Case Formulation for Personality Disorders

Tailoring Psychotherapy to the Individual Client

Ueli Kramer, Ueli Kramer

• Publisher: Academic Press
• Year: 2019
• ISBN:
  9780128136126
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Case Formulation for Personality Disorders provides clinical guidance on how to build effective treatment plans for patients presenting with personality disorders. Anchored within a disorder-specific approach, the present volume reviews the evidence base of case formulation methodology. The book takes an integrative and differentiated approach to case formulation, with multiple methods of case formulation, all specifically adapted to the psychotherapy of personality disorders, illustrated with many case examples.

• Provides individualized assessment and measurement in practice
• Uses 18 case formulation methods for treating personality disorders
• Identifies evidence-based effective treatment
• Includes real life case examples

Chapter 1

Case Formulation in Dialectical Behaviour Therapy

Shelley McMain^1,2, Michelle Leybman¹, and Tali Boritz^{1,2 1}Centre for Addiction and Mental Health, Toronto, ON, Canada ²Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Abstract

Case formulation, a method of personalizing brand-name psychotherapies for individual clients, is considered essential to the effective implementation of dialectical behaviour therapy (DBT). Despite the development and utilization of a case formulation being a core competency for certification in DBT practice, many clinicians lack training on how to do so. This chapter presents the underlying theoretical framework of case formulation in DBT and describes the steps and elements involved. Each of the steps is illustrated through the presentation of a case study in which case formulation is used to guide the treatment of a client diagnosed with borderline personality disorder.

Keywords

Case formulation; Dialectical behaviour therapy

Introduction

Dialectical behaviour therapy (DBT) is an evidence-based form of psychotherapy that can be used to treat individuals with severe emotional and behavioural dysregulation. While it is widely implemented, DBT—like all psychotherapies—is not one-size-fits-all, and its effectiveness hinges on the ability of the clinician to tailor the treatment for each client. Case formulation, a method for personalizing psychotherapy, is considered essential for effective implementation of DBT, and is a core competency for DBT certification (see https://dbt-lbc.org/). In real-world settings, however, for a variety of reasons, many practitioners are neither well informed about case formulation, nor well trained in its implementation. It has been observed that clinicians often come to appreciate the value of this process once it becomes clear to them how it can be used to coordinate treatment and improve outcomes in complex cases (Davidson, 2006; Hart, Sturmey, Logan, & McMurran, 2011).

The preparation of a case formulation is especially important when working with clients with personality disorders (Davidson, 2006). First, such individuals often have multiple co-morbid problems, which makes it difficult for clinicians to know where to focus any interventions. Further, clients who are highly emotionally and behaviourally dysregulated are likely to become emotionally aroused and reactive in session, which can cause the clinician to feel confused or overwhelmed and may contribute to countertherapeutic reactions. A sound case formulation helps the therapist understand the client better, thereby allowing for accurate empathy and validation, which in turn promotes collaboration and strengthens the therapeutic alliance. Finally, understanding a client’s patterns of thinking, feeling, and acting improves the therapist’s ability to anticipate challenges and to determine how and when to effectively intervene.

As with other therapeutic approaches, case formulation in DBT is both a process and a product. As a process, case formulation acts as a systematic method of organizing complex and diverse clinical information into clear and meaningful explanations which provide both therapist and client with an awareness and understanding of what and how to change. Like a GPS device, it provides information about the starting point (the target problems), the endpoint (the desired outcomes), and a suggested route (the treatment plan). It maps out the client’s psychological condition, which issues to prioritize, hypotheses about how the client will respond to suitable interventions, and ideas on how to evaluate the impact of interventions (Logan, Nathan, & Brown, 2011). This map can then be turned into a product, such as a written document that can be referred to throughout treatment and shared with the client.

DBT case formulation integrates theory and research (i.e., what we understand broadly about a particular condition or a certain type of human behaviour) to create a specific and idiographic understanding of each client, including how to effectively navigate the therapeutic process. In keeping with the GPS metaphor, we may have in mind a route to get from Point A to Point B but will need to change course if we encounter unexpected road closures or particularly rough pavement. As with the practice of DBT overall, case formulation is a transparent and collaborative process between therapist and client, and is discussed explicitly throughout the course of treatment.

The process of generating a case formulation in DBT, which begins within the first few sessions, involves five essential steps (Koerner & Linehan, 1997). First, the therapist gathers information about the biological and environmental factors that have contributed to the development and maintenance of the client’s mental state. Second, the client’s goals are identified, and treatment targets are specified and prioritized. Third, the function of specific behaviours and the variables that control these behaviours are assessed, primarily through the method of behavioural chain analyses. Fourth, data collected from behavioural chain analyses are synthesized across behaviours to identify common themes relevant to the client’s mental functioning. Finally, suitable interventions are selected to address these common problematic themes.

This chapter provides an overview of case formulation in DBT. It begins by describing the theories that underpin DBT, and then presents a detailed explanation of each of the five steps for generating a case formulation, using a case history to illustrate each step.

Theoretical Foundation of Dialectical Behaviour Therapy (DBT)

Learning Theory

An assumption in DBT is that all behaviours develop through a complex interplay of biological and environmental factors that are governed by the laws of learning: antecedent stimuli precede a behaviour (classical conditioning), and consequential stimuli follow it (operant conditioning). Modelling plays a role as well. The variables that control (i.e., cause or maintain) problematic behaviours therefore become the target of intervention. For a review of the behaviour therapy approach, see Goldfried and Davison (1994).

In keeping with the above, the development of a case formulation is based on a learning theory perspective, and involves a problem-solving approach to identify the stimulus-response relationship associated with problematic behaviours. Behavioural strategies are used to assess both the classical conditioning links in the sequence of events leading up to a behaviour (e.g., cognitions, actions, emotions) and the operant conditioning links that follow that behaviour (i.e., the contingencies that reinforce or punish it) (Swales & Heard, 2017). From a DBT perspective, the therapist is encouraged to contemplate the function of behaviours. For example, one common assumption is that dysfunctional behaviour is motivated by urges to achieve ‘amelioration of unendurable pain’ (Linehan, 1993a,b, p. 265).

Zen Philosophy

DBT focuses on both change and acceptance. The part of DBT that focuses on change is based on learning theory, whereas the emphasis on acceptance is anchored in Eastern mindfulness; specifically, Zen philosophy. The present moment is considered inevitable given the ‘collective impact of all previous moments’ (Swenson, 2016, p. 46). That is, all behaviour that happens should happen, and is understandable (Linehan, 1997). The DBT concept of ‘wise mind’ refers to a state of balance between viewing the world rationally and viewing it emotionally, sometimes experienced as a ‘gut feeling’ about the best course of action to take.

Following these Zen principles, a therapeutic stance of acceptance and nonjudgment guides the process of developing an explanatory theory of a client’s problems, and the therapist seeks to discover how these problems are perfectly understandable in context of the client’s biology, history, and current reality. The concept of wise mind informs the process through which the therapist seeks to clarify and identify the wisdom in the client’s responses or behaviours.

Dialectical Philosophy

The dialectical perspective in DBT adopts a holistic understanding of the client. Dialectical philosophy posits that reality is composed of interrelated parts that cannot be defined without reference to the system as a whole. The system and its parts are in a constant state of flux, and changes in one part of the system influence changes in the others. Dialectical philosophy also emphasizes the understanding that reality consists of opposites or polarities. Tensions or polarizations in thinking, feeling, and acting are seen to naturally arise. This natural tension between opposites is resolved through a process of synthesis.

This perspective influences the development of a case formulation in several ways. We seek a systemic and contextual understanding of the client, taking both emotional aspects and the external environment into account. A DBT therapist considers how polarizations in thoughts, feelings, or actions contribute to problematic behaviour, and determines how to identify polarizations when these occur and how to target them for intervention. As the process of change involves the synthesis of opposites, when selecting interventions there is usually a focus on helping the client move either toward acceptance or toward change.

Biosocial Theory

The biosocial theory of DBT posits that the core dysfunction underlying borderline personality disorder and certain other clinical disorders is pervasive emotion dysregulation, which arises from the combination of a biological predisposition toward emotional vulnerability and an invalidating developmental environment (Linehan, 1993a). Emotional vulnerability refers to experiencing heightened sensitivity to emotions, heightened reactivity, and a slow return to baseline. An invalidating environment refers to an environment that minimizes, ignores, dismisses, or punishes the expression of emotion, thereby communicating to a person that his or her understanding of events and internal experiences are fundamentally wrong and are due to unacceptable and socially undesirable character traits.

When biological emotional vulnerability is combined with an invalidating interpersonal environment, people may fail to learn how to understand, label, modulate, and tolerate emotional distress, or how to solve the problems contributing to their emotional reactions (Linehan, 1993a,b; McMain, Korman, & Dimeff, 2001). Instead, they learn to manage their emotional vulnerabilities through maladaptive strategies. In case formulation, biosocial theory is used to construct a developmental explanation for emotion dysregulation and associated problems. Based on the information gathered when obtaining a developmental history, we are able to begin making hypotheses about how a particular client is coping with emotions in the present.

Step-By Step Approach to Developing a Dialectical Behaviour Therapy (DBT) Case Formulation

The five steps involved in developing a case formulation are detailed below, using a case study to illustrate each step.

Step 1: Obtain a Developmental History

Starting at the first session, gather historical information to help understand how the client experiences, modulates, and expresses emotions. The types of information include relationships with significant family members (parents, siblings) as well as with peers. Assess for any events of childhood abuse, neglect, and bullying, as well as for the environmental response to any disclosures of traumatic experiences.

Assess for evidence of biologically based emotional vulnerability. Was the client a sensitive child, or described as such by others? Emotional vulnerability may include shyness, anxiety, temper tantrums, or other sensitivities to the environment. Assessing for family history of mental health and substance use disorders or other psychological difficulties can also provide valuable information.

Assess for evidence of invalidation in the developmental environment, with specific questions about what messages were received about emotion. For example, when the client became emotional in childhood, what w...