1. Making CBT Work For You With Case Formulation Cedar Koons, LCSW and Alisa Montano, LMSW presenters

2. Case Conceptualization— Why? Helps you understand what is causing and maintaining your client’s problems. Helps you understand what is causing and maintaining your client’s problems. Makes it clear what new behaviors the client needs to learn to replace old, problematic behaviors Makes it clear what new behaviors the client needs to learn to replace old, problematic behaviors Helps you recognize when exposure techniques are needed. Helps you recognize when exposure techniques are needed. Highlights client’s problematic beliefs and thinking errors. Highlights client’s problematic beliefs and thinking errors. Clarifies where to start. Clarifies where to start.

3. From Conceptualization to Formulation Step One—Understand the Problem Behaviors Step One—Understand the Problem Behaviors Step Two—See the Patterns in Behavior Step Two—See the Patterns in Behavior Step Three—Recognize the Stage of Treatment Step Three—Recognize the Stage of Treatment Step Four—Formulate the Targets Step Four—Formulate the Targets Step Five—Formulate the Solutions Step Five—Formulate the Solutions

4. Review’s Today’s Case 1.Read through your case. 2.Rank problems in order of severity 3.What crucial information do I not know? 4.Rank problems in order of priority to address 5.You have ten minutes for this exercise

5. Getting Started: Conceptualize your Case 1.What are this persons goals? 2.Why are they seeking treatment? 3.What is their environment and how does it contribute to the problems? Does the environment reinforce the problem? 4.You have 15 minutes.

6. Step One: Understand the Problem Behavior

7. Behavior Analysis Antecedents Antecedents Behavior Behavior Consequences Consequences

8. Conduct a Pattern Analysis of the Behavior Analyze several instances of the problematic behavior including mild, moderate and severe episodes Analyze several instances of the problematic behavior including mild, moderate and severe episodes Determine the common antecedents for the behavior Determine the common antecedents for the behavior Explore the similar kinds of thoughts, emotions and events that happen before and after the behavior Explore the similar kinds of thoughts, emotions and events that happen before and after the behavior Analyze the consequences of the behavior—are they often similar? Analyze the consequences of the behavior—are they often similar?

9. Common Antecedents: Examples Feeling rejected Feeling rejected Feeling abandoned Feeling abandoned Health crisis Health crisis Work or financial crisis Work or financial crisis Relapse on drugs or alcohol Relapse on drugs or alcohol Onset of a depressive or manic episode Onset of a depressive or manic episode Discontinuance of medications Discontinuance of medications Traumatic cues or triggers Traumatic cues or triggers

10. Common Behaviors: Examples Self-harm, suicide ideation, suicide attempt Self-harm, suicide ideation, suicide attempt From substance use to abuse to addiction From substance use to abuse to addiction From treatment noncompliance to treatment dropout From treatment noncompliance to treatment dropout From overeating to binge eating, from purging to severe restriction From overeating to binge eating, from purging to severe restriction From problem gambling to gambling addiction. From problem gambling to gambling addiction. From avoidance to total isolation. From avoidance to total isolation.

11. Common Thoughts, Emotions and Events Thoughts such as “I can’t help myself,” or “I am such a loser,” or “I deserve this.” Thoughts such as “I can’t help myself,” or “I am such a loser,” or “I deserve this.” Emotions such as shame, sadness, anger, fear, disgust, even love or joy. Emotions such as shame, sadness, anger, fear, disgust, even love or joy. Events such as a lonely holiday, a family fight, reaching out and being rejected, being unable to sleep, not eating, being sick. Events such as a lonely holiday, a family fight, reaching out and being rejected, being unable to sleep, not eating, being sick. Hallucinations, delusions and disordered thinking. Hallucinations, delusions and disordered thinking.

12. Common Consequences: Examples Immediate relief Immediate relief Distraction from the main problem Distraction from the main problem Possible reinforcing attention from family and friends Possible reinforcing attention from family and friends Possible reinforcing attention from care providers Possible reinforcing attention from care providers Long term loss of self-respect, relationships, self- efficacy Long term loss of self-respect, relationships, self- efficacy Addiction, misery, hopelessness Addiction, misery, hopelessness

13. Common Factors Influencing the Problem Behavior Common Factors Influencing the Problem Behavior Client lacks skills to manage the antecedents— Client lacks skills to manage the antecedents— Client gets rewarding consequences for the maladaptive behavior and/or punished for adaptive behavior, or is mainly ignored except when misbehaving. Client gets rewarding consequences for the maladaptive behavior and/or punished for adaptive behavior, or is mainly ignored except when misbehaving. Client has problematic thinking anywhere during the behavior Client has problematic thinking anywhere during the behavior Client avoids or misinterprets due to overwhelming or classically conditioned response. Client avoids or misinterprets due to overwhelming or classically conditioned response.

14. Once you have the pattern examine specific examples

15. Understand the Behavior Each Time it Occurs All behavior takes place in a context—it is your job to know that context so you can help the client change the context. All behavior takes place in a context—it is your job to know that context so you can help the client change the context. Examine the ABC’s of each episode of behavior as it occurs. Be specific! Examine the ABC’s of each episode of behavior as it occurs. Be specific! Assess do not assume—purpose of behavior analysis. Assess do not assume—purpose of behavior analysis.

16. Practice with Cases 1.What do you know about antecedents of the most severe behavior? 2.What do you know about the consequences of the most severe behavior? 3.What skills does client lack? 4.What is the client avoiding? 5.What problematic thinking do you see?

17. Step Two: See the Patterns in the Behavior What behavior patterns does this client manifest? What behavior patterns does this client manifest? How do these patterns set them up to fail? How do these patterns set them up to fail? How do the patterns link together? How do the patterns link together?

18. Examples of Patterns Acting on intense, hard to manage emotions Acting on intense, hard to manage emotions Avoidance and mood dependent behavior Avoidance and mood dependent behavior Emotional shutdown, going numb Emotional shutdown, going numb Self-Invalidation, self-loathing Self-Invalidation, self-loathing Lack of clarity about goals and values Lack of clarity about goals and values Problems with the sense of self Problems with the sense of self Perfectionism Perfectionism Not following through on commitments Not following through on commitments

19. Examine Underlying Influences What behavior patterns might underlie the problem behaviors? Why do you think so-what is your evidence? What behavior patterns might underlie the problem behaviors? Why do you think so-what is your evidence? What emotions might be most prominent for this client? Why do you think so—what is your evidence? What emotions might be most prominent for this client? Why do you think so—what is your evidence? Discuss the relationship between the underlying patterns, emotions and the problem behaviors Discuss the relationship between the underlying patterns, emotions and the problem behaviors How do you think the problem behaviors might affect your feelings about your client? How do you think the problem behaviors might affect your feelings about your client?

20. Step 3: Stage of Treatment Is client engaging in behavior that is dangerous to herself or others? Is client engaging in behavior that is dangerous to herself or others? Is client able to engage in therapy effectively? (example, will they attend sessions and comply with treatment?) Is client able to engage in therapy effectively? (example, will they attend sessions and comply with treatment?) Does client engage in behaviors inconsistent with an adequate quality of life such as being homeless, abusing drugs or alcohol or being totally isolated? Does client engage in behaviors inconsistent with an adequate quality of life such as being homeless, abusing drugs or alcohol or being totally isolated? Is client so impaired by PTSD that they cannot have normal functioning? Can the client tolerate the distress of exposure treatment without decompensating? Is client so impaired by PTSD that they cannot have normal functioning? Can the client tolerate the distress of exposure treatment without decompensating?

21. Orientation and Commitment All CBT treatment starts with a full orientation to what to expect in treatment. All CBT treatment starts with a full orientation to what to expect in treatment. Orientation includes a lot of teaching of the client about what you will do and why as well as revealing your training and expertise to conduct treatment. Orientation includes a lot of teaching of the client about what you will do and why as well as revealing your training and expertise to conduct treatment. Each phase of treatment requires a full commitment to what is required. Whenever commitment appears to fade, return to commitment strategies. Each phase of treatment requires a full commitment to what is required. Whenever commitment appears to fade, return to commitment strategies.

22. Step 4: Targeting

23. Behaviors to Decrease Self-harming behaviors Self-harming behaviors Self-destructive behaviors Self-destructive behaviors Behaviors that interfere with therapy Behaviors that interfere with therapy Behaviors that interfere with quality of life Behaviors that interfere with quality of life Behaviors that interfere with accomplishing the client’s goals. Behaviors that interfere with accomplishing the client’s goals.

24. Behaviors to Increase Behaviors directed toward the client’s goals Behaviors directed toward the client’s goals Self-care around eating, exercise, health maintenance. Self-care around eating, exercise, health maintenance. Positive social interactions Positive social interactions Adaptive work related behavior Adaptive work related behavior Observing and describing emotions Observing and describing emotions Noticing thoughts, feelings, urges Noticing thoughts, feelings, urges

25. How to Monitor Use of diary card—orient and commit Use of diary card—orient and commit Review the diary card each week Review the diary card each week Deal with diary card non-compliance Deal with diary card non-compliance Change up the targets as client progresses Change up the targets as client progresses Get consultation if client is not progressing Get consultation if client is not progressing

26. Case Work: What Will You Target? 1.Describe, as specifically as possible, three behaviors that need to decrease, starting with the most severe. 2.Describe, as specifically as possible, what three behaviors you would like to see increase. 3.What emotions or health behaviors do you need to monitor?

27. Casework: Troubleshoot your Targets 1.What might I anticipate coming up when I target these problems—even if we are successful? 2.What environmental factors are most likely to interfere with progress toward these targets? 3.What might I do that will get in the way of staying on target?

28. Step 5: Formulate Solutions If the behavior happens because skills are lacking teach skills and get skills to “pop out” in life If the behavior happens because skills are lacking teach skills and get skills to “pop out” in life If the behavior happens because the client is reinforced by the consequences use contingency management and self-management If the behavior happens because the client is reinforced by the consequences use contingency management and self-management If the behavior happens because of faulty thinking use cognitive modification If the behavior happens because of faulty thinking use cognitive modification If the behavior happens because of avoidance use exposure If the behavior happens because of avoidance use exposure

29. Step 5a: Skills What skills are already on board? What skills are already on board? What skills are needed? What skills are needed? Teaching skills in session Teaching skills in session Finding resources in the community to impart skills Finding resources in the community to impart skills Behavioral rehearsal Behavioral rehearsal Assigning homework practice Assigning homework practice

30. Step 5b: Contingencies How contingencies work in the real world How contingencies work in the real world Use of contingencies in therapy Use of contingencies in therapy The use of self-management The use of self-management

31. Step 5c: Cognitive Modification Examine and challenge thinking errors Examine and challenge thinking errors Help client to step back from automatic thoughts Help client to step back from automatic thoughts Notice the role thoughts play “on the chain” toward problem behavior Notice the role thoughts play “on the chain” toward problem behavior Practice skills to censor ruminating, stop obsessive thoughts and manage worry Practice skills to censor ruminating, stop obsessive thoughts and manage worry

32. Step 5d: Exposure Formal vs. Informal Learn the protocol and use the protocol Avoid reinforced exposure Get consultation as needed

33. Additional Solutions Problem-solving for complex environmental problems Problem-solving for complex environmental problems Evidence- based protocols for panic, PTSD, BPD, etc. Evidence- based protocols for panic, PTSD, BPD, etc. Orient, commit, troubleshoot Orient, commit, troubleshoot

34. When Change is Slow or Impossible Teach Acceptance strategies Teach Acceptance strategies Teach Mindfulness Teach Mindfulness Validate, validate, validate Validate, validate, validate

35. What Solutions Will Work? Examine all the problems for your case that might be solved. Examine all the problems for your case that might be solved. What solutions will work? Consider skills training, cognitive modification, contingency management and exposure. What solutions will work? Consider skills training, cognitive modification, contingency management and exposure. What evidence-based protocols might you explore? What evidence-based protocols might you explore? What community resources should you try to access? What community resources should you try to access? What kind of consultation do you need? What kind of consultation do you need?

36. Formulate Your Case Prepare a summary of your findings to bring to the group including any insights you have gained from this case formulation process. Prepare a summary of your findings to bring to the group including any insights you have gained from this case formulation process. Name your top targets and the solutions you plan to work on with your client Name your top targets and the solutions you plan to work on with your client Describe what you think will get in your way, both from the client, from the environment and from yourself. Describe what you think will get in your way, both from the client, from the environment and from yourself. Describe how you will monitor your progress Describe how you will monitor your progress