Beyond Diagnosis

Case Formulation in Cognitive Behavioural Therapy

Michael Bruch

• Publisher: Wiley-Blackwell
• Year: 2015
• Print ISBN: 9781119960751, 9781119960768
• eBook ISBN: 9781118600375
• Edition: 2
• Topic: Psychology
• Subtopic: Cognitive Behavioral Therapy (CBT)
• Index: Psychology

The second edition of Beyond Diagnosis is a fully updated and expanded examination of Vic Meyer's pioneering case formulation approach and its application to cognitive behavioral therapy.

• Recommends dynamic, individualized assessment over standard diagnostic classification for complex individual problems
• Presents detailed analysis of advanced cases that are relevant for clinical practice
• Features a foreword by Ira Turkat, as well as discussion of the most up-to-date clinical procedures from a world-wide group of case formulation experts

1
The Development of Case Formulation Approaches

Michael Bruch

There is nothing as practical as a good theory.

Kurt Lewin

Case Formulation and Psychiatric Diagnosis

Beyond diagnosis? The title of this book may sound intriguing to the reader, especially as, at first glance, cognitive–behavioural psychotherapy and psychiatric classification appear to be quite well suited to each other as evidenced by not only research publications but also textbooks on therapeutic techniques mostly presented according to diagnostic categories.

Are there any limitations with the psychiatric model? How can we define a relationship between psychiatric diagnosis and case formulation? Does case formulation require a diagnosis? And what is really necessary to know when understanding a problem and making a treatment plan? To answer these questions, it seems appropriate to produce reasons and developmental conditions for case formulation as a clinical approach.

Traditionally, clinicians dealing with behavioural disorders, especially in the psychiatric setting, were mostly expected to define and organize their clinical work in terms of nosological categories.

The practical end result of this was mostly classification and medication. There was little room for psychotherapy, and novel approaches were usually not encouraged. When, in the 1950s, behaviour therapy (BT) arrived on the scene, there seemed little willingness on part of the psychiatric establishment to change this tradition (Eysenck, 1990).

However, this attitude caused growing irritation and dissatisfaction among behaviour therapists, as hardly any instrumental value could be found in a classification system that aimed mainly at ‘scientific’ order and communication (often with dubious validity and reliability [British Psychological Society [BPS], 2011]), but appears less helpful or even intent in explaining mechanism and directing treatment of respective disorders.

What are the problems with psychiatric diagnosis?

Apart from being merely descriptive, there can be considerable overlap between categories. Despite considerable improvements and refinements over the last two decades (APA/DSM IV-TR, 2000), this is largely true to this day, as Turkat (1990) has pointed out in the case of personality disorders: For example, when clinicians were asked to sort the criteria for all disorders to the matching categories, they were only able to assign 66% of these correctly, indicating lack of validity and diagnostic overlap (Blashfield & Breen, 1989). They also found a tendency to assign presented problems to multiple categories to (six to eight in the case of personality disorders).

More recently, Sturmey (2009) has provided an excellent critique from the methodological point of view about the shortcomings of the psychodiagnostic approach according to the medical model. In the field of BT, the adoption of diagnostic criteria when selecting treatment procedures came about in the 60s, in tandem with the development of standardized techniques evaluated in randomized controlled trials (RCTs). Although this approach is presented in a very persuasive way by many professional bodies, mostly of a medical background, Sturmey points out the many limitations of this approach. Given the problems of validity and reliability of psychiatric diagnosis, it is questionable if homogenous groups for controlled trials can ever be constructed. Psychological processes in development are mostly ignored, and individualization of treatment is not encouraged.

Furthermore, any interaction between diagnosis and treatment is not contemplated in these designs as one treatment method is simply compared with another one, placebo or waiting list control, etc. Such a design does not allow us to determine whether a treatment effective for one diagnosis would also be effective for another diagnosis or whether it was the most effective treatment for a diagnosis. One might speculate that anxiety-based disorders associated with a range of symptoms might be best treated with a method addressing the mechanism of the disorder rather than focusing on individual complaints (symptoms), which are presumably the main focus of a diagnosis.

From a clinical standpoint, which deals with a unique patient, average improvement, as established in RCTs, does not make much sense – the average patient simply does not exist. Besides, significance in trials can be achieved with large size samples and sensitive measures. And usually, substantial number of individuals improve little or not at all. And even with those who do improve, the effective ingredient remains unclear and might include non-specific effects such as the therapeutic interaction.

Taking these points together, it seems highly questionable whether parametric statistical methods are appropriate in evaluating the efficacy of psychotherapeutic treatments. On the assumption that treatment should be individualized, single-case experimental design methodology might be used instead.

Sturmey (2009) points out further limitations of the diagnostic model: When medication is recommended, individual responses can be varied and often quite problematic in the long term. For example, if perceived effectiveness of treatment is seen to lie outside one’s own resources, dependency on medication may occur and self-efficacy arising out of personal coping responses is not encouraged.

Standardized psychological treatments are equally problematic as the response to them is unpredictable, improvements are often not maintained or some problems remain unchanged.

For all these reasons, creative and experienced clinicians tend to reject the straightjacket of the diagnostic model and prefer an individualized approach.

Finally, reliability and validity issues are a continuous problem with ongoing DSM and ICD (World Health Organization, 2010) revisions. Research trials on these criteria are few and far between and are usually conducted after criteria have already been established. Sturmey also points out that clinicians tend to use their own methods and not the recommended structured assessment procedures that may achieve better reliability.

Unfortunately, over time, these developments did lead to an increasing medicalization in treating behavioural disorders – a far cry from what was originally intended by the pioneers of BT such as Eysenck, who preferred to focus on a learning principle-based analysis of individual cases. This was motivated by complex and difficult cases that were rejected by the established providers, usually psychiatry or dynamic psychotherapy (Eysenck, 1990).

As the latest revision towards DSM-5 clearly demonstrates, scientists and clinical experts still share many disagreements and, despite considerable non-medical input, there does not appear much progress regarding advice and guidance for non-medical treatments.

It is difficult to see how, after many controversial revisions, DSM-5 will ever deliver a classification system acceptable to clinicians and sufferers. The recent response by the BPS (2011) addresses these expected shortcomings:

The Society recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with ‘normal’ experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or ‘symptoms’ or ‘complaints’. Statistical analyses of problems from community samples show that they do not map onto past or current categories (Mirowsky, 1990; Mirowsky & Ross, 2003). We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety, etc.)? These would be more helpful too in terms of epidemiology.

While some clinicians find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person’s real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person’s problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives. There is ample evidence from psychological therapies that case formulations (whether from a single theoretical perspective or more integrative) are entirely possible to communicate to staff or clients.

Another problem with diagnosis is the lack of interest in understanding the underlying psychological mechanism of a disorder. Obviously, this is quite unacceptable from a behavioural-learning perspective. Grouping problems into categories cannot advance this search for causes as learning biographies are ignored. Thus, psychiatric diagnosis will not help us to explain onset, development and maintenance of a behavioural disorder. Such information, however, must be considered to be crucial for a comprehensive case formulation with explanatory power.

Finally, psychiatric classification is clearly linked with concepts of mental illness and normality. Such labels are frequently experienced as stigmatizing value judgements by clients and have been shown to be counterproductive for learning-oriented therapy (e.g. Szasz, 1961). Despite great efforts towards operationally defined categories in diagnosis, the issue remains contentious, especially for non-medical psychotherapists.

However, it seems surprising that only recently claims were made to the contrary, i.e. the suggestion that medicalization of behavioural problems might provide relief for the sufferer (Markowitz & Swartz, 2007). There appears no substantial clinical evidence for this; however, labelling may be preferred by some individuals as it allows evading personal responsibility in preference for medicated treatment over psychological therapy. I believe this to be a short cut likely to undermine a personal locus of control in the development of new resources and coping behaviours, thus preventing enhancement of self-efficacy processes (Bandura, 1977).

These comments on the recent development of psychiatric...

Table of contents

• Cover
• Dedication page
• Title page
• Copyright page
• List of Contributors
• Foreword
• Preface
• 1 The Development of Case Formulation Approaches
• 2 The UCL Case Formulation Model
• 3 Case Formulation
• 4 Case Formulation and the Therapeutic Relationship
• 5 The Therapeutic Relationship as a Critical Intervention in a Case of Complex PTSD and OCD
• 6 Generalized Anxiety Disorder
• 7 Cognitive-Behavioural Formulation and the Scientist-Practitioner
• 8 Cognitive-behavioural Case Formulation in the Treatment of a Complex Case of Social Anxiety Disorder and Substance Misuse
• Appendix: Invited Case Transcript
• Index
• End User License Agreement