Clinical Case Formulation & Treatment Planning: A Fact-to-Inference Strategy for Teaching Psychologists in Training

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Clinical Case Formulation & Treatment Planning: A Fact-to-Inference Strategy for Teaching Psychologists in Training

James Tobin, Ph.D.

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Inherent Difficulty

Research indicates that case formulation is one of the most difficult skills for graduate students to learn/achieve a basic level of competence.

It is also the most seldom taught and the most poorly taught.

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Training Sites

Pre- and postdoctoral training sites typically rate case formulation as the most under-developed skill among trainees.

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Major Transition in Professional Development

Achieving competence in case formulation represents a major transition in professional development from mastery of introductory material and rote memory (declarative knowledge) and the application of theoretical constructs to clinical data (applied knowledge).

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Attitudinal Shift

It also represents an attitudinal shift in the mind of the trainee from “getting the right answer” to identifying, organizing and articulating one’s subjective opinion and judging its plausibility and coherence.

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Personhoodof the Trainee

Accomplishing this transition reflects an advanced level of cognitive functioning and self-assessment in which the personhood of the trainee and his/her vision of the human condition is successfully incorporated into an ability to evaluate, infer and synthesize complex clinical data.

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Delayed or Inhibited Progression

In my view, what is most surprising about the skill development of many students across their doctoral training years is that the transition from declarative and applied knowledge to this more advanced level of cognitive functioning and the use of the self (for a range of professional activities including, but not limited to, case formulation) is slow to occur or does not occur as readily as we would expect or like.

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Why is this the case?

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Against Hierarchical Learning

In my view, there is an erroneous pedagogical assumption underlying most doctoral training programs: learning is hierarchical in nature (i.e., “learn the basics first” before more advanced competencies pertaining to subjective judgment, creativity, inferential and critical thinking, and self-assessment can be developed).

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Erroneous Assumption

This erroneous assumption emanates from the belief that the student’s capacity to draw from his/her subjective experience in order to organize and integrate clinical data is not available or is largely misguided.

It is also presumed that most students feel anxious and overwhelmed if “left to their own devices” (i.e., they need a structure or approach to case material first before they can execute higher levels of inferential and critical thinking).

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I disagree!!

https://www.youtube.com/watch?v=S6xyHna-NuM

“I think you have something inside of you that is worth a great deal”



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Anxiety and Intellectual Paralysis

Anecdotal evidence suggests that many students, either at the beginning of training or as training proceeds, suffer from a similar anxiety and intellectual paralysis as the boy in the film: they lose confidence (or never had it in the first place) in their own perspective, subjective vantage point and personal/professional voice.

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Interiority Diminishes

Consequently, their “subjective voice” is subdued and lies dormant as they progressively become more invested in appeasing instructors/supervisors and more distanced from personifying what they are learning (and failing to learn what they are personifying).

Along the way, an investment in one’s interiority gradually diminishes -- readily seen in the difficulty students have with writing personal essays for the APPIC internship application and in the interview process.

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Attempting Case Formulation in the Wake of Lost Subjectivity

I present a 1-paragrah case vignette and ask students to provide a case formulation.

What I typically get are responses that feature: (1) a recycling of the vignette (no formulation); (2) an incoherent or oversimplified narrative about the case that fails to delineate cause or maintenance of symptoms or distress (no inference); and/or (3) the absence of a compelling appraisal of the human condition inherent in the case.

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The “Failure to Think on Your Feet” Syndrome

I believe these typical responses are due NOT to a lack of basic knowledge or an organizational model for how to formulate a case, but a paralyzed capacity to draw from one’s subjective experience in order to mobilize declarative and applied knowledge.

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Subjectivity as a Portal for Learning

I would take this argument one step further: the failure to think on one’s feet indicates not only that one lacks confidence in, and the capacity to articulate, one’s subjective view, but that actual learning (that previously occurred) was not encoded in a personalized way.

I believe subjectivity must first be engaged and supported before subsequent learning can occur – subjectivity is a portal; this is in contrast to the view that declarative knowledge must first occur before subjectivity can be encouraged.

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“Subjectifying” Learning

Clinical case formulation features the tension and complex interplay between objective knowledge and subjective refinement: I am suggesting that if foundational learning was not “subjectified” all along, when the moment of truth arises (in an interview, for example) declarative and applied knowledge will not be available to the trainee’s creative, critical and synthetic capacities (resulting in a failure to think on one’s feet).

Knowledge can be accessed and utilized only if it had been initially encoded through and within a portal of personalization.

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An Exercise

I have begun to raise the following question to students: What is your personal view of the cause of human suffering, distress and/or psychopathology?

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Resistance

It is shocking to me the degree of resistance on the part of most students even to the question; it’s as if they already believe their own personal view of the human condition/subjectivity is irrelevant (indicating that the“subjectifying” learningprocess I am proposing has already been abandoned inthe minds of most students).

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Freud’s Personal View of the Human Condition

I give examples: i.e., Freud: humans are oriented toward their own demise – all mental conflict (“neurosis”) and all misguided behavior and emotions (the death instinct) are the consequences of an innate need to avoid/deny reality.

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The Diathesis-Stress Model

I then present the diathesis-stress model and ask students to apply this model to the same 1-paragragh case vignette described previously.

The differences are startling! And then I explain that the diathesis-stress model is inherently a personalized value system (focusing on the interplay between predisposition or vulnerability and stressors).

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Summary: Subjectified Learning Instead of Hierarchical Learning

I believe that if students’ personhoods/subjective accounts of the human condition (their “personal value system”) were invited, supported, and articulated in the early stages of training, professional competencies that are inherently value-laden, subjective and “personal” (such as case formulation) would more successfully evolve across the training years as the portal of subjectivity consistently encodes and binds with accumulated declarative and applied knowledge.

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A five-phase approach to teaching case formulation (that includes treatment planning and interviewing a potential new patient)

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Phase I: “Personal View of the Human Condition”

Prime students’ readiness to subjectify the declarative and applied knowledge they will soon gain.

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A New Exercise I am Trying

• 1.) Create the logo for your practice/practice approach

• 2.) Articulate your unique view of the human condition and how distress/psychiatric symptoms/problems (e.g., obesity) emerge and can be addressed with your treatment approach: encapsulate all of this into a unique construct you create and trademark

• 3.) Create a product or service based on #2 that you will market

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https://www.youtube.com/watch?v=YDYcOnEqtzI

(6:00 .... “Imago”)



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Imago Therapy: Unique View of the Human Condition

The basic principles of Imago Relationship Therapy are as follows:

• We were born whole and complete.• We became wounded during the early nurturing and

socialization stages of development by our primary caretakers.

• We have a composite image of all the positive and negative traits of our primary caretakers deep in our unconscious mind. This is called the Imago. It is like the unconscious blueprint of the one we need to be our partner in a committed, intimate relationship.

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• We look for someone who is an "Imago match," that is, someone who matches up with the composite image of our primary caretakers. This is important because we marry or commit for the purpose of healing and finishing the unfinished business of childhood. Our parents are the ones who wounded us, but a primary love partner who matches their traits is their stand-in.

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• Romantic love is the door to a committed relationship and/or marriage and is nature's way of connecting us with the perfect partner for our eventual healing.

• We move into a power struggle as soon as we make a commitment to this person. The power struggle is necessary, for imbedded in a couple's frustrations lies the information for healing and growth.

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• The first two stages of a committed relationship, "romantic love" and the "power struggle," are engaged in at an unconscious level. Our unconscious mind chose our partner for the purpose of healing childhood wounds.

• Inevitably, our love partner is incompatible with us and least able to meet our needs and most able to wound us all over again.

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• The goal of Imago Relationship Therapy is to align our conscious mind, which usually wants happiness and good feelings, with the agenda of the unconscious mind, which wants healing and growth. Thus, the goal of therapy is to assist clients to develop conscious, intimate, committed relationships.

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• This transition cannot take place through insight alone. Specific skills and processes are necessary that need to be practiced daily to shift us from having an unconscious relationship to a conscious relationship.

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Phase II: “Content & Applied Knowledge”

Help students learn basic theory and accurately apply theoretical constructs to clinical data.

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Case Formulation & Treatment Planning Primer: November, 2013

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Overview of Case Formulation• Ingram, B.L. (2006). Integrative case formulations in psychotherapy: An

elusive goal or an emerging clinical reality. Hoboken, NJ: Wiley.• Eells, T.D. (Ed.) (2010). Handbook of psychotherapy case formulation (2nd

ed.). New York, NY: Guilford Press.• Melchert, T. P. (2013). Beyond theoretical orientations: The emergence of a

unified scientific framework in professional psychology. Professional Psychology: Research and Practice, 44, 11-19.

• Tarrier, N., & Calam, R. (2002). New developments in cognitive-behavioural case formulation. Epidemiological, systemic and social context: An integrative approach. British Association for Behavioral and Cognitive Psychotherapies, 30, 311-328.

• Blott, M.R. (2008). Encountering differences in graduate training: Potential for practicum experience. Journal of Psychotherapy Integration, 18, 437-452.

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1. Family Systems

• Chabot, D.R. (2011) Family systems theories of psychotherapy. In J. Norcross, G.R. VandenBos, & Freedheim, D.K. (Eds.), History of psychotherapy: Continuity and change (2nd ed.) (pp. 173-202). Washington, D.C.: American Psychological Association.

• Stanton, M., & Welsh, R. (2012). Systemic thinking in couple and family therapy research and practice. Couple and Family Psychology: Research and Practice, 1, 14-30.

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2. Cognitive/Cognitive-Behavioral• Persons, J.B., & Davidson, J. (2001). Cognitive-behavioral case

formulation. In K.S. Dobson (Ed.), Handbook of cognitive–behavioral therapies (2nd ed.) (pp. 86-110). New York, NY: Guilford Press.

• Persons, J.B., Davidson, J., & Tompkins, M.A. (2001). Individualized case formulation and treatment planning. In J.B. Persons, J. Davidson, & M.A. Tompkins, M.A. (Eds.), Essential components of cognitive- behavior therapy for depression (pp. 25-55). Washington, D.C.: American Psychological Association.

• Persons, J.B., Curtis, J.T., & Silberschatz, G. (1991). Psychodynamic and cognitive-behavioral formulations of a single case. Psychotherapy, 28, 608-617.

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3. Behaviorism• G.R. VandenBos, & D.K. Freedheim (Eds.), History of

psychotherapy: Continuity and change (2nd ed.) (pp. 101-140). Washington, D.C.: American Psychological Association.

• Wagner, A.W. (2005). A behavioral approach to the case of Ms. S. Journal of Psychotherapy Integration, 15, 101-114.

• Kohlenberg, R.J., & Tsai, M. (1995). Functional analytic psychotherapy: A behavioral approach to intensive treatment. In W. O’Donohue, & L. Krasner (Eds.), Theories of behavior therapy: Exploring behavior change (pp. 637-658). Washington, DC, US: American Psychological Association.

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4. Multicultural/Cross-Cultural• Shea, M., Yang, L.H., & Leong, F.T.L. (2010). Loss, psychosis, and chronic suicidality in a

Korean American immigrant man: Integration of cultural formulation model and multicultural case conceptualization. Asian American Journal of Psychology, 1, 212-223.

• Cheung, F.M. (2012). Mainstreaming culture in psychology. American Psychologist, 67, 721-730.

• Lewis-Fernandez, R., & Diaz, M. (2002). The cultural formulation: A method for assessing cultural factors affecting the clinical encounter. Psychiatric Quarterly, 73, 271-295.

• Bracero, W. (1996). Ancestral voices: Narrative and multicultural perspectives with an Asian schizophrenic. Psychotherapy: Theory, Research, Practice, Training, 33, 93-103.

• Comas-Diaz, L. (2012). Humanism and multiculturalism: An evolutionary alliance. Psychotherapy, 49, 437-441.

• Hendricks, M.L., & Testa, R.J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43, 460-467.

• Constantine, M.G. (2001). Multicultural training, theoretical orientation, empathy and multicultural case conceptualization ability in counselors. Journal of Mental Health Counseling, 23, 357-372.

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5. Feminism• Carneiro, R., Russon, J., Moncrief, A., & Wilkins, E. (2012). Breaking

the legacy of silence: A feminist perspective on therapist attraction to clients. World Academy of Science, Engineering, and Technology, 66, 1064-1067.

• Evans, K.M., Kincade, E.A., Marbley, A.F., & Seem, S.R. (2005). Feminism and feminist therapy: Lessons from the past and hopes for the future. Journal of Counseling and Development, 83, 269-275.

• McAndrew, S., & Warne, T. (2005). Cutting across boundaries: A case study using feminist praxis to understand the meanings of self-harm. International Journal of Mental Health Nursing, 14, 172-180.

• Vandello, J.A., & Bosson, J.K. (2013). Hard won and easily lost: A review and synthesis of theory and research on precarious manhood. Psychology of Men & Masculinity, 14, 101-113.

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6. Psychodynamic

• Ivey, G. (2006). A method of teaching psychodynamic case formulation. Psychotherapy: Theory, Research, Practice, Training, 43, 322-336.

• Curtis, J.T., Silberschatz, G., Weiss, J., Sampson, H., & Rosenberg, S. E. (1988). Developing reliable psychodynamic case formulations: An illustration of the plan diagnosis method. Psychotherapy, 25, 256-265.

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7. Humanistic/Existential

• Farber, E. W. (2010). Humanistic-Existential psychotherapy competencies and the supervisory process. Psychotherapy: Theory, Research, Practice, Training, 47, 28-34.

• Sachse, R., & Elliott, R. (2002). Process-outcome research on humanistic therapy variables. In D.J. Cain (Ed.), Humanistic psychotherapies: Handbook of research and practice (pp. 83-115). Washington, D.C.: American Psychological Association.

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8. Narrative/Constructivist• Lambie, G.W., & Milsom, A. (2010). A narrative approach to

supporting students diagnosed with learning disabilities. Journal of Counseling and Development, 88, 196-203.

• Bob, S.R. (1999). Narrative approaches to supervision and case formulation. Psychotherapy, 36, 146-153.

• Martin, J. (2013). Life positioning analysis: An analytic framework for the study of lives and life narratives. Journal of Theoretical and Philosophical Psychology, 33, 1-17.

• Daniel, S.I.F. (2009). The developmental roots of narrative expression in therapy: Contributions from attachment theory and research. Psychotherapy: Theory, Research, Practice, Training, 46, 301-316.

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9. Interpersonal Neurobiology

• Siegel, D.J. (2002). The developing mind and the resolution of trauma: Some ideas about information processing and an interpersonal neurobiology of psychotherapy. In Shapiro, F. (Ed.), EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism (pp. 85- 121). Washington, D.C.: American Psychological Association.

• Fishbane, M.D. (2007). Wired to connect: Neuroscience, relationships, and therapy. Family Process, 46, 395-412.

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10. Developmental/Developmental Psychopathology

• Nigg, J.T., Martel, M.M., Nikolas, M., & Casey, B.J. (2010). Intersection of emotion and cognition in developmental psychopathology. In S.D. Calkins, & M.A. Bell (Eds.), Child development at the intersection of emotion and cognition. Human brain development (pp. 225-245). Washington, D.C.: American Psychological Association.

• Miklowitz, D.L. (2004). The role of family systems in severe and recurrent disorders: A developmental psychopathology view. Development and Psychopathology, 16, 667-688.

• Masten, A.S., Faden, V.B., Zucker, R.B., & Spear, L.P. (2009). A developmental perspective on under-age alcohol abuse. Alcohol Research and Health, 32, 3-15.

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11. Biopsychosocial Approach

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Phase III: “Inference and Style”

Help students differentiate and begin to move seamlessly between observation/fact and inference, which starts to promote integrative complexity and the capacity to self-assess plausibility, coherence, and the tension between ignoring some data and/or over-emphasizing other data.

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The Six Styles

Case Conceptualization and Treatment Planning: Integrating Theory With Clinical Practice (Second Edition)

Pearl S. BermanIndiana University of Pennsylvania2010

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Berman’s Six Styles (see handout)

• Assumption-based • Symptom-based• Interpersonally-based • Historically-based • Thematically-based• Diagnosis-based

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The Assignment to Promote Phase III: “Inference and Style”

For the Conceptual Formulation Section of the Diagnostic CCE, I ask students to (1) choose one of the six styles, (2) limit the case formulation to 1-2 paragraphs, and (3) demarcate in different colors the following:

• descriptive material/facts (25%)• inferential material/leaps from observations or facts to theoretical

concepts (25%)• mixture of fact, inference, and one’s vision of the human condition

(50%)

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Phase IV: “The Treatment Plan”

Capitalize on phases I, II, and III by helping students develop treatment plans directly related to their case formulations (a range of treatment plan structures are provided in the Berman text).

In the Diagnostic CCE, I focus students’ attention on the quality of their summaries of their case formulations – these summaries are positioned right before the short- and long-term treatment goals.

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Phase V: “Interviewing a Potential Patient”

Bring the prior four phases to bear on the organization and choice points when initially meeting with a potential patient in a 2-3 session assessment phase (which leads to the determination of whether or not the trainee thinks he/she would be able to help a particular patient and, if so, if the trainee actually wants to work with a particular patient).

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• For the first interview, try this:

-welcome the patient, make sure he/she has filled out all informed consent paperwork

-before anything really starts, go over with the patient verbally issues of privacy and confidentiality and talk about the situations in which you may be required by law to breach confidentiality

-you then can say: “Let's begin – what’s on your mind? what’s happening in your life that is distressing or concerning for you?”

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• The patient will start talking (I never take notes, but you may want to in starting out)

-As the patient is talking, you are attempting to understand and empathize, and from time to time you make a few inquiries if they come up for you

-try to understand in a general way when the issues or problems first arose, etc.

-as the patient is talking, try to hit some general areas so that you at least know a little about them even if they don't come up in what the patient presents: any medical problems, school/career/finances, are they married/single, etc.

-ask if they have been in therapy before and if so get details .... ask if they have ever been on meds and get details

-you will want to try to get some basics on their family of origin and early development

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• As you're listening to all of this information, you are thinking in your mind about your personal value system (view of the human condition) and using it to generate inquiries and begin to organize the clinical material: i.e., for Dr. Tobin: what was the basic need the patient did not get met from significant others in his or her past, and what is the patient now looking for in relationship with others (and you the therapist) that he/she has not received or is ambivalent about receiving?

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• This is about all the detail you can get into in the first session, which is fine .... as the session begins to near to a close, stop the patient and indicate that you only have about 8 or 9 minutes left in the session

-summarize what you heard, identify the major areas the patient wants to address, and then say something general about how you think therapy may help or be warranted

-BUT DON'T AGREE TO START THERAPY AT ALL YET ... SAY YOU WOULD LIKE TO MEET AGAIN TO GET SOME MORE INFORMATION (you can refer to this as the “second assessment interview”)

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• EXPLAIN THAT AT THE END OF THAT SECOND SESSION THE PATIENT CAN (1) TALK ABOUT HIS/HER COMFORT LEVEL WITH YOU, AND (2) YOU CAN DISCUSS YOUR COMFORT LEVEL WITH THE PATIENT

- AT THAT POINT, (3) YOU CAN DEVELOP TREATMENT GOALS AND EXPLAIN MORE ABOUT HOW THERAPY WORKS IF YOU FEEL TREATMENT IS WARRANTED

-make sure you are clear about the process of all of this so that the patient feels like he/she is an informed consumer ... explain that you will be glad to meet again for a second assessment session, and at that point you will make recommendations and determine if therapy is warranted and, if so, if you feel you are the right person for the patient.

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• This is very important because you must learn that you don't have to take on a patient you don't want, and that therapy is NOT warranted for all patients ....

-go through all of this, and then set up a second assessment time for the following week .... if the patient alludes to a regular time to meet, avoid that and say "we are not there yet" .... just schedule the next appt. time

...... you and I will need to discuss what to say/do at the end of that second assessment session.

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THE END!Thanks for your attention!!

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James Tobin, Ph.D.• Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1Newport Beach, CA 92660• Assistant Professor of Clinical PsychologyThe American School of Professional Psychology at Argosy University

Email: [email protected] Website: www.jamestobinphd.com 949-338-4388

mailto:[email protected]

http://www.jamestobinphd.com/

Education

Clinical Case Formulation & Treatment Planning: A Fact-to-Inference Strategy for Teaching Psychologists in Training