The case formulation describes all of the patient’s disorders and problems, and proposes hypotheses about the mechanisms causing the disorders and problems, the precipitants of the disorders and problems, and the origins of the mechanisms, and ties all the elements together into a coherent whole.
Disorders and Problems
The case formulation accounts for all of the disorders and problems a patient is experiencing. To obtain a comprehensive problem list, the therapist assesses the following domains: psychiatric symptoms, interpersonal, occupational, school, medical, financial, housing, legal, leisure, and difficulties with mental health or medical treatment. A comprehensive list is critical for three reasons.
First, the importance of any symptom, problem, or diagnosis depends on the patient’s other problems and diagnoses. For example, a symptom of derealization has different implications for a person with panic disorder than for a person who abuses substances or has a dissociative disorder. To understand the case fully, the therapist must know all of the problems. Second, the therapist who simply focuses on the obvious problems or those on which the patient wishes to focus may miss important problems. Patients frequently wish to ignore problems such as substance abuse, self-harming behaviors, or others that can interfere with the successful treatment of the problems on which the patient does want to focus. Third, a comprehensive problem list often reveals common elements or themes that cut across problems. Awareness of these themes can help to generate initial mechanism hypotheses.
The problem list overlaps considerably with Axes I, II, III, and IV of a DSM diagnosis. However, in the Problem List the therapist begins to translate diagnostic information into terms that facilitate conceptualization and intervention from a CB point of view. One way that the Problem List facilitates CB treatment planning is by giving higher priority to problems in functioning than does the DSM, which places those problems down the list on Axis IV. Also, the Problem List details the symptoms of the particular Axis I and II psychiatric disorders the patient is experiencing, and symptoms can often be described in terms of the cognitions and behaviors that are the currency of CBT.
Mechanisms
The heart of the case-level formulation is a description of psychological mechanisms that cause and maintain the patient’s problems and symptoms. The formulation might also include biological mechanisms (e.g., low thyroid can contribute to depressive symptoms), but we focus here on primarily psychological mechanisms.
To develop a mechanism hypothesis, the therapist can, as already discussed, rely on a nomothetic disorder formulation that underpins an EST, such as the formulation of obsessive–compulsive disorder that underpins exposure and response prevention (ERP) or the formulation of depression that underpins behavioral activation therapy (BA; Martell, Addis, & Jacobson, 2001). A second strategy is to base the case formulation on a more general psychological theory (e.g., the theory of operant conditioning). The case example presented later in this chapter uses both strategies.
Precipitants
The CB formulation is typically a “diathesis–stress” hypothesis; that is, it describes how vulnerability factors or mechanisms (“diatheses”) interact with “stressors” to cause and/or maintain symptoms and problems. Stressors can be external events (e.g., death of a parent) or internal factors (e.g., an endocrine disorder). Thus, many CB formulations are biopsychosocial formulations and include a description of the events that triggered the mechanisms to produce the symptoms and problems.
Origins of the Mechanisms
It is useful to develop a hypothesis about how the patient acquired the mechanisms that cause the problems. An understanding of the likely origins of the problems in the patient’s history lends the formulation internal coherence and can also encourage the use of interventions that target symptoms that are tied to early learning events (Padesky, 1994; Young, 1999).
Tying All the Elements Together
The case formulation describes what origins led to the development of what mechanisms, which, activated by specific precipitants, cause the patient’s symptoms, disorders, and problems, and links all of these elements together into a coherent whole. It identifies treatment targets and the relationships among them that therapy will attempt to change. The elements of the case formulation for Hazel are identified with CAPITAL LETTERS.
As a result of being the oldest female in a large family, in which her mother was overwhelmed and expected Hazel to play a major caretaking role for her siblings (ORIGINS), Hazel learned the schemas “I’m unimportant,” “Others are more important,” and “My role in life is to meet the needs of others” (MECHANISMS). These schemas were activated by her husband’s illness and his need for a great deal of care from Hazel (PRECIPITANT). As a result of exhausting herself to care for him, Hazel began experiencing symptoms of depression (PROBLEM) and became socially isolated (PROBLEM), which exacerbated her depression. She also experienced worsening of chronic hypertension and diabetes (PROBLEMS), because her excessive attention to her husband’s needs prevented her from attending to her own medical needs.
Handbook of Cognitive-Behavioral Therapies, Third Edition, Keith S. Dobson 편집, 178-180.
Jacqueline B. Persons 가 사례개념화에 관련된 챕터(6장)를 맡아서 썼는데 사례개념화를 어떻게 해야 되는 것인지 간명하게 잘 요약되어 있는 부분을 가져 왔다. 사례개념화라는 게 어렵고 시간이 많이 드는 작업으로만 느껴지는데 좀 쉽게 생각할 필요도 있는 것 같다. 사실 보고서 요약에 사례개념화가 들어가는 거니까.. 하지만 제일 나중에 개념화하기보다 간단하게라도 사례개념화를 먼저 해보고 그 다음에 개념화에 기반해 보고서 쓰는 연습을 해야 할 것 같다.
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