The aim of this primer is to support the learning of clinical case conceptualization and treatment planning for graduate students in clinical psychology, other trainees in the mental health professions, and early-career psychologists and mental health workers.

1. Case Formulation &
Treatment Planning: A Primer
Psy.D. Program in Clinical Psychology
Compiled by James Tobin, Ph.D.
Version 1.0 - November, 2013

2. Note of Introduction
The Clinical Faculty of the Psy.D. Program is invested in supporting students’ capacity to (1) conceptualize
clinical case from diverse theoretical perspectives, and (2) apply competence in this area to treatment planning
and implementation. This initial version of “Case Formulation & Treatment Planning: A Primer” began as a class
exercise in Adult Psychopathology II during Spring semester, 2013 in which students were asked to organize brief
thumbnail sketches (“cliff notes”) on the nuts and bolts of numerous theoretical orientations regarding the etiology
and maintenance of psychiatric disorder and psychological distress. Students provided summary information on 11
theoretical orientations in a structured format that included the following components:
• Key writers
• Major themes
• Key terms/ideas
• Primary view of the cause of psychopathology
• Disorders most closely linked to this perspective
• The role of the therapist in intervening from this perspective
• Target interventions/intervention style
• Therapeutic mechanism of change
• Case formulation/vignette material
In addition, information on treatment planning (featuring integrated, eclectic and synthetic approaches) was
organized, along with select references published by writers with an expertise in the different theoretical areas
represented. A special thanks is extended to Ms. Jennie Jones who graciously devoted her time to translate the
content generated by students into a stylized, pictorial summary for each theoretical perspective that is included at
the ends of sections in this primer.
What follows is a fairly raw, initial compilation of this first wave of work. This compendium is meant to provide
students with a rudimentary exposure to the complex field of case formulation and treatment. It is my hope that it
will serve as a starting point for students that they might refer to again and again throughout training as a dictionary
of basic terms, reference tool, and nomenclature of the most influential theoretical views and constructs in the field.
It is also intended to provide the Clinical Faculty with a foundational structure and basic sourcebook of information
which, over time, each instructor, can add to and refine based on his/her expertise. Future versions of this primer
undoubtedly will provide more detail and elaboration, inclusion of updated empirical findings and theoretical
advancements, and perhaps also access to selected readings in a coursepak form.
James Tobin, Ph.D.
Assistant Professor of Clinical Psychology

3. Table of Contents
Section I Select Scientific References 2
Section II Case Formulation in Psychotherapy 4
Section III Thirteen Leading Case Formulation and Treatment Planning Texts 9
Section IV Family Systems 15
Section V Cognitive/Cognitive-Behavioral 18
Section VI Behaviorism 22
Section VII Multicultural/Cross-Cultural 26
Section VIII Feminism 32
Section IX Psychodynamic 34
Section X Humanistic/Existentialism 39
Section XI Narrative/Constructivism 42
Section XII Interpersonal Neurobiology 44
Section XIII Developmental/Developmental Psychopathology 49
Section XIV Biopsychosocial Approach 52
Section XV Treatment Planning 53
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4. Section I: Select Scientific References
Overview of Case Formulation
• Ingram, B.L. (2006). Integrative case formulations in psychotherapy: An elusive goal or an
emerging clinical reality. Hoboken, NJ: Wiley.
• Eells, T.D. (Ed.) (2010). Handbook of psychotherapy case formulation (2nd ed.). New York, NY:
Guilford Press.
• Melchert, T. P. (2013). Beyond theoretical orientations: The emergence of a unified scientific framework in
professional psychology. Professional Psychology: Research and Practice, 44, 11-19.
• Tarrier, N., & Calam, R. (2002). New developments in cognitive-behavioural case formulation.
Epidemiological, systemic and social context: An integrative approach. British Association for Behavioral
and Cognitive Psychotherapies, 30, 311-328.
• Blott, M.R. (2008). Encountering differences in graduate training: Potential for practicum experience.
Journal of Psychotherapy Integration, 18, 437-452.
Family Systems
• Chabot, D.R. (2011) Family systems theories of psychotherapy. In J. Norcross, G.R. VandenBos, &
Freedheim, D.K. (Eds.), History of psychotherapy: Continuity and change (2nd ed.) (pp. 173-202).
Washington, D.C.: American Psychological Association.
• Stanton, M., & Welsh, R. (2012). Systemic thinking in couple and family therapy research and practice.
Couple and Family Psychology: Research and Practice, 1, 14-30.
Cognitive/Cognitive-Behavioral
• Persons, J.B., & Davidson, J. (2001). Cognitive-behavioral case formulation. In K.S. Dobson (Ed.),
Handbook of cognitive–behavioral therapies (2nd ed.) (pp. 86-110). New York, NY: Guilford Press.
• Persons, J.B., Davidson, J., & Tompkins, M.A. (2001). Individualized case formulation and treatment
planning. In J.B. Persons, J. Davidson, & M.A. Tompkins, M.A. (Eds.), Essential components of cognitive-
behavior therapy for depression (pp. 25-55). Washington, D.C.: American Psychological Association.
• Persons, J.B., Curtis, J.T., & Silberschatz, G. (1991). Psychodynamic and cognitive-behavioral formulations
of a single case. Psychotherapy, 28, 608-617.
Behaviorism
• Fishman, D.B., Rego, S.A., & Muller, K.L. (2011). Behavioral theories of psychotherapy. In J. Norcross,
G.R. VandenBos, & D.K. Freedheim (Eds.), History of psychotherapy: Continuity and change (2nd ed.) (pp.
101-140). Washington, D.C.: American Psychological Association.
• Wagner, A.W. (2005). A behavioral approach to the case of Ms. S. Journal of Psychotherapy Integration,
15, 101-114.
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5. • Kohlenberg, R.J., & Tsai, M. (1995). Functional analytic psychotherapy: A behavioral approach to intensive
treatment. In W. O’Donohue, & L. Krasner (Eds.), Theories of behavior therapy: Exploring behavior change
(pp. 637-658). Washington, DC, US: American Psychological Association.
Multicultural/Cross-Cultural
• Shea, M., Yang, L.H., & Leong, F.T.L. (2010). Loss, psychosis, and chronic suicidality in a Korean American
immigrant man: Integration of cultural formulation model and multicultural case conceptualization. Asian
American Journal of Psychology, 1, 212-223.
• Cheung, F.M. (2012). Mainstreaming culture in psychology. American Psychologist, 67, 721-730.
• Lewis-Fernandez, R., & Diaz, M. (2002). The cultural formulation: A method for assessing cultural factors
affecting the clinical encounter. Psychiatric Quarterly, 73, 271-295.
• Bracero, W. (1996). Ancestral voices: Narrative and multicultural perspectives with an Asian
schizophrenic. Psychotherapy: Theory, Research, Practice, Training, 33, 93-103.
• Comas-Diaz, L. (2012). Humanism and multiculturalism: An evolutionary alliance. Psychotherapy, 49,
437-441.
• Hendricks, M.L., & Testa, R.J. (2012). A conceptual framework for clinical work with transgender and
gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology:
Research and Practice, 43, 460-467.
• Constantine, M.G. (2001). Multicultural training, theoretical orientation, empathy and multicultural case
conceptualization ability in counselors. Journal of Mental Health Counseling, 23, 357-372.
Feminism
• Carneiro, R., Russon, J., Moncrief, A., & Wilkins, E. (2012). Breaking the legacy of silence: A feminist
perspective on therapist attraction to clients. World Academy of Science, Engineering, and Technology, 66,
1064-1067.
• Evans, K.M., Kincade, E.A., Marbley, A.F., & Seem, S.R. (2005). Feminism and feminist therapy: Lessons
from the past and hopes for the future. Journal of Counseling and Development, 83, 269-275.
• McAndrew, S., & Warne, T. (2005). Cutting across boundaries: A case study using feminist praxis to
understand the meanings of self-harm. International Journal of Mental Health Nursing, 14, 172-180.
• Vandello, J.A., & Bosson, J.K. (2013). Hard won and easily lost: A review and synthesis of theory and
research on precarious manhood. Psychology of Men & Masculinity, 14, 101-113.
Psychodynamic
• Ivey, G. (2006). A method of teaching psychodynamic case formulation. Psychotherapy: Theory, Research,
Practice, Training, 43, 322-336.
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6. • Curtis, J.T., Silberschatz, G., Weiss, J., Sampson, H., & Rosenberg, S. E. (1988). Developing reliable
psychodynamic case formulations: An illustration of the plan diagnosis method. Psychotherapy, 25,
256-265.
Humanistic/Existential
• Farber, E. W. (2010). Humanistic-Existential psychotherapy competencies and the supervisory process.
Psychotherapy: Theory, Research, Practice, Training, 47, 28-34.
• Sachse, R., & Elliott, R. (2002). Process-outcome research on humanistic therapy variables. In D.J.
Cain (Ed.), Humanistic psychotherapies: Handbook of research and practice (pp. 83-115). Washington,
D.C.: American Psychological Association.
Narrative/Constructivist
• Lambie, G.W., & Milsom, A. (2010). A narrative approach to supporting students diagnosed with learning
disabilities. Journal of Counseling and Development, 88, 196-203.
• Bob, S.R. (1999). Narrative approaches to supervision and case formulation. Psychotherapy, 36,
146-153.
• Martin, J. (2013). Life positioning analysis: An analytic framework for the study of lives and life narratives.
Journal of Theoretical and Philosophical Psychology, 33, 1-17.
• Daniel, S.I.F. (2009). The developmental roots of narrative expression in therapy: Contributions from
attachment theory and research. Psychotherapy: Theory, Research, Practice, Training, 46, 301-316.
Interpersonal Neurobiology
• Siegel, D.J. (2002). The developing mind and the resolution of trauma: Some ideas about information
processing and an interpersonal neurobiology of psychotherapy. In Shapiro, F. (Ed.), EMDR as an
integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism (pp. 85-
121). Washington, D.C.: American Psychological Association.
• Fishbane, M.D. (2007). Wired to connect: Neuroscience, relationships, and therapy. Family Process, 46,
395-412.
Developmental/Developmental Psychopathology
• Nigg, J.T., Martel, M.M., Nikolas, M., & Casey, B.J. (2010). Intersection of emotion and cognition in
developmental psychopathology. In S.D. Calkins, & M.A. Bell (Eds.), Child development at the intersection
of emotion and cognition. Human brain development (pp. 225-245). Washington, D.C.: American
Psychological Association.
• Miklowitz, D.L. (2004). The role of family systems in severe and recurrent disorders: A developmental
psychopathology view. Development and Psychopathology, 16, 667-688.
• Masten, A.S., Faden, V.B., Zucker, R.B., & Spear, L.P. (2009). A developmental perspective on under-age
alcohol abuse. Alcohol Research and Health, 32, 3-15.
page 3

7. Section II: Case Formulation in Psychotherapy
(Taken from: Case Formulation in Psychotherapy: Revitalizing Its Usefulness as a Clinical Tool by Kang Sim,
M.D., Kok Peng Gwee, M.D., & Anthony Bateman, M.D., Academic Psychiatry, 2005, 29, pp. 289 292)
Abstract: Case formulation has been recognized to be a useful conceptual and clinical tool in psychotherapy as
diagnosis itself does not focus on the underlying causes of a patient’s problems. Case formulation can fill the gap
between diagnosis and treatment, with the potential to provide insights into the integrative, explanatory, prescriptive,
predictive, and therapist aspects of a case. Despite the acknowledgment that case formulation is a basic, necessary,
and key clinical skill, it is still largely undertaught and underlearned. Some of the issues faced in the development of
a case formulation include that of immediacy versus comprehensiveness, complexity versus simplicity, observation
versus organization, and the need for cultural sensitivity toward each individual patient.
The science of formulations must be combined with art. Something vital is lost if the formulation does not
capture the essence of the case.
—Denman (1)
Case formulation is a topic of interest in psychotherapy not only in its utility as a conceptual and clinical tool (2,
3) but also because of its potential as a research tool into the outcomes of psychotherapeutic work (4—6). As
clinicians, we seek to help our patients with accurate diagnoses and effective management plans. In the process,
we need to identify a patient’s main problems and understand the predisposing, precipitating, and perpetuating
factors of these problems as well as the relationship between these factors within the patient. The subsequent
treatment plans can and often do involve psychotherapy with goals ranging from reduction of symptoms,
improvement of functioning, prevention of relapse, increase in insight, and recognizing obstacles to progress
in therapy.
However, diagnosis itself does not complete the process of evaluation just as descriptive and atheoretical
classifications such as DSM—IV criteria do not necessarily focus on the underlying cause of a patient’s problems
(7). Certainly they do not help us predict which patients are suitable for which therapy. Suitability is an ill-defined
concept but commonly refers to an individual’s psychological characteristics that facilitate a good fit between the
method and the establishment of a therapeutic alliance (8). Therapists must evaluate patient suitability for specific
types of psychotherapy and information such as demographic features, and symptom presentation are often
inadequate; hence something more is needed. Case formulation can fill this gap between diagnosis and treatment
and can be seen to lie at the intersection of etiology and description, theory and practice and science and art. This is
the case for psychotherapies such as dynamic psychotherapy, interpersonal psychotherapy, and cognitive behavior
therapy (CBT). This article discusses the definition of case formulation, highlights its clinical utility for therapists and
residents in training, and argues for its indispensability as an important integrative, clinical tool despite the inherent
tensions involved in the process of case formulation.
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8. Definition and Useful Models
There is no agreed definition of case formulation by practitioners of a specific model of therapy or between
practitioners of different models, and the formulation generally follows the theoretical approach and attempts
to integrate different perspectives (9, 10). In the literature, various authors have proposed various definitions of
case formulation but essentially cover the same scope (i.e., the descriptive, prescriptive and predictive aspects
of the case [11—13]). Sperry et al. (11) define case formulation as “a process of linking a group of data and
information to define a coherent pattern and it helps to establish diagnosis, provides for explanation and prepares
the clinician for therapeutic work and prediction.” Wolpe and Turkat (12) define it as “a hypothesis that relates all of
the presenting complaints to one another, explains why these difficulties have developed and provides predictions
about the patient’s condition.” In short, it is a succinct description of the chief features of the case as well as
an encapsulation of the diagnosis, etiology, treatment options, and prognosis of patients’ problem. Denman (1)
went further by maintaining that the attributes of a good formulation capture the essence of the case and include
presence of a theoretical basis, sensitivity about the patient, and specificity to the patient.
An example of a case formulation model in CBT is one proposed by Persons (13), which is comprised of seven
components, namely problem list, core beliefs, precipitants and activating situations, origins, working hypothesis,
treatment plan, and predicted obstacles to treatment. There are two aspects of assessment in this model: the
structural and functional aspects. The structural aspect derives heavily from the theory of psychopathology by Beck
(14) in that the problems of the patient are the result of the activation of core cognitions by stressful life events, and
these often have early childhood origins. At a functional level, it draws from behavior therapy with emphasis on the
identification and assessment of the functional utility of maladaptive behavioral patterns.
In dynamic psychotherapy, an example of a good formulation structure is one prepared by Perry et al. (15), which
includes a summarizing statement, description of nondynamic factors, description of core psychodynamics using the
ego psychology, object relations, self psychology model, and prognostic assessment, which identifies the potential
areas of resistance in therapy.
Despite the acknowledgment by most clinicians and therapists that case formulation is a basic, necessary, and
key clinical tool, it remains an undertaught and underlearned clinical skill (15—17). Ben-Aron and McCormick
(16) noted that 80% of the respondents in their survey believed that the topic of case formulation was important
but insufficiently emphasized in residency training. A study conducted by Fleming and Patterson (17), only 31%
of the residents stated that guidelines for case formulation were provided by schools. This may be partly due
to misconceptions surrounding topics such as 1) that only long-term cases require case formulation; 2) case
formulation can be elaborate and time consuming; 3) there is no need for written formulation; and 4) the concern
that the focus on formulation may shift the therapist focus from the actual communication of the patient. However,
Perry et al. (15) argued that case formulation can be useful for both short-term and long-term cases and need not
be time
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9. consuming. In addition, it may in fact save more time due to the expediency of an appropriate therapeutic strategy.
The written form is preferable to oral presentation in order to allow for longitudinal comparison and reformulation
whenever necessary, and it is also more likely to facilitate rather than hinder the communication of the patient.
There are clear benefits of having a case formulation for therapists and residents in training and these are related to
the following five aspects of the case: integrative, explanatory, prescriptive, predictive, and therapist.
Integrative
A case formulation summarizes the salient features of the case in a nutshell (18, 19) and identifies important issues
quickly (20), particularly for complex cases with multiple problems (21). Furthermore, the act of writing helps to
organize and integrate the clinical data around a linchpin and allows the clinician to focus on the heart of the matter
in each individual case (22).
Explanatory
The case formulation provides insight into the intra- as well as interindividual aspects of the case (23), thus allowing
a better grasp of the evolution of the illness and its impact on the patient and caregivers. It also gives a framework
to examine the interactions between underlying dynamic and nondynamic factors, including psychological and
neurobiological vulnerability, in understanding the development, maintenance, and resolution of a patient’s
difficulties (24).
Prescriptive
At the prescriptive level, an adequate formulation is a precious blueprint guiding therapy, including the setting of
appropriate goals and choice of intervention point, modality, and strategy (25). This is of value, especially for the
trainees, in being grounded in the formulation and staying the course rather than feeling the need to change tack
with a patient’s intense and shifting moods or behaviors in treatment (24).
Predictive
The initial formulation sheds light on the prognosis of the case (26) and points toward a need to redirect the focus
onto other areas such as exploring other underlying core beliefs and challenging other automatic negative thoughts
when therapy is not progressing. It also provides a useful baseline marker for later comparison and reformulation
as new information unfolds and as therapy outcome is assessed over time (27). In reality, a final conceptualization
never exists unless the patient is fully recovered. The process is iterative with constant revalidation with the patient.
In some therapies this is done by presentation to the patient either verbally or in writing, but in dynamic therapies it
is done through interpretation using the transference relationship to highlight the new understanding.
Therapist
A case formulation helps the therapist to understand the nature of the therapeutic relationship, relationship
difficulties, and, ultimately, to experience greater empathy for the patient beyond the presenting problems (27).
Patients’ explanatory model for their problems and their own formulation and expectations for treatment should be
explored as well. Thus, case formulation allows for anticipation and management of therapy interfering events such
as noncompliance with homework, acting in and out behaviors, or other forms of resistance to change in therapy,
including pharmacological treatment (6, 24).
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10. Inherent Tensions and Inadequacies
The issues faced in the development of a case formulation include immediacy versus comprehensiveness,
complexity versus simplicity, observation versus organization, and cultural sensitivity.
Immediacy Versus Comprehensiveness
Immediacy versus comprehensiveness involves how soon and how complete a case should be conceptualized. In
this regard, the therapist must identify what is needed in order for a patient’s condition to improve, which should
be considered in comparison with other aspects of the patient’s condition. It is invariably linked with the therapeutic
frame and the contracted sessions. The foci may be more short-term in dealing with the here and now in individual,
short-term dynamic psychotherapy compared with long-term dynamic psychotherapy.
Complexity Versus Simplicity
The tension of complexity versus simplicity relates to the fact that if the conceptualization is too simple, salient
aspects of the case may be missed, and, conversely, if the conceptualization is too complex, it may become too
unwieldy and time consuming for practical use.
Observation Versus Organization
If a therapist focuses mainly on clinical data and his or her subjective feeling state, paying no heed to the underlying
organizing hypotheses, opportunities for meaningful interpretation of the patient’s difficulties may be missed.
Conversely, if too much emphasis is placed on the therapist’s own hypotheses and organization about a case,
the empirical link with the personal experiences of the patient may be lost. Here, it is important to be aware that
personal biases, countertransference, past experiences, and preconceptions of the therapist can also affect and
distort clinical evaluation of a case.
Cultural Sensitivity
The therapist must seek a formulation that is sensitive to the cultural context within which a patient is found so that
the patient can feel more understood (28).
In addition, research on psychotherapy (including case formulation) can be fraught with issues pertaining to validity,
replicability, standardization, and comparability of content by different therapists (6). Moreover, as with all theoretical
models and approaches, a therapist must not be too confined to a single model or approach, although it may
provide a certain structure and discipline to the evaluation of the presenting problems of the patient. Instead, the
therapist should be able to view it as part of a holistic approach, encompassing the biological, psychological, and
social, cultural, and spiritual perspectives of the patient so that other significant details are not lost. Notwithstanding
the above comments, available research has supported the hypothesis testing approach and process to patient
evaluation (5, 29), although more data about its translation to treatment efficacy or effectiveness outcome studies
are still needed (26).
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11. Conclusions
Case formulation in psychotherapy is a useful clinical, therapeutic, and integrative tool for the therapist and residents
in training. Regarding diagnosis and treatment, it serves as a practical tool to translate diagnosis to specific
interventions. Concerning theory and practice, it serves as a connection between theories of psychotherapy and the
application of these theories to the particular patient. Regarding science and art, it encapsulates scientific principles
and an understanding of the uniqueness and humanity of the person in therapy. Case formulation is an important and
indispensable tool in psychotherapeutic interventions.
page 8

12. Section III: Thirteen Leading Case Formulation
and Treatment Planning Texts
(1) Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client
BARBARA LICHNER INGRAM, PhD,
“Two major splits dominate the field of psychotherapy today: alienation between
researchers and practitioners, and the fragmentation of theoretical approaches
into self-contained, frequently warring subgroups. In this contentious environment,
Ingram’s important book is a wonderful breath of fresh air, for she develops a
dramatically successful conceptual and practical model for bridging these splits.
Her approach masterfully does this first by developing a generic case formulation
paradigm that is both theory and data friendly for researchers, and individual-
case friendly for practitioners. Second, in a far-ranging and seamless integration
of the field, Ingram demonstrates how her case formulation model can incorporate concepts and principles from a
wide variety of theoretical orientations, vividly showing how the different approaches can provide complementary
perspectives on the same case. This complementarily in turn provides more options for treatment planning and
intervention so as to best shape the therapy to the specific clinical needs and contexts of the individual client, while
at the same time providing rich material to facilitate the further development and refinement of the theories.”
—Daniel B. Fishman, PhD, Professor, Graduate School of Applied
and Professional Psychology, Rutgers University
(2) Case Conceptualization and Treatment Planning: Integrating
Theory With Clinical Practice Pearl S. (Susan) Berman (Author)
Using compelling client interviews and skill-building exercises, this text shows
students how to develop effective case conceptualizations and treatment plans. Case
Conceptualization and Treatment Planning presents a comprehensive model that
simplifies a task that is potentially overwhelming to a student—figuring out how to tailor
clinical work to the specific background and values of a client. This new edition has
been thoroughly revised and expanded, including the addition of two new theoretical
orientations: feminist perspective and constructivist perspective.
(3) Case Conceptualization in Family Therapy (New 2013 Counseling Titles)
Michael D. Reiter
In this highly-anticipated new text for courses in family therapy, key concepts and
techniques of the most prominent family therapy models are presented and put into
practice. Each chapter utilizes the same unique case family to explore the intricacies
of how that model views the theory of problem formation as well as the theory
of problem resolution. Readers will work their way through nine engaging theory
chapters written from the perspective of the founder. As theories are presented, the
development of a case conceptualization will take shape and a deeper understanding
of the unique situation of one case family currently having difficulties will be explored
and studied, and a solution as to what course of treatment might be most appropriate
will be evaluated.
page 9

13. (4) Diagnosis and Treatment Planning Skills for Mental Health Professionals: A
Popular Culture Casebook Approach
Alan M. Schwitzer (Author), Lawrence (Larry) B. Rubin (Author)
“A true strength of this book is that the authors are able to describe complex, abstract concepts in a practical,
straightforward manner that is highly accessible for students from a variety of mental health professions. The
authors should be commended for integrating detailed models for developing diagnostic, case conceptualization,
and treatment planning skills into one text. Students often learn these types of clinical thinking skills in separate
courses and then experience difficulty in weaving this information together to inform their work with actual clients.
The authors of this book succeed in bridging this gap for students. With the use of thirty fascinating case studies
drawn from popular culture and from across the spectrum of mental health concerns, students are able to see in
vivid detail how diagnosis, case conceptualization, and treatment planning skills may be applied in clinical practice.
The rich case descriptions help make the material come alive for the reader so that he or she remains actively
involved in the learning process. I recommend this extremely practical and engaging tool for all beginning clinicians
as a foundation for developing strong clinical thinking skills.” (Laura Choate, Ed.D., LPC, NCC 2011-06-14)
“Diagnosis And Treatment Planning Skills For Mental Health Professionals: A Popular Culture Casebook Approach
is a hit. We all think about popular culture figures and wonder what they’d be like if they were real. Schwitzer and
Rubin carry this concept steps further by imagining 30 pop culture figures as clinical cases, and approaches them
as mental health professionals. Using the Inverted Pyramid Method as an organizing structure, the authors walk
students through the process of diagnosing clients, conceptualizing cases, and planning treatment. They illustrate
this method and the theories and research underpinning it through the cases
derived from popular culture figures and in doing so make the material engaging,
compelling, and memorable.” (Robin S. Rosenberg, Ph.D. 2011-07-10)
“If you are interested in finding a text that creatively describes common clinical
issues, this is your book! Distinguished pop-culture-in-counseling authors and
educators, Schwitzer and Rubin, collaborate on this vast compilation of material
to present step by step directions using often poignant vignettes within a DSM
counseling paradigm. A must- read for all counselors, psychotherapists and popular
culture enthusiasts!” - Thelma Duffey, Editor, The Journal of Creativity in Mental
Health, University of Texas at San Antonio (Thelma Duffy 2011-11-04)
page 10

14. (5) Handbook of Psychotherapy Case Formulation, Second Edition
Tracy D. Eells PhD (Editor)
“Case conceptualization is the cognitive hub of the wheel of psychotherapy. It provides
a framework for linking theory, the assessment of individual needs and strengths,
possible techniques and change processes, and desired outcomes.This comprehensive
volume draws together in one place the major perspectives on the process of case
conceptualization. Eells has produced a volume that is both theoretically grounded and
practical, and that will help students and professionals explore a variety of models and
approaches. If you want the best of current thinking about case conceptualization, there
is no better volume to own.”--Steven C. Hayes, PhD, University of Nevada
“Case formulation is a necessary component of treatment planning, yet it often has been
overlooked in the literature. This volume sets a standard for the field. Clear and accessible, the book is written and
edited by leading authorities, and can be used both in graduate classes and by professionals. A significant feature of
the second edition is the focus on cultural factors.The reader will come away with a better understanding of what case
formulation is and why and how to do it.”--Clara E. Hill, PhD, University of Maryland, College Park
“For many reasons, case formulation has become more topical and relevant than ever in contemporary psychotherapy
practice and research. Eells has again assembled an impressive group of scholars who represent the various traditions
and who are at the forefront of the field. The strength of this book remains its organization and coverage. In addition,
the second edition provides complete examples of case formulation and addresses multicultural considerations. Eells
has also included material that provides a critical analysis of the various presentations and of the field at large. In
short, Eells has significantly advanced the ball with this new edition.”--J. Christopher Muran, PhD, Department of
Psychiatry, Beth Israel Medical Center and Albert Einstein College of Medicine
(6) Psychoanalytic Case Formulation
Nancy McWilliams PhD (Author)
What kinds of questions do experienced therapists ask themselves when facing a
new client? How can clinical expertise be taught? From the author of the landmark
Psychoanalytic Diagnosis, this book takes clinicians step-by- step through developing
an understanding of each client’s unique psychology and using this information to guide
and inform treatment decisions. McWilliams shows that while seasoned practitioners
rely upon established diagnostic categories for record-keeping and insurance purposes,
their actual clinical concepts and practices reflect more inferential, subjective, and
intuitive processes. Interweaving illustrative case examples with theoretical insights
and clinically significant research, chapters cover assessment of client temperament,
developmental issues, defenses, affects, identifications, relational patterns, self-esteem
needs, and pathogenic beliefs.
page 11

15. (8) Handbook of Psychological Assessment, Case Conceptualization, and
Treatment, Vol 1: Adults
by Michel Hersen and Johan Rosqvist (Nov 2, 2007)
Edited by recognized experts Michel Hersen and Johan Rosqvist, Handbook of
Psychological Assessment, Case Conceptualization, and Treatment, Volume 1, Adults,
is a thorough and practical reference for those working with adults. Bringing together
the most current theories and evidence-based applications, chapters address issues
of importance including ethics, medical issues, panic and agoraphobia, obsessive-
compulsive disorder, and posttraumatic stress disorder. Each chapter follows a
structured format, opening with an overview of assessment, followed by case
conceptualization, and, finally, recommended treatment.
(9) Handbook of Psychological Assessment, Case Conceptualization, and
Treatment, Children and Adolescents (Volume 2)
by Michel Hersen (Editor), David Reitman (Editor)
Edited by recognized experts Michel Hersen and David Reitman, Handbook of Psychological Assessment, Case
Conceptualization, and Treatment, Volume 2, Children and Adolescents, is a thorough and practical reference for
those working with children and adolescents. Bringing together the most current theories and evidence-based
applications, chapters address issues of importance including depressive disorders, substance use disorders, and
childhood psychosis. Each chapter follows a structured format, opening with an overview of assessment, followed
by case conceptualization, and, finally, recommended treatment.
(10) The Case Formulation Approach to Cognitive-Behavior Therapy (Guides to Individualized Evidence-
Based Treatment...
by Jacqueline B. Persons PhD (Oct 22, 2012)
“Persons’s insights into case formulation are second to none. This book brilliantly demonstrates that you don’t
have to sacrifice good science to be an excellent clinician, and vice versa. I recommend it to psychotherapists
and students at all levels of experience who are interested in using the best theories and clinical techniques to
help their patients achieve real and lasting change. Persons’s rare combination
of clinical practicality and scientific dedication makes her a role model for every
young scientist-clinician.”--Marsha M. Linehan, PhD, ABPP, Professor and Director,
Behavioral Research and Therapy Clinics, University of Washington
“This groundbreaking volume will train the next generation of cognitive-behavioral
therapists. Its sophisticated blending of case-level formulation with empirical
principles of behavior change is a threshold event in CBT’s ongoing engagement
with clinical complexity, comorbidity, and nonadherence.”--Zindel V. Segal, PhD,
Cameron Wilson Chair in Depression Studies and Professor of Psychiatry, University
of Toronto
page 12

16. “Decades of research and clinical experience meet in this seminal book. Persons provides a guide for both the
novice and experienced practitioner to deal with even the most complex of cases. This significant work will no
doubt become the shining light by which the idiographic approach to CBT will be guided in the future. One of the
few books that is worth even more than the purchase price!”--Nicholas Tarrier, PhD, FBPsS, Department of Clinical
Psychology, University of Manchester, UK
“There is no greater challenge facing mental health professionals than moving from scientific theory and research
to clinical practice. Persons has addressed this critical issue for many years, and has come up with solutions that
demand the attention of serious health professionals. She convincingly shows how to analyze complex cases in
ways that are both scientifically sound and practically feasible and effective. Persons is the consummate scientist-
practitioner. This book is a ‘must read’ for students, academics, and practitioners.”--Gerald C. Davison, PhD, William
and Sylvia Kugel Dean’s Chair, and Professor of Gerontology and Psychology, University of Southern California
(11) Clinical Case Formulation: Varieties of Approaches
by Peter Sturmey (Editor)
“This volume provides examples of case formulations representing the most
common mental health problems. Each case is described, and then followed by
two contrasting formulations and a commentary from a different perspective. These
examples provide readers with clear models of case formulations, and highlight
the different constructs and world views that characterize alternate theoretical
approaches to case formulation.” (Book News, December 2009)
Case formulation is a key clinical skill for mental health practitioners, and many
clinicians use it on a regular basis. It summarizes the essential features of a case
and allows practitioners to derive an individually-based treatment– a treatment
which is more accurate than one based on diagnosis alone. However, despite the
centrality of this approach to diagnosis in mental health, students and practitioners
often lack appropriate models.
This book presents students and practitioners with the fundamental models by providing examples of case
formulations which represent the most common mental health problems found within a variety of populations and
contexts. These include:
• Depression in a middle-aged woman
• Psychosis
• An eating disorder
• Hoarding in an older adult
• Anger in a person with intellectual disabilities
Each chapter describes a case, before presenting two contrasting formulations and a commentary from a different
perspective. These examples not only provide the reader with clear models of case formulations, they also highlight
the different constructs and world views that characterize alternate theoretical approaches to case formulation.
page 13

17. (12) Case Conceptualization and Treatment Planning: Integrating Theory With Clinical Practice by Pearl S.
by Pearl S. (Susan) Berman (Nov 2, 2009)
• Using compelling client interviews and skill-building exercises, this
text shows students how to develop effective case conceptualizations
and treatment plans. Case Conceptualization and Treatment Planning
presents a comprehensive model that simplifies a task that is potentially
overwhelming to a student—figuring out how to tailor clinical work to
the specific background and values of a client.This new edition has
been thoroughly revised and expanded, including the addition of two new
theoretical orientations: feminist perspective and constructivist perspective.
(13) Clinical Case Formulations: Matching the Integrative
Treatment Plan to the Client
by Barbara Lichner Ingram (Jun 23, 2006)
• This innovative new guide addresses the essential question facing every therapist with a new client: How do
I create a treatment plan that is the best match for my client? This unique resource provides a systematic
method to integrate ideas, skills, and techniques from different theoretical approaches, empirical research,
and clinical experience to create a case formulation that is tailor-made for the client.
Clinical Case Formulations is divided into three parts:
• Getting Started—provides an overview that sets forth a framework for case formulation and data gathering.
• 28 Core Clinical Hypotheses—offers a meta-framework embracing all theories, orientations, and mental
health intervention models and presents clinical hypotheses within seven categories: Biological Hypotheses;
Crisis, Stressful Situations, and Transitions; Behavioral and Learning Models; Cognitive Models; Existential and
Spiritual Models; Psychodynamic Models; and Social, Cultural, and Environmental Factors. These hypotheses
are combined and integrated to develop a coherent conceptualization of
the client’s problems.
• Steps to a Complete Case Formulation—provides a structured framework
known as the Problem-Oriented Method (POM). Using the POM and
integrating multiple hypotheses, the therapist learns how to think
intelligently, critically, and creatively in order to develop a tailor-made
treatment plan.
A list of thirty-three standards for evaluating the application of this method
is provided.
With this practical guide you will learn to conceptualize your clients’ needs
in ways that lead to effective treatment plans while finding the tools for
troubleshooting when interventions fail to produce expected benefits.
page 14

18. Section IV: FAMILY SYSTEMS

19. 1. Key writers and works
• Ackerman
- One of the founders of family therapy. Cultivated awareness of social context on the internal
dynamics of the family system.
• Jackson
- Among the first to observe the camouflaging function that a child’s symptoms provide for covert
parental conflict. Thus, the child becomes the identified patient instead of the dysfunctional f
family process.
• Minuchin (1962)
- Formed model of the family as a relationship system. Model rests heavily on the notion that
most symptoms, whether they present as a dysfunction in an individual or as a conflict
in a relationship, are a byproduct of structural failing within the family organization.
Major breakthrough in the history of family therapy.
• Bowen
- Most comprehensive model of family systems. Emphasized the emotional process in the
system, rather than the individual.
2. Major Themes
• Radical departure from the intrapsychic model—the individual or the individual’s mind is not the cause of
symptoms and is also not the treatment target, rather, it is related to the system that the individual
is apart of.
• A system is hierarchically ordered into networks of relationships, each with greater complexity. Systems
have systemic properties, including the ability to self-organize in states far from equilibrium, self-regulate
through feedback, and are continuously changing in a nonlinear fashion toward a trajectory.
• Each member of the system influences the others in predictable and recurring ways. This influences the
way we respond in multiple settings as it shapes our expectations of how the larger world will interact
with us.
• Must think of systems as dynamic, continuously changing, spontaneously organizing, and
relentlessly adaptive
• As complex systems move further away from equilibrium, the system can destabilize and transform into an
even more complex system (emergence).
3. Major Constructs
• System: two people or more (i.e., a couple, company, classroom, family, patient-therapy, etc.)
• Roles: sets of standards, laws, or traditions that tell us how to live in relation to each other, have long-term
and far-reaching effects. Roles are evolutionary in advancing us as a species. Human systems survive and
thrive by roles.
• Homeostasis (or equilibrium): all human systems like to go to a calm state and they reject chaos. Chaos is
directly related to the alterations of roles
- Dysfunctional systems will attack the individual with the problem and put them back in their role
to achieve homeostasis
page 15

20. - Functional systems will see a need for alteration of roles when the individual develops the
problem and the system will evolve into something more complex
- Double bind: multiple, often contradictory, levels of communication in relationships. In certain
relationship situations, an overt and explicit meaning of a communication is
• Induction: nonverbal and verbal communication that affirms the roles within a system, usually an
unconscious act. Examples of induction include:
- Made to feel they can do certain things but not others
- Being induced to play a role
• Contingencies: behavioral responses that increases or decreases the probability of certain
utterance being exchanged
- Healthy systems: contingencies are weak and the responses are difficult to predict
• Boundaries: relate to limits, togetherness, and separateness. Can show signs and degrees of each type
and vary depending on different factors or events
- Enmeshed: identity is very much tied to the family
- Disengaged: autonomy and separateness are present
• Hierarchy: helps answer the question “who’s the boss?” and is related to decision-making control, and
power in the family. Whenever a family composition changes, there is a shift in where family members are
in the hierarchy.
• Climate: emotional and physical home environments.
4. Cause of Psychopathology
• Psychopathology or distress is caused by the system that the individual is embedded in
• Psychopathology is due to the system’s attempt at maintaining homeostasis. A system may be maintaining
homeostasis by implementing rigid roles, or through induction.
• Ultimate goal is emergence, or the transformation into a more complex system, versus a rigid system.
• Pathology is co-determined; reciprocal effects and processes
- Reciprocal effects: must understand the mutually interactive nature of the relationship and
understand that the actions of each are simultaneously influencing and being influenced by the
other, creating a causal loop that defies reduction to linear cause-effect
5. Major Disorders/Life Stressors
• Oppositional Defiant Disorder
• Eating Disorders
• Depression
6a. Therapeutic Interventions/Role of Therapist
• Therapist must shift their focus from the parts (i.e., the individual) to the whole (i.e., the system)
• Therapist must be able to comprehend the complexity of the system by understanding the reciprocal
influence of hierarchically ordered systems and resist the temptation to simplify the description of
a problem. Should be aware of the multiple factors that might influence the system.
page 16

21. • The ability to recognize webs of reciprocity is crucial to systemic psychotherapy interventions.
• Therapist must recognize trends and patterns within systems. Should identify the associations between
apparently disconnected issues or behaivors.
6b. Mechanisms of Change
• As complex systems move further away from equilibrium, the system can destabilize and transform into an
even more complex system (emergence). At the heart of change in an open, complex adaptive system is
the ability to transform from one state into a more adaptive complex state.
• Open systems are influenced by outside forces that can assist in the transformation process—therapeutic
intervention is one such outside force
• “Change occurs in self-organizing systems when the build-up of system energy propels the system toward
disruption, disorder, confusion, and irreguliarity.”
• Pattern recognition is crucial, once the partners recognize the pattern, it can be interrupted and adjusted in
a manner that benefits both individuals and the relationship between them
7. Case Formulation
“Lela, go and join the others on the playground. I’ll finish the rest of cleanup for you. You’ve been a big help today,”
says Kathy as she hugs the four-year-old. Lela hesitates at the door and asks, “Are you sure?” Kathy smiles
reassuringly. “Yes, now go play!”
Once on the playground, Lela pushes Sadie, one of the younger children, on the swing. When Sadie tires of
swinging and goes off to play in the sand, Lela helps the teacher carry toys from the storage shed to set up an
activity. Later, Lela mediates a dispute over tricycles between two classmates. A visiting teacher taking anecdotal
notes that day writes, “Lela’s play was limited to ‘helping’ for outdoor playtime and much of the rest of the day. How
can we encourage her to expand to expand her play activities to include other roles?”
Interpretation:
Lela has a clear idea of her role in her family: she is a helper. Helping is a wonderful attribute and not one that
teachers want to disappear. Having Lela teach others how to help is a way to build of her strength. To facilitate
her whole-child development, teachers could set up a situation that does not lend itself to her helping anyone and
encourage her play in that area. They could also refuse some of her offers to help, but with careful wording.
Lela’s teachers will need patience, consistency, and creative ideas to help her learn new roles. Look for her other
strengths and channel her energies in that direction.
page 17

22. Nathan Ackerman:
 One of the
founders of family
therapy.
 Cultivated
awareness of social
context on the
internal dynamics of
the family system.
Gregory Bateson:
 Worked with Jay
Haley and others to
create the concept
of the family
homeostasis.
Murray Bowen:
 Bowenian Family
Systems.
 Most comprehen-
sive model of family
systems.
 Emphasized the
emotional process in
the system rather
than the individual.
Jay Haley:
 Worked with
Minuchin on
Structural Family
Therapy.
 Directive Family
Therapy.
 Covertly giving
directives to the
family system that
are specific to the
treatment of their
problems.
Don Jackson:
 Among the first to
observe the
camouflaging
function that a
child’s symptoms
provide for covert
parental conflict.
 The child becomes
the identified
patient instead of
the dysfunctional
family process.
Salvador Minuchin:
 Structural Family
Therapy
 Formed model of
the family as a
relationship system
 The model rests
heavily on the
notion that most
symptoms, whether
they present as a
dysfunction in an
individual or as a
conflict in a
relationship, are a
byproduct of
structural failing
with the family
organization
 This was a major
breakthrough in the
history of family
therapy.
 Oppositional Defiant Disorder
 Eating Disorders
 Depression
Majors Disorders
Key Figures
Dr. James Tobin
Psychopathology II
Family Systems
Inside this issue:
Key Figures 1
Major Disorders 1
Major
Constructs
2
Causes of
Psychopathology
2
Major Themes 3
Role of the
Therapist
3
Mechanisms
of Change
3
Three Phases
of Case
Formulation
4
Example:
The Cobb Family
4
Example: Lela 5
References 5
Cliff Notes

23. Boundaries relate to the limits,
togetherness, and separateness.
Can show signs and degrees of each
type and vary depending on
different factors or events. (see
enmeshed and disengaged)
Climate emotional and physical home
environments.
Contingencies behavioral responses
that increase or decrease the
probability of certain utterances
being exchanged. In healthy
systems, contingencies are weak
and the responses are difficult to
predict.
Disengaged when the boundaries of
the family are too rigid, not allowing
for flexibility or attachment among
the members of the system.
Enmeshed when the family system
is characterized as being “overly
permeable or absent of
boundaries” (Chabot, 2011).
Family Homeostasis This explains
how a family will resist change and
when the family system is
challenged by change, the other
members will push back or adjust to
bring the system back to
homeostasis. Family systems prefer
an equilibrium or a calm state and
reject chaos. Chaos is directly
related to the alterations of roles.
 Dysfunctional systems will
attack the individual with the
problem and put them back in
their role to achieve
homeostasis.
 Functional systems will see a
need for alteration of roles
when the individual develops the
problem and the system will
evolve into something more
complex.
 Double bind: multiple, often
contradictory, levels of
communication in relationships.
In certain relationship
situations, an overt and explicit
meaning of a communication is
contradicted by the implied or
metamessage.
Fusion highly fused families are
emotionally tied together in an
unhealthy manner.
Genogram a family diagram that can
help identify relationships and find
patterns of behavior in a family
system.
Hierarchy helps answer the
questions “who’s the boss?” and is
related to decision-making control
and power in the family. Whenever
a family composition changes, there
is a shift in where family members
are in the hierarchy.
Identified Patient The person the
family system has identified as the
patient; however, the identified
patient is merely displaying the
symptoms that are the result of a
system that is not experiencing
homeostasis.
Induction nonverbal and verbal
communication that affirms the
roles within a system, usually an
unconscious act. Examples include:
 Made to feel they can do
certain things but not others
 Being induced to play a role
Roles Set of standards, laws, or
traditions that tell us how to live in
relation to each other, have
long-term and far-reaching effects.
Roles are evolutionary in advancing
us as a species. Human systems
survive and thrive by roles.
System two or more people (i.e., a
couple, a company, classroom,
family, patient-therapist, etc.).
Triangulation when a third person is
brought into a relationship in order
to mediate between the couple.
Often this is the role of a child or
the therapist.
 Psychopathology or distress is caused by the system that the individual is
embedded in.
 Psychopathology is due to the system’s attempt at maintaining homeostasis. A system may be maintaining
homeostasis by implementing rigid roles or through induction.
 A Closed System does not allow for change within the system. Rigidity of roles can destabilize the status quo
of the system. When this happens they experience the change as being a crisis, which is what often brings
the system in for therapy.
 The ultimate goal is emergence or the transformation into a more complex system versus a rigid system.
 Pathology is co-determined by reciprocal effects and processes
 Reciprocal Effects: must understand the mutually interactive nature of the relationship and understand that
the actions of each are simultaneously influencing and being influences by the other, creating a causal loop
that defies reduction to linear cause-effect.
An Open System is a system that is healthy. An open system allows for change and makes adjustments for it’s
members.
Page 2
Causes of Psychopathology
Family Systems
Major Constructs
“The touchstone for
family life is still the
legendary ‘and so they
were married and lived
happily ever after.’ It is
no wonder that any family
falls short of this ideal.”
Salvador Minuchin

24.  Family Systems is a radical
departure from the Intrapsy-
chic/Freudian model that the
individual or the individual’s mind
is not the cause of
symptoms and is also not the
treatment target, rather, it is
related to the system that the
individual is a part of.
 A system is a hierarchically
ordered into networks of
relationships, each with greater
complexity. Systems have
systemic properties, including the
ability to self-organize in states
in states far from equilibrium,
self-regulate through feedback,
and are continuously changing in a
nonlinear fashion toward a
trajectory.
 Each member of the system has
role and influences the others in
predictable and recurring ways.
This influences the way we
respond in multiple settings as it
shapes our expectations of how
the larger world will interact with
us.
 Must think of systems as
dynamic, continuously changing,
spontaneously organizing, and
relentlessly adaptive.
 As complex systems move
further away from equilibrium,
the system can destabilize and
transform into an even more
complex system (emergence).
 Avoid linear thinking by
identifying webs of causality or
causal feedback loops; look at the
reciprocity between the members
of the system.
 Developmental Phases Each
member of the system will be at
different stages and each person
brings with them different
historical influences. The system
is constantly evolving and
changing which can create tension
within the system .
webs of reciprocity and
understand that they are crucial
to systemic psychotherapy
interventions.
 The therapist must remember to
acknowledge the established
hierarchy within the system.
 The therapist must resist the
temptation to simplify the
description of the problem.
 The therapist must be empathic
toward each member of the
system.
 The therapist must understand
each person’s perspective and
accurately empathize with them
on each of their issues.
 The therapist must recognize
trends and patterns within
systems. They should identify the
associations between apparently
disconnected issues or behaviors.
 The therapist must shift their
focus from the parts (i.e., the
individual) to the whole (i.e., the
system).
 The therapist must always be
aware of the multiple factors
that might influence the system.
 The therapist must be able to
comprehend the complexity of
the system by understanding the
reciprocal influence of the
system.
 The therapist must recognize
the transformation process.
 Therapeutic intervention is
an example of an outside
force.
 Pattern recognition is crucial.
Once the system recognizes
patterns, these patterns can be
interrupted and adjusted in a
manner that benefit all members
of the system.
 As complex systems move
further away from equilibrium,
the system can destabilize and
transform into an even more
complex system (emergence).
 At the heart of change is an open
complex, adaptive system that
has the ability to transform from
one state into a more adaptive
complex state.
 Open systems are influenced by
outside forces that can assist in
The therapist helps the system
identify these patterns, and
helps the system adapt. The
system needs to first become
destabilized in order for
change begin to occur. This is
often when the system wants
to revert back to previous
roles and behaviors in order to
maintain the homeostasis with
which they are comfortable.
Psychopathology II
Mechanisms of Change
Major Themes
Role of the Therapist
Page 3

25. Problem Formulation
Data collection and assessment
Case Formulation
Interpretation of the case from a systemic perspective
Treatment Formulation
Treatment must consider the goals of the
client (remember: the system is the client)
and focus on areas of intervention
Page 4
Case Formulation Example: The Cobb Family
Family Systems
Three Phases of Case Formulation
The Cobb family is a three-
generational family composed
of the father, David, age 45
years; mother, Juanita, age
42 years; son, James, age 6
years; daughter, Anita, age
12 years; and maternal
grandmother, Lilly, age 65
years. The maternal grand-
father, John, a farmer, died
3 years ago of a heart at-
tack. The paternal grandpar-
ents, Dan, a retired banker,
age 70 years, a Ruth, a home-
maker, age 68 years, live in a
nearby city. The couple, Da-
vid and Juanita, have been
married for 20 years. Like
his father, David is emotion-
ally withdrawn from his fami-
ly and overinvolved with his
job.
In terms of family back-
ground, David comes from a
middle-class background. He
has an older sister, Daisy,
who is 3 years his senior. His
father has a history of high
blood pressure, but his
mother is in good health.
Juanita was an only child.
After 20 years of marriage,
her mother, Lilly, almost di-
vorced her father when
Juanita was 13 years old.
Juanita and her mother
have had a close but con-
flictual relationship since
that time, with Lilly coming
to live with her daughter
after the death of John.
At present, Juanita and Lilly
take care of the house and
children, and David works as
a salesperson for a cleaning
supply company.
The problem for which the
Cobb family has requested
help centers around James.
Instead of doing well aca-
demically and socially,
James is failing all his sub-
jects and staying out late at
night. He has been arrest-
ed once for vagrancy, and
David and Juanita suspect
he is drinking alcohol and do-
ing drugs. Money from
Juanita’s purse has been
stolen twice in recent weeks.
Lilly has written James off
as a delinquent. Interesting-
ly enough, he has the same
first name as her former
lover, who almost ended her
marriage. Anita simply ig-
nores James whenever possi-
ble. Although she is a good
student, her relationship
with her mother is conflict-
ual.
Considerations
 James is the identified pa-
tient; although, problems
exist throughout the family
system
 Repeated pattern of con-
flict between mother and
daughter.
 Repeated patterns of with-
drawn fathers
(Gladding, 2010)

26. “Lela, go and join the others
on the playground. I’ll finish
the rest of the cleanup for
you. You’ve been a big help
today,” says Kathy as she
hugs the four-year-old. Lela
hesitates at the door and
asks, “Are you sure?” Kathy
smiles reassuringly, “Yes, now
go play!”
Once on the playground, Lela
pushes Sadie, one of the
younger children, on the
swing. When Sadie tires of
swinging and goes off to play
in the sand, Lela helps the
teacher carry toys from the
storage shed to set up an
activity. Later, Lela mediates
a dispute over tricycles
between two classmates.
A visiting teacher taking
anecdotal notes that day
writes, “Lela’s play was limited
to ‘helping’ for outdoor
playtime and much of the rest
of the day. How can we
encourage her to expand her
play activities to include
other roles?”
Interpretation
 Lela has a clear idea of
her role in her family: she
is a helper.
 Helping is a wonderful
attribute and not one that
teachers want to
disappear.
 Having Lela teach others
how to help is a way to
build on her strength.
 To facilitate
her
whole-child
development,
teachers could set up a
situation that does not
lend itself to her helping
anyone and encourage
her to play in that area.
 The teachers could also
refuse some of her offers
to help, but they would
need to be careful with
their phrasing, as they do
not want to hurt Lela.
 Lela’s teachers will need
patience, consistency, and
creative ideas to help her
learn new roles.
 Also, look for Lela’s other
strengths and channel her
energies in that direction.
 Stanton, M. & Welsh, R. (2012).
Systemic thinking in couple and family
psychology research and practice. Couple
and Family Psychology: Research and
Practice, 1(1), 14-30.
 Chabot. D.R. (2011). Family systems
theories of psychotherapy. In Norcross,
J.C., VandenBos, G.R., & Freedheim,
D.K. (Eds.), History of psychotherapy:
Continuity and change (173-202).
Washington, D.C.: American Psychologi-
cal Association.
 Gladding, S. (2010). Family therapy:
History, theory, and practice (5th
Ed.).
New York, NY: Prentice Hall .
 Hurst, N.C., Sawatzky, D.D., & Pare,
D.D. (1996). Families with multiple
problems through a Bowenian lens.
Child Welfare, 75(6), 693-708 .
Psychopathology II
References
Case Formulation Example: Lela
Page 5

27. Section V: COGNITIVE/
COGNITIVE-BEHAVIORAL

28. 1. Major figures and writings:
• Beck (1976)
• Persons (1989)
• Freeman (1992)
• Padesky (1996)
• Tarrier & Calam (2002)
• Ledley, D. R., Marx, B. P., & Heimberg, R. G. (2010). Making cognitive-behavioral therapy work: clinical
process for new practitioners (2nd ed.) New York, NY: The Guilford Press
2. Major Themes:
• Schema – core beliefs or deep cognitive structures that enable an individual to interpret his or her
experiences in a meaningful way (view of self, others, the world, and the future)
• Precipitants and activating situations
• Precipitant – large-scale events that appear to have caused an episode of illness
• Activating situations – small-scale events that trigger negative mood or maladaptive behaviors. Often these
are smaller scale events that trigger the same schema activated by the precipitating event
• Origins – early learning history that explains how the patient might have learned his or her problematic
schema. The therapist does this with a simple statement or with a brief description of one or two
particularly poignant or powerful incidents that capture the patient’s early experience
• Summary of the working hypothesis –the therapist “tells a story” that describes how the patient learned
the schema that are now being activated by external events to cause the symptoms and problems on the
patient’s problem list.
3. Major constructs
• Cognitive-behavioral case formulation can occur at three levels: the case, the syndrome or problem, and
the situation.
• Case: an attempt to understand the entire case as a whole, particularly the relationships among the
patient’s presenting problems and the schema that appear to underlie many or all of the problems.
• Syndrome or problem: provides a conceptualization of a particular syndrome or problem
• Situation: information about a particular situation and information about the cognitive, behavioral, and
mood components of the patient’s reaction to that situation.
4. Cause of psychopathology
• Psychopathology is due to thoughts that are attributed by the individual to an external sources. Automatic
thoughts, negative emotions, and problem behaviors (such as unassertiveness, avoidance behaviors,
negative cognitions) result from the activation of negative schemas by stressful life events. Basically,
maladaptive thoughts generate feelings that result in maladaptive behaviors.
5.Major Disorders Relevant or Life Stresses / Events
• Depression
• Anxiety
• Substance Abuse
• Couples Problems
page 18
• Personality Disorder
• Anger
• Eating Disorder

29. 6.Role of therapist/therapeutic interventions:
• Although there are standardized treatment protocols, they are nomothetic (general), not idiographic
(individualized), formulation. In carrying out the protocol, the therapist must individualize it for the patient
at hand.
• Setting and prioritizing treatment goals (based on the problem list)
• The therapist collects data to assess the patient’s response to interventions as the therapy proceeds.
When the treatment response is poor, the therapist reviews the formulation, considers whether an
alternative formulation might generate some new treatment interventions, and collects data to evaluate the
patient’s response to the new interventions. When proposing a new formulation, a therapist might rely
on the nomothetic model on which the original formulation was based or he or she might draw on other
empirically supported models.
• Treatment Plan:
• Treatment goals need to be concrete, measurable, and mutually agreed upon by the therapist and patient
• Interventions – proposed treatment plans are related to the working hypothesis and address some of the
problems on the problem list.
• Obstacles – predictions about difficulties that might arise in the therapy
7.Case formulation:
Cognitive-Behavioral Case Formulation and Treatment Plan for “Jenna”
Name: Jenna Identifying Information: 34 MWF, not working, living with husband and 5-year-old daughter.
Problem List:
1) Depressive symptoms. BDI = 22. Sadness, lack of enjoyment, feeling like a failure, self-criticism, lack of
energy, suicidal thoughts but no plan or intent, difficulty making decisions, loss of interest in others, insomnia,
loss of appetite. “Things are not good. Nothing much matters. Sometimes I don’t care if I live or die.”
2) Not working. Believes work would help “pull her out” of depression, as it did in the past, but “I don’t know
what I want t o do, and I don’t have any energy t o do it. I just can’t get moving.” Enjoyed working as an editor
for 5 years, “but I don’t know what my long-term career goals are.”
3) Marital problems. Following a stillbirth, she wanted to consider adoption, but her husband did not and
refused to discuss it. He wanted her to “let go [of her distress about the stillbirth] and move on”; she is
resentful that he does not acknowledge her pain, loss, suffering. She describes the miscarriage as a “black
hole” in their marriage. She fears asserting herself with him, saying that when she speaks up about her
resentment, “he just throws it back at me.” They do not fight, but they are distant, estranged.
4) Fear of freeway, bridge driving. “There are a lot of bad drivers, and I’m very vulnerable in a car on the
freeway.” “I could turn the steering wheel and slam into a wall.” Fear of panic attacks while driving, onset
following several panic attacks while driving several years ago. She avoids busy streets, freeways, and bridges
and rarely drives outside a 2-mile radius surrounding her home.
5) Socially isolated. Jenna has two women friends, mothers of children that are her daughter’s friends, but
she is not close to either, does not initiate any activities with them.
page 19

30. Diagnosis:
Axis I: Major depressive disorder, panic disorder with agoraphobia
Axis II: Dependent personality disorder
Axis III: None. History of miscarriage, stillbirth.
Axis IV: Unemployed, marital problems, socially isolated.
Axis V: 50
Working Hypothesis:
Schema:
• Self: “I’m not ready for and can’t handle adult responsibilities.” “I can’t make good choices/decisions.” “I’m
weak and vulnerable and need lots of nurturing, support.”
• Other: “My husband doesn’t care, doesn’t want to be supportive of my needs.” “My husband is to blame
for my unhappiness; he must change if I am to be happy.”
• World: “Life shouldn’t be so hard; it should be easier.”
• World/future: “Bad things can happen to me, my child, such as disease, death, accident.”
• Precipitants: Move to California about 5 years ago; as part of this transition, Jenna gave up her job that
had been a confidence builder. Other precipitants include several miscarriages and a stillborn child.
• Activating situations: Challenging driving situations (freeways, bridges), a need to speak up to her husband
about her emotional distress, wanting to seek work.
• Origins: Parents modeled difficulty handling loss of a child who died of leukemia; it was never discussed
in the family, and the patient learned about her dead brother from her grandmother when she was 9 years
old. The patient’s mother was fearful and overprotective: “Don’t try some thing if you’re not sure you can
do it-something bad might happen.”
• Summary of the working hypothesis: Jenna’s move to California and the loss of her job that had given
her some direction, satisfaction, and feedback that she can make decisions and handle adult
responsibilities activated her beliefs that she cannot handle adult/demanding decisions/responsibilities.
In response to these beliefs and the anxiety they produced when activated, she withdrew from
responsibilities, including looking for a job and driving in challenging freeway and bridge situations, which
left her isolated, resulting in a loss of potential sources of gratification, leading to her depression. Jenna’s
beliefs that she cannot make good choices and cannot choose a career path, coupled with driving
problems, inertia from depression, and resentment toward her husband, block her from seeking work. The
stillbirth and miscarriages and resulting unhappiness supported or activated Jenna’s beliefs that she needs
lots of support/nurturing, that her husband is unsupportive, and that he is responsible for her unhappiness,
contributing t o her depression, inertia, and marital problems.
Strengths and Assets: Stable life circumstances (husband who supports the family), a good network of friends, well
educated, bright, psychologically minded.
page 20

31. Treatment Plan:
Goals (measures):
1. Reduce depressive symptoms (BDI).
2. Increase comfort while driving freeways and bridges (measured through patient’s ratings of items on a
fear hierarchy). Increase the distance (now about 2 miles) she is willing to drive from home.
3. Return to work.
4. Reduce marital tension and estrangement, as measured by spending more enjoyable time together
as a couple.
Modality: Individual cognitive-behavior therapy, Frequency: Weekly
Interventions:
1. Activity scheduling to increase sources of pleasure and mastery, alone and perhaps with husband.
2. Build a hierarchy and use gradual exposure t o alleviate driving fears.
3. Teach anxiety-management skills, including diaphragmatic breathing.
4. Interceptive exposure (exposure to internal somatic sensations; see Barlow, Craske, Cerny,
& Klosko, 1989).
5. Cognitive restructuring to work on fears that she cannot handle driving or other challenges, beliefs that
her happiness depends on her husband, fears that bad things could happen, beliefs she cannot choose
and act on a professional goal.
6. Schema change methods to tackle her belief that she is weak/vulnerable.
7. Assertiveness training, especially with her husband.
Adjunct therapies: Consider antidepressant medications, couples therapy.
Obstacles:
1. Jenna’s view that others are responsible for her happiness may make it difficult for her t o work
aggressively in treatment t o overcome her problems.
page 21

32. Key Figures
CBT is a short-term,
goal-oriented psycho-
therapy treatment
that takes a hands-on,
practical approach to
problem-solving. Its
goal is to change
patterns of thinking
and/or behavior that
are behind people’s
difficulties, and so
change the way they
feel.
CBT works by
changing people’s
attitudes and their
behavior by focusing
on the thoughts,
images, beliefs, and
attitudes that we hold
( o u r c o g n i t i v e
processes) and how
this relates to the way
we behave, as a way of
d e a l i n g w i t h
emotional problems.
The client and
therapist are working
together to under-
stand what the
problems are and to
develop a new
strategy for tackling
them. CBT introduces
the patient to a set of
principles that they
can apply whenever
they need to. Thus,
these principles will
place them in a good
position throughout
their lives. CBT can
be thought of as a
combination of
psychotherapy and
behavioral therapy.
Various theorists
put forth their own
models. In this set
of notes, we will
c o v e r c a s e
formulation by
P e r s o n s a n d
Tompkins, Beck, and
Leahy. Each of the
models are distinct;
however, as you will
notice there are
common threads
weaved through each
theory.
 Aaron T. Beck
(Father of
Cognitive Therapy)
 Judith S. Beck
(President of
the Beck Institute
for Cognitive
Behavior Therapy)
 Albert Ellis
(Founder of CBT)
 John Watson
(Behavioral
Approach)
 Ivan Pavlov
(Behavioral
Approach)
 B.F. Skinner
(Behaviorism)
Major Themes
Major Themes 1
Key Figures 1
Major Constructs 2
Causes of
Psychopathology
2
Models 2
Disorders 3
Therapeutic
Interventions/Role of
the Therapist/
Mechanisms of Change
3
Persons & Tompkins
6 Steps for
CBT Formulation
3
Beck’s Cognitive
Conceptualization Model
4
Overview of Case
Conceptualization Models
5
ABC Model 6
Inside this issue:
Psychopathology II
Cliff Notes
Dr. James Tobin
Cognitive Behavioral Therapy

33.  Agendas
 ABC Model (see page 6)
 Attributions (Explanation of
why an event occurred)
 Automatic Thoughts
 Behaviors (Overt and Covert)
 Cognitions
 Cognitive Appraisal (Primary
and Secondary)
 Cognitive restructuring
 Coping Mechanisms
 Core Beliefs
 Empirically Supported Thera-
pies
 Feedback (Within the therapy
session)
 Homework
 Intermediate Beliefs (Rules)
 Maladaptive cognitions and
assumptions
 Reinforcement/Punishment
 Schemas
 Stepwise Progression
 Target Behaviors: Accelera-
tion and Deceleration
The Cognitive Model
Situation/event > automatic thoughts > reaction (emotional, behavioral, physiological)
It is not the situation itself, but rather how people construe a particular situation. The emotional
response is mediated by their perception of the situation meaning the situation itself does not directly
determine how they feel/ what they do.
The Behavioral Model
Isolation of behaviors and the use of ABC model (Antecedent- Behavior- Consequence)
CBT postulates that cognitive factors moderate all interactions or behaviors between the individual,
situational demands, and the person's attempts to cope effectively. This is bidirectional in the sense
that when a situation triggers an automatic thought, an individual’s reaction (emotional, behavioral,
psychological) can result in various forms.
Models
 Cognitive theory assumes most psychological problems derive from faulty thinking processes.
 Behavior theory assumes problematic behaviors are the result of particular antecedents and
consequences.
Causes of
Psychopathology
Major Constructs
Page 2 Cognitive Behavioral Therapy

34. Major Depressive Disorder
Eating Disorders
Substance use Disorders
Personality Disorders
Schizophrenia
Bipolar Disorder
Anxiety Disorders
 Panic Disorder (With or
without Agoraphobia)
 Specific Phobia
 Obsessive-Compulsive
Disorder
 Posttraumatic Stress
Disorder
 Stress Disorders
 Generalized Anxiety
Disorders
Disorders
 Precipitants: large scale
events that cause illness and
activating situations , which
are small-scale events that
trigger negative mood or
maladaptive behaviors.
 Origins: how patients leaned
their problematic schemas..
5. Strengths and Assets
6. Treatment Plan
 Goals: the goals need to be
mutually agreed upon and
specific; something that can be
empirically measured (e.g.,
Beck scale, BSI).
 Interventions: which treat-
ment will be provided to
address the goals
 Obstacles: (similar to Weiss’
1. Identifying information.
2. Problem List: patient’s
complaints or presentation for
treatment; can order the
problems by severity (suicidality,
followed by therapy interfering
events, then behaviors that are
dangerous or interfere with
quality of life, finally other
problems).
3. Diagnosis
4. Working Hypothesis
 Schema: core beliefs; deep
cognitive structures that
enable an individual to
interpret his/her experience in
a meaningful way; view of self,
other, world, and future. (Beck
developed schemas).
psychodynamic formulation,
because he integrated it with
cognitive theory).
Anticipating/predicting what
may lead to the patient with-
drawing from treatment (e.g.,
depressed patients who begin
to experience relief may leave
treatment, because they view
themselves as not worth
caring for; therefore, this view
decreases future improvement.
This is similar to Freud’s
“resistance,” the patient
reacting to the therapist’s
capabilities. If the patient
believes the therapist is able
to promote insight or improve
the patient’s quality of life, the
patient may abandon therapy.
CBT Formulation (Persons & Tompkins, 2010)
practicing a variety of coping
skills, only some of which are
cognitive. A greater emphasis is
also placed on using behavioral
coping strategies, especially
early in therapy. CBT tries to
change what the client both does
and thinks.
Thought informs the emotion
which then informs the behavior
CBT places less emphasis on
identifying, understanding, and
changing underlying beliefs
about the self. Instead CBT
focuses on learning and
Cognitive Therapy- Given the
view that dysfunctional
behavior is determined in part
by faulty cognitions, the role of
the therapist is to modify the
negative or self-defeating
automatic thought processes or
perceptions that seem to
perpetuate symptomology.
Therapeutic Interventions/Role of the Therapist and Mechanisms of Change
Page 3Dr. James Tobin

35. Cliff Notes
Beck: Cognitive Conceptualization Model
Relevant childhood data.
Compare self with older brother and peers
Critical mother
Core beliefs.
I'm inadequate, others are better than me, I won’t succeed.
Intermediate Beliefs (rules)
(positive) If I work very hard, can do okay
(negative) If I don't do great, then I've failed
Compensatory strategies.
Develop high standards A look for shortcomings and correct.
Work very hard Avoid seeking help.
Over prepare
Situation
Talking to students about advanced place-
ment credits
Automatic Thought
They're all smarter than me
Meaning of the Automatic Thought.
I am inadequate (see core beliefs above)
Emotion or Affect
Sadness
Behavior
Avoid the subject and talk about something
else

36. Cliff Notes
Beck’s Cognitive Case
Conceptualization
 Relevant childhood data
 Core beliefs.
 Conditional assumptions, beliefs
or rules.
 Compensatory strategies.
 Specific situation.
 Automatic thought.
 Meaning of the automatic
thought.
 Affect or emotion
 Behaviour
Robert Leahy's Cognitive
Case Conceptualization.
 Developmental history.
 Personal schema .
 Schema about others.
 Automatic thoughts
 Maladaptive assumptions.
 Conditional beliefs.
 Coping strategies.
Jacqueline’s B. Person’s
Case Conceptualization
 Problem list.
 Core beliefs.
 Precipitating and activating
situations
 Origins
 Working hypothesis.
 Treatment plan.
 Predicted obstacles
 Strengths, supports and as-
sets

37. The ABC Model for Cognitive Behavioral Therapy can be described as “as I think, so I feel (and do)!”
There are 3 steps to the ABC Model. They are:
 Activating event - the actual event and the client’s immediate interpretations of the event
 Beliefs about the event - the evaluation of the event van be rational or irrational
C. Consequences - how you feel and what you do, as well as other thoughts
Situation One - Negative Perspective
(A) Mary is walking down the street and her friend,
Sarah walks right on by.
(B) May thinks, “Oh, Sarah is such a jerk.”
(C) Next time, Mary ignores Sarah.
The “B” may or may not be true.
Situation Two - Positive Perspective
(A) Mary is walking down the street and her friend,
Sarah walks right on by.
(B) Mary thinks, “Oh that Sarah, always distracted.”
(C) Mary calls out, Sarah apologizes for missing her,
and they go out for coffee!
The role of the counselor in CBT is to challenge false
beliefs.
Negative Event (A) Rational Belief (B) Healthy Negative Emotion (C)
Negative Event (A) Irrational Belief (B) Unhealthy Negative Emotion (C)
When a negative event happens, it can be interpreted wither positively or negatively. How the event is interpreted
affects how one feels, thinks, and behaves.
ABC Model of CBT
Page 6 Cognitive Behavioral Therapy
(A) Activating Event
 Actual event
 Client’s immediate
interpretation of the event
(B) Beliefs
 Evaluations
 Rational
 Irrational
(C) Consequences
 Emotions
 Behaviors
 Other Thoughts
1. Black-and-White - thinking or either/or
thinking
2. Making Unfair Comparisons - usually in
the negative
3. Filtering - honing in on the negative,
forgetting the positive
4. Personalizing - The Self-Blame Game
5. Mind Reading - thinking we know what
others think (negatively)
6. Catastrophising - imagining the worst case
scenario
7. Overgeneralizing - “I always mess up…”
8. Confusing Fact with Feeling - “If I think or
feel this way then my thoughts/feelings must be
correct.”
9. Labeling - I’m a loser vs. I made a mistake
10. ‘Can’t Standits’ - being unnecessarily
intolerant
The False Beliefs or The Lies We Tell Ourselves
Cognitive Behavioral is not about pretending problems don’t exist. Rather, it’s about being more accu-
rate about strengths and resources and enlisting these to make the changes necessary to live a good life.
Examples
http://www.basic-counseling-skills.com/cognitive-behavioral-therapy.html

38. Section VI: BEHAVIORISM

39. 1. Key Figures and Writers
• J. B. Watson—credited with launching the system of behaviorism (1913)
• B.F. Skinner
• Thorndike
• Pavlov
• P. Zimbardo
• Key Writings
- Behavioral theories of psychotherapy (Fishman et al.)
- Functional analytic psychotherapy: A behavioral approach to intensive treatment (Kohlenberg & Tsai)
2. Major Themes
• Focusing on directly observable, overt behaviors and their interactions with the directly observable,
immediate physical and social environment.
• Derived from the behavioral change principles of classical (respondent) conditioning (Pavlov) and later
operant conditioning (Thorndike and Skinner) that came out of learning experiments with animals, such as
dogs, cats, pigeons, and rats, in which cognition was generally not considered.
• Operant conditioning: the subject is rewarded for making the desired response and punished whenever an
undesired response is elicited.
3. Major Constructs
• Most abnormal behavior is acquired and maintained according to the same principles as normal behavior.
• Most abnormal behavior can be modified through the application of social learning principles.
• Assessment is continuous and focuses on the current determinants of behavior.
• People are best described by what they think, feel, and do in specific life situations.
• Treatment methods are precisely specified, replicable, and objectively evaluated.
• Treatment outcome is evaluated in terms of the initial induction of behavior change, its generalization to
the real life setting, and its maintenance over time.
• Treatment strategies are individually tailored to different problems in different individuals.
• Behavior therapy is broadly applicable to a full range of clinical disorders and educational problems.
• Behavior therapy is a humanistic approach in which treatment goals and methods are mutually contracted
between client and therapist (Fishman et al. 2010)
4. Causes of Psychopathology
• A behavioral approach does not judge behaviors as healthy or unhealthy, separate from their context and
their consequences. Instead, behaviors, whether deficient or excessive, are usually discussed with respect
to whether they are adaptive or maladaptive in a cultural or social context” Gurman and Messer (2003).
• Adaptive and maladaptive behaviors are caused by the same basic learning processes. Differences
between nonclinical manifestations of a problem and clinically relevant symptoms are thought to be
quantitative differences (in frequency, intensity, and consequences of the symptoms).
• Trait view: associated with Five Factor theory of personality, sees behavior as emerging from the individual.
Individuals act as they do primarily because of their inherent natures, without much attention to the
temporal aspects of behavior or to the contexts within which the behaviors are embedded.
page 22

40. • Interactional view: associated with behavior therapy; treats the person and the environment as separate
underlying entities interacting in a linear, causal, predictable manner, like the parts of a watch.
Psychological phenomena are analyzed in terms of the antecedent conditions that lead to certain
behaviors, which in turn lead to various consequences, which in turn become antecedents for certain
subsequent events.
• Organismic view: associated particularly with systems theory; conceives of both the person and the social
environment as a system with complex, reciprocal, and dynamic relationships and influences among its
various parts and subsystems. Change usually occurs in accord with underlying regulatory mechanisms
such as homeostasis and long-range directional teleological mechanisms (e.g., psychological development
from birth to adulthood).
• Transactional view: emphasizes the role of varying perspectives on a particular purposive action or pattern
of such actions in a person’s life, such as deciding to apply to graduate school or to go out on a date. The
act is viewed as intrinsically embedded in the individual’s surrounding life context and unfolding in time.
Thus, the event is viewed as a complex and holistic phenomenon.
5. Major Disorders Relevant or Life Stresses/Developmental Phases
• Obsessive-Compulsive Disorder
• Anxiety
• Phobias
• Eating Disorders (Bulimia, Anorexia, Obesity)
• Social skills
6a. Therapeutic Interventions/Role of Therapist
• Interventions focus on directly changing those relatively immediate factors that are thought to predispose,
trigger, strengthen, or maintain problematic behaviors.
• Systematic desensitization
• Exposure (mainly in vivo)
• Flooding
• Psychoeducation
• Modeling
• Self-report measures
• Problem solving training
• Social skills training
• Mindfulness-Based Treatment Strategies
• Relaxation techniques
• Therapists work directly on problematic patterns of behavior by helping their clients to make changes
such as decreasing avoidance of feared situations, eliminating OCD rituals, and improving social skills, or
changing unhealthy eating patterns.
• Therapist behaviors affect outcome (e.g., empathy, warmth, positive regard, genuineness, etc.)
page 23

41. 6b. Mechanism of change
• Identifying current behaviors as problematic
• Setting up and following thru with achievable goals
• Changes in environmental contingencies
• Emotional processing
• Cognitive models
• Biological changes (through pharmacotherapy)
7. Case Formulation Example (from Gurman & Messer, 2003)
Background information and Pretreatment and Assessment
Deborah was a 43-year-old woman who worked as an elementary school teacher. She was married and had two
children. She reported having difficulties with social anxiety for as long as she could recall. The problem had been
particularly bad since college, when she had to drop several courses due to anxiety over giving presentation.
Although she could not recall how the problem began, she remembered a number of life events that seemed to lead
to exacerbations in her anxiety. For example, during one particularly difficult year in high school, she remembered
being teased on a regular basis and pretending to be ill on several occasions so she could stay home from school to
avoid being around her classmates. She described her home life while growing up as relatively happy,, although she
also reported that her parents were critical at times and that she often felt pressure from her parents to meet high
standards in school and in other areas of her life.
As part of her initial assessment, Deborah received the SCID-IV. DSM-IV criteria were met for a principal diagnosis
of social anxiety disorder (generalized). Criteria were also met for a past diagnosis of major depressive disorder,
triggered by the oloss of a job 10 years earlier. She reported significant fear and avoidance of a wide range of social
situations, including parties, public speaking (except when teaching her students), writing in public, speaking to
people in authority, meeting new people, being assertive, and having conversations with others. She reported that
her social anxiety has prevented her from making freintdds and from returning to school to complete her master’s
degree. She finally decided to seek treatment after reluctantly agreeing to be the maid of honor at her sister’s
wedding, which was approaching in only 3 months. Deborah reported several characteristic thoughts that seemed
to contribute to her social anxiety. Her primary concern in social situations was that she would appear stupid or
incompetent in front of others, despite feedback about her performance. Her anxious thoughts were particularly
problematic at work and around people who she did not know well. She would become upset if she perceived even
the slightest bit of rejection in these situations. However, she was quite comfortable around her family and her
closest friends and was rarely upset if they criticized her behavior. Deborah also reported an fear that she would
seem boring to others and that other people would not want to spend time with her if they had the opportunity to get
to know her. When asked what types of variables affected her fear, Deborah mentioned that she was more anxious
around others who she perceives as better in some way (because others might notice her blushing or shaky hands)
and in more formal situations.
page 24

42. Behavioral Conceptualization
Deborah’ social anxiety seemed, in part, to have been initially exacerbated by some negative experiences she had in
social situations. More recently, the anxiety appeared to be maintained by her avoidance of social situations and her
exaggerated beliefs about the potential dangers of being around other people. A number of situations appeared to
trigger Deborah’s anxiety.
References
Fishman et al. (2010). Behavioral theories of psychotherapy. (Article provided by Dr.Tobin)
Gurman, A. S. & Messer, S. B. (2003). Essential Psychotherapies: Theory and Practice. The Guilford Press.
New York, New York
page 25

43. objective branch of
science focused on
predicting and
controlling behavior
 Systematic
desensitization
—> exposure
therapy
 Ex. Sex offenders
were shown
pictures of naked
minors and were
then given a pill
to make them
vomit (classical
conditioning).
Fishman et al.
Behavioral therapy
began by focusing on
directly observable
behaviors and their
environment
Behaviorism was
derived from operant
conditioning (B. F.
Skinner) and
respondent
conditioning (Pavlov)
Focuses on helping the
individual understand
how their behavior can
lead to changes in
how they feel
Involves identifying
objectionable and/or
maladaptive behaviors
and replacing them
with healthier
behaviors
Behavior modification
therapy utilized in
order to change
undesired behaviors
Behaviorism is different
from CBT
 In cognitive
therapy, the focus
is on the objective
meaning of the
environment to
the individual
 In behavioral
therapy, the focus
is on observable
phenomena
Psychology is an
Behavioral Theories of Psychopathology
pleasure or
displeasure of the
reinforcement with
the behavior” -
(American Herit-
age® Dictionary,
2000).
(Continued on page 2)
B. F. Skinner
Operant condition-
ing= “A process of
behavior modifica-
tion in which the
likelihood of a
specific behavior is
increased or
decreased through
positive or negative
reinforcement each
time the behavior is
exhibited, so that
the subject comes to
associate the
Behaviorism
Cliff Notes
Key Figures
Inside this issue:
Behavioral
Theories
1
Key Figures 1-
2
Three Waves
in Behavior
Therapy
2
Major Themes 3
Major Constructs 3
Major Disorders,
Life Stresses,
Developmental
Phases
3
Causes of
Psychopathology
4
Mechanisms of
Change
4
References 4
Treatment 5
Case Formulation
Example
6
Dr. James Tobin
Psychopathology II

44. Key Figures, continued
Three Waves in Behavior Therapy
wave, while focusing on
how these internal pro-
cesses are functionally
related to the objective
environment (sometimes
called functional contex-
tualism), like the first
wave
 DBT & ACT: integra-
tion of Skinner’s radi-
cal behaviorism and
other behavioral
principles
1st: First wave that focuses
on functional relationships
between observable
behavior and the objective
environment
 Pavlov & Skinner
(operant and classical
conditioning)
2nd: Second wave that
focuses on cognitive
representations of the
environment rather than on
characteristics of the
objective environment per
se
 Beck (CBT): Humans
respond to cognitive
interpretations of the
environment. Cogni-
tive processes can be
cast into testable for-
mulations
3rd: Third wave that en-
compasses the cognitive
processes and inner expe-
rience of the second
BehaviorismPage 2
“While you are experimenting, do not remain content with the surface of things.” - Ivan Pavlov
focuses on changing
an individual's
thoughts (cognitive
patterns) in order to
change his or her
behavior and
emotional state” -
(American Heritage®
Dictionary, 2000)
Thorndike
P. Zimbardo
Pavlov
Classical Conditioning=
“A process of
behavior
modification by
which a subject
comes to respond
in a desired
manner to a
previously neutral
stimulus that has
been repeatedly
presented along
with an uncondi-
tioned stimulus that
elicits the desired
response” -(American
Heritage® Dic-
tionary, 2000)
Beck
Cognitive Behavioral
Therapy (CBT)=
“assumes that
maladaptive
thoughts cause
maladaptive
behavior and
“negative” emotions.
The treatment

45. Major Themes
Major Constructs
range of clinical disorders
and educational problems.
 Behavior therapy is a hu-
manistic approach in which
treatment goals and meth-
ods are mutually contracted
between client and thera-
pist (Fishman et al. 2010)
 Most abnormal behavior is
acquired and maintained ac-
cording to the same princi-
ples as normal behavior.
 Most abnormal behavior can
be modified through the ap-
plication of social learning
principles.
 Assessment is continuous
and focuses on the current
determinants of behavior.
 People are best described by
what they think, feel, and do
in specific life situations.
 Treatment methods are pre-
cisely specified, replicable,
and objectively evaluated.
 Treatment outcome is eval-
uated in terms of the initial
induction of behavior
change, its generalization to
the real life setting, and its
maintenance over time.
 Treatment strategies are
individually tailored to dif-
ferent problems in different
individuals.
 Behavior therapy is broadly
applicable to a full
BehaviorismPage 3
 Focusing on directly observable, overt behaviors and their interactions with the directly observable, imme-
diate physical and social environment.
 Derived from the behavioral change principles of classical (respondent) conditioning (Pavlov) and later op-
erant conditioning (Thorndike and Skinner) that came out of learning experiments with animals, such as
dogs, cats, pigeons, and rats, in which cognition was generally not considered.
 Operant conditioning: the subject is rewarded for making the desired response and punished whenever an
undesired response is elicited.
Major Disorders/ Life Stresses/
Developmental Phases
 Obsessive-Compulsive Disorder
 Anxiety
 Phobias
 Eating Disorders (Bulimia, Anorexia, Obesity)
 Social skills