Clinical Psychology – Presentations
The effect of case formulation training on patient outcome and the working alliance
Naté Wry*, B.S.
Jamie D. Bedics, Ph.D.
California Lutheran University
David C. Atkins
University of Washington
* denotes CLU student
A comprehensive case conceptualization is considered essential to the effectiveness of any evidence-based practice (e.g., Persons, 1989). Eells (2002) defined a case formulation as a set of hypotheses regarding the predisposing vulnerabilities, precipitating stressors, and maintaining factors that form the context of patients' behavioral, cognitive, and affective problems (Eells, 2002). Despite its ubiquity across treatment modalities, little research has been conducted examining the benefit of case conceptualization training on treatment outcome. The present study examined the effect of a specific case formulation training method (Eells, 1998) on the quality of therapists' formulations, patient outcomes, and the working alliance. It was predicted that the quality of therapists' case formulations would improve as a result of the workshop. In addition, it was expected that the quality of the case formulation would be associated with an improved therapeutic alliance and improved client functioning. Therapist participants were 23 doctoral students enrolled in a second year therapy practicum. Therapists were randomly assigned to one of two waves of training groups where the second group acted as a control condition for the first wave. A three hour workshop-based training emphasized four domains of a comprehensive case formulation including: 1) symptoms and problems, 2) precipitating stressors or events, 3) predisposing life events or stressors and 4) mechanisms that link categories to explain the presenting problems. Student therapists completed two written case formulations for current clients (pre- and post-training) and two case formulations for a standardized clinical vignette (pre- and post-training). Three raters assessed the four case formulation domains based on eight indices of quality including comprehensiveness, elaboration of information, complexity, precision, coherence, goodness of fit, treatment elaboration, and systematic process. Clients rated the therapeutic alliance prior to and after training using the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) and overall client outcome was measured monthly by the COMPASS treatment outcome system (Sperry, Brill, Howard, & Grissom, 1996). Preliminary analyses did not find any significant change in the quality of therapists' case formulations post-workshop. Results did, however, show change in patients' perceived agreement on the goals of therapy following therapists' participation in the workshop.