A Case Formulation Approach to Resolve Treatment Complications

There is a tendency to think of case formulation as an activity that occurs at the outset of therapy to guide initial clinical decision-making, but which plays little role once therapy is underway. However, we believe that case formulation is most useful when viewed as a dynamic, iterative process that invites frequent revisiting of hypotheses as new client data become available. As Eells describes in her influential handbook, “A psychotherapy case formulation is a hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioral problems. A case formulation helps organize information about a person, particularly when that information contains contradictions or inconsistencies in behavior, emotion, and thought content.” (Eells, 2007, p. 4). By viewing case formulation as an animate hypothesis-testing enterprise, the process becomes very useful for resolving treatment complications. In particular, it helps with identifying potential “stuck points” by generating alternative approaches and possible explanations for treatment stagnation. In the current chapter, we consider some of the many ways that case formulations can help enhance treatment outcome for anxiety disorders. We will focus predominantly on case formulation from a cognitive behavioral perspective because this approach reflects the dominant treatment perspective for anxiety disorders (see list of empirically supported treatments; e.g., Chambless & Ollendick, 2001). However, we also consider recommendations from alternate therapeutic orientations. In particular, underlying the proposals we offer is a perspective borrowed from Motivational Interviewing (Miller & Rollnick, 2002), which suggests that apparent “resistance” in therapy is better understood as ambivalence about making changes. Moreover, ambivalence is expected when we ask clients to give up well-established (albeit maladaptive) ways of thinking, behaving, and relating to others. Thus, complications in treatment present puzzles for therapists and clients to investigate, rather than purposeful defiance on the client’s part. Case formulation is a valuable tool that can help put the pieces of the puzzle (back) together when a treatment is floundering.