Documentos de Académico
Documentos de Profesional
Documentos de Cultura
48 (2015) 66e74
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 7 July 2014
Received in revised form
17 January 2015
Accepted 22 January 2015
Available online 18 February 2015
Objectives: We examined whether case formulation guides the endorsement of appropriate treatment
strategies. We also considered whether experience and training led to more effective treatment decisions. To examine these questions two related studies were conducted both of which used a novel
paradigm using clinically relevant decision-making tasks with multiple sources of information.
Methods: Study one examined how clinicians utilised a pre-constructed CBT case formulation to plan
treatment. Study two utilised a clinician-generated formulation to further examine the process of
formulation development and the impact on treatment planning. Both studies considered the effect of
therapist experience.
Results: Both studies indicated that clinicians used the case formulation to select treatment choices that
were highly matched to the case as described in the vignette. However, differences between experts and
novice clinicians were only demonstrated when clinicians developed their own formulations of case
material. When they developed their own formulations the experts' formulations were more parsimonious, internally consistent, and contained fewer errors and the experts were less swayed by irrelevant
treatment options.
Limitations: The nature of the experimental task, involving ratings of suitability of possible treatment
options suggested for the case, limits the interpretation that formulation directs the development or
generation of the clinician's treatment plan. In study two the task may still have limited the capacity to
demonstrate further differences between expert and novice therapists.
Conclusions: Formulation helps guide certain aspects of effective treatment decision making. When
asked to generate a formulation clinicians with greater experience and expertise do this more effectively.
Crown Copyright 2015 Published by Elsevier Ltd. All rights reserved.
Keywords:
Cognitive therapy
Formulation
Treatment
Expertise
* Corresponding author. Doctorate of Clinical Psychology, Ridley Building, Newcastle University, Newcastle Upon Tyne, England, NE1 7RU, UK. Tel.: 44 191 222
7925.
E-mail address: r.e.j.dudley@ncl.ac.uk (R. Dudley).
http://dx.doi.org/10.1016/j.jbtep.2015.01.009
0005-7916/Crown Copyright 2015 Published by Elsevier Ltd. All rights reserved.
67
2. Method
2.1. Design
A mixed (between-within) design was used. The withinsubjects (formulation type with two levels, sociotropy or autonomy) manipulation was used to test the main hypothesis that CBT
case formulations have an effect on ratings of treatment options.
The between-subject manipulation (experience; two levels, novice
or experienced) tested the secondary hypothesis that differences in
clinician experience would account for variance in performance.
2.2. Participants
Two groups (labelled as novice and experienced practitioners)
were recruited. The novice group consisted of 23 clinicians who had
an introductory training in CBT and a limited amount of practice in
the use of CBT (e.g. rst year trainee clinical psychologists).
The experienced group included 20 clinicians with extensive
experience and training in CBT. The sample came from a variety of
backgrounds but were clinicians who had supervised others in
training and practice of CBT (e.g. experienced clinical psychologists,
psychiatrists, nurse specialists in CBT). The demographic information for the participants is shown in Table 1.
2.3. Measures
A novel task was developed to assess use of CBT case formulations to plan treatment. Participants were presented with two
prepared case formulation vignettes followed by multiple-choice
options of potential CBT treatments. Participants made judgements as to which treatment planning options were the best t for
the presented case formulations.
Information about the case was presented sequentially to the
participant. This consisted of; a referral letter from the client's GP
relevant history from childhood to present day including early
experiences and problem history, the results of assessment measures relating to emotional distress, a completed thought record
and a completed activity schedule. Then an initial psychological
conceptualisation (described as developed after two assessment
sessions) outlined an early working hypothesis for the development and maintenance of difculties. Finally, a full formulation was
provided. The model for the CBT case conceptualisation diagram
(see Fig. 1 for an example) was based on the cognitive model of
depression (Beck, Rush, Shaw, & Emery, 1979) and featured a diagrammatical representation of the longitudinal (which incorporates information about early experience and how this
predisposes a person to emotional problems owing to their core
beliefs, rules and assumptions) and cross-sectional (also described
Table 1
Demographic information (including professional experience, CBT-related qualications, further/higher education) within clinician experience groups.
Novice (n 23)
Experienced (n 20)
N
N
N
N
N
N
N
N
Mean
Sd
Mean
Sd
Age (yrs)
Further/higher education (yrs)
Months of clinical experience
Months qualied in profession
31.1
4.1
14.3
41.8
8.3
1.4
14.3
16.2
41.8
8
117.2
175.4
6.5
2.4
64.2
86.4
17, 74%
0, 0%
0, 0%
0, 0%
11,
15,
10,
18,
55%
75%
50%
90%
68
1
The rst case material was derived from a published chapter. The second was
an amalgamation of several cases the authors had worked with. In addition, the
cases were anonymised with identiable information removed, and or disguised to
ensure that the person/people they were based on where not identiable.
69
2
Copies of all the materials including treatment options are available from the
corresponding author on request.
70
option more than the novice group. The novice group was expected
to less strongly endorse appropriate treatment options and more
strongly endorse the red herring and irrelevant options.
2.4. Procedure
Participants were recruited from local psychology and CBT
training courses and were provided with an information sheet, and
signed a consent form. The participants were told to imagine that
they were the therapist and that they need to plan treatment based
on the assessment information and the case conceptualisation.
They were instructed they needed to decide how well the treatment options t in relation to the case. An example unrelated to
either of the two subsequently presented cases was provided to
help familiarise them with the task. Each participant was presented
with both of the case vignettes. The order of presentation was
counterbalanced. After reading through the case information and
formulations, participants worked through the treatment planning
task. The order of the treatment planning questions and options
was also counterbalanced throughout.
2.5. Review procedures and ethics
The work was subject to independent peer review, was registered with the Research and Development Department of the local
NHS trust and received a favourable opinion from a Local NHS
Research Ethics Committee.
3. Results
Preliminary analysis revealed no missing data. Extreme responses were identied by boxplot and winsorised. Data analysis
was completed using SPSS 20 for Windows (SPSS, 2012).
Ratings on the response to treatment planning tasks are outlined in Table 2 that shows the ratings across the two groups and by
vignette.
A mixed ANOVA with a between subject variable (experience
with two levels [novice/experienced) and two within subject variables (vignette type with two levels [Jess/Gerald], and response
type with three levels [match/irrelevant/mismatch]) examined
differences between the ratings for responses to treatment planning tasks. The analysis was also run with Order as a between
subjects variable. However, it had no bearing on the results and is
not reported further. The main effect for vignette type across
treatment planning options was not signicant (F(1, 41) 1.26,
p 0.27, h2 .03, CI .00, .18). There was a main effect for response
type (F(2,40) 388.01, p < 0.001 h2 .90, CI .84, .93). Mauchley's
test of sphericity was signicant so the lower-bound Epsilon
correction was used when determining F values. Planned simple
contrasts showed that match responses were signicantly higher in
rated t to the vignette and provided case formulations than both
irrelevant (F(1,41) 221.85, p < 0.001 h2 .84, CI .74, .89) and
mismatch (F(1,41) 516.85, p < 0.001, h2 .93, CI .88, .95), and
Table 2
Mean ratings for response type across the two clinician experience levels and vignette.
Jess
Novice
Experienced
Total
Mean
Std. Deviation
Mean
Std. Deviation
Mean
Std. Deviation
Gerald
Match
Irrelevant
Mismatch
Match
Irrelevant
Mismatch
7.8
0.8
7.6
0.9
7.7
0.9
5.3
1.2
4.7
1.5
4.8
1.5
2.7
1.6
2.1
1.3
2.2
1.4
8.0
1.0
7.5
0.7
7.9
0.9
4.7
1.3
4.2
1.4
4.3
1.3
2.5
1.3
2.5
1.3
2.4
1.2
71
Table 3
Demographic information for each group.
Novice (n 31)
Expert (n 16)
N
N
N
N
N
N
N
N
31, 94%
0, 0%
0, 0%
0, 0%
16, 56%
2, 13%
8, 50%
1, 6%
Mean
Sd
Mean
Sd
27
28.7
0
0
0
4.1
2.7
17.5
0
0
0
4.9
49
271.2
231.7
12.3
20.8
251.9
11.4
63.5
64.2
18.9
19.7
154.0
6.2. Participants
Two groups (different to those in study one) were recruited. One
group consisted of 31 novice therapists all in their rst year of
clinical psychology training. The second group consisted of 15
expert CBT therapists who met at least two of three criteria: a
minimum of ten years of experience; evidence of continuous
reection regarding formulation and/or CBT techniques through
research, publications/conference appearances on related topics,
supervision of other CBT therapists; or evidence of commitment
through delivery of training and continuing professional development (CPD) events on the topic of formulation (Skovholt et al., 1997).
Table 3 indicates that the expert group were very highly experienced (with a mean of 271 months of experience). Whilst these
participants were more experienced than the group of experienced
therapists in study one they were less likely to have completed a
diploma or equivalent in CBT, or to supervise on diploma level
training but were just as likely to be BABCP accredited. However, in
terms of publications, books, and other esteem indicators the experts differed substantially.3
6.3. Measures
The assessment and formulation materials (Jess) developed in
study one were utilised within study two. However, participants
were not provided with the provisional or nal completed formulation, instead they were asked to generate their own which was
recorded on to a blank formulation template. They then used this to
answer the treatment planning questions.
A manual4 used to score the quality of the participants formulations was utilised in this study. It was based on the manuals
developed by Kuyken et al., (2005) and Eells et al. (2005). Four
components were chosen as important measures for the current
study namely; parsimony (correct items divided by total items
entered), internal consistency or coherence of the formulation
(which was scored out of a maximum of 11), exibility (number of
changes made as new information was provided) and errors
(number of mistakes in either providing material that experts had
not seen as appropriate in the formulation or entering the correct
information in the wrong section of the formulation).
The quality manual was developed and tested on the formulations produced by a separate group of 30 novice, and experienced
but not expert clinicians (this data was not used within the main
analyses as it was used for manual development) who undertook
the same task as the novice and experts in this study. Initially ve of
6.1. Design
A mixed between groups (novice versus expert) with within
subject (three levels treatment option) design was utilised.
3
Further information about the expert participants is available on request from
the corresponding author.
4
A copy of this is available from the corresponding author.
72
Novice (n 31)
Expert (n 15)
81.7 (5.2)
79.8e83.6
93.0 (3.2)
91.3e94.8
7.9 (.9)
7.6e8.3
8.7 (1.3)
7.9e9.4
3.4 (3.8)
2.1e4.8
0.4 (0.6)
#0.01e0.7
35
Novice
Expert
Mean
Std. Deviation
Mean
Std. Deviation
Match
Irrelevant
Mismatch
8.9
1.5
7.9
2.9
6.9
1.6
4.5
1.3
4.4
2.0
1.9
1.2
73
74
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