Case Formulation in Cognitive Behaviour Therapy

The Treatment of Challenging and Complex Cases

Nicholas Tarrier, Judith Johnson, Nicholas Tarrier, Judith Johnson

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317438847
• Edition: 2
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Since the successful first edition of Case Formulation in Cognitive Behaviour Therapy, there has been a proliferation of psychological research supporting the effectiveness of CBT for a range of disorders. Case formulation is the starting point for CBT treatment, and Case Formulation in Cognitive Behaviour Therapy is unique in both its focus upon formulation, and the scope and range of ideas and disorders it covers. With a range of expert contributions, this substantially updated second edition of the book includes chapters addressing; the evidence base and rationale for using a formulation-driven approach in CBT; disorder-specific formulation models; the formulation process amongst populations with varying needs; formulation in supervision and with staff groups. New to the book are chapters that discuss:

Formulation amongst populations with physical health difficulties

Formulation approaches to suicidal behaviour

Formulation with staff groups

Case Formulation in Cognitive Behaviour Therapy will be an indispensable guide for experienced therapists and clinical psychologists and counsellors seeking to continue their professional development and aiming to update their knowledge with the latest developments in CBT formulation.

Chapter 1

Introduction

Nicholas Tarrier and Judith Johnson

In introducing this second volume on case formulation we thought it worthwhile to revisit some of the stages in the development of case formulation and review and update some of the issues that have been raised. As with all aspects of clinical practice, the process of case formulation – working towards a psychological explanation of a client’s problem – is not static. There remain numerous challenges and no doubt further challenges will arise in the future. To stop and reflect on these issues and the challenges they impose is helpful both to the individual clinician and to the clinical researcher. This is especially true with increasing changes in clinical services brought about by prevailing economic conditions and the accelerating development of new technologies. These factors potentially change the environments within which cognitive behaviour therapy (CBT) is delivered and hence in which case formulation is practiced.

The Boulder model of training in clinical psychology enshrined the concept of the scientific practitioner in both the training of clinical psychologists and in the practice of psychological treatment. The historical importance of this cannot be overestimated. This represented a new paradigm in psychological practice in general and in psychological treatment in particular. The scientific practitioner established the idea that psychological knowledge can be applied to clinical problems and that this should be done in a manner in accordance with scientific methodology and convention. This has many implications, but two are important here. First, psychological treatments are evaluated and adopted based upon the results of empirical evaluation. This has now been subsumed into the wider paradigm of evidence-based practice or evidence-based health care (see, for example, Sackett, 1998). The second implication is that a psychological understanding of clinical problems is adopted to underpin psychological intervention. A seminal paper published in 1965 by Kanfer and Saslow further advanced this endeavour by proposing a psychological alternative, behavioural analysis, to the then-dominant medical conceptualisation of mental health problems.

Kanfer and Saslow’s (1965) paper can really be thought of as the natural precursor to case formulation, which represented a second paradigm shift. It is interesting to look in a little more detail at what Kanfer and Saslow proposed. They dismiss psychiatric diagnosis as being limited by issues of precision, consistency, reliability and validity to ‘a crude and tentative approximation to a taxonomy of effective individual behaviours’ (1965: 529). Some may well argue that this situation has not radically altered over the past 40 years. Kanfer and Saslow also outlined the criticisms, current at the time, of the medical model in psychiatry with which the contemporary reader will no doubt be familiar. Their main point remains pertinent: given the wide range of variability in an individual’s circumstances and condition and the largely unknown aetiology of most psychiatric disorders, does a reduction to a crude taxonomic classification help or hinder treatment? They progressed to outline an alternative model of understanding clinical problems based upon learning theory in the form of a functional behavioural-analytic approach. This is encapsulated by:

It [functional analysis] implies that additional information about the circumstances of the patient’s life pattern, relationships among his behaviours, and controlling stimuli in his social milieu and his private experience is obtained continuously until it proves sufficient to effect a noticeable change in the patient’s behaviour, thus resolving ‘the problem’.

(Kanfer and Saslow, 1965: 533)

Interestingly, although their model is couched in learning-theory terms, they anticipated the cognitive revolution that was to follow by including the necessity to assess subjective experience. They suggested that the clinician should collect and organise information from a number of areas: analysis of a problem situation, classification of the problem situation, motivational analysis (reinforcers), developmental analysis (including ‘biological equipment’ and ‘socio-cultural experience’), analysis of self-control, analysis of social relationships and analysis of the social-cultural-physical environment. The formulation, and Kanfer and Saslow used this term, is ‘action oriented’ (535) in that the problem is defined in operational terms so as to specify a feasible treatment option. Although written over 40 years ago there is much within this paper, both in terms of the inadequacies of psychiatric diagnosis and alternative conceptualisation of clinical problems, that modern-day cognitive behaviour therapists and clinical psychologists would find very familiar.

One of the problems that this new individualised approach unveiled was how to know whether an individualised formulation of a particular person’s problem is correct and parsimonious: that is, is it true in a broad sense of the word and does it have functional value – is it clinically useful? That a formulation can be incorrect would also imply that there would be ways, potentially identifiable, by which a formulation could go wrong or deviate from accuracy. However, it may be difficult to discriminate a ‘right’ from a ‘wrong’ answer when the formulation pertains only to one individual. The nature and types of error that may contaminate clinical decision-making may include availability heuristic, representative heuristic, anchoring heuristic, biased search strategies, overconfidence and hindsight bias (Nezu and Nezu, 1989a). By this, Nezu and Nezu meant that a clinician may be subject to a number of sources of bias such as being overly influenced by recent clinical experience, being too quick to categorise or reach a conclusion on insufficient information and, without the flexibility to adjust or modify those conclusions, selectively attending to types or aspects of information and further searching for information based upon a confirmatory bias and being unable to react to new information in a way that increases accuracy and precision rather than confirms initial impressions. There is a tendency to look back retrospectively on a case with confirmatory zeal. Unfortunately, although perhaps not surprisingly, clinicians and therapists appear to be subject to all the information-processing distortions that they try to assess and rectify in their clients. The area of clinical judgement and decision making is clearly one that requires further research and clinicians would benefit from reflection upon it.

A consideration of alternative explanations, a wider viewpoint and a further appraisal of possible options would perhaps benefit clinical practice. A related difficulty identified by Nezu and Nezu (1989a: 29) is how and when to select the appropriate treatment techniques from the array available. This problem is also pivotal to the work of other writers on case formulation (for example, Bruch, 1998; Persons, 1989; Turkat, 1985) and in my experience it is often the issue that trainees and students find one of the most difficult. Nezu and Nezu (1989a) rightly say that because individual formulations take into account a large array of unique characteristics across a variety of person and environmental variables it is very difficult to know how to select the most effective treatment strategy. Nezu and Nezu (1989b: 57) advocate a problem-solving approach to clinical decision-making which consists of problem orientation, problem definition and formulation, generation of alternatives, decision-making and solution implementation and verification. They also make the useful distinction between treatment strategy, tactics and methods. Treatment strategies are linked to each identified problem and provide a general approach to how that problem will be resolved, such as decreasing negative cognitive biases and self-defeating thoughts in someone with a depressed mood. Each treatment strategy should have a list of specific treatment tactics which indicate how the strategy will be achieved. For example, in the strategic example given the tactics might include monitoring automatic thoughts, investigation of the cognitive processes and identification of bias, examination of supporting evidence, generation of alternative interpretations of events, behavioural experiments to test out various expectations and so on.

Nezu and Nezu (1989b) also introduce the idea of different treatment methods: they mean different ways in which tactical treatment techniques might be implemented. For example, a behavioural experiment to test out a biased interpretation of events may well be applied differently if the client is a depressed adolescent male of 14, rather than a depressed middle-aged woman with a family, or a 28-year-old man with a psychotic illness who is also depressed. The overall approach is that the formulation is a way of generating testable hypotheses about the clinical case; these hypotheses are tested through the application of treatment, and whether the formulation is functional or not will depend on the consequences – whether the problem is resolved. Case formulation is thus the translation of theory into therapy, but it is the function of all theories to be disproved if possible. The clinician should create explanatory structures or heuristics for understanding the client’s problems but proceed with caution not to muster evidence selectively only in their support but to examine critically why their heuristic and hypotheses may be incorrect and can be shown to be so. It is this refinement of testable hypotheses upon which treatment strategies are based that prevents cognitive behaviour therapy from becoming a mere cookbook of clinical techniques.

A further ongoing issue has been whether it is possible to abandon psychiatric classification altogether or replace it with an alternative, psychologically based system of taxonomy. This has been of mixed success. One of the advantages of a classificatory system is that it lumps together clinical problems on the basis of their shared characteristics which aids research and provides a starting point for case formulation. As a method of providing a shorthand for communication it has its advantages but also brings with it the baggage of psychiatric diagnosis and by implication the medical model. Currently we have tended to stick with the extant classification as a method of organisation, largely because this is the world in which we find ourselves and because as of yet there has not arisen a viable behavioural alternative. This does not suggest that case formulation is less than an individualised approach but more that it will be carried out within an existing classificatory system which provides that shorthand.

Although Kanfer and Saslow (1965) anticipated the importance of personal and subjective experience, the inclusion of this into clinical formulation and treatment following the ‘cognitive revolution’ introduced further challenges. The greater interest in unobservable cognitive products and processes rather than observable behaviour undoubtedly increased the availability of clinically powerful techniques but it also increased the possibility of biases in formulation, as described by Nezu and Nezu (1989a, 1989b). In some ways the concept of disease, rejected along with the psychiatric medical model, was in danger of being replaced by explanatory concepts such as dysfunctional assumptions, schema and similar, that could be equally diffuse (Tarrier and Calam, 2002). Persons (1989) usefully made the distinction between ‘overt difficulties’, which were the client’s ‘real life’ difficulties, and the ‘underlying psychological mechanisms’, which were the putative psychological dysfunctions which underpin the client’s overt difficulties. The overt difficulties could be described at the macro or micro levels. These distinctions not only referred to quantifiable levels of analysis, where the macro level was an overall description and the micro level was a much more detailed description of the problem, but also referred at the macro level to how the problems ‘might be described in the patient’s own terms’ (Persons, 1989: 2). The micro level includes a breakdown into the three components of cognition, behaviour and moods (emotion or affect), and includes concepts such as synchrony – the positive correlation between these three components (or lack of it as in desynchrony) – and interdependence, where a change in one component will bring about a change in the others. So not only do the macro and micro levels involve a difference in the level of description and detail; they also imply a difference in explanation. The client’s subjective description and most probably explanation or representation is characterised by the overall descriptor at the macro level, for example being depressed, anxious, having relationship problems and so on. The psychologist or clinician’s view is characterised by the more detailed micro level.

A number of implications arise from this: to be effective the process of case formulation should be collaborative and not imposed, and it needs to take into account and accommodate the client’s views and beliefs about their problem. In health psychology this is known as illness representation, which is a set of complex beliefs about the origin, nature, severity, course and progress, prognosis and potential and appropriate and acceptable treatments of the client’s condition (see, for example, Leventhal et al., 1997). It seems safe to assume that anyone seeking the services of a cognitive behaviour therapist or psychologist will have similar representations or beliefs about their condition. These beliefs may be well worked out or rudimentary, and they may be held with strong conviction or be more tentative, but they do need to be assessed so that the client collaborates in the process of arriving at a case formulation. This is encapsulated in a quote from Persons (1989: 24): ‘[A] failure to agree on the problem list dooms the treatment.’ Persons gives an excellent example of this. She describes a client, after six months of unsuccessful treatment, declaring that she did not really consider that an inability to leave the house was her major problem, which instead she construed as the fact that ‘she was fragile and delicate and that she needed to stay home and rest’ (63–65). It would appear that the client’s definition of her problem was different from the therapist’s and her cognitive (illness) representation and beliefs were also contrary. Part of the case formulation should be a thorough understanding of the client’s beliefs, understanding and expectations about his/her condition and what has lead them to consultation and treatment and into the health care system.

Persons’s 1989 book, Cognitive Therapy in Practice: A Case Formulation Approach, provided one of the first guidebooks on case formulation and had an immense impact in terms of formalising the procedure and in particular incorporating psychological and cognitive mechanisms. It became the natural successor to Kanfer and Saslow’s (1965) paper on behaviour analysis. Persons described the process of case formulation as having six parts: (a) creating the problem list; (b) describing the proposed underlying mechanisms; (c) accounting for the way in which the proposed mechanisms produce the problems on the problem list; (d) identifying the precipitants of current problems; (e) identifying the origins of the mechanism in the client’s early life and (f) predicting obstacles to treatment based on the formulation. Central to Persons’ process of case formulation is describing and understanding the underlying psychological mechanisms; these are in the main cognitive and information-processing factors although due attention is paid to the antecedents and consequences of any problem. Persons addresses the problem that these mechanisms are not frequently open to observation and run the potential risk of becoming causal fictions by suggesting a number of tests to which the hypothesised underlying mechanism can be subjected. The first test relates to how well the mechanisms account for the identified problems. This is a good criterion because a logical, comprehensive and above all parsimonious explanation has very clear advantages. Further, the formulation should easily be able to accommodate and be in accord with aspects of the client’s report, such as events associated with the onset of the problem or episode.

The formulation, as an explanation, should generate specific hypotheses which when tested will support or refute the explanation. The sign of a robust formulation is that it can survive the rigours of such tests. Furthermore, the outcome of treatment based upon the formulation can also be viewed as hypothesis testing and thus there is a pragmatic test of the formulation which, if correct, should result in a good response to treatment. Persons also includes the client’s reaction to the formulation as a final test; if the formulation makes sense to the client then it has at least some validity. The formulation, in common with any hypothesis put to an experimental test, can be refined, modified or even abandoned. All advocates of case formulation agree that the testable nature of the formulation is an essential characteristic (e.g. Bruch and Bond, 1998; Persons, 1989; Tarrier and Calam, 2002), and that this should be embarked upon in a collaborative manner. There are also ethical reasons why the formulation should be shared with the client, in that they have the right to know how the therapist has formulated their problem and intends to treat it (Turkat, 1990: 12). It is very difficult to understand how without this shared information and collaborative approach the client could give informed consent to be assessed and treated.

It is the collaborative nature of this activity that should help forge engagement. However, whether this is so is an empirical question and there is some evidence to suggest that, in some patient groups, it might not always be the case. Chadwick et al. (2003), in a study of case formulation as part of cognitive behaviour therapy in the treatment of psychosis, found that although the formulation strengthened the therapeutic alliance as perceived by the therapist, ...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of figures and tables
• Contributors
• Preface
• 1. Introduction
• 2. Case formulation and the outcome of cognitive behaviour therapy
• 3. Formulation from the perspective of contextualism
• 4. A biopsychosocial and evolutionary approach to formulation
• 5. Cognitive and metacognitive therapy case formulation in anxiety disorders
• 6. Cognitive behavioural case formulation for complex and recurrent depression
• 7. Case conceptualisation in complex PTSD: Integrating theory with practice
• 8. A cognitive behavioural case formulation approach to the treatment of psychosis
• 9. Cognitive behavioural case formulation in bipolar disorder
• 10. Cognitive behavioural formulation for personality problems
• 11. Cognitive behavioural case formulation in complex eating disorder
• 12. Case formulation in suicidal behaviour
• 13. Physical health problems: A framework and checklist for case formulation
• 14. Formulating collaboratively with carers
• 15. Working with people seeking asylum
• 16. Clinical supervision
• Index