Case Conceptualization in CBT Case Formulation Treatment Plan

Case Conceptualization in CBT Case Formulation Treatment Plan Conceptualization of Problems

7 Steps in CBT Case Formulation 1. What are the patient’s problems? 2. 5 axis DSM diagnosis 3. Primary (anchoring) diagnosis (problem) 4. Nomothetic formulation of the primary problem 5. Idiographic formulation of the primary problem 6. Develop hypotheses 7. Identify recent precipitants and/or common antecedents/consequences to primary problem

Case Formulation: SORC Model § Stimuli (i. e. , triggers) § Organism factors (inside the skin) § Response (i. e. , problem behavior) § Consequence (i. e. , what happened next)

Basic Structure of a Treatment Plan I. Treatment Target 1 A. Objective 1 1) Goal 1 2) Goal 2 II. Treatment Target 2 A. Objective 1 1) Goal 1 2) Goal 2 B. Objective 2 1) Goal 1 2) Goal 2

Basic Structure of a CBT Treatment Plan: Patient Example(48 y/o divorced female) I. Prevent relapse of depression I. Treatment Target 1 A. Objective 1 1) Goal 1 2) Goal 2 B. Objective 2 1) Goal 1 2) Goal 2 A. Improve relationships with family 1) Identify clear values/goals relevant to relationships with each family member (i. e. , what does she want? ) 2) Assertiveness skills (e. g. , DEARMAN) B. Regulate acute emotions well 1) Enhance emotional awareness and discrimination of emotions 2) Use cognitive reappraisal C. Maintain social activities 1) Behavioral activation

Basic Structure of a NON-CBT Treatment Plan: Patient Example I. Prevent relapse of depression A. I. Treatment Target 1 A. B. Objective 1 B. Objective 2 C. 1) Goal 1 2) Goal 2 Improve relationships with family 1) Have better boundaries 2) Become less enmeshed with family 3) Increase self-esteem Regulate acute emotions well 1) Bring unconscious defenses into awareness 2) Vent emotions when upset Enhance social opportunities 1) Overcome unconscious patterns of early childhood attachment 2) Overcome childhood trauma by expressing one’s inner self

Targeting • Presenting Problem • Dx Asmt. • Psychosoc. Asmt. Evidence. Based Treatment Problem du jour Conceptualization of Problem (SORC, ABCs) Homework Your New Ideas!

Change in CBT Thoughts Feelings Behaviors Physiology

An example: Thought: I won’t be able to go to the mall Behavior: Avoidance Procrastination Feeling State: Anxiety Fear Physiology: Limbic system (e. g. , amygdala) Endocrine (e. g. , cortisol) Autonomic (e. g. , sweating)

Validation 1. Paying attention 2. Active listening 3. Therapeutic mindreading 4. Making sense of bx due to past or biology 5. Making sense of bx due to the present 6. Radical genuineness

Behavioral “Chain” Analyses

Vulnerability Factors Inside the Skin Outside the Skin Antecedents Behavioral Problem Consequences

Vulnerability Factors • • Inside the Skin Outside the Skin Tired Physically ill Meds not taken Pain Antecedents • • Thoughts Emotions Sensations Memories Behavioral Problem • • • Fear, anxiety, shame, anger action urges Increased physical pain Problematic beliefs Consequences • • Temporary relief of shame, anger, etc. Feel out of control Feel incapable Feel victimized

Vulnerability Factors Inside the Skin • • • Outside the Skin Stressful events Nighttime Unpredictable situation Antecedents Behavioral Consequences • People • Places • Things • Freeze • Fight • Flight • Harm to self • Harm to others • Do not learn Problem

Building and Refining a CBT case Conceptualization Initial Assessment Behavioral Analyses Case Conceptualization Hypotheses

Conceptualizing Dysfunctional Thoughts Assumptions, Rules, Attitudes Automatic Thoughts Core Beliefs

Conceptualizing Dysfunctional Thoughts “Men will use me” “Who cares about relationships? They always end badly” “I will always be alone” “I am not lovable” “If I am vulnerable bad things will happen”

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 theirs