Cyclical Maladaptive Patterns: Interpersonal Case Formulation for Psychotherapy with Children

This paper proposes the use of Hans Strupp's case formulation method, Cyclical Maladaptive Patterns, with child clinical cases. While Strupp's case formulation method was developed for use with adults in Time-Limited Dynamic Psychotherapy, this interpersonally-based model is viewed as consistent with recent literature in child development and psychopathology which emphasizes the centrality of peer relationships, interpersonal schema, and social attribution biases in the development of maladaptive interpersonal behavior. Application of this method underscores the interpersonal nature and context of childhood problems as well as their cyclical and self-perpetuating quality. Use of this case formulation method with children is proposed as a basis for individually tailoring treatment plans with children who have problems with aggression, rejection, and other maladaptive interpersonal patterns.     

Resolution of an impasse at a network meeting: Dialogical sequence analysis of the use of a shared formulation

The study describes the resolution of an impasse at a network meeting during clinical child neurological assessment procedure, analysed by dialogical sequence analysis (DSA) a micro-analytic method for analysing utterances. The two earlier studies of the project describe how a DSA-based case conceptualisation can be used to assess change in the dyadic interaction between neuropsychologist and parent. This study applies the same formulation to analyse group level interaction at the network meeting. The case of a four-year-old girl was selected from a database of videotaped and transcribed child neurological team assessment processes. A repetitive problematic pattern was clearly manifested between parents and the child. At an early stage of the assessment, the neuropsychologist formulated and shared with the parents a clinical formulation of the pattern, summarised as the controlling/coercive parents to the rebellious child. In the earlier studies, microanalysis using DSA confirmed the accuracy of the neuropsychologist’s initial formulation, which she had used in the encounters with the parents. This study traces how she made use of it to address a re-enactment of the problematic pattern, now between the parents and professionals at the network meeting. The analysis of the phases of the conflict resolution by using DSA suggests that the impasse represented a re-enactment of the role positions of coercion and rebelliousness. The use of the original formulation at the meeting helped the conflicting parties to reach an observing stance to the pattern and a more empathic attitude to each other. The micro-analytic methodology by DSA used in this study allows to show the therapeutic potential of the network meeting and also how the development of an empathic stance is manifested in the discourse content.     

Naturalistic outcome of case formulation-driven cognitive-behavior therapy for anxious depressed outpatients

This article describes a case formulation-driven approach to the treatment of anxious depressed outpatients and presents naturalistic outcome data evaluating its effectiveness. Fifty-eight patients who received case formulation-driven cognitive-behavior therapy (CBT) in a private practice setting were studied. All received individual CBT guided by a case formulation and weekly outcome monitoring; in addition, 40 patients received adjunct therapies, including pharmacotherapy, which were added as indicated by the case formulation and the results of weekly outcome monitoring. Patients treated with case formulation-driven CBT showed statistically and clinically significant changes in anxiety and depression that were generally comparable to those reported in published randomized controlled trials of empirically supported therapies (ESTs) for single mood and anxiety disorders. Findings support the proposal that anxious depressed patients who have multiple comorbidities and require multiple therapies can benefit from empirically supported treatments guided by a case formulation and weekly outcome monitoring.     

Problem Anger in Psychotherapy: An Emotion-Focused Perspective on Hate, Rage, and Rejecting Anger

This paper explores applies emotion-focused theory, for the first time, to the emotions of hate, rage, and destructive anger. The general case formulation proposed in this paper is that these emotions are always an elaboration of secondary anger. The body of the paper describes three clinical case formulations. First, problem anger is described in terms of an individual’s self-criticism. Second, we present a form of secondary anger, in which hostility and rage are reactive feelings to avoid more vulnerable (primary) experiences. An unfortunate example of this is has been described as a common underlying process in domestic violence. A alternate manifestation of secondary anger results from the deterioration of what may have initially been adaptive anger; thus, excessive arousal and the loss of meaning or focus that one’s anger embodied also leads to rage or destructive anger. Finally, the experience and expression of hate is described as a primary maladaptive and/or instrumental anger. This appears in-session particularly among those with certain personality disorders. The paper highlights implications for research and practice.     

Validation of idiosyncratic cognitive schema in cognitive case formulations: an intraindividual idiographic approach

This article describes a method for the intraindividual clinical validation of a cognitive case formulation (CCF) involving hypotheses about the patient's idiosyncratic cognitive schema (ICS). The two-stage approach begins by testing the convergent and discriminant validity of the hypothesized ICS against the individual's daily ratings of cognition items using confirmatory dynamic factor analysis. The second stage evaluates the extent to which the ICS factor scores predict daily variability in symptoms and distress and further addresses convergent and discriminant validity by evaluating intraindividual cognitive content specificity and the incremental validity of the idiographic cognition factors compared with nomothetic measures of thoughts/beliefs. This approach to validating idiographic assessment is illustrated with the CCF of a woman with comorbid mood and anxiety disorders.     

Adlerian marital therapy with the passive-aggressive partner

Abstract

This paper describes the passive-aggressive personality and provides an Adlerian formulation of the PAP in couples functioning. It points out the similarities of this formulation to DSM-III-R, cognitive therapy, and transactional analysis. A specific treatment plan incorporating several types of intervention for helping such couples lead more effective marital lives is presented.     

The Protective Skin of the Analyst’s Case Formulation: Commentary on Paper by Tom Wooldridge

The contours of every psychoanalytic process are shaped by its case formulation. This discussion of Tom Wooldridge’s paper (this issue) of the long-term, psychodynamic treatment of a patient with severe anorexia provides opportunity to demonstrate that formulation derives from aspects of the clinician’s clinical education and personal growth. Wooldridge’s metaphor of the containing functions of the entropic body is extended to include particular paternal functions that an analyst provides his patient and that are suggested in the dialogue of this clinical material. Psychoanalytic case formulation distinguishes it from other aspects of an integrated treatment plan for eating disorder patients; in particular, clinician and patient discover important metaphors and elaborations of personal history that assist in recovery. Thinking through a case from different lenses provides real gratification for the psychoanalyst and a bulwark to assist in potentially life-saving work because of its protective and enriching functions. Drawing upon the metaphors Wooldridge expands upon such as secondary skin formations and the entropic body, I suggest that clinicians who work in the field of eating disorders could draw great benefit from learning more about what psychoanalytic case formulation offers patients. Detailed, evocative case examples such as the one Tom Wooldridge puts forward may be one way to reach this important audience because they bring to life many of the unique features of contemporary psychoanalysis.     

The Patient Who Was Not There

Many clinicians attest to the challenges of working with the adolescent patient. The phase itself prescribes resistances to forming a transference relationship, not to mention that passions and conflicts can be stirred in the therapist that had long been dormant. Various theoretical positions have dictated different paths, from systems theory to Freud’s treatment of Little Hans. This article describes a case that took an unorthodox route based on an adolescent’s refusal and Lacan’s formulation of the function of a child’s symptom in the intrapsychic world of the parent. The outcome opened pathways for growth for both the adolescent and the parents, suggesting that the uniqueness of the phase of adolescence allows for new pathways for clinical intervention as well.     

Family Augmented Cognitive Behavioural Therapy: Make Room for Mum!

Familial processes are gaining an increased amount of attention in cognitive behavioural therapy. Their role in initiating, maintaining, and exacerbating distress in children and adolescents has clear clinical implications. Therefore, including parents in their children’s therapy sessions as coaches, collaborators, and co-patients is becoming commonplace in CBT approaches to internalizing disorders such as anxiety. This article describes a case of a 13?year old female who presented with features of Generalized Anxiety Disorder and Separation Anxiety whose course of treatment involved her mother as a coach, collaborator and co-patient. A case formulation is offered and the specific examples of CBT practices used in each session are detailed. Ways of evaluating treatment outcome are also discussed.     

Cognitive Behavioral Therapy Across the Stages of Psychosis: Prodromal, First Episode, and Chronic Schizophrenia

Since the early 1990s, cognitive behavioral therapy (CBT) has been increasingly used as an adjunctive treatment for psychotic disorders. This paper describes the CBT of three cases, each at a different stage of psychotic disorder: at-risk mental state, first-episode psychosis, and chronic psychotic disorder. For the at-risk mental state, treament focused on anxiety and social phobia, whereas the treatment of first-episode psychosis focused on the development of a shared formulation of the factors leading to and maintaining psychotic symptoms. For the chronic case, treatment emphasized the possibility of improving strategies to prevent symptoms from interfering with life goals. The potential contribution of CBT to improve outcomes in psychotic disorders beyond those obtained through traditional pharmacotherapy is discussed.     

The Application of Acceptance and Commitment Therapy to Obsessive-Compulsive Disorder

This paper is part of a case series illustrating the application of different therapies to a case of obsessive-compulsive disorder (OCD). It describes the hypothetical application of Acceptance and Commitment Therapy (ACT). This paper covers the philosophy and basic research on language and cognition that inform ACT. It also provides an ACT-based case conceptualization of this case and examples of therapeutic procedures. The goal of this paper is to familiarize clinicians with the use of ACT for OCD.     

The Case(s) of Gordon Allport

ABSTRACT Gordon Allport has frequently been criticized for advocating the use of idiographic studies but undertaking only one such study himself. This article describes Allport's work on the case of Marion Taylor, an unpublished study that clearly contributed to his later work on the case method. The unfinished Taylor case materials suggest that Ada Allport was an important collaborator in Allport's work with individual cases. The case of Taylor is compared with the later case of Jenny Masterson using Allport's rules for the preparation of case studies in order to shed light on Allport's ambivalence regarding case studies.     

Revisiting ‘What works for whom?’: A qualitative framework for evaluating clinical effectiveness in child psychotherapy

This paper describes a framework for evaluating the effectiveness of child psychotherapy used by child psychotherapists in an inner city Child and Adolescent Mental Health Service (CAMHS). The Hopes and Expectations for Treatment Approach (HETA) involves using the assessment for psychotherapy that normally precedes treatment to derive a baseline from which to generate a set of hopes/expectations as regards the effects of the treatment on the part of parents and the psychotherapist, to be revisited one year after the start of the psychotherapy and/or at its completion. The Strength and Difficulties Questionnaire, for parents and schools, was also administered before and after the treatment. The characteristics of the first 30 children referred for psychotherapy over a particular time period are described. Of the first 15 children in this group to complete one year of individual psychotherapy, all showed change or significant change in the areas concerning parents' and therapists' hopes at the end-of-year review, as rated by parents and psychotherapists. A case of a child with conduct disorder is used to describe how the assessment generated a psychoanalytic formulation, how the therapist's understanding was fed back to the parents, and how the parents' and therapist's hopes and expectations were derived and recorded. This case illustrates powerfully the impact of trauma in the parents' backgrounds on the internal world of the child, and how the method provides a useful bridge between parent and child work. Feedback from the psychotherapists, the parents and the referrers using the framework is reviewed, and in conclusion the paper argues for the framework's value in promoting good practice in the treatment and management of complex cases and in enhancing awareness of the nature and scope of the psychotherapy process.     

Bereavement and triangular relationships in a case of a child suffering from anorexia

This paper describes the mother–child assessment of a five-year-old girl suffering from anorexia since weaning, which was carried out in an Italian NHS neuropsychiatric child and adolescent unit. The author aims to show how she was able to link the little girl’s refusal of food to a death in the maternal family, which occurred soon after her birth. As well as this post-traumatic formulation, the author links the child’s anorexia to two related aspects of the family dynamics: avoidance of the awareness of death and the inability to manage triangular relationships, due to important intrusion and exclusion anxieties. Using extracts from the sessions, the author shows how the little girl was able to begin to work through the death phantasy which was previously inaccessible to her and her family. The concept of the death phantasy is defined and explored and possible analogies between this case and what is observed in some anorexic adolescent girls and their families are described.     

Four noble truths based problem solving: a therapeutic view

This paper presents the application of the four noble truths based problem solving (FNTBPS) approach to supplement the contemporary and traditional Thai Theravada Buddhism literature on psychological healing. This paper outlines the core concept of FNTBPS, its key components and application, using an illustrated case example of Tom (????), a 50-year-old Thai man facing psychological problems due to his worsening eyesight. Lastly, this paper outlines the therapeutic implications of how an understanding of psychological healing via the knowledge of FNTBPS can be used for case formulation and treatment planning.     

Treatment of Maternal Depression With In-Home Cognitive Behavioral Therapy Augmented by a Parenting Enhancement: A Case Report

Depression is prevalent among mothers who participate in home visitation programs. This case study describes In-Home Cognitive Behavioral Therapy (IH-CBT), an empirically based treatment for depressed mothers that is strongly integrated with ongoing home visitation. The use of a Parenting Enhancement for Maternal Depression (PEMD) module was added to address parenting difficulties in a depressed mother. This case describes issues and challenges encountered in delivering treatment in the home with low-income, depressed mothers. Issues involving engagement, adaptation to the setting, responding to the unique needs of low-income mothers, and partnership with concurrent home visiting to optimize outcomes are considered. Long-term follow-up (18 months after the end of treatment) permits examination of sustainability of gains. Implications for treating this high-risk population are discussed.