Clinical Case Formulations E-Book

Barbara Lichner Ingram

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1078

Veröffentlichungsjahr: 2011

Beschreibung

Praise for Clinical Case Formulations Matching the Integrative Treatment Plan to the Client, Second Edition "[Barbara Ingram has put] a career into the development of this book and it is wonderful! My students love that it was written with them in mind and they love the statements designed to reduce anxiety and normalize the learning process. This is an excellent book!"--Amy M. Rees-Turyn, PhD Associate Professor of Counseling Psychology, Lewis & Clark College A step-by-step model for individualized case conceptualization Fully revised and updated, the second edition of Clinical Case Formulations provides step-by-step tools and insightful guidance for moving from first contact with a client to the development of an effective, personalized treatment plan. Addressing the essential question every therapist faces--How do I create a treatment plan that is the best match for my client?--this unique resource provides a systematic and thoughtful method for integrating ideas, skills, and techniques from different theoretical approaches. It combines empirical research and clinical experience to create a case formulation that is tailor-made for the client. This comprehensive resource offers two tools to guide case formulations: a problem-oriented framework, with a list of 28 standards for evaluating its application, and a set of 30 core clinical hypotheses derived from the knowledge bases of psychology, psychiatry, counseling, and social work professions. The new edition includes: * Hypotheses on Emotional Focus, Trauma, and Metacognitive Perspective * More detailed attention given to empirically supported therapies such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT) * Discussion on the importance of bringing cultural competence to case formulation tasks with every client * Skill-building activities throughout the text Offering a thorough framework to help clients experience effective clinical service, practitioners will learn to conceptualize clients' needs in ways that lead to strong and individualized treatment plans, as well as advice and guidance on what to do when selected interventions fail to produce the expected benefits.

Leseprobe

Contents

List of Tables

Preface

Acknowledgments

Part One: Case Formulation Skills

Chapter 1: A Framework for Clinical Case Formulations

Tasks and Processes of Case Formulation

Evidence-Based Practice and Case Formulation Skills

Culturally Competent Formulating

Integrative Case Formulation

The Learning Process

Suggested Readings

Chapter 2: Gathering Data

The Intake Process

The Therapeutic Relationship

Cultural Competence

Frameworks for Data Gathering

Additional Tools for Data Gathering

Suggested Readings

Chapter 3: Defining Problems

What Are Problems?

The Problem-Identification Task

The Problem-Definition Task

Standards for Problem Definition

Chapter 4: Setting Outcome Goals

Benefits of Clearly Defined Future Goals

Helping Clients Describe Their Desired Future

Standards for Outcome Goals

Chapter 5: Organizing and Presenting the Database

Processes for Organizing Data

Standards for Database

Chapter 6: Creating the Formulation

Standards for Formulation

Chapter 7: Writing the Treatment Plan

Standards for Treatment Plans

Cultural Competence

Three Concepts for Tailoring Treatment

Part Two: Thirty Core Clinical Hypotheses

Chapter 8: Crisis, Stressful Situations, Transitions, and Trauma

Suggested Readings

Situational Stressors

Suggested Readings

Developmental Transition

Suggested Readings

Loss and Bereavement

Suggested Readings

Trauma

Suggested Readings

Recommended Crisis Journals

Chapter 9: Body and Emotions

Biological Cause

Suggested Readings

Medical Interventions

Suggested Readings

Mind-Body Connections

Suggested Readings

Emotional Focus

Suggested Readings

Chapter 10: Cognitive Models

Suggested Readings

Metacognitive Perspective

Limitations of Cognitive Map

Deficiencies in Cognitive Processing

Blocks to Listening

Dysfunctional Self-Talk

Chapter 11: Behavioral and Learning Models

Suggested Readings

Recommended Behavior Therapy Journals

Antecedents and Consequences

Conditioned Emotional Responses

Skill Deficits

Chapter 12: Existential and Spiritual Models

Existential Issues

Selected Existential Themes

Suggested Readings

Journals

Freedom and Responsibility

Suggested Readings

Spiritual Dimension

Suggested Readings

Chapter 13: Psychodynamic Models

Internal Parts

Suggested Readings

Recurrent Pattern

Suggested Readings

Deficits in Self and Relational Capacities

Suggested Readings

Unconscious Dynamics

Suggested Readings

Chapter 14: Social, Cultural, and Environmental Factors

Family System

Suggested Readings

Cultural Issues

Suggested Readings

Social Support

Suggested Readings

Social Roles and Systems

Suggested Readings

Social Problem is A Cause

Suggested Readings

Social Role of Patient

Suggested Readings

Environment

Suggested Readings

Chapter 15: Practice, Practice, Practice

Recognize How Hypotheses Match The Data

Explore Hypotheses in The Clinical Interview

Apply and Test Hypotheses With Case Vignettes

Combine Hypotheses to Explain Problems

Use The Three-Column Worksheet

Write A Formal Case Formulation Report

References

Appendix I: Useful Charts

Appendix II: Useful Forms

Appendix III: Case Material for Practice

Appendix IV: Answers and Samples for Activities

Author Index

Subject Index

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Library of Congress Cataloging-in-Publication Data:

Ingram, Barbara Lichner.

Clinical case formulations : matching the integrative treatment plan to the client / Barbara Lichner Ingram.—2nd ed.

p. ; cm.

Includes bibliographical references and indexes.

ISBN 978-1-118-03822-2 (pbk. : alk. paper); 978-1-118-12974-6 (eMobi); 978-1-118-12975-3 (ePub); 978-1-118-12973-9 (ePDF)

1. Psychotherapists—Training of. 2. Psychotherapy—Study and teaching. I. Title. [DNLM: 1. Psychotherapy—methods. 2. Mental Disorders—therapy. 3. Models, Psychological. 4. Psychological Theory. WM 420]

RC459.I54 2012

616.89’14—dc23

2011019562

To Sami, Paulie, Tony, and Keats

List of Tables

Table 1.1How to SOHP a ProblemTable 2.1Four Frames for Exploring a Specific ProblemTable 2.2The BASIC SID: An Adaptation of Lazarus’s BASIC IDTable 2.3Metamodel QuestionsTable 2.4Suggested Data Topics for Three ProblemsTable 3.1Strengths and Weaknesses in Domains of FunctioningTable 4.1Criteria for Good Outcome StatementsTable 5.1Organizing the Subjective SectionTable 7.1Components of Treatment PlanTable 7.2Plans That Focus on the Therapeutic RelationshipTable 8.1Assessment of Suicide RiskTable 8.2Steps in Crisis InterventionTable 9.1Sample Problems for Biological Cause (BE1) HypothesisTable 9.2Elements in the Self-Management of Chronic DiseaseTable 9.3Sample Problems for Mind-Body Connections (BE3) HypothesisTable 9.4Techniques of Relaxation TrainingTable 9.5Sample Problems for the Emotional Focus (BE4) HypothesisTable 9.6Therapeutic Strategies for Awareness and Processing of EmotionsTable 10.1Underlying Schemas for Disorders and ProblemsTable 10.2Sample Errors in ThinkingTable 10.3Sample Problems for Dysfunctional Self-Talk (CS4) HypothesisTable 10.4Steps in Treatment to Modify Self-TalkTable 11.1Samples of Disorders Treated With Operant InterventionsTable 11.2Behavior Change Strategies Using Operant Learning PrinciplesTable 11.3Examples of Disorders Treated With Exposure InterventionsTable 11.4Examples of Skills-Training DomainsTable 12.1Sample Problems for Existential Issues (ES1) HypothesisTable 12.2Sample Problems for Freedom and Responsibility (ES2) HypothesisTable 12.3Stages of Self-Directed Responsible ActionTable 12.4Sample Problems for Spiritual Domain (ES3) HypothesisTable 13.1Sample Problems for Internal Parts (P1) HypothesisTable 13.2Sample Problems for Recurrent Pattern (P2) HypothesisTable 13.3Examples of Empirically Supported Short-Term Psychodynamic PsychotherapiesTable 13.4Stages of Development of Self and Relational CapacitiesTable 13.5Mature Relational CapacitiesTable 13.6Sample Problems for Deficits in Self and Relational Capacities (P3) HypothesisTable 14.1Family Systems ConceptsTable 14.2Working With CouplesTable 14.3Using Family System Concepts in Individual TherapyTable 14.4Issues of Lesbian, Gay, Bisexual, Transgender, Questioning, and Intersex Clients

Preface

This book teaches how to conceptualize clinical cases by integrating ideas from a variety of theoretical perspectives, in order to design treatments that are the best match for the needs of a client. I first learned a definition of case formulation in my own doctoral training: A clinical case formulation is “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions (Lazare, 1976). I discovered then that graduate programs do not provide systematic training in case formulation skills, and I am not convinced that this omission has been remedied. Students learn about various theoretical orientations, and how to apply the case formulation implicit in each model, but not how to access the ideas they have learned from multiple orientations to create a formulation that is tailor-made for a specific client.

The aim of this book is to:

Bridge the gap between graduate school and clinical placement, and between conceptualization and the treatment that is actually delivered.Provide tools for the development of effective treatment plans that match the client’s needs, with full consideration of cultural as well as individual differences.Teach a systematic method for writing a comprehensive case formulation report that integrates ideas and techniques from biological, cognitive, behavioral, psychodynamic, humanistic-existential, spiritual, family systems, and sociocultural perspectives.Promote evidence-based practice by requiring specification of treatment outcomes, ongoing monitoring of clients’ progress, and access to research literature.Help students organize their thoughts, develop critical thinking skills, improve cognitive flexibility, and apply their creativity as well as their knowledge.

Grinfield (2009), in a review of a case study I published (Ingram, 2009a), made me aware of another goal that this book accomplishes:

Early clinicians are also invested in developing a professional identity, but some, like Ingram, resist pressure to “choose an orientation” and instead prefer to let the client’s individual characteristics and preferences lead the way. In this sense, Ingram’s model provides graduate students the opportunity not only to pursue psychotherapy integration within a structured and practiced framework, but also to pursue identities as “integrationally-oriented” therapists. (p. 66)

CONTENT AND ORGANIZATION

This book offers two tools for case formulations: a problem-oriented framework, with a list of 28 standards for evaluating its application; and a set of 30 core clinical hypotheses derived from the knowledge base of psychology, psychiatry, counseling professions, social work, and other social sciences.

Problem-Oriented Framework

Part One (Chapters 1–7) leads you, step-by-step, toward competence in writing a comprehensive case formulation report. The first step is gathering data—information about the unique client—and using tools to organize it. For each client, you will create a “problem list”; you will be formulating the problems, not the whole person. The titles of problems typically fall into “V-Code” categories, but are more specific. Instead of “Partner Relational Problem,” a client’s problem title might be “difficulty resolving differences in a calm, constructive way,” or “inability to express tender affectionate emotions toward spouse.” The criteria for psychiatric disorders also serve as problem titles but the name of a psychiatric disorder, without a detailed database for a specific client, is never enough to guide treatment planning. Problem definition flows into the task of specifying outcome goals—and it is the clarity of these goals that assures accountability in clinical practice. Skillful description of outcome goals is based on consideration of your client’s culture, values, and unique preferences—essential components of evidence-based practice. The core of the formulation is the application of clinical hypotheses that fit the data and lead to treatment plans.

Gawande (2009) recognized a problem for airline pilots and surgical teams that also applies to psychotherapists: “The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably” (p. 13). His solution is to develop a checklist; the steps of case formulation serve that function. By following these steps, you assure that each client benefits from your comprehensive professional knowledge base, scientific attitude, and problem-solving skills:

Gather data about each unique client.Define problems, writing clear, specific, jargon-free titles.Specify outcome goals that are realistic and attainable.Apply relevant clinical hypotheses to conceptualize problems.Design treatment plans that follow logically from conceptualization and focus on achieving goals.Monitor progress as you begin to implement the plan.

There are 16 learning activities to assure mastery of both knowledge and skills, with answers and samples provided in the appendix.

Thirty Core Clinical Hypotheses

A list of 30 core clinical hypotheses provides a different kind of checklist, assuring attention to all possible explanations for human problems—from the synapses in the brain to the surrounding physical environment. Chapters 8 to 14 in Part Two cover seven domains, each of which includes between three and seven hypotheses: (1) crisis, stressors, transitions, and trauma; (2) biology and emotions; (3) cognitive; (4) behavior and learning; (5) existential and spiritual; (6) psychodynamic; and (7) social, cultural, and environmental. Because the description of each hypothesis is free of technical jargon, this framework has the potential to break down barriers among orientations and professional guilds and to unify the knowledge base of all of the professions that provide psychotherapy and other mental health services.

With 30 different clinical hypotheses available, the clinician has “ingredients” to make individualized “recipes” of treatment plans. For each hypothesis, I have provided brief clinical vignettes, a summary of key ideas, some examples and guidelines for when this hypothesis is a good match, and a set of treatment suggestions. The references and suggested readings will steer readers toward sources with more complete and comprehensive presentations of the different models.

An Integrative Theory for Each Client

Because hypotheses are the building blocks of theory, combining them makes a coherent integrative theory for each unique client. This method differs from the approach to integration called technical eclecticism, which combines interventions and procedures with a disregard for theoretical foundations. Lambert, Garfield, and Bergin (2004), following a massive review of empirical literature in psychotherapy, predicted a “trend toward minitheories centered on specific problem domains and empirical evaluations” (p. 819). In this book, the case formulation can be viewed as just such a minitheory, individualized for each client’s specific problem, and the empirical evaluation occurs when you implement the plan based on the minitheory and gather data about the client’s improvement or lack thereof. Validation of the theory comes from evidence of changes in client functioning, which translates to consumer satisfaction in meeting personally chosen outcomes.

CHANGES IN SECOND EDITION

This second edition retains the framework and method of the first, with the following major improvements:

There are three new hypotheses, bringing the number of hypotheses to 30 (one hypothesis from the original 28 was merged with another). The new hypotheses are Emotional Focus (a topic previously embedded in Mind-Body Connections), Trauma (previously combined with Situational Stressors), and Metacognitive Perspective. Modification of the list was based on valued feedback from reviewers as well as my own intensive search of the clinical literature for the past six years.The sections for all of the hypotheses have been updated, with more detailed attention to empirically supported therapies such as Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 2011), Dialectical Behavior Therapy (Linehan, 1993a, 1993b), and Emotionally Focused Therapy (Greenberg & Johnson, 2010), among many. More than 300 references have been added.The importance of bringing cultural competence to case formulation tasks with every single client is emphasized. The fact that there is only one hypothesis with the word culture in its title has given the mistaken impression to some readers that culture is being neglected when that hypothesis is not included in the formulation. In this second edition, the topic of culture appears throughout, and it is repeatedly stressed that culture must be attended to, regardless of which hypotheses you are choosing. Culture must be addressed in both the data-gathering task (Chapter 2) and in treatment planning (Chapter 7). Moreover, cultural diversity is discussed with many hypotheses, especially to clear up misconceptions that certain hypotheses fit only western clients. Finally, I have added a section to the case formulation report outline (see pp. 418–419) for noting cultural issues in the client-therapist relationship.

Other modifications in this second edition make the book more user-friendly:

The organization of chapters is changed so that all of the steps toward a case formulation appear in Part One and all of the hypotheses are in Part Two.The skill-building activities appear in the text where they are relevant, instead of in an appendix. The appendix still contains answers and samples.Many revisions in the text have increased the clarity and organization of the material.More references are provided to allow easy follow-up of material of special interest to the reader.

The method in this book will lead to good treatment plans for clients; a caveat is needed that these plans must not be held rigidly. In a sense, all clinical case formulations are working formulations. Therapy involves art as well as science, the healing magic of a healthy human relationship along with the products of higher education, rigorous research, and expert training. Moreover, while therapy is in progress, from the point of view of the client, life happens: unexpected events, unpredicted behaviors of other people, forces of nature and social systems enter the mix. I love the saying, “Flirt with your hypotheses, don’t marry them.” In a similar spirit, I can suggest that the case formulation is an essential framework for therapy, but rather than being an architectural blueprint, it is an ever-evolving itinerary on an unpredictable journey.

Barbara Lichner Ingram

Calabasas, CA

Acknowledgments

My appreciation for their help with research reviews and manuscript preparation goes to a wonderful group of graduate assistants and volunteers: Clara Bertan, Ashley Casselman, Matt Gunther, Anahita Kia, Nansi Manokian, Mark Miller, Christine Montagna, Salvatore Mucciolo, Liza Preminger, and Megan St. Clair. Many faculty colleagues at Pepperdine gave me valuable input: Thema Bryant-Davis, Geoff Buckley, Anat Cohen, David Foy, David Levy, and Francie Neely. I am also grateful to Dean Margaret Weber and Associate Dean Robert de Mayo for their support. I have learned so much at the annual meetings of the Society for the Exploration of Psychotherapy Integration (SEPI; http://sepiweb.org/) and received valuable feedback when presenting my integrative case formulation model there.

The time spent preparing this new edition was brightened by my husband, Paul Greenfield; the 100th birthday celebration of his fabulous mother, Rose; and every minute spent with my stepdaughter, Sami. I thank Tim Shamroy, Anita Bavarsky, and Ruth Blaug for our friendships, and the Flynns—Sharon, Sean, Ethan, and Devon—for being a special part of my life. My sister, Susan Fields, deserves recognition for her contributions to my academic pursuits.

My gratitude goes to the people at John Wiley & Sons who magically turn words into a book. Patricia Rossi, Executive Editor for Psychology, deserves my thanks for many reasons, not least of which is her excellent choice of reviewers, whose comments and suggestions were of enormous benefit: Jay Lebow, Northwestern University, IL; Amy M. Rees-Turyn, Lewis and Clark College, OR; and Nikki Wooten, Boston University. I also want to thank everyone at Wiley who contributed to the release of this book, especially: Kara Borbely, Editorial Program Coordinator; Kim A. Nir, Senior Production Editor; Judith Cardanha, proofer; Judith Knott, Senior Marketing Manager; and Heather Dunphy, Assistant Marketing Manager.

Finally, I thank the students who take my PSY 637 class at Pepperdine’s Graduate School of Education and Psychology. They demonstrate every semester, with their excellent case formulation reports and heartfelt words of thanks, that the method in this book really does build competence and confidence for facing real clients.

Bli

PART ONE

CASE FORMULATION SKILLS

Chapter 1 provides an overview of the case formulation method, including definitions of key concepts, descriptions of the steps to a case formulation, and 28 standards for evaluating its quality (also printed in Appendix I, Chart I.A). Chapters 2 through 7 lead you step-by-step through skills, teaching you to:

Gather data about each unique client.Define the client’s problems, writing clear, specific, jargon-free titles.Specify outcome goals that are realistic and attainable.Apply relevant clinical hypotheses to conceptualize problems.Design treatment plans that follow logically from your conceptualization and focus on achieving goals.

You will then be ready to bring formulation skills to clinical practice and to add a sixth skill, gathering data about the client’s real-world functioning to evaluate the effectiveness of the plan.

The quality of a formulation is judged by whether it is effective in achieving desired results. The treatment plan is an experiment: Based on the hypotheses that I have selected, here is a strategy that should achieve the client’s desired outcome goals. If positive change occurs and the desired goals are achieved, then the merit of the formulation is confirmed. If positive change does not occur, then the formulating process must be repeated, using new data, possibly selecting different hypotheses, and designing different treatment strategies.

This approach to case formulation provides a framework for evidence-based practice. The discipline and the structure of the method will help you organize your thoughts about a client, integrate ideas from theories as well as the research literature, and place the needs of your clients at the center of clinical service.

Chapter 1

A FRAMEWORK FOR CLINICAL CASE FORMULATIONS

About to face a client for the first time, beginning therapists wonder, How am I going to know what to do? Later, we plead to supervisors, What should I do? As we gain experience, the question matures: When I face any new client, how do I create a treatment plan that is the best match? The answer: case formulation skills—the focus of this book.

A clinical case formulation is “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions” (Lazare, 1976).

I discovered the need for case formulation skills from my own frustration as a trainee and new therapist. My supervisors did not teach me how to think critically and creatively about cases; instead, they expected me to either follow the rules of a specific orientation or trust in a process of trial and error. When I expressed my anguish, supervisors assured me that most beginners had similar feelings and that I was doing fine. My humanistic supervisor said that developing good relationships with clients was enough. From my psychodynamic supervisor’s perspective, I had a countertransference issue, namely a need for structure and control. In a behavioral clinical setting, I found structure, but it was not the best fit for every client. I was discovering the principle that is the core of this book:

You must create a formulation that fits the client, rather than squeeze the client into your preferred formulation.

Teachers, supervisors, and program administrators are generally not aware that it is possible to teach case formulation skills in a systematic way; they probably learned their skills in a haphazard way in the apprenticeship model of clinical training, through mentorship relationships with supervisors and their own trial-and-error learning. They assume that conceptualization abilities flow naturally from native intelligence, experience, and unstructured conversations with supervisors. This book presents an alternate viewpoint: Case formulation skills can be directly taught, by using a structured framework and providing step-by-step guidelines.

Figure 1.1 shows all 30 hypotheses. They are listed in Appendix I, Chart I.B; it is recommended that you copy that chart and laminate it for convenience. Chart I.C gives examples of useful treatment ideas for each hypothesis and serves as a convenient reference tool.

Figure 1.1 Map of 30 core clinical hypotheses

The framework in this book originated with the Problem-Oriented Method, developed in medicine (Weed, 1971) and adapted for psychiatry (Fowler & Longabaugh, 1975). This method provides structure to the problem-solving skills that are taught in many fields: Problems and goals are clearly defined; we do not rush to solutions without coming up with possible explanations; and interventions are focused on resolving problems. When you take your car to a mechanic, you expect a demonstration of the same problem-solving framework. Mechanics identify the problem (e.g., car will not start; funny noise when brakes are applied), seek out explanations (e.g., fuel pump is broken; brake pads are worn down), and implement a plan to resolve the problem (e.g., replace bad parts with new parts). The quality of the work is evaluated not by the elegance of the theory or by research findings from studies of other cars but by the attainment of the desired outcome goals with this particular car: It starts when you turn the key, and it stops when you step on the brakes.

Overview

Part I: A Step-by-Step Process for Creating a Case Formulation

Gathering data (Chapter 2)Defining problems (Chapter 3)Specifying outcome goals, the desired change in the client’s functioning (Chapter 4)Organizing and presenting the database (Chapter 5)Creating the formulation by applying core clinical hypotheses (Chapter 6)Writing a treatment plan and monitoring progress (Chapter 7)