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Therapeutic Impact of Case Formulation in Beck's Cognitive Therapy for Depression

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Therapeutic Impact of Case Formulation in Beck's Cognitive Therapy for Depression Therapeutic Impact of Case Formulation in Beck's Cognitive Therapy for Depression by Craig Martyn Hargate BA (HONS), BSc (HONS), MSc, PhD Dissertation submitted to the Clinical Psychology Unit, University of Sheffield in Part Fulfilment of the Requirements for the Degree of Doctor of Clinical Psychology July. 2006 Therapeutic Impact of Case Forn1ulation in Beck's Cognitive Therapy for Depression Declaration and Statement of Originality In accordance with the General Regulations for the Degree of Doctor of Clinical Psychology I declare that this thesis is substantially my own work and that it has not been submitted to any other institution or for any other qualification than the one for which it is being submitted here. Where reference is made to the works of others the extent to which that work has been used is indicated and duly acknowledged in the text and list of references. July. 2006 STRUCTURE AND WORD COUNTS Literature Review ............................................................ 8,048 \vords (Prepared for the Clinical Psychology Review) I With References ......... l 0,433 words Research Report (Option A) ..................................... 11 ,005 words With References ......... 13,41 0 words Critical Appraisal .................................................. 2,003 words With References ......... 2,090 words TOTAL ......... 21,324 words Total including references ......... 26,201 words Total including references and appendices ......... 31,160 words I The letter approving this choice of journal can be found in Appendix A (p.89). In addition. the instruction fOf' authors for this journal can be found in Appendix 8 (p.90). 1 ACKNOWLEDGEMENTS First and foremost I would like to express my appreciation and gratitude to the sixteen wonderful clients upon which this research is based. They all gave so freely of their time during a most difficult period in their lives. ] would also like to express my deepest gratitude to the nine wonderful therapists who worked hard to find clients for me. and who spent a good amount of their valuable time meeting with me and learning and applying the protocol for the study. Much thanks goes to my family; my Mum and Dad. Karen. Lee and Georgia Leigh. Wayne and Andrea. and Toby and Max who have supported me throughout in so many different ways. Also to my many friends Wayne Wilson. Nigel Warrington. Paul Gray. Shaun Speight. Rebecca HoIling. Alex Love and Roger Underwood for their on going and valuable support behinds the scenes. Thanks also go to my research supervisors Professor Gillian Hardy and Dr Georgina Rowse for their help and support throughout this project. Thanks for hanging in there with me. Special thanks to Lynda Matthews who is a CBT therapist working at the Keresford Centre in Barnsley for giving me confidence in my project. I also wish to thank my great friend and colleague Dr Alan Kessedjian for his wonderful support throughout this research. Without equivocation I can confidently say that without your continued help and support I would have never been able to complete this research. I would also like to thank the many individuals from the Clinical Psychology Unit at the University of Sheffield who. at various times. supported me and devoted their valuable time to me. Particular thanks go to Carole GilIespie and Rachel Saunders. 11 CONTENTS LITERATURE REVIEW: A Review of the Role and Impact of Case Formulation in the The()J'~' and Practice of CBT Ahstract The importance of formulation in clinical psychology The importance of formulation in eBT Aim of the review 4 Literature search strategy 4 Definition of case formulation 5 Role of case formulation in eBT 6 [}nderslanding q{clients and their difficulties Planning and guidance (?{treaI1l1ent Facililaling lhe therapeUlic relaliol1ship R Understanding and managing d(fJicullies in treatment ~ Concerns associated with the use of case formulation in eBT 9 Impact of case formulation on therapeutic outcome in eBT 11 SlUdies comparing interventions with and lFilholll./i)rmulalion l2 Single case sfudies 1"7 Single case experiments 19 Smal/-n (within su~iect) studies Qualitative (interview) studies 2] Summary and Discussion 24 References 27 RESEARCH REPORT (Option A): Therapeutic Impact of Case Formulation in Beck's Cognitive Therapy for Depression Abstract 36 Introduction 36 Rationale 42 Aim 42 Hypotheses 42 Method 43 Research design -13 Participants -13 Recruitment ofparticipanls -15 Treatment procedure -15 Adminislralion o.f111easures -IR Measures -18 Psychometric properties o.{t he measures -19 Ensuring protocol integrity 52 Operationalised hypothesis 54 Results 54 Selection o.f statistical tests 5-1 Analysis o.f overall changes across the study period 55 Evaluating the stability o.lthe baselines 58 Comparison o.fpre with post-formulation means 60 III DiscLlssion 6~ S'wtistica/limi/atioI1S o(this study 65 Limitations of the scope of the SIU(~)' 0- ('ritiqllc oflhe measures used in this sflll.(r 08 Conclusion 70 References 71 CRITICAL APPRAISAL Origins of the project 82 Timing and progress of the research 82 Barriers and facilitators of progress 83 Lessons learnt from doing the research 86 References 87 APPENDICES Appendix A: Letter of approval for journal 89 Appendix B: Journal instructions for literature review 90 Appendix C: Letter of ethical approval 93 Appendix D: Ethics letter of application for amendments 95 Appendix E: Letter of ethical approval for amendments 97 Appendix F: The Beck Depression Inventory II 99 Appendix G: The Mental Health Recovery Measure 101 Appendix H: The Empowerment Scale 103 Appendix I: The Hope Scale 105 Appendix J: The Rosenberg Self-Esteem Scale 106 Appendix K: Letter of invitation to therapists 107 Appendix L: Therapist infonnation sheet 108 Appendix M: Therapist consent form 111 Appendix N: Therapist response form 112 Appendix 0: Letter of invitation to clients ] 13 Appendix P: Client inforn1ation sheet 114 Appendix Q: Client consent fom1 117 Appendix R: Research briefing programme 118 Appendix S: Instructions for use of Sheffield Psychotherapy Rating Scale 121 Appendix T: Table of raw data 123 Appendix U: Raw data of means calcu lated during baselines 124 Appendix V: Distributions of Difference Scores (Tl and T2) 125 Appendix W: Distributions of Difference Scores (Pre and Post-Formulation) 127 Appendix X: Comparison of scores attained at T3 and T4 ] 29 Appendix Y: Power Analyses 130 IV LITERATURE REVIE",l A Critical Review of the Role and Impact of Case Formulation in the Theory and Practice of eHT Abstract \\'ithin the field of clinical psychology, case formulation (CF) is considered central to the treatment of individuals with psychological difficulties (Bie\ing & Kuyken. ~002). The impOliance of formulation has also been emphasised in a number of psychological therapies, particularly CBT (Persons, 1989). Within CBT, CF is repOJ1ed to play many roles in the therapeutic process with the aim of securing improved treatment outcomes. This review identified sixteen quantitative studies that examined the relationship between CF and outcomes in CBT. Contrary to expectations. no (statistical) evidence was found to SUpp0l1 the relationship: it was only through personal interviews that clients reported CF to have an impact on them. Quantitative studies, however. may be criticised for \"iewing treatment outcome exclusively in terms of changes in symptom presentation. To understand the impact of CF on treatment outcomes, studies need to assess aspects of therapeutic change beyond the narrow focus of symptomatology and relief from symptoms. The importance of formulation in clinical psychology Within the field of clinical psychology it has come to be regarded as axiomatic that 'formulation' plays a central role in the treatment of individuals experiencing psychological difficulties. In the DCP's Core Purpose and Philosophy of the Profession (Division of Clinical Psychology, 2001), formulation is one of the four "core skills" of a clinical psychologist working in the NHS (p.2). Formulation is also a central process in the role of scientific practitioner (Tarrier & Calam, 2002) and at the heal1 of evidence-based practice (Bieling & Kuyken. 2003). I This review was prep~red for publication in the Clinical Psychology Review. Appendix A (p.83) contains the letter approving this choice of journal. The instruction for authors can be found in Appendix B (p,84), I Tht: il11portanc~ of formulation in clinical psychology has been emphasised h) a number of commentators. Bieling and Kuyken (2002) assert that formulation occupies a fundamental place in clinical psychology. like the role of diagnosis in psychiatry. For Kinderman (2001). clinical psychology is a discipline and a profession hased on formulation. and he argues that the success enjoyed by clinical psychology is. in fact. the success of formulation. Furthermore. he argues that the ability to use psychological formulations in training. consultancy and supervision is what makes clinical psychology unique to other professions associated with the field of mental health. It is true that other professions formulate. but it is the clinical psychologist's special skills in de\·eloping and llsing formulations that set them apart from the rest (Harper & Moss. 2003). The impOltance of formulation in clinical psychology is evident from the sheer volume of journal articles discussing formulation in recent years and the recent publication of books (e.g . .Tohnstone & Dallos. 2006) and various conferences (e.g. EABeT conference. Manchester. September 2004) devoted
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