aw 12 Cognitive-Behavioral Case Formulation JACQUELINE B. PERSONS MICHAEL A. TOMPKINS Cognitive-Behavioral (CB) Case Formulation, described in this chapter, is an elaboration of the method described by Persons (1989, 1993). Others who have presented methods for cognitive case conceptualization include Judith S. Beck (1995), Arthur Freeman (1992), and J. Christopher Muran and Zindel V. Segal (1992). Contributors to the field of behavioral case conceptualization are too numerous to mention; for overviews of this field, see Bellack and Hersen (1988) and Nelson and Hayes (1986a); for good clinical examples, see Haynes and O’Brien (1990) and Turkat (1985). HISTORICAL BACKGROUND OF THE APPROACH CB Case Formulation has its origins in cognitive therapy and theories and in fanctional analysis. It incorporates aspects of both structuralassessment, which focuses on the topography and underlying causal mechanisms of behavior, and functionalassessment, which focuses on the functions of behavior (Nelson & Hayes, 1986b). Cognitive Therapy and Theories CB Case Formulation draws heavily on cognitive diathesis-stress theories of depression, particularly A. T. Beck’s (1976) cognitive theory of psychopathol- ogy. Beck’s theory states that psychopathological symptoms and problems 314Cognitive-Behavioral Case Formulation 315 result from the activation of core cognitions (variously termed schemas, dys- functional attitudes, and core beliefs) by stressful life events. The links between CB Case Formulation and Beck’s cognitive theory can be seen in the fact that three components of the CB Case Formulation match the three key components of Becks’ model: the patient’s symptoms and prob- lems, the core beliefs underpinning the symptoms or proble d the life events that activate the core-belicfs. (We use the term “core beliefs” because itis easier to communicate to patients than the terms “schemas” or “dysfunc- tional attitudes.”) Beck’s model also proposes that schemas are learned via early childhood experiences, and the CB Case Formulation method includes a de- scription of the origins of the patient’s core beliefs. Functional Analysis Functional analysis has been defined by Haynes and O’Brien (1990) as “the | Lib, identification of important, controllable, causal functional relationships ap- | plicable toa specified set of target behaviors for an individual client” (p. 654). | The links between CB Case Formulation and functional analysis can be seen in three characteristics of the CB Case Formulation method: its emphasi identification and measurement of overt problems, its specification of tional hypotheses, and in the fact that the quality of the CB Formulation is a function of its contribution to treatment outcome. In emphasizing the specification and measurement of overt problems, the CB Case Formulation model borrows heavily from behavior therapy; indeed, a hallmark of functional analysis and of behavior therapy is its emphasis on identification of overt, concrete problems and the objective measurement of them so that treatment progress can be monitored. The CB Case Formulation method allows for specification of a functional hypothesis in the component of the formulation. Not all CB Case Formulations involve functional hypotheses, but many do. For example, a CB Case Formulation of a depressed patient might include notions from Lewinsohn, Hoberman, and Hautzinger’s (1985) proposal that depres- sion in some individuals stems from reductions in interpersonal or other posi- tive reinforcers. CB Case Formulation adopts a functional approach to assessing the quality of the formulation (cf. Hayes, Nelson, & Jarrett, 1987). That is, the quality of the formulation is seen as a fanction of its ‘treatment outcome—then it is a poor CB Case Formulation no matter how much information it provides (Hayes et al., 1987). In this functional model, the Working Hypothesis component of the CB Case Formulation serves as a hypothesis about the structural and functional mechanisms underpinning and maintaining problematic Bohavions The Hie pist (with the patient) uses the hypothesis to develop a treatment plan designed to alleviate or solve the symptoms and problems. The outcome of treatment based we316 | HANDBOOK OF PSYCHOTHERAPY CASE FORMULATION on the hypothesis serves as a test of its treatment utility. If the outcome is poor, we recommend that the therapist work to revise the formulation and the treat- ment plan based on it. This view of treatment as a single-case empirical study, in which case formulation, treatment planning, monitoring of outcome, and revi- sion of the formulation are parts of an iterative process, is a hallmark of behav- ioral case conceptualization (cf. Barlow, Hayes, & Nelson, 1984; Kanfer, 1985). CONCEPTUAL FRAMEWORK Why Is Cognitive-Behavioral Case Formulation Necessary? Individualized case conceptualization and cognitive-behavior therapy might, to some readers, seem odd bedfellows. One of the strengths of cognitive-be- havioral therapy (CBT) is the body.of outcome data supporting its efficacy (cf. Giles, 1993). However, the CB therap controlled outcome studies do not generally develop a comprehensive case formulation and use it to make an individualized treatment plan. Instead, they follow a standardized treat- ment protocol. If CBT has been shown to be effective in outcome studies in which therapists do not develop an individualized case formulation, why is CB Case Formulation necessary? We offer several answers to this question. First, it is not strictly correct to say that therapists in controlled outcome studies do not conceptualize. Although a formal conceptualization is not usu- ally done, certainly the therapist individualizes treatment by focusing on the individual patient’s particular distorted cognitions, not on distorted cognitions typical of the average depressed patient. In addition, evaluators in the NIMH (National Institute of Mental Health) Treatment of Depression Collabora- tive Research Program (Elkin et al., 1989) developed individualized lists of each patient’s presenting problems and treatment goals (however, it is not clear that this information was used to guide treatment). Linehan’s (1993) proto- col for treating parasuicidal behavior in women with borderline personality disorder is unusual in that it includes individualized behavioral analysis as a central aspect of treatment. For example, when a patient commits a parasuicidal act, the protocol stipulates that the therapist conduct a detailed behavioral analysis of the act, specifying, in gory detail, the chain of behaviors and cir- cumstances leading up to and following the parasuicidal behavior. Second, a limitation of standardized protocols in their application to routine clinical practice is that such protocols (at least those written to date) address single disorders, for example, clinical depression (Beck et al., 1979), social phobia (Heimberg, in press), or alcohol abuse (Sobell & Sobell, 1993). In contrast, most patients have multiple disorders and problems, and for many of these a treatment protocol is not yet available. To treat these cases, the therapist can use the CB Case Formulation model, using the cognitive- behavioral theories that underpin the currently available treatment proto- cols to develop an individualized formulation and treatment plan for his or her patient.Cognitive-Behavioral Case Formulation 317 In cases where all of the patient’s problems ave described in standardized protocols, it might be possible for the therapist to use the protocols, one at a time, in sequence, until all of the problems are addressed. However, the sequential-protocol strategy is often inefficient because many protocols have \-~ overlapping components (e.g., relaxation strategies, cognitive restructuring). In addition, the sequential-protocol strategy does not provide any guidance to the clinician about the order in which to implement the protocols. There- fore, we believe that the strategy of using the CB model to develop a si comprehensive treatment plan for each patient provides a conceptually. elegant and pragmatically- more-efficient. approach to patient care Third, the CB Case Formulation is useful in helping the clinician under- stand and work therapeutically with the patient-therapist relationship and in planning homework assignments and handling homework noncompliance, as illustrated later in this chapter. A well-articulated, individualized formulation that is shared with the patient can strengthen patient-therapist collaboration and reduce treatment noncompliance. Finally, a CB Case Formulation is particularly helpful to the therapist when his or her initial intervention efforts fail or when, after an apparently successful outcome, the patient relapses. In cases like this, the therapist working without a formulation may be reduced to seeking randomly for another intervention strategy. In contrast, the therapist who is carrying out a formulation-driven treatment has an algorithm to follow. If the treatment fails, this suggests that the working hypothesis (formulation) upon which the treatment plan was based may need revision. With this assumption in mind, the therapist reformulates the case and devises a new treatment plan based on the reformulation. ( We ) Two Levels of Formulation CB Case Formulation occurs at two levels: the “case” level and the “situa- tion” level, At the case level, the formulation describes all of the patient’s pre-_ senting problems, their interrelationships, and the mec! underpinning and explaining them, At the situation level, the theray particu- Jar problematic situation (¢.g., a parasuicidal act or a bout of depressed mood) and develops a hypothesis about the mechanisms underpinning or explaining that situation. This chapter focuses primarily on formulation at the case level. However, we also discuss formulation at the situation level, as this level of formulation guides much of the work in therapy sessions and situation-level formulations are a key source of hypotheses about case-level formulation. The CB Case Formulation Method The CB Case Formulation has seven components: the Problem List; Core Beliefs; Precipitants and Activating Situations; the Working Hypothesis; Ori-