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Summary Clinical case formulation
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Detailed notes for the capital selecta elective: Diagnostic models and strategies
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Case formulation:Rationale and importance:
There are now a very large number of treatments available for all mental disorders.
One approach to solve this perplexity as to which treatment to select is to use
psychiatric diagnosis to predict treatment.
The notion that diagnosis predicts effective and ineffective treatment is pervasive.
This model suggests that diagnosis 1 predicts that treatment A will be relatively
effective for this diagnosis and treatment B will be relatively ineffective for this
diagnosis, and diagnosis 2 predicts that treatment A will be relatively ineffective and
treatment B will be relatively effective for this diagnosis.
This model of predicting treatment efficacy has many limitations. First, most outcome
research using RCTs does not address the question of diagnosis by treatment
interaction. Rather, most RCTs merely compare one treatment with some other
procedure, such as a waiting list control, or, more rarely, some placebo or perhaps a
second treatment. Researchers select participants to ensure that they all meet the same
diagnosis. Thus, these kinds of RCTs permit us to conclude that treatment A may be
effective for diagnosis 1. They tell us nothing about the effectiveness of this
treatment for diagnosis 2 and nothing about whether this treatment is the most
effective treatment for this diagnosis.
A second limitation to this model of predicting which treatments might be effective is
that response to treatment is highly varied.
A third limitation is that clinicians frequently work with clients who have apparently
already had standard, diagnosis-based treatment and who did not respond to any
meaningful degree.
A fourth limitation in diagnosis predicting the most effective treatment for each client
is that many clients meet diagnostic criteria for more than one diagnosis.
Case formulation = a hypothesis about the causes, precipitants, and maintaining influences
of a person’s psychological, interpersonal and behavioral problems ... [which] helps organize
information about a person, particularly when that information contains contradictions or
inconsistencies in behavior, emotion and thought content . . . it contains structures that permit
the therapist to understand these contradictions . . . it also serves as a blueprint guiding
treatment
Cognitive formulation of depression
Theoretical orientation and rationale:
Perspective of cognitive therapy: Client’s maladaptive thinking represents fruitful
points of assessment and intervention.
In depression, dysfunctional thinking typically takes the form of unwarranted
pessimism, excessively negative self-assessments, overgeneralized assumptions about
, hardships for oneself and the world and a tendency to overlook opportunities for hope
in solving problems.
Such negative biases in thinking manifest themselves in ‘automatic thoughts’, a silent
dialogue that depressed persons have with themselves in specific situations
As a result, depressed persons such as Sally will experience ongoing emotional
symptoms, and will engage in problematic behavioural strategies, such as avoiding
previously enjoyable activities for fear of being judged harshly by others.
Depressive thinking styles tend to be rigid and self-sustaining, as the propensity for
depressed individuals to think in all-or-none, overgeneralized terms inhibits their
making important distinctions across situations, or designing new solutions to old
problems.
Cognitive therapy is designed to assess, monitor and modify such maladaptive
automatic thoughts and underlying beliefs, with the goal of improving the clients’
quality of emotional life.
Cognitive therapists want to understand the possible etiological factors pertinent to
the clients’ thoughts and beliefs, and will examine important historical data from their
lives.
Cognitive therapists attempt to assess how good or bad a client’s coping strategies are.
The therapeutic relationship is very important in cognitive therapy, in which
developing and maintaining a spirit of collaborative empiricism is a high priority.
Cognitive therapists are also mindful of addressing and repairing ‘alliance ruptures’ in
ways that will be educational and validating for clients and therapists alike
Relevant and irrelevant variables:
It is important to use clinical judgment and objective data in order to prioritize the
variables.
High-priority variables would be those factors that can be measured, tested and
corroborated in some way. An example is diagnostic data, which can be gathered by
means of the SCID. In Sally’s case, using the Beck Inventory and Beck Hopelessness
Scale would be beneficial.
Cognitive therapists place an importance on ascertaining the clients’ key cognitions
associated with their emotional distress. In Sally’s case, these would be her stated
beliefs in the here and now, or poor if-then beliefs.
Additional variables would be measures of Sally’s alcohol intake, and a log of her
eating and sleeping habits. It would also be advantageous to obtain a general charting
of Sally’s daily activities, identifying avoidance behaviours and triggers for symptom
exacerbation, as well as to identify moments of pleasure and mastery.
Role of research and experience:
Indeed, there is a voluminous literature supporting the efficacy of cognitive therapy
for acute, mild-to-moderate depression, and a growing body of research suggesting
, that cognitive therapy can produce favorable outcomes even in the cases of severe
and/or chronic depression
Good therapists use their years of clinical experience to sharpen their observational
skills, such as pattern recognition, and detection of incongruities between clients’
verbal and non-verbal communication. Experience also helps therapists to develop a
broader and more client-friendly repertoire of questions, feedback and homework
assignments, as well as to gain practice in applying a wide range of clinical
techniques and strategies, such as guided imagery, cognitive restructuring and role-
playing
The formulation:
A cognitive case conceptualization is fluid. It develops, changes and otherwise
modifies to accommodate new data as treatment progresses. Thus, the therapist should
be open to revising and up- dating the case conceptualization, perhaps as a result of
information acquired through Sally’s homework assignments, or perhaps in response
to the direct input of Sally’s husband in a conjoint session.
Current factors include Sally’s decrease in doing things for self-efficacy and health
enjoyment (gym, pool), her increase in consumptive, addictive behaviours (eating,
drinking), time alone and ruminating
Treatment plan:
Sally stated that her goals for therapy were to ‘feel better’ and ‘build her confidence’.
One of the tasks of the cognitive therapist will be to help Sally expound on these
goals, towards comprehensiveness and specificity. The treatment plan will focus on
the following targets:
Sally’s compensatory strategy of avoidance is a problem. Sally will need
exposure to these avoided activities, along with constructive modifications
in how she thinks about them.
She is prone to engage in catastrophic, all or none, thinking. She tends to
ruminate and create worst-case scenarios in her mind. The cognitive therapist
would use Socratic questions to help her extreme thinking and generate
friendlier ways of viewing her problems.
Sally’s most salient depressive beliefs center on her sense of being a failure. A
cognitive therapist would not merely dispute Sally’s negative thoughts and
beliefs about herself and her life. Rather, the therapist would help the client
distinguish between objective problems such as the daughter’s
unwillingness to talk to her, and her subjectively biased interpretations,
such as she failed as a mother in that daughter Mary was wrecking her
life. By doing so, the therapist could help Sally learn ways to question, test
and modify her biased beliefs, while beginning the process of doing systematic
problem-solving on those problems that have been objectively confirmed.
Address communication skills and substance use.
Homework will be an important part of the treatment. An example of a
homework assignment for Sally might be to experiment with refraining from
ringing up her daughter, while taking the time to write down a conciliatory
dialogue to use if and when Mary would call her. In the meantime, Sally
, would use the dysfunctional thought record to write down her automatic
thoughts associated with her urges to contact Mary
Behavioral formulation of depression
Theoretical orientation and rationale:
The conceptual foundation for a behavioural approach to depression can be traced
back to the original behavioural models of depression. Specifically, Skinner initially
proposed that depression involved an interruption of established sequences of healthy
behaviour that had been positively reinforced by the social environment, with this
extinction resulting in a variety of emotional side effects that could be characterized
as depressed behaviour.
Specifically, it was hypothesized that depressed affect and behaviour initially could be
maintained through positive and negative reinforcement Although aversive
consequences including social isolation would begin to occur in place of more
positive consequences, the depressed individual’s symptomatic behaviour might
actually increase to regain lost reinforcement in a paradoxical ‘deviation-amplifying’
process resulting in a vicious cycle of further negative consequences and exacerbated
depressive symptoms.
Relevant and irrelevant variables:
Sally’s daughter left home for school. This precluded the mother role for Sally, a role
which has brought her considerable success. Skinner described this phenomenon in
terms of the development of negative emotional side effects in response to unachieved
goals.
This focus on the client’s beliefs and other private events is important, not because
they will be targeted directly as the mechanism for behaviour change, but instead
because they may be used to identify targets for change in her environment and
experiences that would influence these beliefs and the resulting feelings.
In what appears to be an effort to maintain this mother role, she has become quite
involved in the life of her daughter. Thus, it may seem that Sally is reasserting herself
in the role of the mother with her daughter to hold on to this role for which she has
had some success.
She reports a string of compensatory behaviours intended to help her address her
concerns at work, beginning with drinking excess coffee to keep her ‘sharp’.
However, the coffee increases her anxiety and jitters, and actually impairs her
performance in the long run, as well as making it difficult for her to sleep at night.
To address her sleep difficulties, Sally has begun to drink excessive amounts of
alcohol in the evening, which has created further sleep problems. She then wakes up
tired and repeats this cycle throughout the day, with each attempt aimed at
temporarily preventing or removing negative consequences while exacerbating her
depression.
In contrast to a cognitive approach that focuses directly on the lack of confidence
itself, our focus is on her previous experiences and the link between these previous
experiences and her current circumstances. In this way, a lack of confidence itself is
not the problem, but instead serves as a starting point for discovering which
behavioural experiences produced this lack of confidence.
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