Clinical case formulation and treatment planning are core competencies of clinical psychologists and other mental health professionals. Yet there is no clear consensus regarding how to support the development of these skills in formal academic and clinical training. According to Dr. Tobin, the standard approach to supporting the development of these skills is "hierarchical learning," i.e., the trainee is first taught objective facts (declarative knowledge) and then required to transition to more subjective (inferential) forms of thinking in order to understand the cause and maintenance of the patient's problems. Dr. Tobin suggests that this approach is flawed on numerous levels, Instead, using a scene from the film "Dead Poets Society," he argues for the primary need to "subjectify" learning for the clinical trainee. The accomplishment of this initial goal will personalize all subsequent academic and clinical training, thus securing inferential capacities even before object knowledge is fully achieved.

1. Clinical Case Formulation & Treatment
Planning:
A Fact-to-Inference Strategy
for Teaching Psychologists
in Training
James Tobin, Ph.D.
1

2. Inherent Difficulty
Research indicates that case formulation is
one of the most difficult skills for graduate
students to learn/achieve a basic level of
competence.
It is also the most seldom taught and the
most poorly taught.
2

3. Training Sites
Pre- and postdoctoral training sites
typically rate case formulation as the most
under-developed skill among trainees.
3

4. Major Transition in Professional
Development
Achieving competence in case formulation
represents a major transition in professional
development from mastery of introductory
material and rote memory (declarative
knowledge) and the application of theoretical
constructs to clinical data (applied
knowledge).
4

5. Attitudinal Shift
It also represents an attitudinal shift in the
mind of the trainee from “getting the right
answer” to identifying, organizing and
articulating one’s subjective opinion and
judging its plausibility and coherence.
5

6. Personhood
of the Trainee
Accomplishing this transition reflects an
advanced level of cognitive functioning and
self-assessment in which the personhood of
the trainee and his/her vision of the human
condition is successfully incorporated into an
ability to evaluate, infer and synthesize
complex clinical data.
6

7. Delayed or Inhibited Progression
In my view, what is most surprising about
the skill development of many students across
their doctoral training years is that the
transition from declarative and applied
knowledge to this more advanced level of
cognitive functioning and the use of the self
(for a range of professional activities
including, but not limited to, case
formulation) is slow to occur or does not
occur as readily as we would expect or like.
7

8. Why is this the case?
8

9. Against Hierarchical
Learning
In my view, there is an
erroneous pedagogical
assumption underlying
most doctoral training programs: learning is
hierarchical in nature (i.e., “learn the basics
first” before more advanced competencies
pertaining to subjective judgment, creativity,
inferential and critical thinking, and self-
assessment can be developed).
9

10. Erroneous Assumption
This erroneous assumption emanates from the belief that the
student’s capacity to draw from his/her subjective experience in
order to organize and integrate clinical data is not available or is
largely misguided.
It is also presumed that most students feel anxious and
overwhelmed if “left to their own devices” (i.e., they need a
structure or approach to case material first before they can
execute higher levels of inferential and critical thinking).
10

11. I disagree!!
https://www.youtube.com/watch?v=S6xyHna-
NuM
“I think you have something inside of you that
is worth a great deal”
11

12. Anxiety and Intellectual Paralysis
Anecdotal evidence suggests that many
students, either at the beginning of training or
as training proceeds, suffer from a similar
anxiety and intellectual paralysis as the boy
in the film: they lose confidence (or never had
it in the first place) in their own perspective,
subjective vantage point and
personal/professional voice.
12

13. Interiority Diminishes
Consequently, their “subjective voice” is subdued
and lies dormant as they progressively become more
invested in appeasing instructors/supervisors and
more distanced from personifying what they are
learning (and failing to learn what they are
personifying).
Along the way, an investment in one’s interiority
gradually diminishes -- readily seen in the difficulty
students have with writing personal essays for the
APPIC internship application and in the interview
process.
13

14. Attempting Case Formulation in the Wake of Lost
Subjectivity
I present a 1-paragrah case vignette and ask
students to provide a case formulation.
What I typically get are responses that feature:
(1) a recycling of the vignette (no formulation); (2)
an incoherent or oversimplified narrative about the
case that fails to delineate cause or maintenance of
symptoms or distress (no inference); and/or (3) the
absence of a compelling appraisal of the human
condition inherent in the case.
14

15. The “Failure to Think on Your Feet”
Syndrome
I believe these typical responses are due
NOT to a lack of basic knowledge or an
organizational model for how to formulate a
case, but a paralyzed capacity to draw from
one’s subjective experience in order to
mobilize declarative and applied knowledge.
15

16. Subjectivity as a Portal for Learning
I would take this argument one step further: the
failure to think on one’s feet indicates not only that
one lacks confidence in, and the capacity to
articulate, one’s subjective view, but that actual
learning (that previously occurred) was not encoded
in a personalized way.
I believe subjectivity must first be engaged and
supported before subsequent learning can occur –
subjectivity is a portal; this is in contrast to the view
that declarative knowledge must first occur before
subjectivity can be encouraged.
16

17. “Subjectifying” Learning
Clinical case formulation features
the tension and complex interplay
between objective knowledge and
subjective refinement: I am suggesting
that if foundational learning was not
“subjectified” all along, when
the moment of truth arises (in an interview, for example) declarative
and applied knowledge will not be available to the trainee’s creative,
critical and synthetic capacities (resulting in a failure to think on one’s
feet).
Knowledge can be accessed and utilized only if it had been
initially encoded through and within a portal of personalization.
17

18. An Exercise
I have begun to raise the following
question to students: What is your personal
view of the cause of human suffering, distress
and/or psychopathology?
18

19. Resistance
It is shocking to me the degree of resistance
on the part of most students even to the
question; it’s as if they already believe their own
personal view of the human
condition/subjectivity
is irrelevant (indicating that the
“subjectifying” learning
process I am proposing has
already been abandoned in
the minds of most students).
19

20. Freud’s Personal View of the Human
Condition
I give examples: i.e., Freud: humans are
oriented toward their own demise – all
mental conflict (“neurosis”) and all misguided
behavior and emotions (the death instinct)
are the consequences of an innate need to
avoid/deny reality.
20

21. The Diathesis-Stress Model
I then present the diathesis-stress model and
ask students to apply this model to the same 1-
paragragh case vignette described previously.
The differences are startling! And then I
explain that the diathesis-stress model is
inherently a personalized value system (focusing
on the interplay between predisposition or
vulnerability and stressors).
21

22. Summary: Subjectified Learning
Instead of Hierarchical Learning
I believe that if students’
personhoods/subjective accounts of the human
condition (their “personal value system”) were
invited, supported, and articulated in the early
stages of training, professional competencies that
are inherently value-laden, subjective and
“personal” (such as case formulation) would
more successfully evolve across the training years
as the portal of subjectivity consistently encodes
and binds with accumulated declarative and
applied knowledge.
22

23. A five-phase approach to teaching
case formulation (that includes
treatment planning and
interviewing a potential new
patient)
23

24. Phase I: “Personal View of the Human
Condition”
Prime students’ readiness to subjectify the
declarative and applied knowledge they will
soon gain.
24

25. A New Exercise I am Trying
• 1.) Create the logo for your practice/practice
approach
• 2.) Articulate your unique view of the human
condition and how distress/psychiatric
symptoms/problems (e.g., obesity) emerge and
can be addressed with your treatment approach:
encapsulate all of this into a unique construct you
create and trademark
• 3.) Create a product or service based on #2 that
you will market
25

26. 26

27. https://www.youtube.com/watch?v=YDYcOnEqt
zI
(6:00 .... “Imago”)
27

28. Imago Therapy: Unique View of the
Human Condition
The basic principles of Imago Relationship Therapy are
as follows:
• We were born whole and complete.
• We became wounded during the early nurturing and
socialization stages of development by our primary
caretakers.
• We have a composite image of all the positive and
negative traits of our primary caretakers deep in our
unconscious mind. This is called the Imago. It is like
the unconscious blueprint of the one we need to be
our partner in a committed, intimate relationship.
28

29. Imago Therapy: Unique View of the
Human Condition
• We look for someone who is an "Imago
match," that is, someone who matches up
with the composite image of our primary
caretakers. This is important because we
marry or commit for the purpose of healing
and finishing the unfinished business of
childhood. Our parents are the ones who
wounded us, but a primary love partner who
matches their traits is their stand-in.
29

30. Imago Therapy: Unique View of the
Human Condition
• Romantic love is the door to a committed
relationship and/or marriage and is nature's
way of connecting us with the perfect partner
for our eventual healing.
• We move into a power struggle as soon as we
make a commitment to this person.
The power struggle is necessary, for
imbedded in a couple's frustrations lies the
information for healing and growth.
30

31. Imago Therapy: Unique View of the
Human Condition
• The first two stages of a committed
relationship, "romantic love" and the "power
struggle," are engaged in at an unconscious
level. Our unconscious mind chose our
partner for the purpose of healing childhood
wounds.
• Inevitably, our love partner is incompatible
with us and least able to meet our needs and
most able to wound us all over again.
31

32. Imago Therapy: Unique View of the
Human Condition
• The goal of Imago Relationship Therapy is to
align our conscious mind, which usually wants
happiness and good feelings, with the agenda
of the unconscious mind, which wants healing
and growth. Thus, the goal of therapy is to
assist clients to develop conscious, intimate,
committed relationships.
32

33. Imago Therapy: Unique View of the
Human Condition
• This transition cannot take place through
insight alone. Specific skills and processes are
necessary that need to be practiced daily to
shift us from having an unconscious
relationship to a conscious relationship.
33

34. 34

35. Phase II: “Content & Applied
Knowledge”
Help students learn basic theory and
accurately apply theoretical constructs to
clinical data.
35

36. Case Formulation & Treatment
Planning Primer: November, 2013
36

37. Overview of Case Formulation
• Ingram, B.L. (2006). Integrative case formulations in psychotherapy:
An elusive goal or an emerging clinical reality. Hoboken, NJ: Wiley.
• Eells, T.D. (Ed.) (2010). Handbook of psychotherapy case formulation
(2nd ed.). New York, NY: Guilford Press.
• Melchert, T. P. (2013). Beyond theoretical orientations: The
emergence of a unified scientific framework in professional
psychology. Professional Psychology: Research and Practice, 44, 11-
19.
• Tarrier, N., & Calam, R. (2002). New developments in cognitive-
behavioural case formulation. Epidemiological, systemic and social
context: An integrative approach. British Association for Behavioral
and Cognitive Psychotherapies, 30, 311-328.
• Blott, M.R. (2008). Encountering differences in graduate training:
Potential for practicum experience. Journal of Psychotherapy
Integration, 18, 437-452.
37

38. 1. Family Systems
• Chabot, D.R. (2011) Family systems theories of
psychotherapy. In J. Norcross, G.R. VandenBos, &
Freedheim, D.K. (Eds.), History of psychotherapy:
Continuity and change (2nd ed.) (pp. 173-202).
Washington, D.C.: American Psychological
Association.
• Stanton, M., & Welsh, R. (2012). Systemic
thinking in couple and family therapy research
and practice. Couple and Family Psychology:
Research and Practice, 1, 14-30.
38

39. 2. Cognitive/Cognitive-Behavioral
• Persons, J.B., & Davidson, J. (2001). Cognitive-behavioral
case formulation. In K.S. Dobson (Ed.), Handbook of
cognitive–behavioral therapies (2nd ed.) (pp. 86-110). New
York, NY: Guilford Press.
• Persons, J.B., Davidson, J., & Tompkins, M.A. (2001).
Individualized case formulation and treatment planning. In
J.B. Persons, J. Davidson, & M.A. Tompkins, M.A. (Eds.),
Essential components of cognitive- behavior therapy for
depression (pp. 25-55). Washington, D.C.: American
Psychological Association.
• Persons, J.B., Curtis, J.T., & Silberschatz, G. (1991).
Psychodynamic and cognitive-behavioral formulations of a
single case. Psychotherapy, 28, 608-617.
39

40. 3. Behaviorism
• G.R. VandenBos, & D.K. Freedheim (Eds.), History of
psychotherapy: Continuity and change (2nd ed.) (pp. 101-
140). Washington, D.C.: American Psychological
Association.
• Wagner, A.W. (2005). A behavioral approach to the case of
Ms. S. Journal of Psychotherapy Integration, 15, 101-114.
• Kohlenberg, R.J., & Tsai, M. (1995). Functional analytic
psychotherapy: A behavioral approach to intensive
treatment. In W. O’Donohue, & L. Krasner (Eds.), Theories
of behavior therapy: Exploring behavior change (pp. 637-
658). Washington, DC, US: American Psychological
Association.
40

41. 4. Multicultural/Cross-Cultural
• Shea, M., Yang, L.H., & Leong, F.T.L. (2010). Loss, psychosis, and chronic suicidality in a
Korean American immigrant man: Integration of cultural formulation model and
multicultural case conceptualization. Asian American Journal of Psychology, 1, 212-223.
• Cheung, F.M. (2012). Mainstreaming culture in psychology. American Psychologist, 67,
721-730.
• Lewis-Fernandez, R., & Diaz, M. (2002). The cultural formulation: A method for assessing
cultural factors affecting the clinical encounter. Psychiatric Quarterly, 73, 271-295.
• Bracero, W. (1996). Ancestral voices: Narrative and multicultural perspectives with an
Asian schizophrenic. Psychotherapy: Theory, Research, Practice, Training, 33, 93-103.
• Comas-Diaz, L. (2012). Humanism and multiculturalism: An evolutionary alliance.
Psychotherapy, 49, 437-441.
• Hendricks, M.L., & Testa, R.J. (2012). A conceptual framework for clinical work with
transgender and gender nonconforming clients: An adaptation of the minority stress
model. Professional Psychology: Research and Practice, 43, 460-467.
• Constantine, M.G. (2001). Multicultural training, theoretical orientation, empathy and
multicultural case conceptualization ability in counselors. Journal of Mental Health
Counseling, 23, 357-372.
41

42. 5. Feminism
• Carneiro, R., Russon, J., Moncrief, A., & Wilkins, E. (2012).
Breaking the legacy of silence: A feminist perspective on
therapist attraction to clients. World Academy of Science,
Engineering, and Technology, 66, 1064-1067.
• Evans, K.M., Kincade, E.A., Marbley, A.F., & Seem, S.R. (2005).
Feminism and feminist therapy: Lessons from the past and
hopes for the future. Journal of Counseling and Development,
83, 269-275.
• McAndrew, S., & Warne, T. (2005). Cutting across boundaries:
A case study using feminist praxis to understand the meanings
of self-harm. International Journal of Mental Health Nursing,
14, 172-180.
• Vandello, J.A., & Bosson, J.K. (2013). Hard won and easily lost:
A review and synthesis of theory and research on precarious
manhood. Psychology of Men & Masculinity, 14, 101-113.
42

43. 6. Psychodynamic
• Ivey, G. (2006). A method of teaching
psychodynamic case formulation.
Psychotherapy: Theory, Research, Practice,
Training, 43, 322-336.
• Curtis, J.T., Silberschatz, G., Weiss, J., Sampson,
H., & Rosenberg, S. E. (1988). Developing
reliable psychodynamic case formulations: An
illustration of the plan diagnosis method.
Psychotherapy, 25, 256-265.
43

44. 7. Humanistic/Existential
• Farber, E. W. (2010). Humanistic-Existential
psychotherapy competencies and the supervisory
process. Psychotherapy: Theory, Research,
Practice, Training, 47, 28-34.
• Sachse, R., & Elliott, R. (2002). Process-outcome
research on humanistic therapy variables. In D.J.
Cain (Ed.), Humanistic psychotherapies:
Handbook of research and practice (pp. 83-115).
Washington, D.C.: American Psychological
Association.
44

45. 8. Narrative/Constructivist
• Lambie, G.W., & Milsom, A. (2010). A narrative approach to
supporting students diagnosed with learning disabilities.
Journal of Counseling and Development, 88, 196-203.
• Bob, S.R. (1999). Narrative approaches to supervision and
case formulation. Psychotherapy, 36, 146-153.
• Martin, J. (2013). Life positioning analysis: An analytic
framework for the study of lives and life narratives. Journal
of Theoretical and Philosophical Psychology, 33, 1-17.
• Daniel, S.I.F. (2009). The developmental roots of narrative
expression in therapy: Contributions from attachment
theory and research. Psychotherapy: Theory, Research,
Practice, Training, 46, 301-316.
45

46. 9. Interpersonal Neurobiology
• Siegel, D.J. (2002). The developing mind and the
resolution of trauma: Some ideas about
information processing and an interpersonal
neurobiology of psychotherapy. In Shapiro, F.
(Ed.), EMDR as an integrative psychotherapy
approach: Experts of diverse orientations explore
the paradigm prism (pp. 85- 121). Washington,
D.C.: American Psychological Association.
• Fishbane, M.D. (2007). Wired to connect:
Neuroscience, relationships, and therapy. Family
Process, 46, 395-412.
46

47. 10. Developmental/Developmental
Psychopathology
• Nigg, J.T., Martel, M.M., Nikolas, M., & Casey, B.J. (2010).
Intersection of emotion and cognition in developmental
psychopathology. In S.D. Calkins, & M.A. Bell (Eds.), Child
development at the intersection of emotion and cognition.
Human brain development (pp. 225-245). Washington, D.C.:
American Psychological Association.
• Miklowitz, D.L. (2004). The role of family systems in severe
and recurrent disorders: A developmental psychopathology
view. Development and Psychopathology, 16, 667-688.
• Masten, A.S., Faden, V.B., Zucker, R.B., & Spear, L.P. (2009).
A developmental perspective on under-age alcohol abuse.
Alcohol Research and Health, 32, 3-15.
47

48. 11. Biopsychosocial Approach
48

49. Phase III: “Inference
and Style”
Help students differentiate and begin to
move seamlessly between observation/fact
and inference, which starts to promote
integrative complexity and the capacity to
self-assess plausibility, coherence, and the
tension between ignoring some data and/or
over-emphasizing other data.
49

50. The Six Styles
Case Conceptualization and Treatment
Planning: Integrating Theory With Clinical
Practice (Second Edition)
Pearl S. Berman
Indiana University of Pennsylvania
2010
50

51. Berman’s Six Styles (see handout)
• Assumption-based
• Symptom-based
• Interpersonally-based
• Historically-based
• Thematically-based
• Diagnosis-based
51

52. The Assignment to Promote Phase III:
“Inference and Style”
For the Conceptual Formulation Section of the
Diagnostic CCE, I ask students to (1) choose one of the six
styles, (2) limit the case formulation to 1-2 paragraphs,
and (3) demarcate in different colors the following:
• descriptive material/facts (25%)
• inferential material/leaps from observations or facts to
theoretical concepts (25%)
• mixture of fact, inference, and one’s vision of the human
condition (50%)
52

53. Phase IV: “The Treatment Plan”
Capitalize on phases I, II, and III by helping
students develop treatment plans directly related
to their case formulations (a range of treatment
plan structures are provided in the Berman text).
In the Diagnostic CCE, I focus students’
attention on the quality of their summaries of
their case formulations – these summaries are
positioned right before the short- and long-term
treatment goals.
53

54. Phase V: “Interviewing a Potential
Patient”
Bring the prior four phases to bear on the
organization and choice points when initially
meeting with a potential patient in a 2-3 session
assessment phase (which leads to the
determination of whether or not the trainee
thinks he/she would be able to help a particular
patient and, if so, if the trainee actually wants to
work with a particular patient).
54

55. Phase V: “Interviewing a Potential
Patient”
• For the first interview, try this:
-welcome the patient, make sure he/she has filled out all
informed consent paperwork
-before anything really starts, go over with the patient
verbally issues of privacy and confidentiality and talk about
the situations in which you may be required by law to
breach confidentiality
-you then can say: “Let's begin – what’s on your mind?
what’s happening in your life that is distressing or
concerning for you?”
55

56. Phase V: “Interviewing a Potential
Patient”
• The patient will start talking (I never take notes, but you may want to in starting out)
-As the patient is talking, you are attempting to understand and empathize, and from time
to time you make a few inquiries if they come up for you
-try to understand in a general way when the issues or problems first arose, etc.
-as the patient is talking, try to hit some general areas so that you at least know a little
about them even if they don't come up in what the patient presents: any medical
problems, school/career/finances, are they married/single, etc.
-ask if they have been in therapy before and if so get details .... ask if they have ever been
on meds and get details
-you will want to try to get some basics on their family of origin and early development
56

57. Phase V: “Interviewing a Potential
Patient”
• As you're listening to all of this information, you
are thinking in your mind about your personal
value system (view of the human condition) and
using it to generate inquiries and begin to
organize the clinical material: i.e., for Dr. Tobin:
what was the basic need the patient did not get
met from significant others in his or her past,
and what is the patient now looking for in
relationship with others (and you the therapist)
that he/she has not received or is ambivalent
about receiving?
57

58. Phase V: “Interviewing a Potential
Patient”
• This is about all the detail you can get into in the first
session, which is fine .... as the session begins to near to a
close, stop the patient and indicate that you only have
about 8 or 9 minutes left in the session
-summarize what you heard, identify the major areas the
patient wants to address, and then say something general
about how you think therapy may help or be warranted
-BUT DON'T AGREE TO START THERAPY AT ALL YET ... SAY
YOU WOULD LIKE TO MEET AGAIN TO GET SOME MORE
INFORMATION (you can refer to this as the “second
assessment interview”)
58

59. Phase V: “Interviewing a Potential
Patient”
• EXPLAIN THAT AT THE END OF THAT SECOND SESSION THE PATIENT
CAN (1) TALK ABOUT HIS/HER COMFORT LEVEL WITH YOU, AND (2)
YOU CAN DISCUSS YOUR COMFORT LEVEL WITH THE PATIENT
- AT THAT POINT, (3) YOU CAN DEVELOP TREATMENT GOALS AND
EXPLAIN MORE ABOUT HOW THERAPY WORKS IF YOU FEEL
TREATMENT IS WARRANTED
-make sure you are clear about the process of all of this so that the
patient feels like he/she is an informed consumer ... explain that
you will be glad to meet again for a second assessment session,
and at that point you will make recommendations and determine if
therapy is warranted and, if so, if you feel you are the right person
for the patient.
59

60. Phase V: “Interviewing a Potential
Patient”
• This is very important because you must learn that you
don't have to take on a patient you don't want, and
that therapy is NOT warranted for all patients ....
-go through all of this, and then set up a second
assessment time for the following week .... if the
patient alludes to a regular time to meet, avoid that
and say "we are not there yet" .... just schedule the
next appt. time
...... you and I will need to discuss what to say/do at the
end of that second assessment session.
60

61. THE END!
Thanks for your attention!!
61

62. James Tobin, Ph.D.
• Licensed Psychologist PSY 22074
220 Newport Center Drive, Suite 1
Newport Beach, CA 92660
• Assistant Professor of Clinical Psychology
The American School of Professional Psychology
at Argosy University
Email: jt@jamestobinphd.com
Website: www.jamestobinphd.com
949-338-4388
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