The formulation of cases in cognitive-behavioral therapy (2022)

The reader who decides to start the book The formulation of cases in cognitive-behavioral therapy. Manage the therapeutic process and the work allianceby Ruggiero, Caselli and Sassaroli (2022), you know that you will not find yourself in front of an aseptic illustration of concepts, but of a real debate between experts.

Announcements The wording of the case is understood here as a constituent element of Cognitive Behavioral Therapy (CBT), a necessary part of good clinical practice. From the beginning the authors emphasize the perhaps priority aspect of formulation of cases in CBTthat is, sharing with the patient. They do not speak of a process carried out exclusively by the clinician, but of a procedure of co-construction and continuous exchange within the therapeutic couple, thanks to which the individual immediately assumes an active role in the understanding and treatment of their own difficulties. There shared formulation of the case it has the function of intervening in both specific and non-specific aspects of the therapeutic process. We understand by specific aspects those relating to the peculiarities of the patient’s suffering, while non-specific aspects refer to the management of the alliance and the therapeutic relationship, which are part of the therapeutic process itself rather than the specific case. The uses and purposes of sharing the formulation of the case therefore, they are multiple: to declare an explanatory model of the patient’s emotional suffering; create a common ground for the reason for the treatment strategy; monitor the progress of the treatment, which allows any adjustments and changes to be made; manage the relationship and the therapeutic alliance.

It can be said that the primary aim of the book is to conceptualize the “shared formulation of the clinical case as a central and distinctive intervention of the main forms of CBT”. We talk about plural forms to distinguish the various cognitive-behavioral therapies, emphasizing similarities and differences not only between them, but also with respect to some non-CBT approaches of a relational and psychodynamic type. To do this, the authors go through the history and evolution of shared formulation of the case, accompanying the reader to know its implementation in specific clinical settings, also informing of practical descriptions and examples of possible interventions. The division of the volume into chapters devoted to the different therapies allows the reader to have a clear view, examining features, boundaries, and overlapping areas. With this type of structuring, the authors pursue the additional goal of dividing therapeutic approaches into two categories: a proposal that shared formulation of the case it is possible from the beginning of the work, the other believes that it is a result to be achieved in the course of the therapeutic process. At the end of each chapter are also added reflections from other well-known authors in the field of psychotherapy, who delve into the chapter itself or are inspired to add elements of interest.

The first chapter focuses on Beck ‘s standard Cognitive Therapy (CT), where the shared formulation of the case it is the opening movement of the therapeutic process, which allows it to be managed moment by moment. The use of CCD (Cognitive Conceptualization Diagram), that is, the identification of core beliefs, intermediate beliefs, and coping strategies, allows the clinician and patient to jointly find a psychopathological interpretation and a therapeutic restructuring of the reported problematic situations. . There is room for what is perhaps the main criticism of CT, that is, relying on excessive rationality and relegating the patient to a role of passive learning, which offers the opportunity to open up, in response, a broad reflection on collaborative empiricism and on the intrinsic cooperation of shared conceptualization.

The second chapter focuses on behaviorism, which, the authors emphasize, has the merit of having first proposed the shared formulation of the case, in particular with the contribution of Meyer. The behaviorist tradition proposes the use of the formulation as a reason for treatment and emphasizes the provisional nature of the case framework. Attention is focused on voluntary executive functions, as crucial elements of the psychotherapeutic process, as they provide the patient with the ability to make a voluntary choice in the here and now and to disassociate it from any antecedent factors, including one’s own. cognitive reasoning. The idea is that the patient can acquire an awareness of their discomfort to be used in situations of daily life to implement a different behavior.

The third chapter investigates the shared formulation of the case in Ellis’s Rational Emotional Behavior Therapy (REBT). The illustration of the basic ABC-DEF procedure shows how there is a continuous exchange between the doctor and the patient, particularly during the phases of thought-behavior connection (BC), dispute (D) and goal negotiation. . . We are talking here about a shared formulation of the problem, rather than the case, to emphasize that attention is directed to the many difficult situations that the patient experiences in the current context of life.

The fourth chapter deals with shared formulation of the case in CBT approaches focused on more recent processes. Specifically, the following are considered: Acceptance and Commitment Therapy (ACT), in which the evaluation and sharing of their mental functioning with the patient merges with the therapeutic intervention based, in fact, on functioning rather than on the content; Process-Based Cognitive Behavioral Therapy (PB-CBT), a recent, still-developing approach that arises from the effort to integrate standard-based TCs and process-based CBT approaches, considering them as two possible different levels of ‘a single intervention; Schema therapy, where the case is formulated in terms of models of the self that are not purely cognitive; Metacognitive Therapy (TCM), which places great importance on sharing the model of early functioning with the patient, as it focuses on the conscious executive choice function of the individual, which can become dysfunctional due to metacognitive distortions. .

The fifth chapter is devoted to constructivist approaches. The authors illustrate how, in these models, sharing the formulation of the case is the result of an exploratory process rather than the exit from therapy. An important contribution of constructivism is to have introduced, in the process of clinical framing, the concept of subjective meaning that people attribute to themselves, others and the events of their lives. Attention is therefore paid to the systematic and careful exploration of the subject’s interpretations of his experience. A space is also reserved for Liotti’s model, which emphasizes the importance of the relationship both for understanding the patient’s suffering and as a priority area of ​​work and therapeutic change, that is, through the promotion of an attitude. cooperative, careful monitoring and management of relational episodes. crisis. This view refers to the Safran and Muran model based on the concepts of rupture and repair of the therapeutic relationship. The wording of the case would then be the result of the management of these episodes of breakage and repair.

Announcements Continuing with the discussion, the sixth chapter deals with the models of formulation of the case which are based on the role of the therapeutic relationship. In these models the formulation of the case it is the result of the therapeutic process and takes place without being openly declared and shared. The authors present Mitchell and Aron’s Relational Psychoanalysis, a psychodynamic paradigm detached from the classical tradition, where the focus becomes the construction of a meaningful new interpersonal experience that allows the patient to assimilate new relational models. The Bateman and Fonagy model of mentalization-based therapy (MBT) is illustrated below, where mentalization is promoted and encouraged by the therapist without an explicit explanation to the patient. The chapter continues to take the model of Safran and Muran and explains in more detail how it is done formulation of the case it cannot happen initially, as the condition on which the therapy is based would be missing, that is, the rupture of the relationship and its management. The idea of ​​the formulation of cases as a result, the authors continue, is also applicable to the Theory of Control (CMT), which focuses on relational evidence, interpersonal and experiential factors triggered by relational processes, not fully representable in the patient awareness but perceived. emotionally and motivatively.

The seventh chapter presents the formulation of the LIBET case (Life themes and semi-adaptive plans: Implications of biased beliefs, elicitation and treatment), conceived by the authors of the volume, and emphasizes the innovative nature of the integration between the cognitive elements of the Standard CT (self-beliefs and coping strategies), evolutionary elements, which would justify emotional vulnerability as an experience learned during patients’ life history, and procedural elements, which play a role in the pathological maintenance of coping strategies. confrontation. Integration translates into conceiving psychopathology as a rigid management of emotional distress, towards which the patient has a sensitivity, aimed at achieving the suppression of pain. Individual vulnerability corresponds to one or more life issues learned in meaningful experiences and relationships perceived as intolerably painful. For this reason, the individual implements a rigid management of suffering through impulsive avoidance, control and / or coping strategies, called semi-adaptive plans. Life issues and semi-adaptive plans remain constantly active due to procedural aspects, perceived need and uncontrollability, and this would determine psychopathology.

The last chapter is dedicated to the presentation of new psychotherapy scenarios in the context of e-health, which refers to the use of information and communication technologies (ICT) to facilitate prevention, diagnosis, treatment, monitoring and administration in the health system.

It is necessary to underline and appreciate the exploratory tone that distinguishes the whole text and that denotes the intention to promote the knowledge and the critical discussion of shared formulation of the case within the world of psychotherapy. The proposal of different views regarding the various therapeutic approaches with relative limits and strengths, the addition of reflections from other authors, as well as the presentation of criticisms and answers, undoubtedly predispose the reader’s mind to this attitude of openness and curiosity. fundamental. for individual subjective development and for that of the global scientific community.

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  • Ruggiero, GM, Caselli, G. and Sassaroli, S. (2022). The formulation of cases in cognitive-behavioral therapy. Manage the therapeutic process and the work alliance. Erickson Study Center Editions.

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