ASSESSMENTS
In this chapter, I would elaborate most of the assessment procedures for Cognitive Drill Therapy. The repetitions are inevitable but for good. Repetitions should be considered as emphasis and be learnt clearly for enhancing applications and deriving maximum benefits from Cognitive Drill Therapy.
Gather Relevant Case History: It is essential to acquire relevant case history about the problems. An affected person may bring a long list of phobia/OCD and other problems. The problem desired to be healed on priority should be singled out. For example a person came with following problems:
1) Irritability
2) Social anxiety
3) Academic difficulties
4) Obsession for symmetry
5) Obesity
CDT is not applicable in all of the above problems. Other forms of psychological treatment such as Cognitive Behavior Therapy (CBT) may be required. Through mutual discussion, we identified obsession for symmetry as the most prominent problem at the moment. Hence, this problem was taken up for further exploration and application of CDT.
Having selected a specific problem, a relevant history was gathered. In history, I focus on following questions which elicit relevant history in most cases.
i. Tell me in detail about your problem
ii. Tell me when and how this problem started
iii. Tell me how this problem is affecting your life
iv. Tell me some life experiences related to the problem
v. Tell me what body-mind reactions get activated during the problem
vi. Tell me how you have been dealing with this problem
vii. Tell me what scares you in this problem
viii. Tell me the objects/situations/events that trigger this problem
ix. Tell me how your family members react or help you during this problem
x. Any other thing you would like to share with me regarding this problem.
xi. Would you be able to share dark sides of your life?
I recommend maintaining a written record of the replies given by the affected person to these questions. Interview is also conducted with family members and they are also asked similar questions and their replies are also to be recorded. I may also submit the above questions to the affected person through whatsapp or email and ask him/her to record his replies in Drill Diary. As far as possible the dark aspects of life which the affected person keeps on hiding should be gently understood. No force or digging should be done to elicit them. One should be alert and open to take the dark aspects as and when they emerge.
Drill Diary: I recommend the affected person to procure a diary or notebook to record the assessment and on-going activities of CDT. The affected person is required to record as many details of the problems as possible. I also record the drill statements and other homework to be carried out by him/her. Diary is very important as most of the affected persons tend to forget the session details. Also it helps them in revising the work done so far which act as a reminder for applications of drill therapy. We need to appreciate the diary records even if they are sketchy and abridged. The affected persons do not have the clarity of the concepts, theories and procedures as the therapists have.
Formal Assessments: Psychologists and psychiatrists have developed various tools for assessment of anxiety, phobia, depression, OCD and other aspects of human functioning. Some of the relevant tools are listed below and can be downloaded from Internet.
I. Yale-Brown Obsessive Compulsive Scale (Y-BOCS): This is the most frequently used scale to assess the nature and severity of OCD. It assesses both obsessions and compulsions.
II. Beck Depression Inventory (BDI): This is standard and widely acceptable tool to assess severity of depression.
III. Beck Anxiety Inventory (BAI): This is a good tool to assess severity of anxiety.
IV. Generalized Anxiety Disorder Scale (GAD-7): This is a brief scale to quantify Generalized Anxiety.
V. Fear Questionnaire (FQ): This can be used to assess agoraphobia and social phobia.
VI. Sheehan Patient-Rated. Anxiety Scale: This is a good scale to assess anxiety and it can provide rich information on body-mind reactions of the patients.
VII. Depression, Anxiety and Stress Scale (DAS): As the name implies, this single scale can assess three emotional aspects – depression, anxiety and stress.
VIII. Agoraphobic Cognitions Scale: This scale can point out to the underlying fear structure.
IX. Severity Measure for Panic Disorder
X. The Panic Attack Questionnaire
XI. Liebowitz Social Anxiety Scale
XII. Subjective Units of Distress Scale (SUDS)
There are other scales too for which relevant books and internet can be browsed. Some of these tests are available for online administration. An affected person can fill up and get an analysis report online.
It is recommended that a few scales 2-3 should be chosen to assess the current status of the affected person on the selected problem for drill therapy and the same assessment should be repeated periodically in the middle phase of the therapy, at the termination of therapy and on follow ups of one month, three months and six months. This will yield a convincing data to the affected person as well as the therapist.
Moreover, this assessment would form the basis of writing case reports for scientific journals and book writing which many therapists and even the affected persons would be writing in coming years about their personal experiences with Cognitive Drill Therapy.
Global Subjective Rating (GSR): It is useful to ask the affected person to rate the severity of his selected problem out of 100. For this, a simple question, tell me out of 100, how much problem do you have? The affected person would say any number 80% and the like. Keep a record of this global severity. During the course of therapy intermittently this global rating can be obtained, may be after every 3-4 sessions. This single subjective rating would provide extremely useful information to both the affected person as well as the therapist. Even a line diagram of this global rating can be constructed in the records of the therapist as well as the drill diary of the affected person.
Subjective Reports of Distress (SRD): This is a system of moment to moment, on the spot quantification of fear and distress. Any of the following questions can be asked to the affected persons to quantify the anxiety level on a given moment during the application of Cognitive Drill Therapy.
i. Tell me how much fear/distress/anxiety you are experiencing right now: zero-low-medium-high-very high
ii. Out of 100 how much fear/distress/anxiety you are experiencing right now
iii. Out of 10 fear/distress/anxiety you are experiencing right now. 10 is maximum.
iv. Tell me whether it is a mild, moderate, severe or profound reaction
This moment to moment monitoring of distress level is extremely important in CDT. This quantification forms the basis of continuation, modification and pauses during the application of drill therapy. During application of drill, this quantification is done every 30-60 seconds.
Psychophysiological Monitoring: Cognitive Drill Therapy provides a unique opportunity in monitoring of psychophysiological parameters during the actual application. Devices for following psychophysiological responses can be attached to the affected person while he/she is performing the drill. It is not necessary to monitor all the function. Even a single parameter could be useful and serve the purpose. Apart from the listed parameters, any other suitable parameter of monitoring may also be considered.
i. Galvanic Skin Response
ii. Heart Rate Variability
iii. Blood Pressure
iv. Brain Wave Activities
v. Oxygen Saturation
Monitoring through psychophysiological measurement devices provide an objective evidence of what is happening to the body-mind reactions of the affected person in the real time when he/she is performing the drill. The feedback of such a monitoring system can boost the confidence of the person in drill therapy as well as his/her potentials of getting improved through psychological methods.
Reports of Family Members: Some affected persons minimize their problems and even the role of treatment. At times, they can also exaggerate the rate of improvement and the modifications they did in their living style after commencement of the treatment. Family members, can give the accurate picture of the patients functioning in between the sessions of cognitive drill therapy. But even the family members can minimize or exaggerate the reports. A therapist need be vigilant about the progression of drill therapy and the impact on the life of the affected person. There are some tools on Phobia and OCD which can be used on family members to chart the progress of the affected person during therapy. If convenient these tools should also be considered. The tools can be obtained from the internet.
Monitoring Somatic Representations: Emotional reactions such as anxiety, fear and disgust are usually accompanied by body reactions. Each affected person has his/her own patterns of representations of distress in the body. Some will experience it in eyes, others in throat, heart or stomach regions. During drill therapy, I recommend that a note be taken where the distress is located in the body. To capture the body site for the distress, I ask following question, where in your body you are experiencing this distress? Initially, the distress will spread over several body parts, but there will be prominence of one part of the body where it is felt most and which dissolves towards the end during the application of drill therapy. The dissolution of distress from all body parts is accompanied by resolution of anxiety and distress.
Audio Recording: With permission of the affected person a therapist can record the entire session through mobile or Dictaphone. This record will be useful to the person undergoing drill therapy as well as to the therapist for session review which can be used in teaching drill therapy to the students and preparing reports and presentations.
Behavioral Tests: Cognitive Drill Therapy is usually executed at verbal and imagination level. With drill, the distress gets substantially reduced at verbal and imagination level. Often there is spontaneous generalization of the reduction of distress from imagination and verbal level to actual real objects. To ensure, if this generalization has taken place, the affected person is encouraged to expose himself/herself to real objects in order to assess whether, the exposure to real objects still elicit distress reaction. If there is resolution of distress and actual objects fail to elicit the distress, then authentic improvement has taken place and the affected person can be considered to have overcome the reactions to those objects which have passed the behavioral tests. If there is a failure and the actual object still elicit the distress reaction, in that case additional drill can be performed at verbal/imagination level or drill can be performed by exposing to the real objects. This assessment through behavioral test is the ultimate assessment of the efficacy of drill therapy in ameliorating fear/disgust in the affected persons. It must be performed in all cases. The behavioral tests can be conducted in therapist’s clinic and as homework in real life situations.
Recording of Two Layer Structure: Two layer partition of the problem of the affected person is the core foundation of drill therapy. I recommend that comprehensive listing should be done for the following. It should be as comprehensive as possible.
i. List of objects of fear
ii. List of body-mind reactions
iii. List of safety measures and avoidance patterns
iv. List of feared cognition (imagined feared consequences)
It may appear that this assessment would take lots of time. But it is not so. Assessment is an integral part of Cognitive Drill Therapy and should be performed on each affected person. The data generated from formal assessment would go a long way and serve multiple purpose for monitoring the progress and the current status of the problem in the affected person.
--x--