article

Received: 31 March 2016 Revised: 23 May 2017 Accepted: 13 June 2017

DOI: 10.1002/jclp.22516

R E V I E W A R T I C L E

Case conceptualization research in cognitive behavior therapy: A state of the science review

Michael H. Easden1 Nikolaos Kazantzis2

1Massey University, New Zealand

2Monash University, Australia

Correspondence

MichaelEasden,MasonClinicRegionalForensic

PsychiatryServices,PrivateBag19986,Avon-

dale,1746,Auckland.

Email:[email protected].

WethankGregoryMumma,WillemKuyken,

andCatherineSmithforfeedbackonaprevious

versionofthismanuscript.

Objective: Prominent models of cognitive behavior therapy (CBT)

assert that case conceptualization is crucial for tailoring interven-

tions to adequately address the needs of the individual client. We

aimed to review the research on case conceptualization in CBT.

Method: We conducted a systematic search of PsychINFO, MED-

LINE, Psychology and Behavioral Science Collection, and CINAHL

databases to February 2016.

Results: A total of 24 studies that met inclusion criteria were identi-

fied. It was notable that studies (a) focused on the assessment func-

tion of case conceptualization, (b) employed diverse methodologies,

and, overall, (c) there remains a paucity of studies examining the in-

session process of using case conceptualization or examining rela-

tions with outcome.

Conclusion: Results from the existing studies suggest that experi-

enced therapists can reliably construct some elements of case con-

ceptualizations, but importance for the efficacy of case conceptual-

ization in CBT has yet to be demonstrated. Research that involves

direct observation of therapist competence in case conceptualiza-

tion as a predictor of CBT outcomes is recommended as a focus for

future hypothesis testing.

K E Y W O R D S

case conceptualization, case formulation, cognitive behavior ther-

apy, cognitive therapy, review

There is widespread agreement that case conceptualization is an important and necessary foundation for the com-

petent practice of cognitive behavior therapy (CBT; J. Beck, 2011; Kuyken, Padesky, & Dudley, 2009; Persons, 1989,

2008). Case conceptualization serves as a framework for drawing together important developmental history with key

cognitions and behaviors as a basis for developing hypotheses about the etiology and maintenance of the client’s psy-

chopathology (Eells, Kendjelic, & Lucas, 1998) and treatment targets (Nezu, Nezu, & Lombardo, 2004; Persons, 1989,

2006). Comprehensive case conceptualization is not intended to capture a client’s entire life, or the “entire person,” but

to identify psychopathology through the identification of cognitive and behavioral strengths and weaknesses (Bieling

& Kuyken, 2003; Kuyken et al., 2009). The case conceptualization is also fluid and draws on client information from

each session and the experiences of the client resulting from the activities between sessions, and it could be based on

356 c© 2017 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/jclp J. Clin. Psychol. 2018;74:356–384.

EASDEN AND KAZANTZIS 357

any moment that the client interacts with the therapist (e.g., Cronin, Lawrence, Taylor, Norton, & Kazantzis, 2015). In

this way, the case conceptualization is technically never “complete”; it is an evolving hypothesis that both informs and

is informed by therapy (Kuyken et al., 2009).

Prominent models of CBT for different problems and populations emphasize the use of case conceptualization as

the primary means of ensuring that interventions and strategies are relevant and adapted to the client’s specific cir-

cumstances (e.g., Beck, Rush, Shaw, & Emery, 1979; Butler, Fennell, & Hackman, 2008; Clark & Beck, 2010; Cooper,

Fairburn, & Hawker, 2004; Epstein & Baucom, 2002; Rapee, Wignall, Hudson, & Schniering, 2000). Specific practice

guides focusing on case conceptualization in CBT have also been published (i.e., Kuyken et al., 2009, Persons, 1989,

2008). However, the empirical basis for the reliability and validity of case conceptualization in CBT remains unclear.

Previous reviews have critiqued research on the reliability and validity of case conceptualization (Flinn, Braham, & das

Nair, 2015; Persons & Hong, 2016; Rainforth & Laurenson, 2014). However, these have limitations because of a focus

on either reliability or validity and/or because they used a nonsystematic approach or examined other therapeutic

modalities. This is the first systematic review of reliability and validity of case conceptualization in the context of CBT.

1 DEFINING CASE CONCEPTUALIZATION IN CBT

1.1 Forms of conceptualization

The case conceptualization was first outlined as a means for tailoring CBT interventions to meet the specific needs

of the client (A. T. Beck et al., 1979; J. S. Beck, 1995). A variety of forms and formats of CBT conceptualization exist,

which can be focused on understanding problematic situations or iterations of a problem situation in which a problem

isreduced,doesnotrecur,orwhenaclientiseffective.Atthislevel,conceptualizationusuallycentersonidentifyingsit-

uational antecedents, along with cognitive, emotional, physiological, and behavioral experiences as their consequences

(Padesky & Mooney, 1990). This “situation”-level conceptualization has been described elsewhere as a CBT equiva-

lent of “functional analysis” (Haynes & O’Brien, 1990, 2000) and as being similar to the “A-B-C” framework in rational

emotive behavior therapy (Ellis, 1962, 1991, 1994) and “chain analysis” in dialectical behavior therapy (Linehan, 1980,

1993; Waltz & Linehan, 1999).

Another popular approach to conceptualization is “the problem list” (Persons, 1989), which prioritizes centrally

important client problems and measurable goals for intervention. However, the skilled therapist also works to identify

key developmental experiences, core beliefs, intermediate beliefs, assumptions, rules, and cross-situational behavioral

strategies (Young & Beck, 1980). “Overdeveloped” and “underdeveloped” behavioral strategies can also be included in

the conceptualization to assist the therapist in distinguishing between skill deficits and the role of beliefs in client skill

repertoires (e.g., a client may have assertiveness skills, but find them difficult to express in certain relationships).

Some comprehensive conceptualization formats require the therapist to specifically identify key thoughts, emo-

tions, behaviors, and physiology across multiple problematic situations (e.g., “Cognitive Case Conceptualization Dia-

gram” in J. Beck, 2011), whereas others incorporate attachment styles and values within attention to relationship his-

tory together with all the above (e.g., “Cognitive Case Conceptualization with a Relational Focus” in Kazantzis, Dattilio,

& Dobson, 2017). Thus, the CBT case conceptualization can provide a comprehensive understanding of both etiology

and maintenance of the client’s problems within a theoretical framework that explains the client’s psychopathology.

(The term “conceptualization” will be used primarily for present purposes, but it is understood that “formulation” is

used interchangeably in the literature, e.g., Persons, 2008).

1.2 Conceptualization as a guide for interventions

In organizing the client’s “data,” the case conceptualization also serves as a guide for the effective targeting and priori-

tization of treatment strategies (Eells, 2007; Needleman, 1999; Persons, 2006). For example, a client who had already

learned perspective taking and how to evaluate situational thoughts during a previous course of CBT for depression

358 EASDEN AND KAZANTZIS

might find it useful to focus on identifying and changing “processes in thinking,” such as through experiments that

involve attentional refocusing on feedback that does not support their negative core belief about themselves (e.g., “I

am incompetent”). A different client with depression may benefit from a historical evaluation of the same core belief.

Even though the intervention in these two examples is clearly different, both clients may experience symptom relief

and benefit in terms of the prevention of depressive relapse. Deciding between each treatment pathway will be guided

by the client’s presentation (e.g., extent of concurrent negative core beliefs about self, activated schema, competing

compensatory strategies) and attributes (e.g., cognitive capacity, including executive functions). Thus, the case concep-

tualization provides the decision-making framework for selecting interventions and then individually tailoring those

interventions to meet the needs of the client.

1.3 Relational processes in conceptualization

Wehavedefined(a)differenttypesofcaseconceptualization,(b)conveyedthatcaseconceptualizationcanbedesigned

to service initial assessment and therapy, and (c) provided a beginning account of how the effective use of con-

ceptualization depends to a large extent on therapist skill. A final consideration in this topic is the way in which

(a) and (b) are achieved within the therapeutic relationship. A comprehensive definition is important at the out-

set of this review because it presents the context for empirical study into the role of case conceptualization in

CBT.

Collaborative empiricism has long been considered central to the therapeutic relationship and therapeutic process

in CBT (A. T. Beck et al., 1979), often aligned with the process of guided discovery, the naive or curious enquiry, and

Socratic questioning. These elements of the therapeutic relationship intersect with the therapists’ case conceptualiza-

tion. That is, collaborative empiricism is the process by which the therapist and client work together toward develop-

ing and achieving shared goals drawing on each other’s unique knowledge (Dattilio & Hanna, 2012; Kazantzis, Beck,

Dattilio, Dobosn, & Rapee, 2013). Kuyken et al. (2009) provide the metaphor of the “case conceptualization crucible”

whereby CBT theory, research, and data from the client’s experience are integrated to promote change. Consequen-

tially, the different components of the CBT case conceptualization (e.g., thoughts, emotion, behavior, relevant back-

ground information) provide hypotheses for evaluation through data collection.

Thus, the case conceptualization forms the basis for a process of empiricism in which the client is a co-

investigator or self-detective, further testing and refining adaptive behavioral and cognitive skills in collaboration

with the therapist. This might be achieved, for example, either in vivo or as homework tasks; through behav-

ioral experiments, reality testing, or simply seeking client feedback; and checking the fit of the data with the

client’s experience and the evolving case conceptualization (Tee & Kazantzis, 2011). Collaborative empiricism

requires a focus beyond psychological disorder and conceptualization of problems to encompass skills, strengths,

and resilience essential to a comprehensive case conceptualization (Kazantzis, Tee, Dattilio, & Dobson, 2013). As a

result, researchers have used diverse methods to empirically capture and evaluate the reliability and validity of case

conceptualization.

In the next section, we present a systematic review of the existing evidence for case conceptualization in CBT. The

aim was to include empirical studies that provided data on the reliability and/or validity of CBT case conceptualization.

Giventheabovedefinition, thepresentreviewallowedforthepossibilitythatboththecontentandtheprocessofusing

case conceptualization could form the focus of empirical study. The specific aim was to clarify the current state of the

evidence, as well as highlight its strengths and limitations. We examined whether research has (a) correctly used tests

of reliability to determine whether therapists can, for instance, reliably construct and use case conceptualization, and

whether reliability requirements have been sufficiently satisfied to (b) determine the validity of case conceptualiza-

tion, particularly as this related to therapeutic outcomes. Given the interdependence of reliability and validity, it was

considered most useful to consider both in this review. We will then present a synthesis of the above definition with

the findings from the review and offer a research agenda.

EASDEN AND KAZANTZIS 359

Records identified through database searching (n = 6612)

Sc re en in g

In cl ud ed

E lig ib ili ty

Id en ti fi ca ti on Additional records identified

through other sources (n = 2)

Records after duplicates removed (n = 6312)

Records screened (n = 6312)

Records excluded (n = 6075)

Articles assessed for eligibility (n = 237)

Articles excluded, with reasons:

• Not data-based / non- empirical / non- experimental (n = 131)

• Not oriented to cognitive-behavioral model (n = 53)

• Single N case study (n = 26)

• No reliability or validity data (n = 3)

Studies included in systematic review

(n = 24)

FIGURE 1 Flow diagram of systematic search

2 METHOD

2.1 Search strategy

Studies examining case conceptualization were identified by (a) searching the PsychINFO, MEDLINE, Psychology

and Behavioral Science Collection, and CINAHL databases to February 2016 and using the text phrases “case con-

ceptualization,” “case conceptualisation,” or “case formulation,” and (b) manually searching the reference sections

of articles identified and included (see Figure 1). The present research adopted a definition of “Cognitive Behav-

ior Therapy” or “CBT” as reflecting either behaviorally focused or cognitively focused therapies (see discussions

in Kazantzis, Freeman, & Reinecke, 2010; Mennin, Ellard, Fresco, & Gross, 2013). Studies examining “formulation-

driven” case conceptualization were included, while the present study did not seek to provide a review on manual-

ized versus individualized treatment protocols and included studies with a focus on case conceptualization. Studies

were included in the review if they were (a) published in English, (b) had more than one participant (i.e., case stud-

ies were excluded unless multiple raters were used to assess the individual case), and (c) specifically targeted some

aspect of CBT conceptualization and therapeutic intervention (i.e., studies coming from non-CBT orientations were

excluded).

360 EASDEN AND KAZANTZIS

2.2 Data extraction and synthesis

The diversity of methodologies and reporting parameters identified in selected studies meant that application of sta-

tistical pooling was limited. The results are therefore presented in line with the Preferred Reporting Items for System-

atic Reviews and Meta-Analyses (PRISMA) and incorporate elements of narrative synthesis. Specifically, the findings

are charted and summarized where possible by those outlined by the Cochrane Handbook for Systematic Reviews of

Interventions (Higgins & Green, 2011). Of the studies, 50% were double coded by an independent, doctoral-level clini-

calpsychologistandyieldedhighreliabilityinselectionandextraction(i.e.,98.1%agreement).Anycodingdiscrepancies

were resolved by discussion. We offer an overview of data able to be synthesized in a systematic manner, followed by

limited synthesis of data and findings in each subsection, and accompanied by a narrative description of select studies

sufficient to facilitate an understanding of the frequent idiosyncrasies of each study even within study groupings.

3 RESULTS

3.1 Overview of data

A total of 24 studies were identified for the review. Table 1 provides a summary of key reliability and validity data

extracted from each study. Table 2 provides additional data on study aims, model integrity, and outcome assessment.

3.1.1 Reliability

Over half of all studies (n = 14, 58.3%) aimed to evaluate interclinician reliability in constructing case conceptualiza- tions with similar case material. An expert benchmark or criterion conceptualization was frequently adopted (n = 15, 62.5%), primarily to investigate reliability; but in two studies, the expert conceptualization was used to gauge validity.

One study (4.2%) reported on test-retest reliability of interpersonal scenarios (i.e., “mini” formulations).

3.1.2 Validity

Studies also sought (directly or indirectly) to evaluate case conceptualization in relation to symptom change (n = 16, 66.7%). Seven of these studies (29.2%) provided some measure of effect size (i.e., r, R2 or Cohen’s d) concerning the

relationship between aspects of case conceptualizations and patient symptomology, but three of these were small-N

repeated measures (i.e., close analysis and serial observations of a small number of subjects) and each had disparate

methods and/or level of focus. Four studies (17%) sought client or therapist feedback on the perceived clinical utility of

case conceptualizations. Where CBT was delivered, only two studies (8.3%) reported data relevant to integrity checks

to ensure fidelity to the CBT model and/or the treatment condition.

3.1.3 Training

A total of 11 studies (45.8%) carried out their aims in the context of conceptualization training or in the provision of

prescriptive training as part of the research design. Five studies (20.8%) reported some measure of effect size for sta-

tistical associations between training / experience and hypothesized quality of written case conceptualization and/or

ability to identify themes or content based on vignettes.

3.2 Participant characteristics

Table 1 includes a breakdown of raters, therapist and clients/vignettes. A total of 501 clients/vignettes formed the

bases of the total pooled sample. A total pool of 542 therapists and raters were used across studies identified for

review. However, the therapists often served as raters and vise-versa, as well as different numbers of therapists and

raters being used for different analyses. As a result, it is less meaningful to provide the number of therapist versus

raters (i.e., 363 raters and 179 therapists took part across studies).

EASDEN AND KAZANTZIS 361

T A B L E 1

S u m m a ry

o f ke y fi n d in g s fo r re li a b il it y a n d v a li d it y in se le ct e d st u d ie s (N

= 2 4 )

S a m p le si ze

(n )

K e y fi n d in g s

R a te rs

T h e ra p is ts

C li e n ts /

v ig n e tt e s

R e li a b il it y

V a li d it y

1 . C h a d w ic k e t a l.

(2 0 0 3 )U

K 1

2 1 3

• N o n si g n ifi ca n t re su lt s fo r im

p a ct o f ca se

fo rm

u la ti o n o n

a n x ie ty

o r d e p re ss io n u si n g F ri e d m a n ’s A N O V A

(D e p re ss io n :C

h iS q u a re d = 6 .7 8 ,d f = 3 ,n s: A n x ie ty :C

h i

sq u a re d = 3 .3 2 ,d f = 3 ,n s)

• S ig n ifi ca n t in cr e a se

in cl ie n t se lf -r e p o rt ra ti n g s o f

th e ra p e u ti c a ll ia n ce

(H A q )m

a d e a ft e r fo cu se d u se

o f

ca se

fo rm

u la ti o n in -v iv o b e tw

e e n T 1 a n d T 3 (T

= − 2 .1 2 ,

p < 0 .0 5 )a n d T 1 a n d T 4 (T

= − 2 .2 5 ,p

< 0 .0 5 )b u t n s

fi n d in g s fo r o th e r ti m e s (i .e ., T 1 /T 2 a n d T 3 /T 4 w e re

n s)

• Q u a li ta ti v e in te rv ie w s w it h cl ie n ts re p o rt in g sh a ri n g o f

ca se

fo rm

u la ti o n e n h a n ce d u n d e rs ta n d in g o f o w n

p ro b le m s (n

= 9 ), p o si ti v e e m o ti o n s (n

= 6 ),

u n d e rs ta n d in g o f th e ir th e ra p is t (n

= 3 ), n e g a ti v e

e m o ti o n s (n

= 6 ), n o e m o ti o n a li m p a ct (n

= 3 )o r fi n d in g

ca se

fo rm

u la ti o n s co m p li ca te d (n

= 2 )

2 . D u d le y e t a l.

(2 0 1 0 )U

K 8 2 / 3

n /a

1 •

P e rc e n ta g e a g re e m e n t o n ex p e rt b e n ch m a rk

ra n g e d

fr o m 3 2 .2 % to

9 1 .6 %

• H ig h e r a g re e m e n t fo r d e sc ri p ti v e /s u rf a ce

le v e la sp e ct s

a n d lo w e r a g re e m e n t fo r m o re

in fe re n ti a l/ d e e p e r le v e l

co n te n t o f ca se

fo rm

u la ti o n

• T h e “n u m b e r o f C B T ca se s se e n ” w a s p o si ti v e ly

a ss o ci a te d (𝛽

= 0 .2 8 ,t = 2 .1 7 ,p

< .0 5 )w

it h th e m e a n

n u m b e r o f in fe re n ti a lc o m p o n e n ts id e n ti fi e d .S im

il a rl y

“o v e ra ll y e a rs o f ex p e ri e n ce ” (𝛽

= 0 .4 2 ,t = 2 .8 5 ,p

< .0 1 )

h a d a p o si ti v e a ss o ci a ti o n w it h th e to ta lf o rm

u la ti o n

m e a n sc o re ,a lt h o u g h th e “n u m b e r o f p sy ch o si s ca se s

se e n ” h a d a n in v e rs e re la ti o n sh ip (𝛽

= − 0 .3 7 ,t = − 2 .3 8 ,p

< .0 5 )

3 . E e ll s e t a l. (2 0 0 5 )

U S A

6 6 5

6 •

K a p p a co e ffi ci e n ts b a se d o n ‘d e sc ri p ti v e ’( 𝜅 = 0 .6 1 ),

‘d ia g n o st ic ’( 𝜅 = 0 .8 1 ), ‘in fe re n ti a l’ (𝜅

= 0 .6 2 )a n d

‘t re a tm

e n t’ (𝜅

= 0 .6 9 )

• R e li a b il it y (u si n g tw

o -w

ay ra n d o m e ff e ct s IC C )f o r

co m p o n e n ts / ca te g o ri e s o f co n te n t ra n g e d fr o m .6 9 to

.8 9

• E x p e rt co n ce p tu a li za ti o n s w e re

ra te d a s m o re

co m p re h e n si v e ,e la b o ra te d ,c o m p le x ,a n d sy st e m a ti c

th a n le ss ex p e ri e n ce d th e ra p is ts

• G re a te r d e ta il a n d re le v a n ce

w a s o b se rv e d in th e

ex p e ri e n ce d th e ra p is ts ’c o n ce p tu a li za ti o n s

(C on ti nu es )

362 EASDEN AND KAZANTZIS

T A B L E 1

(C o n ti n u e d )

S a m p le si ze

(n )

K e y fi n d in g s

R a te rs

T h e ra p is ts

C li e n ts /

v ig n e tt e s

R e li a b il it y

V a li d it y

4 . E e ll s e t a l. (2 0 1 1 )

U S A

6 6 5

6 •

T h e th e ra p is ts ,v ig n e tt e s, tr a n sc ri p ti o n a n d co n te n t

co d in g p ro ce d u re s a re

th e sa m e a s d e sc ri b e d in E el ls

et al .( 2 0 0 5 )a lt h o u g h w it h d if fe re n t re se a rc h q u e st io n s

a n d a n a ly si s. A s su ch

re li a b il it y d a ta

is d u p li ca te d .

• R e su lt s y ie ld e d sm

a ll to

m o d e ra te

e ff e ct si ze s fo r

ex p e rt s g e n e ra ti n g m o re

d e sc ri p ti v e (d

= .3 3 ), d ia g n o st ic

(d = .2 4 ), in fe re n ti a l( d = .3 5 ), a n d tr e a tm

e n t p la n n in g

in fo rm

a ti o n (d

= .3 2 )i n th e ir ca se

fo rm

u la ti o n s th a n th e

n o n ex p e rt s

• E x p e rt s h a d a g re a te r fo cu s o n tr e a tm

e n t (d

= .3 4 )a n d

p sy ch o lo g ic a lm

e ch a n is m s o f ch a n g e (d

= .2 5 )t h a n

n o n ex p e rt s.

5 . E sb jø rn

e t a l.

(2 0 1 5 )D

e n m a rk

0 8

5 4

• M cN

e m a r’ s te st re v e a le d n o n si g n ifi ca n t re su lt s fo r

d if fe re n ce s o n se lf -r a te d a n x ie ty

le v e ls a n d d ia g n o st ic

st a tu s (d e te rm

in e d u si n g th e A D IS -I V -C /P )b e tw

e e n th e

fo rm

u la ti o n -d ri v e n a n d co n tr o lg ro u p d e sp it e a tr e n d

to w a rd s h ig h e r p e rc e n ta g e sy m p to m re m is si o n th e in

fo rm

u la ti o n -d ri v e n g ro u p

6 . F li tc ro ft e t a l.

(2 0 0 7 )U

K 0

2 3

1 •

Q -s o rt m e th o d o lo g y to

d e te rm

in e im

p o rt a n t fe a tu re s o f

ca se

fo rm

u la ti o n th e n a p p li e d to

fa ct o r a n a ly si s

• T h re e fa ct o r so lu ti o n w it h e ig e n v a lu e s a b o v e 1 .0 0 ,a n d

a cc o u n ti n g fo r 4 9 % o f th e v a ri a n ce

in to ta l( F a ct o r A

“C B T st a te ” = 2 4 % ;F a ct o r B “h e re

a n d n o w ” = 1 8 % ;

F a ct o r C “p ro ce ss a n d fu n ct io n ” = 7 % )

7 . G h a d e ri (2 0 0 6 )

S w e d e n

2 1

5 0

• O f re le v a n ce ,i n th e co u rs e o f a d h e re n ce

ch e ck s,

d e ta il e d su m m a ri e s o f 2 0 ra n d o m ly ch o se n ca se s (h a lf in

th e in d iv id u a li ze d co n d it io n ,h a lf fr o m st a n d a rd

C B T )

w e re

re v ie w e d b y th re e in d e p e n d e n t th e ra p is ts w h o

ju d g e d w h a t co n d it io n th e p a ti e n t b e lo n g e d to ,a n d to

a ss e ss th e q u a li ty

o f th e tr e a tm

e n t. In to ta l, th e ra ti n g s

o f th e co n d it io n s w e re

co rr e ct fo r 9 0 % (t w o p a ti e n ts

w e re

m is id e n ti fi e d to

b e in st a n d a rd iz e d co n d it io n ).

• M o d e ra te

to la rg e e ff e ct si ze s (r e p o rt e d a s p a rt ia lE ta

sq u a re d )f o r g ro u p s o n so m e E D E su b sc a le s a n d

m e a su re s fo r ‘n u m b e r o f w e e k s o f a b st in e n ce

fr o m

o b je ct iv e b u li m ic e p is o d e s (O

B E s) ’( .1 5 ), ‘e a ti n g

co n ce rn s’ (. 1 1 ), a n d ‘b o d y sh a p e d is sa ti sf a ct io n (u si n g

B S Q )’ (. 0 8 )i n fa v o u r o f in d iv id u a li ze d ca se

fo rm

u la ti o n -d ri v e n co n d it io n .A

si g n ifi ca n t g ro u p

d if fe re n ce

w a s o b se rv e d fo r ‘e xc e ss iv e co m p e n sa to ry

ex e rc is in g ’( .1 5 )a n d ‘c o m p e n sa to ry

b e h av io u r’ (. 1 0 ), b u t

n o in te ra ct io n

• T h e re

w e re

n s g ro u p o r in te ra ct io n e ff e ct s fo r o th e r

p re -p o st m e a su re s in cl u d in g th e B D I- II ,R o se n b e rg

S e lf -e st e e m sc a le ,a n d E D I

(C on ti nu es )

EASDEN AND KAZANTZIS 363

T A B L E 1

(C o n ti n u e d )

S a m p le si ze

(n )

K e y fi n d in g s

R a te rs

T h e ra p is ts

C li e n ts /

v ig n e tt e s

R e li a b il it y

V a li d it y

8 . H a a rh o ff e t a l.

(2 0 1 1 )N

e w

Z e a la n d

2 6

n /a

4 •

P e rc e n ta g e a g re e m e n t d a ta

b e tw

e e n ra te rs a n d

b e n ch m a rk

w a s n o t p ro v id e d fo r a ll in d ic e s. A u th o rs

n o te

th e h ig h e st a g re e m e n t fo r ‘r e le v a n t ch il d h o o d d a ta ’,

‘A x is I d ia g n o si s’ ,‘ co m p e n sa to ry

st ra te g ie s’ ,a n d ‘c o re

b e li e fs a b o u t se lf ’, a n d b ro a d o m is si o n s le a d in g to

v e ry

p o o r a g re e m e n t (i .e ., “a lm

o st n o a g re e m e n t” )o n ‘t h e ra p y

in te rf e ri n g b e h av io r’ a n d ‘A x is II p e rs o n a li ty

d is o rd e r

tr a it s’ .K

a p p a a g re e m e n t b e tw

e e n cl in ic ia n a n d

b e n ch m a rk

fo r ‘p ro b le m li st ’w

a s lo w fo r a ll v ig n e tt e s

(𝜅 s<

3 0 % )

9 . K e n d je li c & E e ll s

(2 0 0 7 )U

S A

3 4 3

9 9

• To ta lm

e a n k a p p a fo r co d e d fo rm

u la ti o n s a cr o ss a ll

v a ri a b le s a n d co d e rs w a s .8 6 (r a n g e .6 0 to

1 .0 )

• B a se d o n a la rg e m e a n e ff e ct si ze

(d = 1 .1 2 )t h e

re se a rc h e rs co n cl u d e d th a t th e av e ra g e th e ra p is t in th e

tr a in in g g ro u p h a d a b e tt e r q u a li ty

co n ce p tu a li za ti o n

th a n 8 6 % o f th e ra p is ts in th e co n tr o lg ro u p

1 0 . K u y ke n e t a l.

(2 0 0 5 )U

K 1 1 5 / 2

n /a

1 •

P e rc e n t a g re e m e n t b e tw

e e n 1 1 5 in d iv id u a lc li n ic ia n s

a n d ex p e rt b e n ch m a rk

co n ce p tu a li za ti o n ra n g e d fr o m

7 % to

7 3 %

• T w o in d e p e n d e n t ju d g e s ra te d a g re e m e n t o n ca te g o ri e s

o f in fo rm

a ti o n u n it s (r a n g e 𝜅 = 0 .6 3 to

0 .9 1 )

1 1 . M o rb e rg -P a in

e t a l. (2 0 0 8 )U

K 2

5 1 3

• K a p p a a g re e m e n t fo r id e n ti fi e d th e m e s w a s h ig h (𝜅

= .8 9 )

• P a ti e n ts e n d o rs e d a co m b in a ti o n o f p o si ti v e (n

= 9 ,6 9 % ),

n e g a ti v e (n

= 9 ,6 9 % )a n d n e u tr a l( n = 6 ,4 6 % )e m o ti o n a l

re a ct io n s to

u se

o f ca se

fo rm

u la ti o n s

(C on ti nu es )

364 EASDEN AND KAZANTZIS

T A B L E 1

(C o n ti n u e d )

S a m p le si ze

(n )

K e y fi n d in g s

R a te rs

T h e ra p is ts

C li e n ts /

v ig n e tt e s

R e li a b il it y

V a li d it y

1 2 . M u m m a (2 0 0 4 )

U S A

1 1

1 •

Id io g ra p h ic C o g n it iv e S ch e m a (I C S )[ g e n e ra te d u si n g th e

C B IS S A I] fa ct o rs ex p la in e d a n av e ra g e o f 2 9 % o f th e

d a il y v a ri a b il it y in sy m p to m /d is tr e ss ra ti n g s (R

2 = .1 9 to

.4 3 )a s m e a su re d o n a n ID Q .T h is w a s co m p a ra b le

b e tw

e e n av e ra g e sh ru n ke n R 2 = .2 4 fo r th e IC S

p re d ic to rs a n d R 2 = .2 5 fo r th e n o m o th e ti c co g n it io n

p re d ic to rs .T e m p o ra l/ in cr e m e n ta lv a li d it y :I C S fa ct o r

sc o re s p re d ic te d a n av e ra g e o f 6 % o f th e d a il y v a ri a b il it y

in sy m p to m /d is tr e ss o v e r a n d a b o v e th a t p re d ic te d b y

th e n o m o th e ti c co g n it io n s (R

2 in c = .0 0 to

.1 7 )

1 3 . M u m m a &

M o o n e y (2 0 0 7 )

U S A

2 1

1 •

T h e ex p e rt ca se

fo rm

u la ti o n (i n co rp o ra ti n g se le ct io n o f

Id io sy n cr a ti c C o g n it iv e S ch e m a s [I C S ]d e ri v e d fr o m

v ie w in g th e C B IS S A I) ex p la in e d a p p ro x im

a te ly tw

ic e th e

v a ri a n ce

in th e In d iv id u a li ze d D a il y Q u e st io n n a ir e (I D Q )

d is tr e ss sc o re s co m p a re d to

th e n o v ic e cl in ic ia n ’s

se le ct io n o f IC S C C F (a v e ra g e sh ru n ke n R 2 = .4 6 v s. .2 3 ,

re sp e ct iv e ly )

1 4 . M u m m a & S m it h

(2 0 0 1 )U

S A

1 0

n /a

4 /2 1

• IC C (2 ,1 0 )r a n g e d fr o m .8 3 to

.9 5 a n d IC C (2 ,1 )r a n g e d

fr o m .3 3 to

.6 3 fo r e a ch

o f th e 1 5 ra ti n g d im

e n si o n s (e .g .,

co g n it iv e ,a ff e ct iv e ,a n d sy m p to m sc a le s) [N B :R

a ti n g s

w e re

m a d e to

d e te rm

in e h o w ch a ra ct e ri st ic e a ch

d im

e n si o n w a s fo r e a ch

co g n it iv e -b e h av io ra l

in te rp e rs o n a ls ce n a ri o (C B IS ;N

= 2 1 )g e n e ra te d b a se d

o n v id e o -t a p e d se ss io n s o f cl ie n ts (N

= 4 )

• T h e se t o f C B IS s fo rm

u la te d b y a cl in ic ia n fo r a p a ti e n t

g e n e ra ll y d e m o n st ra te d g o o d co n v e rg e n t (s a m e

p a ti e n t/ d if fe re n t fo rm

u la to r) a n d d is cr im

in a n t (d if fe re n t

p a ti e n t/ sa m e o r d if fe re n t fo rm

u la to r) v a li d it y u si n g

th re e fa ct o r so lu ti o n e n co m p a ss in g g e n e ra ld im

e n si o n s

o f d e p re ss io n ,a n x ie ty ,a n d in te rp e rs o n a lf u n ct io n in g

(C on ti nu es )

EASDEN AND KAZANTZIS 365

T A B L E 1

(C o n ti n u e d )

S a m p le si ze

(n )

K e y fi n d in g s

R a te rs

T h e ra p is ts

C li e n ts /

v ig n e tt e s

R e li a b il it y

V a li d it y

1 5 . M u ra n & S e g a l

(1 9 9 2 )U

S A

3 1

1 •

IC C (2 ,k )=

.9 2 w h e n av e ra g e d a cr o ss tw

o ra te rs a n d .9 3

a cr o ss th re e ra te rs

• IC C (2 ,3 )f o r re li a b il it y a cr o ss in te rv ie w e r, p a ti e n t a n d

o b se rv e r ra ti n g s: S it u a ti o n (. 9 2 ), a ff e ct iv e (. 9 5 )m

o to ri c

(. 9 7 ), co g n it iv e (. 8 8 )

• B a se d o n d e sc ri p ti v e o b se rv a ti o n o f d a ta ,i m p ro v e m e n t

in se lf -s ce n a ri o s co rr e sp o n d e d w it h im

p ro v e m e n t in

o v e ra ll o u tc o m e o n o f G S I o n th e S C L -9 0

1 6 . M u ra n ,S e g a l, &

S a m st a g U S A

2 5

8 •

IC C (3 ,3 )=

.9 2 w h e n av e ra g e d a cr o ss a ll ca se s

• IC C (3 ,3 )f o r re li a b il it y a cr o ss in te rv ie w e r, p a ti e n t a n d

o b se rv e r ra ti n g s: S it u a ti o n (. 9 2 ), a ff e ct iv e (. 9 0 )m

o to ri c

(. 9 1 ), co g n it iv e (. 9 3 )

• IC C (3 ,3 )a cr o ss a ll cl ie n ts (N

= 8 )r a n g e d fr o m .8 0 to

.9 0

• N B :R

e li a b il it y e st im

a te s m ay

a p p e a r in fl a te d d u e to

u se

o f IC C (3 ,k )a n a ly si s

• T h e G S I o f S C L -9 0 a n d su m to ta ls co re

o n D A S u se d fo r

co m p o si te

o u tc o m e s in d ex

w h ic h sh o w e d a si g n ifi ca n t

co rr e la ti o n w it h se lf -s ce n a ri o s i.e ., r( 4 9 )=

.2 9 ,p

< .0 5

• F u rt h e r d if fe re n ce s b e tw

e e n ca se s re p o rt e d a t th e ca se

le v e l

1 7 . M u ra n e t a l.

(1 9 9 8 )U

S A

4 6

6 •

IC C (2 ,k )=

.9 4 w h e n av e ra g e d a cr o ss a ll ca se s (r a n g e .8 8

to .9 7 )b a se d o n cl in ic a lr e le v a n ce

o f in te rp e rs o n a l

sc e n a ri o s fo r cl ie n ts co m p a re d w it h p re d e te rm

in e d

cr it e ri o n

• Te st -r e te st re li a b il it y fo r a ll se lf sc e n a ri o s a cr o ss 2 9

se ss io n s fo r a ll p a ti e n ts ra n g e d fr o m IC C (3 ,k )=

.8 3 to

.9 7

• Id e n ti fi e d “g o o d o u tc o m e ” a n d “w

o rs t o u tc o m e ” ca se s

b a se d o n sc o re s fo rm

th e G S I o f th e S C L -9 0 a n d II P.

T h re e ca se s m e t th e cu t- o ff sc o re ,t w o o f w h ic h

si g n ifi ca n tl y ch a n g e d o n b o th

m e a su re s; th e th ir d

e v id e n ce d si g n ifi ca n t ch a n g e o n o n ly th e II P w h e n

co m p a re d to

ch a n g e in p a ra m e tr ic ra ti n g s o f

in te rp e rs o n a ls ce n a ri o s

1 8 . M u ra n e t a l.

(2 0 0 1 )U

S A

2 1

1 •

IC C (2 ,k )=

.9 6 b e tw

e e n in te rv ie w e r a n d o b se rv e r, .8 7

b e tw

e e n in te rv ie w e r, o b se rv e r a n d p a ti e n t a s cr it e ri o n ,

a n d .9 2 w it h th e a d d it io n o f co n st ru ct o r a ls o re p la ce d a s

cr it e ri o n .R e li a b il it y e st im

a te s b a se d o n cl in ic a l

re le v a n ce

o f in te rp e rs o n a ls ce n a ri o s

• R e p e a te d m e a su re s ti m e -s e ri e s d a ta

o f si n g le cl ie n t

u si n g si m p le tr e n d a n a ly si s to

d e m o n st ra te

fr e q u e n cy

o f

“b e st ca se ” sc e n a ri o s in cr e a si n g o v e r ti m e a n d “w

o rs t

ca se ” d e cr e a si n g ,w

it h si m il a r tr e n d s a ss o ci a ti o n w it h

in cr e a se d se lf -e ffi ca cy

(C on ti nu es )

366 EASDEN AND KAZANTZIS

T A B L E 1

(C o n ti n u e d )

S a m p le si ze

(n )

K e y fi n d in g s

R a te rs

T h e ra p is ts

C li e n ts /

v ig n e tt e s

R e li a b il it y

V a li d it y

1 9 . N a tt ra ss e t a l.

(2 0 1 4 )U

K 3

8 2 9 /7 0

• In te rr a te r re li a b il it y fo r co n te n t a n d q u a li ty

a cr o ss e v e ry

ca se

fo rm

u la ti o n o b ta in e d a m u lt i- ra te r k a p p a

co e ffi ci e n t o f 0 .6 4 (r a n g e .6 0 to

.8 0 )

• IC C y ie ld e d a n o v e ra ll re li a b il it y e st im

a te

o f 0 .7 5 a cr o ss

q u a li ty

ra ti n g s

• In d e p e n d e n t q u a li ty

ra ti n g s y ie ld e d IC C s o f 0 .9 2

(c o m p le x it y ), 0 .8 8 (s y st e m a ti c p ro ce ss ), 0 .7 8

(e la b o ra ti o n ), 0 .7 6 (p re ci si o n o f la n g u a g e )a n d 0 .7 3

(c o h e re n ce )

• N o si g n ifi ca n t fi n d in g s o f co rr e la ti o n o f q u a li ty

o f ca se

fo rm

u la ti o n a n d sc o re s o n Y B O C S (r = .3 6 ;. 3 7 ;. 1 2 ),

C O R E -S F (r = − .2 4 ;. 0 5 ;. 0 9 ), o r A R M -1 2 (r = .0 8 ;. 0 5 ;. 1 2 )

a n d p h a se

o f fo rm

u la ti o n

• P o te n ti a lf o r in su ffi ci e n t sa m p le si ze

to d e te ct si g n ifi ca n t

re su lt s

• P sy ch o lo g ic a ld is tr e ss d u ri n g th e p o st -f o rm

u la ti o n

p h a se

(M = 1 4 .8 1 ,9 5 % C I [1 1 .5 5 ,1 8 .0 8 ]) w a s

si g n ifi ca n tl y lo w e r (p

< .0 1 )t h a n d u ri n g a ss e ss m e n t (M

= 1 8 .2 3 ,9 5 % C I [1 5 .4 8 ,2 0 .9 9 ]) a n d fo rm

u la ti o n p h a se s

(M = 1 7 .2 0 ,9 5 % C I [1 3 .6 1 ,2 0 .8 0 ])

• T h e a ll ia n ce

a t th e e n d o f th e p o st fo rm

u la ti o n p h a se

(M = 7 5 .4 1 ,9 5 % C I [7 2 .3 4 ,7 8 .4 9 ]) w a s si g n ifi ca n tl y

h ig h e r (p

< .0 5 )

2 0 . P e rs o n s e t a l.

(1 9 9 5 )U

S A

4 6

n /a

2 •

A b so lu te

p e rc e n ta g e a g re e m e n t fr o m 1 3 % to

1 0 0 % fo r

p ro b le m id e n ti fi ca ti o n

• B a se d o n to ta ls a m p le m e a n IC C (2 ,2 )f o r u n d e rl y in g

m e ch a n is m s w a s .4 6 (r a n g e .0 7 to

.7 0 )

• IC C (2 ,5 )a v e ra g e d a cr o ss fi v e ju d g e s w e re

.8 3 (r a n g e .6 6

to .9 2 )

2 1 . P e rs o n s &

B e rt a g n o ll i

(1 9 9 9 )U

S A

4 7

n /a

2 •

M e a n p e rc e n ta g e a g re e m e n t w a s 6 7 .4 6 %

• (S D = 1 3 % )f o r co rr e ct p ro b le m id e n ti fi ca ti o n

• IC C s av e ra g e d a cr o ss fi v e ju d g e s w e re

.7 2 (r a n g e .4 4 to

.9 1 )a n d fo r si n g le ju d g e s .3 7 (r a n g e .1 3 to

.6 6 )

• R e g re ss io n a n a ly si s o f 3 8 su b je ct s o n th e re la ti o n sh ip

b e tw

e e n tr a in in g v a ri a b le s a n d p ro b le m id e n ti fi ca ti o n

p ro d u ce d st a ti st ic a ll y si g n ifi ca n t m o d e l( R -s q u a re

is 0 .3 4 ,p

= .0 3 )a n d o n ly P h D -l e v e lt ra in in g ,w

a s

st a ti st ic a ll y si g n ifi ca n t (p

= .0 1 )a s a n in d e p e n d e n t

v a ri a b le

• F o r sc h e m a id e n ti fi ca ti o n n o tr a in in g v a ri a b le s sh o w e d a

si g n ifi ca n t e ff e ct a t th e p < .0 5 le v e l

(C on ti nu es )

EASDEN AND KAZANTZIS 367

T A B L E 1

(C o n ti n u e d )

S a m p le si ze

(n )

K e y fi n d in g s

R a te rs

T h e ra p is ts

C li e n ts /

v ig n e tt e s

R e li a b il it y

V a li d it y

2 2 . P e rs o n s e t a l.

(1 9 9 9 )U

S A

n /a

1 4 5

• A la rg e p re -p o st e ff e ct si ze

fo r d e p re ss iv e sy m p to m s a s

m e a su re d o n th e B D I fo r cl ie n ts tr e a te d w it h

fo rm

u la ti o n -d ri v e n C B T a lo n e (n

= 2 7 ;d

= 1 .4 4 )a n d

fo rm

u la ti o n -d ri v e n C B T p lu s p h a rm

a co th e ra p y (n

= 1 8 ;

d = 1 .4 1 ).

• E ff e ct si ze s co n si d e re d co m p a ra b le to

ex is ti n g R C T s

2 3 . P e rs o n s e t a l.

(2 0 0 6 )U

S A

n /a

1 5 8

• F o r fo rm

u la ti o n -d ri v e n C B T a la rg e p re -p o st e ff e ct si ze

fo r d e p re ss iv e sy m p to m s a s m e a su re d o n th e B D I- II (d

= 1 .3 3 )a n d fo r sy m p to m s o f a n x ie ty

a s m e a su re d b y

B U R N S A I (d

= 0 .9 8 )

• E ff e ct si ze s w e re

co n si d e re d to

b e m o d e st co m p a re d to

ex is ti n g m e ta -a n a ly se s e ff e ct si ze s. T h e d if fe re n ce

p o te n ti a ll y a tt ri b u te d to

d if fe re n ce s b e tw

e e n

n a tu ra li st ic tr e a tm

e n t sa m p le s a n d re se a rc h sa m p le s.

T h is h y p o th e si s w a s su p p o rt e d b y o b se rv e d in cr e a se s in

e ff e ct si ze

a ft e r a d ju st in g fo r in it ia ls y m p to m se v e ri ty

2 4 . R e d h e a d e t a l.

(2 0 1 5 )U

K 1

7 1 0

• N il su b st a n ti v e d a ta

re p o rt e d / co m p a ri so n o f th e m e s in

tw o tr a n sc ri p ts b y a n o th e r in d e p e n d e n t re se a rc h e r

• T h e m a ti c a n a ly si s id e n ti fi e d fo u r m a in th e ra p y

e n h a n ci n g th e m e s, th a t th e ca se

fo rm

u la ti o n :1 )‘ h e lp s

m e to

u n d e rs ta n d m y p ro b le m s’ ,2 )‘ le a d s to

fe e li n g

u n d e rs to o d a n d a cc e p te d ’, 3 )‘ le a d s to

a n e m o ti o n a ls h if t’

a n d 4 )‘ e n a b le s m e to

m o v e fo rw

a rd s’

N ot e. A D IS -I V -C /P

= A n x ie ty

D is o rd e rs

In te rv ie w S ch e d u le fo r D S M -I V , C h il d a n d P a re n t V e rs io n s (A D IS IV -C /P A R M -1 2 = A g n e w -D

av ie s R e la ti o n sh ip

M e a su re ; B D I- II = B e ck

D e p re ss io n

In v e n to ry ;B

u rn s A I = B u rn s A n x ie ty

In v e n to ry ;B

S Q

= B o d y S h a p e Q u e st io n n a ir e ;C

B IS S A I = C o g n it iv e -B e h av io ra lS e m iS tr u ct u re s In te rv ie w ;C

O R E -S F = C li n ic a lO

u tc o m e s in R o u ti n e E v a l-

u a ti o n ; D A S = D y sf u n ct io n a l A tt it u d e s S ca le ; E D E = E a ti n g D is o rd e rs

E x a m in a ti o n Q u e st io n n a ir e ; E D I = E a ti n g D is o rd e rs

In v e n to ry ; G S I = G lo b a l S e v e ri ty

In d ex ; H A q = H e lp in g A ll ia n ce

Q u e st io n n a ir e ;I D Q = In d iv id u a li ze d D a il y Q u e st io n n a ir e ;I IP

= In v e n to ry

o f In te rp e rs o n a lP ro b le m s; S C L -9 0 = S y m p to m s C h e ck li st -9 0 -R e v is e d ;Y

B O C S = Y a le -B ro w n O b se ss iv e C o m p u ls iv e

S ca le .

368 EASDEN AND KAZANTZIS

T A B L E 2

S a m p le si ze s, a im

s, m o d e li n te g ri ty ,a n d o u tc o m e a ss e ss m e n t in co g n it iv e ca se

co n ce p tu a li za ti o n st u d ie s (N

= 2 4 )

S tu d y a im

s M o d e li n te g ri ty

O u tc o m e a ss e ss m e n t

In te r- cl in ic ia n

a g re e m e n t

U se

o f e x p e rt /

b e n ch m a rk

In te g ri ty

ch e ck s

P re sc ri b e d

tr a in in g

L in k to

sy m p to m

ch a n g e

C li e n t o r th e ra p is t

fe e d b a ck

1 . C h a d w ic k e t a l. (2 0 0 3 )

✓ ✓

2 . D u d le y e t a l. (2 0 1 0 )

✓ ✓

✓

3 . E e ll s e t a l. (2 0 0 5 )

✓ ✓

✓

4 . E e ll s e t a l. (2 0 1 1 )

a a

a

5 . E sb jø rn

e t a l. (2 0 1 5 )

✓ ✓

✓

6 . F li tc ro ft e t a l. (2 0 0 7 )

✓

7 . G h a d e ri (2 0 0 6 )

✓

8 . H a a rh o ff e t a l. (2 0 1 1 )

✓ ✓

✓

9 . K e n d je li c & E e ll s (2 0 0 7 )

✓ ✓

✓ ✓

1 0 . K u y ke n e t a l. (2 0 0 5 )

✓ ✓

✓

1 1 . M o rb e rg

P a in e t a l. (2 0 0 8 )

✓ ✓

✓

1 2 . M u m m a (2 0 0 4 )

✓ ✓

1 3 . M u m m a & M o o n e y (2 0 0 7 )

✓ ✓

1 4 . M u m m a & S m it h (2 0 0 1 )

✓ ✓

✓

1 5 . M u ra n & S e g a l( 1 9 9 2 )

✓ ✓

✓

1 6 . M u ra n e t a l. (1 9 9 4 )

✓ ✓

✓

1 7 . M u ra n e t a l. (1 9 9 8 )

✓ ✓

✓

1 8 . M u ra n e t a l. (2 0 0 1 )

✓ ✓

✓

1 9 . N a tt ra ss e t a l. (2 0 1 4 )

✓ ✓

✓ ✓

2 0 . P e rs o n s e t a l. (1 9 9 5 )

✓ ✓

2 1 . P e rs o n s & B e rt a g n o ll i( 1 9 9 9 )

✓ ✓

✓ ✓

2 2 . P e rs o n s e t a l. (1 9 9 9 )

✓ ✓

2 3 . P e rs o n s e t a l. (2 0 0 6 )

✓ ✓

2 4 . R e d h e a d e t a l. (2 0 1 5 )

✓ ✓

a E e ll s e t a l. (2 0 1 1 )u se d th e sa m e d a ta

se t a s E e ll s e t a l. (2 0 0 5 )b u t w it h d if fe re n t re se a rc h fo cu s a n d a n a ly si s. T h u s, d a ta

a re

ex cl u d e d fr o m th e p re se n t a n a ly si s w h e re

d u p li ca te

d a ta

p ro d u ce d .

EASDEN AND KAZANTZIS 369

3.3 Study site

The majority of studies were conducted in the United States (n = 14, 58.3%) or the United Kingdom (n = 7, 29.2%). One study (4.2%) was conducted in each of New Zealand, Denmark, and Sweden.

3.4 Source of conceptualization data

The majority of studies involved construction and analysis of clinical vignettes (n = 17, 71%) or written case concep- tualizations (see Table 3). Over half of the studies (n = 15, 62.5%) used independent observations of real-time ther- apy sessions, likely to increase ecological validity. A third of the studies (n = 8, 33.3%) used video-recorded data, seven (29.1%)usedaudio-recordeddata,andthree(12.5%)usedprimarilyqualitativeapproach-basedinterviewswithclients

to elicit their experience of case conceptualization. Some studies used data from multiple therapy sessions (n = 14, 58.3%), rather than discrete assessment points, to consider the development and change in aspects of the case concep-

tualization over time.

3.5 Level of conceptualization data

Table 3 presents a focused examination of the levels of case conceptualization covered in studies. While all the stud-

ies incorporated some analysis of situational-level case conceptualization data (e.g., through identification of thoughts,

behavior, or emotion using self-report symptom scales or coding self-schema), a little over half (n = 14, 58.3%) consid- ered deeper-level components of a CBT conceptualization (i.e., core beliefs and underlying cognitive mechanisms). All

studies reported some type of diagnosis-level conceptualization. It was interesting to note that very few studies used

a structured case conceptualization format considered to be routinely used in clinical practice. For example, only three

studies (1, 10, and 11) included the use of the J. Beck CCD within the study protocol. The majority of studies (n = 18, 75%) concerned clients with depression (n = 18, 75%) and/or anxiety (n = 19, 79.2%), and one included diagnoses of bipolar disorder (4.2%); six studies included clients with personality disorders or personality disorder features (25%);

and only three studies (12.5%) involved clients with psychotic disorders. Single studies (4.2%) focused on treatment

for bulimia nervosa, obsessive compulsive disorder (OCD), and delusional disorder, specifically. Surprisingly only one

study (4.2%) included those with comorbid substance use disorders.

3.6 Measurement of reliability

The most common reliability index used across all studies was the intraclass correlation coefficient (ICC; n = 8, 33%). Five studies reported Kappa coefficients (20.8%) and five studies reported percentage agreement (20.8%) due to the

data being analyzed. Research that has attempted to calculate interclinician consistency has yielded variable findings

dependent on particular reliability analysis used, the study design and methods employed, level of case conceptualiza-

tion being assessed, and training of those conducting ratings and constructing case conceptualizations. It follows that

the level of reliability across studies varied from almost no agreement to 100% agreement and so reporting a pooled

mean across all studies was not indicated. A close narrative analysis and limited systematic synthesis of results from

groups of studies where appropriate is presented below.

3.7 Reliability of case conceptualization content

The construction of expert “gold standard” benchmark conceptualizations or “mini-formulations” used as criterion in

analysis was a method routinely modified and implemented across studies in the review. Studies focused on differ-

ent case conceptualization components or levels of CBT case conceptualization. For example, Persons, Mooney, and

Padesky (1995) investigated the reliability of clinician’s (N = 46) identification of six problems on a problem list, also using an analogue rating scale (1 to 10) on the centrality of underlying cognitive mechanisms (i.e., core beliefs about

self, world, others, and dysfunctional attitudes) for two depressed and anxious clients. All clinicians were tested in

370 EASDEN AND KAZANTZIS

T A B L E 3

D a ta

so u rc e a n d le v e lo f co n ce p tu a li za ti o n in ca se

co n ce p tu a li za ti o n st u d ie s (N

= 2 4 )

D a ta

so u rc e

Le v e lo f co n ce p tu a li za ti o n

V ig n e tt e / in ta k e

a ss e ss m e n t

D a ta

fr o m m u lt ip le

th e ra p y se ss io n s

U se

o f re a l- ti m e

cl ie n t d a ta

S it u a ti o n a ll e v e l

(“ su rf a ce ” th o u g h ts ,

e m o ti o n s, e tc )

D ia g n o si s le v e l

(s y m p to m o r p ri m a ry

d is o rd e r)

C o m p re h e n si v e

fo rm

u la ti o n

(“ d e e p e r”

m e ch a n is m s, e tc )

1 . C h a d w ic k e t a l. (2 0 0 3 )

✓ ✓

A u d io

✓ P sy ch o ti c D is o rd e r

✓

2 . D u d le y e t a l. (2 0 1 0 )

✓ V id e o

✓ P sy ch o ti c D is o rd e r

✓

3 . E e ll s e t a l. (2 0 0 5 )

✓ ✓

D e p re ss io n ,A

n x ie ty ,

P e rs o n a li ty

D is o rd e r

4 . E e ll s e t a l. (2 0 1 1 )

✓ ✓

D e p re ss io n ,A

n x ie ty ,

P e rs o n a li ty

D is o rd e r

5 . E sb jø rn

e t a l. (2 0 1 5 )

✓ V id e o

✓ A n x ie ty

✓

6 . F li tc ro ft e t a l. (2 0 0 7 )

✓ D e p re ss io n

✓

7 . G h a d e ri (2 0 0 6 )

✓ ✓

✓ E a ti n g D is o rd e r

(B u li m ia )

8 . H a a rh o ff e t a l. (2 0 1 1 )

✓ ✓

D e p re ss io n ,A

n x ie ty

✓

9 . K e n d je li c & E e ll s (2 0 0 7 )

✓ ✓

D e p re ss io n ,A

n x ie ty ,

P e rs o n a li ty

D is o rd e r

1 0 . K u y ke n e t a l. (2 0 0 5 )

✓ V id e o

✓ D e p re ss io n ,

P e rs o n a li ty

D is o rd e r

✓

1 1 . M o rb e rg

P a in e t a l.

(2 0 0 8 )

✓ ✓

A u d io

✓ P sy ch o ti c D is o rd e r

✓

1 2 . M u m m a (2 0 0 4 )

✓ V id e o

✓ D e p re ss io n ,A

n x ie ty

✓

(C on ti nu es )

EASDEN AND KAZANTZIS 371

T A B L E 3

(C o n ti n u e d )

D a ta

so u rc e

Le v e lo f co n ce p tu a li za ti o n

V ig n e tt e / in ta k e

a ss e ss m e n t

D a ta

fr o m m u lt ip le

th e ra p y se ss io n s

U se

o f re a l- ti m e

cl ie n t d a ta

S it u a ti o n a ll e v e l

(“ su rf a ce ” th o u g h ts ,

e m o ti o n s, e tc )

D ia g n o si s le v e l

(s y m p to m o r p ri m a ry

d is o rd e r)

C o m p re h e n si v e

fo rm

u la ti o n

(“ d e e p e r”

m e ch a n is m s, e tc )

1 3 . M u m m a & M o o n e y

(2 0 0 7 )

✓ V id e o

✓ D e p re ss io n ,A

n x ie ty

✓

1 4 . M u m m a & S m it h

(2 0 0 1 )

✓ V id e o

✓ D e p re ss io n ,A

n x ie ty

✓

1 5 . M u ra n & S e g a l( 1 9 9 2 )

✓ ✓

✓ D e p re ss io n ,A

n x ie ty

1 6 . M u ra n e t a l. (1 9 9 4 )

✓ ✓

A u d io

✓ D e p re ss io n ,A

n x ie ty

1 7 . M u ra n e t a l. (1 9 9 8 )

✓ ✓

V id e o

✓ D e p re ss io n ,A

n x ie ty ,

P e rs o n a li ty

D is o rd e r

1 8 . M u ra n e t a l. (2 0 0 1 )

✓ ✓

V id e o

✓ D e p re ss io n ,A

n x ie ty

P e rs o n a li ty

D is o rd e r

1 9 . N a tt ra ss e t a l. (2 0 1 4 )

✓ A u d io

✓ A n x ie ty

(O C D )

2 0 . P e rs o n s e t a l. (1 9 9 5 )

✓ A u d io

✓ D e p re ss io n ,A

n x ie ty

✓

2 1 . P e rs o n s & B e rt a g n o ll i

(1 9 9 9 )

✓ A u d io

✓ D e p re ss io n ,A

n x ie ty

✓

2 2 . P e rs o n s e t a l. (1 9 9 9 )

✓ ✓

D e p re ss io n ,B ip o la r,

A n x ie ty

S u b st a n ce

A b u se

2 3 . P e rs o n s e t a l. (2 0 0 6 )

✓ ✓

D e p re ss io n ,A

n x ie ty

2 4 . R e d h e a d e t a l. (2 0 1 5 )

✓ ✓

A u d io

✓ D e p re ss io n ,A

n x ie ty

372 EASDEN AND KAZANTZIS

relation to benchmark problem lists devised by experts, yielding a wide range of absolute agreement (13% to 100%)

in the identification of problems.

Clinician reliability on underlying cognitive mechanisms produced a low ICC of 0.46 (range was 0.07 to 0.70). “How-

ever, when a subgroup of five clinicians’ data were examined as a group, a higher ICC value of 0.83 (range was 0.66

to 0.92) was found, which is considered “adequate” to “excellent” by Shrout and Fleiss (1979) criteria. The authors

attributed instances of exceptionally poor agreement to low interitem variation, which can compromise the ICC statis-

tic (see review of ICC in Petrik, Farchione, Dobson, & Kazantzis, 2017). A further study (Persons & Bertagnolli, 1999)

attempted to replicate and extend the findings reported in Persons et al. (1995) by providing greater structure for the

content of core beliefs (i.e., groupings for self, world, or future were required). However, reliability coefficients for pairs

of clinicians were poor and produced an overall mean ICC of 0.37.

In the largest study of clinicians identified in the review, 115 practitioners with a range of professional backgrounds

and experience in CBT participated in a workshop that assessed their case conceptualization skills (i.e., Kuyken,

Fothergill, Musa, & Chadwick, 2005). Clinicians read an assessment summary of a single client “Anna” (an actress)

diagnosed with major depressive disorder and personality pathology and were provided additional information (e.g.,

short video clips of therapy, thought records). Clinicians were required to provide conceptualizations, which were then

assessed against a benchmark conceptualization created by J. Beck. Participants also completed the standard Beckian

Cognitive Conceptualization Diagram format (CCD; J. Beck, 1995), to incorporate a routinely used conceptualization

structure.

All conceptualizations were rated for quality using the Quality of Cognitive Case Formulation Rating Scale

(Fothergill & Kuyken, 2002). The procedure for this involved transferring information onto cards and using two inde-

pendent judges to form agreement on categories of information units (range 𝜅 = 0.63–0.91). Agreement ratings were based on correct placement of conceptualization information in the diagram (i.e., rather than the accuracy of the con-

tent). Percent agreement between individual clinicians and expert benchmark conceptualization ranged from 7% to

73%, and the overall sample identified less than half the available conceptualization information (i.e., mean < 50%

agreement). However, this study was unable to determine whether variable responses were due to deficits in clinicians’

case conceptualization skill, their understanding of CBT, their familiarity with the diagnostic criteria for depression, or

their familiarity the general cognitive model of depression.

Five studies (20.8%), also incorporating use of benchmark conceptualizations or predetermined criterion, focused

on using semistructured interviews and measures to elicit and identify idiosyncratic conceptualization data in the form

of self-schema. These studies have tended to yield high interrater reliability (i.e., mean ICCs ranging from .87 to .96 for

self-scenarios). Muran and Segal’s (1992)method for development of “self-scenarios” or sets of “self-schema” was com-

monly employed, which included assessing for prescribed components: (a) stimulus situation, (b) affective response, (c)

motoric response, and (d) cognitive response. These were coded into sentences about the self (e.g., “When I am in social

situations, I…”) appropriate to the prescribed clinical component. In one such study that adopted and extended this approach (Mumma & Smith, 2001), 10 independent evaluators

examined situation-level case conceptualizations (N = 21) constructed from video recordings of four clients by four clinicians. The extent to which conceptualizations captured cognitive, affective, and motoric responses as well as an

additional interpersonal component (i.e., the anticipated and actual self-reported responses of others) was assessed

using a 15-item measure rated on a 9-point Likert scale (e.g., “to what extent is the cognitive content of this scenario

characterized by thoughts, beliefs, or images of being overwhelmed or unable to cope”). A set of heuristic guidelines

was used to further increase structure for therapists coding self-scenarios from video-recorded interviews (e.g., that

thoughts or beliefs needed to meet criteria for common thinking errors such as “all or nothing thinking” as developed

by Beck et al., 1979).

High levels of agreement (i.e., ICC > 0.83) were found on case conceptualization content. The pattern of reliabil-

ity coefficients between raters suggested convergence for a particular client and discrimination between clients. It is

possible that the use of a clear rating system by independent raters represents a methodological advancement over

previous research. It is also likely that the greater contextual information afforded by actual recordings of clients, as

EASDEN AND KAZANTZIS 373

compared to written vignettes, resembled usual clinical and supervision work to a greater extent and provided a better

assessment of clinicians’ case conceptualization skills.

Of note, in terms of validity (as it would related to treatment outcome), these study methods then allow for deter-

mination of content validity by examining convergent and/or discriminant validity (the results for relevant studies are

presented in Table 1). This is done by examining the relationship between temporal changes in case idiosyncratic con-

ceptualization data (i.e., specific negative cognitive schema) and the level of statistical variance explained in measures

of symptom distress change over time.

In synthesizing findings across this group of studies the form of reliability coefficient is particularly relevant to inter-

preting the level of reliability in comparison with other groups of studies. Specifically, it is noted that averaging across

increasing numbers of raters or use of the ICC (3, k) form (which presumes the sample is representative of a total pop-

ulation) is likely to inflate the resultant reliability estimate (i.e., as outlined in Shrout & Fleiss, 1979). However, the

methodology employed and applied at a symptom level to idiosyncratic self-schema can be distinguished from other

researchonconceptualizationthroughtheuseofmultipledatasources,andtheattempttoprioritizetheclinical impor-

tance of the material for the case.

3.7.1 Evaluation of level of training

Although a number of studies were conducted in the context of training, some studies (n = 5, 20.8%) specially examined and reported on the extent to which clinician’s levels of training and experience can influence their ability to consis-

tently formulate case information relative to prespecified criteria or categories. In these studies, therapists are classi-

fied by their relative experience levels. According to Eells, Lombart, Kendjelic, Turner, and Lucas (2005), the categories

and criteria commonly used are “novice” (i.e., psychology graduate students), “experienced” (psychiatrists and clinical

psychologists with 10 or more years of experience), and “expert” (psychiatrists and clinical psychologists with greater

supervisory experience and specific expertise in case conceptualization).

In one such study, a group of 65 clinicians comprising those classified as novice, experienced and expert constructed

comprehensive conceptualizations based on six standardized vignettes with a range of disorders and prototypicality,

yielding 390 case conceptualizations (Eells et al., 2005). After reading the vignettes, therapists were given 5 minutes to

“think aloud” and verbalize a case conceptualization in an unstructured manner with instructions to “address whatever

you [the clinicians] think is important.” The Case Formulation Content Coding method (CFCCM; Eells et al., 1998) was

used to code the transcribed case conceptualizations. Recoding was conducted on a random 10% of transcripts and

the resulting kappa coefficients based on “descriptive”- (𝜅 = 0.61), “diagnostic”- (𝜅 = 0.81), “inferential”- (𝜅 = 0.62), and “treatment”-related (𝜅 = 0.69) information reflected good to excellent rates of agreement between raters about how to categorize content.

In addition, multiple 5-point Likert scales were rated by pairs of raters to judge the relative presence / sufficiency

or absence / insufficiency of essential features of quality case conceptualizations. The reliability for the level of “con-

ceptualization elaboration” across all categories of information (e.g., diagnosis, predisposing stressors, precipitating

stressors, strengths) was considered good to excellent (ICC ranged from 0.69 to 0.89). Similarly “precision of language”

(ICC = 0.77), “complexity” (ICC = 0.83), “coherence” (ICC = 0.75), “treatment plan elaboration” (ICC = 0.86), “goodness- of-fit” (ICC = 0.73), and “systematic process” (ICC = 0.77) also reflected good to excellent levels of reliability. Subse- quently, expert conceptualizations were rated as more comprehensive, elaborated, complex, systematic, and better

quality overall compared with experienced and novice therapists.

In a second study investigating therapist training in conceptualization, a sample of 20 novice therapists undertook

a 2-hour conceptualization training session, in contrast to 23 therapists that did not receive training (Kendjelic & Eells,

2007). Using data from 99 conceptualizations of primarily depressed and anxious clients and based on a large mean

effect size of 1.12, the researchers concluded that the average therapist in the training group had a better quality con-

ceptualization than 86% of therapists in the control group. In an extended analysis of data from the Eells et al. (2005)

study, Eells et al. (2011) found small to moderate effect sizes for experts generating more descriptive (d = 0.33), diag- nostic (d = 0.24), inferential (d = 0.35), and treatment planning information (d = 0.32) in their case conceptualizations

374 EASDEN AND KAZANTZIS

than the nonexperts. Similarly, experts had a greater focus on treatment (d = 0.34) and psychological mechanisms of change (d = 0.25) than nonexperts.

Another study (Haarhoff, Flett, & Gibson, 2011) examined the content and quality of case conceptualizations also

constructed by novice clinicians (n = 26) based on four clinical vignettes, resulting in 104 written case conceptual- izations examined in relation to an expert benchmark. While the clinicians had diverse backgrounds and training, all

had completed the same postqualification CBT training course (i.e., Kennedy-Merrick, Haarhoff, Stenhouse, Merrick, &

Kazantzis, 2008). Agreement at different levels of conceptualization was calculated using range of different measures

including the CFCCM, the Quality of Cognitive Case Formulation Rating Scale, and the CBT Case Conceptualization

Rating Scale (Haarhoff, 2008). Over 50% produced “good” or “good enough” conceptualizations across all vignettes.

Only five of the clinicians produced “poor” and “very poor” conceptualizations for some vignettes. Reasons for poor

quality conceptualizations were related to omissions of information, lack of inferential information with a sole focus

on descriptive elements, and similarly lack of CBT-specific hypotheses (e.g., core beliefs, underlying assumptions, com-

pensatory strategies not identified). The problem list was identified as the weakest category, with 54% of clinicians

leaving this out entirely. Similarly, the agreement between clinician and benchmark in problem content was low for all

vignettes (𝜅s< 30%).

It was further noted that incorporation of protective factors or client strengths was generally omitted from writ-

ten case conceptualizations, despite obvious strengths being included in each of the case vignettes provided. Although

the same prescribed and extensive CBT-specific training was provided, a lack of prescribed structure for conceptual-

ization construction (i.e., relatively free-form written case conceptualization construction), and use of limited clinical

information (i.e., vignettes) in this group of novice clinicians is notable.

Dudley, Park, James, and Dodgson (2010) examined the extent to which 82 mental health professionals were able to

reach agreement on the content of a case conceptualization for a delusional client. The benchmark conceptualization

was developed by three experts within a generic CBT framework incorporating disorder-specific features of psychosis

considered central to the case conceptualization. Mental health professionals watched a 30-minute video of a CBT

assessment session role-played by an actor. They then completed a conceptualization template with which they were

oriented. A scoring manual assessed the extent to which different components and levels of the case conceptualization

content identified received a score of inaccurate (0), theme identified (1) or accurate (2). Rates of agreement on the

expert benchmark ranged from 32.2% to 91.6%.

Consistent with previous research the highest scores were for less inferential components of the conceptualization

(i.e., behavior and physical symptoms) and the lowest for more inferential components (e.g., core beliefs, dysfunctional

assumptions). However, identification of “thoughts” had the poorest agreement, conceivably because this component

is well learned in routine CBT practitioners compared with those professionals simply oriented to the therapy with

greater representation in this study. The “number of CBT cases seen” was positively associated (𝛽 = 0.28, t = 2.17, p < .05),withthemeannumberofinferentialcomponentsidentified.Similarly“overallyearsofexperience”(𝛽 = 0.42,t= 2.85, p < .01) had a positive association with the total conceptualization mean score, although the “number of psychosis

cases seen” had an inverse relationship (𝛽 = −0.37, t = −2.38, p < .05). As the authors identified, a number of mental health professionals had extensive experience working with psychosis, although they lacked extensive training and

knowledge in CBT.

In terms of study methods, across each of these studies, it remains unclear how case conceptualizations derived

by different professional groups, either those in agreement or at odds with the expert benchmark conceptual-

ization, would impact on primary outcomes such as client symptom change. There is an inherent assumption,

while reasonable to infer, that benchmark conceptualizations constructed by an expert are likely to be the gold

standard. However, this raises a second assumption previously highlighted in literature (Bieling & Kuyken, 2003)

that there is one “accurate” or “correct” psychological conceptualization, which is not necessarily in fitting with

notions of alternative conceptualizations, relative competence and success in the use of divergent conceptualiza-

tions, different levels and forms of case conceptualization, or even the emphasis and timing in the use of case

formation.

EASDEN AND KAZANTZIS 375

3.8 Evaluations of case conceptualization-symptom change relations and outcomes

3.8.1 Formulation-driven CBT

Of the sixteen studies (66.7%) that investigated some aspect of symptom change relations, five of these studies

(31.3%) fell under the umbrella of “formulation-driven CBT” studies. These studies provide a comparison between

the formulation-driven treatment group and treatment as usual (i.e., standard manualized treatment), lending to

a traditional randomized controlled trial (RCT) approach or retrospective comparison of treatment effects with

equitable or matched preexisting data sets. The criteria used to define the formulation-driven group, and differenti-

ate this form the control group, differed between studies (e.g., stating a requirement that the therapist routinely or

systematically engage in an active process of case conceptualization, and/or engage in specific or discrete interven-

tions targeted on developing and integrating case conceptualization into naturalistic therapy sessions). Each study has

generally reported a measure of effect size of the formulation-driven treatment in the moderate to large range (see

Table 1) and determined that this was comparable to the control condition or other comparable samples in existing

RCTs.

For example, one study (Persons & Bertagnolli, 1999) found comparable results between conceptualization-

driven CBT versus CBT plus pharmacotherapy (n = 27). A second study (Persons, Roberts, Zalecki, & Brechwald, 2006) assessed 58 anxious depressed outpatients and found significant results, as well as large effects sizes for

conceptualization-driven CBT based on reduction of depressive symptoms scored on the Beck Depression Inventory

(d = 1.3) and anxiety on the Burns Anxiety Inventory (d = 0.98). Recent meta-analytic reviews suggest these effect sizes are equivalent for CBT and “conceptualization-driven CBT” (for reviews see Hofmann, Asnaani, Vonk, Sawyer, & Fang,

2012; Johnsen & Friborg, 2015).

Only one study in the review focused on investigating case conceptualization with families and children. Esbjørn

et al. (2015) investigated “formulation-driven CBT” for anxiety disorders with children (aged 7 to 12 years) and fami-

lies (N = 54). Case conceptualization construction was prescribed for the first sessions and systematically constructed based on child and family interactions. Additionally parents were randomized into a co-client group (n = 28), in which they were only given guidelines for homework completion, or a co-facilitator group (n = 26), in which they had addi- tional individual therapy sessions incorporating additional case conceptualization information in regards to the role of

the parent (e.g., either overinvolved, lack of warmth, or reinforcement of avoidance behavior in the maintenance of a

child’s difficulties). However, no significant difference was found between these groups for both “conceptualization-

driven CBT” conditions combined.

In a similar vein, Ghaderi (2006) compared standard manualized CBT for eating disordered patients with an “indi-

vidualized” or arguably conceptualization-driven CBT adaptation incorporating logical functional analysis. Patients (N

= 50) were randomized into one of the two treatment conditions. Overall, patients in both conditions improved equiv- ocally on the Eating Disorders Examination, which was the primary outcome measure. Response to treatment was

further defined by reduction in objective bulimic episodes (OBE) and compensatory behavior posttreatment.

There were significant group differences, suggesting greater efficacy of the individualized condition, notably in OBE

(P = 0.007), which revealed that at posttreatment, 92% in the individualized condition and 69% in the manualized con- dition met predefined criteria for reduced OBE. Similarly, posttreatment reduction of excessive compensatory exer-

cise found a significant group difference (P = 0.005) in the individualized condition, in which all of the patients (n = 10) stopped excessive compensatory exercise posttreatment, while 50% (8 of 16) continued to use excessive compen-

satory exercise posttreatment. It was noted further that of the 20% of patients that did not respond well to treatment,

80% were from the standard manual-based intervention. A point of difference in this study has to do with more clearly

systematized case conceptualization modification (i.e., targeted functional analyses) as a point of focus in the study.

Of note, during treatment adherence checks, the authors noted a wide range of individualization, akin to that of the

formulation-drive condition, within the standardized treatment condition.

Nattrass, Kellet, Hardy, and Ricketts (2015) sought to more directly measure case conceptualization and symptom

change relations. In a sample of 29 patients with OCD, they investigated how the content, timing, and quality of case

conceptualizations related to symptom outcomes. The authors used the CFCCM with additional descriptors added

376 EASDEN AND KAZANTZIS

specifically for OCD and applied this to a selection of audio recordings of therapy sessions (N = 70). These sessions were selected using inclusion and exclusion criteria derived from the CFCCM (i.e., instances in which the therapist or

client explicitly referred to case conceptualization, a summary of problems, symptoms or descriptive information, links

with other components of the case conceptualization, links with strengths and treatment outcome or therapy inter-

fering events in the process of therapy). As such, the authors excluded sessions with a relative absence of in-session

case conceptualization (i.e., poor or no explicit discussion and reflection), although as tradeoff reduced the ability draw

conclusions based on this additional data and variance herein. A correlation analysis of the impact of case conceptu-

alization quality at three distinct phases of therapy and outcomes of primary measures failed to achieve significant

results.

A number of conclusions can be drawn from this group of studies. First, studies incorporating conceptualization

within treatment protocols have generated limited support for the assertion that cognitive conceptualization leads to

improved CBT outcomes (Persons, 2006; Persons, Bostrom, & Bertagnolli, 1999; Persons, et al., 2006). Second, across

this group of studies inadequate statistical power to detect significance has consistently been identified as limitation as

in other areas of CBT process research (e.g., Kazantzis, 2000). Third, the determination that treatment effects are com-

parable to standard manualized treatments is likely influenced by a lack of operationalized differentiation between the

two treatment conditions (i.e., that therapists in the control condition might potentially be constructing and integrat-

ing individualized case conceptualizations with more competence than others in the formulation-driven condition). As

such, this group of studies have not clearly articulated how the adapted approaches to CBT represents an enhance-

ment over standard CBT, which if competently delivered, should include case conceptualization to adapt process and

techniques (see Young & Beck, 1980). A fourth and related point is that in terms of quality, we note that studies that

provided systematic and operationalized modification of aspects of the formulation-driven group (or perhaps better

described as a formulation-enhanced group) provided a relative methodological strength.

3.8.2 Client and therapist feedback on the utility of case conceptualization

The final group of outcome-oriented studies (n = 4) sought client and therapist feedback on the perceived utility of case conceptualization. These studies adopted a mixed-method and qualitative approach.

One study involved 11 clients diagnosed with schizophrenia-spectrum disorders (Chadwick, Williams, & Mackenzie,

2003). The initial two sessions (T1, T2) of therapy involved information gathering to inform the case conceptualization

without any direct evaluation of client cognitions. This was followed by two sessions (T3, T4) devoted to further explor-

ing and refining the case conceptualization in verbal, written (i.e., a letter in the client’s words, without jargon), and

diagrammatic form (e.g., situation level conceptualization). Clients and therapists met separately with the researcher

to examine perceptions of their case conceptualizations. Nine clients (82%) reported that the case conceptualization

increased hope and understanding, while some reported negative emotional reaction (n = 6, 55%) or neutral emotional reaction (n = 3, 27%). Therapists reported positive impacts including increased hope, validation, adherence to CBT model, strengthened alliance, and collaboration with their clients.

Morberg-Pain, Chadwick, and Abba (2008) used the same collaborative study design in a sample of 13 clients

diagnosed with schizophrenia-spectrum disorders. The study also incorporated a robust qualitative coding method

(i.e., content analysis) based on audio recordings and transcripts of therapist and client interviews. This yielded

high interrater agreement for identified themes (𝜅 = 0.89). Their results were broadly consistent with the Chadwick et al. (2003) study in terms of clients commonly endorsing a mixture of positive emotional reactions

(n = 9, 69%) to shared conceptualizations, negative emotional (n = 9, 69%), and neutral emotional reactions (n = 6, 46%).

Chadwick et al. (2003) also reported further data on six clients undergoing CBT for psychosis delivered in phases

of at least four sessions per phase focusing on case conceptualization, beliefs about voices, and cognitive restructur-

ing of negative self-evaluative beliefs and secondary delusions (Chadwick, Birchwood, & Trower, 1996). Conviction in

delusional beliefs as measured on a visual analogue scale (anchored form “not true” to “all true”) fell between 40% and

100% from baseline to follow-up for all clients. The Psychotic Symptom Rating Scales (Haddock, McCarron, Tarrier, &

EASDEN AND KAZANTZIS 377

Faragher, 1999) scores fell steadily and showed a reduction of between 11% and 50% at follow-up. Despite the phased

delivery of CBT, the study lacked the appropriate controls to rule out the specific effects due to the focus on conceptu-

alization early in therapy from its benefits later in therapy.

Onenovelstudyfocusedontherapists’(N=23)viewsoftheimportantfeaturesinthecontentofaconceptualization (Flitcroft, James, Freeston, & Wood-Mitchell, 2007). Based on a literature search, 86 items pertaining to the purpose

of conceptualization were generated by the research team and rank ordered by therapists. The “most important” pur-

poses were that “it explains how problems are maintained,” “it is acceptable to the client and others,” and “it informs

on possible ways to intervene (the how rather than where).” A factor analysis revealed three factors: a “CBT state”

factor (explained 24% of the variance) representing those therapists who placed greater emphasis on the “here-and-

now” aspects of case conceptualization, a “process and function” factor (explained 18% of the variance) representing

those viewing case conceptualization as integral to the process of therapy, and a “trait” factor (explained 7% of the vari-

ance) representing those therapists emphasizing a longitudinal and developmental perspective to current presenting

problems.SuchfindingssuggestthatdifferentaspectsofCBTcaseconceptualizationmaybeemphasizedamongdiffer-

ent therapists. It remains to be seen whether systematic differences between clinicians’ use of case conceptualization

could represent an enhancement or hindrance to CBT’s efficacy.

In the only exclusively qualitative study, Redhead, Johnstone, and Nightingale (2015) used a qualitative analysis

to explore clients’ (N = 10) experience of case conceptualization. The clients underwent CBT for depression and/or anxiety and participated in semistructured interviews within 1 month after treatment. Thematic analysis revealed four

main themes regarding clients’ experiences of case conceptualization: (a) “helps me to understand my problems,” (b)

“leads to feeling understood and accepted,” (c) “leads to an emotional shift,” and (d) “enables me to move forwards.” All

clients had used diagrams depicting their individual case conceptualizations alongside verbal discussion during therapy

sessions. Although the study was based on self-report and no empirical analysis was conducted, the themes identified

represent important areas that might serve as the focus of future empirical investigation.

This group of studies suggests that both clients and therapists have a diverse range of reactions to dif-

ferent aspects of case conceptualization and different emphasis on what is determined to be personally

meaningful.

4 STRENGTHS OF THE EVIDENCE

The most recent research has increasingly focused on the process of the case conceptualization because this evolves

collaboratively and naturalistically during therapy. This renewed focus on “collaborative empiricism” provides greater

possibilities for understanding the impact of case conceptualization on therapy outcomes and a striking gap in the CBT

evidence base. This perhaps represents an important shift in moving away from the notion of arriving at an “accurate”

or “correct” case conceptualization toward a case conceptualization that is useful or is accepted as “fitting” with the

client’s experience. This review highlights the variability of research methods used to examine in-session procedures

and clinical application of case conceptualization in CBT, and this variation also mirrors naturalistic use of case concep-

tualization in practice. For example, similar variability exists in the manner with which two clinicians may implement

“mood diaries” in a standard protocol of CBT for depression. That is, the same paper-and-pencil tools may be used to

achieve different therapeutic aims (e.g., for one patient the technique may be used as a basis for behavioral activa-

tion, whereas for another patient it may be used to strengthen beliefs about emotion-behavior links). Alternatively, the

standard mood chart may be modified to focus on relapse prevention (e.g., addiction contexts) or to promote healthier

dietary choices (e.g., eating disorder treatment) but is actually modified and adopted in as many contexts in which CBT

is applied (Petrik, Kazantzis, & Hofmann, 2013).

A major finding from the above review is that a range of research questions have been examined, although with

some adjustment, could more immediately offer guidance for practice. Let us first consider the specific strengths of the

existing data.

378 EASDEN AND KAZANTZIS

4.1 Support for interclinician reliability

There is a finding that specific aspects of the cognitive case conceptualization can, at least under certain conditions,

be reliably rated between clinicians. Data for this assertion have been found in several studies, from different research

groups using different measures and methods. The results have been variable, but there was more evidence of inter-

clinician consistency (i.e., agreement and reliability), where research methods involved more structured data collection

and complete case material (i.e., recorded session vs. case vignette). Where benchmark or criterion content has formed

the focus of the evaluation, these studies have shown that with different levels of training and experience, therapists

can generally use case conceptualization to make sense of client data, in a way that experts would use the same data.

However,thisappearsdependentontheamountandqualityofcaseconceptualizationdata(i.e.,real-timerecordingsof

therapy sessions versus brief written vignettes). There is some evidence that without a clearly prescribed case concep-

tualization structure or method, experts will outperform novice clinicians in ability to identify and prioritise important

case conceptualization information in a reliable manner (e.g., internal consistency). The extent to which training and

broader skills in CBT influence the effective use of case conceptualization remains unclear.

4.2 Enhancement of therapy outcomes

There are also preliminary data to suggest that when practiced in a manner true to its tenets and when “driven” by

case conceptualization, CBT’s effects can be observed to be larger than those without the same emphasis. However,

the findings have not been consistent, and there is some lack of clarity regarding the notion of “formulation-driven

CBT.” To meaningfully integrate these findings, it is important to emphasise that while a therapist might focus more

systematically or spend more time reflecting and explicitly integrating case conceptualization, it is arguably impossible

to partial out or remove case conceptualization from CBT. Conversely, case conceptualization has always been integral

totheprocessoftailoring therapytotheuniquepresenting problemsandsymptomsoftheclient(A. T. Becketal., 1979;

J. Beck, 1995, 2011). Therefore, it is unclear how this differs from competently delivered “standard” CBT. A clear link

between case conceptualization and outcome in CBT has yet to be demonstrated.

5 LIMITATIONS OF THE EVIDENCE

Inevaluating thereliabilityandvalidityofconceptualizationinCBT, thepresentreviewfoundthatsomegroupsofther-

apists can agree on the content of case conceptualization or produce content similar to an expert, but the results are

variable. A major limitation of the research has been the attempted translation of psychometric concepts of “reliability”

and “validity.” While case conceptualization does make important contributions to assessment, it is not a psychomet-

ric tool, per se. Case conceptualization is intended to both inform and be informed by the process of therapy and the

client’s experience and benefit from CBT techniques (i.e., treatment is informed by client feedback and the outcome

of homework tasks, such as behavioral experiments, which inform decisions for selecting and tailoring future interven-

tions). The process benefits from shared collaborative work between client and therapist, and its product serves as a

hypothesis about maintaining factors to the client’s presentation. Thus, case conceptualization is a process of CBT, and

its true function is likely to be missed if therapists are given written or single session recordings and asked to organize

the information in a meaningful way. Such research methods also fail to capture the clinician use of conceptualiza-

tion during sessions, and the extent to which different pathways or approaches to the same intervention are flexibly

adapted for the client.

A second major limitation in this research has been the failure to adequately assess the extent of CBT knowledge

and skills among the clinicians who are contributing data to these studies. It is necessary to first ascertain that CBT

knowledge and broader skills are equivalent among the clinician group. Without such assurances, it is impossible to

determine whether the lack of consistency between clinicians actually reflects a problem or inherent limitation with

the case conceptualization method, or whether it is simply an artifact of the therapist sample that contributed those

EASDEN AND KAZANTZIS 379

data. Any study of the use of case conceptualization should specifically focus on the assessment of existing skill in the

therapist sample (Kendjelic & Eells, 2007).

We suggest that the content of the case conceptualization is inextricably linked to the preexisting clinician skill

in case conceptualization, as well as their knowledge and skill in CBT. Previous research has generally involved the

evaluation of interclinician consistency in case conceptualization and has missed the ways in which a clinician may use

case conceptualization during sessions, including the adaptation of CBT interventions to meet the unique therapeutic

needs of the client. To assist the development of more meaningful data to support the use of case conceptualization in

CBT, we offer a recommended research agenda.

6 A RESEARCH AGENDA

Prior research has not provided an adequate test of case conceptualization as a reliable or valid strategy for assess-

ment and organization of clinical information. Evaluating the extent to which a group of clinicians, who have not oth-

erwise been assessed or monitored for CBT knowledge or skills, can organize limited material about a single case in a

similar way is a relatively poor test of a central feature of a therapy. The importance of ensuring a sufficient number

of cases, adequate contextual case information, due consideration of the specific session(s) being evaluated, control-

ling for variation in prior training, and broader skills in conceptualization (e.g., diagnostic, problem, disorder specific,

comprehensive) are necessary to negate potential threats to reliability and validity in this area. It would also be an

interesting empirical question to determine the relative clinical utility of different formats of case conceptualizations,

and thus it would be useful to ensure inclusion of commonly used formats of case conceptualization in research designs

and describe this explicitly in the study method. In this regard, comparison of CBT case conceptualization formats with

transdiagnostic conceptualization approaches would also offer interesting avenues for empirical investigation (Barlow

et al., 2011; Dudley, Kuyken, & Padesky, 2011; Norton & Kazantzis, 2016).

6.1 Reliability and validity

We suggest that psychometric concepts of reliability and validity would be more relevant to research on case concep-

tualization in which there was comprehensive assessment information and/ or access to multiple session video record-

ings. We also suggest that this research area would be greatly strengthened by examination of the range of functions

of case conceptualization, and certainly beyond its role in assessment.

In terms of reliability, rather than focusing on interclinician consensus based on a single session or case vignette,

it would be more comprehensive and representative of practice to evaluate consistency by directly (a) observing the

extent to which the case conceptualization information was incorporated into a series of therapy sessions, or (b) within

specific techniques in relation to (c) the information synthesized within the conceptualization appearing in the client’s

file compared with discussion during therapy sessions. Once again, utilization of standard and structured case concep-

tualization formats would facilitate this process. It would also be possible to examine the extent to which those stable

attributes, such as key developmental experiences, core beliefs, values, and cultural rules and beliefs, were consistently

attended to across a sequence of sessions. However, it could be hypothesized that a good proportion of case concep-

tualization content would change over time (as such tests of re-test reliability are problematic if misapplied) either

because new information could be shared by clients as therapy progresses or because the client’s belief system could

change during CBT. An examination of the evolution of conceptualization in CBT across sessions remains a major gap in

conceptualization literature (Bieling & Kuyken, 2003; Haynes, Leisen, & Blaine, 1997). Thus, evaluations of consistency

of content would need to be sensitive to changes in specific aspects of the case conceptualization.

In terms of validity, it would be possible to evaluate the extent to which the content of the case conceptualization

was associated with beliefs assessed in structured psychometric measures, such as the Attributional Style Question-

naire (Peterson et al., 1982) and the Personality Belief Questionnaire (Beck & Beck, 1991). Similarly, research could

examine the extent to which conceptualization content evaluated early in therapy (e.g., assumptions, rules, beliefs)

380 EASDEN AND KAZANTZIS

form the focus of interventions throughout the course of therapy (e.g., cognitive and behavioral experiments), as long

as therapists’ CBT competence was assessed and taken into account within analytic models. It would also be possible

to examine changes in central case conceptualization content (e.g., maladaptive coping strategies) as predictors of

symptomatic and functional changes. Such research would not only provide assurance for the reliability and validity of

case conceptualization in CBT, but it would also help to elucidate its role of attending to this information in treatment

planning. For example, research following these recommendations could consider the extent to which interventions

that were more closely linked to case conceptualization resulted in enhanced shorter and longer term outcomes.

6.2 Therapist competence in case conceptualization

The assessment of therapist competence in the practice of CBT has traditionally included attention to the integration

of case conceptualization material in sessions. The Cognitive Therapy Rating Scale (CTRS; Young & Beck, 1980) is the

most widely used and comprehensively evaluated measure of therapist competence in CBT (i.e., Academy of Cogni-

tive Therapy; also see reviews in Kazantzis, 2003; Kazantzis, Cronin, Clayton, Farchione, & Dobson, 2017). The CTRS

includes an item “focusing on key cognitions and behaviors” to assess skill in targeting interventions, and an item “strat-

egy for change” to assess skill in selecting the most appropriate techniques for the client. However, many CTRS items

broadly consider therapist work in tailoring in-session process for the client (e.g., agenda, homework), so there is an

opportunity to expand the assessment of therapist competence to more comprehensively capture skill in case concep-

tualization. For example, seeking client feedback and agreement that there is alignment between the conceptualiza-

tion, the goal, and target of intervention is one way in which collaboration can be emphasized in the process of case

conceptualization (Bieling & Kuyken, 2003).

After satisfying the basic prerequisites for attaining meaningful CBT case conceptualization, it would also be poten-

tially useful to investigate the triangulation of agreement, or disagreement, among therapist, supervisor (observer),

and client conceptualizations over time and in relation to therapeutic outcomes. Similar ratings of clinical importance

would also help to assure the utility of the content being identified and summarized in the case conceptualization.

Zarafonitis-Müller, Kuhr, and Bechdolf (2014) conducted a meta-analysis of the impact of therapist competence and

adherence on outcomes in CBT. On the basis of the studies identified (N = 13), they concluded that although compe- tence in CBT techniques had a relationship with outcomes, adherence to a manualized protocol did not. The authors

further identified the importance of controlling for a therapeutic relational component in addition to therapist com-

petence (i.e., collaborative empiricism), which appeared to account for symptom change. The authors advocated for

greater focus on processes related to therapist competence.

To investigate therapist competence in case conceptualization, it is necessary to first develop an appropriate mea-

surement tool. Bucci, French, and Berry (2016) identified at least eight existing measures that assess the quality of case

conceptualizations, most of these identified as being developed within a CBT orientation. The vast majority of these

measures were designed to measure therapist construction of discrete written case conceptualizations rather than

examine the process by which a therapist skilfully develops a collaborative case conceptualization over the course of

therapy. However, additional measures under development and evaluation include the Collaborative Case Conceptu-

alization - Rating Scale (Kuyken et al., 2016; Padesky, Kuyken, & Dudley, 2011) and the Conceptualization Rating Scale

(Easden, 2010).

In CBT case conceptualization, a therapist is required to demonstrate skillful clinical decision making in (a) inte-

grating all elements of a comprehensive conceptualization into therapy when appropriate (e.g., exploration of auto-

matic thoughts, emotions, core beliefs, and relevant background information) and (b) demonstrating skillful integra-

tion of these components in coherent and meaningful written conceptualizations that reflect and inform in-session

work. Research that evaluates the manner with which therapists adapt the use of conceptualization based on the

attributes and strengths of the client, as well as a broader range of difficulties beyond primarily depression and anxiety,

would also be helpful. For instance, a client with working memory difficulties, either preexisting or as a feature of their

psychological distress, may benefit from a very different way of working with the same conceptualization format than

a client with reduced executive functions (e.g., ability to expel or inhibit negative thoughts during a sad mood).

EASDEN AND KAZANTZIS 381

The various domains of therapist competence highlight the need for robust training of therapists to become pro-

ficient in skills pertinent to CBT case conceptualization (Eells et al., 2005; Kendjelic & Eells, 2007). While there has

been significant attention to the delineation of specific elements of therapist competence in the practice of CBT (e.g.,

Newman, 2013) and large-scale training efforts such as the Beck Initiative (Creed, 2014) and Improving Access to Psy-

chological Therapies (Clarke, 2011), evaluation of the training in those competencies, such as use of case conceptualiza-

tion, has not received adequate attention. Delineation of therapist competence in other core skills in CBT relationships

(e.g., collaborative empiricism) and process (e.g., between-session therapeutic tasks/ homework) would be particularly

useful for such research.

7 SUMMARY

The utility of CBT case conceptualization has yet to be empirically demonstrated. Prior research has focused on the

evaluation of the case conceptualization content (i.e., the reliability and validity of the product of conceptualization).

Missing are studies that investigate the actual integration of comprehensive case conceptualization during therapy ses-

sions (i.e., the in-session processes of tailoring techniques based on case conceptualization). In this article, we con-

ducted a review of the available data and suggested that there have been a variety of limitations to the research

methodologies employed. First, research has yet to adequately establish whether case conceptualization can enhance

the outcomes of CBT. Second, prior research studies have not adequately separated the role of therapist training and

demonstrated skill (i.e., in vivo therapist competence) in CBT case conceptualization. It remains unclear whether case

conceptualization directly or indirectly enhances mechanisms of cognitive change and positive therapeutic outcomes.

A range of potentially fruitful avenues for future research can be examined. We most strongly advocate for research

that involves direct observation of therapist competence in case conceptualization as a predictor of CBT outcomes.

REFERENCES

Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B. & Ehrenreich-May, J. (2011). The unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. New York: Oxford University Press.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.

Beck, A. T., & Beck, J. S. (1991). The Personality Belief Questionnaire. Unpublished assessment instrument, University of Penn-

sylvania.

Beck, A. T., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

Beck, J. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York: Guilford Press.

Bieling, P., & Kuyken, W. (2003). Is cognitive case formulation science or science fiction? Clinical Psychology: Science and Practice, 10(1), 52–69.

Bucci, S., French, L., & Berry, K. (2016). Measures assessing the quality of case conceptualization: A systematic review. Journal of Clinical Psychology, 72(6), 517–533.

Butler, G., Fennell, M., & Hackman, A. (2008). Treating anxiety disorders: The state of the art. In G. Butler, M. Fennell, & A.

Hackman, Cognitive-behavioral therapy for anxiety disorders: Mastering clinical challenges (pp. 1–26). New York: Guilford.

Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy of delusions, voices, and paranoia. New York: John Wiley & Sons.

Chadwick, P., Williams, C., & Mackenzie, J. (2003). Impact of case formulation in cognitive behavior therapy for psychosis.

Behavior Research and Therapy, 41, 671–680.

Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and practice. New York: Guilford.

Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: The

IAPT experience. International Review of Psychiatry, 23, 375–384.

Cooper, Z., Fairburn, C. G., & Hawker, D. M. (2004). Cognitive-behavioral treatment of obesity: A clinician’s guide. New York: Guil- ford Press.

Creed, T. A. (2014). Training Aboriginal practitioners in cognitive behavior therapy. Australian Psychologist, 49, 14–16.

382 EASDEN AND KAZANTZIS

Cronin, T. J., Lawrence, K. A., Taylor, K., Norton, P. J., & Kazantzis, N. (2015). Integrating between-session interventions (home-

work)intherapy:Afocusonthetherapeuticrelationshipandcognitivecaseconceptualization. JournalofClinicalPsychology, 71(5), 1–12.

Dattilio, F. M., & Hanna, M. A. (2012). Collaboration in cognitive-behavior therapy. Journal of Clinical Psychology, 68, 146–158.

Dudley, R., Kuyken, W., Padesky, C. A., (2011). Disorder specific and trans-diagnostic case conceptualisation. Clinical Psychology Review, 31, 213–224.

Dudley, R., Park, I., James, I., & Dodgson, G. (2010). Rate of agreement between clinicians on the content of a formulation of

delusional beliefs: The effect of qualifications and experience. Behavioural and Cognitive Psychotherapy, 38, 185–200.

Easden, M. H. (2010). The relationship between case conceptualization and homework in cognitive behavioural therapy (CBT)

for depression. Unpublished doctoral dissertation, Massey University, Auckland, New Zealand.

Eells, T. (2007). Handbook of psychotherapy case formulation (2nded.). New York: Guilford Press.

Eells, T., Kendjelic, E. M., & Lucas, C. (1998). What’s in a case formulation? Development and use of a content coding manual.

Journal of Psychotherapy Practice and Research, 7(2), 144–153.

Eells, T., Lombart, K. G., Kendjelic, E. M., Turner, L., & Lucas, C. P. (2005). The quality of psychotherapy case formulations: A

comparison of expert, experienced, and novice cognitive–behavioral and psychodynamic therapists, Journal of Consulting and Clinical Psychology, 73(4), 579–589.

Eells, T., Lombart, K. G., Salsman, N., Kendjelic, E. M., Schneiderman, C. T., & Lucas, C. P. (2011). Expert reasoning in psychother-

apy case formulation. Psychotherapy Research, 21(4), 385–399.

Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

Ellis, A. (1991). The revised ABC’s of rational-emotive therapy (RET). Journal of Rational-Emotive & Cognitive-Behavior Therapy, 9(3), 139–172.

Ellis, A. (1994). Reason and emotion in psychotherapy, revised and updated. New York: Carol Publishing Group.

Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association.

Esbjørn, B. H., Reinholdt-Dunne, M. L., Nielsen, S. K., Simth, A. C., Breinholst, S., & Leth, I. (2015). Exploring the effect of case

formulation driven CBT for children with anxiety disorders: A feasibility study. Behavioural and Cognitive Psychotherapy, 45, 20–30.

Flinn, L., Braham, L., & das Nair, R. (2015). How reliable are case formulations? A systematic literature review. British Journal of Clinical Psychology, 54(3), 266–290.

Flitcroft, A., James, I. A., Freeston, M., & Wood-Mitchell, A. (2007). Determining what is important in a good formulation. Behav- ioral and Cognitive Psychotherapy, 35, 325–333.

Fothergill, C., & Kuyken, W. (2002). Quality of cognitive therapy case formulation rating scale. Unpublished assessment

instrument.

Ghaderi, A. (2006). Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad)

cognitive behavior therapy for bulimia nervosa. Behaviour Research and Therapy, 44, 273–288.

Haarhoff, B. (2008). The CBT Case Conceptualization Rating Scale. Unpublished assessment instrument. Auckland, New

Zealand: Massey University.

Haarhoff, B. A., Flett, R. A., & Gibson, K. L. (2011). Evaluating the content and quality of cognitive-behavioural therapy case

conceptualizations. The New Zealand Journal of Psychology, 40(3), 104–114.

Haddock, G., McCarron, J., Tarrier, N., & Faragher, E. B. (1999). Scales to measure dimensions of hallucinations and delusions.

The psychotic symptom rating scales (PSYRATS). Psychological Medicine, 29(4), 879–889.

Haynes, S. N., Leisen, M. B., & Blaine, D. D. (1997). Design of individualized behavioral treatment programs using functional

analytic clinical case models. Psychological Assessment, 9(4), 334–348.

Haynes, S. N., & O’Brien, W. H. (1990). Functional analysis in behavior therapy. Clinical Psychology Review, 10, 649–668.

Haynes, S. N., & O’Brien, W. H. (2000). Principles and practice of behavioral assessment. New York: Plenum.

Higgins, J., & Green, S. (Eds.) (2011). Cochrane handbook for systematic reviews of interventions, version 5.1.0. Retrieved from

www.cochrane-handbook.org

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review

of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440.

Johnsen, T. J., & Friborg, O. (2015). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A

meta-analysis. Psychological Bulletin, 141(4), 747–768. https://doi.org/10.1037/bul0000015

EASDEN AND KAZANTZIS 383

Kazantzis, N. (2000). Power to detect homework effects in psychotherapy outcome research. Journal of Consulting and Clinical Psychology, 68, 166–170.

Kazantzis, N. (2003). Therapist competence in cognitive behavior therapies: A review of the contemporary empirical evidence.

Behavior Change, 20(1), 1–12.

Kazantzis, N., Beck, J. S., Dattilio, F. M., Dobson, K. S., & Rapee, R. (2013). Collaborative empiricism as the central therapeutic

relationship element in cognitive behavior therapy: An expert panel discussion at the 7th International Congress of Cogni-

tive Psychotherapy. International Journal of Cognitive Psychotherapy, 6(4), 386–399.

Kazantzis, N., Clayton, X., Cronin, T. J., Farchione, D., & Dobson, K. S. (2015). Testing the psychometric properties of two mea-

sures of therapist competence in cognitive behavior therapy for depression. Manuscript submitted for publication.

Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017). The therapeutic relationship in cognitive behavior therapy: A clinician’s guide to the heart and soul of effective practice. New York: Guilford Publications.

Kazantzis, N., Reinecke, M., & Freeman, A. (Eds.). (2010). Cognitive and behavioral theories in clinical practice. New York: Guilford.

Kazantzis, N., Tee, J. M., Dattilio, F. M., & Dobson, K. S. (2013). How to develop collaborative empiricism in cognitive behavior

therapy: Conclusions from the C&BP Special Series. Cognitive and Behavioral Practice, 20(4), 455–460.

Kennedy-Merrick, S. J., Haarhoff, B. A., Stenhouse, L. M., Merrick, P. L., & Kazantzis, N. (2008). Training cognitive behavioural

therapy practitioners in New Zealand: From University to clinical practice. New Zealand Journal of Psychology, 37, 8–17.

Kuyken, W. (2006). Evidence-based case formulation: Is the emperor clothed? In N. Tarrier (Ed.), Case formulation in cognitive behavior therapy: The treatment of challenging and complex clinical cases (pp. 12–35). London: Brunner-Routledge.

Kuyken, W., Beshi, S., Dudley, R., Abel, A., Görg, N., Gower, P., … Padesky, C. A. (2016). Assessing competence in collaborative case conceptualization: Development and preliminary properties of the Collaborative Case Conceptualization Rating Scale

(CCC-RS). Behavioural and Cognitive Psychotherapy, 44(2), 179–192.

Kuyken, W., Fothergill, C., Musa, M., & Chadwick, P. (2005). The reliability and quality of cognitive case formulation. Behavior and Research Therapy, 43, 1187–1201.

Kuyken, W., Padesky, C., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive- behavioral therapy. New York: The Guilford Press.

Linehan, M. M. (1980). Content validity: Its relevance to behavioral assessment. Behavioral Assessment, 2, 147–159.

Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.

Mennin, D. S., Ellard, K. K., Fresco, D. M., & Gross, J. J. (2013). United we stand: Emphasizing commonalities across cognitive-

behavioral therapies. Behavior Therapy, 44, 234–248.

Morberg-Pain, C., Chadwick, P., & Abba, N. (2008). Clients’ experience of case formulation in cognitive behaviour therapy for

psychosis. British Journal of Clinical Psychology, 47, 127–38.

Mumma, G. (2004). Validation of idiosyncratic cognitive schema in cognitive case formulations: An intraindividual idiographic

approach. Psychological Assessment, 16(3), 211–230.

Mumma, G., & Mooney, S. R. (2007a). Comparing the validity of alternative cognitive case formulations: A latent variable, mul-

tivariate time series approach. Cognitive Therapy and Research, 31(4), 451–481.

Mumma, G., & Mooney, S. R. (2007b). Incremental validity of cognitions in a clinical case formulation: An intraindividual test in

a case example. Journal of Psychopathology and Behavioral Assessment, 29, 17–28.

Mumma, G., & Smith, J. (2001). Cognitive–behavioral-interpersonal scenarios: Interformulator reliability and convergent valid-

ity. Journal of Psychopathology and Behavioral Assessment, 23(4), 203–221.

Muran, J. C., Samstag, L. W., Segal, Z. V., & Winston, A. (1998). Interpersonal scenarios: A measure of self-schemas. Psychother- apy Research, 8(3), 321–333.

Muran, J. C., Samstag, L. W., Ventur, E. D., Segal, Z. V., & Winston, A. (2001). A cognitive-interpersonal case study of self. Journal of Clinical Psychology, 57(3), 307–330.

Muran, J. C., & Segal, V. (1992). The development of an idiographic measure of self-schemas: An illustration of the construction

and use of self-scenarios. Psychotherapy, 89, 524–535.

Muran, J. C., Segal, Z. V., & Samstag, L. W. (1994). Self-scenarios as a repeated measures outcome measurement of self-schemas

in short-term cognitive therapy. Behavior Therapy, 25, 255–274.

Nattrass, A., Kellett, S., Hardy, G. E., & Ricketts, T. (2015). The content, quality and impact of cognitive behavioural

case formulation during treatment of obsessive compulsive disorder. Behavioural and Cognitive Psychotherapy, 43(5), 590–601.

Needleman, L. (1999). Cognitive case conceptualization: A guidebook for practitioners. Mahwah, NJ: Lawrence Erlbaum Associates.

384 EASDEN AND KAZANTZIS

Newman, C. F. (2013). Core competencies in cognitive-behavioral therapy: Becoming a highly competent cognitive-behavioral thera- pist. New York: Routledge.

Nezu, A. M., Nezu, C. M., & Lombardo, E. R. (2004). Cognitive-behavioral case formulation and treatment design: A problem-solving approach. New York: Springer.

Norton, P. J., & Kazantzis, N. (2016). Dynamic relationships of therapist alliance and group cohesion in transdiagnostic group

CBT for anxiety disorders. Journal of Consulting and Clinical Psychology, 84, 146–155. https://doi.org/10.1037/ccp0000062

Padesky,C.A.,Kuyken,W.,&Dudley,R.(2011).CollaborativeCaseConceptualizationRatingScaleandCodingManual(version

5). Retrieved from http://padesky.com/pdf_padesky/CCCRS_Coding_Manual_v5_web.pdf

Padesky, C. A., & Mooney, K. (1990). Clinical tip: Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13–14.

Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. New York: Norton.

Persons, J. B. (2006). Case formulation-driven psychotherapy. Clinical Psychology: Science and Practice, 13(2), 167–170.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York: Guilford.

Persons, J. B., & Bertagnolli, A. (1999). Inter-rater reliability of cognitive-behavioral case formulations of depression: A replica-

tion. Cognitive Therapy and Research, 23(3), 271–283.

Persons,J.B.,Bostrom,A.I.,&Bertagnolli,A.(1999).Resultsofrandomizedcontrolledtrialsofcognitivetherapyfordepression

to generalize to private practice. Cognitive Therapy and Research, 23(5), 535–548.

Persons, J., & Hong, J. J. (2016). Case formulation and the outcome of cognitive behavior therapy. In N. Tarrier and J. John-

son (Eds.), Case formulation in cognitive behavior therapy: The treatment of challenging and complex cases (2nd ed.). New York: Routledge.

Persons, J. B., Mooney, K., & Padesky, C. (1995). Interrater reliability of cognitive-behavioral case formulations. Cognitive Ther- apy and Research, 19(1), 21–34.

Persons, J. B., Roberts, N., Zalecki, C., & Brechwald, W. (2006). Naturalistic outcome of case-formulation-driven cognitive-

behavior therapy for anxious depressed outpatients, Behavior, Research and Therapy, 44, 1041–1051.

Peterson, C., Semmel, A., von Baeyer, C., Abramson, L., Metalsky, & Seligman, M. (1982). The Attributional Style Questionnaire.

Cognitive Therapy and Research, 6, 287–300.

Petrik, A. M., Farchione, D., Dobson, K. S., & Kazantzis, N. (2017). Calculating inter-rater reliability in clinical research: A sys-

tematic review and evaluation of statistical indexes. Manuscript submitted for publication.

Petrik, A. M., Kazantzis, N., & Hoffman, S. G. (2013). Distinguishing integrative from eclectic practice in cognitive behavioral

therapies. Psychotherapy: Theory, Research, Practice, Training, 50(3), 392–397.

Rainforth, M., & Laurenson, M. (2014). A literature review of case formulation to inform mental health practice. Journal of Psy- chiatric and Mental Health Nursing, 21(3), 206–213.

Rapee, R., Wignall, A., Hudson, J., & Schniering, C. (2000). Treating anxious children and adolescents: An evidence-based approach. Oakland, CA: New Harbinger Publications.

Redhead, S., Johnstone, L., & Nightingale, J. (2015). Clients’ experiences of formulation in cognitive behavior therapy. Psychol- ogy and Psychotherapy: Theory, Research, Practice, 88(4), 453–467.

Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin, 86, 420–428.

Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: A definition and theory for the relationship con-

struct. Clinical Psychology: Science & Practice, 18, 48–62.

Waltz, J., & Linehan, M. M. (1999). Functional analysis of borderline behavioral criterion patterns: Links to treatment. In J.

Derksen & H. Groen (Eds.), Treatment of Personality Disorders. New York: Plenum Press.

Young, J., & Beck, A. (1980). Cognitive Therapy Scale rating manual. Unpublished assessment instrument, University of Penn-

sylvania, Philadelphia.

Zarafonitis-Müller, S., Kuhr, K., & Bechdolf, A. (2014). The relationship between therapist’s competence and adherence to out-

come in cognitive-behavioural therapy: Results of a meta-analysis. Fortschritte der Neurologie-Psychiatrie, 82(9), 502–510.

How to cite this article: Easden MH, Kazantzis N. Case conceptualization research in cognitive behavior ther-

apy: A state of the science review. J Clin Psychol. 2018;74:356–384. https://doi.org/10.1002/jclp.22516

Copyright of Journal of Clinical Psychology is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.