Scribd
Upload

CBT Case Formulation Overview

426 views18 pages
This document discusses case formulation in cognitive-behavioral therapy. It defines case formulation as a set of hypotheses about the causes, triggers, and maintaining factors of a person's…

Uploaded by

Sanda Alina
  • Case Formulation Overview
  • Nezu's Case Formulation
  • Differing Views
  • General Guidelines
  • Ultimate vs. Instrumental Goals
  • Problem-Solving Model
  • Problem Orientation
  • Defining Problems
  • Decision Making
  • Generating Alternatives
  • Evaluating Solution Outcomes
  • Format of Case Formulation
  • Person’s Case Formulation
  • Problem List
  • Working Hypothesis
  • Strengths and Assets
  • Treatment Plan
  • Recursive Model of Case Formulation
  • Distinctive Activities of CBT
  • Homework
  • Direction of Session Activity
  • Teaching Skills to Patients
  • Information Sharing

12/2/2009

Case Formulation in Cognitive-Behavioral Therapy

What is Case Formulation?


A set of hypotheses regarding what variables serve as causes, triggers, or maintaining factors for a persons problems Description of symptoms and means of organizing an understanding of how those symptoms can be alleviated An idiographic theory based on a nomothetic theory A patient story
Persons & Davidson (1999); Eels (1997)

Rationale

12/2/2009

General Guidelines
Keep your formulation as simple as possible Keep an open mind, both before, during, and after your formulation process
Allow your conceptualization to change based on new data or disconfirmed hypotheses

Dont confuse case formulation with treatment planning or diagnosis

Differing Views
A number of CBT clinicians have extensively written about case formulation and/or conceptualization We will review models by Arthur M. Nezu and Jacqueline B. Persons

Nezus Case Formulation


Goals are to: 1. Obtain a detailed understanding of the patients presenting problems 2. Identify those variables that are functionally related to such difficulties 3. Delineate treatment targets, goals, and objectives
Nezu et al. (2004)

12/2/2009

Ultimate vs. Instrumental


Ultimate outcome goals are more general and reflect why therapy is undertaken
E.g., relieving depression or decreasing anxiety

Instrumental outcome goals are changes that serve as instruments to achieve other goals
E.g., increasing self-esteem or improving coping skills (both of which might in turn relieve depression)

Ultimate vs. Instrumental


Instrumental outcomes are the therapists hypotheses about variables that are thought to be related to ultimate outcomes Instrumental are independent variables (what the therapist will change), ultimate are dependent variables (which change as a result of instrumental outcomes)

Problem-Solving Model
The PSM of case formulation involves 1. 2. 2 3. 4. 5. Problem orientation Defining problems Generating alternatives Decision making Evaluating solution outcomes

12/2/2009

Problem Orientation
Behavior an be multiply caused Different paths can end in the same symptoms Different methods can end in symptom reduction Variable can contribute to psychopathology in either proximal or distal ways

Problem Orientation
Behavior occurs within various systems Instrumental and ultimate outcome variables relate to each other in multiple ways We must assess how these variables interact to gain a picture of a persons unique network This allows for targeting of multiple variables simultaneously, increasing likelihood of change

Defining Problems
In general, this step involves Gathering information Separating facts from assumptions IDing factors that contribute to problem

12/2/2009

Defining Problems
First step is identifying ultimate outcomes
Assess patients functioning Delineate goals from patient (Im feeling sad and want to get better) and/or therapist (treat major depression)

Next you identify instrumental outcomes


Attempt to review a range of empirically supported outcome variables for a problem Dont rely on just one treatment model

Defining Problems
To ID instrumental outcomes, you can use theory-driven strategy (e.g. causes of anger) or diagnosis-driven strategy (e.g., GAD) Literature linking instrumental and ultimate outcomes guide search for meaningful targets Determine the idiographic applicability to individual patients

Defining Problems
To conduct a multidimensional assessment framework, the clinician must consider Client-related variables Cli l d i bl Environment-related variables Temporal dimensions Functional dimensions

12/2/2009

Defining Problems
Client-related variables are all factors related to the client, including
Behavioral deficits or excesses Problematic affect / emotions / mood states Cognitive deficiences and distortions Biological variables Socio / ethnic / cultural variables

Defining Problems
Environment-related variables can be either
Physical (e.g., housing, living conditions) Social (relationships with people)

Temporal factors involve both current and past functioning and symptoms, as well as potential distal and proximal causal factors

Defining Problems
Functional dimensions refer to the function of each of the previous variables with respect to the ultimate outcome(s) Stimulus (intrapersonal or environmental antecedents) Organismic variable (client-related variables) Response (what client does in response to stimulus) Consequence (effects engendered by the response)
Goldfried & Spafkin (1974)

12/2/2009

Defining Problems
SORC labeling allows one to identify potential target problems and suggests interventions at different levels

S
Work stress

O
Coping ability

Depressive affect Decreased positive interactions

Possible levels of intervention

Generating Alternatives
The goal here is to generate a large number of possible target problems to increase chance that the most effective one will be identified Use brainstorming method of idea production
Quantity principle Deferment of judgment principle Strategies-tactics principle

Decision Making
The clinician now selects specific instrumental goals for a client from the list made during Generating Alternatives Make decisions about goals based on utility
The likelihood that an alternative will achieve a particular goal The value of that alternative

12/2/2009

Decision Making
Estimates of likelihood tell you the probability
That an alternative will facilitate goal attainment That the person will be able to do so optimally

Find this by asking the probability that


This alternative will help this client with a goal The target problem is amenable to treatment The therapist is able to treat this problem The treatment is available

Decision Making
The value of an idea is estimated by assessing 1 - Personal consequences
Time / effort / resources needed to reach the instrumental outcome Emotional cost / gain involved in reaching it Consistency of this outcome with ones ethics Physical or life-threatening effects involved in changing the target Effects changing this problem will have on other problems

Decision Making
2 - Social consequences, the impact on
Significant others Family members Friends Community (if relevant)

3 - Short-term effects on other problem areas 4 - Long-term effects on future functioning

12/2/2009

Decision Making
In essence you want to choose instrumental outcomes that have a high chance of Maximizing positive effects i i i ii ff and Minimizing negative effects

Evaluating Solution Outcomes


During this step, clinicians do the following: Implement the solution response Monitor the outcome of this solution Evaluate the match between predicted and actual consequences

Evaluating Solution Outcomes


Development of a Clinical Pathogenesis Map allows the clinician to chart out the SORC functional relationships and design a treatment plan Consists of distal, antecedent, organismic, and response variables, as well as consequences

12/2/2009

Evaluating Solution Outcomes


Distal variables are developmental or historical factors that cause vulnerabilities
Trauma, early learning experiences, stressful life events, etc.

Antecedent variables are any of the client- or environmental-related variables that serve as triggers or stimuli for instrumental outcomes or symptoms
Social isolation, being rejected or teased

Evaluating Solution Outcomes


Organismic variables are client-related variables that represent response Mediators (explain why a response occurs in the presence of certain antecedents)
E.g., poor social skills, cognitive distortions, fear

Moderators (influence the strength/direction of relationship between antecedent and response)


E.g, level of problem solving ability

Evaluating Solution Outcomes


Response variables refers to
Client-related instrumental outcomes closely related to ultimate goals (e.g., suicidal ideation) Set of symptoms that constitute the ultimate goal (e.g., depression, pain)

Consequential variables are all client- and environment-related variables that occur in reaction to a response

10

12/2/2009

Evaluating Solution Outcomes


Effectiveness of the CPM is determined via: Social validation
Sharing CPM with client and getting feedback

Hypothesis testing
See if predictions based on CPM are accurate

Persons Case Formulation


Happens at three levels: Case explains relationships among patients problems, helps select treatment targets
Try to develop after 3-4 sessions 34

Problem provides a conceptualization of a clinical syndrome Situation provides a mini-formulation of reactions to particular situations
Persons & Davidson (1999)

Format of Case Formulation


1. 2. 3. 4. 5. Five components to CBT case formulation Problem list Diagnosis Working hypothesis Strengths and assets Treatment plan

11

12/2/2009

Problem List
An exhaustive list of all client difficulties stated in concrete terms, across domains of
Psychological symptoms Interpersonal difficulties Occupational Medical Financial Housing Legal Leisure

Problem List
Useful to search for causal relationships to develop a Working Hypothesis Ensures important problems are not overlooked Decrease feelings of being overwhelmed Keep therapy on track and focused

Diagnosis
Not absolutely critical, but it can lead to initial formulation hypotheses based on established theories
E.g., if criteria for panic disorder are met, g consider Barlows theories as a template (nomothetic) for the client (idiographic) formulation

Can also pint to empirical interventions for potential use in therapy

12

12/2/2009

Working Hypothesis
The heart of case formulation; the adaptation of a nomothetic theory to the individual client
E.g., tailoring Barkleys theories of ADHD to a particular childs situation

Also describes relationships among items on the Problem List Includes schemata (organismic), precipitants (antecedents), origins (distal factors), and summary (CPM)

Strengths and Assets


Protective factors or factors that may make treatment more likely successful A i in developing Working Hypothesis, Assists i d l i ki h i using strengths can enhance Treatment Plan, and setting realistic treatment goals

Treatment Plan
Not part of case formulation, but stems from and is based on it, particularly the Problem List and Working Hypothesis Comprised of:
Goals Modality Frequency Interventions Adjunct Therapies Obstacles

13

12/2/2009

Treatment Plan
Goals can be seen as ways to solve items on the Problem List
Try to develop goals that both client and therapist can agree on

Include information on how progress will be measured for each goal


Self-report measures, idiographic measures, count of behaviors

Treatment Plan
Based on other parts of formulation, therapist can make predictions about what obstacles may impede therapy May include items on Problem List, or more distal variables

Why have a Case Formulation?


Constructing a Problem List can clarify treatment Goals Helps the therapist maintain clear focus while working on multiple problems Helps the client play an active and collaborative role in treatment Helps therapist understand and manage negative reactions to the client

14

12/2/2009

Recursive Model of Case Formulation

Treatment Plan

Assessment (data collection)

Case Formulation (hypothesis)

Evaluate Your Formulation

15

12/2/2009

Distinctive Activities of CBT

Blagys & Hilsenroth (2002)

What makes CBT CBT?


Six distinctive activities separate CBT from psychodynamic or interpersonal therapy
1. 2. 2 3. 4. 5. 6. Homework Direction of session activity Teaching of skills Emphasis on future experiences Information sharing Cognitive focus

Homework
Provides an opportunity for client to practice and generalize skills learned in therapy Equips a client with a way of coping outside of therapy, thereby maintaining progress Master CBT therapists place more emphasis on between-session activities than novices

16

12/2/2009

Direction of Session Activity


CBT therapists
Set an agenda at the start of each session Use preplanned techniques at specific times Decide therapy content prior to session Actively direct the patient during session

A directive, but collaborative style of therapy

Teaching Skills to Patients


Skills are taught so that a client will be able to cope more effectively, both now and in the future CBT is a highly psychoeducational approach, focusing on giving client the means to be their own therapist in the future

Emphasis on Future Experiences


CBT focuses on the impact a persons thoughts / behaviors / emotions have on their current and future functioning Emphasis is on learning new skills to improve quality of life in the future, not on how past experiences impact current life

17

12/2/2009

Information Sharing
CBT therapists discuss treatment rationales and techniques with clients, as well as providing educational materials Helps to orient client to therapy, increase hope for change, and increase problem solving ability outside of therapy

Cognitive Focus
CBT focuses on illogical or irrational cognitions, rather than inner impulses, conflicts, wishes, etc. By challenging and evaluating these cognitions, client gains control over what was previously seen as immutable

18

Common questions

Powered by AI

The problem-solving model within CBT aids case formulation by providing a structured approach to identify and address the factors contributing to a client's issues. It involves five stages: problem orientation, defining problems, generating alternatives, decision making, and evaluating solution outcomes. This model ensures a thorough assessment of the client’s problems, identification of potential solutions, and systematic evaluation of their efficacy, ultimately enabling a more effective and individualized treatment approach .

In cognitive-behavioral therapy (CBT), ultimate outcome goals are more general objectives that reflect the overarching reasons for engaging in therapy, such as relieving depression or decreasing anxiety. In contrast, instrumental outcome goals are specific changes that act as tools to achieve ultimate goals, for instance, increasing self-esteem or improving coping skills that might subsequently relieve depression. This distinction is crucial because it helps identify the factors that can be directly changed (instrumental) to indirectly achieve broader therapeutic aims (ultimate).

A case formulation in CBT comprises five critical elements: a problem list, diagnosis, working hypothesis, strengths and assets, and a treatment plan. These elements help structure therapy by clearly outlining the client’s difficulties (problem list), guiding initial treatment hypotheses (working hypothesis), recognizing potential therapeutic interventions (diagnosis), leveraging client’s positive attributes (strengths and assets), and specifying therapeutic activities and goals (treatment plan). Overall, they ensure that therapy is systematic, comprehensive, and tailored to the individual client’s needs, facilitating effective treatment .

CBT therapists promote skill development by teaching clients skills that are essential for effectively coping with current and future challenges. Techniques include psychoeducation about skill applications, providing homework to practice skills beyond therapy sessions, and fostering the development of problem-solving and coping mechanisms. This skill development is vital as it empowers clients to manage their difficulties independently, ensuring long-term efficacy beyond therapy sessions .

Information sharing enhances CBT's effectiveness by increasing the client’s understanding of the treatment rationale and techniques, thus fostering greater engagement and collaboration. Its primary objectives are to orient the client to the therapy process, boost their hope for change, and improve problem-solving abilities outside of sessions. By demystifying treatment methods, clients are better equipped to apply these strategies in their daily lives, thereby enhancing therapeutic outcomes .

The working hypothesis in CBT integrates theoretical models with individual client experiences by adapting general nomothetic theories to fit the specific context of the client. It describes the relationships among the client's issues as outlined in the Problem List, employing theoretical concepts like schemata, antecedent factors, and CPM summaries to create an individualized understanding of the client's condition. This integration ensures that the therapy is theoretically grounded yet personalized to the client’s unique circumstances .

Evaluating solution outcomes in CBT is significant as it determines the effectiveness of therapeutic interventions and ensures that therapy is achieving its intended goals. Methods used include developing a Clinical Pathogenesis Map to visually map out functional relationships, conducting hypothesis testing to match predicted and actual results, and using social validation to gather client feedback on the perceived effectiveness. This ongoing evaluation helps refine the treatment plan to better suit the client's evolving needs .

In CBT, client-related variables include personal factors such as behavioral deficits, cognitive distortions, and biological variables, while environment-related variables encompass physical surroundings and social relationships. Both sets of variables are considered in the problem-definition stage to provide a comprehensive understanding of the factors contributing to the client’s issues. This allows for the identification of instrumental outcomes that are relevant and tailored to the individual, thereby facilitating more effective therapeutic interventions .

CBT therapists maintain the collaborative nature of therapy sessions by setting an agenda at the beginning of each session, planning session content in advance, and actively directing the session content. By clearly outlining the goals and activities, therapists can balance providing direction with engaging the client as an active participant, fostering responsibility for their own therapeutic process and reinforcing the client's role in deciding and implementing therapeutic interventions .

Focusing on multidimensional assessments is important for CBT therapists as it provides a comprehensive view of the factors influencing a client’s problems. They consider client-related variables like cognitive and emotional difficulties, environment-related variables such as social and physical conditions, and temporal and functional dimensions that include both proximal and distal causal factors. This holistic evaluation allows for more precise identification of therapeutic targets and better tailoring of interventions to the client's multifaceted situation, ultimately enhancing therapy effectiveness .

12/2/2009 1 Case Formulation in Cognitive-Behavioral Therapy What is Case Formulation? • A set of hypotheses regarding what v
12/2/2009 2 General Guidelines • Keep your formulation as simple as possible • Keep an open mind, both before, during, and a
12/2/2009 3 Ultimate vs. Instrumental • Ultimate outcome goals are more general and reflect why therapy is undertaken – E.g.
12/2/2009 4 Problem Orientation • Behavior an be multiply caused • Different paths can end in the same symptoms • Different m
12/2/2009 5 Defining Problems • First step is identifying ultimate outcomes – Assess patient’s functioning – Delineate goals
12/2/2009 6 Defining Problems • Client-related variables are all factors related to the client, including – Behavioral defic
12/2/2009 7 Defining Problems • SORC labeling allows one to identify potential target problems and suggests interventions at
12/2/2009 8 Decision Making • Estimates of likelihood tell you the probability – That an alternative will facilitate goal at
12/2/2009 9 Decision Making • In essence you want to choose instrumental outcomes that have a high chance of i i i i i ff •
12/2/2009 10 Evaluating Solution Outcomes • Distal variables are developmental or historical factors that cause vulnerabilit

You might also like