Making CBT Work For You With Case FormulationCedar Koons, LCSW and Alisa Montano, LMSW presenters

Case Conceptualization—Why?

Helps you understand what is causing and maintaining your client’s problems.

Makes it clear what new behaviors the client needs to learn to replace old, problematic behaviors

Helps you recognize when exposure techniques are needed.

Highlights client’s problematic beliefs and thinking errors.

Clarifies where to start.

From Conceptualization to Formulation

Step One—Understand the Problem BehaviorsStep Two—See the Patterns in Behavior Step Three—Recognize the Stage of

TreatmentStep Four—Formulate the Targets Step Five—Formulate the Solutions

Review’s Today’s Case

1. Read through your case.2. Rank problems in order of severity3. What crucial information do I not know?4. Rank problems in order of priority to address5. You have ten minutes for this exercise

Getting Started: Conceptualize your

Case1. What are this persons goals? 2. Why are they seeking treatment?3. What is their environment and how does it

contribute to the problems? Does the environment reinforce the problem?

4. You have 15 minutes.

Step One: Understand the Problem Behavior

Behavior Analysis

AntecedentsBehaviorConsequences

Conduct a Pattern Analysis of the BehaviorAnalyze several instances of the problematic

behavior including mild, moderate and severe episodes

Determine the common antecedents for the behavior

Explore the similar kinds of thoughts, emotions and events that happen before and after the behavior

Analyze the consequences of the behavior—are they often similar?

Common Antecedents: Examples

Feeling rejected Feeling abandoned Health crisis Work or financial crisis Relapse on drugs or alcohol Onset of a depressive or manic episode Discontinuance of medications Traumatic cues or triggers

Common Behaviors: Examples

Self-harm, suicide ideation, suicide attemptFrom substance use to abuse to addictionFrom treatment noncompliance to treatment

dropoutFrom overeating to binge eating, from purging

to severe restrictionFrom problem gambling to gambling addiction.From avoidance to total isolation.

Common Thoughts, Emotions and Events

Thoughts such as “I can’t help myself,” or “I am such a loser,” or “I deserve this.”

Emotions such as shame, sadness, anger, fear, disgust, even love or joy.

Events such as a lonely holiday, a family fight, reaching out and being rejected, being unable to sleep, not eating, being sick.

Hallucinations, delusions and disordered thinking.

Common Consequences:

Examples Immediate reliefDistraction from the main problemPossible reinforcing attention from family and

friendsPossible reinforcing attention from care providersLong term loss of self-respect, relationships, self-

efficacyAddiction, misery, hopelessness

Common Factors Influencing the

Problem BehaviorClient lacks skills to manage the antecedents—Client gets rewarding consequences for the

maladaptive behavior and/or punished for adaptive behavior, or is mainly ignored except when misbehaving.

Client has problematic thinking anywhere during the behavior

Client avoids or misinterprets due to overwhelming or classically conditioned response.

Once you have the pattern examine specific examples

Understand the Behavior Each Time it

OccursAll behavior takes place in a context—it is

your job to know that context so you can help the client change the context.

Examine the ABC’s of each episode of behavior as it occurs. Be specific!

Assess do not assume—purpose of behavior analysis.

Practice with Cases

1. What do you know about antecedents of the most severe behavior?

2. What do you know about the consequences of the most severe behavior?

3. What skills does client lack? 4. What is the client avoiding?5. What problematic thinking do you see?

Step Two: See the Patterns in the BehaviorWhat behavior patterns does this client

manifest?How do these patterns set them up to fail?How do the patterns link together?

Examples of Patterns

Acting on intense, hard to manage emotions Avoidance and mood dependent behavior Emotional shutdown, going numb Self-Invalidation, self-loathing Lack of clarity about goals and values Problems with the sense of self Perfectionism Not following through on commitments

Examine Underlying Influences

What behavior patterns might underlie the problem behaviors? Why do you think so-what is your evidence?

What emotions might be most prominent for this client? Why do you think so—what is your evidence?

Discuss the relationship between the underlying patterns, emotions and the problem behaviors

How do you think the problem behaviors might affect your feelings about your client?

Step 3: Stage of Treatment

Is client engaging in behavior that is dangerous to herself or others?

Is client able to engage in therapy effectively? (example, will they attend sessions and comply with treatment?)

Does client engage in behaviors inconsistent with an adequate quality of life such as being homeless, abusing drugs or alcohol or being totally isolated?

Is client so impaired by PTSD that they cannot have normal functioning? Can the client tolerate the distress of exposure treatment without decompensating?

Orientation and Commitment

All CBT treatment starts with a full orientation to what to expect in treatment.

Orientation includes a lot of teaching of the client about what you will do and why as well as revealing your training and expertise to conduct treatment.

Each phase of treatment requires a full commitment to what is required. Whenever commitment appears to fade, return to commitment strategies.

Step 4: Targeting

Behaviors to Decrease

Self-harming behaviorsSelf-destructive behaviorsBehaviors that interfere with therapyBehaviors that interfere with quality of lifeBehaviors that interfere with accomplishing

the client’s goals.

Behaviors to Increase

Behaviors directed toward the client’s goalsSelf-care around eating, exercise, health

maintenance.Positive social interactionsAdaptive work related behaviorObserving and describing emotionsNoticing thoughts, feelings, urges

How to Monitor

Use of diary card—orient and commitReview the diary card each weekDeal with diary card non-complianceChange up the targets as client progresses Get consultation if client is not progressing

Case Work: What Will You Target?

1. Describe, as specifically as possible, three behaviors that need to decrease, starting with the most severe.

2. Describe, as specifically as possible, what three behaviors you would like to see increase.

3. What emotions or health behaviors do you need to monitor?

Casework: Troubleshoot your Targets

1. What might I anticipate coming up when I target these problems—even if we are successful?

2. What environmental factors are most likely to interfere with progress toward these targets?

3. What might I do that will get in the way of staying on target?

Step 5: Formulate Solutions

If the behavior happens because skills are lacking teach skills and get skills to “pop out” in life

If the behavior happens because the client is reinforced by the consequences use contingency management and self-management

If the behavior happens because of faulty thinking use cognitive modification

If the behavior happens because of avoidance use exposure

Step 5a: Skills

What skills are already on board?What skills are needed?Teaching skills in sessionFinding resources in the community to impart

skillsBehavioral rehearsalAssigning homework practice

Step 5b: Contingencies

How contingencies work in the real worldUse of contingencies in therapyThe use of self-management

Step 5c: Cognitive Modification

Examine and challenge thinking errorsHelp client to step back from automatic

thoughtsNotice the role thoughts play “on the chain”

toward problem behaviorPractice skills to censor ruminating, stop

obsessive thoughts and manage worry

Step 5d: Exposure

Formal vs. InformalLearn the protocol and use the protocolAvoid reinforced exposureGet consultation as needed

Additional Solutions

Problem-solving for complex environmental problems

Evidence- based protocols for panic, PTSD, BPD, etc.

Orient, commit, troubleshoot

When Change is Slow or Impossible

Teach Acceptance strategiesTeach MindfulnessValidate, validate, validate

What Solutions Will Work?

Examine all the problems for your case that might be solved.

What solutions will work? Consider skills training, cognitive modification, contingency management and exposure.

What evidence-based protocols might you explore?What community resources should you try to

access?What kind of consultation do you need?

Formulate Your Case

Prepare a summary of your findings to bring to the group including any insights you have gained from this case formulation process.

Name your top targets and the solutions you plan to work on with your client

Describe what you think will get in your way, both from the client, from the environment and from yourself.

Describe how you will monitor your progress