The Case Formulation Approach to Cognitive-Behavior Therapy

The Case Formulation Approach to Cognitive-Behavior Therapy Jacqueline B Persons. New York (NY): The Guilford Press; 2008. 273 p. US$35.00

Reviewer rating: Excellent

Cognitive-Behavioural Therapy

Trainees new to cognitive-behavioural therapy (CBT) often worry about their capacity to do the technical interventions for which CBT is best known. How does one use a thought record to change key assumptions? What is an exposure hierarchy, and how is it made? What is the best way to carry out behavioural activation? When they begin treating patients with CBT, they soon discover that the tough part of CBT is not really technique, but rather the choices the therapist makes during the therapy: choosing what to target, choosing when to do so, choosing which interventions would be the most fruitful.

This book focuses on the "decision-making tasks"1' l(1 the therapist must make in the course of therapy. The case formulation approach to CBT is in contrast to the manual ized CBT protocols featured in research trials (those same trials, it must be said, that have established the evidence of CBT's efficacy in emotional disorders). Research trials typically treat highly selected groups with a single diagnosis, while the average therapist in practice is faced with patients with comorbidity, not otherwise specified diagnoses, or diagnoses for which there are no protocols. Further, the burgeoning number of treatment approaches to common disorders makes it hard for any therapist to know how best to treat their patient.

The case formulation approach involves making a comprehensive list of the patient's problems, and developing hypotheses about how these problems relate to each other and to putative underlying mechanisms. These hypotheses are derived from the principles of the cognitive, learning, and emotion theories which currently underpin most empirically supported treatments for emotional disorders. The case formulation chosen will then guide the treatment targets and interventions, and guide the therapist in the management of the minute-to-minute interactions in therapy. An example: the case of lateness for a session can be understood in many different ways, depending on the person's case formulation. The patient with underlying beliefs relating to worthlessness ("my needs don't matter") may have found it difficult to break away from a telephone conversation that will make her late for her appointment (cognitive theory). Another patient whose therapist tends to be late, responds to the lack of reinforcement of punctuality by being late himself (learning theory). Or the overwhelmed person whose last session was intense, responds with emotional avoidance by arriving late in a detached frame of mind (emotion theory). Whether cognitive restructuring, attention to behavioural consequences, or emotional engagement strategies are called for in response will be dictated by the understanding of the problem.

Persons is the world's expert in CBT case formulation. This volume is a welcome update to her first book on this topic, Cognitive Therapy in Practice: A Case Formulation Approach, published in 1989, which quickly became a classic. The depth of knowledge and understanding she displays in the field of CBT is impressive - reflecting her years as a clinician, writer, researcher, and teacher. (She is also the editor of the Guides to Individualized EvidenceBased Treatment Series, an excellent series of texts on CBT for a number of disorders.) Persons effortlessly summarizes key research findings in the cognitive, learning, and emotional literature, and their clinical implications. She integrates these findings with the many kinds of CBTs available today, including dialectic behavioural therapy for borderline personality disorder, behavioural activation for depression, cognitive-behavioural analysis system of psychotherapy for chronic depression, acceptance and commitment therapy, and emotional processing therapies for posttraumatic stress disorder. Her treatment of disparate approaches is even-handed, and her message is refreshing in this time of competing psychotherapy approaches: there are many ways to conceptualize a patient's difficulties, and they do not necessarily conflict. In fact, if interventions based on one formulation are not bearing fruit, go back to the data and come up with another formulation hypothesis to retest.

Well written, well laid out, organized, adequately detailed, and full of interesting illustrative examples, I am hard pressed to find fault with this book. Persons says in her introduction: "My goal is to help clinicians do effective work that is responsive to the situation at hand, guided by clear thinking, and evidence based. "pv" Absolutely.

[Author Affiliation]

Review by Gail Myhr, MD, CM, MSc, FRCPC Montreal, Quebec