Psychodynamic case formulation: A roadmap to protocol adaptation in CBT.

Abstract

Cognitive–behavioral approaches are considered the treatment of choice for traumatic stress reactions in childhood. In spite of documented effectiveness of these approaches in reducing traumatic reactions, criticism has been raised regarding difficulties in implementing these treatments effectively in community-based clinical settings. In these settings many of the children suffer from complex and multiple traumatic experiences, live in chaotic households, and have parents that are often traumatized themselves and struggle to provide the support expected in those treatment approaches. Using a case study of a patient with complex trauma, this paper will demonstrate the challenges involved in implementing short-term, evidence-based cognitive–behavioral treatment in the community. It will offer a model for psychodynamically informed protocol adaptation, and demonstrate ways in which integrating psychodynamic case formulation can enable effective implementation of cognitive–behavioral treatment protocols with complex cases.

From symptom to process: Case formulation, clinical utility, and PDM-2.

“…Finally, PDM-2 information is not only useful for a psychodynamic formulation of the patient’s underlying dynamics and expressed behavior, but for other theoretical models as well. In this context it is important to note that developing a psychodynamic case formulation does not preclude implementing alternative, eclectic, or integrative treatments (see, e.g., Gershy, 2017, for a discussion of psychodynamic case formulation and cognitive–behavior therapy). With this in mind, clinicians and clinical researchers must continue to document the clinical utility of PDM-2 data using established criteria (see Gordon & Bornstein, 2018, for preliminary results in this area).…”

“…Given the construct’s psychoanalytic roots, it is not surprising that psychodynamic clinicians and researchers have devoted considerable effort to defining case formulation and contrasting the psychodynamic perspective with other perspectives on this issue (see, e.g., Bloch-Elkouby, Knopf, Gold, & Muran, 2017; Gershy, 2017). Ivey (2006, p. 323) provides an excellent summary of the ways in which psychodynamic case formulation extends the traditional approach: Whereas a psychological formulation refers to any psychological conceptualization of a person’s presenting difficulties, a psychodynamic formulation is typically informed by psychoanalytic assumptions about personality functioning.…”

“…So, for example, in PDM-2 paranoid personalities are conceptualized as (1) being preoccupied with attacking versus being attacked; (2) experiencing chronic fear, rage, shame, and contempt; (3) perceiving themselves as being in constant danger from malevolent others; and (4) tending to rely on the defense mechanisms of projection, projective identification, denial, and reaction formation. These process-focused P Axis descriptions provide a rich picture of the patient’s underlying dynamics, and capture core elements of psychodynamic case formulation as described by Ivey (2006) and others (e.g., Gershy, 2017). P Axis information can help the therapist weigh the relative advantages of uncovering/probing versus supportive treatment, delineate therapeutic goals and strategies, and anticipate and interpret the patient’s transference responses (and the therapist’s countertransference reactions as well).…”

“…Given the construct's psychoanalytic roots, it is not surprising that psychodynamic clinicians and researchers have devoted considerable effort to defining case formulation and contrasting the psychodynamic perspective with other perspectives on this issue (see, e.g., Bloch-Elkouby, Knopf, Gold, & Muran, 2017;Gershy, 2017). Ivey (2006, p. 323) provides an excellent summary of the ways in which psychodynamic case formulation extends the traditional approach:…”