BABCP spring meeting: collaborative case conceptualization - cross-sectional & longitudinal (second post)
Last updated on 27th April 2010
Yesterday, in "BABCP spring meeting, first post", I described my initial thoughts arriving at the "Collaborative case conceptualization" workshop. Well, now it's Friday morning. A very social time yesterday evening after the workshop. Slept on a friend's couch. It's fairly bright and early now and their kids haven't yet emerged. How was yesterday's workshop?
It was good. Interesting. A pleasure to spend a day with two experienced, thoughtful, caring clinician/researchers. I suppose the most important question for me is how do I want the workshop to inform or change my practice? I feel comfortable "cherry picking" the model that was presented. As I'd guessed yesterday, there doesn't seem to be any particularly good direct evidence as yet that "When done well conceptualization empowers clients and increases CBT's effectiveness." There are good indirect reasons for suspecting that this is so. And I take my hat off to Willem Kuyken - back in 2003, he and Peter Bieling had looked seriously at this question in a paper entitled "Is cognitive case formulation science or science fiction?". They concluded that it was science fiction! That's a bit mean, but they did state - amongst other things - that "In terms of the scientific status of the cognitive case formulation process, current evidence for the reliability of the cognitive case formulation method is modest, at best. There is a striking paucity of research examining the validity of cognitive case formulations or the impact of cognitive case formulation on therapy outcome." And I saw no evidence that more recent research has changed this picture.
As I've said though, there are good indirect reasons for suspecting that aspects of this "Collaborative conceptualization" model probably would be helpful to incorporate into my current practice. The three key principles we were presented with were "Collaborative empiricism, incorporation of client strengths, and levels of conceptualization". Starting with the last of these principles - levels of conceptualization - it seems reasonable to begin therapy using the better-supported CBT approaches that target recent or current precipitating and maintaining factors. The Kuyken et al model classifies conceptualizations as descriptive (focusing on the presenting issues), cross-sectional (looking at triggers and maintaining factors), and longitudinal (exploring longer term protective and predisposing factors). The recommendation is to work with descriptive and cross-sectional conceptualizations first and only add a more historical longitudinal conceptualization further into the therapy if it seems needed to boost outcome. I already do this, often saying to clients something like "I don't want to engage in emotional archaeology for its own sake. If you're managing to get where you want to go to, with us working on present and future issues, that's fine. If a bit further down the line, you're not making progress as fast as we expect then we'll look at boosting what we're doing. One of the options we would then consider would be looking at whether effects of past experiences are holding you back. We'll work on this kind of 'ball and chain around your ankle' issue if we need to. The research suggests that - more often than not - this won't be necessary."
This kind of approach flows naturally from a general internal direction I work with - to try to help with a particular problem first by using therapies that are backed by better research evidence, and typically only move on to using less well-supported therapies when first line approaches aren't achieving good enough results. This means that using CBT for Axis I disorders like depression and anxiety is going to first involve currently well-validated approaches like behavioural activation for depression or Clark & Salkovskis' cognitive therapy for panic. Usually I would only consider adding less well-researched methods focusing on earlier life experience - for example imagery rescripting for social anxiety - when first line approaches aren't doing as well as I would want. This focus-initially-on-the-present attitude clearly isn't appropriate for some Axis I disorders like PTSD, and it may not be such a good general rule when working with long term Axis II personality disorder problems. This is partly because more straightforward CBT approaches are much less researched for these kinds of long term patterns. Where good research has been done - for example with Arnoud Arntz & colleagues' schema-focused CBT for borderline personality disorder - it actually seems perfectly reasonable to work the other way round, from an early longitudinal conceptualization forward to more present/future focused work. See, for example, Arntz's paper "Effectiveness of treatment of childhood memories in cognitive therapy for personality disorders: A controlled study contrasting methods focusing on the present and methods focusing on childhood memories". In this study starting with the past and moving to the present was as effective as starting in the present and moving to the past - and both clients and therapists preferred the past to present order.
On reflection, maybe even this start-with-better-validated-more-present-time-focused-methods with Axis I disorders like depression and feel freer to start with past-focused longitudinal conceptualizations with Axis II personality problems isn't as straightforward as it looks. So Zimmerman et al's 2008 paper "The frequency of personality disorders in psychiatric patients" concludes that "Diagnosing co-occuring personality disorders in psychiatric patients with an Axis I disorder is clinically important because of their association with the duration, recurrence, and outcome of Axis I disorders. This article reviews clinical epidemiological studies of personality disorders and finds that in studies using semi-structured diagnostic interviews, approximately half of the patients interviewed have a personality disorder. Thus, as a group, personality disorders are among the most frequent disorders treated by psychiatrists." And this is important as Newton-Howes et al's 2006 systematic review "Personality disorder and the outcome of depression: meta-analysis of published studies" found - "Comorbid personality disorder with depression was associated with a doubling of the risk of a poor outcome for depression compared with no personality disorder." So maybe with difficult cases of depression, the question as to whether to start with present-focused cross-sectional or past-focused longitudinal conceptualizations is still very much an open one?
Tomorrow, in "BABCP spring meeting, third post", I look at the two further key principles introduced in this workshop - collaborative empiricism and incorporation of client strengths.