Case Conceptualization Flashcards
In this deck…
- Psychotherapy Case Formulation (ch. 1)
> Defining formulation: benefits, goals, history and influences - Psychotherapy Case Formulation (ch. 4)
> Formulation in the context of psychotherapy integration - lecture
Case conceptualization in the course
(lecture)
- learn to recognize and ask for precipitating, inducing and maintaining factors
- develop working hypothesis (link between narrative and treatment)
- not expected to create a full case conceptualization
- use of a general, integrative framework
> integrative because many different models/theories can be applied in this framework
Defining formulation: benefits, goals, history and influences (ch.1)
- Introduction
- What is a psychotherapy case formulation?
- Why formulate?
- Historical and contemporary influences on case formulation
- Tensions inherent in case formulation
How do you know what to do in psychotherapy? (as a clinician)
- there is never one correct, obvious answer
- we must always have a plan
> case formulation starts here - to make a plan, we need:
> theory
> evidence
> expert practice
What is a psychotherapy Case Formulation?
Process for developing a hypothesis about, and a plan to address,
> the causes, precipitants, and maintaining influences
> of a person’s psychological, interpersonal, and behavioral problems
> in the context of that individual’s culture and environment
- study of why the client has certain symptoms, where/when they started, why they are still present instead of resolving themselves
Case formulation: plan vs tool
- Plan
- it explains WHY the individual has problems
- it includes a treatment plan
> from conceptual hypothesis → to proposal for treatment
> includes goals and client’s preferences and readiness to change - Tool for planning
- formulation of case must be testable
- monitoring and revision are often necessary
> this is because there are always new factors to take into consideration, or the client is not responding well
What must be taken into consideration for a Case Formulation?
1- Within-person factors
> e.g. person’s learning history, style of interpreting information, coping style, self-concept, core beliefs, basic assumptions about the world
2- Behavior
> under- vs over-expressed
> normative vs nonnormative
> adaptive vs maladaptive
3- Interactions with others
> 3.1 what basic or automatic beliefs the person has about the intentions and wishes of others
> 3.2 what the responses to those expectations are
4- Environment
> cultural influences and social roles
> whether they conflict with each other
> potential influence of the physical environment on functioning (e.g. safety of neighborhood, socioeconomic factors, education, work opportunities)
What are the four categories of questions?
(+ examples)
! Read the example of Rochelle
-
Symptoms and Problems
> what are her main problems, and how are they interrelated? Is she still grieving the loss of her son? Are there problems that if successfully treated would also solve others? What triggers her symptoms? Why did she scratch her husband’s car instead of seeking better solutions? -
Diagnosis
> What is Rochelle’s diagnosis? Does she
have major depression or another mood disorder? Does she have an anxiety disorder or a personality disorder? Does she meet criteria for more than one diagnosis? If so, which diagnosis should be the primary focus in therapy? What are her psychosocial stressors? What is her overall level of functioning? -
Explanation (of behavior)
> What is her self-concept? How does she view others? What are her wishes and fears? What are her primary coping strategies? How well integrated is her personality? How strong is her sense of identity? What automatic thoughts does she have? What factors influence her mood regulation? What are her goals and why is she not able to achieve them? How is her environment, both interpersonal and physical, affecting her behavior? How are her current and past family dynamics influencing her current
functioning? Is diabetes contributing to her mood? What role are finances playing? What are her strengths? What is her risk for suicide? How are cultural factors and social role expectations affecting her behavior? -
Treatment planning
> Are there evidence-based treatments or treatment processes that can help Rochelle? Does she need behavioral therapy? Cognitive–behavioral? Psychodynamic? Supportive? Some other modality? How long does she need to be in treatment? What short-term and long-term goals would be most helpful? Which problem or problems should we start with? Will she be able to form a therapeutic alliance with me? How motivated is she? Above all, will she or can she come for treatment?
Why is Case Formulation important?
- diagnoses are descriptive, but lack etiology of problems; therefore, something more complete is necessary
- it provides a framework to organizing answers to questions like the ones above
(lecture)
Why do we need case conceptualization?
- taxonomy is not enough
- we need to take personal context, development and goals into account
- personal narratives and recovery are not enough
- general theories and general scientific knowledge have to be applied to specific situation
- a good working-theory and rationale is supportive for the “common factors” that are crucial in promoting good treatment outcome
> if you have a good reason to choose a theory/therapy, than it’s supportive to treatment outcome - it is a great tool for learning clinical thinking and for supervision
> easier supervision if there is evidence and theories being developed by clinicians for each specific client
Process vs Content aspects of formulation
- Process aspect→ therapist’s activities aimed at gaining information from the client
- Content aspect→ problems identified, diagnosis, explanation and treatment
Case vs Event vs Prototype formulations
Event formulation:
- explains particular episode/event in therapy, not entire treatment
> e.g. onset of tears, sudden shift in mood
- the therapist attempts to unfold events
- usually fits with case formulation (adds onto it)
Prototype formulation:
- based on theoretical conception of disorder
> e.g. conceptualizing depression as characterized by negative views of oneself, others and the world (…)
- useful for a concrete case formulation
Why should we use Case Formulation?
1) Guides treatment by:
- helping the therapist stay on track from one session to the next
- monitoring progress
- be alert when a change in direction is indicated
> it provides the therapist with an overarching perspective of the treatment
2) Increases treatment efficiency
- time-effective, evidence-based routes can be applied from the beginning because therapist has a plan
3) Tailors treatment to specific circumstances a client is facing
4) Enhances therapist empathy, which contributes to treatment outcome
Historical and Contemporary influences on C.F.
- rooted in medicine of Hippocrates and Galen
> emphasis on observation and experimentation (with physical focus) - now depends on close observation, takes a holistic perspective, and considers multiple facets of functioning (biological, psychological, and social)
What contemporary developments have influenced case formulation?
- Nature and classification of psychopathology
- Theories of psychotherapy
- Psychometric tradition
- Advent of structured case formulation models
1. Nature and Classification of Psychopathology
What is the most important focus point for case formulation?
- we need to distinguish abnormality vs normality
> this allows us to identify problem and symptoms, explanations, treatments and investigation
> e.g. normal stress vs abnormal stress response
1. Nature and Classification of Psychopathology
Categorical vs Dimensionalist view of disorders
- Categorical view
- mental disorders are syndromal and qualitatively distinct from each other and from normal states
- “medical model” view of mental disorders, with several assumptions
> diseases have predictable causes, courses and outcomes
> symptoms are expressions of underlying pathogenic structures and processes
> disease are individual, and not social or cultural phenomena
> medicine focuses on diseases, not on promoting well-being
1. Nature and Classification of Psychopathology
What are the pros and cons of the categorical view?
PROS
- easier to use in order to make a diagnosis
CONS
- some clients have problems, but do not meet the diagnostic categories
- some clients meet criteria but not enough for a diagnosis
1. Nature and Classification of Psychopathology
Categorical vs Dimensionalist view of disorders
- Dimensionalist view
- psychopathology is a on a continuoum from normal to abnormal
- the difference between the extremes is a degree, not black and white
- in terms of small set of uncorrelated personality dimensions (developed through testing large amounts of people)
- psychopathology is viewed as an interindividual frame
1. Nature and Classification of Psychopathology
What are the pros and cons of the dimensionalist view?
PROS
- easier to use this view to make descriptions (compared to categorical view)
- dimensions can be measured more easily
- they capture better subclinical phenomena
-more parsimonious way of understanding psychopathology (no need for many resources)
1. Nature and Classification of Psychopathology
Categoricalistic vs Dimensionalistic therapy
- differences
- what’s best?
Dimensionalist:
- more likely to use well-normed personality tests
- might propose set of cardinal traits as composing the core of case formulation
- might develop treatment plans that aim at modifying maladaptive traits
Categoricalists:
- more prone to stigmatize clients by concretizing social constructs
- at the same time, in the right context it might help with formulation and planning of interventions
→ they should both be integrated in practice
2. Theories of Psychothetapy
Why is the importance of the theoretical orientation of the therapist in case formulation?
- what are the 4 major models?
- the therapist’s theoretical orientation to psychotherapy provides a framework for explanation in case formulation
- the four major models:
> psychodynamic
> (cognitive) behavioral
> humanistic
> phenomenological
2. Theories of Psychothetapy
The influence on the psychotherapeutic field
- Psychoanalysis and Psychodynamic psychotherapy
- big influence on views on personality and unconscious
- influence on the role of therapy
> before, the client would come and just talk about their problems
> now, it is a collaboration to tackle the client’s interpersonal problems
The influence on the psychotherapeutic field
- Cognitive therapy
- provided lexicon for case formulation
- provided sets of standardized formulations of psychological constructs (e.g. depression)
- emphasis on cognitive patterns, schemas, faulty reasoning and core beliefs
The influence on the psychotherapeutic field
- Behavior therapy
- emphasis on symptoms
- skepticism toward mental representations
- focus on empiricism
- emphasis on the role of environmental conditions in maladaptive behavior
- (role of mindfulness)
The influence on the psychotherapeutic field
- Phenomenological and humanistic psychotherapy
- emphasis on person as a whole (and not viewed as a disorder)
- view of therapist and client as equal
- focus on here and now
- The Psychometric Tradition
- what is it?
- influence on case formulation
- it refers to validity of tests, statistical significance, base rates, …
- small influence on case formulation, because many clinicians don’t associate psychometrics to therapy
- Structured Case Formulation Models
- history
- examples
- at first, much disagreement among clinicians regarding case formulations of the same symptoms
→ formal models have been created to standardize everything - e.g. Configurational analysis, Plan formulation method, Core conflictual relationship theme
→ some are cognitive-behavioral, some behavioral, some integrative
4. Structured Case Formulation Models
what do those models have in common?
- identify problems
- infer maladaptive relationships transactions and concepts
- rely on clinical observations
- structure case formulation task in components and sequences
4. Structured Case Formulation Models
Core conflictual relationship theme (CCRT)
- aims at identifying client’s central problematic relationship pattern
- focuses on narrative:
> client’s wishes
> expected response of others
> responses of the self - narratives on relationships are common in therapy
Tensions inherent in case formulation
(permanently exhisting)
- what are the five basic tensions?
- Immediacy vs Comprehensiveness
- Complexity vs Simplicity
- Therapist bias vs Objectivity
- Observation vs Inference
- Individual vs General formulations
- Immediacy vs Comprehensiveness
- problem + solution
- the therapist has limited time to gather information, formulate a case and implement it
- it relies on one-sided information (comprehensive knowledge would be better)
→ Rule of Parsimony
- How much information is enough to formulate?
- How much more information is needed? What type?
- Complexity vs Simplicity
- humans are complex in nature
- too much complexity is not needed for formulation, but sufficient complexity is needed for treatment goals
- Complexity: extent to which multiple aspects of the client’s problems are integrated into a meaningful presentation
→ a formulation should be as simple as possible and as complex as necessary (depends on the individual case)
- Therapist bias vs Objectivity
- no therapist is free from bias
- most often it is bias regarding the therapist’s own experience
→ therapists should aknowledge own bias and strive to manage tendencies
- Observation vs Inference
- Observation: theory-free descriptive evidence gathered by careful watching and listening
- Inference: conclusion formed on the basis of observation
→ therapists need a balance of the two
- too much observation= miss patterns and mere collection of facts
- too much inference= more likely to be incorrect, and reliability would suffer
- Individual vs General formulations
- formulation is by nature individual, but much research and theories have been done on clinical problems, therefore sometimesthere are recognizable patterns over different individuals
→ therapists should strive to find balance between individual cases (idiographic approach - no missing of uniqueness) and recognizable patterns (nomothetic approach - no missing of collection of research)
Formulation in the context of psychotherapy integration (ch.4)
- Introduction
- Integrative, evidence-based, case-formulation-guided psychotherapy
- conclusion
Why is the Case Formulation “integrative”?
- it can be applied to different therapy models
- different perspectives on therapy can be brought together
1. Integration as common practice
2. Allows for multitheoretical approaches
3. No individual theoretical approach outranks others
- Integration as common practice
- the vast majority of therapists use integrative approaches in their practice
- strong commitment to psychotherapy integration
! from integrative theoretical orientation of therapists, follows an integrative case formulation (I.C.F.)
- Allows for multitheoretical approaches
- unitheoretical approaches often do not allow for efficient case formulation in cases where the client has many different problems
- I.C.F. allows to draw from different theoretical perspectives, intervention strategies and psychological knowledge
- ICF allows to implement empirically-supported treatment to cases where specific treatment course does not exist
- No individual theoretical approach outranks others
- the reasons behind good outcomes is facets that different treatments have in common
> e.g. client and therapist characteristics, change processes, treatment structures, relationship elements - categories: common support, learning and action factors
What characteristics of psychotherapy account for the therapy effectiveness?
- Emotional and confidential relationship between therapist and client
- Clear and culturally accepted roles for both therapist and client (mutual expectation of therapist helping client, and client really wanting to get better) + clear length and setting of the sessions
- Shared understanding and acceptance of a believable and convincing explanation for the client symptoms and problems
- Prescribed treatment is carried out with participation of both client and therapist (collaboration)
Integrative, evidence-based, case-formulation guided psychotherapy
- what are the steps?
(look at graph)
1. Gather information
2. Formulate
3. Treat
4. Monitor progress
- Gather information
- done via interviews, symptom measures, psychometric testing, record reviews, and interview with people close to client
- information used as input in case formulation (but continues throughout process)
(lecture)
1. Problems
- what are the current problems?
- in a broad sense
> behaviors, emotions, cognitions, experiences, consequences, interpersonal issues, symptoms, … - problems ≠ diagnosis
- gotten through interview with client and his close people
1. Gather information
what type of information is necessary?
- individual’s presenting complaint
- history of mental problems and treatment for self and family
- medical history of self and family
- developmental and social history
- education and work history
- history of any legal problems
- information about the client’s mental status
1. Gather information
Process vs Narrative information
- what is Process information?
- concerns how the individual presents himself
- how the therapist experiences the client
> e.g. Connection? Are narrated experiences stereotypical/vague? …
1. Gather information
Process vs Narrative information
- what is Narrative information?
- particularly important: description of specific life events
- thorough understanding of nature of interactions, self-concept, sequence of events, …
> chain analysis: examination of moment-to-moment sequence of events that lead to problem (e.g. suicide attempt)
> free form: following client’s stream of thoughts
- Formulate
- what are the steps of case formulation?
- Develop a comprehensive problem list
- Diagnose
- Develop and explanatory hypothesis
- Plan treatment
2. Formulate
how can we develop an explanatory hypothesis?
- most challenging part of case formulation
- Gathered information + empirical resources, theory, clinical expertise
- used to arrive to best conclusion of what are predisposing, inducing and maintaining factors
2. Formulate
what sources of information are used to create an hypothesis?
+ explanation
Theory & Evidence
→ Theory
- any empirically supported hypothesis that helps explain the problem
- can include research on cognitive and behavioral processes
→ Evidence
- other sources of information
- epidemiological studies, results from psychometric testing, narrative or autobiographical information provided by client
2. Formulate
what other categories should be taken into account for formulation?
- Precipitating stressors
> events that trigger distress - Origins
> key experiences, traumas, learning events that contribute to current presentation and client’s worldview (e.g. don’t trust others) - Resources
> client’s strengths - Obstacles
> factors that may interfere with treatment success
(lecture)
(2) Maintaining factors
“What mechanisms keep these problems in place?”
- vicious cycles
> e.g. such as in depression (sad→ not go out→ sad)
- interaction between problems
- Effects of:
1. core beliefs
> very strong underlying schema, which is hard to change
> different therapies for different core beliefs
> e.g. when you are young you learn to distrust people)
2. coping
> the way people cope with their problems is sometimes self-defeating
> e.g. avoiding social situations not to feel the anxiety
3. emotion regulation
(lecture)
(3) Inducing factors
“How did these problems start?”
- important for getting narrative correct (how it started, and how it is continuing)
- events
> e.g. getting fired, traumatic experience, …
> no direct relation from event to problems now
- personal context at the time
> e.g. is worry in normal levels? what does it mean to this person? does he always worry?
(lecture)
(4) Predisposing factors
“What made you vulnerable?”
- Temperament
- Learning history
- Skill deficit
! we have to be careful: we only have to look for relevant information, we can’t associate problem only to predisposing factors
! it is important for treatment plan and efficacy
! this part is less important if one-time problems, and not occurred before
! important for prevention (e.g. no isolation if vulnerable to psychosis)
2. Formulate
what does stage 4 (planning treatment) entails?
- explicit statements of both short-term and long-term goals
- process and ultimate goals
- steps to follow to achieve goals
3. Treat
Relationship between formulation and treatment: the three characteristics
1) plan is only a plan
- plan will inevitably change throughout treatment
- therapist should always be ready to revise/adjust treatment plan
- new and unanticipated problems will arise
- throught “Monitor Progress” process
3. Treat
Relationship between formulation and treatment
2) Case formulation skills ≠ Treatment skills
- even if you have full understanding of client, you might lack skills on how to apply understanding to treatment
- “inert knowledge”: declarative knowledge without instinctual practical knowledge
3. Treat
Relationship between formulation and treatment: the three characteristics
3) theory vs personness
- treatment always involves theory + methods + therapist’s humanity
- each therapy will be unique
(lecture)
(5) Treatment considerations
“What is needed to get better?”
- request for help
- motivation
> e.g. getting read of anxiety for work presentations
- intervention options
- obstacles
> e.g. negative core beliefs
(lecture)
What other side factors should we take into consideration?
- Strenghts
> skills
> coping
> personality - Vulnerabilities
> pitfalls
> beliefs
> habits
> emotionality - Support (what resources can you use?)
> social
> help
> activities
> medication - Stressors (what is currently weighting on you?)
> events
> social, family
> occupation
> living conditions
> finances
- Monitor Progress
- what is the purpose?
- provide objective feedback to therapist so that he knows whether to change the treatment course
- associated to positive outcomes and reduction in treatment failure
- initial state of client is important in predicting treatment outcome
- provides means of testing explanatory hypothesis
4. Monitor Progress
what aspects of client functioning improve?
1st - symptoms
2nd - social role functioning
3rd - interpersonal functioning
4. Monitor Progress
Monitoring - objective measures and extra info
- the use of objective measures maximizes the potential of progress monitoring
> therapist bias would otherwise hinder the progress monitoring as well - monitoring may reveal important information that otherwise might not be revealed
From now on, the flashcars are only from the lecture
The Intersubjective Dialogue
- attunement to the “first person” perspective
- interest in personal narratives and processes of meaning-making + expertise of clinician
- in case conceptualization: try to use the client’s language
How can you find a balance between objectivity and subjectivity in case conceptualization?
+ core questions
- cases are neither simply facts, certain and fully objective, nor just speculation, very unlikely and merely subjective
- therefore, we need working hypothesis developed in collaboration between therapist and client
Core questions:
> credible enough?
> acceptable for the client?
> useful for treatment?
What sources do we have for constructing hypotheses?
- theories and research
- client experience and narrative
- clinical experience of therapist
→ this shows variation in case conceptualizations (e.g. different clinician= different professional experiences)
(see graph)
What knowledge do we have for creating valid conceptualizations?
- Diathesis-stress model
- Evidence-based treatments
- Common factors
- Theories and proposed mechanisms
- Diathesis-Stress model
(see graph)
1- Heritable predispositions (distal - past)
> e.g. genotype, temperament
+
2. Early experiences
> e.g. nurture, trauma, deprivation
=
3. Strengths and Vulnerabilities (proximal - present)
> e.g. phenotype, schemas/cognitions, attachment style, personality, …
+
4. Support and Stress
> e.g. social, medication, psychotherapy, daily stress, trauma, life events, …
=
5. Complaints / Symptoms
- Evidence-based treatments
- the list is like, suuuuper long
- direct comparison between treatments show no big difference across treatment effectiveness
Evidence-based treatment (EBT) → Case conceptualization (CC)
- EBT will give a prototype CC
> e.g. people with social anxiety will have these kinds of maintaining factors, … - from prototype CC to intersubjective dialogue
- from intersubjective dialogue to personalized CC
- Common factors
- therapeutic alliance
- collaboration
- goal consensus
- adapting treatment to specific client characteristics
- empathy
- promoting treatment credibility
- …
! these are big predictors of treatment outcome
Common factors & CC
Common factors will help with…
- adaptation to specific client needs and characteristics
- person-specific rationale why a certain therapy fits and will work
- validation and empathy
> helps with demoralized clients (happens often)
- indications for alliance ruptures to take care of
> alliance rupture: e.g. client was hurt by therapist but does not say so
- shared ground for setting goals
- starting point for adequate collaboration
- Theories
- Behaviorism, Cognitivism, Schemata, Psychoanalysis, Mentalization, Emotion-focused, Attachment, Body oriented, System-based
- we have little evidence about how these mechanism work in real life
Example 1 & 2
(look at pictures)
