Clinical Case Formulations

Matching the Integrative Treatment Plan to the Client

Barbara Lichner Ingram

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9781118038222
• eBook ISBN: 9781118129753
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

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.

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.

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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).

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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:

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

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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.

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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)

A list of 28 standards for evaluating the application of this method is in Appendix I, Chart I.A. The chapters in Part I explain each of these standards.

Part II: Thirty Core Clinical Hypotheses

Hypotheses are essential ideas from different theoretical orientations, mental health intervention models, and social science research: They have been freed from theoretical jargon; given names, codes, and brief descriptions; and organized into seven categories.

1. 1. Crisis, Stressful Situations, Transitions, and Trauma (CS: Chapter 8)
2. 2. Body and Emotions (BE: Chapter 9)
3. 3. Cognitive Models (C: Chapter 10)
4. 4. Behavioral and Learning Models (BL: Chapter 11)
5. 5. Existential and Spiritual Models (ES: Chapter 12)
6. 6. Psychodynamic Models ...

Table of contents

• Cover
• Table of Contents
• Title
• Copyright
• Dedication
• List of Tables
• Preface
• Acknowledgments
• PART ONE: CASE FORMULATION SKILLS
• PART TWO: THIRTY CORE CLINICAL HYPOTHESES
• 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
• End User License Agreement