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Individual Case Formulation for Post-Traumatic Stress Disorder Individual Case Formulation for Post-Traumatic Stress Disorder: A Single Case Series. Alicia Griffiths June, 2017 Research submitted in partial fulfilment of the requirements for the degree of Doctor in Clinical Psychology (DClinPsy), Royal Holloway, University of London. Acknowledgements Firstly and most importantly I would like to thank my parents. Your unwavering belief in me throughout this journey and across my whole life alongside the support, encouragement, love and motivation has enabled me to complete this piece of work. I could not have done it without you both. My six incredible and inspiring Grandparents have also maintained my drive to succeed, having always encouraged hard work and dedication. Thank you for teaching me these qualities. Thank you also to my wonderful sister for the endless invites on holiday to keep me motivated! I love you all so much. I feel truly blessed to have such special friends (new and old) who have encouraged me throughout this journey and provided me with much needed support and care during some difficult thesis times and put up with me having to miss so many social events! A mention must also go the cohort, who made this whole experience more achievable, emotionally validating and fun. I would also like to thank Dr Gary Brown for his help, advice, guidance and feedback throughout this process, and for answering my many, many questions. A huge thanks to Dr Harry O’Hayon for believing in this project and for his enthusiasm. As a driving force behind recruitment, I am incredibly grateful. Thank you also to Dr Jon Wheatley for guidance and support during recruitment. Thank you to the admin teams for your help and for answering my endless emails. I would also like to thank the therapists for getting involved in the study and for all of the work they put in to being so meticulous in completing the tasks. Lastly, but certainly not least, a huge thank you to the participants of this study for sharing their journeys with me and, without whom, this project would not be possible. 2 Abstract Little is known about the usefulness of Case Formulation (CF) to Cognitive Behavioural Therapy (CBT) practice and outcome despite its highly held esteem within Clinical Psychology. The aim of this study was to explore the use of a new approach to formulating, Hallam’s (2013) Individual Case Formulation (ICF), as a potential mechanism for contributing to change in PTSD treatment using a single case experimental design (SCED). The study had two components: firstly, training on ICF to shed light on how skills in formulation are developed and secondly, use of ICFs during PTSD treatment of eight individuals. It was hypothesised that ICF workshop training could increase therapist formulation skill. It was also tentatively hypothesised that quality and complexity of ICFs might relate to outcome for people with PTSD and that other specific elements captured within the ICF might link to outcome and rate of improvement for people with PTSD. A secondary hypothesis that sharing a formulation during treatment could be associated with reducing symptoms was also investigated. Formulation diagrams were coded using a newly devised rating scale in order to identify potential elements within ICFs. Coding results from diagrams and patterns of outcome measures from the eight participants were explored at group and individual levels. Due to the small sample size and the observational nature of many of the analyses, results were interpreted with caution. Findings from the training indicated increased formulation quality, suggesting that formulation skill can be enhanced in therapists. Group and individual analysis offered initial, preliminary support for the idea that higher quality CFs might be associated with reduction in symptoms. Other specific items within CFs appeared to show some association with change in symptoms. It was difficult to adequately address the hypothesis regarding 3 complexity, as very little complexity was shown across the sample of diagrams. Initial support was found for the secondary hypothesis, with visual analysis suggesting that some participants demonstrated symptom change following the shared formulation, suggesting that change in symptoms was linked to this process. Potential implications of the findings and suggestions for future research are discussed. 4 List of Tables Table 1. Summary of ICF-RS items……………………………………………….58 Table 2. Summary of the content of the ICF workshop……………………….…..59 Table 3. Individual participant information……………………………………….62 Table 4. Summary of measures taken within each session……………………......77 Table 5. Comparison of scores for pre-/post- workshop formulation diagrams......80 Table 6. Summary of pre-/post- scores for PTSD measures……………………....83 Table 7. Summary of pre-/post- scores and interpretations for PHQ-9, GAD-7 and W&SAS…………………………………………………….………....84 Table 8. Scores on each item of the ICF-RS for Participants A-H………………..90 Table 9. Definitions of visual analysis terms……………………………………...95 Table PA1. Trauma type, specific images, encapsulated beliefs, formulation shared, treatment type for PA……………………………………………...96 Table PA2. Tau-U analysis for Frequency, Interference, Uncontrollability, Distress, Nowness and Key Meaning for PA…………………...................99 Table PA3. ICF-RS content code………………………………………………...100 Table PB1. Trauma type, specific images, encapsulated beliefs, formulation shared, treatment type for PB…………………………………………….101 Table PB2. Tau-U analysis for Frequency, Interference, Uncontrollability, Distress, Nowness and Key Meaning for PB.……………………………105 Table PB3. ICF-RS content code………………………………………………...107 Table PC1. Trauma type, specific images, encapsulated beliefs, formulation shared, treatment type for PC…………………………………………….109 Table PC2. ICF-RS content code………………………………………………...112 Table PD1. Trauma type, specific images, encapsulated beliefs, formulation shared, treatment type for PD…………………………………………….114 Table PD2. Tau-U analysis for Frequency, Interference, Uncontrollability, Distress, Nowness and Key Meaning for PD.…………………………….117 5 Table PD3. ICF-RS content code.………………………………………………..118 Table PE1. Trauma type, specific images, encapsulated beliefs, formulation shared, treatment type for PE…………………………………………….120 Table PE2. Tau-U analysis for Frequency, Interference, Uncontrollability, Distress, Nowness and Key Meaning for PE. .…………………………...123 Table PE3. ICF-RS content code…………………………………………….…...124 Table PF1. Trauma type, specific images, encapsulated beliefs, formulation shared, treatment type for PF……………………………………………..125 Table PF2. Tau-U analysis for Frequency, Interference, Uncontrollability, Distress, Nowness and Key Meaning for PF.…………………………….129 Table PF3. ICF-RS content code………………………………………………....130 Table PG1. Trauma type, specific images, encapsulated beliefs, formulation shared, treatment type for PG…………………………………………….131 Table PG2. Tau-U analysis for Frequency, Interference, Uncontrollability, Distress, Nowness and Key Meaning for PG……………………………135 Table PG3. ICF-RS content code………………………………………………...136 Table PH1. Trauma type, specific images, encapsulated beliefs, formulation shared, treatment type for PH…………………………………………….137 Table PH2. ICF-RS content code………………………………………………...141 6 List of Figures Figure 1. Example of a constructed ICF as according to Hallam (2013)………….35 Figure 2. Ehlers & Clark (2000) Cognitive Model of PTSD (from Grey, 2007).…43 Figure 3. Flow of therapists into the workshop and Phase 1…………….………...56 Figure 4. Final service and participant involvement………………………..……..65 Figure 5. Scatter plot of pre- and post- Symptom Severity scores…………,……..86 Figure 6. Scatter plot of pre- and post- IES-R scores…………………….………..87 Figure PA1. Frequency VAS: raw data, central tendency and trend……….….......97 Figure PA2. Interference VAS: raw data, central tendency and trend…….………97 Figure PA3. Uncontrollability VAS: raw data, central tendency and trend….……97 Figure PA4. Distress VAS: raw data, central tendency and trend……………,…...97 Figure PA5. Nowness VAS: raw data, central tendency and trend…………,…….98 Figure PA6. Key Meaning VAS: raw data, central tendency and trend…….……..98 Figure PB1. Frequency VAS: raw data, central tendency and trend……………..103 Figure PB2. Interference VAS: raw data, central tendency and trend……………103 Figure PB3. Uncontrollability VAS: raw data, central tendency and trend……....103 Figure PB4. Distress VAS: raw data, central tendency and trend…………….…..103 Figure PB5. Nowness VAS: raw data, central tendency and trend……………….104 Figure PB6. Key Meaning VAS: raw data, central tendency and trend….……….104 Figure PC1. Frequency VAS: raw data, central tendency and trend……….……..110 Figure PC2. Interference VAS: raw data, central tendency and trend……………110 Figure PC3. Uncontrollability VAS: raw data, central tendency and trend………110 Figure PC4. Distress VAS: raw data, central tendency and trend………………...110 Figure PC5. Nowness VAS: raw data, central tendency and trend…………….....111 Figure PC6. Key Meaning VAS: raw data, central tendency and trend…………..111 Figure PD1. Frequency VAS: raw data, central tendency and trend……………...115 Figure PD2. Interference VAS: raw data, central tendency and trend…………....115 Figure PD3. Uncontrollability VAS: raw data, central tendency and trend…….. .115 7 Figure PD4. Distress VAS: raw data, central tendency and trend………………...115 Figure PD5.Nowness VAS: raw data, central tendency and trend………………..116 Figure PD6. Key Meaning VAS: raw data, central tendency and trend…………..116 Figure PE1. Frequency VAS: raw data,
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