Table Of Contenttitle: 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
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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
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Cognitive Case Conceptualization
A Guidebook for Practitioners
Lawrence D. Needleman
Ohio State University
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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
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Dedicated to Edie and William
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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
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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
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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)
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(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
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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.
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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
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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
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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
