Role-relationship models for case formulation

Case Conceptualization in Clinical Practice and Training

Case conceptualization is central to the success of the therapeutic process. However, integrative case conceptualization research has lagged behind research on integrating therapeutic intervention techniques. A successful case conceptualization provides (a) a dynamic, context-sensitive, yet parsimonious model of the client's functioning; (b) relevant treatment targets and associated assessment procedures; and (c) a treatment plan including intervention phases and potential obstacles. Success in case conceptualization is a core clinical competency goal for trainees in clinical psychology and a career-long learning goal even for expert clinicians. Emerging technological trends and the formation of adversarial collaborative teams may assist research on the utility of well-constructed case conceptualizations.

The Sense of Self in Anorexia-Nervosa Patients

This paper has two purposes: to study a central psychological feature of anorexia nervosa, the disturbed sense of self, and to demonstrate the utility of an empirical research method to explore a psychoanalytic concept such as self-representation. The aim of the study was to distinguish the sense of self of anorexia-nervosa patients from that of other psychiatric patients, as well as from non-patients. We obtained open-ended self-descriptions, which provide access to self-representations, from 77 young women between the ages of 14 and 24 who made up three groups-anorexia-nervosa patients (n = 15), control psychiatric patients (n = 15), and control non-patients (n = 48). The self-descriptions, when rated on 18 scales that fell into four factors (Agency, Reflectivity, Differentiation, and Relatedness) and two affective scales (Anxiety and Depression), showed that the two patient groups shared characteristics that significantly differentiated them from women who were not patients-a lower sense of agency and relatedness. What significantly differentiated the anorexia-nervosa patients from the other psychiatric patients, as well as from the nonpatients, were a heightened and harsh self-reflectivity and more openly expressed depressive and anxious affect in the self-descriptions. The implications for treatment and for understanding eating disorders are discussed.

The heuristic system. Precision and creativity in addiction treatment

The Heuristic System (HS) is a method of developing case formulations for use in addiction treatment. Pertinent guidelines, models, or rules of thumb (heuristics) are applied in a stepwise process in order to generate at least two competing or complementary hypotheses concerning the clinical dynamics of the case. These hypothesis are then integrated and/or their relative utility for use in treatment is appraised. Key elements of HS include (a) a model of addiction based on cycles of self-experience, (b) a structured method for arriving at clinical problem formulations, (c) a schematic of the recovery process, (d) a menu of fundamental principles of substance abuse treatment, and (e) a format for providing updatable guidance to the patient for use in treatment. A case developed from the HS approach is presented. This article concludes with a discussion of the implications of HS theory and methods for program design and research.

Early childhood trauma and disorders of extreme stress as predictors of treatment outcome with chronic posttraumatic stress disorder

History of early childhood trauma was prevalent and highly correlated with Disorders of Extreme Stress Not Otherwise Specified (DESNOS) in a sample of veterans in inpatient treatment for chronic posttraumatic stress disorder (PTSD). DESNOS predicted reliable change on a variety of measures of psychiatric symptomatology (including PTSD) and psychosocial functioning independently of the effects of PTSD diagnosis and early childhood trauma history. DESNOS also predicted treatment outcome on PTSD and quality of life measures after controlling for the effects of ethnicity, war zone trauma exposure severity, initial level of symptomatic severity or quality of life, Axis I (PTSD and major depression) and Axis II (personality disorder) diagnostic status, and early childhood trauma history. Early childhood trauma was not predictive of outcome. DESNOS appears to play an important role in assessment and treatment planning for psychotherapeutic rehabilitation of chronic PTSD.