cool off being experienced by Vietnam veterans.The term Post Traumatic Stress Disorder was coined in the mid-1970s. azoic in 1978, the term was employ in a operative group finding presented to the Committee of Reactive Disorders of the American psychiatrical Association. The term was formally recognised in 1980 in the third mutation of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.Although a controversial diagnosis when low gear introduced, PTSD has filled an important gap in psychiatric theory and practice. From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the aetiologic agent was outside the individual him or herself (i.e., the traumatic event ) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of trauma.DSM-IV-TR criteria for PTSDIn 2000, the American Psychiatric Association revised the PTSD diagnostic criteria in the tail edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)(1). Diagnostic criteria for PTSD include a hi allegory of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters intrusive recollections, avoidant/ blunt symptoms, and hyper-arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning.PTSD is unique among other psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one can non make a PTSD diagnosis unless the patient has actually met the stressor criterion which means that he or she has been capable to an his torical event that is considered traumatic. Clinical experience with the PTSD diagnosis has sh deliver, however, that there are individual differences regarding the capacity to hump with ruinous stress so that while some mess showd to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have nimbleed a recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional growthes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected and some more conquerable to development clinical symptoms after exposure to extremely stressful spaces. Although there is a renewed pursuit in subjective aspects of traumatic exposure, it must be emphasised that exposure to events such as rape, t orture, genocide, and severe war zone stress, are experienced as traumatic events by nearly e preciseone.The National fetch for Clinical Excellence (NICE) has published guidance to help the National Health Service (NHS) recognise and treat people who develop PTSD after traumatic events. Recommendations include psychological treatment in the form of trauma-focussed cognitive behavioural therapy (CBT) and/or a course of anti-depressant medication while receiving therapy.Trauma-focussed CBT focuses on a persons sad feelings, thoughts (or cognitions) and behaviour and helps to bring near a positive change. In trauma-focused CBT, the treatment concentrates specifically on the memories, thoughts and feelings that a person has about the traumatic event.Imaginal exposure therapy (IET) is a component of trauma-focused CBT and involves revisiting the traumatic recollection or memories in a safe and controlled purlieu so that the intensity of the individuals anxious and fearful reactions (thoughts, emotions, physical sensations and behaviours) is reduced.Clients are exposed to the trauma memory by repeatedly describing the events of the trauma aloud until the foreboding result is reduced. This process is referred to as habituation. The treatment aims to eventually eliminate the fearful responses so that the client can face a feared situation without experiencing anxiety or fear. The goal IET is to process the trauma memories and to reduce distress and avoidant behaviours that the traumatic memory evokes.CBT, as we know it today, is a result of a group of modern related therapies that have empirical psychological support. There have been two main influences to modern CBT and these are behaviour therapy (BT), as developed by Wolpe, Skinner and others in the 1950s and sixties and cognitive therapy (CT) as developed by Beck and others in the 1960s and 1970s (Westbrook, et al. 2011, p2).Freudian psychoanalysis had dominated the psycho-therapeutic world since the late 1800s, but in the 1950s, Eysneck and others in the psychological community questioned the lack of empirical evidence to support psychoanalysis. As a result, BT developed within the faculty member and scientific psychology community, basing its methodology on observable events between stimuli and response. Despite the success of BT, there was still some dissatisfaction with what was seen as the limitations of a purely behavioural approach (Westbrook, et al. 2011, p3). Beck and others were developing ideas about CT as early as the 1950s these ideas focussed on mental processes such as thoughts, dogmas and our interpretation of events, and go along to maintain an empirical approach to validate its theory to the psychological world (Westbrook, et al. 2011, p3). Although Beck was not the premier(prenominal) to intimacy faulty behaviour with irrational thought and unhealthy emotions, his work revolutionised the psychology world and tolerates to be used today.Background to the Clien tThroughout this assignment the client will be referred to as T. Protecting the clients identity operator complies with the British Association for Counselling and Psychotherapy (BACP) and the British Association of Cognitive and Behavioural Psychotherapies (BABCP) guidelines regarding client namelessness as described in the Ethical Framework for Good Practice and fulfils the requirements of the Universitys School of Health and sociable Cares policy on confidentiality.T was seen in a primary care setting with a counselor service that offers short to medium term therapy for clients over the age of 16 years. She was referred to the service by her GP. She is a 25 year old female who is married with two boys aged 7 and 5 years. She is presently unemployed and lives in kind housing with her husband who works in a local factory. T was raised and lived in an area where the 2007 Index of Deprivation (ID2007) indicates deprivation is 110.6% higher than the national average. There is a h igher proportion of the working age population claiming incapacity benefit than the County average (Area Action Partnership). T first went to her GP shortly after being released from hospital after an RTA. She was a front empennage passenger and received injuries to her face, arms and legs which include severe bruising, cuts and a temporal mandibular joint (TMJ) injury. tierce months after the accident T continued to experience nightmares and flashbacks. The GPs letter to the service illustrious the clients deterioration and the sea captain diagnosis of acute stress disorder (ASD) that had been diagnosed in the first month avocation the accident was revise to PTSD. Several studies have provided convincing evidence that early CBT treatment of ASD reduces the possibility of the development of PTSD (Moulds, et al. 2009, p16). ASD was introduced into the fourth edition of the diagnostic statistical manual (DSM) in 1994. The diagnostic criteria for ASD (Appendix A) are similar to t hose of PTSD, but differ in two fundamental areas. Firstly, ASD can only be diagnosed in the first month following the traumatic event and minute of arcly, ASD includes a greater emphasis on dissociative symptoms (American Psychiatric Association, 1994).During their consultation, the GP noted that T had become withdrawn and distanced from her family and friends, she account feeling like she was watching the world from inside a bell jar, this dissociative symptom is described as derealisation, and is commons in ASD patients (Simeon and Abugel, 2006, p86). The GP assessed T using the Patient Health Questionnaire (PHQ 9) and the General Anxiety Disorder Assessment (GAD 7) which resulted in readys of 15 and 19 respectively. These signs indicate that T was suffering with moderate to severe anxiety with depression.T was seen over a intent of 13 seances. The duration of each session lasted between 1 hour and 90 minutes. monthlong sessions were included to provide sufficient meas ure for sharing the trauma history and include time for anxiety levels to descend (Leahy and Holland, 2000, p197).The contract between the counselling service and T was explained. This included informed consent to tape measure sessions, confidentiality and its limitations and an valuation of essay. Evaluation of risk is an important part of the therapeutic process and is done throughout therapy. It involves assessing the client, the environment and also the healers own personal and professional limitations (Mueller, et al. 2010, p 65). CORE OM was used to calculate a risk score and also to assess Ts suitability for therapy. The Cognitive Therapy Rating Scale as developed by Safran and Segal was not available to the therapist during the first session, but subsequent reviewing of the scale indicated that T was a suitable chance for cognitive behavioural interventions. CORE OM score is shown below in figure 1.Prior to developing a treatment fancy, the therapist socialised the c lient to CBT explaining the evidence that supported using CBT interventions for PTSD. (Bryant, et al. 1999) and (Westbrook, et al. 2011, p81-83). First session therapist notes detailed Ts early(prenominal) history, the development of problems and the protective factors in her life (Appendix B). T was clear about what she cherished from therapy. Her problems fell into three main areas (1) Nightmares, poor sleep, anxiety around bedtime, which resulted in an increased peevishness with others (2) Avoiding locomotion in any form of transport, which resulted in her relying on others to take her children to direct and other social or sporting events (3) Withdrawing from friends and family, which led to her isolating herself socially. She believed that if she avoided all forms of transport and stayed inside, she would reduce the chances of experiencing any flashbacks or pop outting very panicky which she found extremely distressing and frightening. T and the therapist created a Proble m and close form to capture this selective in data formation (Appendix C) and agreed to discuss the problems and goals over again when the treatment cast was formulated.The specific client issue selected is Post Traumatic Stress Disorder (PTSD). PTSD is defined as a common anxiety disorder that develops after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened (DSM-IV-TR 463). The DSM-IV-TRs criteria are precisely written as exposure to a traumatic event, persistent re-experience of the event, avoidance of the stimuli, persistent avoidance of increased arousal, duration of disturbance and hurt of social occupational or other important areas of functioning. Within the criteria there are subsets portraying greater detail of the types of symptoms that may be experienced by the client (Appendix A).T was seen over a period of 13 sessions. The duration of each session lasted between 1 hour and 90 minutes. Longer sessions were included to p rovide sufficient time for sharing the trauma history and allow time for anxiety levels to decrease (Leahy and Holland, 2000, p197).The contract between the counselling service and T was explained. This included informed consent to tape sessions, confidentiality and its limitations and an evaluation of risk. Evaluation of risk is an important part of the therapeutic process and is done throughout therapy. It involves assessing the client, the environment and also the therapists own personal and professional limitations (Mueller, et al. 2010, p 65). CORE OM was used to calculate a risk score and also to assess Ts suitability for therapy. The Cognitive Therapy Rating Scale as developed by Safran and Segal was not available to the therapist during the first session, but subsequent reviewing of the scale indicated that T was a suitable candidate for cognitive behavioural interventions. CORE OM score is shown below in figure 1.Prior to developing a treatment plan, the therapist socialise d the client to CBT explaining the evidence that supported using CBT interventions for ASD. (Bryant, et al. 1999) and (Westbrook, et al. 2011, p81-83). First session therapist notes detailed Ts past history, the development of problems and the protective factors in her life (Appendix B). T was clear about what she wanted from therapy. Her problems fell into three main areas (1) Nightmares, poor sleep, anxiety around bedtime, which resulted in an increased irritability with others (2) Avoiding travelling in any form of transport, which resulted in her relying on others to take her children to school and other social or sporting events (3) Withdrawing from friends and family, which led to her isolating herself socially. She believed that if she avoided all forms of transport and stayed inside, she would reduce the chances of experiencing any flashbacks or drumting very panicky which she found extremely distressing and frightening. T and the therapist created a Problem and Goal form t o capture this information (Appendix C) and agreed to discuss the problems and goals again when the treatment plan was formulated.The therapist asked T if she could give her most recent experience of a flashback ( fingers breadth 2a). T reported that the pattern of events leading to feeling fear or experiencing a flashback were the same. She would make an effort to do a certain activity, but flashbacks and panic were triggered by (in particular) smells or sounds that could not be avoided. The hot cross pealing formulation in figure 2a tracks events from release the house, auditory modality cars and smelling gasoline, which was the trigger point. On this occasion T reported having a clear memory of being trapped in the car (which was also her recurring nightmare), she could remember smelling petrol and hearing the screeching of brakes. Her brain misinterpreted these signs for an actual threat, creating reprobate thinking Ive got to get home something terrible is going to happe n, offensive emotions fear, anxiety and terror, unpleasant physiological reaction heart pounding, shaking, feeling nauseous, which led to her avoidant behaviour to reduce her anxiety and escape her perceived fearful situation.Flashbacks are defined in DSM IV as a payoff of a memory, feeling, or perceptual experience from the past (American Psychiatric Association,1994). Another example of a flashback bear on T sitting in her garden when a neighbour was mowing the lawn with a petrol engine lawn lawn mower. T could smell the petrol and this triggered a flashback to the events of the RTA. The therapist encouraged T to follow the formulation and create her own diagram based on her experience in the garden (Figure 2b). T and the therapist were able to notion at both diagrams and see that the pattern was similar. A sound or smell was identified as the trigger in both examples. Her thought process, affect and physiology were similar, but crucially, this led again to her avoidant behav iour.Hot Cross bowl FormulationEvent/TriggerWalking to the shop to buy milk, hearingthe cars and smelling petrolFlashback of being trapped in the carThoughtsIm going to die, Ill never see me children againIve got to get away from hereIve got to get home, something terrible is going to happenBehaviour EmotionsEscape the situation revereTearful TerrorAnxietyPhysiologyHeart pounding, Nausea,Tense, Sweating, ShakingBased on Hot Cross Bun (Padesky, 1993)Hot Cross Bun Formulation (originally hand drawn by client)Event/Trigger seated outside in the garden, having a cup of teaHearing neighbour start up his lawn mowerSmelling petrol from the lawn mowerFlashback of fear of being burned aliveThoughtsOh God Its happening againIve got to get inside the house. Ill be safe thereBehaviour EmotionsTearful FearNeeding to get inside the house TerrorAnxietyPhysiologyHeart pounding, Nausea,Tense, Sweating, Shaking,Based on Hot Cross Bun (Padesky, 1993)T and the therapist discussed the process of ente r details in this format and agreed that it gave them both a greater understanding of Ts situation. This collaborative approach is characteristic of CBT and was necessary when working towards a treatment plan for factors that needed to be targeted in therapy and homework setting. Padesky and Greenberger (1995, p6) explain the importance of the client and therapist working as a team, particularly as clients may have an expectation that the therapist is going to fix them. Milton (2009, p104) agrees lending that the therapist also plays the role of a trainer, back up the client to become an observer of themselves in order to argufy their thoughts, feelings and rulings. Westbrook et al (2011, p238) cites Kazantzis et al (2002) in providing evidence of greater improvement in those clients who complete homework. T was discriminating to monitor any anxiety provoking scenarios at home using the hot cross bun model. She was aware that if her second goal was to be achieved (Appendix C) s he needed to reduce and eventually eliminate her avoidant behaviour (Wells, 1997, p49-50).A treatment plan was discussed and agreed with T based on her problem list and goals for therapy (Appendix C). The treatment plan included the following elementsPyscho-EducationGrounding and Safety WorkImaginal Exposure TherapyCognitive RestructuringRelapse ManagementThe session on psycho-education gave T the opportunity to learn about her symptoms, and to recognise and anticipate them for effective management. Fisher, (1999) states that psycho-education is an essential element for stabilising a trauma client. Briere and Scott (2006, p87) agree, adding that psycho-education provides the client with accurate information about the nature of their trauma, which gives them a greater understanding of their situation. Psychoeducation winding justification of use of IET, a history of our learnedness experience and the fight or flight response. Regular reference was made to the clients formulation so that she could understand how and why her threat response had been activated.Once T understood her anxiety response in relation to her experiences, she felt ready to continue onto the next stage of therapy. Grounding and safety work was completed prior to IET. Herman (1997, p155) argues that the central task of the first phase of trauma therapy must be safety. The client needs to feel safe within themselves learning grounding and safety skills gives the client the opportunity to manage potential uncontrolled flashbacks. This also formed part of Ts relapse management in the later stages of therapy. Once safety and grounding work was completed, the therapeutic process moved onto the trauma itself using IET.Throughout therapy there were opportunities to explore Ts present situation and past events. This information was initially written down in a mind map format and shared with T during the session. As additional information was gathered in subsequent sessions this was written in long itudinal format (Figure 3). From the information gathered, the client recognised how and why she had always been the rescuer in the family. This included an age wrong responsibility when her father had left the family home and T had taken on the role of carer to her distraught set about and siblings. She suffered an emotional breakdown at the age of 14, over whelmed by the pressure of doing well at school so that she could get a good job and support the family. T recognised how this belief organization developed after her father left and how it was effecting how she saw herself in the present. During therapy T and the therapist discussed the importance of this belief and how it had allowed her to cope during those years growing up. The therapist asked what purpose this belief served in her life now when she was gifted with her family and well supported by her husband. She no longer needed to be the rescuer. T and the therapist explored how this belief may be affecting what was ha ppening to her when she was fearful of having a flashback. T concluded that she needed to add I must always cope to her beliefs in Figure 3 and I cant cope to her thought process. T recognised the contradiction between this thought and her rescuer belief.Longitudinal FormulationEarly Experiences5 years old, Dad leaves family homeOldest of four children, Takes on a helping role ulterior supports mother through depressionBreakdown at school aged 14 years delinquent to self- imposed pressureMet future husband aged 16,Pregnant at 17 years and married at 18 years oldBeliefsIts my responsibility to take care of everyone and make things rightI must always copeAssumptions and RulesI must be perfect and do everything right, otherwise I will let everyone downIf something goes wrong it will be my faultCritical IncidentCar hazardActivation of BeliefsIts my responsibility to save everyoneAutomatic ThoughtsI should have got B out of the car. I didnt do everything I could haveI failed. I cant co pe with thisBehavioural EmotionsAvoidance FearSocial withdrawal AnxietyFearful to go outside GuiltFearful to travel in any transportationWorryPhysiologyPoor Sleep Tense Heart Pounding SweatingThe goal of IET is to expose the client to the memory of the trauma rather than to relive the trauma itself. Ts therapy involved her retelling the story initially in the past tense and then in the present tense. An important part of the healing process was encouraging T to bring those traumatic memories to mind, in a safe and trusting environment, while remaining in the present. The client learns through repetitive description, that the memory of the event is not dangerous and will also allow habituation to take place (Zayfert and Becker, 2008, p127). T decided that she would record the sessions on the voice recorder role of her mobile phone and listen to the recordings at home as part of her homework. Zayfert and Becker (2008, p130) emphasise how critical earreach to the tapes at home is as the repetition is vital if the exposure is going to be successful.The therapist explained that T would be asked to close her eyeball and describe the events of that day. Leahy and Holland (2000, p 198) suggest breaking the clients story down into little parts if there are a series of traumatic events. T was asked to recall the events of that day in terms of chapters several chapters were listed (Appendix D). Ts experienced anticipatory anxiety at the thought of retelling the story and this was discussed. The therapist quieten her she would be experiencing the memory, that the RTA was not happening right now and that she was safe in the room and could overspread her eyes at any time. T began at a point in time when she felt safe and ended the narration at a point in time when again she felt out of danger. The therapist explained the Subjective Units of Distress ( launder) Rating Scale and then T began narrating her story in the past tense and was allowed to do this uninterrupt ed the therapist only intervening to check on Ts anxiety. Ts SUDS score was noted for each chapter (Appendix D col A). At the end of each session, T was given time to process her experience before leaving. T gave the therapist feedback on how she felt sessions had gone, and what, if anything she had learned.The next session involved the client narrating the story, but this time in the present tense. T found this difficult at first and often resumed the past tense. T and the therapist had discussed the likelihood of this happening and T agreed that the therapist would prompt her to return to the present tense. SUDS scores were again noted (Appendix D col B). T reported being surprised at the change in scores from the previous week. There were certain sections of the story that T found very difficult to narrate these sections were narrated without much detail. After discussing this briefly, T and the therapist listened to the recording of the present tense narration. T recorded SUDS levels herself (Appendix D col C) and once complete, the three SUDS scores were examined and discussed. T noted how scores had both increased and decreased from first narration to second narration, but that all scores had reduced on her first listening to the tape. T was then asked to score the chapters and chose five (the most anxiety provoking) to work on. The five chapters were listed chronologically (figure 4) and then in order of their anxiety rating (figure 5). For the next five sessions each chapter was narrated and listened to repeatedly until Ts SUDS rating had dropped starting with the least and working towards the most anxiety provoking. The therapist asked questions relating to the clients senses and emotions and physiology so that her memories were fully activated (Leahy and Holland, 2000, p197). To Ts surprise, narrating in the present tense and centripetal questioning produced additional memories that T had not remembered in the previous narrations.Figure 4 Chrono logical grade1Car flips over upside down smell of petrol2Wood advent towards the car3The car door wont open (Ts recurring nightmare)4B is not moving5G is screaming at T to get them out of the carFigure 5 Order of Severity Least to Worst54321Wood coming towards the carCar flips over upside down smell of petrolG is screaming at T to get them out of the carThe car door wont open (Ts recurring nightmare)B is not movingThe therapist noted the five chapters as hot floating policy (Figure 6) and asked T what her thoughts were when she brought the scene to mind. These were also noted together with the emotion that went with them.The therapist was able to challenge Ts distorted thoughts through cognitive restructuring which included her rescuer belief that she was somehow responsible for getting everyone out of the car that day. Once SUDS levels had been reduced for all five chapters Appendix E), T was able to say out loud her re-evaluation statement for each chapter accepting and believing it.Fig 6Re-Evaluation of Peak ExperiencesHot routine Thought Belief Emotion Re-EvaluationThe car has flipped Ive break downd the crash Fear I did not burn to death. over onto its top there but now Im going to burn I did not die, I did surviveIs a smell of petrol to death the experience and I am safe now.Its over. THIS IS A circumstanceWood from a fence is The wood is going to scratch Fear The wood did not hit me or anyone else.Flying towards the car me. Ill never see my boys I did survive the experience. I am safe.again. My children are safe. Its over.THIS IS A FACTThe car door wont open. Its not going to open, Terror I was not trapped. I did get out of the car.It just wont budge at all Im trapped. I am not trapped now, I am safe now.Its over. THIS IS A FACTB goes tour and his head Oh my God B is dead Terror B did not die. He did survive the accidentFalls forward He is safe now. Its over. THIS IS A FACTSister G screams to T to I must break the window. Fear We all got out of the car. We did not die.Get them all out of the car I have to get us all out. We are all safe now and its over.If I dont break the window THIS IS A FACTWere all going to dieOutcomes and Personal ReflectionTs post therapy CORE score of 31 (figure 7) represents a mean score of 0.912 (9.12) and falls within the healthy pasture of the Core measure. As there is a mean difference of over 5, this, according to CORE measuring indicates a clinical and reliable change (CORE ims).Fig. 7 Core OM Results Pre and Post therapyPre PostWell existence 14 06Functioning 21 05Risk 02 00Problems 42 20Total 79 31Ts demo improved in the finals stages of therapy. Her cuts and bruises had healed well and she was no longer suffering with TMJ. T reported better sleeping patterns, but still with occasional dreams. She believed that she had spent so much time listening to her chapter on being trapped in the car that she became fed up of listening to it, rather than it provoking any anxiety. She was able to travel as a passenger in a car, and also to drive the car herself, but did not feel ready to drive on her own in the car. As a result understanding her an