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Assignment: Comparison of Behavioural Formulation and Cognitive Conceptualisation

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Introduction

The National Survey of Mental Health and Wellbeing in 2007 predicted that around 45% of the population of Australia, amounting to a figure of 7.3 million individuals, will experience mental disorders in 2008 at some point in their life and the survey also indicated that in 2007 20% of the population, amounting to 3.2 million individuals, already experienced different mental disorders (Australian Bureau of Statistics, 2008). It was further estimated that these figures are likely to increase each year and out of all the mental disorders, a wide range of Australian population is becoming a victim of Mental Depressive Disorders (MDD) (Morgan, 2012) which according to Kerr (2010) have the potential of becoming the leading cause of disability in the next 10 years. The Australian Government Department of Health and Ageing (2014) mentioned that MDD is a type of depressive disorder in which the targeted individual becomes low-spirited and loses its interest in recreational activities. The individuals face changes in their sleep patterns and appetite and lack energy and concentration. The seriousness of this disorder can be understood through its potential to despair the feelings of hopelessness which can lead to suicidal thoughts (ibid, 2014). The World Health Organisation (WHO) found that MDD is strongly correlated with completed suicide, which is now the leading cause of death among adolescents aged between 15 and 19. The above discussion indicates the prevalence of depressive disorders, especially MDD, in the Australian population and it was required to select either an anxiety disorder or depressive disorder. Considering the prevalence of MDD and its consequences, it has now become necessary that effective interventions are planned and implemented as also advocated by Jacob, et al. (2013).

According to Moradveisi, et al. (2013), different therapies are available for the treatment of MDD and other depressive disorders but before any therapy or intervention is applied, the case formulation and or conceptualization is a necessary component. Teachman and Clerkin (2010) referred to case formulation as an activity which occurs at the outset of a therapy so that clinical decision-making can be initially guided, however, have a very little role to play once the therapy is underway. The authors consider case formulation as the most useful when it is viewed as an iterative process which allows the frequent reexamining of the hypothesis as the data of a new client becomes available. As Eells (2007, p. 4) describes, ““A psychotherapy case formulation is a hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioural problems. A case formulation helps organise information about a person, particularly when that information contains contradictions or inconsistencies in behaviour, emotion, and thought content.” Case formulation is very useful in effectively resolving the complication of treatment, provided it is viewed as an animated hypothesis-testing enterprise. Specifically, it helps in identifying the “stuck points” with the generation and implementation of alternative approaches as well as possible explanations for the stagnation of the treatment (Teachman and Clerkin, 2010).

With that being said, the major purpose of this study is to critically compare and contrast the behavioural formulation and cognitive conceptualization for the major depressive disorder and the treatment approaches it offers for the aforementioned depressive disorder. After discussing the case formulation through both the approaches, relevant therapies, including behavioural therapies, behavioural activation and Cognitive-Behavioural Therapy (CBT), will be discussed in light of the underpinning theories and evidence to support the efficacy of both the behavioural and cognitive model for MDD. Lastly, the discussion will be supported with clinical examples of different patients to provide an in-depth understanding of both the approaches.

Literature review

Case study

For simplicity and to adequately identify the differences in behavioural and cognitive formulation, a single case study is taken. Due to the scope and limitations of this study, the complete case study is not presented but can be found from Sturmey (2009, pp. 33-41), however, a brief demographic overview is provided to understand the context.

Sally, a 55-year-old woman, living with her husband, Dave and two children Jack (age: 21) and Mary (age: 23). Jack studies at the university, enrolled 6 months ago, which is around 350 miles from their house and Mary left her parents 2 years ago so that she can live with her boyfriend. Sally with her husband lives in a four-room house and has always taken pride in her home but in the past few days has started to lose interest as she feels that it is just too big for her. Five years ago, she returned to job to raise her family after leaving her job as an accountant. At that time, she was having difficulties in finding a job, so signed up a temporary contract with a temping agency as a bookkeeper but finds the jobs as unsatisfactory as the position were contract-based (short term). Soon she found that the job is not fulfilling her basic requirements as there was no regular cash and other benefits. All this left Sally with the feeling of helplessness and thought that she has failed to live up to her own expectations. On the other hand, the husband of Sally is the director of a local parking agency and his work involved significant time and travel away from the home.

During the initial assessment of Sally, her symptoms were indicating towards Major Depressive Disorder or sometimes referred to as Major Depression. The assessment of her symptoms was conducted through the criteria mentioned in the Diagnostic and Statistics Manual of Mental Disorders V (DSM-V).

Behavioural formulation of Sally’s case

The original behaviour models of depression are behind the conceptual formulation of behavioural approaches to depression. Years ago, Skinner (1953) argued that every individual contains some sequences of healthy behaviour that are positively influenced by the social environment and depression tends to interrupt them. Further, this process results in a variety of emotional side-effects which can, therefore, be characterised as “depressed behaviour”. Further extensions of the work of Skinner were conducted by Ferster (1973) and Lewinsohn (1974) in which they discussed different concepts and theories involving the role of available reinforcements for depressed behaviour including a two-phase process. Specifically, it was initially hypothesised that behaviour and depressed behaviour can be maintained through both positive and negative reinforcements. Coyne (1976) also proposed some etiological models in which it was proposed that the conventional behavioural therapies have the primary aim of increasing the health behaviour of an individual through making contact with ‘contingent response reinforcements’ and decreasing the punishments (negative reinforcements) for such behaviours as well as reducing the access to reinforcements specifically designed for depressed behaviours (Lejuez, Hopko and Hopko, 2003; Martell, Addis and Jacobson, 2001).

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