Patient and therapist agreed to this compromise plan with the understanding that they would monitor progress in session every week to determine whether the patient benefitted. If treatment failed to help, they agreed that the patient would add pharmacotherapy. At that point, the therapist was able to refer back to the informed consent process to remind the patient that he had agreed that if treatment failed, he would add pharmacotherapy to the treatment plan.
All of the elements of therapy described so far initial assessment, diagnosis, case formulation, treatment planning, and informed consent comprise the pre-treatment phase of the therapy.
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This phase of therapy lasts 1 to 4 sessions depending largely on the complexity of the case. If these elements are successfully accomplished and patient and therapist can agree on a treatment plan, treatment begins. Treatment is guided by the formulation.
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The cases of two people who suffered from insomnia illustrate this point. Jane complained that she spent long blocks of time awake in bed each night. The diary indicated that Jane generally went to bed at 9 p. These long blocks of wake time were very disturbing to Jane, and she was also frustrated about spending so many hours in bed each night.
From the diaries, the therapist and Jane determined that she lay in bed for approximately 11 hours nightly but averaged only about 7. This behavior contributed to insomnia by promoting poor sleep efficiency; that is, it led Jane to obtain short fragments of sleep throughout the long hours in bed rather than consolidated blocks of several hours of sleep. This formulation suggested that sleep restriction could be helpful to Jane [ 19 ]. The sleep restriction intervention requires the individual to reduce the time spent in bed so that it more closely resembles actual sleep time, and then gradually lengthen the time in bed as sleep efficiency improves.
The therapist initially suggested that Jane restrict her time in bed to 7. Jane was happy with this result, as she was no longer spending long periods of time awake in bed. Jeffrey also sought treatment for insomnia. He complained that he had difficulty falling asleep at night and that while trying to fall asleep, his mind raced with worry about his job and his insomnia. His sleep diary indicated that he averaged minutes to fall asleep each night.
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He awoke each day at 6 a. Furthermore, as part of the daytime worry, Jeffrey monitored signs of fatigue, such as yawning or losing concentration. This monitoring fueled his anxiety about sleep. Jeffrey also spent a lot of time worrying about job problems instead of developing solutions to the problems. Based on these mechanism hypotheses, interventions to help Jeffrey targeted the worry and the insomnia by scheduling problem-solving time during the day, teaching skills to disengage from worry at other times, and implementing cognitive restructuring to address unhelpful beliefs about sleep.
Behavioral experiments also addressed the daytime monitoring mechanism. As an example, the therapist and Jeffrey collaboratively designed an experiment in which he spent two hours monitoring for signs of fatigue and two hours in which he instead focused on the sights and sounds around him [ 21 ]. After each period, he rated his mood, performance, and fatigue. This experiment taught Jeffrey that when he constantly monitored for signs of fatigue, his fatigue worsened and he became more anxious about his sleep, which made it more difficult to fall asleep.
As these interventions helped Jeffrey reduce his worry and monitoring, his sleep improved. Often formulations at both the symptom and disorder level are helpful in guiding treatment. Consider Fred, a young man who met criteria for schizophrenia. Fred frequently failed to shave or take care of himself in other ways, and was quite distressed about these difficulties.
The therapist developed a mechanism hypothesis for these symptoms drawing from the disorder-level finding that individuals with schizophrenia have a deficit in anticipatory but not consummatory pleasure [ 22 ]. That is, individuals with schizophrenia report as much pleasure in the moment as do healthy individuals but they predict that future events will be less pleasurable than do healthy individuals.
Using this finding, the therapist proposed the formulation that although Fred experienced pleasure in the form of relief and satisfaction upon completing his shaving; he did not anticipate these feelings prior to the task and thus could not use them to motivate himself to shave. The therapist explained the formulation to Fred and tested it informally by asking Fred about his experiences and predictions of pleasure. Consistent with the formulation, Fred reported that indeed he did feel good after he shaved, but that before he shaved he had little awareness of the fact that after he shaved he would feel good about having done it.
Fred agreed that this failure to anticipate positive feelings might be an impediment to shaving, and he was receptive to using this idea to develop an intervention that might help. The therapist worked with Fred in the therapy session to help him practice imagining shaving and experiencing the good feelings of pride and satisfaction that he felt after shaving. The therapist also helped Fred develop and write down some explicit reminders e. As treatment proceeds, the patient and therapist collect data to test the formulation and monitor the process and outcome of therapy.
Some data are collected formally, using written tools, and other data are collected informally, using therapist observations or patient verbal self-report. Data collection allows patient and therapist to answer questions like: Are the symptoms remitting? Is the patient accepting and adhering to the interventions the therapist provides?
Are the mechanisms changing as expected? Are problems in the therapeutic relationship interfering? Thus, therapy is an iterative, idiographic, hypothesistesting process, where the treatment of each case is like an experiment in which the formulation is the hypothesis. Sometimes the therapist carries out assessments to directly test the formulation [ 23 , 24 ]. More commonly, the therapist tests the formulation indirectly by monitoring the degree to which the treatment plan based on the formulation helps the patient accomplish his or her treatment goals and leads to the expected changes in mechanisms.
In addition to its key role in the hypothesis-testing process, progress monitoring strengthens the therapeutic alliance by promoting and building a shared evidence-based collaborative process. It also helps the therapist identify non-adherence and failure early so they can be addressed before they undermine the therapy. It is difficult to collect formal data to evaluate all aspects of outcome and progress. However, we do recommend that the therapist monitor symptoms at every session in writing or using a software or online tool. This can be done using a standardized assessment instrument such as the Quick Inventory of Depressive Symptoms [ 25 ] or an idiographic measure like a Diary Card [ 26 ] or an Activity Schedule [ 27 ].
After a period of good functioning, the patient began missing and arriving late to his therapy sessions, his scores on the Beck Depression Inventory indicated that his symptoms were worse, and three months into treatment he lost his job as a result of manic behavior. These data caused the therapist to conclude that the treatment plan was failing, helped the therapist convince the patient of this, and motivated the patient to agree to meet with a pharmacotherapist.
The case of a married couple provides another example of the benefits of progress monitoring. In reviewing their weekly marital satisfaction ratings across a number of areas, the therapist saw that the couple moved remarkably in tandem. Termination occurs when the goals of treatment have been met, when patient and therapist agree that treatment has failed, or when logistical or other obstacles such as non-adherence arise and cannot be solved.
The case formulation can aid the termination process in many ways. Sometimes the formulation can help the patient and therapist decide whether termination is indicated. The fact that no change has occurred in the mechanisms in this case, problemsolving skill deficits that appear to cause the depressive symptoms indicates that more treatment is needed. In other cases, even when the patient has learned skills and achieved some change in the mechanisms that underpin the symptoms e.
The therapeutic relationship supports all of the other elements of the therapy. Additionally, case formulation-driven CBT relies on a dual view of the relationship.
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One part of the relationship is the necessary-but-not-sufficient NBNS view. In this view, the trusting collaborative relationship is the foundation upon which the technical interventions of CBT rest. The other view of the relationship is as an assessment [ 28 ] and intervention tool [ 29 ], as illustrated in the case of Ann, the client with social phobia. Ann reported that she feared that if she provided more information, the therapist might find her unappealing and want to stop working with her.
It was this discussion that led to the discovery that minimizing self-disclosure was a key avoidance behavior that Ann used to protect herself from harm in social situations. Thus, the interactions between the patient and therapist provided important assessment information that contributed to the case formulation and to the treatment. When Ann shared more personal details, the therapist took care to spontaneously, warmly, and immediately let Ann know that the therapist felt closer to Ann and experienced her as more interesting and appealing in that moment.
Moreover, the monitoring element of the treatment allows the therapist to quickly identify problems in the treatment process and difficulties in the quality of the relationship so they can be addressed early.
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It is available free of charge over the internet. The HAq-II is a item self-report scale; it can measure the alliance from either the patient or the therapist point of view. The approach described here is simply one approach to cognitivebehavioral case conceptualization, and it borrows heavily from many of the other cognitive-behavioral approaches to formulation described here, especially the writings of Ira Turkat [ 32 ]. Functional analysis is the most important alternate approach to cognitive-behavioral case formulation in that it is the oldest, most developed and most evidence-based see below.
As this definition indicates, the model is based on conditioning theories, and therefore formulation emphasizes identifying the antecedents and consequences of target behaviors as a route in to identifying the external e. Koerner [ 39 ] provides a model for conceptualizing and treating problem behaviors in borderline personality disorder based on dialectical behavior therapy DBT. DBT relies on identification of functional relationships e. DBT interventions are founded on and flow out of idiographic functional analyses that the therapist carries out and teaches the patient to implement.
Other cognitive-behavioral approaches include the problem-solving approach to case formulation and intervention developed by Nezu, Nezu, and Lombardo [ 40 ] and the approaches to case formulation and intervention described by Tarrier and colleagues [ 41 ]. In addition, of course, as was illustrated here in the case of Ann, the disorder-focused literature provides cognitive-behavioral conceptualizations of disorders that can be used as templates for formulating and designing treatment for individual cases.
Empirical Support for Case Formulation-Driven CBT Here we briefly review empirical support for the case formulation approach to cognitive behavior therapy; a more comprehensive review is provided in [ 42 ]. We also examine evidence that progress monitoring improves outcome of cognitive behavior therapy. There is more empirical support for the treatment utility of case formulation based on functional analysis than for other methods of case formulation.
The evidence is particularly strong for self-injurious behavior.
Developing and Using a Case Formulation to Guide Cognitive-Behavior Therapy
However, when interventions that did not address the function of the SIB were delivered, almost no change occurred. Several other studies using applied behavioral analysis have examined the degree to which behavioral treatments for severe problem behaviors meet the APA standard as empirically-supported, including studies of Functional Communication Training [ 43 ] and Noncontingent Reinforcement [ 44 ] and for specific disorders such as pica [ 45 ] for individuals with intellectual and developmental disorders. Several randomized controlled trials have randomly assigned patients to treatment guided by one type or another of a case formulation and treatment that is not individualized based on a formulation or an individualized assessment procedure.
These are studies of behavioral marital therapy [ 46 ], social skills training of behavioral disordered children [ 47 ], individuals with substance abuse problems [ 48 ], individuals with phobic disorders [ 49 ], internet-based CBT for depression Johansson and colleagues [ 50 ], modular CBT for youths with anxiety, mood, and conduct problems [ 51 , 52 ], and behavioral treatment of alcohol abuse [ 53 ]. Our reading is that these studies show that treatment guided by a case formulation based on individualized assessment findings produces outcomes that are superior to or not different from standardized treatment.
No study found standardized treatment to be superior to individualized treatment. The studies reviewed here converge to provide some support for the assertion that reliance on a cognitive-behavioral case formulation can improve treatment outcome. However, relatively few studies have examined the contribution to outcome of the use of a case formulation to guide treatment.
We have some hope this situation will change. Intended both for the starting or trainee therapist and the experienced clinician, Individual Case Formulation provides a practical guide for those looking to improve their case formulation skills. The Best Books of Check out the top books of the year on our page Best Books of Product details Format Hardback pages Dimensions x x Looking for beautiful books?
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Individual Case Formulation Richard S. Culture and Children's Intelligence James Georgas. Succeeding with Difficult Clients Wessler. Table of contents 1. Formulation-the Main Issues 2. Conceptual Frameworks for Case Formulation 3. Diagnostic and Transdiagnostic Approaches 4.
Theory and Evidence in Individual Case Formulation 5.