Cognitive-Behavioral Therapy: Theory, Techniques, and Applications, 3rd Edition _ _____________________
Hopelessness Scale (BHS), Clark-Beck Obsessive-Compulsive Inventory (CBOCI), and BDI – Fast Screen for Medical Patients (Patient Assessment Tools, n.d.). Additional instru- ments include the Cognitive Therapy Rating Scale – Revised (Blackburn et al., 2001); Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND; Tolin et al., 2018); and the public domain scales Generalized Anxiety Disorder Screener (GAD-7; Spitzer et al., 2006) and Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001). Pearson Assessment provides guidance on using self- report instruments as part of tele practice, including ethical, legal, and competence issues related to tele practice (Corey & Ben-Porath, 2020). Assessment is an ongoing process for cognitive therapists. They use information collected during the assessment to develop the initial case formulation. When new information emerges during the course of therapy, they revise the case formulation and resulting treatment plan as appropriate. Case Formulation Case formulation is used in various treatment approaches, and cognitive therapy is no exception. Essentially, case formulation reflects the therapist’s hypothesis about a client’s challenges and what causes precipitants and maintaining factors related to those challenges (J. S. Beck, 2020). Such formulations typi- cally include and consider the presenting issues, associated developmental history, and coping abilities. Additionally, the mechanism(s) by which these factors are linked and contribute to the maintenance or worsening of pathology are posited and inform the selection of the treatment approach and techniques. Within cognitive therapy, case formulation models vary regard- ing what is emphasized but generally address underlying mecha- nisms by which problematic cognitions, beliefs, and behaviors are maintained. Those mechanisms are then targeted through the deliberate and purposeful determination of a treatment plan and the selection of associated techniques or approaches. Key and Bieling (2015) propose five main tasks of case formula- tion in cognitive therapy: 1. First, they suggest developing a comprehensive problem list that includes multiple domains, not solely symptoms or DSM diagnoses. These domains may consist of overall health and well-being, physical functioning, medical health, mood complaints, interpersonal challenges, achievement issues, and so on. The problem list should be individualized and client-driven through clinical interviews and assessment tools. Consider also that problems can fall at different levels; there are problems associated with daily life, and then there are deeper problems that potentially underlie those the client observes or experiences in their day-to-day existence. Importantly,
determining problems should be a client-centered approach in which clients are asked what their goals and values are for their lives and their health, what they believe is interfering with them reaching their full potential, what they would like to target for change, and so forth. 2. A case formulation’s second component is identifying the proposed underlying mechanism. The underlying mechanism is the central, dysfunctional beliefs that influence a client’s overt (or evident) difficulties. The problem list can help point the way to the underlying belief that is maintaining a client’s suffering. Hypothesizing underlying mechanisms can be accomplished through disorder-specific therapies associated with empirically supported treatments or the application of the general cognitive theory itself (Brown & Clark, 2015; Persons, 2012). 3. Next, the case formulation reflects the therapist’s hypothesis of how the client acquired the underlying mechanisms that are causing their symptoms and also determines what activating events or stressors may have contributed to the exacerbation or presentation of the symptoms at this point in time. Identifying both the distant origins and present or recent precipitants of mechanisms can be challenging and typically relies on the combination of clinical interviews and structured assessment (Brown & Clark, 2015). 4. The fourth and fifth steps bring the case formulation together to determine treatment directions and implications and to continue to modify and refine the formulation as more is learned via the process. Initially, bringing together the case formulation does not require additional assessment (as that would have been completed via the earlier steps). Instead, it means that the therapist is integrating the information learned thus far in the context of cognitive theory. However, refining this formulation will require integrating additional information as it is discovered, other assessment data, and incorporating what is learned through treatment techniques and interventions and client self-monitoring (Brown & Clark, 2015). 5. Case formulation is an ongoing process and is not done once and forgotten. It is informed by available client data and specific to the client. The therapist should refine the formulation, hypothesis, and inferences as new information and data become available. Case formulation helps to guide clinical decision-making and provides a framework from which the therapist can plan treatment and collaborate with the client.
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