Cognitive Behaviour Therapy: Case Formulation

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Outline

Introduction
Topic Relevance
The Role of Formulation in CBT
Assessment and Goal Setting
CBT and Client Experience
Problem-Specific Formulation and Levels of Formulation
Principles of Formulation in Nursing Practice
Conclusion

Introduction

Case formulation in psychology is an activity that allows a therapist to combine all relevant patient data in a single structure, outline possible underlying issues and propose a plan for future action. Many psychiatrists consider the use of case formulation in Cognitive Behavioural Therapy a necessary part of treatment (Beck 7; Nezu et al., 62; Persons and Tompkins 291). Nevertheless, research on its effectiveness has not found an abundance of supporting evidence, with some scholars raising concerns about the employment of case formulation or conceptualisation (Aston 65; Dudley et al. 67).

Therefore, it is important to describe and assess various aspects of formulation in order to understand what benefits it can bring to both therapists and patients. First, one should consider why the topic of case formulation is relevant to research on CBT. Second, the role of formulation in the process of CBT should be reviewed.

As case formulation is one of the steps in treatment, its position between the initial assessment and goal setting needs to be discussed. Conceptualisation implies that all gathered data will be synthesised, which may raise concerns or overwhelm a therapist or patient. Thus the utility of case formulation and how patients perceive it may also influence its effect on therapy. Finally, one should consider how the use of formulation may inform nursing practice. This paper aims to show the critical role of formulation in CBT as well as discuss its characteristics and features.

Topic Relevance

The investigation into the characteristics and impacts of case formulation on CBT is guided by the fact that the existing literature does not provide sufficient evidence to prove that it should be the basis for treatment. For example, Persons and Tompkins argue that formulation is one of the most valuable strategies for helping therapists develop a treatment plan (295). Some authors show how beneficial this approach can be for both experienced and novice medical professionals (Dudley et al. 66). This strategy is also approved by Zayfert and Becker, who experiment with CBT in cases of PTSD.

The scholars provide evidence that case formulation leads to rapid improvement of patients and their understanding of their core issues (58). Naeem et al. show that formulation can be utilised in self-help CBT and note that it is more effective than other methods since it provides insight and systematises patient information (771). Therefore, one should understand how formulation works and what knowledge it requires.

On the other hand, some scholars raise concerns about using formulation as the sole basis for developing treatment. Hoyer, for example, states that formulation may require therapists to engage in longer sessions than they would while using other methods (88). Tarrier and Calam introduce new ideas in order to improve the current procedures and make formulation more complex and thoughtful in relation to the patient’s social context (320). Nevertheless, one can see that such concerns are not targeted at eliminating case formulation as a part of CBT, but at enhancing its effectiveness.

The Role of Formulation in CBT

In CBT, formulation can be described as a step between initial data collection and development of the required therapeutic activities. Persons defines case formulation as a ‘framework for providing cognitive-behavior therapy (CBT) that flexibly meets the unique needs of the patient at hand, guides the therapist’s decision making, and is evidence-based’ (1). The author puts this step in between patient assessment and treatment planning, which means that it acts as a bridge between theory and action. Therefore, the central role of case formulation in therapy is to use information in order to reveal which steps a therapist and a client should take to resolve a problem.

During the first meeting, a patient may not know what mental health problems (if any) they have. At the same time, a therapist has to understand the thoughts and explanations of the patient in order to provide help.

Case formation has a structure which allows one to assess information quickly and identify major signs and symptoms. Moreover, it examines the problems and underlying causes, noting not only directly related data (such as acute mental health problems) but also family history (Persons and Tompkins 292).

As a result, formulation can become the framework for a treatment plan which outlines potential causes and diagnoses along with any mechanisms, activities and actions affecting the person. In CBT, the investigation of a patient’s moods, physical symptoms, thoughts and actions is the foundation of treatment. CBT strategies target the relations between these aspects and aim to improve them and their effect on each other (Persons 2). Thus, a plan in the form of a case formulation plays a leading role in guiding a patient through therapy.

Assessment and Goal Setting

Formulation’s role as a bridge between assessment and goal development can be understood with the help of examples. Bucci and Tarrier describe the case of a patient who presents symptoms characteristic of psychosis (168). A therapist collects information about the patient’s current concerns, as well as their family history, social life, and psychological well-being. This process constitutes the assessment part of the meeting.

However, this information should be structured and reviewed in order to provide the therapist with ideas for treatment. For this purpose, one uses case formulation: the therapist creates a list of problems, outlines diagnoses according to the DSM, presents an anchoring diagnosis and chooses a nomothetic formulation for the patient (Persons and Tompkins 303). The combination of these steps results in a formulation that indicates the patient’s symptoms, beliefs and processes. Then the therapist uses this data as the basis for selecting appropriate activities.

Here, case formulation acts as a template which requires therapists to fill in all required information in order to identify patterns that provide insight into the possible diagnosis. This does not mean that all formulations follow the same set of rules. There is a system, but each case is personalised to fit the patients’ social and psychological history. Nevertheless, the steps mentioned above for creating a formulation make it a template for examining patient information and turning the information into useful material for therapeutic planning.

Some tools for psychologists even include a pre-made formulation which includes such points as relevant childhood data, core beliefs, and coping strategies, as well as descriptions of situations, thoughts, emotions and behaviours (“Cognitive Case Formulation”). They should be used with caution, however, as CBT requires an individual approach.

CBT and Client Experience

As can be seen, case formulation uses patient data in order to adapt it for treatment development. Thus it can be viewed as a link between therapeutic activities and patients’ understanding of them. Persons writes that case formulation can reduce patients’ nonadherence to therapy since it highlights areas of concern and shows the connections between patient factors and outcomes (12). Moreover, the anchoring diagnosis in formulation is usually established when a therapist finds a disorder that fits the majority of problems listed by or noticed in the patient. Therefore, it allows one to choose the most appropriate treatment. Furthermore, formulation accounts for the patient’s social and medical well-being, which also contributes to the creation of a connection and mutual understanding between a professional and a client.

On the other hand, a poor assessment may cause a patient to become unresponsive to the proposed treatment. If a therapist is imposing a certain bias by focusing on a single diagnosis and refusing to review the situation in detail, therapy sessions may end in the patient becoming disinterested in further communication. According to Persons, this outcome can be avoided if the case formulation is viewed as a template with changing contents (14).

If a patient’s problems shift in priority or severity, the diagnosis and treatment also need to be analysed again (Dobson and Dobson 44). Additionally, hypotheses developed by therapists after formulation can be entirely rejected by clients based on a lack of understanding or fear of exploring underlying issues. In such cases, patient feedback should be used to discuss these barriers and develop a plan that helps the client the most.

Problem-Specific Formulation and Levels of Formulation

It should be noted that formulation uses a nomothetic approach to investigating patient data. This means that most conclusions are made with the general laws of psychiatry in mind. For instance, a formula for treating eating disorder-related obesity is that the majority of clients express a positive response to food and eating which then cause them to overeat (Dalle Grave et al. 196; Murphy et al. 615). Similarly, the notion that physical illnesses have a negative impact on mental health and exacerbate disorders is another nomothetic statement (Farrand and Woodford 14). However, not all clients can be treated using nomothetic theories alone; they require an idiographic (person-specific) strategy. In case formulation, idiographic aspects are applied to nomothetic statements in order to build the treatment up from general beliefs into a personalised plan.

Therapists perform formulation in multiple steps; these include symptom, problem and case. The symptoms of a disorder or an issue represent separate concerns such as mood changes, insomnia, social isolation, or high pulse. A problem is a combination of symptoms, and it can be described with a diagnosis. For example, Major Depressive Disorder is a problem that includes negative emotions and automatic thoughts caused by previous events and stress (Persons and Tompkins 295).

This is a general description of all the patient’s symptoms assigned to a particular condition. Finally, a case is a concept that includes all information available to a therapist – symptoms, problems and their connections (Persons and Tompkins 296). While ‘problems’ are standardised, each case is individual, describing relevant aspects and factors that contribute to a patient’s state. Each level has a purpose in formulation. Symptoms make it possible to reveal a larger issue; the problem points to a foundation for treatment; and the case enhances the therapy plan by acknowledging the personal differences of each client.

Principles of Formulation in Nursing Practice

The use of case formulation in CBT can benefit and inform one’s practice in many ways. Hawley et al. find that alternative case formulation, for example, can help alleviate depression symptoms by critically examining a person’s core beliefs (31). Case formulation-driven therapy enhances patients’ positive outcomes and provides therapists with a manageable and flexible framework (Persons and T. 8).

This approach helps to make mental health nurses’ practice more focused on clients’ individual traits without abandoning certain nomothetic notions. Kazantzis notes that this strategy combines unified protocols and clients’ individual needs, enhancing the therapeutic work (117). In fact, focusing on the patient’s history, social and personal characteristics is vital for implementing formulation (“CBT Case Formulation”). As a result, the use of case formulation in CBT provides a nurse with the ability to use patient data meaningfully.

Formulation can be easily adopted into one’s practice of CBT. The templates and plans described above can be used during sessions with clients since their feedback is an essential part of the process. Moreover, the description of steps and levels in analysing patient data shows how case formulation can be utilised in discussion and diagnosis. Cognitive behavioural approaches are centred on assessing people’s emotions, behaviours and thoughts; formulation can be incorporated into practice, with the data being combined with patients’ history and social factors.

Conclusion

CBT is a strategy that focuses particularly on the links between people’s emotions and actions. Formulation can be considered a vital part of this approach because it acts as a bridge between patient data and the goals one sets for a client. One should note that it is crucial to avoid reaching biased conclusions, as the client’s feedback and consideration of alternative formulations can improve the result. Case formulation can be used for various disorders.

It combines nomothetic theories based on common ideas and the idiographic aspects of individuals, leading to the creation of highly personalised treatment plans. It also allows therapists to see the underlying causes of problems and discuss them with patients, revealing the connections between symptoms and outcomes. The levels of formulation outline the procedure’s multifaceted nature: symptoms analyse a patient’s current concerns, a problem establishes a framework for future action and a case adds unique factors to each person’s therapy. Overall, with its structured but flexible nature and concern for personalisation, case formulation can be a helpful asset to a mental health nurse.

Works Cited

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Beck, Judith S. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed., Guilford Press, 2011.

Bucci, Sandra, and Nicholas Tarrier. “A Cognitive Behavioural Case Formulation Approach to the Treatment of Psychosis.” Case Formulation in Cognitive Behaviour Therapy: The Treatment of Challenging and Complex Cases, edited by Nicholas Tarrier and Judith Johnson, 2015, pp. 166-190.

“CBT Case Formulation–The Importance of Focus.” YouTube, uploaded by Beck Institute for Cognitive Behavior Therapy. 2013. Web.

“Cognitive Case Formulation.” Psychology Tools. Web.

Dalle Grave, Riccardo, et al. “Personalized Multistep Cognitive Behavioral Therapy for Obesity.” Diabetes, Metabolic Syndrome and Obesity, vol. 10, 2017, pp. 195-206.

Dobson, Deborah, and Keith S. Dobson. Evidence-Based Practice of Cognitive-Behavioral Therapy. 2nd ed., Guilford Publications, 2018.

Dudley, Robert, et al. “The Utility of Case Formulation in Treatment Decision Making; The Effect of Experience and Expertise.” Journal of Behavior Therapy and Experimental Psychiatry, vol. 48, 2015, pp. 66-74.

Farrand, Paul, and Joanne Woodford. Goal Setting in Low Intensity CBT. Web.

Hawley, Lance L., et al. “Cognitive-Behavioral Therapy for Depression Using Mind Over Mood: CBT Skill Use and Differential Symptom Alleviation.” Behavior Therapy, vol. 48, no. 1, 2017, pp. 29-44.

Hoyer, Jürgen, et al. “Manualized Cognitive Therapy Versus Cognitive-Behavioral Treatment-As-Usual for Social Anxiety Disorder in Routine Practice: A Cluster-Randomized Controlled Trial.” Behaviour Research and Therapy, vol. 95, 2017, pp. 87-98.

Kazantzis, Nikolaos. “Introduction to the Special Issue on Processes of Cognitive Behavioral Therapy: Does “Necessary, but Not Sufficient” Still Capture It?” Cognitive Therapy and Research, vol. 42, no. 2, 2018, pp. 115-120.

Murphy, Rebecca, et al. “Cognitive Behavioral Therapy for Eating Disorders.” Psychiatric Clinics, vol. 33, no. 3, 2010, pp. 611-627.

Naeem, Farooq, et al. “Preliminary Evaluation of a ‘Formulation-Driven Cognitive Behavioral Guided Self-Help (fCBT-GSH)’ for Crisis and Transitional Case Management Clients.” Neuropsychiatric Disease and Treatment, vol. 13, 2017, pp. 769-774.

Nezu, Christine Maguth, et al. “Case Formulation for the Cognitive and Behavioral Therapies: A Problem-Solving Perspective.” The Oxford Handbook of Cognitive and Behavioral Therapies, edited by Christine Maguth Nezu and Arthur M. Nezu, 2nd ed., Oxford University Press, 2015, pp. 62-78.

Persons, Jacqueline B. The Case Formulation Approach to Cognitive-Behavior Therapy. Guilford Press, 2008.

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Persons, Jacqueline. B., and Michael A. Tompkins. (2007). “Cognitive-Behavioral Case Formulation.” Handbook of Psychotherapy Case Formulation, edited by Tracy D. Eells, Guilford Press, 2007, pp. 290-316.

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Zayfert, Claudia, and Carolyn Black Becker. Cognitive-Behavioral Therapy for PTSD: A Case Formulation Approach. Guilford Press, 2006.

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