The disorder-specific strategy for Step 3 cases will be effective most of the time, but not all of the time. The reason for this is that multiple factors are not always sympathetically linked: sometimes B worsens when A improves, and A worsens when B improves. This suggests antagonistic rather than sympathetic links. In this scenario, change in one area will not necessarily have a trans-diagnostic or helpful effect on other problems. There can also be unstable relationships between factors; in other words, the relationship between A and B is not constant. Some multiple parts are not just interacting; they are changing unpredictably over time. They form a moving target and this makes it difficult to maintain a consistent treatment focus. In Step 3 there are multiple paths to recovery and it may not always matter what the primary target is. In Step 4 the path to recovery is much harder to find. Whichever target is chosen it is difficult to produce change; other factors have a limiting effect or deteriorate when the primary target improves. Consequently, working at Step 4 requires careful navigation: finding a way through densely inter-woven difficulties in spite of cul-de-sacs, wrong turns and dead ends. A good case formulation is essential to map and explore the territory and therapists need to be tenacious, flexible and hopeful, viewing all set-backs as learning opportunities.
Case illustration: Jeff
At the time of his referral, Jeff was aged 48 and married with two daughters. He was a public service employee with a 20-year history of obsessive compulsive disorder (OCD) with recurrent major depressive episodes (MDE). Jeff had previously received three courses of CBT:
Treatment 1: CBT for OCD (National Collaborating Centre for Mental Health, 2005). Jeff received 14 sessions over a 4-month period. Due to unpredictable changes in mood and affect, it was difficult keeping the focus on OCD. During this treatment a psychiatric assessment resulted in a diagnosis of bipolar II disorder. Jeff disclosed his diagnosis to his employer, believing this was the right thing to do, and this initiated a lengthy process of occupational health assessment. The bipolar diagnosis coincided with staffing changes and Jeff was offered a new therapist who specialized in the area of unstable mood.
Treatment 2: CBT for bipolar disorder (Meyer and Hautzinger, 2012). Jeff received 53 sessions over a 3-year period. The therapeutic dose reflected the severity of Jeff's depression, mood swings and occasional hypomanic episodes. Treatment was strongly affected by the occupational health process. Jeff was assessed by a number of medical practitioners, not all with psychiatric training. The stress and uncertainty provoked by these assessments interacted with Jeff's unstable moods and made it challenging to progress. Over an extended period there was a gradual improvement and stabilization of Jeff's mood. OCD was not the priority during this period and it was not targeted explicitly within treatment.
Treatment 3: Consolidation of CBT for bipolar disorder. Jeff received a further 23 sessions over a 2-year period to consolidate progress and help him cope with the occupational health process. In the intervening period, his employer had reacted in a risk-averse way, moving him to a less senior role within the organization. His manager informed him: ‘your mental health problems mean you cannot talk to the public’. This had a devastating effect on Jeff's self-esteem and shattered his assumptions about his employer's competence, loyalty and duty of care. It provoked extreme anger, reactivated Jeff's OCD and led to further mood de-stabilization. The context of acute occupational stress was a complicating factor because it increased uncertainty and made it difficult for Jeff to maintain a consistent treatment focus.
In spite of the benefits gained from these treatments, Jeff relapsed into moderate depression with occasional expansive moods and his OCD had also been re-activated. He was pre-occupied by anger with his employer and this was interfering with his functioning at work. Disorder-specific protocols had not had a lasting effect so an alternative approach was adopted. Jeff was offered a new therapist and subsequently received 44 sessions of CBT over a 2-year period. The strategy was firstly to map the non-depression factors that could be complicating his presentation, illustrated in Fig. 3.
Figure 3. Biopsychosocial map of complexity factors associated with Jeff's depression
This revealed three social factors and three psychological factors. The therapist did not assume that these were complicating Jeff's mood disorder; rather, there was a process of guided discovery to find out whether or not they were having a complicating effect. There was a potential healthcare factor concerning Jeff's repeated relapses that may have reduced his confidence in CBT or the clinical service. In fact, this was not the case. Jeff reported experiencing the benefits of the previous courses of CBT but something stopped them having a sufficiently potent and lasting effect. There was a potential interpersonal factor following significant tensions between Jeff and his wife; however, they had managed to overcome these difficulties and they were no longer problematic. There was a clear and pronounced occupational factor that had a complicating effect on Jeff's depression both during and after the occupational health process.
The occupational stress interacted with three psychological factors: hypomanic moods, OCD and post-traumatic anger. Occupational stress over the previous five years had a traumatic impact on Jeff. He was not suffering from PTSD but he continued to feel ‘devastated’ by his employer's actions. They had a profoundly disruptive impact on his self-identity and Jeff felt extremely hurt and angry several years after the most stressful events had occurred. Jeff's work had been a significant and self-defining aspect of his self-identity throughout his adult life.
At Step 4 the strategy is not to deliver a disorder-specific protocol for any one of these problems. Instead, an individualized formulation is developed of the interactions between these factors, i.e. the functional links where the output of A is the input to B, and so on. At the outset of therapy a simple map is used with the main presenting problems on it and this is used to explore the interactions between them. In Jeff's case, as the map grew and became better specified there were three main benefits to having an over-arching formulation. Firstly, because Jeff's problems were inter-dependent and highly changeable the formulation helped to identify his mental state at any point and enabled reflection on how it was affecting his other difficulties. Secondly, the emerging map made it more straightforward to agree the optimal treatment focus at that point. Thirdly, by paying close attention to the interaction between Jeff's difficulties, functional links became apparent and these could then be targeted for change.
Using this approach it is important to ensure that therapy is evidence-based in two key respects: firstly, the formulation should be tested empirically through guided discovery, collaboration, behavioural experiments, etc., so that hypotheses about functional links are disconfirmed and not just assumed. Secondly, only treatment components from evidence-based protocols should be used, even if they are delivered in a novel sequence or innovative way. In Jeff's case occupational stress, depression, hypomania, OCD and post-traumatic anger were interacting in a way that complicated the usual maintenance of depression and made it harder for disorder-specific protocols to have a lasting effect.
The formulation evolved gradually over several sessions and the final version is presented in Fig. 4. Jeff's difficulties were re-triggered by continuing to work in the same organization. Memories of how he had been treated were re-activated on a daily basis and this provoked intense upset, anger and occasional rage. The anger triggered vengeful thoughts and images in which he would retaliate against his managers with extreme physical violence. A complicating factor was the unpredictable effect of those thoughts on Jeff's obsessional and hypomanic tendencies. Sometimes he would experience the thoughts as unwelcome intrusions and an OCD cycle would be triggered with inflated responsibility to prevent harm, anxiety about acting on the thoughts and then various forms of neutralization, including behavioural avoidance and thought suppression. On other occasions Jeff would experience the thoughts as liberating: they enabled him to emotionally process traumatic memories but this could also have a disinhibiting effect, leading to grandiose ideas about being powerful and dominant, resulting in elated mood and raising concerns about risks of harm to others.
Figure 4. Jeff's individualized case formulation
Jeff had learned the harmful consequences of hypomania during earlier treatments and he was wary of acting inappropriately with other people. Memories of past hypomanic behaviour were sometimes activated, leading to guilt and shame-based rumination which had the potential to depress Jeff's mood and spiral into helplessness and social disengagement. Guilt and shame also activated Jeff's felt-sense of responsibility to act dutifully as a husband, father and public servant and this had a reinforcing effect on the OCD cycle. As Fig. 4 illustrates, by mapping out the links between disorders Jeff and his therapist were able to make sense of his different mental events and mood states. The formulation helped to de-mystify and explain what Jeff otherwise experienced as ‘mental turmoil’ or ‘going mad’.
The main complication was anger simultaneously triggering an inhibiting process (OCD) and a disinhibiting process (hypomania) that produced unstable moods, internal conflict and cognitive disorganization. In this respect the maintenance of Jeff's depression was subtly different from many clinical presentations. His depressed moods had classic features such as social withdrawal, rumination and self-critical thinking. However, targeting depressed moods did not automatically improve interactions between depression, hypomania, OCD and post-traumatic anger.
Three trans-diagnostic factors also became apparent; firstly, across different mood states Jeff would often engage in unhelpful repetitive thinking. The content tended to be self-critical in the depressed mode, self-actualizing in the hypomanic mode, retaliatory in the traumatized mode and obsessional in the OCD mode. The common process was repeated dwelling on emotionally charged topics that was generally unproductive and created further distress. Secondly, Jeff's affect was unstable irrespective of which disorder was dominating his current mental state. Thirdly, across different mental states Jeff's self-identity was often uncertain and confused. There was a degree of self-identity confusion prior to treatment that had been exacerbated by the occupational health process. These trans-diagnostic factors were placed in the centre of the formulation as a reminder of higher-order processes that could be targeted in any mood state, for example, encouraging Jeff to be reflective rather than ruminative, encouraging acceptance of affect in favour of emotional avoidance, and affirming experiences in which he felt grounded in his ‘true self’.
In addition, Jeff's treatment included a series of sessions delivering exposure and response prevention (ERP) for his obsessional thoughts (McKay et al., 2015). Their content was primarily based on the perceived threat of acting on his anger and harming his employer. Jeff was able to expose himself to these thoughts, tolerate the distress they provoked and gradually recognize that they were only thoughts and not intentions. The only deviation from standard protocol was monitoring for hypomania and behavioural disinhibition; this occurred in some of the early exposures. This was used to elaborate the formulation. Overall, the formulation had an integrating effect on Jeff's learning; he was able to identify which processes were active at any point and developed greater mastery in counteracting them with different cognitive and behavioural strategies. Jeff has since made a successful transition into early retirement and his treatment has ended.