Topic 8: CBT Case Formulation & Treatment Plan {by 4/12}

There are multiple readings on CBT Case Formulation due this week (J. Beck – 2 Chapters & Appendix A; Wright et al. – 1 Chapter; Persons & Tompkins [2006]; Academy of Cognitive Therapy: Candidate Handbook – Appendix D & E).  For this discussion, share at least two main thoughts: (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)? (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?  Your original post should be posted by the beginning of class 4/12.  Have your two replies no later than 4/14.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

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24 Comments (+add yours?)

  1. Abbey Lake
    Apr 09, 2018 @ 17:17:27

    1.) CBT case formulation is a critical aspect of effective therapy. According to Wright et al., (2006) case formulation in cognitive behavioral therapy acts as a road map for a clinician’s work with a client as it combines information from multiple important domains and considers all of the important findings from assessment of the client. CBT case formulation is an effective way to organize important information such as observations of a patient’s current diagnoses and symptoms, developmental history, formative influences, situational issues, strengths, and biomedical background and articulate a hypothesis and then a treatment plan linked to the hypothesis. It helps to organize a client’s way of handling particular typical events that may be distressing for them that are associated with a client’s maladaptive cognitions, emotions, and behavior and formulate treatment goals. It also includes any underlying schemas that may be impacting the client. Case formulation is helpful as it provides an effective plan for treatment goals and acts as a guide for each therapy session. Effective case formulation helps clients to get “better” because it helps the clinician to conceptualize a client’s struggles in a detailed manner so that the clinician can formulate a unique treatment plan that is customized for each specific client. It also incorporates a longitudinal view of cognitions and behaviors, which is helpful for the clinician to understand and reference which symptoms are most persistent. It helps the clinician to set goals, keep treatment on track, be able to elicit feedback accurately, and be more aware of progress in therapy that way therapy can be as productive and effective as possible for each client (Beck, 2011). According to Persons & Tompkins (2006) CBT case formulation is particularly helpful when therapy is not going well. This is true because it helps the client to become more engaged in therapy, have more input in therapy, and make substantial progress.
    2.) It is necessary to have specific, concrete, and measurable treatment goals whenever possible in therapy. Specific and concrete goals are helpful in the way that they provide organization and structure in sessions. With specific and concrete goals the clinician and the client are both aware of what each session will be focused on and they are more able to stay on task and effectively work towards successful treatment goals. Measurable and attainable treatment goals are essential whenever possible in therapy because they set the client up for success, which also gives them more confidence and ability to be able to eventually become their own therapist. Measurable treatment goals also provide organization in the sense that they allow the therapist and the client to be able to track how therapy is going and what progress is being made. It also provides insight into what progress is not being made so that the clinician and the client will know which goals require more time and effort to reach. This will also help the clinician and the client to decide whether or not to focus on any particular problem that arises (Beck, 2011). According to the Academy of Cognitive Therapy: Candidate Handbook, a treatment plan (not including course of treatment) should only be about 250 words and should include a problem list, treatment goals, and plan for treatment. The plan for treatment should include what the plan is, what has been worked on in therapy, and what is currently being worked on.

    Reply

    • Lexie Ford-Clottey
      Apr 13, 2018 @ 15:42:32

      Hey Abbey,

      I think you bring up a good point in your post when you mention that a case formulation can be particularly useful when therapy is not going well or progress is slow. The point of a case formulation is to build a bigger picture of the client, in which information from multiple areas of an individual’s life is considered in regards to the presenting problem. In instances where therapy is not going well therapists can always modify or make changes to the existing case formulation, since assessment is viewed as a continuous process. Making changes to a case formulation could strengthen the therapeutic relationship and the course of therapy by shedding light on something that was missed the first time around. I also agree that client involvement through this process is crucial, in which the feedback and perspective of clients helps guide the case formulation and treatment plan. When discussing the importance of specific, concrete, and measurable goals I like how you highlight the idea of setting a client up for success. As therapists it is important that we meet a client where they are at, in which the goals we establish for them are viewed as reachable and achievable and not complex or unattainable.

      Reply

    • Aleksa Golloshi
      Apr 14, 2018 @ 15:49:29

      Hi Abbey!

      I really appreciate that you stated specific and concrete goals are important because they aid in the client’s ability to succeed. I believe that should always be the main focus during each session because that is how the client will no longer have maladaptive thoughts and emotions. I also like when you discussed that an effective case formulation involves the clinician creating a unique and individualized treatment plan that is customized for each client. No two clients will be the same, even if they have similar maladaptive thoughts. I believe this distinction you made is extremely important for each clinician to recognize so that they are aiding each client the best way they can.

      Reply

  2. Tori Bryant
    Apr 11, 2018 @ 16:39:51

    1) In order for effective therapy to take a place a therapist needs to have a holistic grasp on the patient and the patient’s presenting problems based upon evidence, there needs to be organization and a focus in addressing those problems to reach therapeutic goals, and the therapeutic alliance needs to be strong and collaborative. A CBT case formulation greatly assists in ensuring these elements of successful therapy are thoroughly understood and executed.
    As beginning trainees, it could be very easy to become overwhelmed with clients who have many problems and complex problems. Utilizing a case formulation may provide a trainee with a better idea of how to track progress for addressing these problems, which problems to tackle first, and how to best help the complex client, which can help ease the overwhelming need to solve all problems the client has presented. It may also appear that various elements of a client are somewhat unrelated or all over the place; however, a case formulation can provide a more cohesive narrative of a client and connect pieces therapists may not otherwise put together. Clients can throw a lot of information at their therapists and a case formulation will help therapists tie together the origins, mechanisms, precipitants, and problems together in an understandable way. Clients will “get better” when their therapists understand the all of these different factors and selects the best interventions based on these factors.
    A case formulation can also be beneficial to clients being successful in therapy because it will help the therapist formulate a diagnosis. Not only can a diagnosis be given, but the therapist will be able to better explain how this diagnosis applies to their client as an individual. For example, if a client is diagnosed with depression, a therapist can go over what depression is as a mental illness and then because they have that client’s problems, origins, precipitants, and mechanisms, the therapist can explain how this diagnosis has come to be (maybe the client’s mother was depressed), continues to manifest itself (may be in need of behavioral activation), and how the client is personally displaying symptoms (lack of interst in a hobby they used to love). Without a case formulation, it would be difficult for a therapist to make a diagnosis individualized to the client; therefore, the client may not connect with his or her diagnosis and lack motivation to make change.
    Case formulations also allow the therapist to ask his or her client what they believe his or her problems are, where they stem from, and how they are maintained. Collaborating on sections of the case formulation can strengthen the therapeutic alliance because the client will feel heard, understood, and like he or she contributed in a positive way to his or her therapy.

    2) It is important to have specific, concrete, and measurable treatment goals whenever possible for many reasons in therapy. As therapists, we should want to see our clients improve and feel successful and in order for that to happen, they need to feel a sense of accomplishment and hope. If a therapist is setting goals with their client and those goals are unachievable due to resources or ability, the client is going to feel very discouraged and may lose hope and even lose trust in the therapeutic process.
    Specific, concrete, and measurable goals provide clients with structure and a very clear idea of what they are attempting to achieve. To say that a client should feel less anxious is incredibly vague and does not provide them with a way to accomplish this feeling. It would also be very difficult for a therapist to track the subjective feelings of being “less anxious” and therefore, would make moving forward in the appropriate direction unclear. When a client is meeting their specific, concrete, and measurable treatment goals therapy can progress forward as needed. If these specific, concrete, and measurable goals are not being met, it gives the therapist and client a better opportunity to look at the evidence and process they determined better than if the goal had been broad, generalized, and unmeasurable because it would be difficult to determine where to go and what to try next.

    Reply

    • Teresa DiTommaso
      Apr 14, 2018 @ 10:58:02

      Hi Tori,

      One aspect of case conceptualization that you mentioned stood out to me. That was what you mentioned about as beginning clinicians it will be easy for us to get overwhelmed by all of the problems or issues our clients might be sharing with us during the first couple sessions. It was your point about organization that really stuck with me. Not only does this organization help us to help the client, but on another level it helps the clinician individually as well. Although we always focus on what is doing best for the client, the organization aspect of a case conceptualization helps the clinician on an individual level as well. This, in turn, allows the clinician to do all of the things you mentioned in your post, like track progress and understand how to best help a complex client (which is more than likely going to be the case). Therefore, by using a case conceptualization to stay organized for our own sake, we are still doing what is best for the client because the organization helps us do so. I just thought those points you made were very helpful, not from the perspective of just helping clients, but helping us as clinicians help the client.

      Reply

  3. Lexie Ford-Clottey
    Apr 12, 2018 @ 12:01:13

    1. In order to provide clients with the tools and resources to “better” themselves, a CBT case formulation serves as a critical feature for effective therapy. The use of a case formulation in therapy allows the clinician to gain insight to his/her clients presenting problems by considering the individual as a whole. More specifically, a case formulation brings together information from multiple areas of a client’s life (e.g.., diagnoses/symptoms, situation/interpersonal issues, biological factors, and strengths) in order to consider how these factors relate and contribute to the current situation. Essentially, a CBT case formulation paints a bigger picture of a client and aids in the clinician’s ability to understanding his/her client on a deeper level, which strengthens the therapeutic relationship. When case formulations are organized and concise this allows for effective session structure, where the goal of each session can be tailored towards working on smaller pieces of the bigger problem. An effective case formulation will lead to effective treatment strategies/plans, where the therapist will strive to select interventions that are evidence-based. By incorporating evidence-based research into CBT case formulations a clinician is setting his/her clients up for success, in which knowing these techniques have worked for others facilitates the optimism and motivation for getting better. Effective case formulations also help clients get better when the process at certain points is collaborative. When clients feel they are contributing to therapy and are given the opportunity to work with therapists, this will increase the likelihood of wanting to improve. Overall, a CBT case formulation is beneficial in how it aims to lay out and tie together essential aspects of an individual’s life in order to come face to face with the root of the problem. This helps clients who did not have the means or resources to address these underlying issues begin to better themselves.

    2. When possible, it is important to have specific, concrete, and measurable treatment goals in order to enhance treatment outcomes. Specific and concrete goals set clients up for success by allowing them to take one step at a time towards achieving the overall goal. By breaking up bigger goals into those that are smaller and specific, they appear reachable and are often achieved easily. When clients see themselves progressing and making steps in the right direction this facilitates optimism and motivation. When clients are faced with goals that are deemed unachievable or too complex this threatens the therapeutic relationship and leads to feelings of hopelessness, where progress will not be made and goals not accomplished. Goals that are specific, concrete, and measurable also foster structure to the course of therapy, in which therapy sessions are organized around specific goals. This is helpful because both the therapist and the client come in knowing what to focus on and what goals are being targeted for that specific session. Specific goals also provide clients the ability to master these skills outside of therapy through homework assignments. In instances where progress is slow or not being met, a client is given the opportunity to work on these goals outside of sessions. Essentially, when goals are specific, concrete, and measurable it is easier for a client to keep track of where they are at and what should be worked on.

    Reply

    • Abbey Lake
      Apr 12, 2018 @ 18:39:55

      Hi Lexie,

      I enjoyed reading your post because it was very inclusive of each of our readings for the week. You mentioned that the case formulation helps the clinician to view the client as a whole by bringing together information pertaining to the individual in many different aspects of his/her life. I agree with this and feel as though the case formulation brings this information together in a way that is very concise and easy to read and understand. This is important because clients may come to a clinician with an excessive amount of information and only portions of what the client is mentioning may pertain to the treatment goals the client has. The case formulation helps to keep the clinician and the client on task and track any progress that is being made. This is particularly helpful with concrete treatment goals because when the client is having distress in multiple areas of his/her life it may help the client and clinician to prioritize what treatment should be focused on and work towards goals that are measurable and achievable.

      Reply

    • Allexys Burbo
      Apr 14, 2018 @ 20:43:05

      Hey Lexie,

      Your discussion around the purpose of implementing concrete, specific, and measurable treatment goals offers great insights from the client perspective. Since the main objective is to afford the client the opportunity to attain his/her personal success, it is important that the client is regarded as central to the therapeutic process. The idea is that the client is the primary concern and that he/she be instilled with confidence in his/her ability to achieve therapeutic goals. In this instance, goals that are concrete, specific, and measurable help the client envision exactly what success looks like, ultimately increasing client autonomy – that is, if he/she is able to envision goals as attainable, he/she may feel reassured in his/her attempts to progress independently (beyond the therapeutic setting). In identifying and treating the client autonomously, he/she is better able to face barriers (autonomously), gaining the desired confidence with every foreseeable success outcome.

      Reply

  4. Stephanie Mourad
    Apr 12, 2018 @ 13:41:02

    1. Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?
    Case formulation brings together information from seven key domains; diagnosis and symptoms, contributions of childhood experiences and other formative influences, situational and interpersonal issues, biological, genetic, and medical factors, strengths and assets, typical patterns of automatic thoughts, emotions, and behaviors, and underlying schemas. The clinician uses CBT constructs to develop an individualized theoretical formulation relevant to the patient’s particular blend of symptoms, problems, and resources. All of these are important findings from your assessment of the patient and help develop a case formulation. Case formulation helps the therapist keep information organized and it also allows the therapist to point out client strength and weaknesses and the therapist can focus on what the client is having most trouble with. It helps the therapist and client keep an outline of potential treatment goals and outcomes.

    2. Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?
    Therapists may be uncertain about the diagnosis or may still be collecting critical parts of the data. Observations are made as you get to know the patient better and layers of complexity can be added to the formulation. It is important to have treatment goals so that there is always potential homework and goals that the patient has. The patient does not want to come in and feel as though there are no outcomes of therapy or that there is no progress being made. These treatment goals will keep things organized and it allows the therapist to focus on the parts of therapy that the patient has the most concerns with. As new information comes up with the patient and as the therapeutic relationships becomes stronger, treatment goals will most likely be added or modified and it is important to create treatment goals that are specific to the plan and the patient. You will be able to test your theories to see if they are accurate and you will learn if your treatment methods are on target. If not, then you can revise your treatment to work better with the client.

    Reply

    • Louis D’Angelo
      Apr 13, 2018 @ 15:31:52

      Hey Stephanie,

      You bring up a very important aspect of a treatment plan. This is the tentativeness of both diagnoses and goals. The tentativeness of the case conceptualization and treatment plan in a strength because as the patient-client relationship continues, new symptoms my be disclosed that could change a diagnosis or focus in treatment. This ensures better quality care. However, a weakness of a tentative treatment plan is of course managed care and the ethical issue of needing to extend treatment sessions based on a new diagnosis or prevalence of symptoms. New disclosures of symptoms or clinician oversights can deeply effect the quality of treatment the client receives because of the regulation of treatment sessions by managed care. Often times a clinician will have to request or even make a case about why a client need to exend treatment sessions. This could, and has, resulted in several ethical issues that we have discussed in our ethics course.

      Reply

    • Aleksa Golloshi
      Apr 14, 2018 @ 16:00:21

      Hey Steph,

      I like when you stated that a client would most likely be unmotivated to participate in a session if they feel as if their efforts are not benefitting them. I agree with this statement and believe it is important to have concrete and specific goals so that the client does not have these feelings, but rather has positive thoughts when thinking about therapy sessions. For this reason, it is important to communicate to the client what specific goals the sessions are trying to alter so that they are interested and motivated. I also enjoyed when you said that it is important to create treatment goals that are specific to the client because this will ensure that the client is being treated efficiently as they work on altering their maladaptive behavior.

      Reply

  5. Teresa DiTommaso
    Apr 12, 2018 @ 14:24:27

    1. The case formulation is integral to providing effective treatment because it provides a roadmap of what the client and clinician need to work on in order to help the client get better. Without a case conceptualization, it is impossible to decide what interventions are needed for treatment. The case conceptualization is created by evaluating all different domains of the client’s lives, such as their diagnosis, symptoms, developmental experiences, interpersonal issues, medical factors, strengths, and patterns of automatic thoughts and core beliefs (Wright, 2006). Without a thorough assessment of what is causing the client distress, there is no way to formulate goals to treat the client. A case formulation guides treatment, which essentially helps the client improve. A CBT case formulation provides all the information, including a problem list, diagnosis, “anchoring diagnosis,” psychological mechanisms, origins of such mechanisms, and precipitants of the distressing symptoms (Persons & Tompkins, 2006). When the problems of the client are organized in a systematic way, like the CBT case formulation exhibits, then the clinician can develop treatment options that are individualized to the client’s presenting problems. The CBT case formulation is a platform that breaks down an individual’s struggles or disorders into pieces that are more managable. This managable process allows for a clearer implementation of treatment, which in turn helps the client. If there is not clear conceptualization, then effective treatments cannot be used because the clinician will not know what he or she is treating. A clear case conceptualization also gives the client a better understanding of his or her presenting problems and why he or she is so distressed as this point in time. That can provide an opportunity to instill hope within the client and give them back some semblence of control.
    2. Although a clinician will not always be able to conceptualize a concrete goal for a client, it should always be something each clinican strives to do. Without the operationalization of goals, there is no way to measure progress. Of course, progress is always somewhat subjective to the client; but when the client’s perceptions are tainted by their distress or diagnosis, the measurable, specific goals offer an opportunity for clarity and cognitive restructuring. Specific goals within a treatment plan allow for the client and clinician to create specific objectives and interventions that relate to that goal. If the goal is vague and unmeasurable, then the treatment will be as well. The vagueness of treatment itself could be harmful to clients and maybe make them lose hope. Alll in all, having measurable goals allows for clarity in treatment and case conceptualization and provides the opportunity to see client progress from an empirical, objective standpoint. Wtihout that objective standpoint, there really is no concrete way to know if the client is improving.

    Reply

  6. Cassie McGrath
    Apr 12, 2018 @ 14:30:12

    1. Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?

    Case formulation is an important aspect of effective therapy but especially for CBT. The Case formulation brings together all of the information that is involved with the client with information from the client’s diagnosis to interpersonal experiences to symptoms. The case formulation acts as a way to put together the larger picture of the client into a formalized document that can be used as a reference for the therapist. With the written case formulation the therapist is given an opportunity to make plans with the client for treatment based on the evidence that has been collected. Using all of the information that is in the case formulation and the conclusions that have been drawn to then be used to apply appropriate treatments. The case formulation is works as a network of guidelines towards the treatment. A treatment progresses the case formulation continues to grow. The case formulation is important in CBT because it allows for evidence for the treatment plan but it also works as a guide for treatment, making sure that there is a plan and set goals and that the client is not simply going to sessions for talk therapy. The case conceptualization allows for there to be evidence as to what needs to be improved on based on more than just a diagnosis but the overall picture of the client.

    2. Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?

    Similar to what I mentioned prior there is a benefit to having specific treatment goals but also goals that are measurable. Having specific treatment goals is important because it gives a direction to the therapy. It provides a basis for what the clinician and the client are working towards and with having specific goals the client and clinician can then work towards each goal with specific tasks or in specific treatments. The goals need to be concrete so that they are achievable and in order for something to be measurable it also has to be concrete. Having the goal be measurable is important because it can increase the clients buy in to the process and it allows for there to be a way to determine the progress on the goal. If the goal is not measurable there is no way to track the progress and tracking the progress is important so that the client is aware that there is progress being made but it can also be beneficial to the clinician if the progress moves in the opposite direction. Either way the tracking of progress through measurable goals is crucial to the process of therapy.

    Reply

    • Abbey Lake
      Apr 12, 2018 @ 15:44:21

      Hi Cassie,

      I think it is interesting how you pointed out that the case formulation acts as a way to put together the client’s story into a formalized document that can be used as a reference for the clinician. Case formulation is particularly helpful in the way that it organizes a substantial amount of information into a condensed, easy to read outline. You also made an important point that as treatment progresses the case formulation continues to grow. This is important because as more evidence is collected and obstacles occur it is imperative to adjust the case formulation to address the difficulties that the client is having. As you also mentioned the case formulation consists of set goals and a plan for therapy. This helps both the clinician and the client to stay on task. As you mentioned, having specific treatment goals is important for therapy because this provides direction to therapy. I agree that ensuring that these goals are measurable is important in making sure that they are truly making progress and that it also helps to motivate the client and keep them involved in the process.

      Reply

    • Teresa DiTommaso
      Apr 14, 2018 @ 11:06:29

      Hi Cassie,

      One important thing you wrote in your response that I did not think of before is how specific, concrete goals can serve, as a “buy in” for clients to participate and engage in the therapeutic process. This is another important aspect of having measurable goals that not only hits at the obvious advantages, but advantages to engage the client. Some clients may be mandated or sent to therapy by their parents and resist treatment because they do not want to be there or do not think that they need treatment. However, the measurable goals can provide clear-cut answers on how they are doing and those results can be easily administered to outside parties that are responsible for the client being in treatment. Therefore, when it comes to resistant clients, the explanation of measurable goals as a way to show improvement may open the door for their active participation in treatment. Although at firs the motivation may be external rather than internal, participation is participation and once the therapeutic relationship begins to develop, because of this notion of trying to accomplish concrete goals, the motivation and participation in treatment may become deeper in nature.

      Reply

  7. Allexys Burbo
    Apr 12, 2018 @ 14:53:31

    (1) Within the realm of CBT case formulations are considered an integral component of the therapeutic process and are especially significant for achieving positive therapeutic outcomes. Case formulations not only provide a comprehensive outline of the scope and history of a client’s presenting problems, it also affords the clinician a basis for inferring their own clinical analysis of the origin and perpetuation of the presenting symptoms. In this instance, if the clinician is able to identify at least a semblance of an idea about the origins of the behavior, it will become easier to both assess and create a better/representative clinical picture of the client. A good case formulation includes assessment tools and integrates the most integral aspects of the client’s life to create a clinical narrative. This entire aspect of the therapeutic process helps bring focus and structure to the exchange and highlights both client strengths and points of disturbance. Since the objective is to create a singular document which both organizes the clinical picture and provides insight into the client’s history, implementing therapeutic techniques in the presence of a case formulation will prove more effective – and the combination of these features will inevitably enable positive change. A clinician who is able to understand their client dimensionally will have a better chance at creating a strong therapeutic environment and relationship and which may ultimately support effective therapy.

    (2) Establishing specific, concrete, and measurable treatment goals is an essential feature of the therapeutic process. Similar to the very nature of the case formulation, treatment goals help focus and direct the therapeutic process – that is, particular attention is paid to only the most significant problems and other extraneous factors are given less consideration. In creating treatment goals, both the client and clinician are better able to objectively assess treatment progress and modify the process. In this instance, if the alliance is one of a collaborative nature, both parties will play an integral role in determining the nature and content of effective therapeutic techniques that will promote behavior change. When clients are able to imagine specific, detailed accounts of treatment expectations, they may be better enabled to take the necessary steps to achieving these goals. Outlining therapeutic goals in this way adds structure to the therapeutic exchange and promotes a motivation to attain successful outcomes. Since the very nature of these goals is that they are measurable, being afforded the opportunity to track progress may increase a client’s motivation to continue integrating change. Similarly, measurable goals will prove especially helpful when examining the effectiveness treatment techniques. A client who experiences little to no progress with the integration of a specific treatment tool may need to reconsider and reflect on why exactly this might be. In this case, treatment goals are not only important for the client but will also prove considerable for the clinician.

    Reply

    • Lexie Ford-Clottey
      Apr 13, 2018 @ 23:57:04

      Hey Allexys,

      I think it was important in your post to emphasize how a case formulation highlights both client strengths and points of disturbance. Although therapy is mainly focused on restructuring or reframing client behaviors, thoughts, and patterns, therapists should also be finding ways to let clients know that they are more than their difficulties. When constructing case formulations I think there should and has to be a balance, in which the information gathered from clients should reflect both strengths and weaknesses. This lets clients know that yes they have things to work on (why he/she is in therapy) but that they also have other great qualities about themselves. I think case formulations are most effective when the client as a whole is considered, in which client strengths can be useful when formulating treatment goals/plans. I also agree that in order to establish specific, concrete, and measurable treatment goals the process must be collaborative between client and therapist. When both parties are on the same page regarding the course of therapy the client will appear more willing to accomplish goals and progress is likely to be made. This shows that the therapeutic relationship plays a major role for effective case formulations and treatment goals.

      Reply

    • Stephanie Mourad
      Apr 14, 2018 @ 11:45:51

      Hi Lex,
      I agree that outlining therapeutic goals adds structure tp the therapeutic exchange and promotes behavior change. It is important to stay organized because it can show the client and the therapist what goals need to be addressed first and it can show the success in goals. It can also help show what goals are most difficult for the client and it can also show the therapist what needs to change or be more worked on.

      Reply

  8. Sarah Mombourquette
    Apr 12, 2018 @ 14:58:55

    Case formulation is important for effective therapy because it acts as a guide for the continuing sessions with your client. The case formulation will consider the importance of and interactions between various significant domains within the individuals life. These domains include childhood and formative experiences, situational and interpersonal issues, biological factors, strengths of the individual, what the individual’s typical automatic thoughts and behaviors are, and the individual’s core beliefs. By factoring in each of these domains within the case formulation, the therapist can create an individualized plan that will be specific to the individual’s needs. Because the individual’s needs will include a blend of his or her symptoms, problems and resources, the case formulation will provide treatment interventions that will be most effective for that specific person. By developing a case formulation, the clinician can begin to see what treatment methods will be effective for the client and which treatment methods will not be effective for the client. If the clinician finds that his or her plans are not on the right track, then the case formulation can be revised. Similarly, the clinician can find other strengths that might have been overlooked. A case formulation will also be cross-sectional and longitudinal. Cross-sectional approaches are beneficial to the client because they focus on how the client currently elicits patterns of automatic thoughts, emotions, and behaviors in response to specific situations. The longitudinal view is helpful to the client because it considers not just present situations, but also past situations. This is particularly impactful because of the role past experiences have in the formation of core beliefs.

    In terms of specificity, a clinician should analyze specific problems that the client addresses when creating treatment goals. This is because emphasis on specific problems enables the clinician to enhance the difficulties of the client in detail to better understand the thoughts, behaviors and situations that surround that problem. In focusing on specific problems rather than a general idea of the issues, the clinician will also be able to create an individualized case formulation. Treatment goals also serve as a guide for the therapy sessions by helping to keep both the clinician and the client focused, maintain consistency across sessions, and allow for a better understanding of the therapeutic process from one session to another. Having measurable goals is very important because it will allow the client to observe progress. If the clinician and client regularly keep track of progress, the client will be able to see where he or she began compared to where he or she is throughout various points in treatment. Concrete goals will help to keep the client motivated throughout the sessions because he or she will have something specific to work toward. Ultimately, goals act to guide the sessions and to show the client how far he or she has come.

    Reply

    • Louis D’Angelo
      Apr 13, 2018 @ 15:12:56

      Hey Sarah!

      I like how in both of your responses you talked about how a case conceptualization and goals in a treatment plan focuses on specific symptoms rather than the overal diagnosis. This connects directly to what we discussed in class this week. This being the transtheoretical approach to treatment. Here, an individual who is diagnosed with multiple co-occurring disorders, can find treatment difficult. With the transtheoretical approach, treatment is focuses on concurrent symptoms within the separate diagnoses rather than a primary diagnosis first, then a secondary diagnosis. For example, with an individual who is diagnosed with both Panic Disorder and PTSD may have a concurrent symptom of intrusive thoughts within both diagnoses. Treatment focused on these intrusive thoughts and other concurrent symptoms between the diagnoses is the transtheoretical treatment appoach rather than treating these diagnoses separatly. Focusing on specific, problematic, and concurrent symptoms within several co-occurring diagnoses greatly improves the efficiency and effectiveness of treatment.

      Reply

    • Stephanie Mourad
      Apr 14, 2018 @ 11:57:19

      Hi Sarah,
      I like that you included the importance of various domains within the individuals life. It is important to incorporate these factors to best accommodate the client when creating treatment goals that are effective for them. It is important to revise the treatment plan and goals to best accommodate the client and the therapist should understand that revising, changing, or adding goals is a natural progress in creating treatment plans.

      Reply

  9. Louis D'Angelo
    Apr 12, 2018 @ 15:00:52

    A cognitive behavioral therapy case formulation is important for effective therapy because in takes in consideration multiple aspect of the client’s life as well as including problems, strengths, and treatments that are tailored to the clients needs. Seeing these in depth examples of case formulations and treatment plans in the work of Judy Beck as well at the assigned appendix publications was extremely helpful when understanding the daunting task of paperwork and case conceptualization. The CBT approach to a case conceptualization is strg because it takes in consideration multiple aspects of the client including current cross-sectional antecedents of the problem areas as well as longitudinal development of these now surfacing problems. The addition of chief complaints and an overview of diagnosis and symptoms include both a client’s perspective of prioritized problems as well as the therapists interpretation of problems through symptoms evaluation and diagnosis. The inclusion of client strengths is paramount in a CBT case conceptualization because it demonstrates the client-centered approach to therapy and knowing these strengths of the client will help greatly when framing tailored interventions that are most effective. The case conceptualization also includes necessary details such as family and medical/mental health history as well as underlining automatic thoughts and core beliefs that are presented using quotes from the client. These case conceptualizations are important for record keeping as well as use for later reference when showing the client ther progress in therapy and further providing hope for the client. These case conceptualizations can also be tentative as they can be revisited and adjust as new problems emerge. The advantage of recording problem areas, specific goals, objective to meet those goals, and planned intervention strategies help client progress as they establish specific problem areas and goals and interventions to meet those goals. It allows the therapeutic sessions to be structure, goal directed, personal to the client, and always effective and productive. Later seeing client progress by revisiting case conceptualization further supports effective treatment and client self-efficacy.

    2. It is important to have specific, concrete and measurable goals in treatment planning so that the goals are realistic and directly defined. This makes sure the client is aware of the goals as the objective steps to meet those goals rather than making ambiguous or daunting goals that provide no steps to complete them. In other classes, we have talked about S.M.A.R.T goals. These are goals that are specific, measurable, achievable, realistic, and timely. Having these 5 necessities in goal and objective setting are important for establishing effective treatment. If goals are too ambiguous (lacking specificity or operationally defined measures) treatment is ineffective as goals are poorly defined and questionable in the manner of taking them. If goals are too daunting (are not achievable, are not realistic, and do not provide an effective timeline) then treatment is difficult and stressful for the client. Goal and objective setting must take in consideration clients abilities, obstacles, preferences, and level of understanding so that objective are clearly defined and are possible to achieve through treatment towards goals in treatment.

    Reply

    • Allexys Burbo
      Apr 14, 2018 @ 19:51:51

      Hey Louis,

      I think you make a subtle and significant connection between the role of the case formulation and its function for the client within the context of the therapeutic alliance in that the document is not only essential for the clinician, but that it also proves a key element for the client. While the idea is that the case formulation provides the clinician with an organized recollection of the client’s presenting problems/symptoms, insight, interpretations, etc., it also serves as a tool for navigating the therapeutic process if understood as such from the client’s perspective. The idea is that the formulation is indeed an integral feature of therapy and that it should be used to both inform and structure the treatment process – with a primary focus on goals/progress. The case formulation helps track individual changes and helps both the client and clinician understand the capacity of the individual in relation to therapy in an organized and concrete way (emphasizing both strengths and barriers). The clinician who utilizes the case formulation beyond its primary purpose (to inform) and uses it as an integral feature of the therapeutic process may not only help increase the likelihood for positive treatment outcomes, but may also inadvertently strengthen the therapeutic relationship. Since within the realm of CBT the experience is one that is regarded as collaborative, the idea is that each tool is implemented strategically to both help track client progress and manifest positive change. The case formulation, in this instance, functions as both a record and as a tool for conditioning the therapeutic exchange – effective for both client and clinician.

      Reply

  10. Aleksa Golloshi
    Apr 14, 2018 @ 15:36:36

    1. Wright and colleagues suggest there are many important domains involved in a CBT case formulation that will result in an effective therapy experience for a client. Aspects such as diagnosis, symptoms, situational and interpersonal behavior, strengths and assets, patterns of automatic thinking, and underlying schemas need to be explored. Exploring these topics informs a therapist about what specific areas need attention most, to ensure that the client is being ethically treated. When a therapist has the opportunity to explore these domains they will be prepared to formulate a working hypothesis. This then aids them in creating an effective treatment plan. As the therapeutic relationship progresses, more observations and information will be prevalent about the client that can be included in the case formulation. The therapist will be able to test these new observations and see if their theories are accurate. During the middle to late phase, a CBT case formulation will be an effective guide for the client’s intervention. Understanding a client’s diagnosis and symptoms, as well as their situational and interpersonal behaviors need to be included in a case formulation so that the therapist can create a precise and effective intervention. Reviewing a taped session during an intervention will help the client and therapist understand why a specific action is beneficial to perform.
    Judy Beck shares similar ideas on CBT case formulation in terms of its effectiveness in therapy. Beck believes conceptualization should be fluid so that the therapist is able to make hypotheses about the client that can be altered if need be. If the therapist is accurate with his/her conceptualization the client will express feelings of the therapy “feeling right,” which will then motivate and encourage them. (Beck, 2011, p. 40) Persons and Tompkins have similar cognitions by stating that a CBT case formulation has good treatment utility, signifying that its treatment is effective. The pair also discusses the importance of parsimony, indicating that case formulation requires minimal detail to create an effective treatment. Additionally, the case formulation should be evidence-based. There should be present evidence that indicts the treatment or intervention that will be used truly works and will aid the client’s progress. Mechanisms that cause and maintain the client’s maladaptive behavior should also be included in the formulation and the origins of these mechanisms should be discussed. This will aid the therapist in a better understanding as to why the client has these maladaptive behaviors. Persons and Tompkins additionally discuss that formulations should include any precipitants that are activating these mechanisms to cause these maladaptive inconsistencies.

    2. It is vital to have specific and measurable treatment goals to track the client’s progress and to motivate them. If the client feels as if he/she does not want to partake in the intervention during the session the therapist can physically show them all the progress they’ve done. This will most likely motivate the client to continue participating in the session and reduce their maladaptive thinking or behavior. By physically seeing the progress they’ve made they might partake in self-talk and tell themselves that they’re already accomplished some of their goals and need to keep going. Having measurable treatment goals also helps the client be certain of what it is they are working on. They might have a couple maladaptive thoughts but by having concrete treatments goals they will understand what specific goal they are trying to achieve and what goals should not be attended to for the time being. Lastly, helping a client develop a specific and measurable treatment goals will make the therapist appear more professional and attractive to the client, which will most likely result in the client having positive feelings towards the therapist. This may then lead to the client expressing and sharing more information with the therapist, which in turn helps the therapist formulate a treatment plan that is completely tailored to the client’s maladaptive thoughts or behaviors.

    Reply

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Adam M. Volungis, PhD, LMHC

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