By:
Jacqueline B. Persons
Establishing a clear boundary between assessment and treatment is an ethical obligation of mental health professionals (American Psychological Association, 1992). It is not ethical to provide treatment before providing patients with information about the proposed treatment and obtaining their consent to proceed.
Obtaining full informed consent is particularly
important for the therapist doing case formulation-driven treatment because the
therapist is often modifying and combining ESTs or drawing on basic theory to develop a
formulation and treatment plan to address problems and disorders for which no EST is available.
Initiating treatment without informing the patient about what
is needed to get a successful outcome can be dangerous, much as embarking
on a hike in the desert without taking water is dangerous. It is the
therapist’s job, as leader of the expedition, to make sure the patient is
adequately prepared.
Many of the interventions of CBT are
stressful and demanding
and this heightens the importance of taking some time to prepare patients and
get their agreement to proceed. Linehan (1993a) uses a pretreatment
phase in DBT for
borderline personality disorder. This is when she asks, as a condition of providing treatment
that the patient agree to goals of stopping suicidal and self-harming
behaviors. Therapists who neglect this task can find themselves attempting to
prevent the suicide of a
patient who has not agreed that stopping suicidal behaviors is a goal of treatment.
The conditioning and emotion theories alert us to the
usefulness of a
pretreatment phase. When patients first come to us, they are often quite
uncomfortable and eager
to get some help. Principles of operant conditioning tell us that they are more likely to
sign on to a more aggressive treatment plan at this point than they will agree to later,
after they have obtained some relief.
The therapist can (benevolently) capitalize on this by asking
for a commitment to a comprehensive treatment
package as a condition
of beginning treatment. Emotion theory tells us that the patient’s distress is likely to
elicit complementary emotional responses from the therapist that prompt him or her to begin to
offer interventions without first carrying out a complete assessment or obtaining the
patient’s agreement to the needed treatment. Installing an explicit pretreatment phase
prior to the formal beginning of treatment helps the therapist avoid this trap.
I keep in mind be assertive in asking patients for what is
needed to accomplish the changes they want. Instead of agreeing quickly to a
treatment plan that the patient is asking for and feels comfortable with, I encourage
therapists to think through carefully what is actually needed and to use motivational
interviewing (W. R. Miller & Rollnick, 2002) and other strategies to
help the patient understand this and agree to it (Gruber
& Persons, 2008).
The impossibility
of completely separating assessment and
treatment
Despite the importance and advantages of demarcating
assessment from treatment, it is not completely possible or
even desirable to do this for several reasons. First, assessment often
functions like an intervention. For example, monitoring a behavior typically
causes it to change in
the desired direction (Korotitsch & Nelson-Gray, 1999).
Second, one very useful way to inform patients about the
treatment and help them determine whether they want to go forward is to
demonstrate some of the interventions in order to provide them with both intellectual and
experiential information about the therapy. For example, to teach the cognitive model and
give the potential patient information about the therapy process,
the therapist can work through a Thought Record addressing one of the patient’s
current concerns.
Third,
occasionally the patient arrives at the therapist’s office in a crisis that
requires immediate intervention. When that happens, the therapist makes a
contract with the patient to suspend pretreatment to address the crisis and
then return to pretreatment when the crisis has been resolved.
In
addition, the problems for which patients seek treatment often impede them from
agreeing to a good treatment plan to address them. For example, the person who has
difficulty making decisions can find it difficult to make the decision to go
forward to treat his indecisiveness!
Finally,
people are often ambivalent about change (Prochaska & DiClemente, 1992). Thus,
although patients must give informed consent before treatment begins, some interventions
are often needed to inform patients about treatment and help them overcome
reluctance to accept a good plan (W. R. Miller & Rollnick, 2002). The
pretreatment phase, a term I borrow from Linehan (1993a), helps resolve this
tension.
The Tasks of pretreatment
The
tasks of pretreatment are:
(1)
Beginning to build a therapeutic relationship;
(2)
Obtaining a diagnosis;
(3)
Developing an initial case formulation;
(4)
Developing an initial treatment plan; and
(5)
Informing the patient about the results of the assessment and reaching agreement
about how to proceed.
Although
I describe these tasks in order, in fact the therapist works on all of them
simultaneously. That is, at the same time he is collecting information to
obtain a diagnosis and initial formulation, the therapist is working to build a
relationship with the patient, generate ideas about the treatment plan, and
inform the patient about his thinking.
Beginning to build a relationship
Relationship building is a key task of pretreatment. The patient is unlikely to accept even an outstanding empirically supported treatment plan if he does not like and trust the therapist and believe that the therapist truly understands his struggles. For that reason, I discuss the relationship first. It is a foundation upon which everything else rests.
However,
this is not to say that the therapist first works to develop a relationship and
after that is done approaches the other pretreatment (and treatment) tasks. Instead,
working collaboratively with the patient to accomplish the pretreatment tasks of
obtaining agreement on a diagnosis, formulation, and treatment plan, as
described here, is a key part of the process of building a strong therapeutic relationship
(Bordin, 1979).
Thus,
the main relationship-building tasks during pretreatment are the collaborative
ones undertaken to develop a shared formulation and treatment plan. In
addition, patient and therapist use the pretreatment phase to assess how well
they work together at these tasks in order to evaluate whether they are a good
match to work together in treatment.
Diagnosis
Why diagnose? Many clinicians see diagnosis as irrelevant and are reluctant to conduct a formal diagnostic assessment. They don’t want to interrupt the patient’s “telling his story,” they fear the patient will have a negative reaction to diagnosis, and they note that diagnostic classification and cognitive-behavior theories are difficult to reconcile conceptually (Follette, 1996). Despite the validity of these and other concerns, diagnosis yields information that is helpful in treatment.
One
key example is the important implications for both psychotherapy and
pharmacotherapy of distinguishing between unipolar and bipolar mood disorders.
In addition, the treatment efficacy literature and even the epidemiological and
psychopathology literatures are organized by diagnosis and effective clinicians
will want to draw on those literatures in their clinical work. In fact, one of
the main methods for developing an individualized case conceptualization
and treatment plan calls for the therapist to rely on evidence-based formulations
and treatment protocols; these usually target a DSM disorder.
Diagnosis
can provide the therapist with some immediate formulation hypotheses. For
example,
a diagnosis of panic disorder suggests the formulation that panic symptoms result from catastrophic interpretations of benign somatic sensations (Clark, 1986).
a diagnosis of panic disorder suggests the formulation that panic symptoms result from catastrophic interpretations of benign somatic sensations (Clark, 1986).
Initial Case Formulation
A key task of pretreatment is to develop an initial case formulation.
The
elements of the case-level formulation are
(1)
A
complete list of all the patient’s problems and disorders,
(2)
The mechanisms
(e.g.,
schemas or CRs) maintaining all of the patient’s problems and disorders,
(3)
The precipitants
that
are triggering the mechanisms to cause the problems, and
(4) The origins of the mechanisms (e.g., how the schemas or the conditioned responses were acquired).
(4) The origins of the mechanisms (e.g., how the schemas or the conditioned responses were acquired).
The
formulation describes the relationships among all of these elements. The goal
in pretreatment is to obtain enough of a formulation to identify the key features
of the treatment plan and to give the patient enough information about it to allow
him to make an informed choice about whether to accept the therapist’s
treatment plan. That is, the goal is to avoid learning in the fifth—or
twenty-fifth!—session that the patient uses self-harming behavior to regulate painful emotions and
refuses to agree on a goal to stop it.
A
formulation (and the process of collaboratively developing it) also helps build
the alliance by assuring the patient that the therapist understands his
situation. Nevertheless, the case formulation that the therapist obtains during
the pretreatment phase is preliminary, for two reasons.
One
is that in pretreatment therapists usually don’t get all the information they need
to get a complete and fully detailed case formulation. Thus, the therapist may
find out in pretreatment that the patient has a panic disorder and may
conceptualize it as resulting from irrational fears of panic sensations.
However,
the therapist will probably not have time during pretreatment to collect all of
the idiographic details of the catastrophic thoughts, the feared disastrous
consequences, the exact somatic sensations, and their sequence that are part of
a detailed and fully elaborated formulation. Much of this information will be obtained later, during treatment.
Second,
the case formulation developed during pretreatment is preliminary because it is
likely to be modified as treatment proceeds. Often during the course of
treatment, as some problems are solved, new ones emerge and the therapist
obtains new information that leads to a new case formulation.
Finally,
remember that the case-level formulation is just one of many formulations that
help guide treatment. Symptom-level formulations and disorder-level
formulations also guide the clinician’s decision-making during treatment.
Treatment planning
The treatment plan flows out of the formulation of the case. For example, if the formulation proposes that the patient’s panic symptoms result from catastrophic fears of benign somatic sensations, then the treatment plan will entail interventions to help him overcome his fears of those somatic sensations. As already mentioned, in pretreatment the therapist will probably not have the information needed to flesh out every detail of a treatment plan but must provide enough information to allow the patient to make an informed consent about whether to proceed.
At
a minimum the therapist must make some recommendations about what treatment
modality (that is, individual, group, or couple), frequency, and adjuncts
(e.g., pharmacotherapy or pharmacotherapy consult) are needed and what sorts of
interventions the psychotherapy will entail. For example, patients who want to
overcome phobias and anxiety disorders must be informed that CBT will entail approaching
feared situations to some degree or another.
The
therapist may also ask the patient to agree to certain treatment goals. DBT for
borderline personality disorder, for example, typically requires the patient to
agree to goals of stopping suicidal and self-harming behaviors as a condition of treatment.
A major challenge of pretreatment is that patients are usually quite uncomfortable and wish to begin treatment immediately but the therapist wants to accomplish all of the pretreatment tasks before beginning treatment. To address this dilemma, remember that assessment and treatment planning and relationship building are themselves interventions. In addition, the therapist can assign homework during pretreatment, including psychoeducational reading, which facilitates the assessment process and may provide the patient with some symptom relief.
Obtaining informed Consent
Before going forward with treatment, the therapist summarizes her hypotheses about diagnosis and formulation, describes the treatment plan she recommends and other options that are available to the patient, and obtains the patient’s permission to the proposed treatment plan. Some interventions may be needed to obtain the patient’s permission.
Unless
the patient and therapist can agree on a treatment plan, they do not go
forward. Thus, as she carries out all the tasks of pretreatment, the therapist
keeps in mind and reminds the patient that no decision to work together in
treatment has yet been made.
After
collecting information in pretreatment, the therapist may conclude that she
does not have the expertise to treat the patient. Or the patient may not agree
to the treatment plan the therapist recommends. In these cases, the clinician
must refer the patient to another treatment provider.
To
summarize, the therapist works in pretreatment on five tasks: relationship
building, diagnosis, formulation, treatment planning, and obtaining the patient’s
informed consent to the treatment plan proposed by the therapist. In the
balance of this, I focus on three of these tasks: relationship building, diagnosis,
and obtaining the first part of the formulation—the Problem List. Although I
focus on these pieces here, the therapist works simultaneously on all elements
of pretreatment.
Thus,
while working on the relationship, diagnosis, and the Problem List, the therapist
is also collecting data to develop mechanism hypotheses and taking advantage of
opportunities to inform the patient about what the treatment plan the therapist
is contemplating looks like.
References
Jacqueline
B. Persons, THE CASE FORMULATION APPROACH TO COGNITIVE-BEHAVIOR THERAPY, 2008,
The Guilford Press
Read Also
Definitions of case formulationModels of Treatment for Mental Disorder
Introduction to Classification of psychiatric disorders and their principal treatments
Validity of psychiatric diagnoses
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