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Developing a Case Formulationand Using it to Guide Treatment

Jacqueline B. Persons, Ph.D.

hternational Congress of Cognitive psychotherapy

Hong Kong, rune 25, 2014

(ffi.,r. B6hsvror'.-rapy\* & sci€nc€ cGntci

Handouts are available at . . .

. www.cbtscience.com on the Training page

@* Clehavior The.apyScl6nce Center

. Case formulation-driven CBT

. Developing a case formulation forNancy

. Using the formulation to

- guide treatment

-solve problems

Things I want to remember

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Action ltems

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- guide treatment

-solve problems

Definition of formu lation

A formulation is a hypothesis about the

psychological mechanisms (e.g., schemas,

automatic thoughts, contingencies, skills

deficits) that cause and maintain a patient's

symptoms, problems, and disorders.

A Case Formulation-driven Approach toCognitive-behavior Therapy

Assessment 4 lr'Jilllil:.,J @

Formulation for M r. Catastrophizer A ='""t'"ni''

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social depressionand lsolatlon

"If I say hi she'll

lack of enjoymentguilt"I'm a loser."think I'm a nerd.':

"I'm a loser.""If I am not perfect,

I'll be reiected."

Definition of formulation

A formulation is a hypothesis about the

psychological mechanisms (e.g., schemas,

automatic thoughts, contingencies, skills

deficits) that cause and maintain a patient's

symptoms, problems, and disorders.


Assessment @ ir"J[llij:?J @




- guide treatment

-solve problems

Elements of a Case Formulation

Mechanisms

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The case formulation helps thetherapist . . .

. ldentify mechanisms and target them in

treatment to attack multiple problems

simultaneously

. Solve problems that arise in treatment


Mechanismst--:-:l--tI uflgrns

I

A problem is

. . . a symptom or disorder or difficulty that is

observable/behavioral. E.g., suicidalrumination, OCD, marital fighting and otherdifficulties, substance abuse, panic attacks.

*

A mechanism is

. . . a psychological construct (e.g.,maladaptive schemas, problematiccontingencies, perfectionism, intolerance ofuncertainty, skills deficit) that causesand/or maintains the person's problems

Domains Covered in aComprehensive Problem List

. Psychological/psychiatricdisorders andsymptoms

. Medical disorders and symptoms

. Interpersonal

. Work

. Finances

. Legal

. Leisure

. Healthcare difficulties

Additional intake measures areadded as indicated for each patient

For Nancy, I added the Yale-Brown ObsessiveCompulsive Scale (Y-BOCS)

-,t"";:"r interviewer scale adapted to a self-report

- Further information available from the author.Wayne K. Goodman, M.D., Dept of PsychiatryUniv of Florida. [email protected]

Developing a ComprehensiveProblem List

Intake Measures Used at the{tr=All Cognitive Behavior Therapy\* & Science Cenior

. Adult Questionnaire

. Diagnostic Screen

. Depression Anxiety Stress Scales (DASS)

. Functioning and Satisfaction Inventory (FSl)

. Obsessive Beliefs Questionnaire

. Two scales assessing social supportGo to M.cbtsience.com, click on Treatment, then on lhtake Forms

In-session assessments I conducted toobtain a comprehensive Problem List

for Nancy

. Diagnostic screens for insomnia, OCD andother anxiety disorders, and mood disorders

. Yale Brown Obsessive-Compulsive Scale (Y-

BOCS) Symptom Checklist

s

Problem List for Nancy. Insomnia treated with seroquel. OCD; YBOCS = 24, plus lots ofavoidance. Depressive symptoms; DASS-D = 10 (mild). Stress symptoms; DASS-S = 30 (severe). Family problems; over-responsible for elderly father,

resentful at sibs for their lack of involvement. Difficulties in volunteer work; over-preparation for

adult ed classes she taught; over-responsible forrefugees she aided

. Concerns about spirituality; what is the best wav?

. Skin picking

Developing MechanismHypotheses

Strategies I used to developmechanism hypotheses for Nancy

Start with an evidence-based disorderformulation (the cognitive model ofOCD); identify the idiographic details, andextend it to account for other problemsand disorders

Use assessment scales (e.g., Obsessive BeliefsQuestionnaire; OBQ-a )

Use the downward arrow technique


Mechanisms

tr.';l

€

Cognitive Model of OCD

BeliefsOver importance of

thoughtsControl of thoughts

Overestlmation of dangerDesire for certainty

R€sponsibilityPerfectlonlsm

Consequences of anxietyFear of posltive expeil€nces

Cor€ EeliefsSelf

Others

Cognitive Model of Nancy's OCD

l- -r"* II Intrusion I

I Thought, image, II impulse I

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BelicfsOver importance of

thoughtscontrcl of thoughtsOverestimation ot

dangerDetire for certainty

ResponsibilityPerfedionism

Consequences of anxietyFear Of posltive experiences

Core BeliefsSelf

Other


Start with an evidence-based disorderformulation (the cognitive model of OCD);identify the idiographic details, and extendit to account for other problems anddisorders

Use assessment scales (e.g,, ObsessiveBeliefs Questionna ire; OBQ-44)

Use the downward arrow technioue

Nancy responded "agree very much"to these OBQ items

. Responsibility

- When I see any opportunity to do so, I must act to prevent bad thingsfrom happening.

- lf I don't act when I foresee danSet then I am to blame for anvconsequences.

- For me, not prcventing harm is as bad as causing harm.

- | should make sure othe6 are protected fbm any netativeconsequences of my decisions or actions.

. Desire for certaintv

- lt is essential for me to consider all possible outcomes of a situation.. Perfectionism

- | must wo.k to mv full Dotential at all tames.

- Even minor mistakes mean a job is not complete.


Start with an evidence-based disorderformulation (the cognitive model of OCD);identify the idiographic details, and extendit to account for other problems anddisorders

Use assessment scales (e.g., Obsessive BeliefsQuestion naire; OBQ-44)

Use the downward arrow technique

Obsessive Beliefs Questionnaire (OBe)

. 87-item self-report scale; 44-item shortened version

. Assesses beliefs common to individuals with OCDand related oroblems

. Six subscales: Overestimation of threat, tolerance ofuncertainty, responsibility, perfectionism, importanceof thoughts, control of thoughts

. OBQ-44 and excel scoring document are available atwww.cbtscience.com in the Training section.

Nancy's OBQ Score at theBeginning of Treatment

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Downward arrow method

After eliciting an automatic thought abouta situation that appears to be common andhighly-charged for the patient, askrepeatedly, 'And if that were true, whywould that be upsetting to you?"

Burns, Feeling Good, 1999

Thought RecordDote Situotion Behovior(s) Emotions Thoughts Coping

Responses

Difficultyfollingosleep

lwill never get tosreep.

!There's somethingwrong with mymind thol keepsme from sleeping.

!l'll aa araztr

!l'llkillmyself.sMy fomily willsufferond it willbe myfoult.

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- guide treatment

-solve problems

Interventions ta rgeted themechanisms underpinning all ofthe problems, and included . . .

. Psychoeducation about OCD

. Behavioral experiments

. Pros and cons of striving to eliminate alluncertainty vs increase ability to tolerateit

. Many others. . .

A behavioral experiment to test Nancy'sbeliefs about overestimation of threat,

overresponsibility,and need for certainty

It

Treatment Targets Flowing From the Cognitive Model of OCD

BeliefsOver importance of

thoughtsControl of thoughts

Overestimation of dangerDesire for certainty

ResponsibilityPerfectionism

Consequences of anxietyFear of positive experiences

Co.e Beliefs5eI

Others

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. Using the formulation to- guide treatment

-solve problems

Change in Nancy's OBQ Score

6liliidy tl€vacd


Assessment @ ffJ[l]i::?J ry

Changes in seroquel dosage overthe course of treatment

. At the beginning of treatment:

2 pills nightly. At the end of treatment:

%tolz pill nightly

THAN K YOU !

Jackie Personscbtscience.com

Nancy's YBOCS scores at every session

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cognitive Behavior Therapy and Science center5435CollegeAvenue I Oakland, CA94618 | Tel 51O.gg2.4O4O I www.cbtscience.com

Readings on Case Formulation-guided Cognitive Behavior Therapy

Bennett-Levy, J, Butler, G., Fennell, M., Hackmann, A., Mueller, M., & Westbrook, D. (Eds.).(2004). Oxford guide to behavioural experiments in cognitive thterapy. Oxford: OxfbrdUniversity Press.

Eells, T' D. (Ed.). (2007). Handbook of psychotherapy case formulation (2nd ed.). NewYork: Guilford.

Gawande, A. (2007). The bell curye. ln Better. (pp.2O1-230). New york: MetropolitanBooks.

Haynes, S. N., & O'Brien, W. H. (2000). Principles and practice of behavioral assess ment.New York: Kluwer Academic/plenum publishers

Kazdin, A. E. (1993). Evaluation in clinical practice: Clinically sensitive and systematicmethods of treatment delivery. Behavior Therapy, 24, 11-45.

Kazdin, A. E. (2001). Behavior modification in applied seffings (Oth ed1. Belmont:Wadsworth/Thomson Learning.

Kuyken, W., Padesky, C.A., & Dudley, R. (2009). Cottaborative case conceptuatization.New York: Guilford.

Lambert, M. J., Harmon, c., slade, K., whippre, J. L., & Hawkins, E. J. (2005). providingfeedback to psychotherapists on their patients'progress: Clinical results and practiclsuggestions. Journal of Clinical psychology, 61, 165-174.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. NewYork: Guilford.

Persons, J. B. (2005). Empiricism, mechanism, and the practice of cognitive-behaviortherapy. Behavior Therapy, 36, 107-118.

Persons, J. 8., Beckner, v. L., & Tompkins, M. A. (2013). Testing case formulationhypotheses in psychotherapy: Two case examples. Cognitive and Behavioral practice,20,399-409.

Persons, J. 8., & Mikami, A. Y. (2002). Strategies for handling treatment failure successfully.P sy c h oth e ra py : T h e o ry/Re se a rc h /p ra cti ce/T ra i n i n g, 39, is g- t s t .

Persons, J. B., Tompkins, M. A., & Davidson, J. (2000). Cognitive-behavior therapy fordepression: lndividualized case formulation and treatment planning tDVDl.Washington, DC: American Psychological Association.

Tarrier, N. (Ed.). (2006). Case formulation in cognitive behaviour therapy. New york:Routledge.

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