Introduction to CBT - Case Conceptualization

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28 Terms

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Case Conceptualization

The formulation is a hypothesis about the mechanisms causing and maintaining the patient’s problems.

  • The therapist uses the formulation (and other information) to develop a treatment plan and obtain the patient’s informed consent to it.

  • Context is important

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Case Conceptualization

  • Comorbidity

  • Idiographic vs nomothetic

  • Functional analysis

  • Of behavior: Triggers, Consequence (can be a “reinforcer” or “punisher)

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Idiographic

Individual traits and experiences

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Nomothetic

General traits, laws, and principles

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Purpose of Case Conceptualization

  • To better understand behavior

  • To increase empathy

  • To identify ways to engage clients

  • To identify targets for intervention

  • To create a shared understanding of a child or adolescent

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Goals of Case Conceptualization

Patient story

  • Obtain understanding of patient’s presenting problems

  • Identify variables related to difficulties

  • Identify treatment targets, goals, and objectives

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Case Conceptualization - Characteristics

  • A method and clinical strategy to obtain and organize information about the patient. 

  • Incorporates areas such as learning history, maintaining factors, and presenting problem

    • Emphasis of factors may differ depending on theoretical orientation

  • Can work as a “map” or “blueprint” of treatment based on personalized factors

  • Should continually be updated throughout treatment

    • Collaborative empiricism

  • Diagnosis vs. formulation

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Diagnosis

  • Categorical

  • Useful to quantify outcomes

  • May help cluster shared symptoms

  • Easy to use

  • More reliable than formulation

  • May ease clinical decision making

  • Increases familiarity between professionals

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Formulation

  • Dimensional/personalized

  • May improve clinical decision making/outcomes

  • Can address shared mechanisms

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Why Do We Need Conceptualization?

  • Why not just follow the manuals?

    • Even the most efficacious interventions have non-100% success rates

      • Limitations of clinical trials, RCTS

  • Why not just really on clinical wisdom?

    • Therapist judgement is highly fallible (internal and external biases)

    • Ethics: boundaries of competence

  • Why not just defer to the patient as the expert on themselves?

    • Patients don’t seek care if they know what to do and can do it alone

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Case Conceptualization Terminology

  • Biopsychosocial assessment model

  • Case conceptualization: more broad

  • Functional analysis: more narrow, part of a case conceptualization

  • Statistical significance vs. clinical significance

  • Effect sizes: can lead to determine clinical significance

  • Meta analyses

  • Randomized controlled trials (RCT)

  • Efficacy vs. effectiveness

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Efficacy vs. Effectiveness

Efficacy: internal validity

  • Does it work in a controlled environment?

Effectiveness: external validity

  • Does it work in the real world?

Most treatments/studies start in an efficacy trial and then move to effectiveness trials.

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General Process of Case Conceptualization

  • Descriptive emphasis

    • Derived from assessment

  • Treatment recommendations

    • Flows directly from assessment, hypotheses, and proposes a treatment plan.

  • Review and update

    • Based on additional data, response to treatment.

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Data to Help Inform Case Conceptualization

  • Observations

  • Clinical interview

  • Information from sources in client’s life

  • Psychological tools for assessment

  • Past records (medical, academic, etc.)

  • Self-report questionnaires

  • Self-monitoring

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5 Ps

Idiographic framework

  • Presenting problem

  • Predisposing factors

  • Precipitating factors

  • Perpetuating factors

  • Protective factors

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5 Ps - Presenting Problem

What the patient and clinician identify as difficulties.

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5 Ps - Predisposing Factors

Biological, genetic, environmental, psychological, or personality risk factors

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5 Ps - Precipitating Factors

Significant events preceding onset of disorder.

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5 Ps - Perpetuating Factors 

Repeating behavioral, cognitive, or biological patterns that maintain dysfunction. 

  • Focus of CBT

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5 Ps - Protective Factors

Strengths and supports.

  • Examples: friends and family, animals, religion

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Case Formulation - SORC Model

  • Stimuli (e.g., triggers)

  • Organism factors

  • Response (e.g., problem behavior)

  • Consequence

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5 Ps vs. SORC 

Focus: 

  • 5 Ps: Broad bio psychosocial formulation of overall case

  • SORC Model: Functional analysis of a specific behavior/problem

Strength: 

  • 5 Ps: Big-picture understanding of the person’s history, context, and strengths

  • SORC: Vert practical for identifying and changing specific behaviors

Include Strengths? 

  • 5 Ps: Yes, protective factors

  • SORC: Not explicitly

Common in: 

  • 5 Ps: CBT, general clinical/psychiatric assessment, complex cases

  • SORC: Behavioral/CBT casework, worksheets, behavior plans

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Cognitive Model

Cognitive tread: thoughts, feelings, and behaviors

  • Seek to make thoughts truthful

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Challenges to Case Conceptualization

  • Complex cases

  • Connecting seemingly different problems

  • Prioritizing

  • Time management

  • Changes in what the patient/client wants to target

  • Client/patient insight

  • Client/patient willingness

  • Client/therapist expectations about therapy

  • Having hypotheses and refining them

  • Congruence between your goals and their

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Results of Case Conceptualization

Treatment planning

  • Goal: use case formulation to select appropriate, matched interventions

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Basic Structure of Treatment Plan

Treatment target

  • Objective 1

    • Goal 1

    • Goal 2

  • Objective 2

    • Goal 1

    • Goal 2

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Example of CBT Treatment Plan Structure

Target: Prevent relapse of depression

  • Goal 1: Improve relationships with family

    • Objective 1: Identify clear values/goals relevant to relationships with each family members

    • Objective 2: Assertiveness skills

  • Goal 2: Regulate acute emotions well

    • Objective 1: Enhance emotional awareness and discrimination of emotions

    • Objective 2: Use cognitive reappraisal

  • Goal 3: Maintain social activities

    • Objective 1: Behavioral activation

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Ways to Reassess Treatment Plan if it’s not Working

  • Return to the formulation

  • Modification in data used to create the formulation

  • Modification in formulation

  • Modification in treatment approach to change the targets