Käytäntöä ja tutkimustietoa tapausjäsennyksistä - Tracy Eellsin täydellinen haastattelu.
Me Formulatorilla olemme digitalisoineet psykologisen tapausjäsennyksen, ja siksi psykologimme Sini-Sofia Savola on innoissaan päästessään haastattelemaan Tracy Eellsia tähän podcast-jaksoon. Tracy tuntee todennäköisesti tapausjäsennysprosessin paremmin kuin kukaan muu maailmassa. Onhan hän aiheen tunnetuin kliinikko ja tutkija. Kuuntele podcast-jakso täältä tai lue se alta.
Sinnu Savola
Hello, you're wonderful listeners. And welcome to the third episode of our podcast serious well ahead. I'm a psychologist Sini-Sofia Savola from Formulator. And you have tuned in to learn all about global mental health challenges and what are the most cutting edge solutions to those. In this podcast, we'll talk about psychology, therapeutic work and technological innovations around them. Today, I am excited and honoured to have a discussion with Tracy Eells, Professor of Psychiatric and Behavioral Sciences at the University of Louisville, and the author of The Handbook of Psychotherapy Case Formulation. Welcome to the show, Tracy.
Tracy Eells
Thank you, Sinnu. So nice to be here.
Sinnu Savola
As you know, we as Formulator have digitalized and we are developing further on this digital psychological case formulation tool. So it's no secret that I'm overly happy to have you here answering my questions as you probably know the process of case formulation better than anyone in the world, and you are the most famous clinician and researcher on this topic. So let's dive into the case formulation right away. First of all, I want to know why you think therapy and mental health professionals should be interested in case formulation and should have it as part of their practice.
Tracy Eells
Well, from my stand point of view, and I'm certainly not alone in this, I think most would agree with me that case formulation is a core skill in psychotherapy. Every psychotherapist ought to have at least some basic case formulation skills. I mean, a case formulation is essentially a hypothesis about why the patient is suffering. It's a structure that can contain the therapists understandings of the patient, their understanding of the patient's problems, what's causing and what's maintaining the problems, and then a plan to to deal with those problems.
When I teach formulation, the first question I always ask is, how do you know what to do next in therapy? So I may ask them to imagine you're sitting in the consultation room, well, increasingly these days, maybe you're in the Zoom Room, you know, and the patient is doing something. They're asking you a question and maybe sitting silently, maybe they're sitting with their arms across their chest and looking defensive, but they're not maybe aware of how they're coming across. What does the therapist do next? How do you know what is the next thing you can say? Or what would best facilitate a treatment outcome? Again, there's all sorts of things a therapist can do. You can ask a question, you could let some silence happen, you can ask him about some homework or about what he talked about the previous week. There's all sorts of things you can do. If you want to ask a question, of course, then the question is, well, what question do you ask? And so when I ask this of students, I'll get all kinds of answers from them. And my answer back to them is that, you know, we never really know what the best thing to do is. We can't know what the best thing to do is. But the best guide as to what to do next can come from the case formulation.
So having in mind your treatment plan and how it connects to your understanding of the patient, and how that links to the problems that you have jointly, along with the patient, come to agreement on, will provide the best guide. And if you're off and we're often off, you know, then you can use a formulation to guide you back to to a course. It will hopefully lead to a good outcome and feedback from patients. That feedback from patients about the interventions that are based on the formulation are, are a huge part of, of the process as well.
Sinnu Savola
Yeah. So maybe we should first define case formulation a bit more? What's in it?
Tracy Eells
Well, I would say a case formulation, at its very core is a jointly, collaboratively arrived at understanding of what is causing, and what is maintaining the patient's problems. And that maintaining piece is important too. Because often, you know, sometimes you have a problem, but what is it that causes the problem to not go away, that causes a problem to repeat. So, what causes it, and what maintains it. And so that's the core of the formulation.
But there are other pieces too, like the initial part, always is a problem list. You know, and I think that problem step can seem, I'd say deceptively easy. Deceptively easy, because there may be problems that the patient is having that maybe they're not reporting to the therapist. They might be downplaying problems. They, you know, may not be as aware of problems that they're having, that are actually leading to, you know, various other problems in their life that they want to talk about. Sometimes patients will test a therapist, maybe they'll throw out a problem to see how the therapist responds to it. And depending on whether the therapist sort of passes the test or not, they might reveal what they actually want out of out of the therapy.
Another aspect of the problem phase is that the therapist and the patient, you know, arrive at some agreement as to what are the problems that they're going to work on it sometimes. I mean, this is also a crucial step. Because sometimes when you solve one problem, you can solve a whole chain of problems. So that's an important step, and then from a problem to arrive at a diagnosis. And I use the ICD 10. There's, you know, reporting reasons to diagnose a patient, important practical reasons of course, you know, communication reasons. And then to arrive at the core of the formulation, as I said, which is the the sort of statement of what are and what is going on, what is the explanation for the problems, and then a treatment plan that is connected to that explanation. So, it sees four parts prop a problem list, a diagnosis that flows from the problem list, a explanatory hypothesis, that flows from the problems and diagnosis and then a treatment plan that is linked to all of the above.
Sinnu Savola
How does it differ from assessment as usual? Do you see that this is like, complementary to diagnostical tools? Or are they in in conflict, or how do you see case formulation differs from assessment as usual?
Tracy Eells
Well, I guess I view assessment as a very broad term, particularly in psychology, human assessment can include psychological testing. So you know, what one might want to administer. I typically will have patients complete a symptom checklist, you know, at the beginning of every session, especially if we're doing it in person, it's a little tougher when you're doing it remotely. But that's a part of assessment. But psychological testing could be part of an assessment.
I think about case formulations to be essentially interview driven, though, and that, you know, often people will vary in their views on this, but I think, you know, in the first few sessions of therapy, through the interview, the initial intake interview, you gather the information that you need to, to formulate the case, that is to arrive at, you know, what are the problems we're going to work on? What are the goals to know, what's the understanding of what's, again, driving the problems? And what are we going to do to do about it? What are we going to do to help the patient? So I would say that, you know, probably all therapists to some degree kind of formulate, they come to do some of these things that we're talking about, but they may not do it in as systematically and as evidence based way as, as they might.
Sinnu Savola
Right. Yeah. I think you've have said really well, at least it struck me that, how was it, you said like, don't use the case formulation as a shield but as, I don't know, as a tool to stay longer with the patient in the room and to, you know, emotionally to be prepared for more than you could. I think this is like, really interesting and humane and great viewpoint for professionals about where case formulation is at its best, in a way, right?
Tracy Eells
Well, I think, you know, a formulation helps the therapist develop empathy for the patient, because it's all about trying to understand the patient. Right, and patients when they feel understood, you know, you've made some, some progress in, in the therapy. So empathy is part of it. And, you know, part of the treatment planning, I think, is recognizing both the strengths that a patient brings to, to the therapy, but also the, the therapy interfering. Posture possibilities.
So, for example, and these can be evolved, of many varieties, but understanding what might get in the way of a successful outcome is important, because the therapist can then anticipate it. And I will sometimes say to a patient, you know, that I work for, you know, for reasons related to the, to their presentation in the formulation, you know, that I, I worry that they might leave therapy before they allow themselves to actually improve, let's say, like, take a person who has a history of problems in their interpersonal relationships, that once they get that they're fearful of intimacy. And once they begin to feel close to someone, then they reject them, they ward them off, and they they leave them. Well, I mean, I had a supervisor many years ago, who said to me, that there is no relationship that existed is any more intimate than a psychotherapy relationship. So at some point, you know, as the relationship gets closer between the patient and the therapist there, if that is the maladaptive interpersonal pattern that the patient has, then you know, I want to be alert to that as a therapist and then for warn the patient that I'm concerned this might happen in our case, and you know, that might help circumvent that from happen.
And there are other cases too where, you know, sometimes patients will come in and what Lorna Benjamin used to call a wrong patient syndrome meaning, you know, I'm not the person that should be sitting here, it should be my spouse who's here, or they're the one with the problem. And so, you know, that's important to know, because that can be a therapy interfearing phenomenon. I recently actually saw someone who was there only to please their psychiatrists. They said "my psychiatrist", who's a colleague of mine, "wanted me to come and see you", this patient says to me, "but I don't believe in therapy, I don't believe it's going to help me. And doubt, you know, asked me to reflect on anything. And don't ask me to, you know, do a workbook or anything like that." So, you know, that presents a problem in the therapy, that, you know, I would put as a very high priority. So that's a way that the treatment plan component of a case formulation can help circumvent premature termination.
Sinnu Savola
Right, that's a very good point. How have you seen that agood formulation is beneficial for the client? Or is there something else? Of course, that is one thing you said it's always benefiting the clients. What else? What have you seen?
Tracy Eells
Let me say, before I answer that quiz, I want to provide a little context what I've talked about. So far, I would say as formulation, generally speaking, what I've done work on is what I call evidence based case formulation. And I think that adds a very important element to these four pieces. And there are some components that are that are added. And I'd say one is an evidence based formulation that is systematic, and it's structured. Now, what I just laid out for you is a systematic structure, the problem, the diagnosis, the explanatory hypothesis, and a treatment plan. So that's one piece, I think that makes it evidence based, because when you do science, science is structured and systematic. So it's kind of following that.
The other piece of it is probably the most crucial, is drawing on the best available science, and the best available and on clinical expertise to arrive at a scientifically reasonable, coherent, understanding of the patient drawing upon the science. And then in the treatment plan, piece of it, drawing from the evidence of what we know works in therapy.
So what benefits the patient when the therapist uses an evidence based case formulation, is that they can be assured that the therapist is drawing upon the best evidence in the field that they're not so to speak, shooting from the hip. That is an US expression? I don't know how broad that expression is. And the formula, I think the patient also benefits when therapy is more focused and more organized. And the communications the interventions from the therapist from session to session, are more consistent when there is a formulation that is guiding the therapy.
Sinnu Savola
Yeah, right. Can we go a bit back to that because I find that important? Can you give some, maybe even concrete examples? How does it look like when when the formulation is evidence based? Like what what makes it like that in your work, for instance?
Tracy Eells
Right. Well, one, it's, as I said, it's structured. So you'll see you'll see a bit of the advantage of having a structure is that you have categories of information that you kind of look for or I think of them as like bins empty little bins or boxes, you know that you you want to fill with information. So there are all sorts of models of based on theory, some of which is supported by evidence on arriving at the explanatory hypothesis. We can take one, take the core conflictual, the CC relationship theme model, which is developed by Lester Luborsky back in the 70s. And it's probably the first evidence based case formulation model that's been developed. And it's got basically three bits of information, and that is the wishes of the patient, the expected responses of other people to those wishes, and then how the patient responds to the response of the other.
So, sometimes patients will give one component of that we part mild, they might say, you know, I am so disappointed at how my boyfriend treated me on Valentine's Day, okay, all he could talk about was himself. Alright, so that is a risk, in a sense, a response from other it's a response from the boyfriend. Having this model of Lebowski says, I might be thinking, well, what is it that you were wishing, what were you hoping for? What did you want from this important person in your life? You know, to be appreciated, to be validated, to feel prized, and so forth. And then what is the worst? How did you respond when you felt you're rejected by your boyfriend, or when the boyfriend or the friend only spoke of themselves. Well, I got depressed, I withdrew, I got angry. And so organizing it in that manner, I think, is helpful in the therapy.
There's been a tremendous amount of research on the the CCRT model that I just described, that supports using it as a way to to understand the patient. So that would be a a one example, at least, of how you can apply evidence based explanatory model, but there are all the other explanatory models, there's a, I'd say a very general model would be the stress diathesis model. And most models are based on a kind of a stress diathesis approach there. Maybe they elaborate to various degrees on this.
The idea being that symptoms are produced as a result of a combination of on the one hand, strap in vulnerable people, is a combination of of stress to persons dealing with in their life, and their vulnerabilities to, to those strengths. And those vulnerabilities can be of many types, they can be biological vulnerabilities, they can be learned vulnerabilities based on experiences earlier in their life, that sensitize them to respond to stresses in perhaps maladaptive ways or in ways that produce symptoms. So that would be you know, one model, very basic model, what are the vulnerabilities. And what are the stresses, if you get enough of those, then to exceed a threshold, then you have symptoms.
Another model would be a wish fear compromise model, this is a really goes back to Freud originally. But, you know, there are some empirical support for this basic approach, where you look at what are the wishes, what are the fears that interfere with the achievement of the wishes, the satisfaction of those wishes, and how does the patient try to navigate through that through compromises, compromises are ordinarily the symptoms.
There are cognitive behavioral models from the cognitive where you would look at schemas, you'd look at automatic thoughts. You might want to do a functional analysis where you are exploring, what are the sort of things that happen in a person's life that precede an instance of a problem and argument or an episode of a depressed mood. And then what happens to help the person out of it and exploring that now often say to, to patients, who might say, you know, I felt fine in the morning, but then I got depressed later on in the day. Well, let's think about just what happened. What were you thinking? What happened during the course of the day, that led you from feeling relatively okay, at one point and then depressed? And often that will reveal these vulnerabilities that I mentioned, there's a, I think, a underappreciated book that Lebowski wrote called The symptom context method, where he reported a great deal of research where he showed that often he was it's really a study of symptom onset, which is critical in case formulation. But what he found was that when symptoms begin, they are often tied to that core for interpersonally based formulation.
So for example, a patient says, you know, I woke up, I felt fine. And I decided to, you know, go mow the lawn, and my wife then got upset with me, because she wanted me to go to the store to get something for and then I got depressed. Okay, so that interaction between the, the two, in that case, arguably may have triggered the may have activated, so to speak, the cognitive structures that lead to a depressed state of mind and unpacking that in the therapy. Can be helpful. So the patient can, I will say, like, take off ramps, so that they don't, you know, get depressed.
Sinnu Savola
Thank you for these very good examples, which dive really into what formulation is about. How do you see the mental health professionals? How do you see the field? How good are mental health professionals in forming comprehensive formulations?
Tracy Eells
Right. I'd say highly variable. We did a study several years ago, where we took intake evaluations of clinic of therapists and just an outpatient psychiatry clinic, we left at about 56, I think it was of these, we content coded them. And there's, at that time, there was a section, there was basically a form that people were asked to fill out, this wes in paper pencil days, and there was one section called formulation. So we were very interested in what did they say in that section? And what we found by large, is that they did not do what I am proposing is a systematic structured case formulation.
Essentially, what they did was summarize the case, they would say again, what they had said in the earlier for portions of the form of giving the patient history and so forth. So it was used as a summary, rather than as an opportunity to make inferences based on that, on the data that they've gathered about patients about what again is causing and maintaining the problems. We did another study years later, where we asked CBT therapist - cognitive behavioral therapists and psychodynamic therapists at one of three levels, either they were novices meaning they were students, or they were experienced therapists, meaning they had at least 10 years of experience doing psychotherapy work. They were expert case formulators. And these expert case formulators are people in the world who have written about case formulation, who have published research on case formulation, who sort of our thinking was, they eat, drink, sleep case formulation. They're always thinking about it, they've made it clear that this is the lens through which they view therapy. And we present it to each of these, there were 65 therapists at all, we presented six vignettes to them.
Okay, and we asked them to formulate the cases. And what we found was, as we had had hypothesize, and hope was that the experts, the people that ate, drank, slept case formulation, constructed vastly, superior, higher, much higher quality case formulations as we had defined quality. And we defined quality along the lines of, is it comprehensive, meaning does it cover a variety of aspects, you know, in the person's life, was it complex, in appropriately complex in that it pulled together and sort of integrated different components of things going on in a person's life, how sort of coherent was it. We also asked them to think about a treatment plan. So we looked at how elaborated the formulation was, first of all, and also how the formulation linked to the treatment plan. Did they sort of logically make sense?
So, you know, if you have a dynamic formulation, but you're proposing behavioral interventions, and I would say that is not theoretically consistent, you would want it's a CBT formulation, you would want of course, CBT interventions, and so on. So we looked at all of that, and the experts did, yep, they prepared much higher quality formulations. They had many more ideas, too. And they tended, their reasoning processes were different from both the experienced and the novices in a way that I found quite interesting, which was that they made sort of small inferential leaps. This is all done verbally, orally, okay, and we transcribe it.
So they would maybe repeat a piece of information that was in the vignette about the patient. And then they would make a small inferential leap from that. This might mean x. Or they might also notice or they were much more likely to notice when information was missing that might be relevant. "I don't see anything about you know why", let's say "I would want to ask more about why", "I don't know why", then they some might say, "I don't know why this is in here, I would want to know, know more about". So, there are other studies to show that. You know, that are consistent with some of what I've just summarized for you.
We did another study where we, this was with a graduate student of mine, where we put together a very brief case formulation training: two hours. And we did kind of a pre post test where we looked at a set of formulations from these therapists, prior to the training, and then after, and just after two hours, the quality of the formulations were much much improved. So people, you know, it's a very learnable, teachable skill. But I think it's under emphasized.
Sinnu Savola
That's very fascinating. How have you found that? How much time does it take to form a proper case formulation? And does it differ from person to person from a novice to the more experienced professionals?
Tracy Eells
Yes. I would. There's a learning process, just like with anything. Like how long is it learned to play a musical instrument to to learn a tune on a musical instrument? It depends on the person, of the starting point of the person, trying to learn a tune. And the ordinarily, one would start slow when you're learning a tune, and then sort of get it up to speed. And I would say the same with case formulation. Initially, it you know, it can take some time to really think through. Okay, well, what are the problems? What's the diagnosis? What's the hardest part is its explanatory hypothesis, and then a treatment plan. It's hard for me to come up with a, like a number of hours or something along those lines.
I would say two things. One is, over the course of time, it becomes much quicker. And I think one develops a kind of case formulation lens through which you understand patients, why you're doing therapy. You're asking yourself what are the problems, letting you maybe even asking the patient that let's put together a list of problems here. And then maybe you're testing various explanatory hypotheses with the patient, seeing how they respond to that. So you're kind of formulating as you're, as you're going along. I don't think that therapists need to, as they get more experienced, to write out a lengthy case formulation. And, you know, patients vary in their complexity. And for some patients, a relatively simple formulation is adequate to meet their needs and and others. You know, you really need to think more about it. And you might need to reformulate if, if they're not responding to the initial formulation.
The other piece, I would say about how long does it take is being that we're always learning and keeping up with the literature, keeping up with psychotherapy process and outcome research, keeping up with research that may not bear directly on therapy, but is relevant to therapy is part of it too. So, what they say it takes 10,000 hours to develop expertise, now people were calling that into question, I don't know the latest research on that, but to develop cognitive structures as a therapist are akin to the cognitive structures of master chess players where they just see patterns, takes a while and that bears on case formulation.
And another thing that bears on formulation to is to you know to be skeptical about you know, when you see a pattern in therapy to be skeptical about that pattern and to not let yourself be drawn into a to over believe or be overconfident in an initial formation because we know that from research again that overconfidence is not always correlated with with accuracy.
Sinnu Savola
Yeah. And did I understand you correctly that you think that there is kinda no end game in case formulation? It could evolve forever and forever, or would you say like, when it comes to single case formulation, there is like clear start and clear ending.
Tracy Eells
I would say more the former than the latter, but I do think that significant gains just like with learning therapy can happen, you know, I'd say in a relatively short period of time. I teach students and they learn case formulation over the course of, you know, say three months period of time. And then I do long term supervision. And we talk a lot about formulation there, I think often feeling much more confident in their case formulation skills at the end of it.
So, core basic formulation skills, I think can be gained relatively quickly. Part of it is like, you know, learning, again, to like think in a case formulation way. And also to learn when to apply the case formulation, when it's relevant to apply it in. In the therapy there is this this concept of, of inner knowledge that's been identified, which would be knowledge kind of that's in your head that you get from book learning, or you get in the course of supervision, perhaps that you put into your case formulation. But then knowing how and when to apply that knowledge in the context of therapy is another piece of it.
Sinnu Savola
Yeah, right. I still have two more quite interesting questions, but only if you have some time. Who is it for, the case formulation? What we have now talked about, is it because often when at Formulator, we end up to this discussions about different therapy school, different paradigms how we how we see a person as a psychological creature. What would you say? Who is case formulation for, like, is it for some sort of therapy school representatives only or for every therapy school mental health professional?
Tracy Eells
Right. I think the ladder. There are a variety of through these explanatory templates that can come from from different theoretical orientations. So there's a psychodynamic explanatory models, that theoretical model can fit into this general formulation model that I described earlier. So can CBT, cognitive, behavioral so can behavioral. So can an emotion focused, you know, and there's of course, you know, not just one version of each of these and ACT, Acceptance and Commitment Therapy model can be fit into this general structure.
So, a variety of kind of, if you will, like mono theoretical models could be fit in. But also, the one advantage of, as I see it of this general model, is one can pull from multiple theoretical orientations and apply them as relevant to the specifics of a case. Now, a lot of therapists actually practice in a eclectic or in a an integrated manner where they take, you know, elements of different theoretical orientations and apply them. And there's evidence for efficacy of multiple, you know, models of therapy. Some disorders I think, are probably more treatable with from certain theoretical orientations. Now, the second one kind of very clear example would be trichotillomania or you know, hair pulling. There's some pretty good behavioral and cognitive-behavioral models for that and evidence for successful treatment through those models. I'd say less so with some, like a psychodynamic model.
So, you know, having a therapist who has at their disposal, a whole broad set of tools doesn't need to apply the same tool to to any problem that comes before them. It's good to be able to, to select.
Sinnu Savola
Right. That makes sense. One last question. As you have done also some research on digital therapeutics or chats. And also we are building digital tool at Formulator. To this is broad question you can answer whenever you want, but how do you see digitalization when it comes to therapeutic work? So I'm trying to make you say some possible challenges, or if you see some possible opportunities, some specific opportunities in there?
Tracy Eells
I think there's tremendous possibilities, there's tremendous challenges. In some, you know, I think, what the research shows, including research I've been involved with, is that digital approaches computer assisted, if you will, approaches to therapy are as effective often as therapies that are delivered solely by the therapist.
However, a major caveat is that there has to be some involvement of a clinician for that equivalence. Okay. We did a meta analysis, where we looked at computer assisted cognitive behavioral therapy for depression. And what we found was just that there was no equivalence in outcome, when there was at least, maybe more than minimal, but not a great deal of clinician involvement in the therapy. Otherwise, people drop out quickly, or they just don't get better.
One of the big advantages is access. Digital tools can reach anywhere in the world where there's an internet and electricity, and there's large areas of untreated mental illness throughout the world. I mean, even I would say, in my own state of Kentucky, you know, we've got the Appalachian as part of Kentucky. And there's a largely underserved population there. There's also largely underserved populations and even parts of pockets throughout the state. So access is another big advantage.
But I think that the human element has to be a part of it. I think the the digital component can provide important tools, to the therapist, for example, might provide a kind of a checklist of things to think about. Or "here is a potential explanatory hypothesis, given these problems, have you considered this?" And then the therapist thinks about that maybe takes that to the patient. And then again, that collaboration between the therapist and the patient, you know, is, I think critical. Then the evidence from psychotherapy research, supports that. Hope that answers your earliest response to your question.
Sinnu Savola
It does. And that's very interesting. And so let's not discuss more about that as we've already talked about, like 45 minutes or so. So I think we have come to an end. Thank you. Thank you so much Tracy for visiting the podcast.
Tracy Eells
Happy to do it, Sinnu. Thanks for inviting me to do it. I enjoyed it.
Sinnu Savola
And thank you for all the listeners and viewers on YouTube for listening to the episode and we'll hear you on the next one in the next month. Okay, see you. Bye!