Case Formulation and the Therapeutic Alliance in Contemporary Problem-Solving Therapy (PST) Christine Maguth Nezu, Arthur M. Nezu, and Meghan M. Colosimo Drexel University In addition to providing psychoeducation and sharing clinical explanations and treatment goals, case formulation serves as a potential mechanism by which therapists may facilitate an alliance with their patients. This article illustrates how a case formulation shared with a patient early in the process of contemporary problem-solving therapy (PST) may yield both a road map to treatment and a means to build and adapt a therapeutic alliance based on patient attributes. We provide a description of a clinical case in which PST was carried out with a woman who, in the midst of alcohol recovery, experienced C 2015 Wiley Periodicals, Inc. J. Clin. Psychol.: symptoms of anxiety, depression, and binge eating. In Session 71:428–438, 2015. Keywords: therapeutic alliance; problem-solving therapy; case formulation; contemporary PST
A growing body of research supports the significant association between the therapeutic relationship and psychotherapy outcome. For example, a meta-analysis of 79 studies indicated a moderate but consistent effect between therapeutic alliance and therapy outcome (Martin, Garske, & Davis, 2000). Another review of the research literature concluded that improvement in psychotherapy “may best be accomplished by learning to improve one’s ability to relate to clients and tailoring that relationship to individual clients” (Lambert & Bartley, 2001, p. 357). Our use of the term therapeutic alliance refers to the collaborative relationship between a patient and therapist as they engage in a common path toward overcoming the patient’s self-defeating behavior or self-engendered obstacles toward attaining his or her life goals. In a meta-analysis of 201 research reports spanning 14,000 treatments, Horvath, Del Re, Fluckiger, and Symonds (2011) reported a moderate but robust and highly reliable relationship between alliance and psychotherapeutic outcome. Horvath and colleagues concluded that a strong alliance is required for successful therapy and that the development of an alliance is not separate from the inventions employed but rather intertwined in the therapeutic process. Horvath et al. (2011) also noted that a case formulation in the early stages of psychotherapy is important to building the alliance: “Bridging the client’s expectations and personal resources and what the therapist believes to be the most appropriate intervention is an important and delicate task. Alliance emerges, in part, as a result of the smooth coordination of these elements” (p. 15). For example, to facilitate a collaborative engagement, a case formulation can serve as a road map for both client and therapist to construct on the journey they will embark on together. Based on the results of a subsequent, multilevel, longitudinal meta-analysis, Fluckiger, Del Re, Wampold, Symonds, and Horvath (2012) found that the quality of the alliance, particularly in the early stages of treatment, was significantly associated with outcome across intervention type, including manualized treatments, for specific disorders. Fluckiger et al.’s (2012) conclusions created the impetus for this article, which describes how the therapeutic alliance with a patient treated with contemporary problem-solving therapy (PST) was enhanced by providing a case formulation in the early stages of treatment. After a brief description of PST, we will provide a case illustration.
Please address correspondence to: Christine Maguth Nezu, ABPP, Nezu Psychological Associates, 123 S Broad Street, Suite 2040, Philadelphia, PA, 19109. E-mail: [email protected] C 2015 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 71(5), 428–438 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22179
Case Formulation and the Therapeutic Alliance
429
Contemporary PST PST is a psychosocial intervention historically developed within a cognitive-behavioral therapy framework. Specifically, this treatment approach was initially developed to teach individuals a set of cognitive and behavioral skills, often referred to as tools, aimed at enhancing their ability to more effectively cope with a variety of life stressors that potentially engender negative health and mental health outcomes. More recent work has underscored the role of emotions, early learning experiences, and emotional regulation as equally important elements of PST. Life stressors can involve a wide range of events, including those referred to as major negative life events, such as the death of a loved one, the diagnosis and treatment of a chronic illness, the loss of one’s job, getting incarcerated, or extreme stressors such as experiencing combat during military service. Distress-engendering stressors can also be less severe and involve chronic and cumulative daily problems. These include, for example, continuous tension with coworkers, reduced financial resources, discrimination, or relationship difficulties. As can be inferred from the above-mentioned description, PST is based on a diathesis–stress model of psychopathology. Specifically, PST is theoretically rooted in stress models that are not limited to a cognitive diathesis–stress model; rather, PST takes into account multiple explanations of stress sensitivity, including those derived from neuroscience. According to newly developed models (e.g., Nezu, Nezu, & D’Zurilla, 2013), distal factors, in the form of genetic propensities and early life stress, can produce certain biological vulnerabilities (e.g., increased stress sensitivity leading to lowered thresholds for triggering depressive reactions later in life) and psychosocial vulnerabilities (e.g., lack of opportunity to develop effective problem solving skills due to overtaxed efforts to cope) that make one more susceptible to negative health outcomes. Thus, various biological, psychological, and sociocultural variables influence individuals’ vulnerabilities to stress and social problem solving (SPS) abilities. A basic tenet of PST is that much of what is conceptualized as psychopathology and behavioral difficulties, including significant emotional problems, is a function of ineffective coping with life stress. Conceptually, teaching people to become more effective problem solvers is proposed to eventuate in decreased physical and mental health problems. Therefore, the overarching aim of PST is to foster the adoption and effective implementation of certain adaptive problem-solving attitudes (i.e., optimism, enhanced self-efficacy, awareness, and acceptance of one’s emotional experience) and behaviors (i.e., adaptive emotional regulation and planful problem solving) as a means of reducing distress and improving overall wellbeing. The techniques and strategies patients learn regarding increased emotional regulation and planful problem solving combine to build an improved resilience to stress. While some techniques employed in PST are similar to other cognitive, behavioral, and mindfulness-based therapies, the intervention is unique in that it is framed as an opportunity for individuals to learn skills to help them become more effective in their efforts toward reaching their goals and life dreams. Historically, the genesis of PST from a cognitive-behavioral perspective can be traced to D’Zurilla and Goldfried (1971), who developed a model of training for individuals who present with significant challenges in their ability to cope effectively with problems encountered in daily living. Early clinical applications of this model include Nezu’s (1986) adoption of PST to treat adults with major depressive disorder. Since that time, variations of this model have been applied to a wide variety of psychological disorders and medical patient populations (see D’Zurilla & Nezu, 2007, for a review). An adapted version of PST (problem-solving training for primary care patients [PST-PC]) has been extensively evaluated and is highly effective in treating depression ¨ among primary care patients (e.g., Unutzer et al., 2001). PST has also been demonstrated to be an efficacious approach in helping caregivers of a variety of medical patient populations, including individuals with stroke, traumatic brain injury, cancer, and dementia. It has also been applied as a means of enhancing one’s adherence to other psychosocial interventions (Perri, et al., 2001). While PST interventions are not tied to specific models that explain the etiology, maintenance, and treatment of many Diagnostic and Statistical Manual of Mental Disorder disorders, based upon its demonstrated effectiveness, it is now viewed as a transdiagnostic system of psychotherapy.
430
Journal of Clinical Psychology: In Session, May 2015
In tandem with these research efforts, Nezu as well as colleagues (2013) have continuously revised and updated the basic PST model to incorporate new findings from the PST outcome literature and basic research from affective neuroscience, cognitive psychology, and abnormal psychology. These refinements, reflecting what we refer to as “contemporary PST” (e.g., Nezu, Nezu, & D’Zurilla, 2013), have led to an enhanced adaptation of this therapy for individualized case formulation. These changes have also led to an enhanced, more collaborative case formulation that has, in turn, led to an enhanced, more effective working alliance. In providing an overview of PST, it is important to note that some theorists and researchers have mistakenly equated “problem-solving therapy” with training exclusively in specific rational or planful problem-solving skills (e.g., defining a problem, generating alternative solutions, decision making, solution implementation, and evaluation). They have not taken into account the cognitive–affective context surrounding problems in real-life (as compared to “intellectual”) problems. It is our observation that this limited application suggests a limited use of PST case formulation. The cognitive–affective elements of PST have been referred to as one’s problem orientation (PO). PO refers to the set of relatively stable cognitive–affective schemas that represent individuals’ generalized beliefs, attitudes, and emotional reactions about problems in living and their ability to successfully cope with such problems. Failing to address how this orientation affects one’s ability to cope with real-life problems can render actual problem-solving attempts less effective (Nezu & Perri, 1989). In fact, two meta-analyses that have found PST to be an effective intervention for a wide variety of psychological problems, particularly depression, further noted that programs including components that foster a positive PO fared significantly better than those PST protocols that included training only in rational problem-solving skills (Bell & D’Zurilla, 2009; Malouff, Thorsteinsson, & Schutte, 2007).
SPS As noted above, PST focuses on helping individuals cope more effectively with real-life problems. As noted earlier, the process by which people attempt to handle or solve such problems is referred to as social problem solving to distinguish it from the type of processes involved in solving more basic cognitive or intellectual problems. We have defined SPS as the process by which people attempt to identify, discover, or create adaptive means of coping with a wide variety and range of stressful problems, both acute and chronic, encountered during the course of daily living (D’Zurilla & Nezu, 2007). More specifically, SPS reflects the process whereby people direct their coping efforts at altering the problematic nature of a given stressful situation, their reactions to such problems, or both. Rather than representing a singular type of coping behavior or activity, SPS represents the multidimensional, meta-process of ideographically identifying and selecting various coping responses to implement, to adequately address the unique features of a given stressful situation at a given time (Nezu, 2004). According to our model, problem solving is conceived of as a broad and versatile coping strategy in that problem-solving goals are not limited to mastery goals. Rather, goals can include those that are problem-focused and emotion-focused, depending on the nature of the particular problematic situation and how it is defined and appraised. It is likely that most problems that are particularly stressful require both types of goals to be identified. As such, patients learn how to identify (a) their own problem-solving strengths and weaknesses and (b) both emotion- and problem-focused aspects of a challenging problem or personal goal.
A Multidimensional Model of SPS According to contemporary SPS theory, two general but partially independent dimensions– PO and problem-solving style (D’Zurilla, Nezu, & Maydeu-Olivares, 2004)–influence problemsolving outcomes. PO represents the set of cognitive–affective schemas regarding people’s generalized beliefs, attitudes, and emotional reactions concerning real-life problems and their ability to successfully cope with such difficulties. Originally thought of as being two ends of the same
Case Formulation and the Therapeutic Alliance
431
continuum, research during the past several years has continued to characterize the two forms of POs as operating mostly independent of each other (Nezu, 2004). These two orientation components are positive PO and negative PO. A positive PO involves the tendency for individuals to
r r r r r
perceive problems as challenges rather than major threats to one’s well-being, be optimistic in believing that problems are solvable, have a strong sense of self-efficacy regarding their ability to handle difficult problems, believe that successful problem solving usually involves time and effort, and view negative emotions as important sources of information that are necessary to tune into for effective problem solving. A negative PO refers to the tendency of individuals to
r r r r r
view problems as major threats to one’s well-being, generally perceive problems to be unsolvable, view negative emotions as threatening and overwhelming, maintain doubts about their ability to cope with problems successfully, and become particularly frustrated and upset when faced with problems or when they experience negative emotions.
As their content suggests, both types of orientations can have a strong influence on people’s motivation, either positive or negative, and their ability to engage in focused attempts to solve problems and cope with stress. The importance of addressing the quality and valence of one’s dominant orientation within a given context is considered a key component of the overall PST approach. The second major dimension, problem-solving style, refers to the core cognitive-behavioral activities that people engage in when attempting to solve stressful problems. Three differing styles have been identified (D’Zurilla, Nezu, & Maydeu-Olivares, 2002; D’Zurilla et al., 2004): rational problem solving (now often referred to as “planful problem solving”; Nezu et al., 2013); avoidant problem solving; and impulsive–careless problem solving. Planful problem solving is the constructive approach that involves the systematic and planful application of the following set of specific skills:
r r r r
Problem definition: Clarifying the nature of a problem, delineating a realistic set of problemsolving goals and objectives, and identifying and validating the obstacles that prevent one from reaching such goals Generation of alternatives: Brainstorming a range of possible solution strategies geared to overcome the identified obstacles Decision making: Predicting the likely consequences of the various alternatives, conducting a cost-benefit analysis based on these identified outcomes, and developing a solution plan that is geared to achieve the problem-solving goal while simultaneously overcoming the obstacles that are present Solution implementation and verification: Carrying out the solution plan, monitoring and evaluating the consequences of such a plan, and determining whether one’s problem-solving efforts have been successful or need to continue.
During the process of mutual identification of obstacles or barriers to the patient’s goals, the therapist provides acknowledgement and validation of each obstacle (lack of financial resources, lack of time, specific fears, motivation, etc.). Indeed, it is the obstacles that must be considered when one begins to generate ideas of possible solutions. This is one example of an important philosophy of PST, specifically, that the patient selects the goals, the barriers are validated as authentic and respected as challenging, and the alternatives are brainstormed as ways in which the patient may get closer to the goal while attempting to get around, over, or through his or her unique barriers.
432
Journal of Clinical Psychology: In Session, May 2015
In addition to planful problem solving, two social problem-solving styles have been identified, both of which, in contrast, are typically dysfunctional or maladaptive. An impulsive/careless style is the problem-solving approach whereby an individual tends to engage in impulsive, hurried, and careless attempts at problem resolution, often attempting to control negative thoughts and feelings. Avoidant problem solving is the maladaptive problem-solving style characterized by procrastination, passivity, and overdependence on others to provide solutions, often to avoid negative feelings and thoughts. Both styles are associated with ineffective or unsuccessful coping. Moreover, people who typically engage in these styles tend to worsen existing problems and even create new ones. It is important to note that these styles do not represent personality “traits.” Rather, each represents a strong tendency to either view or react to problems from a particular perspective based on one’s learning experiences. For example, it is possible (and common in our clinical experience) for individuals to be characterized as having a positive PO when dealing with problems related to achievements goals, such as those involving work or career while concomitantly adopting a negative PO when addressing affiliation themes, such as those involving romantic or family relationships. The opposite can be true as well. The five-component model of SPS (i.e., positive PO, negative PO, planful problem-solving style, avoidance style, and impulsive/careless style) has been cross-validated across various populations, ethnic minority cultures, and age groups; Nezu, 2007). It is also important to underscore that PST is conceptualized as an intervention that is particularly flexible in nature. This flexibility allows for the clinician’s goals and treatment plan to rest on the case formulation conducted during assessment and to be adapted specifically for the patient, rather than on the dictates of a manual.
Assessment in PST The three basic categories of clinical assessment of problem solving are as follows:
r r r
Assessment of problem-solving abilities and attitudes Assessment of current problem-solving activities Assessment of problems experienced by a given patient
These attitudes and skills are best assessed through a combination of quantitative measurement, clinical interview, understanding of learning history, and observation of the ways in which the patient has attempted to solve the problems that he or she is experiencing. Assessing these three basic categories allows for an evaluation as well as a possible explanation of a patient’s problem-solving strengths and weaknesses; it is also critical in determining whether PST is a useful intervention for a given individual. Moreover, when a therapist shares his or her view of the ways in which patients have learned to manage their difficulties in the context of their past learning history and expresses hope that they may learn to get closer to their valued goals, the alliance is invariably strengthened.
Social Problem-Solving Inventory-Revised A measure that was developed to address the assessment goals described above is the Social Problem-Solving Inventory-Revised (SPSI-R; D’Zurilla et al., 2002). This Likert-type inventory contains 52 items and provides a total score, as well as five major scale scores (described below), that map onto the two PO dimensions and the three problem-solving styles previously described. The five major scales are as follows:
r r
Positive Problem Orientation Scale (PPO; five items; e.g., “Whenever I have a problem, I believe it can be solved”) Negative Problem Orientation Scale (NPO; 10 items; e.g., “Difficult problems make me very upset”)
Case Formulation and the Therapeutic Alliance
r
r r
433
Rational Problem-Solving Scale (RPS; 20 items; e.g., “Before I try to solve a problem, I set a specific goal so that I know exactly what I want to accomplish”). The items are further divided into four subscales (each with five items), corresponding to the four planful problem-solving skills: Problem Definition and Formulation (PDF), Generation of Alternatives (GOA), Decision Making (DM), and Solution Implementation and Verification (SIV). Impulsivity/Carelessness Style Scale (ICS; 10 items; e.g., “When I am attempting to solve a problem, I act on the first idea that comes to mind”) Avoidance Style Scale (AS; seven items; e.g., “I wait to see if a problem will resolve itself first before trying to solve it myself”)
The SPSI-R has strong psychometric properties (see SPSI-R test manual, D’Zurilla et al., 2002), including strong structural, concurrent, predictive, convergent, and discriminant validity. The SPSI-R, along with the clinical interview, examples of current problem areas, psychosocial history, and other measures of mental health functioning can provide specific information toward a clinical case formulation featuring a detailed “profile” of an individual’s characteristic way of reacting to, and then attempting to solve, the stressful problems he or she confronts in life. Furthermore, we have found that therapists who embrace the use of principles and strategies of PST in their own lives—demonstrating their confidence in the intervention and a respect for the challenges of solving real-life problems–communicate a genuineness that enhances the therapeutic alliance.
Case Formulation Example We will present the case of Shannon (all identifying information has been changed to protect her confidentiality), who underwent a PST approach to treatment with one of the authors (CMN). This case is presented to provide a clinical context for explaining how one’s individualized case formulation, with a specific focus on a clinical problem-solving assessment, can provide a map for treatment, as well as a potentially strong bridge to the therapeutic alliance. Shannon, a 25-year-old woman, stated her referral problems as: “I’ve reached a point where I need to reevaluate what I want to do with my life and change some of my habits toward a better life.” She described experiencing anxiety and depression. She made the commitment 3 months prior to attending treatment to stop drinking alcohol completely, after a weekend of heavy drinking and a subsequent blackout. The day after this blackout, Shannon had experienced a sense of detachment, frightening sensory experiences (e.g., hypervigilance and seeing movement out of the corner of her eye), concentration difficulties, panic, and a fear of losing control of her thoughts. She stated that her problems began during adolescence and continued in college. Her college years were described as a time of minimal studying, the choice of an “easy major,” and weekends of partying. Her postcollege employment was not stable, and she described herself as drifting from job to job. Shannon would exercise responsibility at work during the week, followed by socializing with friends and heavy drinking on weekends. She stated that her friends were also heavy drinkers and enjoyed activities such as playing board games or cards. She also reported that she had almost no sober sexual relationships; rather, she had occasional brief sexual encounters while drinking, mostly during blackouts. Over the 3 months since Shannon stopped drinking and remained abstinent, she attended meetings of Alcoholics Anonymous, but considered the organizational culture a poor match for her. She enlisted the support of a sister and close friend as her way to successfully maintain her sobriety. Over the last few months, her limited episodes of panic and sensory hallucinatory experiences had diminished. However, her fears concerning loss of control, anhedonia, and low motivation remained challenging for her. Additionally, she started to engage in binge-eating episodes, which she thought might be a replacement for her previous alcohol abuse on weekends. She also began to mistrust her roommate, with whom she used to drink. Shannon was particularly concerned when, after drinking, her roommate would bring men over to the apartment for sexual activity. Despite
434
Journal of Clinical Psychology: In Session, May 2015
her unease and concern about her roommate’s allowing unfamiliar men into their apartment, Shannon was unable to assert her worries to her roommate. Shannon worked as an administrative assistant for a biotechnology company and reported that she experienced little reward for her work. Despite her evaluation of the work as boring, and her relationships with coworkers as detached, she performed her duties relatively well and was rarely absent. Her few friendships outside of work had remained the same, although she stated that she was drifting from these friends and feeling lonely because she no longer frequented the neighborhood bar where they congregated on Friday evenings. In spite of having very few social supports, she did note that her relationship with her older sister and a male friend provided her with some sense of safety and enjoyment. She described her family background as “good” and remembered herself as initially a “basically happy kid,” recalling family activities such as camping trips. However, Shannon also described the family home as having an undercurrent of tension between her parents. When she was in high school, her parents divorced, maintaining residences in close proximity for several years, and then later remarrying.
Shannon’s Assessment and Case Formulation Shannon’s comprehensive assessment included a series of clinical interviews, communication with her primary care physician, several diagnostic screening measures, psychological testing, symptom checklists, and the SPSI-R. The results of this evaluation indicated that Shannon met criteria for generalized anxiety disorder with a history of alcohol abuse; she also experienced subclinical levels of depression. In addition, she reported periodic binge-eating episodes and was concerned about her weight. While her primary care physician reported her overall health as “good,” she also noted that Shannon smoked approximately one pack of cigarettes per day and had a diagnosis of mild hypertension. Shannon expressed a strong desire to be healthier and live her life without drugs of any kind. Regarding the standardized testing measures, Shannon’s scores confirmed a diagnosis of generalized anxiety disorder. And although not reaching criteria for a personality disorder, her scores on the Minnesota Multiphasic Personality Inventory (MMPI-II; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 2001) suggested a compulsive personality style. Evident from other self-report questionnaires, a structured interview, and unstructured clinical interviews were the presence of life-long schemas reflecting hypervigilance, unrelenting standards for herself, and emotional inhibition, suggesting that her home environment tended to place an emphasis on suppressing feelings, impulses, and independent choices. Further, her family appeared to promote rather rigid rules and expectations. Verbal reports of her early life were consistent with self-report measures, and she conveyed an undercurrent of pessimism and worry in the family home. The SPSI-R revealed specific strengths and vulnerabilities in solving everyday problems. Her positive PO responses were consistent with scores of individuals in the normative, nonpsychiatric group, which reflected her optimism and desire to seek help for the significant symptoms and fears that she was currently experiencing. However, the scores regarding her negative PO were more than two standard deviations above the average normed score, which reflected her significant worry and intense fears of not coping well with life. Her concentration difficulties, feelings of detachment, experiences of depersonalization, and continual worry about her roommate’s behavior when drinking all left her feeling hypervigilant, insecure, and chronically anxious and tearful. Shannon’s scores on the various components of planful problem solving (i.e., the RPS scale score) indicated that she had not only strengths regarding her ability to define problems clearly but also limited abilities concerning flexibility and creativity in generating solutions, weighing alternatives, and following through on intended plans of thoughtful action. One example of the latter was her intention to eat better, organize her home, and exercise. She believed that if she could just “get started” then she would follow through with what she needed to do. However, she reported that her motivation to begin engaging in these activities was very poor. Her total scale score regarding her planful or rational problem-solving ability reflected the cumulative challenges she had regarding these areas, as it was similar to those of psychiatric
Case Formulation and the Therapeutic Alliance
435
outpatient sample groups and showed many deficits. Her scores regarding impulsive/careless responding were a full standard deviation beyond the average nonpsychiatric patient. This was frequently expressed by her attempt to quickly control the emotional reactions of others or her own negative emotions and negative thoughts, only to end up feeling hopeless about remaining in a constant state of worry and tension. In particular, regarding Shannon’s high negative PO and an impulsive/careless style of attempting to solve problems, her history of alcohol abuse and binge eating episodes was not surprising. Finally, her scores regarding avoidant responding were slightly but nonsignificantly above average. Overall, her total problem-solving score was two standard deviations below the average score for nonpsychiatric samples, indicating significant problem-solving deficits and limitations. What was especially striking regarding Shannon’s presentation is that externally she appeared friendly, confident, and socially secure, regardless of her chronic sense of shame regarding her fears, worries, and attempts to hide her flaws. The therapist’s awareness of this level of fragility and impulsive urge to rid herself of negative feelings and thoughts informed the need for a strong focus on the therapeutic alliance early in treatment.
The Collaborative Case Formulation Consistent with our problem-solving philosophy of clinical decision making, Shannon’s therapist shared her case formulation with her. Rather than focusing on the diagnostic labels or descriptions of her difficulties or weaknesses, her therapist presented this case formulation to provide an explanation of Shannon’s “life story.” More specifically, it was explained to Shannon how her early emotional learning experiences and family environment had contributed to the types of implicit emotional and cognitive responses that comprised her reactions to current stressors, as well as her various explicit concerns, triggers, learned behavior, and desire for change. Thus, Shannon was introduced to the view that her early learning had led to her implicit urge to hide or rid herself of negative internal experiences. However, her therapist intentionally reassured her that although awareness and acceptance of her negative internal experiences were important points of information and focal points for treatment, therapy would proceed slowly, with Shannon maintaining the ultimate control over this new exposure. In addition, Shannon’s individual strengths regarding her positive PO were underscored as one initial means of instilling hope and reinforcing constructive approaches to life problems. In sharing her understanding of Shannon’s life story, the therapist also identified possible targets for change that would have the most significant impact on her current overarching goals for treatment. These appeared to be improved management of anxiety, reduction of feelings of interpersonal detachment and sadness, and increased participation in activities associated with her valued life goals. Shannon indicated that she believed that some of her binge-eating episodes were taking the place of her former drinking episodes and that she wanted to add this to the list of problems for which to find solutions. Her therapist reinforced her courage and insight and suggested adding this to the list of problem areas on which to focus during the course of treatment. It was explained to Shannon that, from a PST perspective, her binge eating represented an “ineffective solution” to discomfort. We have found that simultaneously sharing the case formulation with a patient, using an easyto-understand visual depiction or Clinical Pathogenesis Map (CPM; Nezu, Nezu, & Cos, 2007) of the factors influencing her current level of distress, and highlighting how SPS is an important mediator of the stress-distress relationship are useful ways to underscore the relevance of PST for a given individual. The CPM (Nezu et al., 2007) is a graphic depiction of those variables hypothesized to contribute to the initiation and maintenance of a given patient’s difficulties, specifying the functional relationships among each other. It can be viewed as a path analysis or causal modeling diagram idiographically developed for a particular patient. Comprising squares with various factors identified in each one and arrows that lead from one to another, the CPM offers a concrete statement of the therapist’s initial causal hypotheses against which to test alternative hypotheses. As new information is obtained, and various predictions are confirmed or disconfirmed, the CPM can be altered.
436
Journal of Clinical Psychology: In Session, May 2015
The advantage of developing a CPM is to provide a means by which the therapist can “document” his or her hypotheses about the etiopathogenesis of a client’s problems and to share this conceptualization with patients to foster increased understanding. A CPM incorporates the following five elements: (a) distal or developmental learning variables, (b) antecedent variables or stressful triggers, (c) organismic variables such as problem solving abilities or schemas, (d) response variables, and (e) consequential variables. Patients such as Shannon have the opportunity to understand how using effective problem-solving skills and other new learning experiences can affect their ability to effectively manage life problems. In addition, this activity, so collaborative in nature, provides an extra boost to the therapeutic alliance. Shannon responded very positively to hearing her case formulation shared in this manner, reporting that it provided a “different way” of looking at her current problems and symptoms. Moreover, she indicated that she felt reassured that the therapist “listened to and respected” her, attempting to understand how hard she was trying to manage her distress and encouraging her to do the best that she could. While discussing the case formulation, Shannon volunteered additional information, describing that the tension and uncertainty in her childhood home regarding her parents’ disagreements had given her the feeling that “something bad was going to happen,” but not knowing what. As a consequence of this discussion, she began to understand that these early childhood stressful experiences had likely contributed to her current reactivity when under stress. Further, she was able to see how her current attempts at managing the stress in her life, that is, heavy drinking, served to help her avoid, rather than confront, problems. Moreover, she realized that such “ineffective solutions” served only to engender further worries regarding her health and overall well-being and to create new problems. As part of the case formulation, it was explained to Shannon that she had been drinking for so long that she had learned few other ways by which she could begin to challenge her worries, hypervigilance, and avoidance of social confrontation, such as, her current concerns regarding her roommate’s behavior. As Shannon was provided with an explanation of how problem-solving ability was related to stress, she was shown a CPM (described above), a user-friendly diagram of her learning history, current major life stressors, and daily problems. It was suggested to her that these stressors and problems might be alleviated if she learned skills that would enable her to become more aware of and, consequently, more able to manage negative feelings, think planfully, and motivate herself to put more positive strategies into action. This would ultimately involve a new overall learning experience regarding her reactions to herself and others and a different way of coping with life’s problems. Shannon’s reaction to this rationale was positive, indicating that she found this approach helpful, as it provided her with a view of herself as having certain reactive habits, albeit ineffective, that were learned earlier in life, as compared to her initial perceptions of her inability to change. She also realized that by drinking she missed multiple opportunities to learn how to cope more effectively with life’s difficulties. Moreover, she indicated that the case formulation convinced her that she had a future and that she was “not on the brink of a mental crash!” As part of providing a rationale for PST, her therapist also indicated the areas in which it would be important to incorporate techniques and strategies from other interventions in her overall treatment plan. This included mindfulness–based strategies that allowed her to nonjudgmentally observe her internal experiences.
Shannon’s Psychotherapy Outcome Shannon remained in psychotherapy for 16 sessions, which occurred over 6 months. She became increasingly confident in her ability to use her feelings as a guide to what she valued as important goals, and she recognized that negative feelings were an important part of defining problems. One striking change was that Shannon now respected how difficult and challenging her problems were and, in turn, minimized blaming herself for their presence. One turning point for Shannon was when she stated: “I realize that a lot of what I learned was not my fault, but I can be responsible to change the way I deal with problems.”
Case Formulation and the Therapeutic Alliance
437
At the end of treatment, her panic was minimal, her depressive symptoms significantly reduced, and she had become involved in activities to promote her health. These included visiting the gym daily, eating an improved diet, practicing mindfulness meditation, and starting a garden. She had become more assertive with her roommate, although she continued to face challenges in becoming more assertive with her family members. She was promoted to a senior supervisory position at work and was gradually developing a few friendships there. We believe that a potent ingredient of Shannon’s improvement was the therapeutic alliance that was developed during the initial stages of treatment when her therapist shared her case formulation. Specifically, the therapist explained the formulation with user-friendly diagrams in the form of a “clinical map” to obtain initial feedback and, ultimately, established a mutual agreement and consent regarding which treatments to use to work toward therapy goals. This provided a basis for dialogue and resolution of possible obstacles toward the attainment of those goals and “side effects” that might be experienced, such as exposure to negative emotions. Our collective clinical experience is that patients walk away from a case formulation feedback session, as Shannon did, with a greater understanding of and motivation for treatment. Particular considerations in sharing a case formulation with a patient might include restricting the discussion to those aspects deemed most relevant to describing the recommended treatment, asking for validation and feedback from the patient, and using everyday language, rather than scientific jargon. Regarding this last point: Developmental variables can be referred to as “how your background relates to your current problem areas,” mediating mechanisms as “how you tend to react to stressful problems of this type” and behavioral responses as “what you have learned to do when you experience these thoughts or feelings.”
Summary We believe that a case formulation focused on problem-solving strengths and weaknesses can serve as a best practices approach in conducting contemporary PST, specifically by adapting the scientific knowledge regarding SPS to specific client areas most in need of therapeutic intervention. Of equal importance, we believe that the use of a case formulation approach when conducting contemporary PST allows a clinician to adapt and individualize the therapy and to validate and remain respectful to a patient’s obstacles to their goals, thus creating a strong therapeutic alliance.
Selected References and Recommended Readings APA (2013). Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5), American Psychiatric Association. Bell, A. C., & D’Zurilla, T. J. (2009). Problem-solving therapy for depression: A meta-analysis. Clinical Psychology Review, 29, 348–353. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (2001). Minnesota Multiphasic Personality Inventory-2. Minneapolis: University of Minnesota Press. D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78, 107–126. D’Zurilla, T. J., & Nezu, A. M. (2007). Problem-solving therapy: A positive approach to clinical intervention (3rd ed.). New York: Springer. D’Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2002). Manual for the Social Problem-Solving Inventory-Revised. North Tonawanda, NY: Multi-Health Systems. D’Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2004). Social problem solving: Theory and assessment. In E. C. Chang, T. J. D’Zurilla, & L. J. Sanna (Eds.), Social problem solving: Theory, research, and training (pp. 11–27). Washington, DC: American Psychological Association. Falkenstrom, F., Granstrom, F., & Holmqvist, R. (2013). Therapeutic alliance predicts symptoms improvement session by session. Journal of Counseling Psychology, 60(3), 317–328. Fluckiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59(1), 10–17.
438
Journal of Clinical Psychology: In Session, May 2015
Horvath, A. O., Del Re, A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16. Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38(4), 357. Malouff, J. M., Thorsteinsson, E. B., & Schutte, N. S. (2007). The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clinical Psychology Review, 27, 46–57. Martin, J. D., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438–450. Nezu, A. M. (1986). Cognitive appraisal of problem solving effectiveness: Relation to depression and depressive symptoms. Journal of Clinical Psychology, 42, 42–48. Nezu, A. M. (2004). Problem solving and behavior therapy revisited. Behavior Therapy, 35, 1–33. Nezu, A. M., & Nezu, C. M. (Eds.). (1989). Clinical decision making in behavior therapy: A problem-solving perspective. Champaign, IL: Research Press. Nezu, A. M., Nezu, C. M., & Cos, T. A. (2007). Case formulation for the behavioral and cognitive therapies. In T.D. Eells (Ed.), Handbook of psychotherapy case formulation (2nd ed., p. 349). New York: Guilford Press. Nezu, A. M., Nezu, C. M., & D’Zurilla, T. (2013). Problem-solving therapy: A treatment manual. New York: Springer. Nezu, A. M., Nezu, C. M., Friedman, S. H., & Haynes, S. N. (1997). Case formulation in behavior therapy: Problem-solving and functional analytic strategies. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (pp. 368–401). New York: Guilford Press. Nezu, A. M., Nezu, C. M., & Perri, M. G. (1989). Problem-solving therapy for depression: Theory, research, and clinical guidelines. New York: John Wiley & Sons. Nezu, C. M., Martell, C. R., & Nezu, A. M. (2014). Special competencies in cognitive and behavioral psychology. New York: Oxford University Press. Perri, M. G., Nezu, A. M., McKelvey, W. F., Shermer, R. L., Renjilian, D. A., & Viegener, B. J. (2001). Relapse prevention training and problem-solving therapy in the long-term management of obesity. Journal of consulting and clinical psychology, 69, 722–726 ¨ Unutzer, J., Katon, W., Williams, J. W., Callahan, C., Harpole, L., Hunkeler, E. M., . . . Langston, C. A. (2001). Improving primary care for depression in late life: The design of a multicenter randomized trial. Medical Care, 39, 785–799.
A growing body of research supports the significant association between the therapeutic relationship and psychotherapy outcome. For example, a meta-analysis of 79 studies indicated a moderate but consistent effect between therapeutic alliance and therapy outcome (Martin, Garske, & Davis, 2000). Another review of the research literature concluded that improvement in psychotherapy “may best be accomplished by learning to improve one’s ability to relate to clients and tailoring that relationship to individual clients” (Lambert & Bartley, 2001, p. 357). Our use of the term therapeutic alliance refers to the collaborative relationship between a patient and therapist as they engage in a common path toward overcoming the patient’s self-defeating behavior or self-engendered obstacles toward attaining his or her life goals. In a meta-analysis of 201 research reports spanning 14,000 treatments, Horvath, Del Re, Fluckiger, and Symonds (2011) reported a moderate but robust and highly reliable relationship between alliance and psychotherapeutic outcome. Horvath and colleagues concluded that a strong alliance is required for successful therapy and that the development of an alliance is not separate from the inventions employed but rather intertwined in the therapeutic process. Horvath et al. (2011) also noted that a case formulation in the early stages of psychotherapy is important to building the alliance: “Bridging the client’s expectations and personal resources and what the therapist believes to be the most appropriate intervention is an important and delicate task. Alliance emerges, in part, as a result of the smooth coordination of these elements” (p. 15). For example, to facilitate a collaborative engagement, a case formulation can serve as a road map for both client and therapist to construct on the journey they will embark on together. Based on the results of a subsequent, multilevel, longitudinal meta-analysis, Fluckiger, Del Re, Wampold, Symonds, and Horvath (2012) found that the quality of the alliance, particularly in the early stages of treatment, was significantly associated with outcome across intervention type, including manualized treatments, for specific disorders. Fluckiger et al.’s (2012) conclusions created the impetus for this article, which describes how the therapeutic alliance with a patient treated with contemporary problem-solving therapy (PST) was enhanced by providing a case formulation in the early stages of treatment. After a brief description of PST, we will provide a case illustration.
Please address correspondence to: Christine Maguth Nezu, ABPP, Nezu Psychological Associates, 123 S Broad Street, Suite 2040, Philadelphia, PA, 19109. E-mail: [email protected] C 2015 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 71(5), 428–438 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22179
Case Formulation and the Therapeutic Alliance
429
Contemporary PST PST is a psychosocial intervention historically developed within a cognitive-behavioral therapy framework. Specifically, this treatment approach was initially developed to teach individuals a set of cognitive and behavioral skills, often referred to as tools, aimed at enhancing their ability to more effectively cope with a variety of life stressors that potentially engender negative health and mental health outcomes. More recent work has underscored the role of emotions, early learning experiences, and emotional regulation as equally important elements of PST. Life stressors can involve a wide range of events, including those referred to as major negative life events, such as the death of a loved one, the diagnosis and treatment of a chronic illness, the loss of one’s job, getting incarcerated, or extreme stressors such as experiencing combat during military service. Distress-engendering stressors can also be less severe and involve chronic and cumulative daily problems. These include, for example, continuous tension with coworkers, reduced financial resources, discrimination, or relationship difficulties. As can be inferred from the above-mentioned description, PST is based on a diathesis–stress model of psychopathology. Specifically, PST is theoretically rooted in stress models that are not limited to a cognitive diathesis–stress model; rather, PST takes into account multiple explanations of stress sensitivity, including those derived from neuroscience. According to newly developed models (e.g., Nezu, Nezu, & D’Zurilla, 2013), distal factors, in the form of genetic propensities and early life stress, can produce certain biological vulnerabilities (e.g., increased stress sensitivity leading to lowered thresholds for triggering depressive reactions later in life) and psychosocial vulnerabilities (e.g., lack of opportunity to develop effective problem solving skills due to overtaxed efforts to cope) that make one more susceptible to negative health outcomes. Thus, various biological, psychological, and sociocultural variables influence individuals’ vulnerabilities to stress and social problem solving (SPS) abilities. A basic tenet of PST is that much of what is conceptualized as psychopathology and behavioral difficulties, including significant emotional problems, is a function of ineffective coping with life stress. Conceptually, teaching people to become more effective problem solvers is proposed to eventuate in decreased physical and mental health problems. Therefore, the overarching aim of PST is to foster the adoption and effective implementation of certain adaptive problem-solving attitudes (i.e., optimism, enhanced self-efficacy, awareness, and acceptance of one’s emotional experience) and behaviors (i.e., adaptive emotional regulation and planful problem solving) as a means of reducing distress and improving overall wellbeing. The techniques and strategies patients learn regarding increased emotional regulation and planful problem solving combine to build an improved resilience to stress. While some techniques employed in PST are similar to other cognitive, behavioral, and mindfulness-based therapies, the intervention is unique in that it is framed as an opportunity for individuals to learn skills to help them become more effective in their efforts toward reaching their goals and life dreams. Historically, the genesis of PST from a cognitive-behavioral perspective can be traced to D’Zurilla and Goldfried (1971), who developed a model of training for individuals who present with significant challenges in their ability to cope effectively with problems encountered in daily living. Early clinical applications of this model include Nezu’s (1986) adoption of PST to treat adults with major depressive disorder. Since that time, variations of this model have been applied to a wide variety of psychological disorders and medical patient populations (see D’Zurilla & Nezu, 2007, for a review). An adapted version of PST (problem-solving training for primary care patients [PST-PC]) has been extensively evaluated and is highly effective in treating depression ¨ among primary care patients (e.g., Unutzer et al., 2001). PST has also been demonstrated to be an efficacious approach in helping caregivers of a variety of medical patient populations, including individuals with stroke, traumatic brain injury, cancer, and dementia. It has also been applied as a means of enhancing one’s adherence to other psychosocial interventions (Perri, et al., 2001). While PST interventions are not tied to specific models that explain the etiology, maintenance, and treatment of many Diagnostic and Statistical Manual of Mental Disorder disorders, based upon its demonstrated effectiveness, it is now viewed as a transdiagnostic system of psychotherapy.
430
Journal of Clinical Psychology: In Session, May 2015
In tandem with these research efforts, Nezu as well as colleagues (2013) have continuously revised and updated the basic PST model to incorporate new findings from the PST outcome literature and basic research from affective neuroscience, cognitive psychology, and abnormal psychology. These refinements, reflecting what we refer to as “contemporary PST” (e.g., Nezu, Nezu, & D’Zurilla, 2013), have led to an enhanced adaptation of this therapy for individualized case formulation. These changes have also led to an enhanced, more collaborative case formulation that has, in turn, led to an enhanced, more effective working alliance. In providing an overview of PST, it is important to note that some theorists and researchers have mistakenly equated “problem-solving therapy” with training exclusively in specific rational or planful problem-solving skills (e.g., defining a problem, generating alternative solutions, decision making, solution implementation, and evaluation). They have not taken into account the cognitive–affective context surrounding problems in real-life (as compared to “intellectual”) problems. It is our observation that this limited application suggests a limited use of PST case formulation. The cognitive–affective elements of PST have been referred to as one’s problem orientation (PO). PO refers to the set of relatively stable cognitive–affective schemas that represent individuals’ generalized beliefs, attitudes, and emotional reactions about problems in living and their ability to successfully cope with such problems. Failing to address how this orientation affects one’s ability to cope with real-life problems can render actual problem-solving attempts less effective (Nezu & Perri, 1989). In fact, two meta-analyses that have found PST to be an effective intervention for a wide variety of psychological problems, particularly depression, further noted that programs including components that foster a positive PO fared significantly better than those PST protocols that included training only in rational problem-solving skills (Bell & D’Zurilla, 2009; Malouff, Thorsteinsson, & Schutte, 2007).
SPS As noted above, PST focuses on helping individuals cope more effectively with real-life problems. As noted earlier, the process by which people attempt to handle or solve such problems is referred to as social problem solving to distinguish it from the type of processes involved in solving more basic cognitive or intellectual problems. We have defined SPS as the process by which people attempt to identify, discover, or create adaptive means of coping with a wide variety and range of stressful problems, both acute and chronic, encountered during the course of daily living (D’Zurilla & Nezu, 2007). More specifically, SPS reflects the process whereby people direct their coping efforts at altering the problematic nature of a given stressful situation, their reactions to such problems, or both. Rather than representing a singular type of coping behavior or activity, SPS represents the multidimensional, meta-process of ideographically identifying and selecting various coping responses to implement, to adequately address the unique features of a given stressful situation at a given time (Nezu, 2004). According to our model, problem solving is conceived of as a broad and versatile coping strategy in that problem-solving goals are not limited to mastery goals. Rather, goals can include those that are problem-focused and emotion-focused, depending on the nature of the particular problematic situation and how it is defined and appraised. It is likely that most problems that are particularly stressful require both types of goals to be identified. As such, patients learn how to identify (a) their own problem-solving strengths and weaknesses and (b) both emotion- and problem-focused aspects of a challenging problem or personal goal.
A Multidimensional Model of SPS According to contemporary SPS theory, two general but partially independent dimensions– PO and problem-solving style (D’Zurilla, Nezu, & Maydeu-Olivares, 2004)–influence problemsolving outcomes. PO represents the set of cognitive–affective schemas regarding people’s generalized beliefs, attitudes, and emotional reactions concerning real-life problems and their ability to successfully cope with such difficulties. Originally thought of as being two ends of the same
Case Formulation and the Therapeutic Alliance
431
continuum, research during the past several years has continued to characterize the two forms of POs as operating mostly independent of each other (Nezu, 2004). These two orientation components are positive PO and negative PO. A positive PO involves the tendency for individuals to
r r r r r
perceive problems as challenges rather than major threats to one’s well-being, be optimistic in believing that problems are solvable, have a strong sense of self-efficacy regarding their ability to handle difficult problems, believe that successful problem solving usually involves time and effort, and view negative emotions as important sources of information that are necessary to tune into for effective problem solving. A negative PO refers to the tendency of individuals to
r r r r r
view problems as major threats to one’s well-being, generally perceive problems to be unsolvable, view negative emotions as threatening and overwhelming, maintain doubts about their ability to cope with problems successfully, and become particularly frustrated and upset when faced with problems or when they experience negative emotions.
As their content suggests, both types of orientations can have a strong influence on people’s motivation, either positive or negative, and their ability to engage in focused attempts to solve problems and cope with stress. The importance of addressing the quality and valence of one’s dominant orientation within a given context is considered a key component of the overall PST approach. The second major dimension, problem-solving style, refers to the core cognitive-behavioral activities that people engage in when attempting to solve stressful problems. Three differing styles have been identified (D’Zurilla, Nezu, & Maydeu-Olivares, 2002; D’Zurilla et al., 2004): rational problem solving (now often referred to as “planful problem solving”; Nezu et al., 2013); avoidant problem solving; and impulsive–careless problem solving. Planful problem solving is the constructive approach that involves the systematic and planful application of the following set of specific skills:
r r r r
Problem definition: Clarifying the nature of a problem, delineating a realistic set of problemsolving goals and objectives, and identifying and validating the obstacles that prevent one from reaching such goals Generation of alternatives: Brainstorming a range of possible solution strategies geared to overcome the identified obstacles Decision making: Predicting the likely consequences of the various alternatives, conducting a cost-benefit analysis based on these identified outcomes, and developing a solution plan that is geared to achieve the problem-solving goal while simultaneously overcoming the obstacles that are present Solution implementation and verification: Carrying out the solution plan, monitoring and evaluating the consequences of such a plan, and determining whether one’s problem-solving efforts have been successful or need to continue.
During the process of mutual identification of obstacles or barriers to the patient’s goals, the therapist provides acknowledgement and validation of each obstacle (lack of financial resources, lack of time, specific fears, motivation, etc.). Indeed, it is the obstacles that must be considered when one begins to generate ideas of possible solutions. This is one example of an important philosophy of PST, specifically, that the patient selects the goals, the barriers are validated as authentic and respected as challenging, and the alternatives are brainstormed as ways in which the patient may get closer to the goal while attempting to get around, over, or through his or her unique barriers.
432
Journal of Clinical Psychology: In Session, May 2015
In addition to planful problem solving, two social problem-solving styles have been identified, both of which, in contrast, are typically dysfunctional or maladaptive. An impulsive/careless style is the problem-solving approach whereby an individual tends to engage in impulsive, hurried, and careless attempts at problem resolution, often attempting to control negative thoughts and feelings. Avoidant problem solving is the maladaptive problem-solving style characterized by procrastination, passivity, and overdependence on others to provide solutions, often to avoid negative feelings and thoughts. Both styles are associated with ineffective or unsuccessful coping. Moreover, people who typically engage in these styles tend to worsen existing problems and even create new ones. It is important to note that these styles do not represent personality “traits.” Rather, each represents a strong tendency to either view or react to problems from a particular perspective based on one’s learning experiences. For example, it is possible (and common in our clinical experience) for individuals to be characterized as having a positive PO when dealing with problems related to achievements goals, such as those involving work or career while concomitantly adopting a negative PO when addressing affiliation themes, such as those involving romantic or family relationships. The opposite can be true as well. The five-component model of SPS (i.e., positive PO, negative PO, planful problem-solving style, avoidance style, and impulsive/careless style) has been cross-validated across various populations, ethnic minority cultures, and age groups; Nezu, 2007). It is also important to underscore that PST is conceptualized as an intervention that is particularly flexible in nature. This flexibility allows for the clinician’s goals and treatment plan to rest on the case formulation conducted during assessment and to be adapted specifically for the patient, rather than on the dictates of a manual.
Assessment in PST The three basic categories of clinical assessment of problem solving are as follows:
r r r
Assessment of problem-solving abilities and attitudes Assessment of current problem-solving activities Assessment of problems experienced by a given patient
These attitudes and skills are best assessed through a combination of quantitative measurement, clinical interview, understanding of learning history, and observation of the ways in which the patient has attempted to solve the problems that he or she is experiencing. Assessing these three basic categories allows for an evaluation as well as a possible explanation of a patient’s problem-solving strengths and weaknesses; it is also critical in determining whether PST is a useful intervention for a given individual. Moreover, when a therapist shares his or her view of the ways in which patients have learned to manage their difficulties in the context of their past learning history and expresses hope that they may learn to get closer to their valued goals, the alliance is invariably strengthened.
Social Problem-Solving Inventory-Revised A measure that was developed to address the assessment goals described above is the Social Problem-Solving Inventory-Revised (SPSI-R; D’Zurilla et al., 2002). This Likert-type inventory contains 52 items and provides a total score, as well as five major scale scores (described below), that map onto the two PO dimensions and the three problem-solving styles previously described. The five major scales are as follows:
r r
Positive Problem Orientation Scale (PPO; five items; e.g., “Whenever I have a problem, I believe it can be solved”) Negative Problem Orientation Scale (NPO; 10 items; e.g., “Difficult problems make me very upset”)
Case Formulation and the Therapeutic Alliance
r
r r
433
Rational Problem-Solving Scale (RPS; 20 items; e.g., “Before I try to solve a problem, I set a specific goal so that I know exactly what I want to accomplish”). The items are further divided into four subscales (each with five items), corresponding to the four planful problem-solving skills: Problem Definition and Formulation (PDF), Generation of Alternatives (GOA), Decision Making (DM), and Solution Implementation and Verification (SIV). Impulsivity/Carelessness Style Scale (ICS; 10 items; e.g., “When I am attempting to solve a problem, I act on the first idea that comes to mind”) Avoidance Style Scale (AS; seven items; e.g., “I wait to see if a problem will resolve itself first before trying to solve it myself”)
The SPSI-R has strong psychometric properties (see SPSI-R test manual, D’Zurilla et al., 2002), including strong structural, concurrent, predictive, convergent, and discriminant validity. The SPSI-R, along with the clinical interview, examples of current problem areas, psychosocial history, and other measures of mental health functioning can provide specific information toward a clinical case formulation featuring a detailed “profile” of an individual’s characteristic way of reacting to, and then attempting to solve, the stressful problems he or she confronts in life. Furthermore, we have found that therapists who embrace the use of principles and strategies of PST in their own lives—demonstrating their confidence in the intervention and a respect for the challenges of solving real-life problems–communicate a genuineness that enhances the therapeutic alliance.
Case Formulation Example We will present the case of Shannon (all identifying information has been changed to protect her confidentiality), who underwent a PST approach to treatment with one of the authors (CMN). This case is presented to provide a clinical context for explaining how one’s individualized case formulation, with a specific focus on a clinical problem-solving assessment, can provide a map for treatment, as well as a potentially strong bridge to the therapeutic alliance. Shannon, a 25-year-old woman, stated her referral problems as: “I’ve reached a point where I need to reevaluate what I want to do with my life and change some of my habits toward a better life.” She described experiencing anxiety and depression. She made the commitment 3 months prior to attending treatment to stop drinking alcohol completely, after a weekend of heavy drinking and a subsequent blackout. The day after this blackout, Shannon had experienced a sense of detachment, frightening sensory experiences (e.g., hypervigilance and seeing movement out of the corner of her eye), concentration difficulties, panic, and a fear of losing control of her thoughts. She stated that her problems began during adolescence and continued in college. Her college years were described as a time of minimal studying, the choice of an “easy major,” and weekends of partying. Her postcollege employment was not stable, and she described herself as drifting from job to job. Shannon would exercise responsibility at work during the week, followed by socializing with friends and heavy drinking on weekends. She stated that her friends were also heavy drinkers and enjoyed activities such as playing board games or cards. She also reported that she had almost no sober sexual relationships; rather, she had occasional brief sexual encounters while drinking, mostly during blackouts. Over the 3 months since Shannon stopped drinking and remained abstinent, she attended meetings of Alcoholics Anonymous, but considered the organizational culture a poor match for her. She enlisted the support of a sister and close friend as her way to successfully maintain her sobriety. Over the last few months, her limited episodes of panic and sensory hallucinatory experiences had diminished. However, her fears concerning loss of control, anhedonia, and low motivation remained challenging for her. Additionally, she started to engage in binge-eating episodes, which she thought might be a replacement for her previous alcohol abuse on weekends. She also began to mistrust her roommate, with whom she used to drink. Shannon was particularly concerned when, after drinking, her roommate would bring men over to the apartment for sexual activity. Despite
434
Journal of Clinical Psychology: In Session, May 2015
her unease and concern about her roommate’s allowing unfamiliar men into their apartment, Shannon was unable to assert her worries to her roommate. Shannon worked as an administrative assistant for a biotechnology company and reported that she experienced little reward for her work. Despite her evaluation of the work as boring, and her relationships with coworkers as detached, she performed her duties relatively well and was rarely absent. Her few friendships outside of work had remained the same, although she stated that she was drifting from these friends and feeling lonely because she no longer frequented the neighborhood bar where they congregated on Friday evenings. In spite of having very few social supports, she did note that her relationship with her older sister and a male friend provided her with some sense of safety and enjoyment. She described her family background as “good” and remembered herself as initially a “basically happy kid,” recalling family activities such as camping trips. However, Shannon also described the family home as having an undercurrent of tension between her parents. When she was in high school, her parents divorced, maintaining residences in close proximity for several years, and then later remarrying.
Shannon’s Assessment and Case Formulation Shannon’s comprehensive assessment included a series of clinical interviews, communication with her primary care physician, several diagnostic screening measures, psychological testing, symptom checklists, and the SPSI-R. The results of this evaluation indicated that Shannon met criteria for generalized anxiety disorder with a history of alcohol abuse; she also experienced subclinical levels of depression. In addition, she reported periodic binge-eating episodes and was concerned about her weight. While her primary care physician reported her overall health as “good,” she also noted that Shannon smoked approximately one pack of cigarettes per day and had a diagnosis of mild hypertension. Shannon expressed a strong desire to be healthier and live her life without drugs of any kind. Regarding the standardized testing measures, Shannon’s scores confirmed a diagnosis of generalized anxiety disorder. And although not reaching criteria for a personality disorder, her scores on the Minnesota Multiphasic Personality Inventory (MMPI-II; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 2001) suggested a compulsive personality style. Evident from other self-report questionnaires, a structured interview, and unstructured clinical interviews were the presence of life-long schemas reflecting hypervigilance, unrelenting standards for herself, and emotional inhibition, suggesting that her home environment tended to place an emphasis on suppressing feelings, impulses, and independent choices. Further, her family appeared to promote rather rigid rules and expectations. Verbal reports of her early life were consistent with self-report measures, and she conveyed an undercurrent of pessimism and worry in the family home. The SPSI-R revealed specific strengths and vulnerabilities in solving everyday problems. Her positive PO responses were consistent with scores of individuals in the normative, nonpsychiatric group, which reflected her optimism and desire to seek help for the significant symptoms and fears that she was currently experiencing. However, the scores regarding her negative PO were more than two standard deviations above the average normed score, which reflected her significant worry and intense fears of not coping well with life. Her concentration difficulties, feelings of detachment, experiences of depersonalization, and continual worry about her roommate’s behavior when drinking all left her feeling hypervigilant, insecure, and chronically anxious and tearful. Shannon’s scores on the various components of planful problem solving (i.e., the RPS scale score) indicated that she had not only strengths regarding her ability to define problems clearly but also limited abilities concerning flexibility and creativity in generating solutions, weighing alternatives, and following through on intended plans of thoughtful action. One example of the latter was her intention to eat better, organize her home, and exercise. She believed that if she could just “get started” then she would follow through with what she needed to do. However, she reported that her motivation to begin engaging in these activities was very poor. Her total scale score regarding her planful or rational problem-solving ability reflected the cumulative challenges she had regarding these areas, as it was similar to those of psychiatric
Case Formulation and the Therapeutic Alliance
435
outpatient sample groups and showed many deficits. Her scores regarding impulsive/careless responding were a full standard deviation beyond the average nonpsychiatric patient. This was frequently expressed by her attempt to quickly control the emotional reactions of others or her own negative emotions and negative thoughts, only to end up feeling hopeless about remaining in a constant state of worry and tension. In particular, regarding Shannon’s high negative PO and an impulsive/careless style of attempting to solve problems, her history of alcohol abuse and binge eating episodes was not surprising. Finally, her scores regarding avoidant responding were slightly but nonsignificantly above average. Overall, her total problem-solving score was two standard deviations below the average score for nonpsychiatric samples, indicating significant problem-solving deficits and limitations. What was especially striking regarding Shannon’s presentation is that externally she appeared friendly, confident, and socially secure, regardless of her chronic sense of shame regarding her fears, worries, and attempts to hide her flaws. The therapist’s awareness of this level of fragility and impulsive urge to rid herself of negative feelings and thoughts informed the need for a strong focus on the therapeutic alliance early in treatment.
The Collaborative Case Formulation Consistent with our problem-solving philosophy of clinical decision making, Shannon’s therapist shared her case formulation with her. Rather than focusing on the diagnostic labels or descriptions of her difficulties or weaknesses, her therapist presented this case formulation to provide an explanation of Shannon’s “life story.” More specifically, it was explained to Shannon how her early emotional learning experiences and family environment had contributed to the types of implicit emotional and cognitive responses that comprised her reactions to current stressors, as well as her various explicit concerns, triggers, learned behavior, and desire for change. Thus, Shannon was introduced to the view that her early learning had led to her implicit urge to hide or rid herself of negative internal experiences. However, her therapist intentionally reassured her that although awareness and acceptance of her negative internal experiences were important points of information and focal points for treatment, therapy would proceed slowly, with Shannon maintaining the ultimate control over this new exposure. In addition, Shannon’s individual strengths regarding her positive PO were underscored as one initial means of instilling hope and reinforcing constructive approaches to life problems. In sharing her understanding of Shannon’s life story, the therapist also identified possible targets for change that would have the most significant impact on her current overarching goals for treatment. These appeared to be improved management of anxiety, reduction of feelings of interpersonal detachment and sadness, and increased participation in activities associated with her valued life goals. Shannon indicated that she believed that some of her binge-eating episodes were taking the place of her former drinking episodes and that she wanted to add this to the list of problems for which to find solutions. Her therapist reinforced her courage and insight and suggested adding this to the list of problem areas on which to focus during the course of treatment. It was explained to Shannon that, from a PST perspective, her binge eating represented an “ineffective solution” to discomfort. We have found that simultaneously sharing the case formulation with a patient, using an easyto-understand visual depiction or Clinical Pathogenesis Map (CPM; Nezu, Nezu, & Cos, 2007) of the factors influencing her current level of distress, and highlighting how SPS is an important mediator of the stress-distress relationship are useful ways to underscore the relevance of PST for a given individual. The CPM (Nezu et al., 2007) is a graphic depiction of those variables hypothesized to contribute to the initiation and maintenance of a given patient’s difficulties, specifying the functional relationships among each other. It can be viewed as a path analysis or causal modeling diagram idiographically developed for a particular patient. Comprising squares with various factors identified in each one and arrows that lead from one to another, the CPM offers a concrete statement of the therapist’s initial causal hypotheses against which to test alternative hypotheses. As new information is obtained, and various predictions are confirmed or disconfirmed, the CPM can be altered.
436
Journal of Clinical Psychology: In Session, May 2015
The advantage of developing a CPM is to provide a means by which the therapist can “document” his or her hypotheses about the etiopathogenesis of a client’s problems and to share this conceptualization with patients to foster increased understanding. A CPM incorporates the following five elements: (a) distal or developmental learning variables, (b) antecedent variables or stressful triggers, (c) organismic variables such as problem solving abilities or schemas, (d) response variables, and (e) consequential variables. Patients such as Shannon have the opportunity to understand how using effective problem-solving skills and other new learning experiences can affect their ability to effectively manage life problems. In addition, this activity, so collaborative in nature, provides an extra boost to the therapeutic alliance. Shannon responded very positively to hearing her case formulation shared in this manner, reporting that it provided a “different way” of looking at her current problems and symptoms. Moreover, she indicated that she felt reassured that the therapist “listened to and respected” her, attempting to understand how hard she was trying to manage her distress and encouraging her to do the best that she could. While discussing the case formulation, Shannon volunteered additional information, describing that the tension and uncertainty in her childhood home regarding her parents’ disagreements had given her the feeling that “something bad was going to happen,” but not knowing what. As a consequence of this discussion, she began to understand that these early childhood stressful experiences had likely contributed to her current reactivity when under stress. Further, she was able to see how her current attempts at managing the stress in her life, that is, heavy drinking, served to help her avoid, rather than confront, problems. Moreover, she realized that such “ineffective solutions” served only to engender further worries regarding her health and overall well-being and to create new problems. As part of the case formulation, it was explained to Shannon that she had been drinking for so long that she had learned few other ways by which she could begin to challenge her worries, hypervigilance, and avoidance of social confrontation, such as, her current concerns regarding her roommate’s behavior. As Shannon was provided with an explanation of how problem-solving ability was related to stress, she was shown a CPM (described above), a user-friendly diagram of her learning history, current major life stressors, and daily problems. It was suggested to her that these stressors and problems might be alleviated if she learned skills that would enable her to become more aware of and, consequently, more able to manage negative feelings, think planfully, and motivate herself to put more positive strategies into action. This would ultimately involve a new overall learning experience regarding her reactions to herself and others and a different way of coping with life’s problems. Shannon’s reaction to this rationale was positive, indicating that she found this approach helpful, as it provided her with a view of herself as having certain reactive habits, albeit ineffective, that were learned earlier in life, as compared to her initial perceptions of her inability to change. She also realized that by drinking she missed multiple opportunities to learn how to cope more effectively with life’s difficulties. Moreover, she indicated that the case formulation convinced her that she had a future and that she was “not on the brink of a mental crash!” As part of providing a rationale for PST, her therapist also indicated the areas in which it would be important to incorporate techniques and strategies from other interventions in her overall treatment plan. This included mindfulness–based strategies that allowed her to nonjudgmentally observe her internal experiences.
Shannon’s Psychotherapy Outcome Shannon remained in psychotherapy for 16 sessions, which occurred over 6 months. She became increasingly confident in her ability to use her feelings as a guide to what she valued as important goals, and she recognized that negative feelings were an important part of defining problems. One striking change was that Shannon now respected how difficult and challenging her problems were and, in turn, minimized blaming herself for their presence. One turning point for Shannon was when she stated: “I realize that a lot of what I learned was not my fault, but I can be responsible to change the way I deal with problems.”
Case Formulation and the Therapeutic Alliance
437
At the end of treatment, her panic was minimal, her depressive symptoms significantly reduced, and she had become involved in activities to promote her health. These included visiting the gym daily, eating an improved diet, practicing mindfulness meditation, and starting a garden. She had become more assertive with her roommate, although she continued to face challenges in becoming more assertive with her family members. She was promoted to a senior supervisory position at work and was gradually developing a few friendships there. We believe that a potent ingredient of Shannon’s improvement was the therapeutic alliance that was developed during the initial stages of treatment when her therapist shared her case formulation. Specifically, the therapist explained the formulation with user-friendly diagrams in the form of a “clinical map” to obtain initial feedback and, ultimately, established a mutual agreement and consent regarding which treatments to use to work toward therapy goals. This provided a basis for dialogue and resolution of possible obstacles toward the attainment of those goals and “side effects” that might be experienced, such as exposure to negative emotions. Our collective clinical experience is that patients walk away from a case formulation feedback session, as Shannon did, with a greater understanding of and motivation for treatment. Particular considerations in sharing a case formulation with a patient might include restricting the discussion to those aspects deemed most relevant to describing the recommended treatment, asking for validation and feedback from the patient, and using everyday language, rather than scientific jargon. Regarding this last point: Developmental variables can be referred to as “how your background relates to your current problem areas,” mediating mechanisms as “how you tend to react to stressful problems of this type” and behavioral responses as “what you have learned to do when you experience these thoughts or feelings.”
Summary We believe that a case formulation focused on problem-solving strengths and weaknesses can serve as a best practices approach in conducting contemporary PST, specifically by adapting the scientific knowledge regarding SPS to specific client areas most in need of therapeutic intervention. Of equal importance, we believe that the use of a case formulation approach when conducting contemporary PST allows a clinician to adapt and individualize the therapy and to validate and remain respectful to a patient’s obstacles to their goals, thus creating a strong therapeutic alliance.
Selected References and Recommended Readings APA (2013). Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5), American Psychiatric Association. Bell, A. C., & D’Zurilla, T. J. (2009). Problem-solving therapy for depression: A meta-analysis. Clinical Psychology Review, 29, 348–353. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (2001). Minnesota Multiphasic Personality Inventory-2. Minneapolis: University of Minnesota Press. D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78, 107–126. D’Zurilla, T. J., & Nezu, A. M. (2007). Problem-solving therapy: A positive approach to clinical intervention (3rd ed.). New York: Springer. D’Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2002). Manual for the Social Problem-Solving Inventory-Revised. North Tonawanda, NY: Multi-Health Systems. D’Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2004). Social problem solving: Theory and assessment. In E. C. Chang, T. J. D’Zurilla, & L. J. Sanna (Eds.), Social problem solving: Theory, research, and training (pp. 11–27). Washington, DC: American Psychological Association. Falkenstrom, F., Granstrom, F., & Holmqvist, R. (2013). Therapeutic alliance predicts symptoms improvement session by session. Journal of Counseling Psychology, 60(3), 317–328. Fluckiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59(1), 10–17.
438
Journal of Clinical Psychology: In Session, May 2015
Horvath, A. O., Del Re, A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16. Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38(4), 357. Malouff, J. M., Thorsteinsson, E. B., & Schutte, N. S. (2007). The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clinical Psychology Review, 27, 46–57. Martin, J. D., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438–450. Nezu, A. M. (1986). Cognitive appraisal of problem solving effectiveness: Relation to depression and depressive symptoms. Journal of Clinical Psychology, 42, 42–48. Nezu, A. M. (2004). Problem solving and behavior therapy revisited. Behavior Therapy, 35, 1–33. Nezu, A. M., & Nezu, C. M. (Eds.). (1989). Clinical decision making in behavior therapy: A problem-solving perspective. Champaign, IL: Research Press. Nezu, A. M., Nezu, C. M., & Cos, T. A. (2007). Case formulation for the behavioral and cognitive therapies. In T.D. Eells (Ed.), Handbook of psychotherapy case formulation (2nd ed., p. 349). New York: Guilford Press. Nezu, A. M., Nezu, C. M., & D’Zurilla, T. (2013). Problem-solving therapy: A treatment manual. New York: Springer. Nezu, A. M., Nezu, C. M., Friedman, S. H., & Haynes, S. N. (1997). Case formulation in behavior therapy: Problem-solving and functional analytic strategies. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (pp. 368–401). New York: Guilford Press. Nezu, A. M., Nezu, C. M., & Perri, M. G. (1989). Problem-solving therapy for depression: Theory, research, and clinical guidelines. New York: John Wiley & Sons. Nezu, C. M., Martell, C. R., & Nezu, A. M. (2014). Special competencies in cognitive and behavioral psychology. New York: Oxford University Press. Perri, M. G., Nezu, A. M., McKelvey, W. F., Shermer, R. L., Renjilian, D. A., & Viegener, B. J. (2001). Relapse prevention training and problem-solving therapy in the long-term management of obesity. Journal of consulting and clinical psychology, 69, 722–726 ¨ Unutzer, J., Katon, W., Williams, J. W., Callahan, C., Harpole, L., Hunkeler, E. M., . . . Langston, C. A. (2001). Improving primary care for depression in late life: The design of a multicenter randomized trial. Medical Care, 39, 785–799.
