High-Risk Profile

There are five types of questions the therapist should ask about each patient profile. First, for this patient, what is the most distressing chronic symptom or symptoms (e.g., back pain on walking, headache, angina) and what is the frequency (times per day or hour), intensity (patient’s subjective rating, absent 0–5 severe), duration (length of symptomatic episode), the antecedents (psychological mood and situational) and the consequences (onset or offset of aversive events, attention, sympathy, etc.) of this distressing symptom or symptoms. Investigating these questions involves finding out why an acute problem became chronic in this case. Second, what factor or factors does the patient believe have caused or is presently maintaining the distressing symptom or symptoms. Third, what conceptual or procedural links can be made between the patient’s beliefs about the etiology or present condition of the disorder and the five components of the high-risk profile. Fourth, what elevations or deficits discovered through the patient’s performance on the high-risk profile (Wickramasekera, 1979) can account for parts or all of the patients presenting problems. In other words, what predisposes, triggers, and buffers are operating in this case at this point in time. Fifth, what maladaptive, unattended, or unconscious and overlearned beliefs and behavioral responses block this patient’s assimilation of major life changes (e.g., rape, physical impairment, death, loss of job, loss of lover, loss of child, etc.) in intimate relationships (commitment, sex, affection, confiding) and work (commitment, production, challenge, control) relationships. In intimate relationships it is crucial to be able to feel committed; and to be sexually, affectionally, and verbally uninhibited with at least one person. In the work situation too, it is important to feel committed to what one is doing and to feel some degree of control over the products of one’s work and to be challenged by them. Impairments of adaptation in areas of work and love are destructive to normality. Unconscious (unattended) and overlearned belief filters or schemata the patient holds may block the assimilation of and adaptation to a traumatic incident or major life change. For example, the premature death or betrayal of a loved one may be incongruent with one’s unconscious, unattended, or over-learned belief in a just world. This unconscious cognitive incongruence may obstruct the assimilation and adaptation to this irreversible life change. Repeated episodes of unstable angina or a myocardial infarction in a young adult may not fit the overlearned belief “I am intact and invulnerable.” A discrepancy between unattended and overlearned unconscious beliefs and everyday empirical experiences can generate feelings of incoherence, disorientation, and hopelessness. A serious breach of personal or professional standards may be incongruent with the deep unattended belief “I do not do bad things.” This guilt may torture the person. A series of incomprehensible personal and/or professional losses or failures may be incongruent with the unconscious belief that “my world has meaning and I am in control of my life.” Deep unconscious or overlearned beliefs like I am “unworthy” or “incompetent” can be threatened by life events like the prospect of promotion, marriage, or love. These threats to unattended and overlearned or unconscious deep schemata can unwittingly trigger intrusive ruminative episodes, attack, or escape behaviors that block or impede functional adaptation to major life changes that have, in fact, occurred. For example, symptoms like chronic anxiety, depression, dissociative acting-out episodes, guilt, insomnia, rheumatoid arthritis, torticollis, chronic pain, or an ulcer can occur in response to the loss of a loved one or a major personal or professional failure.