I Love it when a Plan Comes Together: Case Formulation in Integrative CBT

Case Formulation in Counselling/Psychotherapy can be seen as consisting of

(a) a hypothesis, or set of hypotheses, concerning the sources and maintaining factors of the client’s presenting psychological problem(s)
(b) a plan, based on the above hypotheses, as to when, where and how to intervene, with a view to bringing about some reduction in the client’s problems.

The Case Formulation process therefore guides and structures the course of treatment by unifying and prioritising symptoms, influencing the choice and timing of interventions, and predicting possible difficulties. It should be an ongoing process, open to modification at any stage.

This process is not carried out explicitly in all forms of counselling/therapy, though presumably all therapeutic intervention must be based on some such hypothesising and planning, even if it remains largely implicit. Carl Rogers considered that “a diagnosis of the psychological dynamics is not only unnecessary but in some ways is detrimental or unwise” (1951, p. 223). He was concerned that the process of making a diagnosis leads to an inequality in the power dynamic between counsellor and client. Similar concerns are part of Integrative CBT (at Level 1), but I believe that a collaborative approach to arriving at a formulation should resolve this difficulty. In practice, this means that the therapist presents his own formulations to the client as hypotheses for discussion, and also helps the client to formulate his own hypotheses through guided discovery (J. Beck, 1995). The client should have as full as possible an understanding of what is happening in their own treatment. As Persons remarks (1989, p. 48), ‘If the formulation is so helpful to the therapist, we might also expect it to be helpful to the patient in understanding and managing his behaviour.’


In Integrative CBT, developing the hypothesis is an explicit process, and is part of the work that we do at Levels 3 and 4. Because this is “Integrative Cognitive Behavioural Therapy”, and not just Integrative Psychotherapy in general, the formulation is based on the Cognitive Model of emotional disorders, which “proposes that distorted or dysfunctional thinking (which influences the client’s mood and behaviour) is common to all psychological disturbances” (Judith Beck, 1995, p. 1). As we have seen in earlier blogs, at its simplest level it focuses on Negative Automatic Thoughts which are locked into vicious cycles with dysfunctional emotions, behaviours and physiology. It can also be expanded to include more ongoing dysfunctional underlying cognitions in the form of Assumptions and Core Beliefs.


So the questions an Integrative CBT therapist would be asking themselves about any client would be:

1. How do I best connect with this particular person, and form a therapeutic relationship with them?

There are some general principles here, of course, but also individual differences in how we need to adjust to different clients. Our initial therapeutic engagement will be based on initial impressions, but this can be adjusted in line with whatever emerges at the next levels of exploration. For example, a currently active addiction problem may require a firmer and more directive stance; hopeless thinking may require a gentle exploration of possible suicidality; mistrust and abandonment schemas may require reassurance and clearer discussion of contractual boundaries.


2. What are the immediate problems that need action?

Often the client and therapist agree to work on the most urgent problems, i.e. the most damaging ones, first. But there are also other possible criteria for prioritising problems, such as the likelihood of achieving reasonably quick progress (thereby raising hope and increasing motivation). And new priority issues may emerge as therapeutic exploration continues, especially at Levels 3 and 4.


3. What is the individual psychology/psychopathology of this person?
What are their typical cognitive distortions, automatic thoughts, compensatory behaviours?
What is the inner logic of their irrational problems?
What are the relevant emotional and physiological factors, and maintaining cycles?

Sometimes the pattern which emerges fits well into an existing diagnostic category such as Social Anxiety (see e.g. the Case Example blog from 30 June); in other cases it is a more idiosyncratic mix. But this distinction is a continuum, not a dichotomy – there is always an individual aspect to the most textbook diagnosis, and familiar patterns in the most idiosyncratic psychopathology.


4. What are the developmental sources of the above difficulties?
How does this client see the world, what are their Core Beliefs?
What has been their relevant experiential learning?

This is a crucial piece – it can help clients enormously to see that their problems, and dysfunctional strategies, can actually make sense in the light of their underlying beliefs, and that these beliefs in turn can make sense in the light of their core learning experiences.


5. What core human issues are they struggling with?

It can also be helpful for both client and therapist if problems are seen in their larger human context. Social Anxiety problems, for instance, can be seen as understandably arising in relation to such central human concerns as Status, Belonging, Community, Reputation etc.


As mentioned above, the formulation which emerges at these later levels may in turn influence the style and focus of our work at Levels 1 and 2.


What I have described at levels 2, 3 and 4 are classic Cognitive Case Formulation; 1 and 5 are essential to any good therapy work, whether Cognitive-Behavioural, Humanistic or Psychodynamic. I believe that only Integrative CBT Case Formulation clearly combines them all.

Next week, some I plan to discuss some case examples from an Integrative CBT Case Formulation viewpoint, which hopefully will make everything clear...!



References

Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Persons, J.B. (1989) Cognitive Therapy in Practice: A Case Formulation Approach. New York: W.W. Norton.

Rogers, C.R. (1951) Client-centered Therapy. Boston

Holiday Reading (not!)

I’m signing off for holidays now – the next blog will be at the start of September.

In the meantime, as a partial follow-up to my comments on training last week, here are some books that I have found interesting and helpful in relation to the Integrative CBT approach.

These choices are personal, eclectic, and of the moment... some of them will be very familiar, others not. I’ll let you do your own googling if you want to find out more about any of them.



Level 1:

Clarkson, P. (2004) Gestalt Counselling in Action. London: Sage.

Gilbert, P. & Leahy, R.L. (2009) The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies. Routledge.

Power, M. (2010) Emotion-Focused Cognitive Therapy. West Sussex: Wiley-Blackwell.

Rogers, C.R. (1951) Client-Centered Therapy. Boston: Houghton Mifflin.

Safran, J. & Segal, Z. (1996) Interpersonal Process in Cognitive Therapy. Jason Aronson




Level 2:

Egan, G. (1994) The Skilled Helper: a Problem-management Approach to Helping.
5th edn. Pacific Grove: Brooks/Cole.

Glasser, W.R. (1999) Choice Theory: A New Psychology of Personal Freedom. HarperCollins.

Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change. New York: Guilford.

Nelson-Jones, R. (2006) Human Relationship Skills. Routledge.

Rosenberg, M.B. (2003) Nonviolent Communication: A Language of Life. Puddle Dancer Press.




Level 3:

Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York:
International Universities Press.

Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Bennett-Levy, J. et al (eds) (2004) Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: OUP.

Kouimtsidis, C. et al (2007) Cognitive Behavioural Therapy in the Treatment of Addiction. Chichester: Wiley.

Kuyken, W., Padesky, C.A. & Dudley, R. (2009) Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive Behavioural Therapy. New York: Guilford Press.

Sanders, D. & Wills, F. (2005) Cognitive Therapy: An Introduction. London: Sage.




Level 4:

Young, J.E., Klosko, J.S., & Weishaar, M. (2003). Schema Therapy: A Practitioner's Guide. Guilford Publications: New York

Harris, J.R. (1999) The Nurture Assumption. Bloomsbury Publishing.

Ridley, M. (2004) Nature via Nurture: Genes, Experience & What Makes Us Human. Harper Perrenial.

Bradshaw, J. (1991) Homecoming: Reclaiming and Championing Your Inner Child. Piatkus Books.

Fennell, M. (2009) Overcoming Low Self-Esteem: A Self-Help Guide Using Cognitive-Behavioural Techniques. London: Robinson




Level 5:

Buss, D. (2003) The Evolution of Desire: Strategies of Human Mating. New York: Basic Books.

Feltham, C. (2007) What’s Wrong with Us? – The Anthropology Thesis. West Sussex: John Wiley & Sons

Frankl, V.E. (1997) Man’s Search for Meaning – revised and updated. Simon & Schuster.

Gilbert, P. & Bailey, K.G. (2000) Genes on the Couch: Explorations in Evolutionary Psychotherapy. Hove: Brunner-Routledge.

Nabakov, V. (2000) Lolita. Penguin Classics.

Solomon, A. (2002) The Noonday Demon: An Anatomy of Depression. London: Vintage.

Tolstoy, L. (2003) Anna Karenina. Penguin Classics.

(And many more fiction classics, old and new – here’s a link to an interesting article from Psychiatric Times on “Why Psychiatrists Should Read the Humanities”)




Bye for now, see you in September…

Choosing from the Integrative CBT Menu

This week’s blog comes to you from Manchester University, where this year’s annual conference of the British Association for Behavioural & Cognitive Psychotherapies is being held, so I’m surrounded by CBT...

In this blog, the second-last one before I break for August, I want to say a bit more about how to make use of the ideas of Integrative CBT. In future blogs, I will explore Cognitive Case Formulation further, as this is the essential tool which guides the choice of interventions. In the meantime, Integrative CBT can also be seen as offering a menu of interventions to choose from, based on therapist style, preference and orientation, as well as on the client’s preference, the main issues/problems, and the stage of therapy. Many therapists will identify more with one level than with the others; this is fine, and is presumably based on training, personality, type of client issues, etc. From a theoretical viewpoint, however, the Integrative CBT model is based centrally around the Cognitive/Emotional focus of Level 3. This is based on sound scientific principles and research findings. However, therapy, especially with complex clients, is also an art, with an element of creativity needed – perhaps I should be using the metaphor of the palette rather than the menu...

The elements I have listed here may fall into various categories such as attitudes, skills, techniques, strategies, change factors, etc. Some are found at more than one level; for example, I have put Immediacy in at Levels 3 and 5, and it could probably be seen as relevant at other levels also. Some are more relevant to the therapist, some to the client. Please feel free to add to the list...

Level 1: Therapeutic Relationship

Contracting

Pacing

Attending

Active Listening, including non-verbal

Reflecting

Paraphrasing, summarising

Prompting, evoking

Empathising

Using Advanced Empathy

Containing, Supporting

Accepting, Validating, Encouraging

Use of self, Contact, Congruence

Using silence

Providing the client with a rationale

Assessment, Diagnosis

Getting feedback from the client

Level 2: Problem-Solving Action

Problem-clarification

Psychoeducation

Goal-setting

Prioritising, establishing an agenda

Planning, Committing, Reviewing and Evaluating

Specific life-skills training in areas such as Stress Management, Assertiveness etc

Giving advice, information, suggestions, recommendations

Exploring choices

Decreasing desirability of damaging options

Developing discrepancy, confronting

Providing feedback

Active helping

Supporting self-efficacy

Looking at previous solutions

Posing the Miracle Question

Level 3: Experiential Re-learning

Use of inventories, ratings

Diagnosis-specific Case Formulation

Untangling self-perpetuating vicious cycles

Self-monitoring

Identifying emotions

Staying with emotions

Socratic Questioning

Identifying cognitive distortions

Evaluating Evidence

Behavioural Experimentation

Continuum thinking

Cost/benefit analysis

Discovering alternative thoughts

Mindfulness training

Changing language

Immediacy

Formulating and testing concrete hypotheses

Level 4: Schema Change

Detailed life-history exploration

Identifying key schemas, core beliefs

Deeper Cognitive/Emotional restructuring

Exploring Transference/counter-transference issues

Catharsis

Individualised, longitudinal, developmental Case Formulation

Imagery, visualisation

Rescripting

Metaphor

Writing

Art therapy

Inner Child work

Psychodrama, Role Play, Modelling

Empty Chair work

Symbolic Letter

Level 5: Coming to Terms with the Human Condition

Exploring what it means to be human

Exploring the nature of sexuality, gender etc

Values exploration

Making individual spirituality/philosophy more explicit

Exploring individual meanings in relation to loss, death, transition etc

Self-disclosure

Immediacy

Meditation

12-Step work

Compassion-Focused Therapy

Exploring voluntary work, giving to community

Exploring Literature, History, Art

A detailed list like this has implications for Training & Development in Integrative CBT, which obviously requires a wide range of abilities. Many therapists are very skilled in some of the 5 levels, and not in others. Some may have skills at all 5 levels, but don’t conceptualise their work overall in a Cognitive way. Others have a set of CBT skills, but little training in relational therapy skills or longer-term developmental work. Many have some training and experience in pretty much everything else but good, evidence-based, Level 3 CBT. Only a very few have a well-thought-out view on human nature, based on wide-ranging study and reflection on lived experience. Training is something which I will come back to in a later blog.

For now, goodbye from Manchester...

Judith Beck on CBT Myths

Go to:
http://www.huffingtonpost.com/judith-s-beck-phd/cognitive-behavior-therap_b_638396.html


A few days ago, Judith Beck, president of the Beck Institute for Cognitive Therapy and Research and daughter of Aaron T. Beck, posted this blog on the Huffington Post, which I thought was worth re-posting here.

Case example 1, Part 2

My work with Richard continued on various fronts for about 12 weekly sessions, after which he came less regularly to monitor progress. The areas of principal focus were always agreed collaboratively and explicitly, although I provided strong guidance and direction, based on my experience of the kind of issues he was struggling with.

Level 3:
We initially focused primarily on trying to weaken some of the maintaining cycles of Richard’s social anxiety problem, in order to give him some relief, hope and energy. He borrowed a copy of “Overcoming Social Anxiety: A Self-help Guide using Cognitive-Behavioural Techniques”, and found this useful in educating himself about the problem and the ways in which it can be addressed.

The classic Social Anxiety pattern, as described a couple of weeks ago, consists of tendencies
• To worry and mentally rehearse before social events
• To practice a range of “Safety Behaviours” in social settings
• To carry out a self-critical “post mortem” after social events.

Richard did not do a lot of the pre-event rehearsal and anticipation, because of his huge avoidance of (and avoidance in) social settings, but he was quite capable of self-punishing post-mortems, “chewing over” almost any interpersonal encounter in a negative way. We worked together to try and get a sense of what was going through his mind when he was feeling anxious during and after social situations, and discovered that the following Negative Automatic Thoughts were common for him:

“I’m different”
“They don’t like me”
“They’re only being nice”
“I look/sound stupid”
“I made a mess of that”

He could also identify typical cognitive distortions such as All or Nothing Thinking, Discounting Positive Feedback, Mind-reading, Emotional Reasoning, and Catastrophising.

We agreed that, in order to reality-test some of these in an experiential way, he must, at some point, begin to drop some of his safety behaviours, and see what happens. Some of his main safety behaviours were:
• Avoiding eye-contact and conversation – he would spend minimal time in the staff room, preferring to stay busy, volunteering for every possible activity with pupils
• Sticking to task-oriented, work-related conversation
• Avoiding social outings (pubs, parties etc).

Fortunately he had never developed the habit of using alcohol to cope with social situations or with his loneliness, so this was not an issue.


Level 1:
Lots of support was needed, as Richard was very fearful of even thinking about changing any of these patterns. The therapeutic relationship was very important in this regard, as well as in the use of Immediacy, by providing positive feedback as to how Richard was coming across in the therapy relationship.


Level 2:
This opened up the possibility of rehearsal and practice. Richard feared that his social skills were poor, but in fact they were mostly fine, apart from the lack of practice that comes from too little time spent with people and too much time spent with a computer.
Reality-testing his fears took a lot of courage, so we also did some motivational work on risk assessment and cost/benefit analysis.


Level 3:
Fortunately, when Richard took the risk to make a little more eye contact, and to ask colleagues about their holidays etc, he was amazed at how much less awful it was than he had feared it would be. Of course, this result was in large part due to appropriate cognitive preparation and therapeutic support.


Level 4:
Richard made so much progress that he began to be puzzled as to how his problems could have been so deeply ingrained, so we talked again about the maintaining cycles and blocks to experiential learning. We also spent some time again talking about the early maladaptive schemas that were probably part of the roots of his difficulties. His father had had very rigid rules for the family, and no friends were allowed to visit the home. This had always embarrassed Richard greatly, and his sense of shame and his withdrawal had gradually reinforced each other to the extent that even when he left home to go to college, he still felt very different from everyone else. This in turn left him still very dependent on his parents for his age, and one of the Level 2 skills we needed to work on was Assertiveness.


Level 5:
We also discussed the fact that people vary in their sociability, both in amount and in style, and that it was important that he develop his own way, rather than try to be too much of what he thought he “ought” to be. I also reassured him that relationships could be difficult for everyone at times, and that now that he was getting more confident and considering the possibility of dating, the fun was only starting!