1
Q
CH1: Defining Formulation: Benefits, Goals, History, and Influences
A
2
Q
Example questions: symptoms and problems
A
- What are the main problems?
- How are the problems interrelated?
3
Q
Example questions: Diagnostics
A
- What is the diagnosis?
- Does client have X or another disorder?
- Does client meet criteria for more than one diagnosis?
4
Q
Example questions: Explanations
A
- What is the self-concept of client?
- What is overall level of functioning?
- What are wishes and fears?
- What are main coping strategies?
- How is the environment of client?
5
Q
Example questions: treatment planning
A
- Are there evidence-based treatments or treament processes that can help client?
- Does client need behavioral therapy?
- How long does client need to be in treatment?
- What short term and long term goals would be most helpful?
6
Q
What are the three main sources of information for a psychotherapy treatment plan, according to Eells?
A
Plans for psychotherapy are based on:
1. Theory
2. Evidence
3. Expert practice
7
Q
Why does Eells say diagnosis alone is not enough for guiding psychotherapy?
A
Because most psychiatric diagnoses are descriptive and do not address etiology, they provide limited guidance on why problems occur and how specifically to plan treatment; therefore, something beyond diagnosis—case formulation—is needed.
8
Q
Provide Eells’s working definition of a psychotherapy case formulation.
A
Psychotherapy case formulation is a process for developing a hypothesis about, and a plan to address, the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioral problems, in the context of that individual’s culture and environment.
9
Q
Why is a formulation described as a “hypothesis”?
A
A formulation is the therapist’s best current account of the client’s problems—why they occur, what precipitates them, and why they are maintained—which must remain tentative and open to testing and revision, like any hypothesis.
10
Q
What within‑person factors are typically included in a case formulation?
A
- Learning history
- Style of interpreting information
- Coping style
- Self-concept
- Core beliefs and axiomatic assumptions about the world
11
Q
How does a formulation address behavior and interpersonal functioning?
A
It considers whether behavior is under‑ or overexpressed, normative or nonnormative, adaptive or maladaptive, and how the person interacts with others, including automatic beliefs about others’ intentions and typical responses to those expectations.
12
Q
What environmental and cultural aspects does a formulation take into account?
A
It includes the client’s cultural influences, social roles (and conflicts between them), and aspects of the physical environment such as neighborhood safety, socioeconomic status, and education and work opportunities.
13
Q
Why is a formulation more than a summary of history and presenting problems?
A
Because it not only describes but also explains why the client has these problems; an explanatory account is a necessary component of formulation.
14
Q
How is the treatment plan related to the explanatory hypothesis in a formulation?
A
The treatment plan flows from the explanatory hypothesis, translating the conceptualization into concrete goals and interventions that account for the client’s preferences and readiness to change.
15
Q
In what sense is a formulation both a “plan” and a “tool for planning”?
A
It is a plan because it contains a proposal for treatment, and a tool for planning because, when articulated in testable terms and monitored over time, it guides ongoing decisions and revisions throughout therapy.
16
Q
How should formulations be tested and revised over the course of treatment?
A
Through regular progress monitoring using symptom and problem measures; if the client is not responding or new information emerges, the formulation and plan should be revised accordingly.
17
Q
What are “process” aspects of case formulation?
A
Process aspects refer to the therapist’s activities in eliciting information needed to formulate—for example, how the therapist conducts interviews and gathers data.
18
Q
What are “content” aspects of case formulation?
A
Content aspects include the problems identified, the diagnosis, the explanation of the problems, and the treatment plan.
19
Q
What is an “event formulation” in psychotherapy, and how does it differ from a case formulation?
A
An event formulation explains a particular episode in therapy (e.g., a sudden mood shift), whereas a case formulation explains the client’s problems overall across time. Event formulations should fit with and test the broader case formulation.
20
Q
What is a “prototype formulation” of a psychological disorder?
A
A prototype formulation is a theoretically based conceptualization of a disorder (e.g., a standard model of depression) that describes typical mechanisms and can serve as a starting point for building an idiographic case formulation for an individual client.
21
Q
How does Beck’s cognitive model conceptualize depression?
A
Beck’s model sees depression as involving negative views of self, others, and the world, characterized by automatic negative thoughts, negative emotions, and problematic behaviors arising when negative schemas are activated by stressful events.
22
Q
What does the learned helplessness model propose about depression?
A
It proposes that depression develops after repeated non‑contingent experiences (uncontrollable outcomes), leading to attributions where negative events are seen as internal, global, and stable causes, while positive events are attributed to external factors.
23
Q
How do Lewinsohn and colleagues conceptualize depression behaviorally?
A
They propose that a low rate of positive reinforcement is an antecedent to depression, with insufficient rewarding experiences contributing to depressive symptoms.
24
Q
How does an attachment‑based prototype explain vulnerability to depression?
A
It attributes vulnerability to early failures in achieving secure, stable relationships with caregivers, repeated messages of being unlovable, or experiences of genuine loss.
25
What is the first major reason Eells gives for engaging in case formulation?
A formulation guides treatment by helping the therapist stay on track across sessions, monitor progress, and recognize when a change of direction is needed; it provides an overarching perspective on treatment and has been likened to a map, blueprint, or north star and the “heart” of evidence‑based treatment.
26
What is the second major reason for formulating a case?
Formulation increases treatment efficiency: with a plan, the therapist can design a time‑effective, evidence‑based route from the beginning to the end of treatment.
27
What is the third major reason for case formulation?
Formulation allows tailoring treatment to the client’s specific circumstances—problems, diagnoses, context (e.g., multiple providers, past failed treatments)—making the approach client‑centered rather than treatment‑centered.
28
What is the fourth major reason for case formulation?
A well‑crafted formulation should enhance therapist empathy, because understanding a client better through formulation supports empathic engagement, which is linked to better outcomes.
29
How do Hippocratic traditions influence modern psychotherapy case formulation?
Hippocratic medicine emphasized viewing the individual as a whole, encouraging active participation of the patient in the cure, relying on observation and reason, and attributing disease to natural forces—all of which influence the holistic, observational nature of case formulation.
30
What was Galen’s contribution relevant to case formulation?
Galen emphasized experimentation and a focus on physical structure and function as the basis of disease; this legacy is reflected in case formulation’s attention to inference about underlying structures (e.g., schemas, traits, ego structures) and the value placed on testing and experimentation in formulation.
31
How do modern case formulations reflect Hippocratic and Galenic traditions?
They depend on close observation, adopt a holistic perspective, consider biological, psychological, and social facets of functioning, and infer psychological structures while emphasizing testing and empirical evaluation.
32
What four contemporary developments in psychology have influenced case formulation, according to Eells?
1. Conceptions and classification of psychopathology
2. Theories of psychotherapy
3. The psychometric tradition
4. Structured case formulation models
33
Why is defining abnormality central to case formulation?
Because decisions about what is “abnormal” shape how problems and symptoms are identified, explained, and targeted via treatment goals and strategies, providing a reference point for understanding clients in their cultural context.
34
What are some common criteria used to define abnormality? (5)
1. Personal distress
2. Behavior that distresses others
3. Poor adaptation to stress
4. Personality inflexibility
5. Irrationality
35
What is the main difference between categorical and dimensional views of psychopathology?
The categorical view sees disorders as qualitatively distinct syndromes, whereas the dimensional view sees psychopathology as lying on continua from normal to abnormal, differing in degree rather than kind.
36
What are some assumptions of the categorical “medical model” of mental disorders?
It assumes that diseases have predictable causes, courses, and outcomes; that symptoms express underlying pathogenic structures/processes; that medicine’s primary focus is disease rather than health; and that disease is fundamentally an individual rather than social phenomenon.
37
What are some claimed advantages of a dimensional view of psychopathology? (4)
Dimensional approaches are said to:
1. Better reflect psychopathology in nature
2. Capture subclinical phenomena more accurately
3. Be more parsimonious
4. Be easier to measure with continuous scales (e.g., personality dimensions like neuroticism, extraversion).
38
How can categorical and dimensional perspectives be reconciled in case formulation?
Eells suggests therapists need not choose; both perspectives are valid and useful. We think easily in categories, yet dimensional approaches address important limitations, so therapists can learn to alternate between these lenses when understanding clients.
39
How has psychodynamic theory influenced case formulation? ()
1. The notion of active unconscious
2. Id, ego, superego as basic mental structures
3. Defense mechanisms as reality-mediating processes
4. Emphasis on sexuality, aggression, and attachment
5. A theory of psychological development
6. Reframing the psychiatric interview as a place where interpersonal problems are enacted
40
How has cognitive therapy contributed to case formulation?
It provides a rich lexicon (schemas, core beliefs, automatic thoughts, faulty reasoning) and standardized formulations for various disorders, supported by extensive efficacy research, showing how cognitive patterns shape emotional and behavioral problems.
41
How has behavior therapy influenced case formulation?
Behavior therapy emphasizes symptoms, stimulus–response connections, behavioral chains, contingencies of reinforcement, and the role of environmental conditions, leading to formulations that analyze behavior in context and consider how changing the environment can help.
42
What is meant by “third wave” behavioral theories, and how do they relate to formulation?
Third‑wave approaches (e.g., Hayes & Strosahl) emphasize mindfulness, acceptance of past and present realities, and commitment to awareness, which influence how therapists conceptualize maintaining processes and goals in case formulation.
43
What are some humanistic/phenomenological contributions to case formulation?
They contribute an emphasis on:
1. The whole person, not just a disorder
2. The here‑and‑now experiencing of therapist and client
3. A more egalitarian therapist–client relationship, focusing on enabling greater self‑awareness and congruence within the self.
44
What is the “psychometric tradition,” and why is it considered important for case formulation?
The psychometric tradition includes the development of reliable, valid psychological tests, standards for test construction and administration, and application of probability theory; this statistically informed mindset improves formulation by promoting awareness of norms, reliability, validity, and systematic assessment.
45
How does the psychometric tradition support evidence‑based practice and formulation?
It underlies the use of progress monitoring with psychometrically sound instruments, supporting evidence‑based practice and helping therapists test and refine formulations empirically.
46
Why has the influence of the psychometric tradition on case formulation been limited?
Many psychologists see psychotherapy and psychometric assessment as not closely related, and the narrative/configurational structure of case formulations can be quite different from the itemized structure of psychometric instruments, limiting integration.
47
Why were structured case formulation models developed?
They emerged in response to concerns that therapists, even with the same orientation and clinical material, often disagreed in their formulations and sometimes inferred distant, unsupported psychological structures, especially in psychodynamic practice.
48
Name three examples of structured case formulation methods and their broad orientations.
1. CCRT (Core Conflictual Relationship Theme) psychodynamic
2. Configurational analysis (Horowitz) - Psychodynamic / configurational
3. Plan formulation method (Silberschatz & Curtis) - psychodynamic
49
What common features do most structured case formulation methods share? They typically: (4)
1. Identify problems
2. Infer maladaptive relationship transactions and concepts of self, others, and the world
3. Rely primarily on clinical observation
4. Use low-level inferences, structure the formulation into components and sequences, and reflect a trend toward psychotherapy integration
50
What does the CCRT method aim to identify, and from what kind of material?
CCRT aims to identify a client’s central problematic relationship pattern, based on narratives about relationship episodes told in therapy.
51
What are the three key components of a CCRT?
1. The client's wishes
2. Expected responses of others
3. Responses of the self
52
On what theoretical concept is the CCRT based, and what does that concept assert?
CCRT is based on Freud’s concept of transference, which asserts that innate characteristics and early interpersonal experiences predispose people to initiate and conduct close relationships in repetitive, patterned ways later in life.
53
What does research on CCRTs show about relationship narratives and CCRTs over time? Research shows that: (3)
1. Relationship narratives are routinely told in psychotherapy
2. CCRTs are consistent across treatment, relationships, and lifespan
3. CCRTs differ by diagnosis
54
What is the first major tension in case formulation described by Eells?
Immediacy vs. comprehensiveness: therapists have limited time and must formulate with partial information, balancing practical constraints with the need for sufficient data; parsimony helps decide what is "enough" to formulate
55
What is the second major tension in case formulation?
Complexity vs. simplicity: human behavior is highly complex, but a formulation should be as simple as possible and as complex as necessary, integrating relevant aspects without overcomplicating the case.
56
What is the third major tension in case formulation?
Therapist bias vs. objectivity: therapist inevitably bring personal values, feelings, judgements, and cultural history, and are subject to systematic reasoning biases, yet must strive to manage these biases rather than let them dominate formulation.
57
How does overreliance on personal clinical experience illustrate the bias vs. objectivity tension?
Personal experience is selective, unsystematically sampled, lacks context, and is based on measures of unknown reliability/validity, yet clinicians often give it privileged status over more rigorous evidence (e.g., large, controlled studies or meta‑analyses), which can distort formulations.
58
What is the fourth major tension in case formulation?
Observation vs. inference: formulations require both descriptive observation and interpretive inference; too much observation yields only a pile of facts, whereas inferences too disconnected from data reduce reliability and accuracy.
59
Why are “low‑level” inferences often most useful in formulation?
Because they are closer to observable evidence and to the client’s direct experience, making them more reliable and testable than high‑level, abstract interpretations.
60
What is the fifth major tension in case formulation?
Individual vs. general formulations: case formulations must do justice to the client’s unique life history and circumstances, yet also incorporate general knowledge from research and prototypes about disorders and stressors.
61
What is the risk of being overly nomothetic (too general) in formulation?
The therapist may overlook important unique aspects of the client’s presenting problems by relying too heavily on general theories or prototypes.
62
What is the risk of being overly idiographic (too individual) in formulation?
The therapist may disregard valuable research and general knowledge that could aid treatment, potentially missing effective, evidence‑based strategies.
63
How does Eells summarize the overall goal for balancing these tensions in formulation?
Therapists should seek the right balance in each tension—enough information but not too much, sufficient complexity without overload, mindful of bias but informed by experience, grounded in observation yet guided by inference, and integrating both individual uniqueness and general knowledge.
64
What are the 5 major tensions in case formulation?
1. Immedicacy vs. comprehensiveness
2. Complexity vs. simplicity
3. Therapist bias vs. objectivity
4. Observation vs. inference
5. Individual vs. general formulations
65
1. Immediacy vs. comprehensiveness
Limited time and incomplete, one‑sided information vs. the wish for fuller, more comprehensive data.
66
2. Complexity vs. simplicity
Human behavior is highly complex, but a formulation should be as simple as possible and as complex as necessary.
67
3. Therapist bias vs. objectivity
Inevitability of personal values, stereotypes, and selective personal experience vs. striving for more objective, evidence‑based judgment
68
4. Observation vs. inference
Grounding the formulation in careful, theory‑free description vs. interpreting and inferring patterns; overreliance on either side creates problems.
69
5. Individual vs. general formulations
Doing justice to the client’s unique life and problems vs. incorporating general knowledge from research and prototype formulations about disorders.
70
Ch4: Formulation in context of psychotherapy integration
71
What are the two key descriptors of the case formulation model?
It is 1. integrative and 2. evidence based
72
In what sense is the case formulation model integrative? (2)
1. It can be assimilated into different uni-theoretical therapy models
2. It allows different perspectives on therapy to be brought together into one coherent case formulation
73
To what kinds of theoretical approaches is this case formulation model intended to apply?
It is intended to apply to any theoretical approach to psychotherapy.
74
What is one major reason to approach case formulation integratively?
Because an integrative orientation is widely prevalent among practicing therapists and is considered a “therapeutic mainstay.”
75
What do North American surveys show about therapists’ theoretical orientations?
The majority of therapists identify with more than one orientation, and very few report practicing entirely within a single orientation.
76
What is the approximate percentage of psychotherapists who report practicing within a single orientation?
Surveys suggest only about 2–10% practice entirely within a single orientation.
77
Within an integrative orientation, which approach tends to be dominant?
Cognitive–behavioral therapy (CBT) often serves as the dominant approach within integrative orientations.
78
What did the large international survey (3,000+ therapists in 20+ countries) show about theoretical orientation?
About 54% of therapists reported that they draw from multiple perspectives rather than a single orientation.
79
Why is an integrative approach to case formulation said to be “responsive” to the field?
Because it matches the actual theoretical orientation of most practicing therapists, who use multiple frameworks.
80
Why does an integrative, formulation-guided approach allow better tailoring of therapy than a unitheoretical approach?
It enables therapists to tailor treatment to the specific combination of problems a client presents, using strategies and ideas from multiple theoretical perspectives and other psychological sciences, which unitheoretical approaches cannot do as flexibly.
81
Besides psychotherapy theories, which other areas of psychology can inform an integrative case formulation?
Cognitive science, developmental psychology, and social psychology (and other relevant psychological knowledge) can inform formulation and intervention.
82
What did the APA joint task force (Society of Clinical Psychology & SPR North American chapter) summarize regarding change principles?
They summarized empirically supported, cross-theoretical principles of therapeutic change that are beneficial across a range of disorders.
83
Extraverted depressed clients tend to benefit more from action-oriented/reflective interventions.
Action-oriented
84
Introverted depressed clients tend to benefit more from an action-oriented/reflective approach to treatment.
Reflective
85
According to Persons (2008), why is a tailored CBT approach, guided by case formulation, needed?
Because empirically supported treatments (ESTs) do not exist for many problems people bring to psychotherapy; formulation allows adapting existing ESTs to those problems.
86
According to Persons (2008), why extend beyond the CBT school in formulation?
Not limiting the formulation to the CBT school allows a broader range of explanations and treatment plans to be considered.
87
How does a case-formulation-guided approach differ from treatment manuals regarding concurrent treatments?
Unlike manuals, a formulation-guided approach can explicitly take into account multiple concurrent treatments (e.g., medication, church-based support groups, Alcoholics Anonymous) in addition to individual psychotherapy.
88
3 reasons for tailored CBT, formulation-based appraoch
1. Because empirically supported treatments (ESTs) do not exist for many problems people bring to psychotherapy; formulation allows adapting existing ESTs to those problems.
2. Not limiting the formulation to the CBT school allows a broader range of explanations and treatment plans to be considered.
3. Unlike manuals, a formulation-guided approach can explicitly take into account multiple concurrent treatments (e.g., medication, church-based support groups, Alcoholics Anonymous) in addition to individual psychotherapy.
89
What general finding do meta-analyses report about the comparative effectiveness of different therapy orientations?
When bona fide treatments are compared and investigator allegiance is controlled, no single theoretical approach consistently outperforms others.
90
What does this meta-analytic pattern suggest about what primarily explains psychotherapy outcomes?
It suggests that shared, common factors (client/therapist characteristics, processes, relationship, treatment structure) explain much of outcome, more than specific techniques from particular brands of therapy.
91
According to Lambert’s estimates, what percentage of improvement in psychotherapy is due to client and environmental factors?
About 40% of improvement is attributed to client characteristics and the client’s environment.
92
According to Lambert, what percentage of improvement is due to the client’s expectations (placebo, hope)?
About 15% is attributed to client expectations for improvement.
93
According to Lambert, what percentage of improvement is due to other common factors (aside from expectations)?
About 30% is attributed to other common factors.
94
According to Lambert, what percentage of improvement is due to specific therapy techniques?
About 15% is attributed to specific techniques of the therapy model.
95
How does Lambert view the role of techniques, given these percentages?
Techniques are essential but their impact should be kept in perspective, because they account for a smaller proportion of change than client and common factors.
96
Into what three broad categories does Lambert organize common factors?
1. Support
2. Learning
3. Action
97
What are some examples of common support factors in psychotherapy?
1. Catharsis (releasing strong emotions)
2. Mitigation (reducing) of isolation
3. Provision of a safe environment
4. Recognition of the therapist's expertness
5. Therapist warmth, respect, empathy, acceptance, and genuineness
98
What are some examples of common learning factors in psychotherapy?
1. Affective re-experiencing
2. Assimilation of problematic experiences
3. Cognitive learning
4. Corrective emotional experiences
5. Feedback
6. Insight
7. Exploration of one's internal frame of reference
8. Changing expectations of personal effectiveness
99
What are some examples of common action factors in psychotherapy?
1. Cognitive mastery
2. Encouragement to experiment with new behaviors
3. Facing fears
4. Modeling
5. Practicing behavioral and emotional regulation
6. Reality testing
7. Taking risks
100
Who first proposed the idea of common factors in psychotherapy, and when?
Rosenzweig (1936) first proposed the common factors idea
101
What is Frank’s first shared characteristic of effective psychotherapies?
The development of an emotionally charged, confiding relationship between client and therapist.
102
What does research estimate about the average correlation between therapeutic alliance and outcome (Martin et al.)?
The alliance is estimated to correlate about .22 with outcome.
103
What controversy exists regarding the alliance–outcome link?
There is debate about whether a positive alliance causes better outcomes, or whether it is itself a result of other effective processes.
104
What is Frank’s second shared characteristic of psychotherapy?
The therapeutic relationship occurs in a circumscribed, culturally sanctioned context with well-delineated roles (client and professional helper) and typical features such as office setting, fixed session length, fee, and often preset number of sessions.
105
How has the social context of psychotherapy changed since Frank’s original work, and what effect does this have?
Psychotherapy has increasingly aligned with the medical model, gaining a “halo effect” from association with medicine, which supports its cultural acceptance and stable utilization.
106
What is Frank’s third shared characteristic of therapies?
The provision of a credible, persuasive explanation of the client’s symptoms and problems, along with a pathway or set of procedures for resolving them, collaboratively accepted by client and therapist.
107
Why is psychotherapy case formulation especially relevant to Frank’s third characteristic?
Because formulation explicitly provides the explanatory account (why the problems exist) and the treatment plan that flows logically from that explanation.
107
What key condition must this explanatory account meet, according to Frank?
It must be consistent with the client’s worldview, attitudes, and values, or the therapist helps the client come into accord with the rationale.
108
Give the cognitive therapy example of how problems are explained and treated in line with Frank’s third characteristic.
Problems are explained by dysfunctional thought patterns that leave a person vulnerable to symptoms; healing occurs by identifying, changing, or coping with these thought patterns through specific action steps.
109
Give the psychoanalytic example of problems and treatment in line with Frank’s third characteristic.
Problems are explained by unconscious, conflicting wishes and fears; treatment involves exploration and insight into these conflicts, which can alleviate symptoms.
110
Give the behavioral example of problems and treatment in line with Frank’s third characteristic.
Problems are explained by maladaptive reinforcement contingencies and stimulus-control environments; treatment involves changing environmental contingencies and behavioral patterns.
111
According to Frank, what matters most about these different explanatory models—truth or belief?
Frank’s controversial claim is that the literal truth of the account is not critical; what matters is whether client and therapist believe it to be a credible, persuasive explanation with a coherent plan.
112
What is Frank’s fourth shared characteristic of psychotherapy?
The active participation of both client and therapist in the prescribed treatment.
113
How does psychotherapy differ from most medical treatments in terms of client role?
In psychotherapy, the client is not a passive recipient but an active agent in their own change; this activity is itself curative.
114
Why is the integrative case formulation model well-suited to both integrative and unitheoretical approaches?
Because it fits integrative practice (using multiple perspectives) but can also be embedded in a single orientation, providing a general method applicable across theories.
115
How does a general case formulation approach expand treatment planning options?
It lets therapists tailor treatment to the specific problems a person has and make use of the full range of interventions that research and theory have offered, rather than being constrained by one manual.
116
How is the model consistent with meta-analytic findings on psychotherapy outcomes?
It aligns with evidence that no single approach consistently outperforms others and that common factors account for most change, not just specific techniques, supporting an integrative, flexible stance.
117
What are the 3 main components in the integrative model of case formulation and therapy?
1. Gather Problem List
2. Diagnose
3. Develop Explanatory Hypothesis
4. Plan Treatment
118
What overarching process runs across gathering information, formulation, and treatment?
Monitor Progress
119
According to the text, do the steps in the model unfold in a rigid sequence?
No. Although depicted sequentially, in practice the steps do not unfold rigidly; gathering information, formulating, and treating are intertwined throughout therapy.
120
In the model, what is the relationship between “Treat” and “Termination”?
Termination occurs as an outcome of the Treat phase, once treatment is completed.
121
In the model, what two main categories appear under "create problem list"?
1. Red flags
2. Functioning
122
What are the "red flags"?
1. Chemical dependence
2. Domestic violence
3. Suicidality
4. Homicidality
5. Neglect
123
What three levels of functioning are highlighted under the problem list in the model?
1. Self
2. Interpersonal
3. Societal functioning
124
What two main headings appear under “Develop Explanatory Hypothesis”?
1. Sources
2. Components
125
What are the two “Sources” of a case formulation?
1. Theory
2. Evidence
126
What 5 “Components” of the explanatory hypothesis are listed in the model?
1. Percipitants
2. Origins
3. Resources
4. Obstacles
5. Core hypothesis
127
What are "precipitating stressors"?
Events that trigger episodes of distress and often lead the person into therapy.
128
What does “Origins” refer to in an explanatory hypothesis?
Key experiences, traumas, and learning events presumed to contribute to the current presentation and shape the client’s worldview/axiomatic assumptions (e.g., “Don’t trust others”).
129
What are "resources"?
Strenghts the client brings to therapy
130
What are "obstacles"?
Factors that may interfere with treatment success
131
What is meant by the client's "worldview" or "axiomatic assumptions"?
Broad, often implicit beliefs about the world (e.g., "the world is harsh,", "If you work hard, it will work out") that shape perception and behavior.
132
Under plan treatment in the model, what are the three main clusters of considerations?
1. Set point considerations
2. Goal identification
3. Plan interventions
133
What is typically the primary method for gathering information in psychotherapy?
A clinical interview with the client
134
Besides the interview, what other sources of information may therapists use? (4)
1. Symptom measures
2. Psychometic testing
3. Record reviews
4. Interviews with others in the client' s life (e.g., other providers, family)
135
Why is information gathering not a purely sequential, early phase only?
Because information is elicited throughout therapy; in actual practice, gathering, formulating, and treating are closely intertwined.
136
What standard content areas are usually covered when gathering information?
1. Presenting complaint
2. History of mental problems and treatment (self and family)
3. Medical history (self and family)
4. Development and social history
5. Education and work history
6. Legal history
7. Mental status information
137
Why is basic intake information “useful but limited” for case formulation?
Because formulation also requires process information and narrative information beyond standard history and mental status data.
138
What is “process information” in the context of case formulation?
Information about how the client presents (their manner of relating, communication, coherence, affect), including how the therapist experiences the client.
139
How does process information differ from a standard mental status exam?
A mental status exam focuses on mood, affect, memory, coherence, and reality testing; process information additionally emphasizes the therapist’s felt connection, the client’s ability to give coherent narratives, and whether others are described vividly or vaguely, informing the quality of mental representations of self and others.
140
Give examples of process questions a therapist might reflect on.
1. Do I feel connected to this client
2. Can the client tell coherent stories about their life events?
3. Do their descriptions of others feel alive or stereotypical/vague?
141
What is “narrative information” in case formulation?
Detailed stories or episodes from the client’s life, especially at the “he‑said, she‑said” level, used to understand interaction patterns, self‑concept, and sequences that lead to problems.
142
What is “chain analysis,” and which therapy model is it associated with here?
From dialectical behavior therapy, chain analysis involves examining the moment‑to‑moment sequence of events, thoughts, and affects leading up to a problematic event (e.g., suicide attempt, anger outburst, panic attack).
143
What does Benjamin mean by advising a “free form” approach to information gathering?
Therapists should follow the client’s stream of thought and feeling state, rather than mechanically checking off all content areas in sequence.
144
Why is a “free form” approach valuable for formulation?
It still collects needed content but also yields rich, detailed information about how the client thinks and feels about their experiences, which is crucial for formulation.
145
What are the four basic action steps in the integrative case‑formulation‑guided model?
1. Create a problem list
2. Diagnose
3. Develop an explanatory hypothesis
4. Plan treatment
146
In this model, where does one always begin when formulating a case?
By creating a comprehensive problem list, which can later be trimmed as the focus of treatment is clarified.
147
Why is the Diagnose step considered “essential” yet limited?
Diagnosis is practically necessary (e.g., for communication, planning, reimbursement) but has major limitations, discussed elsewhere (e.g., it is descriptive, not fully explanatory).
148
Why is “Develop an Explanatory Hypothesis” described as the most challenging step?
Because it requires integrating all gathered information, empirical resources, theory, clinical expertise, and cultural competence into the therapist’s best account of what causes, maintains, and precipitates the target problems.
149
In this step, what are the two broad, intertwined “sources” of information?
Theory and evidence.
150
In this context, what counts as “theory”?
Any empirically supported hypothesis that helps explain the problems, including basic research on cognitive/behavioral processes, randomized clinical trials, and psychopathology research.
151
What counts as “evidence” (distinct from theory) in building an explanatory hypothesis?
Other reliable information sources, such as epidemiological studies, psychometric test results, and narrative/autobiographical information from the client.
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What four categories should be developed in all formulations, regardless of orientation?
1. Precipitating stressors
2. Origins
3. Resources
4. Obstacles
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What are “precipitating stressors”?
Events that trigger episodes of distress, often the immediate triggers that lead clients to seek therapy.
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In a formulation, what are “origins”?
Key experiences, traumas, and learning events that contributed to the current presentation and shaped the client’s worldview or core assumptions (e.g., “Don’t trust others,” “The world is harsh”).
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What are “resources” in this model?
Strengths and assets the client brings to therapy that can facilitate change.
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What are “obstacles”?
Factors that may interfere with treatment success, such as practical barriers, psychological defenses, or environmental constraints.
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What types of goals may be included in the treatment plan?
1. Short-term and long-term goals
2. Process goals (how therapy will proceed)
3. Ultimate/outcome goals, plus the steps to reach them
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What is the main aim of the Plan Treatment step?
To operationalize the explanatory hypothesis into a sequence of steps that guides treatment and helps the client resolve the target problems.
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Why does the author emphasize that “a treatment plan is only a plan”?
Because plans must change as treatment progresses; therapists should be ready to revise the plan based on the client’s response and newly emerging problems.
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What problem does Binder call “inert knowledge” in psychotherapy training?
Knowledge that exists as declarative information (knowing about theories) but is not integrated into procedural skill, so therapists don’t spontaneously know how and when to apply it in sessions.
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Why are case formulation skills considered distinct from treatment skills?
One can have a coherent understanding of a client (good formulation) but still lack the interpersonal and technical skills to apply that understanding effectively in therapy.
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Why is each therapy dyad considered unique and partly unpredictable?
Because treatment always involves the intermingling of theory/method with the personness of both therapist and client in a specific context, and both can surprise each other.
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Why is progress monitoring considered part of evidence‑based practice?
The APA Presidential Task Force defines evidence‑based practice as including ongoing monitoring to give objective feedback on whether treatment is on track or needs adjustment.
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What two main benefits does research show for progress monitoring?
1. It reduces treatment failure
2. It improves positive outcomes
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What did Lambert et al. (2004) find about predicting deterioration in treatment?
Deterioration can be predicted based on clients’ initial disturbance level and early response to treatment, using instruments like the Outcome Questionnaire‑45.
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How does feedback from monitoring help therapists?
When informed a client is not on track, therapists can take action to modify treatment and improve outcomes.
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According to Lambert (2007), after how many sessions do about 50% and 75% of clients recover?
Roughly 50% recover after 11–21 sessions, and 75% after 25–45 sessions.
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How does initial level of functioning affect needed treatment length?
The worse the initial functioning, the more sessions are typically required for recovery.
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Which domains of functioning tend to improve first, second, and third according to Lambert (2007)?
1. Symptoms improve first
2. Then social role functioning
3. Finally, interpersonal functioning
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What three phases of change do Howard et al. (1993) describe?
1. Remoralization (hope and sense of mastery)
2. Symptom improvement
3. Improved well-being
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How can monitoring be used to test the explanatory hypothesis?
By examining whether interventions derived from the formulation lead to greater depth of experiencing and better outcomes; if not, the hypothesis may need revision.
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What did Silberschatz (2005a) find about formulation‑compatible vs incompatible interventions?
Formulation‑compatible interventions were followed by greater depth of experiencing and better outcomes than incompatible ones.
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Why are objective measures preferred over therapist judgment alone for progress monitoring?
Because objective measures predict risk of treatment failure more accurately and help counter cognitive biases, especially therapists’ overconfidence.
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How can progress monitoring allow comparison with randomized clinical trials?
By using the same outcome measures as RCTs, therapists can compare their clients’ improvement and recovery rates with those in the trials.
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What is the minimum that should be monitored session‑by‑session?
Symptoms and “red flag” issues such as risk of self‑harm and harm to others.
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What additional areas are recommended for monitoring?
Social role functioning, interpersonal functioning, the therapeutic alliance, and overall well‑being.
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What kind of measures are recommended for monitoring, and when should they be completed?
Objective, quantifiable measures with good psychometric properties; ideally completed just prior to each session, then reviewed at the start.
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What should therapists do when no suitable normed measure exists for a specific problem?
Create an idiographic measure tailored to that specific problem.
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Why must monitoring results be “taken with a grain of salt”?
Because clients may under‑report symptoms (e.g., not wanting the “record to show” problems) or over‑report (e.g., to avoid premature termination), so response patterns can reflect needs and conflicts beyond what the measure formally assesses.
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In what two ways is the integrative, evidence‑based case‑formulation model integrative?
1. it can be assimilated into unitheoretical appraoches
2. it provides a framework to generate coherent, high-quality formulations that draw from multiple theories and empirically supported interventions
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According to Lambert (2013a), why have most therapists become eclectic in orientation?
Because evidence suggests there are some specific technique effects but large common effects across treatments, so eclecticism reflects a healthy response to empirical evidence and a move away from rigid school allegiances.
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LECTURE
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How is “psychotherapy case formulation” defined in this course?
It is a process for developing a hypothesis about, and a plan to address, the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioral problems, in the context of that individual’s culture and environment.
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Why is case formulation described as a process rather than just a product?
Because it is developed over time, mainly in the first sessions but revised throughout therapy as new information emerges; it is not a one‑off document.
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Why is the word hypothesis emphasized in the definition?
Because an early formulation never gives full knowledge of the client; it is a tentative, core working hypothesis that must be tested and refined during treatment.
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What does “plan to address” add to the definition of case formulation?
It stresses the explicit link between the explanatory hypothesis (what is going on) and concrete treatment strategies (how to address it).
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What is the relationship between case formulation and broad theories (e.g., schema therapy, reinforcement theory)?
Broad theories describe general mechanisms (schemas, reinforcement, heuristics), but case formulation applies those ideas to a specific individual, bridging textbook theory and the person in front of you.
188
In this course, how are “case formulation” and “case conceptualization” used?
They are closely related; formulation is the broader process, and conceptualization refers to selecting core concepts (e.g., key factors, mechanisms) to focus on in understanding and treating the case.
189
Which time frame is the core of case formulation and why?
The present, because clients want to know what is happening now and how to change it; explaining problems only by distant past events rarely feels helpful to them.
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Why is it “never very useful” to simply tell a client their current problems are due to something long ago?
Because clients usually already know the past events and ask, “How does that help me now?”; without linking past to current mechanisms, the explanation is not therapeutically useful.
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What is meant by the “psychological in‑between” between past events and current problems?
The psychological processes (e.g., schemas, beliefs, meanings) through which past experiences are internalized and carried into the present, mediating between earlier events and current reactions.
192
Give the example from the lecture of how a past critical father can affect present reactions at work.
Repeated childhood criticism leads to a schema like “people are always there to criticise me / I’m not worthwhile.” Later, mild criticism from a coworker triggers this schema, producing disproportionate distress in the present.
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In treatment, do we aim to “treat the past” or the present, according to the lecture?
We primarily treat how past‑based schemas and meanings operate in the here‑and‑now, not the past events themselves.
194
From which sources can current problems be identified? (3)
1. Initially indicated by the client (free speech, complaint)
2. Uncovered during the interview by the therapist
3. Indicated by other sources (e.g., questionnaires, collateral information).
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How broadly should “problems” be understood in this model?
In a broad sense: behaviors, emotions, cognitions, experiences, consequences, interpersonal issues, symptoms, etc.
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Why is the problem list usually the starting point of formulation?
Because formulation aims to explain something, and those “somethings” are the specific problems we want to understand and change.
197
Give an example of how a therapist might uncover additional problems beyond what the client first names.
A client mentions social anxiety; the therapist explores and discovers avoidance of social situations, which is another problem and part of the maintaining mechanism.
198
What is the key question in the Maintaining Factors box?
“What mechanisms keep these problems in place?”
199
Name three types of maintaining mechanisms mentioned in the lecture.
1. Vicious cycles
2. Interactions between problems
3. Effects of core beliefs, coping strategies, and emotion regulation
200
What is meant by a “vicious cycle” in case formulation?
A self‑reinforcing loop where attempts to cope with a problem actually maintain or worsen it (e.g., anxiety → avoidance → no corrective learning → more anxiety).
201
Give a classic example of a vicious cycle in anxiety.
Social anxiety → avoidance of social situations → lack of exposure and skill learning → continued or increased anxiety → more avoidance.
202
How can anxiety and depression interact as maintaining factors?
Anxiety may lead to avoidance and social isolation, which lowers mood and energy, contributing to depression; feeling depressed makes engaging socially even harder, which in turn increases anxiety and isolation, forming a cycle.
203
How do core beliefs (schemas) function as maintaining factors?
Core beliefs shape how situations are interpreted (e.g., “I’ll be laughed at” when presenting), which guides behavior (avoidance, withdrawal) and emotions, thereby continually generating and sustaining problems.
204
Why is emotion regulation included among maintaining factors?
Because difficulties regulating emotions (e.g., seeing emotions as dangerous, using maladaptive strategies) can amplify distress and prevent adaptive coping, sustaining problems.
205
What is the evidential status of maintaining factors compared with problem descriptions?
Problem descriptions can be directly observed and measured, whereas maintaining factors are hypotheses about mechanisms—important but less directly provable.
206
What question is asked in the Inducing Factors box?
“How did these problems start?”
207
What two categories are listed under Inducing Factors on the slide?
1. Events
2. Personal context at the time
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How are “inducing factors” defined in the lecture?
The contextual features and events around the time when the problems first emerged (e.g., being fired, a conflict, a traumatic incident, moving in with a partner).
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Why must a good case formulation connect inducing factors to maintaining factors?
Because we need to understand how initial triggers activated certain mechanisms (beliefs, coping patterns) that now keep problems going, so that treatment can target those mechanisms.
210
In the reorganization‑at‑work example, why do some people develop serious problems while others do not?
Because beyond the same external event, individuals differ in interpretations, vulnerabilities, and schemas (e.g., mistrustful beliefs leading to psychotic‑like fears vs. seeing it as an opportunity).
211
What question is asked in the Predisposing Factors box?
“What made you vulnerable?”
212
What three examples of predisposing factors are listed on the slide?
1. Temperament
2. Learning history
3. Skill deficits
213
How are predisposing factors defined in the lecture?
Long‑term influences that increase vulnerability to later problems, such as genes, temperament, developmental learning history, and enduring skill deficits.
214
How is temperament relevant as a predisposing factor?
Some children are naturally more anxious or inhibited, making them more likely to develop anxiety disorders under stress.
215
What does “learning history” refer to in predisposing factors?
The person’s life‑long experiences and basic ideas learned about the world (what is safe/dangerous, how others behave), which form underlying assumptions.
216
What are “skill deficits” as predisposing factors?
Important abilities the person lacks (e.g., social skills, emotion regulation, problem solving) that make them less equipped to cope with stressors.
217
Why is there theoretical disagreement about how important predisposing factors are?
Some approaches emphasize them strongly, others focus more on current processes; the empirical evidence is mixed and not conclusive.
218
How do pragmatic considerations influence how much we focus on predisposing factors?
Limited time may mean we focus mainly on present and proximal factors, but repeated or chronic episodes (e.g., third severe depression) may justify digging deeper into vulnerabilities.
219
How are genes viewed in this framework?
Genes likely play some role, but they never explain a large proportion of outcome on their own; multiple genes and intergenerational factors (including trauma) are probably involved.
220
What question is asked in the Treatment Considerations box?
“What is needed to get better?”
221
What four elements are listed under Treatment Considerations?
1. Request for help
2. Motivation
3. Intervention options
4. Obstacles
222
What is meant by “request for help” in treatment considerations?
How the client themselves formulate what they want help with, which can guide goals and engagement.
223
Why is motivation central in treatment considerations?
Because the client’s willingness to engage in change strongly influences which interventions will be feasible and how intensive they can be.
224
What is said in the lecture about using case conceptualization to choose between therapies (e.g., CBT vs schema therapy)?
We have limited evidence for precise indication rules; case conceptualization does not strongly determine which model (CBT, schema, etc.) will be superior.
225
How should obstacles be used in planning treatment?
Clinicians should anticipate likely obstacles (e.g., mistrust, excessive agreeableness, avoidance) based on the formulation and plan how to address them in the therapeutic relationship and interventions.
226
In the blue diagram, what overarching domain do “Strengths, Vulnerabilities, Support, Stressors” belong to?
The person’s Current Personal Context
227
How does the Current Personal Context relate to the Problems box?
It represents present‑time factors (strengths, vulnerabilities, resources, stressors) that feed into and shape the current problems.
228
What question is asked in the Strengths box?
“What are your strengths?”
229
What examples are listed under Strengths?
Skills, coping, personality, and other positive attributes.
230
What question is asked in the Vulnerabilities box?
“What makes you currently vulnerable?”
231
What examples are listed under Vulnerabilities?
Pitfalls, beliefs, habits, emotionality, etc.
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What question is asked in the Support box?
“What resources can you use?”
233
What examples are listed under Support?
Social resources, help, activities, and medication.
234
What question is asked in the Stressors box?
“What is currently weighing on you?”
235
What examples are listed under Stressors?
Events, social/family factors, occupation, living conditions, and finances.
236
Why is taxonomy (diagnosis/HiTOP) not sufficient for clinical work?
Because it ignores personal context, development, and goals and doesn’t tell you how to intervene for this particular person.
237
Why are personal narratives and recovery stories alone also not enough?
Narratives give important first‑person meaning, but they must be integrated with general theory and scientific knowledge to guide effective treatment.
238
How does a good working theory/rationale support the “common factors” of therapy?
A clear rationale helps build hope, credibility, collaboration, and engagement, which are central common factors driving positive outcome.
239
Why is explicit case conceptualization a useful learning tool?
Making formulations explicit and systematic helps organize thinking, allows feedback and supervision, and improves clinical reasoning, rather than relying on implicit, untested impressions.
240
What is meant by the ‘intersubjective dialogue’ in therapy?
An ongoing interaction where therapist and client attune to the client’s first‑person perspective, focusing on personal narratives and processes of meaning‑making.
241
According to the “Neither–But–Nor” slide, what is case conceptualization not?
It is neither simply facts, certain, or fully objective, nor is it mere speculation, very unlikely, or purely subjective.
242
How is case conceptualization best described instead?
As a set of working hypotheses developed collaboratively between therapist and client.
243
What three criteria should a case conceptualization meet to be useful?
It should be credible enough, acceptable for the client, and useful for treatment.
244
What three main sources feed into individual case formulations?
1. Theories and research
2. Client experience and narrative
3. Clinical expereince of the therapist
245
How do individual case formulations and individualized treatment influence each other over time?
Formulation guides individualized treatment, and evaluation of outcomes feeds back into revising the formulation, creating a cycle of hypothesis testing and refinement.
246
What four things “do we know” that inform case conceptualization in this course?
1. Diasthesis-stress model
2. Evidence-based treatments
3. Common factors
4. Theories and proposed mechanisms of change
247
In the diathesis–stress model, what are the two main distal (past) components?
Heritable predispositions (genotype, temperament) and early experiences (nurture, care, trauma, deprivation).
248
What are the two main proximal (present) components in the diathesis–stress model?
Strengths and vulnerabilities (schemas, cognitions, attributions, personality, etc.) and support and stress (social factors, daily stress, life events, medication, psychotherapy).
249
How are strengths and vulnerabilities related to current complaints/symptoms?
They form part of the diathesis—the present configuration of risk and resilience that shapes how stress leads (or does not lead) to complaints/symptoms.
250
How are support and stress related to complaints/symptoms in the model?
They represent the current stress side: social conditions, life events, and supports that trigger or buffer the emergence of symptoms.
251
How does the diathesis–stress model link to case formulation?
Case formulation maps a client’s complaints/symptoms onto their predispositions, early experiences, current strengths/vulnerabilities, and support/stress, explaining why this person has these problems now.
252
How can symptoms themselves function within a diathesis–stress formulation?
Symptoms (e.g., anxiety) can be both current complaints and ongoing vulnerabilities or stressors, increasing the risk for additional problems (e.g., depression).
253
What overall conclusion does research reach about the effectiveness of psychotherapy?
There is strong evidence that psychotherapy helps many clients, but also strong evidence that a substantial group does not benefit or is not fully back on track after treatment.
254
What does the “dodo bird verdict” refer to in psychotherapy research?
The finding that, across many studies, no bona fide therapy consistently outperforms others—“everyone has won, and all must have prizes.”
255
Why does the dodo bird verdict not mean “anything goes”?
It means research cannot easily distinguish which treatment is best for which individual, not that all methods are equally good or that method doesn’t matter.
256
In the EBT–prototype CC–personal CC model, what does EBT provide?
Evidence‑based treatments (EBTs) provide a general or prototype case conceptualization of a disorder (what typically goes on in depression, social anxiety, etc.).
257
What is a “prototype case conceptualization” (prototype CC)?
A general model of mechanisms and treatment strategies for a given problem, derived from EBTs and research, not yet tailored to an individual client.
258
How do you move from a prototype CC to a personal case conceptualization (personal CC)?
Through intersubjective dialogue between client and professional, adapting the prototype model to the client’s unique history, context, and meaning‑making.
259
Why must prototype case conceptualizations be individualized?
Because clients differ in vulnerabilities, context, goals, and narratives; a prototype only becomes clinically useful when translated into a person‑specific formulation.
260
What are “common factors” in psychotherapy?
Elements shared across different therapies that are strongly linked to outcome, such as alliance, collaboration, empathy, and treatment credibility.
261
List at least five common factors with strong evidence.
- Therapeutic alliance
- Collaboration
- Goal consensus
- Adapting treatment to specific client characteristics
- Empathy
- Promoting treatment credibility (clear, believable rationale), etc.
262
How do common factors relate to treatment outcome?
They are strong predictors of outcome, often explaining more variance than the specific techniques of any single therapy school.
263
How does case conceptualization help adapt treatment to specific client needs?
By clarifying problems, mechanisms, strengths, and vulnerabilities, CC guides choice and timing of interventions that fit the individual client.
264
What is meant by a “person‑specific rationale” in relation to CC?
A case‑specific explanation of why this particular therapy should help this particular client, derived from the formulation.
265
How can CC support validation and empathy?
A good CC organizes the client’s experiences into a coherent story, helping the therapist name, validate, and understand the client’s struggles in depth.
266
How does CC provide indications for alliance ruptures to monitor?
By highlighting vulnerabilities, expectations, and interpersonal patterns, CC suggests where misattunements or mistrust are likely to arise in the alliance.
267
How does CC contribute to goal consensus and collaboration?
It offers a shared framework for discussing what will be targeted and how, helping client and therapist agree on goals and work together toward them.
268
What is meant by “theories: mostly partial evidence”?
Many therapy theories (behaviorism, cognitivism, schemata, psychoanalysis, mentalization, emotion‑focused, attachment, interpersonal, etc.) are useful for thinking, but only partly supported as unique causal mechanisms.
269
Why are theories still important despite partial evidence?
They help you think beyond what the client already knows, generate hypotheses about mechanisms and maintaining factors, and guide interventions and experiments.
270
How does the partial‑evidence status of theories fit with the dodo bird verdict?
Different theories can lead to similar outcomes, suggesting that no single theoretical mechanism fully explains change; some mechanisms have evidence, others remain speculative.
271
In Example 1 (anxious attachment), what are key predisposing factors?
1. Inconsistent response to attachment needs
2. Inconsistent support for developing autonomy
3. Experiences of strong feelings of being left alone
4. Anxious temperament
272
What inducing factors started the problems in Example 1?
- Starting to live alone in a new city
- The boyfriend wanting to spend less time together while living in another city
273
What are the main current problems in Example 1?
- Strong fear of being alone
- Panic attacks and sleeping problems
- Difficulties with partner complaining about “clinging”
- Worrying about living alone and being able to cope
- Sadness, lack of energy, anxiety, and restlessness.
274
In Example 1, what maintains the problems (maintaining factors)?
- Being alone triggers attachment anxiety
- Anxiety leads to hyperactivation of attachment needs
- Lack of emotion‑regulation skills makes this underregulation feel intolerable
- Coping through avoidance and continuous support seeking (not staying alone, many messages to boyfriend)
- Consequences: not learning to be alone, reduced autonomy, and burdening others
275
What are the main treatment considerations in Example 1 (anxious attachment)?
- Learning emotion‑regulation skills
- Using them to increase tolerance for being alone
- Reducing avoidance and excessive support seeking
- Strengthening desire and ability for autonomy
- Within a safe therapeutic relationship, possibly using “optimal frustration” (gradually tolerating separations).
276
In Example 2 (fragile self‑esteem), what predisposing factors made the client vulnerable?
- Being repeatedly shamed by a parent with very high and rigid expectations
- Feeling loved mainly for competence and success
- Witnessing significant violence between parents.
277
What inducing factors triggered the current problems in Example 2?
- Being promoted to an important, more responsible position at work
- Starting to live together with her boyfriend.
278
What are the current problems in Example 2?
- Anger in relationships at work and with partner
- Intense feelings of shame
- Depressed mood and lack of energy
- Extremely emotional reactions to small criticisms
- Low self‑esteem.
279
What mechanisms keep the problems going in Example 2 (maintaining factors)?
- Small critical remarks trigger the “defectiveness” schema
- This threatens intense shame
- Anger is used to cope with and avoid these feelings and to feel stronger
- Others become anxious and avoid real contact
- This leads to conflict and to the client feeling alone and depressed
280
What are treatment considerations in Example 2 (fragile self‑esteem)?
- Learning when and how the defectiveness schema is triggered
- Developing the emotional skill to tolerate and explore the resulting feelings instead of avoiding them
- Building a safe therapeutic relationship, then introducing “optimal frustration” (safe but challenging work on shame and self‑esteem)
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