Staff Perspective: Book Review of Psychotherapy Case Formulation
Eells, Tracy D. (2015). Psychotherapy Case Formulation. Washington, DC: American Psychological Association.
As part of my job with the Center for Deployment Psychology (CDP) as a Deployment Behavioral Health Psychologist, I have the privilege of training psychology students in their last year of training—the predoctoral internship. Our faculty have a lot to teach them in that one year: military officership AND military psychology. In addition, we want to make sure that each intern’s skills as a generalist are well-grounded with strong abilities in assessment, consultation, and treatment. Since we carefully select our interns from among the most competitive applicants, we usually have the luxury of “fine-tuning” during the internship year. In other words, as faculty, we get to work with advanced psychology students and hone some special skills.
I have noticed, however, over the years, that even the strongest of incoming interns needs more attention/education/practice in the area of case conceptualization. In fact, during our open house at Wright-Patterson AFB, when applicants are coming for in-person interviews, I usually ask applicants in the interview to “Explain what ‘case conceptualization’ means to you. What is it? Why do it? And can you tell me about a case you’ve had along with the conceptualization you developed?” I get all kinds of responses to this question, and most of them hit on some of the basics of case conceptualization. But almost always, the answer reflects only the beginning of understanding of this important part of a psychologist’s work. The book I am currently using to help train interns in case conceptualization, “Psychotherapy Case Formulation,” is a well-organized and robust resource. While there are other books that may be equally or more comprehensive, I like the fact that this one is of reasonable length to use during an intern’s rotation given other reading responsibilities the intern (and faculty member) may have. This review is not all-inclusive, but I will note some of the points highlighted in the book that I find to be most helpful for teaching.
First, it’s important to understand the importance of engaging in case formulation. Why do it? The author points out that planning in general increases the likelihood of making treatment useful, and a good plan must be based on theory, evidence, and expert practice. In addition, a good plan raises questions about a therapy case, and a case formulation answers the question “Why is this client exhibiting these symptoms and problems?” It seems simple when worded this way, but actually the concept of case formulation is multi-dimensional as reflected in the specific definition of psychotherapy case formulation (also referred to as conceptualization) provided by the author: “a process for developing a hypothesis about and a plan to address, the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioral problems in the context of that individual’s culture and environment.”
Chapter 2 covers the relevance of sound decision making in case formulation. Why is this covered? As therapists, we make decisions all the time about our clients pertaining to their diagnoses, the causes of their problems, and the best courses of treatment. Understanding errors in decision-making can help us avoid common pitfalls and be more sophisticated in our thinking about clients. The most salient part of chapter 2 was the author’s distinction between System 1 and System 2 decision-making systems. Briefly, System 1 is the automatic, effortless, intuitive, and fast way of making decisions. System 1 allows us to draw conclusions from limited information and seeks easy solutions to problems. In case conceptualization, you may see System 1 at work when a therapist conducting an intake assumes a client is depressed when he/she cries. System 1 is crucial to survival because of its speed and efficiency, but mistakes are more common when using System 1. Contrasted with System 1 is System 2, which is “effortful, deliberate, orderly, rule-following, and slow.” Problems can be solved with accuracy but with a loss of speed. Also, System 2 demands a lot of cognitive resources, so when we are overloaded or distracted, decision-making with System 2 is compromised. The bottom line according to the author is that case conceptualization works best when Systems 1 and 2 work together. For example, System 1 generates ideas, impressions and feelings about a client and System 2 applies a more thoughtful and logical approach. My experience in training has been that interns’ System 2 skills need more honing than System 1. It is through the use of a hypothesis-testing approach to therapy that this becomes evident in that interns are sometimes likely to accept the first explanations of a client’s problems as complete when actually there are other, less apparent explanations that need consideration.
The author discusses case formulation in the context of psychotherapy integration in Chapter 4. Basically, this explains what role case conceptualization plays in the process of treating clients. The author explains basic steps in doing treatment including: gathering information, conducting a formulation, implementing treatment, and monitoring progress. However, it is the “formulate” step that I want to highlight in this review since it is most directly related to the task of understanding “why” a client has the problems he/she has. Within the task of case formulation, there are four actions that are needed: creating a problem list; diagnosing; developing explanatory hypotheses; and planning treatment. These four steps will be explained in the following paragraphs. A case example presented in Chapter 1 is utilized throughout the book to illustrate how the concepts are applied.
Step 1 - Create a problem list: The author points out that this seems like a simple, straightforward task. However, identifying the real problems for clients can be tricky and in order to do so we must collaborate with the client to achieve agreement on the problems before moving on to treatment planning. He also notes two different types of problems: signs/symptoms, and problems in living. Symptoms are the experiences that the client reports that are distressing (e.g., “I feel so unmotivated.”). Signs are observable by the therapist and others, and the client may or may not be aware of them (e.g., flat affect). Problems in living include a variety of life circumstances such as housing problems, interpersonal problems, and/or existential problems. It is important to elicit priority from the client about what problems should be the focus of treatment—keeping in mind that sometimes the client and/or the therapist can make errors in assuming that the most obvious problem(s) are the “right” ones to focus on.
Step 2 – Diagnose: The author points out that diagnoses in mental health fall short of fully explaining and differentiating mental disorders in a reliable way. However, he also notes that they provide a meaningful avenue for communication among colleagues and can offer comfort to clients who need to put a label on their experience. It also allows the therapist to organize information about the client and begin to form ideas about possible directions of treatment. Several considerations when diagnosing clients are offered. First, consider multiple sources of information when gathering signs, symptoms, and problems in living. Obviously, a comprehensive interview is in order, but checklists, screeners, and more robust testing will also be valuable contributions in formulating an appropriate diagnosis. Second, the diagnosis should flow directly and logically from the problem list. In other words, problems should implicate a diagnosis. Third, attend carefully to the DSM-5 criteria when assigning a diagnosis—this increases the reliability of the diagnostic process. Fourth, be aware of positive and negative repercussions of giving a diagnosis. In many settings (particularly the military), certain diagnoses implicate certain duty restrictions and, while this is sometimes appropriate, the therapist should be cognizant of the impact that diagnostic labels can have on a client’s career. Finally, be aware that a diagnosis is not an explanation—don’t use the diagnosis to explain a client’s behavior (e.g., “you are afraid of people because you are avoidant”).
Step 3 - Develop an Explanatory Hypothesis: The author distinguishes this step from the others by pointing out that it is the hypothesis that is the crux of case conceptualization. It seeks to answer the question “Why?” The framework of the diathesis-stress model is offered as an overall lens through which to consider the reasons for the development of the client’s problems. An advantage of this is that the diathesis-stress framework transcends theory and can contribute to an explanation no matter what theoretical approach is used. Theory and evidence are proposed as the more specific sources of explanatory power in case conceptualization with psychodynamic theory, behavior theory, cognitive theory, and humanistic/experiential theory being discussed in detail as sources. Specifically, the author explains that sound case formulations are the product of the use of hypotheses based on psychological theory coupled with evidence to support them. Evidence can take various forms and these six sources of evidence are covered: the client, psychometric instruments, psychotherapy research, psychopathology research, epidemiology, and behavioral genetics. The steps to developing an explanatory hypothesis are listed and discussed. They are 1) identifying precipitants (triggers) of symptoms and problems, 2) identifying origins (predisposing experiences and risk factors), 3) identifying resources (strengths that the client has), and identifying potential obstacles (factors that may interfere with progress). Finally, the development of a core hypothesis is suggested with examples provided using templates reflecting different theoretical approaches.
Step 4 – Plan Treatment: In Chapter 8, the reader learns how to plan treatment. Again, this sounds simple but involves thought and collaboration with the client. Seven characteristics of a good treatment plan are discussed. First, the plan should be a result of collaboration between the therapist and the client and should be mutually agreed upon by both. Second, it should contain enough detail to guide treatment. For example, the plan should state some specific skills that the client will learn (“Client will learn to replace maladaptive thinking with a more balanced and reality-based perspective”). Third, the treatment plan should propose a reasonable time frame and reflect goals that are attainable but the client. Keep the client’s level of functioning in mind when setting the bar. Fourth, the plan should define goals that are specific, measurable, achievable, realistic, and timely. Fifth, steps and the course of treatment should be prioritized. In other words, some specific skills may need to be learned first, followed by other skills and abilities. For example, perhaps learning how to relax effectively is a more appropriate first goal for anxiety treatment than tackling exposure. Sixth, ideally, the plan should put the explanatory hypothesis from the formulation to the test. For example, if part of the formulation includes the impact of the client’s core beliefs about low self-worth based on early childhood experiences, then the treatment plan should attempt to modify these and lead to changes in self-perception. The seventh component of a good treatment plan is that it be “efficient and parsimonious,” allowing for a direct and succinct path to symptom resolution.
Other important concepts to consider when planning treatment in Chapter 8 are client preferences, cultural context, and the client’s readiness for change. Also discussed as an important consideration is reactance, which is defined as a “state or trait that refers to a general refusal to change or a sensitivity to external demands that reduces the client’s choices.” It can reflect internal motivation of the client, client behavior, or the therapy environment, all of which can impact how treatment progresses. Important to note is that the therapy environment can be strongly influenced by the therapist and it is the responsibility of the therapist to make it as conducive to working toward the goals as possible.
The final chapter of the book discusses evaluation of the quality of a case formulation. The author notes research that demonstrates that most providers, in formulating a case, provide symptoms, problems, and signs but overlook the important part of hypothesizing about precipitants and maintaining factors. In reality, this is an omission of a crucial piece of providing treatment: answering the question “Why is this client demonstrating this problem/sign/symptom?” Chapter 9 also provides helpful checklists pertaining to the formulation of a problem list, diagnosis, an explanatory hypothesis, and treatment plan. These can be used by even seasoned therapists to make sure that their conceptualizations are based on sufficient information.
In summary, “Psychotherapy Case Formulation” is a reasonably short book about a crucial and often under-developed skill among mental health professionals—interns and senior providers alike. It is comprehensive but the material can be covered in a rotation that is several months in duration. The organization of the book is well thought out and conducive to prioritizing different areas of focus if desired. In other words, if one wanted to focus on treatment planning more heavily than creating a problem list, the layout of the book makes it easy enough to do so. I recommend this book for any mental health professional wishing to round out case formulation skills and particularly for those who are involved in training new providers in the field.
Dr. Regina Shillinglaw is a deployment behavioral health psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Eells, Tracy D. (2015). Psychotherapy Case Formulation. Washington, DC: American Psychological Association.
As part of my job with the Center for Deployment Psychology (CDP) as a Deployment Behavioral Health Psychologist, I have the privilege of training psychology students in their last year of training—the predoctoral internship. Our faculty have a lot to teach them in that one year: military officership AND military psychology. In addition, we want to make sure that each intern’s skills as a generalist are well-grounded with strong abilities in assessment, consultation, and treatment. Since we carefully select our interns from among the most competitive applicants, we usually have the luxury of “fine-tuning” during the internship year. In other words, as faculty, we get to work with advanced psychology students and hone some special skills.
I have noticed, however, over the years, that even the strongest of incoming interns needs more attention/education/practice in the area of case conceptualization. In fact, during our open house at Wright-Patterson AFB, when applicants are coming for in-person interviews, I usually ask applicants in the interview to “Explain what ‘case conceptualization’ means to you. What is it? Why do it? And can you tell me about a case you’ve had along with the conceptualization you developed?” I get all kinds of responses to this question, and most of them hit on some of the basics of case conceptualization. But almost always, the answer reflects only the beginning of understanding of this important part of a psychologist’s work. The book I am currently using to help train interns in case conceptualization, “Psychotherapy Case Formulation,” is a well-organized and robust resource. While there are other books that may be equally or more comprehensive, I like the fact that this one is of reasonable length to use during an intern’s rotation given other reading responsibilities the intern (and faculty member) may have. This review is not all-inclusive, but I will note some of the points highlighted in the book that I find to be most helpful for teaching.
First, it’s important to understand the importance of engaging in case formulation. Why do it? The author points out that planning in general increases the likelihood of making treatment useful, and a good plan must be based on theory, evidence, and expert practice. In addition, a good plan raises questions about a therapy case, and a case formulation answers the question “Why is this client exhibiting these symptoms and problems?” It seems simple when worded this way, but actually the concept of case formulation is multi-dimensional as reflected in the specific definition of psychotherapy case formulation (also referred to as conceptualization) provided by the author: “a process for developing a hypothesis about and a plan to address, the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioral problems in the context of that individual’s culture and environment.”
Chapter 2 covers the relevance of sound decision making in case formulation. Why is this covered? As therapists, we make decisions all the time about our clients pertaining to their diagnoses, the causes of their problems, and the best courses of treatment. Understanding errors in decision-making can help us avoid common pitfalls and be more sophisticated in our thinking about clients. The most salient part of chapter 2 was the author’s distinction between System 1 and System 2 decision-making systems. Briefly, System 1 is the automatic, effortless, intuitive, and fast way of making decisions. System 1 allows us to draw conclusions from limited information and seeks easy solutions to problems. In case conceptualization, you may see System 1 at work when a therapist conducting an intake assumes a client is depressed when he/she cries. System 1 is crucial to survival because of its speed and efficiency, but mistakes are more common when using System 1. Contrasted with System 1 is System 2, which is “effortful, deliberate, orderly, rule-following, and slow.” Problems can be solved with accuracy but with a loss of speed. Also, System 2 demands a lot of cognitive resources, so when we are overloaded or distracted, decision-making with System 2 is compromised. The bottom line according to the author is that case conceptualization works best when Systems 1 and 2 work together. For example, System 1 generates ideas, impressions and feelings about a client and System 2 applies a more thoughtful and logical approach. My experience in training has been that interns’ System 2 skills need more honing than System 1. It is through the use of a hypothesis-testing approach to therapy that this becomes evident in that interns are sometimes likely to accept the first explanations of a client’s problems as complete when actually there are other, less apparent explanations that need consideration.
The author discusses case formulation in the context of psychotherapy integration in Chapter 4. Basically, this explains what role case conceptualization plays in the process of treating clients. The author explains basic steps in doing treatment including: gathering information, conducting a formulation, implementing treatment, and monitoring progress. However, it is the “formulate” step that I want to highlight in this review since it is most directly related to the task of understanding “why” a client has the problems he/she has. Within the task of case formulation, there are four actions that are needed: creating a problem list; diagnosing; developing explanatory hypotheses; and planning treatment. These four steps will be explained in the following paragraphs. A case example presented in Chapter 1 is utilized throughout the book to illustrate how the concepts are applied.
Step 1 - Create a problem list: The author points out that this seems like a simple, straightforward task. However, identifying the real problems for clients can be tricky and in order to do so we must collaborate with the client to achieve agreement on the problems before moving on to treatment planning. He also notes two different types of problems: signs/symptoms, and problems in living. Symptoms are the experiences that the client reports that are distressing (e.g., “I feel so unmotivated.”). Signs are observable by the therapist and others, and the client may or may not be aware of them (e.g., flat affect). Problems in living include a variety of life circumstances such as housing problems, interpersonal problems, and/or existential problems. It is important to elicit priority from the client about what problems should be the focus of treatment—keeping in mind that sometimes the client and/or the therapist can make errors in assuming that the most obvious problem(s) are the “right” ones to focus on.
Step 2 – Diagnose: The author points out that diagnoses in mental health fall short of fully explaining and differentiating mental disorders in a reliable way. However, he also notes that they provide a meaningful avenue for communication among colleagues and can offer comfort to clients who need to put a label on their experience. It also allows the therapist to organize information about the client and begin to form ideas about possible directions of treatment. Several considerations when diagnosing clients are offered. First, consider multiple sources of information when gathering signs, symptoms, and problems in living. Obviously, a comprehensive interview is in order, but checklists, screeners, and more robust testing will also be valuable contributions in formulating an appropriate diagnosis. Second, the diagnosis should flow directly and logically from the problem list. In other words, problems should implicate a diagnosis. Third, attend carefully to the DSM-5 criteria when assigning a diagnosis—this increases the reliability of the diagnostic process. Fourth, be aware of positive and negative repercussions of giving a diagnosis. In many settings (particularly the military), certain diagnoses implicate certain duty restrictions and, while this is sometimes appropriate, the therapist should be cognizant of the impact that diagnostic labels can have on a client’s career. Finally, be aware that a diagnosis is not an explanation—don’t use the diagnosis to explain a client’s behavior (e.g., “you are afraid of people because you are avoidant”).
Step 3 - Develop an Explanatory Hypothesis: The author distinguishes this step from the others by pointing out that it is the hypothesis that is the crux of case conceptualization. It seeks to answer the question “Why?” The framework of the diathesis-stress model is offered as an overall lens through which to consider the reasons for the development of the client’s problems. An advantage of this is that the diathesis-stress framework transcends theory and can contribute to an explanation no matter what theoretical approach is used. Theory and evidence are proposed as the more specific sources of explanatory power in case conceptualization with psychodynamic theory, behavior theory, cognitive theory, and humanistic/experiential theory being discussed in detail as sources. Specifically, the author explains that sound case formulations are the product of the use of hypotheses based on psychological theory coupled with evidence to support them. Evidence can take various forms and these six sources of evidence are covered: the client, psychometric instruments, psychotherapy research, psychopathology research, epidemiology, and behavioral genetics. The steps to developing an explanatory hypothesis are listed and discussed. They are 1) identifying precipitants (triggers) of symptoms and problems, 2) identifying origins (predisposing experiences and risk factors), 3) identifying resources (strengths that the client has), and identifying potential obstacles (factors that may interfere with progress). Finally, the development of a core hypothesis is suggested with examples provided using templates reflecting different theoretical approaches.
Step 4 – Plan Treatment: In Chapter 8, the reader learns how to plan treatment. Again, this sounds simple but involves thought and collaboration with the client. Seven characteristics of a good treatment plan are discussed. First, the plan should be a result of collaboration between the therapist and the client and should be mutually agreed upon by both. Second, it should contain enough detail to guide treatment. For example, the plan should state some specific skills that the client will learn (“Client will learn to replace maladaptive thinking with a more balanced and reality-based perspective”). Third, the treatment plan should propose a reasonable time frame and reflect goals that are attainable but the client. Keep the client’s level of functioning in mind when setting the bar. Fourth, the plan should define goals that are specific, measurable, achievable, realistic, and timely. Fifth, steps and the course of treatment should be prioritized. In other words, some specific skills may need to be learned first, followed by other skills and abilities. For example, perhaps learning how to relax effectively is a more appropriate first goal for anxiety treatment than tackling exposure. Sixth, ideally, the plan should put the explanatory hypothesis from the formulation to the test. For example, if part of the formulation includes the impact of the client’s core beliefs about low self-worth based on early childhood experiences, then the treatment plan should attempt to modify these and lead to changes in self-perception. The seventh component of a good treatment plan is that it be “efficient and parsimonious,” allowing for a direct and succinct path to symptom resolution.
Other important concepts to consider when planning treatment in Chapter 8 are client preferences, cultural context, and the client’s readiness for change. Also discussed as an important consideration is reactance, which is defined as a “state or trait that refers to a general refusal to change or a sensitivity to external demands that reduces the client’s choices.” It can reflect internal motivation of the client, client behavior, or the therapy environment, all of which can impact how treatment progresses. Important to note is that the therapy environment can be strongly influenced by the therapist and it is the responsibility of the therapist to make it as conducive to working toward the goals as possible.
The final chapter of the book discusses evaluation of the quality of a case formulation. The author notes research that demonstrates that most providers, in formulating a case, provide symptoms, problems, and signs but overlook the important part of hypothesizing about precipitants and maintaining factors. In reality, this is an omission of a crucial piece of providing treatment: answering the question “Why is this client demonstrating this problem/sign/symptom?” Chapter 9 also provides helpful checklists pertaining to the formulation of a problem list, diagnosis, an explanatory hypothesis, and treatment plan. These can be used by even seasoned therapists to make sure that their conceptualizations are based on sufficient information.
In summary, “Psychotherapy Case Formulation” is a reasonably short book about a crucial and often under-developed skill among mental health professionals—interns and senior providers alike. It is comprehensive but the material can be covered in a rotation that is several months in duration. The organization of the book is well thought out and conducive to prioritizing different areas of focus if desired. In other words, if one wanted to focus on treatment planning more heavily than creating a problem list, the layout of the book makes it easy enough to do so. I recommend this book for any mental health professional wishing to round out case formulation skills and particularly for those who are involved in training new providers in the field.
Dr. Regina Shillinglaw is a deployment behavioral health psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.