1. Case Conceptualization in CBT
Case Formulation
Treatment Plan
Conceptualization of Problems

2. 7 Steps in CBT Case Formulation
What are the patient’s problems?
5 axis DSM diagnosis
Primary (anchoring) diagnosis (problem)
Nomothetic formulation of the primary problem
Idiographic formulation of the primary problem
Develop hypotheses
Identify recent precipitants and/or common antecedents/consequences to primary problem

3. Case Formulation: SORC Model
Stimuli (i.e., triggers)
Organism factors (inside the skin)
Response (i.e., problem behavior)
Consequence (i.e., what happened next)

4. Basic Structure of a Treatment Plan
I. Treatment Target 1
Objective 1
1) Goal 1
2) Goal 2
Objective 2
II. Treatment Target 2
Objective 1
1) Goal 1
2) Goal 2
Objective 2

5. Basic Structure of a CBT Treatment Plan: Patient Example(48y/o divorced female)
I. Prevent relapse of depression
Improve relationships with family
1) Identify clear values/goals relevant to relationships with each family member (i.e., what does she want?)
2) Assertiveness skills (e.g., DEARMAN)
Regulate acute emotions well
1) Enhance emotional awareness and discrimination of emotions
2) Use cognitive reappraisal
Maintain social activities
1) Behavioral activation
I. Treatment Target 1
Objective 1
1) Goal 1
2) Goal 2
Objective 2

6. Basic Structure of a NON-CBT Treatment Plan: Patient Example
I. Prevent relapse of depression
Improve relationships with family
1) Have better boundaries
2) Become less enmeshed with family
3) Increase self-esteem
Regulate acute emotions well
1) Bring unconscious defenses into awareness
2) Vent emotions when upset
Enhance social opportunities
1) Overcome unconscious patterns of early childhood attachment
2) Overcome childhood trauma by expressing one’s inner self
I. Treatment Target 1
Objective 1
1) Goal 1
2) Goal 2
Objective 2

7. Targeting Evidence-Based Treatment Problem du jour Presenting Problem
Dx Asmt.
Psychosoc.
Asmt.
Conceptualization of Problem
(SORC, ABCs)
Homework
Your New Ideas!

8. Change in CBT
Thoughts
Feelings
Behaviors
Physiology

9. An example: Thought: I won’t be able to go to the mall Feeling State:
Anxiety
Fear
Behavior:
Avoidance
Procrastination
Physiology:
Limbic system (e.g., amygdala)
Endocrine (e.g., cortisol)
Autonomic (e.g., sweating)
CRH = corticotrophin releasing hormone

10. Validation Paying attention Active listening Therapeutic mindreading
Making sense of bx due to past or biology
Making sense of bx due to the present
Radical genuineness

11. Behavioral “Chain” Analyses

12. Antecedents Behavioral Problem Consequences Inside the Skin
Vulnerability
Factors
Antecedents
Behavioral Problem
Consequences
Inside the Skin
Outside the Skin

13. Antecedents Behavioral Problem Consequences Inside the Skin
Vulnerability
Factors
Antecedents
Behavioral Problem
Consequences
Tired
Physically ill
Meds not taken
Pain
Thoughts
Emotions
Sensations
Memories
Fear, anxiety, shame, anger action urges
Increased physical pain
Problematic beliefs
Temporary relief of shame, anger, etc.
Feel out of control
Feel incapable
Feel victimized
Inside the Skin
Outside the Skin

14. Antecedents Behavioral Problem Consequences Inside the Skin People
Vulnerability
Factors
Antecedents
Behavioral Problem
Consequences
Stressful events
Nighttime
Unpredictable situation
People
Places
Things
Freeze
Fight
Flight
Harm to self
Harm to others
Do not learn
Inside the Skin
Outside the Skin

15. Building and Refining a CBT case Conceptualization
Initial Assessment
Case Conceptualization
Hypotheses
Behavioral Analyses

16. Conceptualizing Dysfunctional Thoughts
Assumptions, Rules, Attitudes
Automatic Thoughts
Core Beliefs

17. Conceptualizing Dysfunctional Thoughts
“Men will use me”
“If I am vulnerable bad things will happen”
“Who cares about relationships? They always end badly”
“I will always be alone”
“I am not lovable”

18. Challenges to Case Conceptualization
Complex cases!
Connecting seemingly different problems
Prioritizing
Time management
Changes in what the patient/client wants to target
Client/patient insight
Client/patient willingness
Client/therapist expectations about therapy
Having hypotheses and refining them
Congruence between your goals and theirs