Behavioral case formulation: An experimental assessment study of transient tic disorder

A nine-year-old male, who met DSM III-R criteria for transient tic disorder, participated in an experimental assessment strategy to generate support for a case formulation. In addition to presenting motor disturbance, assessment procedures revealed six problem areas. All problems were formulated as manifestations of a hypersensitivity to evaluation, etiologically related to the boy's relationship with an insecure and critical father. It was hypothesized that the patient's tic disorder was a consequence of his hypersensitivity to father's excessive criticism, which then generalized to other evaluative situations. Using a controlled single-subject design, predictions derived from the formulation were tested by exposing the child to a planned combination of evaluative observers (e.g., father, mother, therapist, etc.) who watched him as he worked on a series of puzzles. The dependent measures included (1) behavioral recordings of tic frequency and (2) frontalis EMG responses. The results indicated significant differences in tic rate and EMG as a function of the type of observer. Consistent with the formulation, the patient displayed the highest levels of tic behavior and EMG response when his father was the observer and lowest in the presence of the mother. Predictions regarding other stimulus conditions were also confirmed. These results provided support for the case formulation that was used to design an effective treatment intervention. Findings suggest that the case formulation model offers a method whereby novel case hypotheses can be generated for poorly understood psychopathology and tested later in the experimental situation.     

The Strengths and Limitations of Case Record Reviews in Examining Family Preservation Outcome Formulation and Treatment Planning

Much debate has centered on what are reasonable outcomes of the short-term intensive family preservation services (IFPS). However, little attention has been given to how therapists actually formulate outcomes in their practices. The files of 98 families who used IFPS were reviewed to determine how therapists formulated outcomes and whether formulated outcomes varied by service sector (child welfare or mental health) and child age. It was found that formulated outcomes in mental health were more likely than those in child welfare to have a child focus and an interpersonal locus. Variation in outcome formulation in child welfare by child age was found, with outcomes of younger children more likely to be parent-focused than were outcomes of older children. The issues pointed out by these findings are discussed. Since case records are a potential data source for researchers, the paper concludes with a discussion of the strengths and limitations of case record reviews for research purposes.     

CBT/DBT-Informed Intensive Outpatient Treatment for Anxiety and Depression: A Naturalistic Treatment Outcomes Study

Anxiety and depression are highly prevalent and disabling mental health disorders, with comorbidity often posing as a barrier to successful treatment outcomes, thus creating a need for more intensive treatment options. Outpatient clinicians are more likely to refer patients with severe symptoms of anxiety and depression to inpatient hospitalizations rather than partial hospital programs (PHPs) or intensive outpatient programs (IOPs), despite evidence that inpatient hospitalization is associated with high costs and other risks following discharge. The present study reviews two case studies of patients who received cognitive-behavioral therapy/dialectical behavior therapy (CBT/DBT)-based IOP treatment in a private New York clinic. We evaluated treatment outcomes for 73 adult patients (50.7% female) with a mean age of 29.10 years (SD = 10.30). At intake, patients averaged 2.15 diagnoses (SD = 0.94, range = 4) and the majority (80.8%) were prescribed psychotropic medication. Treatment was structured and individually tailored, with patients receiving an average of 21.77 hours (SD = 15.06) of psychotherapy over 12.63 treatment sessions (SD = 9.76), across 12.21 days (SD = 9.61). We observed a clinically and statistically significant change in symptoms of anxiety (t = 6.24, p < .001), depression (t = 5.55, p < .001), and suicidality (t = 2.32, p < .05) over the course of the IOP. After completing treatment, 68.1% of participants tapered down to once-weekly treatment. The present study highlights the clinical utility of an IOP and suggests that this approach can be effective for adult patients presenting with severe symptoms of anxiety and/or depression.     

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.     

How do counsellors make client assessments?

This paper reports on a consultation exercise undertaken with 18 experienced counsellors on how they make client assessments. These practitioners expressed a high degree of consensus on the purposes of assessment making (to reach a shared understanding with the client about their willingness and ability to undertake a shared therapeutic journey) but the way in which they approached the task varied according to the theoretical orientation they acquired during training. Although most had developed their counselling skills and techniques considerably since initial training, not all had integrated the assessment implications of later experience into their formulation making. The implications of combining single model assessment with eclectic practice are discussed, particularly in relation to making a decision to continue working with a client or to refer a client to a colleague. The authors call for further debate on how counsellors find meaning in what their clients say, why they ask the questions they do at the assessment stage, and how they achieve coherence in relation to ideas and skills accrued through ongoing training and practice. The implications of such a debate for training and supervision are discussed.     

案例概念化在临床上的应用

随着心理治疗方法的发展, 案例概念化作为治疗工作的重要组成部分, 日益成为临床关注的热点。案例概念化主要指在一定治疗理论的基础上, 就来访者的问题成因和维持因素提出假设, 为构建治疗方案提供指导蓝图。西方的临床研究表明案例概念化能有效地促进咨询师和来访者对于问题的认识和理解, 提高治疗效果。以认知行为治疗理论为基础, 具体地介绍案例概念化技术在焦虑症和抑郁症的临床应用。     

Modeling the role of emotions in viewing oneself maturely

Adolescents develop a mature view on themselves: they view positive as well as negative self-attributes, but they hold a positive stance toward themselves. The literatures on identity, the self, parent-offspring relationships, and friendships provide hints on how such a view may develop. This article integrates this literature into an emotion-based dynamic systems mathematical model built to explain the development of maturity of such views. An innovative methodological design was used to collect empirical data: four students daily reported their experiences and emotions for a period of 5 months, while they temporarily studied abroad. At the beginning and end of this period, they were interviewed on their views on themselves. These mostly qualitative data were used to provide support to the suggested mathematical model. The usefulness, weaknesses, and strengths of such a methodological design and mathematical modeling are discussed.     

Cognitive–Behavioral-Interpersonal Scenarios: Interformulator Reliability and Convergent Validity

Although a clinical case formulation can help focus treatment, little is known about the reliability and convergent validity of independently generated, cognitive–behavioral or cognitive–interpersonal formulations. Using videotapes of a semi-structured interview, pairs of clinicians independently formulated 2–3 cognitive–behavioral–interpersonal scenarios (CBISs) on each of 4 women with mood or comorbid mood and anxiety disorders. Ten licensed psychologists then rated each CBIS on 15 dimensions involving cognition, affect, symptoms, and interpersonal functioning. Reliability of the mean ratings (aggregated over the 10 raters) was >.83 for all dimensions. The set of CBISs formulated by a clinician for a patient generally demonstrated good convergent (same patient/different formulator) and discriminant (different patient/same or different formulator) validity on three factor-analytically derived general dimensions of depression, anxiety, and interpersonal functioning. Within each of three patients, pairs of formulators generally agreed on the situational components of the CBISs and demonstrated adequate to very good convergent validity of corresponding CBIS content. These results contribute to accumulating evidence for the reliability and validity of clinical scenarios as an idiographic, situation-level case formulation. Such formulations can help identify multiple cognitive, behavioral, or interpersonal intervention points in the causal chain leading to distress or dysfunction.