Academic journal article Journal of Cognitive Psychotherapy

Case Conceptualization and Treatment Failure: A Commentary

Academic journal article Journal of Cognitive Psychotherapy

Case Conceptualization and Treatment Failure: A Commentary

Article excerpt

This article offers a brief review and comment on the three articles by Robert Leahy, Michael Tompkins, and John Riskind and Nathan Williams on case conceptualization and treatment resistance. It focuses on how each of the authors understands treatment failure as a by-product of inaccurate case conceptualization and their proposal for overcoming resistance to change through improved case formulation. I conclude with some general comments on the similarities and differences between the three articles, and propose a number of questions that remain unanswered about the nature of treatment resistance in psychotherapy.

Most clinicians consider case conceptualization one of the most important components of cognitive-behavioral theories and therapies of the human change process. The importance of case conceptualization is readily apparent, for example, in Beck's cognitive therapy (CT). According to Beck, Rush, Shaw, and Emery (1979) the goal of the initial interview is to establish a diagnostic profile, assess the degree of psychopathology, estimate the patient's assets for therapy, construct a formulation of the patient's problems, and propose a variety of treatment strategies that could address the patient's problems. More recently J. S. Beck (1995) discussed in greater detail the central role of case formulation in not only guiding treatment, but also in identifying ways to overcome failures in standard cognitive interventions. Persons (1989) has provided a more refined and elaborated model of case formulation that she incorporates into a cognitive-behavioral treatment approach to psychological disorders. Thus the importance of case formulation and conceptualization is clearly evident in the past writings of cognitive therapists. The topic of this special series of papers, then, targets a core component of cognitive psychotherapy theory and practice.

All practicing clinicians, regardless of their theoretical orientation, are well acquainted with treatment failure. Various labels have been applied to this phenomenon such as treatment nonresponse, treatment failure, treatment noncompliance or resistance. Given the frequency and seriousness of this problem, it is surprising that so little attention has been devoted to the topic in the cognitive psychotherapy literature. Often standard interventions are described as if failure to respond is a rare occurrence. The novice therapist is often left thinking that a patient's failure to change with intervention must be due to some deficiency in his or her understanding or implementation of a particular therapeutic approach. The three articles presented in this special issue by Leahy, Tompkins, and Riskind/ Williams are consistent in arguing that the key to overcoming treatment nonresponse will be found in the therapist's case conceptualization, or more accurately case "reformulation," rather than in the skill level or experience of the therapist. My comments on the three articles in this series will focus on (a) how each of the authors understands treatment failure, (b) their recommendations for overcoming patient resistance to change, and (c) some general observations on the contribution of the present discussion and possible additional concerns that might be considered when trying to understand patient resistance to change.

UNDERSTANDING RESISTANCE TO CHANGE

Leahy, in his article on strategic self-limitation, utilizes an investment model of decision making to understand why a depressed patient might be resistant to change and so may choose a coping strategy designed to reduce the risk of further loss at the expense of obtaining future gains. Of the three articles, Leahy's provides the most in-depth and elaborated model for understanding the nature of resistance or treatment nonresponse in cognitive therapy of depression. Resistance is not seen as a product of a faulty therapist-patient relationship. Rather Leahy situates the problem of resistance squarely within the psychological motives, beliefs, and behaviors of the patient. …

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