Case Formulation Research Articles

Case conceptualization in clinical practice and training

Case conceptualization is central to the success of the therapeutic process. However, integrative case conceptualization research has lagged behind research on integrating therapeutic intervention techniques. A successful case conceptualization provides (a) a dynamic, context-sensitive, yet parsimonious model of the client’s functioning; (b) relevant treatment targets and associated assessment procedures; and (c) a treatment plan including intervention phases and potential obstacles. Success in case conceptualization is a core clinical competency goal for trainees in clinical psychology and a career-long learning goal even for expert clinicians. Emerging technological trends and the formation of adversarial collaborative teams may assist research on the utility of well-constructed case conceptualizations.

Competence-based trainings for psychological treatments – A transtheoretical perspective

Background Although in most countries psychotherapy trainings focus on one treatment orientation, such an approach is associated with systematic shortcomings. The priorities from teaching one theoretical framework should be moved to a more rigorous orientation in science and evidence-based practice, and to the needs of patients, even if strategies of different theoretical approaches need to be combined. Method We discuss whether competence-based trainings in psychological treatments offer a better framework to facilitate the progress of psychological treatments to a professional academic discipline with transtheoretical exchange, and we provide an example of a transtheoretical education in the basic competences of psychological treatments. A transtheoretical education program requires an umbrella model for case formulation and a transtheoretical definition of intervention goals. Results We provide an adaptation of the traditional model distinguishing vulnerability/resilience, exacerbation, and maintenance of clinical problems for case conceptualization. Dynamic network models offer a further perspective for developing modern, transtheoretical case formulations. Treatment methods should be better classified according to their transtheoretical goals, which offers opportunities to better compare or combine them. We report a case example of how to transform a general competence-based approach in the training of psychological treatments in the academic education system, which found exceptional acceptance from participating students. Conclusion Thus, a rigorous competence-based approach to training early clinicians in applying psychological treatments helps to bridge the artificial divide between psychotherapeutic traditions. It also supports the evolution of psychological treatments into an academically robust and highly professional, integrative discipline.

A process-based approach to transtheoretical clinical research and training

Background The science and practice of psychopathology and psychological intervention of today is more like an island archipelago than it is a single land mass, and connections between different traditions are both limited and fraught with misunderstanding. Method Our analysis and solution to the problem is process-based therapy (PBT). PBT defines psychopathology as failed adaptation processes to a given context. Therapy involves adaptation through context-dependent or context-altering applications of biopsychosocial strategies that allows a goal to be met. Results This coherent approach to more transtheoretical and integrative concepts of clinical training and practice provides a firm foundation by targeting biopsychosocial processes of change, analyzing these processes using an idiographic complex network analytic approach, and organizing findings on the intellectual agora of multi-dimensional and multi-level evolutionary science. Conclusion PBT is a new empirical form of functional analysis, resulting in interventions and trainings that are built on elements or kernels of direct relevance to client’s specific needs. In PBT, case formulation continues as long as treatment persists.

Medical education and creative writing: Poetry and how it can assist trainees in developing psychiatric formulation skills.

To reflect on the importance of teaching formulation skills in psychiatry training and explore how creative writing, particularly writing poetry, can help achieve this goal. It is vital that formulation skills are embedded throughout psychiatry training. Formulations have an artistic element, and writing poetry can help foster a capacity for curiosity that can assist trainees in developing these skills.

Lost Self to Present Self: A Case Report of Narrative Therapy for a Woman with Acquired Brain Injury

BACKGROUND: Psychotherapy for people with acquired brain injury (ABI) is considered to be an important component of a holistic neuropsychological rehabilitation approach. This helps in making sense of the loss of the sense of self they experience. Gender, premorbid personality, and socio-cultural discourses guide this process of understanding. Narrative formulation takes these considerations into account and, thus, can be used for formulating therapeutic plans.
 AIM: To present a case report which highlights the use of narrative case formulation to understand the psychological, social, and cultural factors forming the dominant discourse of a woman with ABI.
 METHODS: Ms. VA, a 43-year-old female, presented herself with a diagnosis of hypoxic ischemic encephalopathy with small chronic infarcts with gliosis in the bilateral cerebellar hemisphere, myoclonic seizures, mild cognitive impairment, depression, generalized dystonia, and bronchial asthma. Along with neuropsychological rehabilitation and cognitive retraining, 25 sessions of psychotherapy using narrative formulation were performed.
 RESULTS: Following the therapy, microgains such as a developing strong therapeutic relationship, accommodating vulnerability in her narrative, and finding moments of independence and assertion within the constraints of ABI were observed. Acceptance of her current predicament vis-à-vis her lost self and finding meaning in her new self were facilitated.
 CONCLUSION: There is paucity of research detailing psychotherapeutic management of ABI, especially in India. Psychotherapy, particularly using narrative formulation, can be helpful in understanding the intersections of gender role and expectations, premorbid personality and ABI, and aiding the post-ABI rehabilitation and adjustment. Future work in this area can explore the socio-cultural aspects that play an important role in the therapy process.

The social-cognitive clinician: On the implications of social cognitive theory for psychotherapy and assessment.

We review Bandura's contributions to cognitive-behavioural theory, research and practice. His basic research on the causal role of cognitive processes in social learning was a major factor in the emergence of cognitive-behavioural therapies in the 1970s. His investigations on observational learning and self-efficacy beliefs led to the development of guided mastery therapy, a specific cognitive-behavioural intervention for anxiety disorders. His research on self-regulatory processes provided an empirical basis for the emergence of numerous therapies targeting self-regulation. We conclude by discussing how Bandura's social cognitive theory, as well as more recent advances in social cognitive theorising, might be further applied to innovative approaches to therapeutic interventions, assessment and clinical case conceptualization.

Assessment and treatment of compulsive sexual behavior disorder: a sexual medicine perspective.

The addition of compulsive sexual behavior disorder (CSBD) into the ICD-11 chapter on mental, behavioral, or neurodevelopmental disorders has greatly stimulated research and controversy around compulsive sexual behavior, or what has been termed "hypersexual disorder," "sexual addiction," "porn addiction," "sexual compulsivity," and "out-of-control sexual behavior." To identify where concerns exist from the perspective of sexual medicine and what can be done to resolve them. A scientific review committee convened by the International Society for Sexual Medicine reviewed pertinent literature and discussed clinical research and experience related to CSBD diagnoses and misdiagnoses, pathologizing nonheteronormative sexual behavior, basic research on potential underlying causes of CSBD, its relationship to paraphilic disorder, and its potential sexual health consequences. The panel used a modified Delphi method to reach consensus on these issues. CSBD was differentiated from other sexual activity on the basis of the ICD-11 diagnostic criteria, and issues regarding sexual medicine and sexual health were identified. Concerns were raised about self-labeling processes, attitudes hostile to sexual pleasure, pathologizing of nonheteronormative sexual behavior and high sexual desire, mixing of normative attitudes with clinical distress, and the belief that masturbation and pornography use represent "unhealthy" sexual behavior. A guide to CSBD case formulation and care/treatment recommendations was proposed. Clinical sexologic and sexual medicine expertise for the diagnosis and treatment of CSBD in the psychiatric-psychotherapeutic context is imperative to differentiate and understand the determinants and impact of CSBD and related "out-of-control sexual behaviors" on mental and sexual well-being, to detect forensically relevant and nonrelevant forms, and to refine best practices in care and treatment. Evidence-based, sexual medicine-informed therapies should be offered to achieve a positive and respectful approach to sexuality and the possibility of having pleasurable and safe sexual experiences.

Bridging Perspectives: Exploring the Convergence of Clinimetrics and Network Theory in Mental Health Assessment and Conceptualization.

Background: Clinimetrics and network analysis are two methodological approaches that, despite different origins, share the goal of improving mental health clinical assessment beyond the limitations of classical psychometrics. Despite their common goal and comparable conceptualization of clinical assessment, the potential connection and integration between these approaches has not been explored. The aim of this review is to identify meeting points for the potential integration of clinimetrics and network theory. Methods: A literature review was conducted by examining key works in clinimetrics and network theory and comparing similar concepts from the two approaches. Results: Two main areas of theoretical and methodological convergence and complementarity between clinimetrics and network theory were identified, as follows: the characteristics of clinical indexes and the strategies to assess and organize complex clinical data. These topics encompassed sub-topics related to the influence of individual symptoms on clinical presentation, longitudinal assessment of conditions, influence of comorbidities, and standardized procedures for case formulation. Conclusions: Results provide an indication of the potential for integration for these approaches in a single, clinically oriented methodology for psychological and psychiatric illness conceptualization and assessment. Despite the literature search strategy limitations, the results provide a basis for further exploring the potential for developing an integrated methodology for clinical assessment and treatment planning.

The compassion connection: Experience sampling insights into romantic attraction

Our study examines the relationship between self-compassion, other-compassion, and romantic attraction in couples, and questions the psychological homogeneity assumption—the idea that psychological responses are uniform across individuals and couples. We analyzed data from 161 participants in 84 couples, with an average age 32 (SD = 12.02), using smartphones for event sampling six times daily over a week to measure self-compassion, other-compassion, and attraction. Through within-person and network analysis, we discovered significant variability in how self and other-compassion influence attraction, identifying two distinct couple types: “synergistic,” where compassion significantly affects attraction, and “independent,” where it does not. Further analysis revealed that, when other-compassion is accounted for, males with high self-compassion were less attracted to their female partners. The significant diversity in how individuals and couples experience compassion and attraction challenges the assumption that conclusions drawn from group averages can be universally applied to individual couples. Clinically this means that efforts to enhance compassion in couples therapy should be tailored to the couple's unique dynamics. Indeed, for some men, emphasizing self-compassion without considering other-compassion could even be detrimental to the relationship. Our findings highlight the need for nuanced case formulation and personalized treatment planning in couples therapy, underscoring the complexity of relationship dynamics and the importance of rejecting “one size fits all” assumptions.

Applying a process-based therapy approach to compassion focused therapy: A synergetic alliance

Compassion Focused Therapy (CFT) targets underlying shame and self-criticism to shift one's style of self-relating and capacity to engage with a soothing-affiliate mode. CFT has a strong evidence-base and has been adapted for diverse presenting problems and populations. CFT can serve as a stand-alone treatment approach, or an effective addition to other evidence-based approaches. This theoretical article proposes that CFT is a complementary and synergetic match with a Process-Based Therapy (PBT). This article outlines the theoretical compatibility of the two approaches before presenting an applied case study to illustrate a CFT case formulation using a PBT framework. An illustrative treatment plan is also proposed using the Extended Evolutionary Meta-Model (EEMM). Directions for further research to understand the exact mechanisms of action of CFT and its potential synergetic effects on other treatment approaches are proposed.

Assessment of Brief Online Approaches for Teaching Neuroscience in Psychiatry.

The goal of this study was to assess an online collection of brief educational resources (videos, case studies, articles) for teaching a broad range of concepts relating to neuroscience in psychiatry. A national sample of 52 psychiatrists enrolled in the study. Forty (77%) completed an assessment before and after having access to the educational resources for 4weeks. Pre- and post-assessments were compared using paired t-tests. Fifteen participants were randomly selected to participate in a semi-structured interview. The mean knowledge score increased on a multiple-choice quiz from 46.9 to 86.4% (p < .01). Based on a 5-point Likert rating, participants reported significant gains in self-confidence in their ability to integrate a neuroscience perspective into their clinical work (p = .03) and to discuss neuroscience with their patients (p = .008). Participants rated the extent that they applied neuroscience concepts (such as neurotransmitters, genetics, epigenetics, synaptic plasticity, and neural circuitry) to their overall case formulation and treatment plan over the past typical work week and how often they discussed these elements with patients. Significant gains were noted across all elements (p ≤ .001). Overall satisfaction with the resources were high: participants agreed that the content was useful and relevant (100%) and the teaching resources were engaging (95%). On semi-structured interviews, participants appreciated the mixed teaching approaches and the brief format. Many commented on how the resources impacted their clinical practice. Brief online teaching resources may be an effective approach for enhancing neuroscience education among psychiatrists and may help facilitate the integration of neuroscience into clinical practice.

Creating a Space to Feel: An Integrative Therapy Approach with an Adolescent Diagnosed with Dissociative Motor Disorder

The dissociative motor disorder is one of the most commonly diagnosed forms of dissociative disorder in the Indian population, especially among adolescents. However, there is a dearth of literature on effective psychotherapy practices in the Indian setting. This article details the unique process of employing an integrative psychotherapy approach with a 16-year-old adolescent girl diagnosed with dissociative motor disorder who presented with complaints of headache, deviation of mouth, multiple somatic complaints, inability to move her legs, episodes of loss of consciousness with jerking of upper limbs and a non-pervasive low mood. A detailed evaluation highlighted significant disruptions in attachment with caregivers, complicated grief, significant anger towards her family which did not find a space for expression, unhealthy coping mechanisms in the background of a slow-to-warm-up temperament and sociocultural stressors. The case formulation drew elements from the psychodynamic perspective, family systems approach, biosocial theory and the cognitive behavioural perspective. The intervention from the first session until termination is delineated in different phases which outline the significant themes that emerged along with the techniques used, challenges faced and therapist reflections. The role of the therapeutic alliance, working through transference, systemic work, primary and secondary gains and the importance of defences along with the aftermath of losing them becomes especially salient as the psychotherapy progresses in this case. The implications of the therapy process that can hold relevance to the management of dissociation disorder in the clinical setting are also discussed.

Associations between transdiagnostic traits of psychopathology and hybrid posttraumatic stress disorder factors in a trauma-exposed community sample.

Dimensional conceptualizations of psychopathology hold promise for understanding the high rates of comorbidity with posttraumatic stress disorder (PTSD). Linking PTSD symptoms to transdiagnostic dimensions of psychopathology may enable researchers and clinicians to understand the patterns and breadth of behavioral sequelae following traumatic experiences that may be shared with other psychiatric disorders. To explore this premise, we recruited a trauma-exposed online community sample (N = 462) and measured dimensional transdiagnostic traits of psychopathology using parceled facets derived from the Personality Inventory for DSM-5 Faceted-Short Form. PTSD symptom factors were measured using the PTSD Checklist for DSM-5 and derived using confirmatory factor analysis according to the seven-factor hybrid model (i.e., Intrusions, Avoidance, Negative Affect, Anhedonia, Externalizing Behaviors, Anxious Arousal, And Dysphoric Arousal). We observed hypothesized associations between PTSD factors and transdiagnostic traits indicating that some transdiagnostic dimensions were associated with nearly all PTSD symptom factors (e.g., emotional lability: rmean =.35), whereas others showed more unique relationships (e.g., hostility-Externalizing Behavior: r =.60; hostility with other PTSD factors: rs =.12-.31). All PTSD factors were correlated with traits beyond those that would appear to be construct-relevant, suggesting the possibility of indirect associations that should be explicated in future research. The results indicate the breadth of trait-like consequences associated with PTSD symptom exacerbation, with implications for case conceptualization and treatment planning. Although PTSD is not a personality disorder, the findings indicate that increased PTSD factor severity is moderately associated with different patterns of trait-like disruptions in many areas of functioning.

Aceptabilidad de un modelo de formulación diagnóstica de casos clínicos como estrategia educativa en una residencia de psiquiatría del niño y del adolescente

IntroductionThe aim of the study is to analyze the acceptability of an Integrative and Multidimensional Case Formulation Model implemented as an educational strategy in the first year of a child and adolescent psychiatry residency by a clinical supervisor within a one-way mirror room. Materials and methodsA qualitative methodology is used through content analysis of interviews conducted with residents of the program who had participated consecutively in clinical supervision between 2018 and 2021. For the analysis, 5 theoretical constructs derived from the Theory of Planned Behavior and Fazio's MODE Model are used: attitudes, subjective norm, perceived behavioral control, motivation and opportunity. ResultsTwenty-six thematic codes that influence acceptability emerged from the analysis: 8 attitudinal codes (e.g. acceptability is favored by the usefulness of the Model to gain theoretical insight of the cases but with a high amount of time required); 4 normative codes (e.g. the approval or disapproval of the model by scholars outside the clinical supervision); 7 perceived behavioral control codes (e.g. the perceived self-efficacy increases over time); 4 motivational codes (e.g. the desire to learn) and 3 opportunity codes (e.g. joint deliberation with peers). ConclusionThe results show valuable information for the development of educational strategies in the specialty residency program by approaching significant cognitive and affective factors which influence learning during the training periods. Aspects of the strategy that stand out as favoring the educational process are identified, along with other aspects that can be improved for better acceptability of the educational strategy.

Social Support and Social Stress Among Suicidal Inpatients at Military Treatment Facilities: A Multidimensional Investigation.

The associations between social support and stress with internalizing symptoms (depressive symptoms and hopelessness) and hazardous drinking were tested in an inpatient sample of suicidal military personnel. Baseline data from a randomized clinical trial were analyzed. Different sources of support and stressors in the social context of military personnel were differentially linked to internalizing symptoms and hazardous drinking. In the full sample (n = 192), family and nonfamily support were both inversely associated with internalizing symptoms but not hazardous drinking. Family stress was positively associated with internalizing symptoms. In a subsample of service members who had a history of deployment (n = 98), postdeployment social support was protective against internalizing symptoms, whereas deployment harassment was associated with increased odds of hazardous drinking. Results underscore the need for assessment of various dimensions of social support and stress to guide case formulation and optimize strategies to support patients' mental well-being and adaptive coping.

Individual Video-Based Case Formulation for Participants With Persistent Physical Symptoms Associated With Indoor Environment or Chronic Fatigue

Persistent physical symptoms (PPS) refer to a wide range of symptoms that cannot be fully explained by traditional medical assessment of bodily pathology or environmental factors. The aim of the current study was to illustrate the application of an online interview and Functional Analytic Clinical Conceptualization to describe psychological and life problems perceived by participants with PPS and to give examples of how a functional analysis approach to case formulation could assist in their treatment. We applied the Functional Analytic Clinical Case Model (FACCM) in the assessment of participants with PPS (n = 50), including three focus groups: those with PPS related to the indoor environment (n = 11), those with PPS related to prolonged fatigue (n = 28), and those with both symptoms (n = 11). Among the 50 participants with PPS, a typical amount of concurrent psychological and life problems was 9. In addition to PPS, the most typical problems reported were symptoms of stress and burnout (74%), low mood (68%), narrowing of daily life (58%), and worrying (52%). The results highlight the complexity of the participants’ life situations. We found that the FACCM was acceptable and useful in identifying potential individual treatment targets.

The effectiveness of the offender personality disorder pathway: a propensity score-matched analysis

ABSTRACT Offenders with severe personality pathology are at significantly increased risk of serious and violent offending. In England and Wales, offenders who are likely to meet criteria for a diagnosis of personality disorder are managed within a network of ‘Offender Personality Disorder Pathway’ services. We conducted a retrospective cohort study over 6 years, using linked routine datasets, to examine the effectiveness of these services on male offenders (n = 28,321). We compared the outcomes of those who received a simple case formulation and had not been referred to Pathway services (the ‘Comparison group’), with a group of offenders who had received a complex case formulation and been referred to Pathway services (the ‘Treatment group’). Over time, significant improvements occurred in re-offending risk scores, and lower rates of behavioural disturbance among both Treatment and Comparison groups of offenders. However, no statistically significant differences were detected in the rates of improvement between Treatment and Comparison groups. Offending rates in both groups significantly increased over time, although there was no significant difference in the increase in offending rates between the Treatment and Comparison groups. Currently, there is no statistical evidence that the Pathway is associated with changes in offender behaviour.

Introducing the Theory of Neurosocial Interdependence

Thoughts, emotions, and behaviors are linked fundamentally to the environments one inhabits. The person-in-environment perspective effectively captures these three aspects of the human experience and serves as a central fixture within social work research and practice. Many social workers use this perspective to guide every facet of the work they undertake, from case conceptualization to ethics of human subject research. At the same time, recent advancements in human neuroscience research and neuroimaging technologies have inspired social workers to embrace how the nervous system is integrally interconnected with one’s environments. In turn, human neuroscience has catalyzed more biologically-informed practice and research in the field of social work, centered on elucidating social and psychological developmental domains within systems. The popularity of the person-in-environment perspective and the integration of human neuroscience in the field of social work has created a nexus that heretofore has not been adequately integrated into the literature. The present paper addresses this gap with a novel theory known as neurosocial interdependence, which integrates insights from human neuroscience into the framework of the person-in-environment perspective. This paper also bolsters the development of the theory of neurosocial interdependence by introducing a novel testing instrument and measurement scale, exploring how these tools might be used to implement the theory of neurosocial interdependence within social work research and clinical settings.

Psychosocial intervention in palliative care: What do psychologists need to know.

Emotional and existential suffering is prevalent in advanced diseases and psychologists have valuable skills to support people in this time of life. Yet, psychologists are rarely integrated in palliative care and relevant training is sparse. Being integrated in other areas of health, it is likely that we will be supporting these patients, whether integrated in a specialized team or not. This article is meant to serve psychologists, already skilled in the art and science of psychosocial intervention, who may find themselves supporting patients with advanced disease. Relevant history of palliative care is provided to elucidate palliative philosophy and approach. Evidence-based existential interventions will be reviewed. Integration of psychological models and both palliative theory and practice is provided to support palliative-appropriate case conceptualizations. Finally, case examples are provided throughout to help readers reconcile their existing practice in this domain of care.

Forensic Case Formulation: Exploring the Knowledge, Opinions, and Training Experiences of Staff Working Within the Offender Personality Disorder Pathway.

Forensic case formulation (FCF) is a key activity within the Offender Personality Disorder Pathway (OPDP), performed by OPDP specialist offender managers (OMs) and psychologists. Although FCF training is provided to OMs, there are a number of questions about the adequacy and effectiveness of this training. Furthermore, it is unclear whether psychologists receive sufficient support to keep their FCF skills relevant and effective over time. This study aimed to investigate the FCF training experiences of OPDP staff, to assess staff satisfaction with this training, to identify ways of improving this training, and to explore the value of FCF from a staff perspective. To meet these aims, OPDP staff were asked to complete an online Qualtrics survey disseminated nationally. Results reveal a lack of standardized FCF training across the OPDP, contributing to poor staff satisfaction and confidence. These results highlight a need for FCF training improvement within the OPDP.