There is great variability in the interventions practiced in cognitive-behavioral counseling and psychotherapy. Cognitive-behavioral interventions include various combinations of cognitive and behavioral techniques and are aimed at changing either cognitions, behavior, or both (Kendall & Hollon, 1979; see Table 9.1). Cognitive-behavioral interventions are directive, structured, goal-directed, and time-limited treatment, and most types involve the client in a collaborative relationship with the counselor or therapist. The use of homework assignments and skills practice is common, along with a focus on problem-solving ability.
Goals of Counseling and Psychotherapy: Case Conceptualization
Before selecting a goal for counseling or psychotherapy or conducting any intervention with a client, a counselor or therapist using a CBT orientation begins with developing a conceptualization, or understanding, of the case. The case formulation in CBT has five components: problem list, diagnosis, working hypothesis, strengths and assets, and treatment plan (Persons & Davidson, 2001). These are illustrated in the case presented at the end of this chapter. The problem list is a comprehensive list of the difficulties stated in concrete behavioral terms. Usually there are five to eight problems identified in a variety of areas, such as psychological symptoms, interpersonal, occupational, medical, financial, housing, legal, and leisure (Persons & Davidson, 2001). Relationships between the problems may become clear when all of the issues are listed in this way. It is also useful to see a list of all the issues so that a prioritization of issues can be used when preparing the treatment plan.
A comprehensive problem list requires a detailed assessment and involves asking clients about areas that they may not have initially discussed. An important issue that clients may not report is substance abuse. It is for this reason that a global assessment is recommended. The counselor or therapist can use information derived from a standardized, structured interview along with the initial description of the presenting problem to develop an accurate picture of the problem. This usually begins by asking the client to describe the problem. However, clients do not always describe the most important problem in initial sessions. Sometimes they may not be ready to reveal the true problem until they have developed trust and confidence in the practitioner.
The second component in this case formulation plan is diagnosis, which refers to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision; American Psychiatric Association, 2000) method of presenting information along five axes. Diagnosis is not always included in CBT conceptualizations, but it is important because it provides a link to the type of treatment that may be selected. (It is beyond the scope of this chapter to describe diagnosis in detail.)
The working hypothesis component is considered the most critical part of the case conceptualization. It is a way to present the connections between the issues on the problem list. There are subsections, including schemata, precipitating or activating situations, and origins. The schemata section concerns the core beliefs held by the client. Core beliefs refer to those thoughts that are central to the problem, and these beliefs may cause or maintain the problems. Usually, they are clients' negative thoughts about themselves, the world, others, or the future. Precipitating or activating situations refer to the specific external events that produce the symptoms or problems. They refer to the things that may have happened just before the problem began. Origins refer to early history that might be related to the problems. Origins might explain how clients learned the schemata that maintain the current situation. Examples include modeling from family; a family with poor communication skills may explain why a client might have problems expressing herself or himself.
Strengths and assets refer to the positive aspects of a person's current situation. For example, clients may have good social skills, the ability to work collaboratively, a sense of humor, a good job, financial resources, a good support network, regular exercise, intelligence, personal attractiveness, and/or a stable lifestyle (Persons & Davidson, 2001). It is always useful to know what is not a problem in a client's life. These strengths can be used when developing the treatment plan.
The treatment plan is the outcome of the case conceptualization. It must be related to the problem list and working hypothesis. The treatment plan tells about the goals for counseling or psychotherapy. Treatment plans are also complex and require attention to goals and obstacles, as well as modality, frequency, interventions, and adjunct therapies. The goals of treatment must be reviewed with the client, and both the counselor or therapist and the client must agree on these goals. It is also important to know how progress in counseling or psychotherapy can be measured and monitored. Because cognitive-behaviorally oriented counselors or therapists are often focused on measuring outcome, it is important to know how the changes will be noted. For example, perhaps the counselor or therapist will ask the client to keep a diary of maladaptive thoughts or a count of binge-eating episodes. Obstacles refer to the potential difficulties that may arise during treatment. An awareness of the obstacles may assist the counselor or therapist and client to cope with them more effectively. Modality refers to the type of counseling or psychotherapy that will be used, in this case, CBT. Frequency refers to the number of sessions a week; most often CBT is offered once a week. Initial interventions refer to the specific strategies that will be used in sessions. An example of initial interventions appears in the case study. Finally, adjunct therapies refer to additional therapy that might be used. An example of an adjunct therapy is pharmacotherapy.