title: Cognitive Case Conceptualization : A Guidebook for Practitioners LEA Series in Personality and Clinical Psychology author: Needleman, Lawrence D. publisher: Lawrence Erlbaum Associates, Inc. isbn10 | asin: 0805819088 print isbn13: 9780805819083 ebook isbn13: 9780585247892 language: English subject Cognitive therapy, Psychiatry--Case formulation. publication date: 1999 lcc: RC489.C63N44 1999eb ddc: 616.89/142 subject: Cognitive therapy, Psychiatry--Case formulation. cover Page i Cognitive Case Conceptualization A Guidebook for Practitioners page_i Page ii The LEA Series in Personality and Clinical Psychology Irving B. Weiner, Editor Exner (Ed.) Issues and Methods in Rorschach Research Frederick/McNeal Inner Strengths: Contemporary Psychotherapy and Hypnosis for Ego-Strengthening Gacono/Meloy The Rorschach Assessment of Aggressive and Psychopathic Personalities Ganellen Integrating the Rorschach and the MMPI-2 in Personality Assessment Handler/Hilsenroth Teaching and Learning Personality Assessment Hy/Loevinger Measuring Ego Development, Second Edition Kelly The Assessment of Object Relations Phenomena in Adolescents: TAT and Rorschach Measures Kelly The Psychological Assessment of Abused and Traumatized Children Kohnstamm/Halverson/Mervielde/Havill (Eds.) Parental Descriptions of Child Personality: Developmental Antecedents of the Big Five? Loevinger (Ed.) Technical Foundations for Measuring Ego Development: The Washington University Sentence Completion Test McCallum/Piper (Eds.) Psychological Mindedness: A Contemporary Understanding Meloy/Acklin/Gacono/Murray/Peterson (Eds.) Contemporary Rorschach Interpretation Needleman Cognitive Case Conceptualization: A Guidebook for Practitioners Nolen-Hoeksema/Larson Coping With Loss Rosowsky/Abrams/Zweig Personality Disorders in the Elderly: Emerging Issues in Diagnosis and Treatment Sarason/Pierce/Sarason (Eds.) Cognitive Interference: Theories, Methods, and Findings Silverstein Self Psychology and Diagnostic Assessment: Identifying Selfobject Functions Through Psychological Testing Taylor (Ed.) Anxiety Sensitivity: Theory, Research, and Treatment of the Fear of Anxiety Tedeschi/Park/Calhoun (Eds.) Posttraumatic Growth: Positive Changes in the Aftermath of Crisis Van Hasselt/Hersen (Eds.) Handbook of Psychological Treatment Protocols for Children and Adolescents Weiner Principles of Rorschach Interpretation Wong/Fry (Eds.) The Human Quest for Meaning: A Handbook of Psychological Research and Clinical Applications Zillmer/Harrower/Ritzler/Archer The Quest for the Nazi Personality: A Psychological Investigation of Nazi War Criminals page_ii Page iii Cognitive Case Conceptualization A Guidebook for Practitioners Lawrence D. Needleman Ohio State University page_iii Page iv Copyright © 1999 by Lawrence Erlbaum Associates, Inc. All rights reserved. No part of this book may be reproduced in any form, by photostat, microfilm, retrieval system, or any other means, without prior written permission of the publisher. Lawrence Erlbaum Associates, Inc., Publishers 10 Industrial Avenue Mahwah, NJ 07430 Cover design by Kathryn Houghtaling Lacey Library of Congress Cataloging-in-Publication Data Needleman, Lawrence D. Cognitive case conceptualization: a guidebook for practitioners / Lawrence D. Needleman. p. cm.(The LEA series in personality and clinical psychology) Includes bibliographical references and indexes. ISBN 0-8058-1908-8 (alk. paper) 1. Cognitive therapy. 2. PsychiatryCase formulation. I. Title. II. Series. IN PROCESS 616.89'142dc21 98-31852 CIP Books published by Lawrence Erlbaum Associates are printed on acid-free paper, and their bindings are chosen for strength and durability. Printed in the United States of America 10 9 8 7 6 5 4 3 2 1 page_iv Page v Dedicated to Edie and William page_v Page vii Contents List of Cases ix Foreword xi Acknowledgments xvii 1. Introduction to Case Conceptualization 1 2 How Case Conceptualizations Facilitate Successful Treatment 9 Guidelines for Developing Case Conceptualizations 12 An Example of a Case Conceptualization Illustration 17 An Example of a Completed Case Conceptualization Summary Form 19 How This Book is Organized 2. The Cognitive Model 22 24 Cognitive Content 29 Information Processing 44 Development of Cognitive, Affective, and Behavioral Response Patterns 50 Factors that Maintain Self-Defeating Response Patterns 3. The Therapeutic Relationship 53 53 Therapist Attitudes and Behavior 55 Collaboration 59 Socialization into Cognitive Therapy 61 Summary 4. Assessment and Information Integration 63 64 Pre-Intake Questionnaires 67 Intake Interview 71 Ongoing Assessment During Therapy page_vii Page viii 5. Cognitive Therapy Interventions 84 85 Deactivating Maladaptive Cognitive, Affective, Motivational, and Behavioral Responses 105 Modifying Psychological Structures 6. Panic Disorder (PD) with Agoraphobia 123 125 Cognitive Model of a Panic Attack 127 Assessment and Conceptualization of PD 149 Cognitive Therapy of PD 178 Summary of Cognitive Therapy of PD: Integration and Sequencing of Treatment Components 7. Obsessive-Compulsive Disorder (OCD) 182 183 Introduction 185 Cognitive Model of OCD 191 Assessment and Conceptualization of OCD 211 Cognitive Therapy of OCD 234 Summary 8. Chronic or Recurrent Major Depressive Disorder 237 240 Cognitive Model of Depression 245 Assessment and Conceptualization of Depression 250 Examples of Case Conceptualizations 267 Cognitive Therapy of Depression 292 Summary Appendix: Blank Forms 294 References 307 Author Index 325 Subject Index 331 page_viii Page ix List of Cases Panic Disorder Case 6.A PD with Agoraphobia; has panic-inducing belief that he will have a heart (Greg): attack during panic; has dependency issues. Case History: pp. 133-134 Conceptualization: pp. 126, 135-138 Treatment: pp. 149-154, 156-157, 159, 161-163, 167, 172-174, 178, 180 Case 6.BPD without Agoraphobia; has panic-inducing belief that he will go crazy; (Jimmy):abuses alcohol and sex to cope with anxiety. Case History: p. 139 Conceptualization: pp. 140-144 Treatment: pp. 154, 157, 159-161, 178, 180 Case 6.CPD with Agoraphobia; is a vasovagal responder; has panic-inducing (Jillian): beliefs that she will faint and humiliate herself. Case History: pp. 144, 149 Conceptualization: pp. 145-148 Treatment: pp. 154, 157, 161, 162, 164, 172-173, 177, 178 Obsessive-Compulsive Disorder Case 7.A OCD Washer; obsessions relate to contracting AIDS and infecting her (Elise): grandchildren. Case History: pp. 193-194 Conceptualization: pp. 195-199 Treatment: pp. 212-214, 217-221, 230, 235 OCD Checker; obsessions relate to unknowingly injuring a pedestrian Case 7.Bwhile driving; compulsions include repeatedly circling back while driving (Carlos): and repeatedly checking rearview mirror to see if he hit someone. Case History: p. 200 (table continued on next page) page_ix Page x (table continued from previous page) Conceptualization: pp. 201-205 Treatment: pp. 215-217, 221-222, 225, 230 OCD with Overt and Covert Compulsions; underlying obsessive theme relates to her core belief that she will suddenly lose a loved Case 7.C one or something precious to her, like her vision; she engages in (Frances): numerous compulsions to prevent catastrophic outcomes. Case History: p. 206 Conceptualization: pp. 207-211 Treatment: pp. 222-226, 230-231, 233-235 Chronic or Recurrent Major Depressive Disorder (MDD) Case 8.A MDD, Recurrent, Severe; is inactive, on disability, has sociotropic (Abby): orientation; depressive episode triggered by loss of marriage. Case History: pp. 250-251 Conceptualization: pp. 252-255 Treatment: pp. 273-282 Case 8.B MDD, Chronic; is perfectionistic, self-critical, and hypervigilant to (Benjamin):interpersonal threat. Case History: pp. 17-19 Conceptualization: pp. 20-21, 256-257 Treatment: pp. 282-287 MDD, Recurrent, In Full Remission; has extreme standards for Case 8.C achievement; this contributes to exhaustion resulting in shift to (Catherine):depressed mode. Case History: pp. 257-258 Conceptualization: pp. 259-262 Treatment: pp. 287-290 MDD, Chronic; has guilt, self-hatred and is alcohol dependent; Case 8.D depression precipitated by son's accidental death that resulted (Mary): from her mistake. Case History: p. 263 Conceptualization: pp. 264-267 Treatment: pp. 290-292 page_x Page xi Foreword Contemporary psychotherapy has taken a decidedly scientific turn as we enter the 21st century. The definition of the therapist as simply a good listener whose job it is to help the patient feel better has changed to the definition of the therapist as an active and directive participant-observer whose job it is to help the patient get better. Indeed, long before the advent of managed care, cognitive behavioral therapists were practicing an empirically based model of treatment planning and therapy. All empirically based models of therapy are the product of an interaction between scientists and practitioners. They are developed and then tested, using standardized protocols. Psychodynamic models (e.g., interpersonal therapy [IPT]) and the cognitive behavioral therapy (CBT) model have several points in common. They both call for a time-limited approach to therapy. Efficacy research protocols generally involve around 12 to 20 sessions, over a period of no more than 20 weeks. In clinical practice, however, the course of treatment is not limited to 20 weeks. For certain patients the length of therapy may be 6 sessions; for other patients, 50 sessions. The length of the therapy, the frequency of the sessions, and the session length are all negotiable. The problems being worked on, the skills of the patient and of the therapist, the time available for therapy, and the financial resources all have the potential to dictate the parameters of treatment. The goal is not simply to limit the number of sessions, but also to determine their most effective use so that even the patient who can come for unlimited sessions can best be worked with in a framework requiring that the therapy be ''administered" in a pre-set modular fashion. The modular approach of working in 5- to 10- session blocks of time and effort keep the therapy, the therapist, and the patient on target. The treatment protocols associated with empirically based models generally have been seen by some as negative and derided as "cookbooks." In point of fact, adherence to a treatment protocol has a positive impact on both patient and therapist in that it helps to maintain a focus in the therapy. page_xi Page xii Therapists who advocate and practice a free-flowing, unfocused, boundaryless therapy seem to be hoping for change without specifying what change they are looking for and what will bring it about. I should note that the appellation of "cookbook" is not one that I shy away from. The use of a standard recipe helps ensure that the product will be predictable from one time to another. Once one knows the "recipe," he or she can start to customize the recipe. We cannot assume that a single size fits all and that just because a model works with one disorder (e.g., depression), it will work equally well without modification on another (e.g., anxiety). Models must be tested in the treatment of each disorder. The therapy must be proactive, not simply reactive. The reactive approach, so often seen as universal, involves the patient coming into the consulting room. The patient talks and the therapist responds. The patient talks and the therapist responds. The patient talks and the therapist responds. The patient talks and the therapist responds. The patient talks and the therapist responds by ending the session. The patient leaves and comes in next time at which point the patient talks and the therapist responds. The patient talks and the therapist responds. The patient talks and the therapist responds. The proactive approach requires that the therapist conceptualize the problems, assess the patient's skills and motivation, assess the available time and resources for therapy, and choose the strategies and techniques best suited for the particular patient, given the time, motivation, and energy constraints, to deal with these problems. There must be a structure to the therapy. First, at the outset, a discrete list of problems must be agreed on. This list helps both patient and therapist to have an idea of where the therapy is going and to know how the therapy is progressing. The content and the direction of the therapy are established early in the collaboration. Following the problem list, the individual sessions are then structured through agenda setting and homework. Agenda setting is used by many groups to help the participants in meetings have a direction for the meeting, add to the agenda, become more active in the meeting process, and generally allow for maximum success in the minimal time often allotted to the meeting. In individual therapy as well, rather than let the therapy session meander, the therapist can work with the patient to set an agenda, help to focus the therapy work, and make better use of time, energy, and available skills. This is all accomplished (and is dependent on) the therapist's strong working conceptualization of the patient's strengths, weaknesses, resources, and pathology. Agenda setting at the beginning of the session allows both patient and therapist to put issues of concern on the agenda for the day. This structuring is important because the reason individuals often become patients is that they have lost their ability to organize and problem solve. By setting an agenda, the treatment model's problem-solving focus is modeled. Moving through the page_xii Page xiii items on the agenda requires that the therapist be skilled at setting priorities and pacing the session, while taking into account the needs of the patient. This is a skill that is refined through practice and experience. However, even seasoned therapists may feel tense and anxious and be less effective when they are first learning how to pace a session that is built around a collaborative agenda. Therapy cannot be limited to a session or two per week. Transfer and generalization of the skills developed within the session can be expanded through the use of intersession "homework." This systematic extension of the work of therapy to nontherapy hours results in faster, more comprehensive improvement. It builds the expectation that new skills, new cognitions, and new behaviors must be applied in vivo. Homework can be specifically cognitive or behavioral. Most often, it is both. Homework early in therapy focuses on helping the person to interrupt automatic patterns or routines (either cognitive or behavioral), and to observe the connections between thought, behavior, and mood. Thus, early homework tasks may include observing automatic thoughts through the use of DTR, activity scheduling, collecting evidence for and against the person's attributions and expectancies, and mastery and pleaure ratings. In the middle of therapy, homework includes trying out new behaviors through graded task assignments; acting differently in order to gather information about alternative hypotheses; noticing, catching, interrupting, and responding to negative thoughts and behaviors; and enacting a plan designed to lead to a specific goal. Ideally, homework should be collaboratively developed and consist of tasks that the client is able to perform with reasonable time and effort. Furthermore, it should provide the client with choices that will enhance the individual's sense of control and self-efficacy. The therapist takes an active and directive role in the therapy based on the treatment conceptualization. Rather than simply restating the patient's words, or reflecting the patient's mood, the active therapist will share hypotheses, utilize guided discovery, encourage the patient, serve as a resource person, be a case manager, and, in certain limited cases, be an advocate for the patient. Therapy must be a collaborative endeavor. The therapist and patient work together as a team. The collaboration is not always 50/50, but may be 30/70, or 90/10, with the therapist providing most of the energy or work within the session or in the therapy more generally. The more severely depressed the patient, the less energy he or she may have available to use in the therapy. The therapeutic effort would be to help the patients to make maximum use of their energy and to build greater energy. Therapy must involve skill building or the development of coping techniques. Rather than cure depression and anxiety, the therapist helps the patient to acquire a range of strategies with which to manage present and future exigencies of life. The focus of therapy is not on why patients act the page_xiii Page xiv way they do, but rather on what keeps them acting that way. Therapy addresses the question of how to make the necessary changes. The plans for therapy, the types of changes that one can expect, and the path to reach the goals all derive from the therapist's formulation of the case conceptualization. Case conceptualization is, without a doubt, the highest order therapy skill. The novice therapist can be given a list of techniques and can then be taught, via a cookbook, about how to use the techniques. If enough techniques are thrown at a patient, something may work. But the skill that we would want the therapist to build and to have is the ability to develop a conceptualization that will then serve as a template for understanding the patient. If our conceptualization is accurate, it will do three things. It will account for the patient's past behavior. It will make sense of the patient's present behavior. And finally, it will allow prediction of the patient's future behavior. The resources to draw on in teaching this crucial skill of case conceptualization have, to this point, been quite limited. I am both personally and professionally pleased that Lawrence Needleman has written the present text. It is the first breath of fresh air on this subject in almost 10 years. Whereas I have spoken of the importance of case conceptualization, stressed it in my workshops and lectures, and discussed it in various chapters and texts I have written, I have never given it the time and energy it deserves. Larry has done that. This superb book has in its title two important terms. They are guidebook and practitioners. It is written for the practitioner of cognitive therapy. It is written in a manner that makes it usable from the first chapter. From that point it only gets better. It takes the therapist, novice or advanced, through the case conceptualization process in a guided discovery manner, typical of the cognitive therapy approach. The book starts with a thorough introduction to case