Persons. J. B. Cognitive therapy in practice: A case formulation approach. H1 & H3.

Chapter 1: The case formulation model

Psychological problems occur at two levels

The case formulation model conceptualizes psychological problems as occurring at two levels: 1) overt difficulties, ‘real life’ problems, like depressed moods or panic attacks 2) underlying psychological mechanisms,the psychological deficits that underlie and cause the overt difficulties. They can often be expressed in terms of one (or a few) irrational beliefs about the self.

Overt difficulties

At a ‘macro’ level, overt difficulties include such things as depression, relationship difficulties, obesity and fears. These are problems as they might be described in the clients own terms.

At a ‘micro’ level, problems can be described in terms of three components: 1) cognitions 2) behaviours 3) moods. All three components of problems usually reflect the irrational, maladaptive nature of the underlying mechanism.

Cognitions

A cognitive component can be found for nearly every problem clients report. Negative mood states usually involve negative automatic thoughts. Automatic thoughts are related to problematic behaviours.

Cognitions can involve thoughts, images, (day)dreams and memories.

Behaviour

Three types of behaviours are considered in the case formulation model 1) overt motor behaviours, such things as spending hours in bed, overeating and arguing with others 2) physiological responses, such things as increased heart rate, dizziness, insomnia 3) verbal behaviours, like continual request for reassurance.

Behavioural components of a client’s problems are usually best described as problematic or maladaptive.

Mood

The term ‘mood’ refers to the client’s subjective report of his emotional experience.

Relationships among the components

Synchrony: Usually a problem in one component indicates that problems in other components are also present. An underlying deficit is usually manifested in all three components at the overt level, not just one or two. If this isn’t the case, the problem is desynchronous.

Interdependence: The synchronous relationship suggest that a change in any one component is likely to produce changes in the other components. These interdependent relationships are indicated by the arrows connecting behaviour, cognitions and mood.

Underlying mechanisms

The underlying psychological mechanism is a problem or deficit that produces, or is responsible for, the individual’s overt difficulties. The therapist’s ideas about the underlying cognitions operating in any given case are best viewed as working hypotheses.

Underlying beliefs are often well-expressed in an ‘if-then’ format. Sometimes they are simpler, blanked statements.

Sometimes the client’s central problem is not efficiently described in terms of an underlying belief.

Various forms of permutations of the underlying mechanism can be operative, depending on the external situation arousing the mechanism and the associated behaviours, cognitions and moods. The client can also have more than one problem. This can make the underlying mechanism difficult to find.

Common underlying mechanisms

Cognitive theorists have described two types of irrational beliefs that underlie depressive symptoms 1) problems of autonomy, the client requires independence, accomplishment, and achievement in order to feel worthwhile. 2) problems of social dependency, the client must be liked, loved, approved of, and cared for by others in order to feel worthwhile

Relationship between overt difficulties and underlying mechanisms

The underlying difficulties cause he overt difficulties. The overt difficulties support, or maintain, the underlying difficulties. Changes at one level can produce changes at the other level.

Role of environmental factors

Environmental factors play a powerful role in causing problems. If the environment behaves in accordance to the maladaptive belief (like people leaving the individual), problems can arise. Situational and environmental factors play a role in triggering and eliciting underlying beliefs and the overt difficulties.

The underlying irrational beliefs are trait-like attributes. They are latent until activated by a particular life event.

Comparison with other models

 Biological models

Mechanism underlying psychological problems may also be biological. The presence of a possible underlying biological problem indicates that biological treatment may be an option, but doesn’t mean it is required. Psychological and biological mechanisms are not mutually exclusive and they are closely linked.

Role of diagnosis

Psychiatric diagnoses are defined largely in terms of symptom clusters, not underlying mechanisms. The assessment process described here focuses on developing a problem list and a hypothesis about het psychological mechanisms underlying the problems.

Implications of the model for the cognitive therapists

The case formulation model has several roles in clinical work: 1) it guides the therapist’s choice of intervention strategies, therapist’s understanding of the three overt, along with the hypotheses about the mechanisms underlying the problem, guide the choice of intervention strategies 2) A major part of a formulation-based treatment involves alerting the client to the nature of his central irrational belief and the way it causes behavioural, mood and cognitive problems, as well as teaching strategies for solving these problems that at the same time produce more adaptive change in the pathological beliefs. 3) it helps the therapist understand and manage difficulties that arise in therapy. Moods, cognitions and behaviours making up these problems can be understood in the same way as those making up other problems

Where does the therapist intervene?

Cognitive behaviour therapist believe that work on over difficulties produces ore change in both overt difficulties and underlying beliefs than work at the underlying level. Therapy inevitably involves both types of work.

Chapter 3: The case formulation

The case formulation is a hypothesis about the nature of the psychological difficulty(s) underlying the problems on the client’s problem list.

Role of the case formulation

The case formulation is the therapist’s compass, it guides the treatment.

The most important role of the formulation is to provide the basis for the treatment plan, which follows directly from the hypothesis about the nature of the underlying deficit producing the client’s problems.

The case formulation helps: 1) Understand the relationship among problems, the case formulation ties together all of a client’s problems. The client sometimes seeks treatment for only some of his problems. 2) Choose a treatment modality 3) Choose an intervention strategy 4) Choose an intervention point. The therapists focuses on the problem most closely related to the client’s central difficulties. 5) Predict behaviour 6) understand and manage noncompliance 7) understanding and work on relationship difficulties 8) Make decisions about ‘extra-therapy’ issues 9) Redirect an unsuccessful treatment.

Format of the case formulation

The case formulation has six parts: 1) problem list 2) the proposed underlying mechanism 3) an account of the way in which the proposed mechanism produces the problems in the problem list 4) precipitants of the current problems 5) origins of the mechanism in the client’s early life 6) predicted obstacles to treatment based on the formulation.

Hypothesized mechanism

The hypothesized underlying mechanism is the heart of the formulation. After fleshing out the problem, the therapist attempts to propose a single psychological problem or underlying mechanism that can account for all the problems in the list. Often this can be stated in terms of a central irrational belief.

Relation of mechanism to problems

The therapist attempts to specify clearly the way in which the hypothesized central problem leads to all of the problems on the problem list.

Percipitants of current problems

The attempt to tie the proposed central mechanism to precipitants of the current problems is a test of the hypothesis about the central mechanism.

Origins of the central problem

The therapist attempts an account of the possible origins of the hypothesized mechanism in the client’s history. Usually relationships with parents play a central role.

Predicted obstacles to treatment

The formulation can be used to make predictions about obstacles that might arise in the course of treatment. The ability to predict difficulties makes it more likely that the therapist can prevent or solve them.

The process of hypothesizing an underlying mechanism

Examine the problem list

A good first start to obtaining an idea about the underlying mechanism is a very close look at the problem list. A central theme often becomes apparent. Nuances can provide clues and looking at the client’s pattern of behaviour can be helpful.

Examine the automatic thoughts

Automatic thoughts are often derivatives of the central underlying belief.

Study the chief complaint

Careful attention to the chief complaint, as well as the words the client uses to frame it, can be informative.

Look for antecedents and consequences

Carefully specifying the antecedents and consequences of the problems frequently leads to a formulation.

Use a standardized measure

Just helpful.

Failure to obtain a formulation

When the therapist is unable to propose a formulation, symptom-oriented treatment can be initiated.

Testing the proposed underlying mechanism

The therapist can never be certain her hypothesis about the underlying mechanism is correct and must always be prepared to revise or change it in the face of evidence. This is a continuous process.

Five tests of the underlying mechanism

The tests of the mechanism are: 1) how well does it account for the problems in the problem lest? Review each problem on the list and attempt to ‘tell a story’ about how the proposed mechanism might lead to the problem 2) the client’s report of the events precipitating the current episode ought to fit with the formulation in an easily understandable way 3) making predictions based on the mechanism, then testing the predictions by collecting the relevant data 4) it’s useful to ask for the client’s reaction to the proposed mechanism 5) the outcome of treatment can be viewed as an indirect test of the accuracy of the formulation.

The process of testing the hypothesis about the mechanism

The process of developing a hypothesis about the underlying mechanism and testing it can begin immediately.