Needleman (2003) views case formulation as the process of developing an explicit parsimonious understanding of patients and their problems that effectively guides treatment. Although the effectiveness of cognitive behavioral therapy (CBT) and cognitive hypnotherapy (CH) in treating depression have been empirically validated, their clinical significance levels were derived from nomothetic (general) or standardized treatment protocols studied
in randomized controlled trials (RCTs). In the clinical setting, no standard treatment protocol can be applied systematically to all patients. The task of the clinician in such a setting is to translate the nomothetic findings from RCTs to idiographic or individual patient in an evidence-based way. To accomplish this task, many writers (e.g., Person, 1989; Persons & Davidson, 2001; Persons, Davidson, & Tompkins, 2001) have recommended an evidence-based case formulation approach to treatment. Persons et al. (2001) regard the evidence-based formulation-driven approach to the treatment of each individual patient as an experiment. Within this framework, treatment begins with an assessment, which generates a hypothesis about the mechanisms causing or maintaining the depression. The hypothesis is the individualized case formulation, which the therapist uses to develop an individualized treatment plan. As treatment proceeds, the therapist collects data via further assessment to evaluate the effects of the planned treatment. If it becomes evident that the treatment is not working, the therapist reformulates the case and develops a new treatment plan, which is also monitored and evaluated. Clinical work thus becomes more systematic and hypothesis-driven. Such an approach to treatment becomes principle-driven rather than delivering treatment strategies randomly or in a predetermined order.

The greatest advantage of the formulation-driven approach to clinical work is that “when the therapist encounters setbacks during the treatment process, he or she can follow a systematic strategy to make a change in treatment (consider whether a reformulation of the case might suggest some new interventions) rather than simply making hit-or-miss changes in the treatment plan” (Persons, et al., 2001, p. 14). Nevertheless, two important drawbacks to formulation-driven approach to treatment must be noted. First, individualized formulation-driven treatments have not been widely subjected to evaluation in RCTs. Second, while monitoring treatment outcome systematically, a clinician may rely on idiosyncratic or non-evidence-based formulation and treatment. To minimize clinical judgment errors and to secure solid evidence-based individualized formulation-driven treatment, Persons, et al. (2001) suggest two recommendations:

The CH case formulation is based on Beck’s (1976) cognitive theory and therapy, Persons and colleagues’ (Persons, 1989; Persons & Davidson, 2001; Persons, Davidson, & Tompkins, 2001) evidence-based formulation-driven treatment, Chapman’s (Chapman, 2006) case conceptualization model of integration of CBT and hypnosis, and Alladin’s (1994, 2006) cognitive-dissociative model of depression. I have adapted the CBT case formulation model utilized by Persons, et al. (2001) to develop the cognitive hypnotherapy case formulation. The cognitive hypnotherapy case formulation approach is recommended for three main reasons: (a) it provides a systematic method for individualizing treatment, (b) it allows the therapist to take an empirical approach to
treatment of each case, and (c) it provides direction and evaluation during the treatment process.

The circular feedback model of depression (CFMD) makes several assumptions about depression. For CH to be effective, the CH therapist should have a complete understanding of the depressed patient’s belief systems and thought processes, and how they relate to the assumptions listed here:

The individualized case formulation should include an exhaustive list of patient’s problems and should describe the relationships among these problems. Exhaustive information is particularly necessary when treating depressed patients with multiple psychiatric, medical, and psychosocial problems. Patients with such profiles are usually not included in RCTs. They are, however, common in the clinical setting, so it is important to obtain an exhaustive list of problems that will help the therapist develop a working hypothesis and prioritize treatment goals. CH case formulation can occur at three different levels:

The initial case level formulation is developed after three or four sessions of therapy. At this level, the clinician develops a conceptualization of the case as a whole. In formulation at this level, it is very important to explain the relationships among the patient’s problems. Establishing the relationship among the problems helps the clinician to focus on problems that may be causing other problems. For example, depression may be caused or maintained by marital problems that merit early intervention.

Formulation at the problem or syndrome level provides a conceptualization of a particular clinical problem or syndrome, such as depressive symptoms, shoplifting, insomnia, obsessive-compulsive disorder, or bingeing and purging. The cognitive-dissociative model is used to conceptualize depression, while
cognitive-behavioral theories are used to explain other associated syndromes (e.g., panic disorder). The clinician’s treatment plan for the syndrome or problem depends on the formulation of the problem. For example, a patient’s complaint of fatigue in response to a recent professional setback can be attributed to either abuse of hypnotics or negative thoughts (“There’s no point in trying – I always fail”). Different formulations suggest different interventions.

Formulation at the situation level provides a “mini-formulation” of the patient’s reactions in a particular situation in terms of cognitions, ruminations, behaviors, and affect that guides the clinician’s intervention in that situation. Beck has provided the Thought Record format (see CAB Form in Chapter 8) to develop a situation-level formulation. The case-level formulation is accrued from information collected in the situation-level and problem-level formulations.

All levels of formulation provide direction for intervention. However, all formulations should be treated as hypotheses, and the clinician should constantly revise and sharpen the formulations as therapy proceeds. Moreover, a complete case formulation should also contain many other relevant components not detailed here, such as family history, medical conditions, and developmental history.

To identify the mechanisms that underlie the patient’s depression, I use an eight-step case formulation, derived from the work of Persons, et al. (2001) and Ledley, Marx, and Heimberg (2005). The eight components, summarized in Table 6.1, are described in detail in the following sections. Appendix 6A supplies a template for a CH case formulation and treatment plan, and Appendix 6B provides the formulated case and treatment plan for Mary, a 29-year-old single woman with a 6-year history of recurrent major depressive disorder.