CHAPTER 3 Cognitive-Behavioral Case Formulation



CHAPTER 3 Cognitive-Behavioral Case Formulation

A case formulation is a theory of a particular case.

A CB case formulation is an idiographic (individualized) theory that is based on a homothetic (general) cognitive-behavioral theory.

The format and content of a case formulation depend on its function.

Individualized case formulation has a long history in Behavior therapy and behavioral analysis and in psychodynamic psychotherapy; it is relatively new in cognitive therapy.

A. Three levels in case formulation:

1. Formulation at the level of the case

2. The level of the problem or syndrome

3. Level of the situation

Levels of Case Formulation

A. At the Case Level

- Therapist develops a conceptualization of the case as a whole

- Explains the relationships among the patients problems

- Helpful when selecting treatment targets, as the therapist would like to focus first on problems that appear to play a causal role in other problems (e.g. depression may be causing marital problems and contributing to a child’s behavior problems meriting early intervention)

- Develop an initial case formulation after 3 or 4 sessions of therapy

B. At the Level of the Problem or Syndrome

- Provides a conceptualization of a particular clinical problem or syndrome (e.g. Depressive symptoms, shop lifting, OCD, Binge eating, purging, insomnia)

- Beck’s cognitive theory of depression is a formulation at this level.

- The therapist’s treatment plan for the syndrome or the problem depends on the formulation of the problem. (e.g. patient who complained of severe fatigue. The assessment process yielded 2 possible formulations, either the fatigue was due to abuse of sleeping meds or negative thoughts in response to a recent professional setback. The different formulations suggest different interventions.)

C. At the Level of the Situation

- Provides a “mini-formulation” of the patient’s reactions in a particular situation

- This formulation guides the therapist’s interventions in that situation.

- Based on Beck’s theory, the Thought Record Format is ideal.

- Includes situations, thoughts, behaviors, and emotions

- Case level formulations often acquired form information collected in situation-level and problem-level formulations.

- All formulations are considered hypothesizes

D. The therapist is constantly revising and sharpening the formulations as the therapy proceeds

Format of the Cognitive-Behavioral Case formulation

A. The C.B. case formulation has 5 components: Problem List, Diagnosis, Working Hypothesis, Strongest Assets, and Treatment Plan

1. Problem List – is an exhaustive list of the patient’s difficulties, stated in concrete, behavioral terms

- Includes psychological/psychiatric symptoms, interpersonal, occupational, medical, financial, housing, legal, leisure.

- Therapist search for themes or speculates about causal relationships in order to develop a working hypothesis that describes relationships among problems

- Use comprehensive Problem List so you don’t overlook important problems

- See CB Case formulation and Tx Plan handout

- Not always easy or possible to make a comprehensive Problem List

o Therapists is unassertive

o Therapist does not take the time

o Patients aren’t always willing to acknowledge problems

o Patients unable to acknowledge problems (shameful, frightful)

o Don’t consider to be problems

- Use of paper and pencil assessment can be helpful in some of these situations (i.e. substance abuse)

- Careful observation can also reveal problem behaviors that patients do not mention directly (overly accommodating and compliant ( may have assertiveness difficulties)

- When therapist observes or suspects problems that the patient does not wish to acknowledge, the therapist must use his/her judgment to determine whether it is necessary to get a particular problem on the table right away or whether a detailed discussed might be postponed.

- Linehan (1993) suggests problems involving suicidal and para-suicidal behaviors, therapy-interfering behaviors (not in compliance with Tx) or “”quality of life interference behaviors” (significant substance abuse, shoplifting. Homelessness) problems that, unless solved, will interfere with person’s ability to achieve any other goals and must be explicitly addressed early on.

- Less acute problems can be put on hold or ignored all together

- Each item on the Problem List consists of a:

1. One-to-Two word description of problem

2. Short description of some typical behavior, cognitive, and mood components of the problem when this is appropriate (for behavioral problems) Not appropriate for medical, housing, legal, financial problems

- Behavior Component might include gross motor behaviors (avoiding driving across bridges), physiological responses (increased heart rate), or both

- Sometimes hard to decide how to categorize problems on the Problem List

- Approach it in whatever way facilitates your work and communication with your patients

- Page 92 Judy’s Problem List

o Depressed, dissatisfied, passive- BDI at intake

o Disorganized unfocused unproductive

o Job-dissatisfaction

o Social Isolation

o No relationship

o Unassertive

Diagnosis

- Psychiatric Diagnosis is not, strictly speaking, part of a CB Case Formulation

- Include it as it can lead to some initial formulation hypothesis

- Dx can give some info about helpful Tx interventions

- Evidence-based therapist will want to rely on the results of randomized trails and randomized trails are generally organized around diagnosises

- Dx for Judy:

o Axis I: Dysthymic disorder

o Axis II: none

o Axis III; None

o Axis IV: Socially isolated, occupational problems

o Axis V: GAF=60

B. Working Hypothesis

- Is the heart of the formulation

- Therapist develops a mini-theory of the case, adapting a homothetic theory to the particulars of the case at hand

- The Working Hypothesis describes the relationships among the problems on the Problem List.

- Some problems result not from the activation of schemata, but from other problems

- Some problems result entirely or in part from biological, environmental, or other non-psychological factors (such as medical problems or financial problems ( resulting from an employer’s bankruptcy)

- Working Hypothesis based on Beck’s Cognitive theory

- Beck’s cognitive diathesis theory states that external life events activate schematas to produces symptoms and problems

o Schemata – therapist offers hypotheses about the schemata or core beliefs, that appear to be causing or maintaining the problems on the Problem List. These are generally negative beliefs. Patients may also hold positive schemata, but the negative ones are usually the ones that cause the problems, so they are the one itemized in this section of the formulation

1. Beck’s theory emphasized the importance of understanding patient’s beliefs about self, other, world and future.

2. Patient’s views of the self and others is especially clinically useful.

3. Patient’s views of the others helpful to the therapist because the therapist is an “other”

4. Patient probably has multiple views of self, other, the world, and the future.

5. May specify some conditional beliefs “if then” terms- “If I speak up, others will get angry and withdraw form me”

o Precipitants and Activating Situations

1. Specify external events and situations that activate schemata to produce symptoms and problems

2. Precipitants refers to a larger scale, events that precipitate an episode of illness or the patient’s decision to seek treatment

3. Activating Situations refers to smaller scale events that precipitate negative mood or maladaptive behaviors

4. Not always easy to draw a distinction between Precipitants and Activating Events

5. Not always crucial for Tx planning purposes

6. Main goal is to say something about the types of external events and situations that are problems for the patient

7. Important to assess external events and situations for several reasons

8. Cognitive theory states that psychopathological symptoms and problems are not due simply to intra-psychic events; they arise from activation by external events, of internal structures (schemata)

9. It is useful to work with patients not just to change their reactions to external situations, but sometimes to help them change the situations themselves (i.e. activity schedule interviews)

o Origins

1. Briefly describe one or a few incident or circumstances in the patient’s early history that account for how the patient might have learned the schemata or functional relationships listed in the Working Hypothesis

2. Includes modeling experiences, failures to learn important skill and behaviors (i.e. social skills deficits)

o Summary of the Working Hypothesis

1. Therapist tells a story that describes the relationships among the components of the Working Hypothesis tying them to the problems on the Problem List

2. Working Hypothesis can be described verbally or in a kind of flow chart

3. Working Hypothesis based on other CB theories. Behavioral analysis offers a particularly powerful and well-developed alternative to cognitive conceptualization schematas

4. A functional-analytic approach to case conceptualization treats psychopathological behaviors as serving a function and as caused and controlled by contingencies in the environment as contrasted to the structural view of psychopathology utilized in Beck’s model, which views psychopathological symptoms as caused by underlying structures (schemata)

5. Functional analyst use this to understand the functions and causes of problems by collecting info about antecedents and consequences

Strengths and Assets

- Can include good social skills, the ability to work collaborately, sense of humor, a good job, financial resources, a good support network, regular exercise, IQ, personal attractiveness, stable lifestyle

- Can help in developing a Working Hypothesis

- Can enhance Tx plan

Treatment Plan

- Not part of the formulation- it stems from and is based on the formulation, particularly the Problem List and the Working Hypotheses.

- Tx Plan has 6 components:

1. Goals

2. Modality

3. Frequency

4. Interventions

5. Adjunct therapies

6. Obstacles

- Goals

o The Problem List often suggests Tx goals. Goals may be seen as ways to solve the problems on the Problem List

o Patients and therapist strive to develop list of Tx goals they can both agree on

o Most patients aren’t eager to solve all of their problems; seek Tx address 1 or 2 particularly distressing problems

o Important to state how progress towards goals will be measured (simple count), self-report inventories, idiographic measures- self-monitoring.

- Obstacles

o Use of case formulation to make predictions about difficulties that might arise in the Tx relationship or the other aspects of the Tx

o Early awareness of potential difficulties can help patient and therapist cope more effectively with them

Using case formulation in Treatment

- Role of the formulation is to assist the therapist in the Tx process

- Main role of formulation is to guide the therapist in Tx planning and intervening

- Tx interventions should target Tx goals and capitalize on Patient’s Strengths and Assets.

- Flow clearly from the Working Hypothesis

- Formulation helped Judy’s therapist at various points in therapy

o Constructing a Problem Check List clarified Tx goals

o Helped therapist maintain a clear focus while working on multiple problems

o Helped patient play an active and collaborative role in Tx

o Helped therapist understand and manage her own negative reactions to the patient

Role of the Individualized Case formulation in Evidence Psychotherapy

- Tension between formulation-driven Tx and Tx supported by Randomized Control trails

- Standardized protocols also rely on a formulation, albeit a nomethetic (general) one rather than an idiographic (individualized) one

- Standardized protocols and individualized-formulation-driven treatments are complementary, not conflicting, formulation-driven therapies treat patients

- Individualized formulation facilitates the therapist’s use of a standard protocol by helping the therapist understand and manage difficulties that arise in the use of the protocol, including non-compliance, ruptures in patient-therapist relationship

- Many patients do not meet the selection criteria utilized in the RCT’s. Therapist extrapolates from the standard protocol or in the case of patients with multiple problems, 2, 3 or more standard protocols individual case formulation provides a systematic methods for carrying out this extrapolation

- Individualized Tx plan based on a conceptualization is invaluable. Little empirical research supports the utility of developing a formal case conceptualization to guide Tx.

To reduce the risk of Tx work based on a case individualized formulation and to structure its empirical foundation:

- Adopt an RCT – validated formulation as an initial working hypothesis

- Have patients provide informed consent for Tx

- Monitor outcome

o RCT- validated Tx’s have been shown to produce a good outcome for the average case.

o In contrast, the clinician treats the unique, individual case

o In evidence based formulation-driven psychotherapy, the clinician conducts the Tx of each case as an n=1 experiment.

o Clinicians begin by collecting data (assessment) in order to develop a hypothesis about the mechanisms causing and maintaining the patient’s problems (the case formulation). The formulation is used to derive a Tx plan. As Tx procedures, the clinician collects additional data to assess the outcome of Tx based on the formulation, and revises the formulation and Tx plan if the Tx plan is based on the original formulation in unsuccessful.

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