Editor’s Note: This is part one of a two-part Q&A with Rochelle Frank, PhD, and Joan Davidson, PhD, authors of The Transdiagnostic Road Map to Case Formulation and Treatment Planning.
In summary, why do we need a transdiagnostic road map?
RIF: As therapists we encounter many patients who do not benefit from standardized treatment protocols because they have elements of multiple diagnostic entities. Even when we do figure it out, some protocols are impractical for certain patients’ lifestyles (for example, financial or scheduling constraints), fully adherent treatment programs often are not available, and protocol guidelines can occasionally preclude completion of treatment despite high levels of need and motivation. The diagnostic waters frequently are muddied, so figuring out what you’re trying to treat and which protocol to apply, or which of several protocols for the same condition would be best for a given individual, can overwhelm even the most senior clinician.
I frequently say to my patients, “I don’t care what we call it; let’s figure out what will be most effective in treating your problems and getting you some relief.” In order to do that, we have to go beneath the surface of problems to figure out what is driving them—that is, the transdiagnostic mechanisms (TDMs). This is important not only for resolving immediate treatment needs, but psychological mechanisms show up throughout our lives, long after therapy is concluded. Knowing what these mechanisms are, how to detect them, and how to best respond to them can provide clients with effective and flexible tools to become self-sufficient in addressing and resolving problems in various life circumstances. As I recognized how my patients have benefited from this approach, regardless of their presenting problems, it became important to me to share it with other clinicians. Psychological mechanisms have been around for several decades and are gaining increasing support for their clinical utility. The transdiagnostic road map provides a way of organizing these constructs by examining their function as both underlying vulnerabilities and patterned responses to different stressors, and illustrates how to use identified TDMs to guide assessment and treatment planning. We also developed a practical way of organizing clinical interventions according to their function in achieving desired outcomes, so that clinicians may more easily choose treatment strategies based on the mechanism-based formulation and patients’ goals.
My own experience with the limitations of ESTs and frequent sense of “drinking from a fire hose” to keep up with the ever-increasing database on psychological mechanisms and disorder-based treatments provided the impetus to write this book. Joan and I have used case formulation models such as Jackie Persons’s and Christine Padesky’s approaches for many years, but frequently would struggle when it came to figuring out exactly which mechanisms to target in treatment. Our main goals in writing this book were to consolidate the empirical literature into an accessible reference guide, help other therapists learn how to identify and target the various TDMs underlying presenting problems and symptoms so they could meet the diverse needs of their patients, and offer a functionally-based listing of empirically sound interventions to complement the transdiagnostic formulation.
Much like how off-label usage of different psychiatric medications has proven to be effective in treating conditions other than what a particular drug was developed for, selected components of ESTs can be used to benefit many patients, even when they do not have the specific problem for which the protocol was developed. For example, emotion regulation strategies from DBT can benefit virtually any client, whether they exhibit anxiety, borderline features, depression, trauma, obsessive-compulsive behaviors, and so on. Similarly, mindfulness practices, compassion-focused interventions, and distress tolerance strategies can be included in treatment planning for virtually any type of problem, providing a solid foundation on which to improve coping and self-esteem and reduce symptomatic behaviors and functional limitations. Using selected elements of different ESTs to target specific TDMs can address the complex nature of patients’ problems, mitigate some of the challenges of protocols, and provide significant and lasting benefit. Thus, depending on the transdiagnostic case formulation, the treatment plan might include a combination of emotional exposure, traditional CBT interventions such as a thought record, compassion-focused techniques, acceptance-based strategies, and dialectical behavioral interventions. The beauty of the road map is that it allows therapists to choose interventions with their patients based on each person’s specific needs, goals, and formulation.
JD: I was fortunate that my first training in CBT was with Jackie Persons, who had just published her first book on case formulation. Jackie was teaching a seminar on case formulation at my training site. So while I learned about using protocols for treating depression and anxiety, I also learned about developing individualized case formulations to address multiple problems and choosing interventions to match the mechanisms hypothesized to underlie problems. This included attending to patients’ strengths, preparing for likely obstacles, and considering multiple factors regarding the priority of problems to be addressed. I had a great introduction to CBT!
Over the course of more than two decades, I worked with Jackie and many talented clinicians to help each other develop and refine our case formulations and treatment plans. At the heart of Jackie’s case formulation model is the concept of “mechanisms,” which are what underlie and contribute to patients’ problems. We frequently drew diagrams with arrows and circles showing how underlying constructs, such as schemas, contributed to someone’s cognitive distortions, and how avoidance or other problematic behaviors related to the cognitive distortions, beliefs, and emotions that maintained the presenting problems. Case formulation is like putting together all of the parts of a puzzle and seeing how they go together to drive presenting problems.
Quite a few years ago, I wrote about a case, in a book chapter I coauthored, in which the patient presented with recurrent depression. I knew the protocols for treating depression. Yet what the patient and I determined was that his fear of negative emotional states led to behavioral and emotional avoidance, which contributed to his depression. Avoidance furthered his belief that he could not handle negative emotional states. Most importantly, the patient believed that if his underlying negative self-schemas were activated, he would become depressed and suicidal. Therefore, he avoided anything that might trigger those schemas. This left him unable to challenge his beliefs, learn that he could handle negative emotions, and live a fuller life. We implemented an exposure-based treatment plan, which opened up many avenues to reduce depression but also helped him to begin living the life he wanted to live. We didn’t follow the depression protocol that was traditional at the time, and he achieved long-lasting results.
I was confident that my understanding of psychological mechanisms contributed to my ability to individualize treatment plans to help my patients. In an effort to improve my clinical skills, I tried to learn as much as I could. I learned about newer treatment approaches such as ACT and DBT. I read more and more articles about underlying psychological mechanisms and how they might interact to explain various disorders and problems. I attended workshops by leaders in our field, as well as many national and international conferences. Everything I learned was backed by research. Then, I got confused. How on earth do I use all of this knowledge when I sit with a patient in my office? How do I guide new clinicians and my students in supervision? There’s too much to teach them! I talked to my colleagues and discovered they also were asking these same questions and were equally perplexed about how to integrate everything we were learning into case formulations and treatment plans. Moreover, ESTs are typically offered as stand-alone treatments that aren’t intended to be broken down into component parts.
The more I looked at the research on psychological mechanisms and transdiagnostic processes, and the more talks I attended about them, the more I realized how great the gap is between research and practice. Clinicians can benefit from advances in research, but only if they know about them. My colleagues and I are often wrestling with the dilemma about how to keep up with the research and how to integrate what we are learning into our actual clinical practice. I thought, “Someone needs to write a book about this!” Right around that time, Shelly asked me to work with her on doing just that. And thus, we set out to create a practical road map to guide clinicians in their everyday practice with clients.
Transdiagnostic approaches target psychological mechanisms rather than attempting to utilize treatment protocols that focus on a singular diagnosis. From your perspective, what are the most notable shortcomings with disorder-based protocols, or treatments that focus on a singular diagnosis?
RIF: Our field increasingly is recognizing the need to go beyond topographical descriptions of patients’ problems (i.e., diagnoses) and focus instead on identifying, assessing, and treating the underlying psychological mechanisms that seem to be driving them. While disorder-based protocols have been the “gold standard” in mental health for decades, and have been indisputably invaluable in advancing patient care and improving treatment outcomes, they can be somewhat impractical at times because of their narrow focus. Most people who come into our offices typically do not present with a single problem, neatly wrapped per DSM classification or research protocols. More frequently, we tend to see various elements of different problems that combine in the unique presentation of each client. For example, we may see someone coping with a job loss, who becomes depressed and also experiences insomnia and anxiety because he can’t figure out how to pay the mortgage and support his family. Similarly, a client being treated for generalized anxiety may experience an overwhelming sense of shame related to losing jobs and relationships because the anxiety compromises her ability to function at home and work. And someone experiencing PTSD after a car accident may develop an increase in symptom related problems that predated the accident, causing her to miss work and isolate herself from her friends. Even when the clinical picture is less complex there are so many protocols from which to choose that it is virtually impossible to stay current and become proficient in all of them; simply figuring out which one is best suited to the needs of any given patient can be quite daunting for any therapist.
JD: Protocols focusing on singular disorders have greatly advanced our knowledge of psychological mechanisms underlying those disorders and the interventions that target them. As Shelly described, the main disadvantage of these protocols is that most patients who come for treatment don’t neatly fit into a single diagnosis without co-occurring diagnoses or problems. As clinicians, we treat individuals with a range of problems, and individuals bring many different strengths and obstacles to treatment, including varying levels of readiness for change. In short, treatment is usually more complicated than what single problem or diagnosis-based protocols can offer. How to meet the multiple needs of clients is the challenge that clinicians face daily.
Briefly explain what transdiagnostic mechanisms are, and what purpose they serve in treatment planning for any given client.
RIF: We define TDMs as underlying vulnerabilities and patterns of response that are hypothesized to trigger and maintain cognitive, behavioral, emotional, and physiological symptoms and functional impairments across diagnostic categories. TDMs are psychological processes that may be directly targeted in treatment, and our unique classification system enables clinicians to select interventions based on the transdiagnostic formulation and each patient’s desired outcome goals. The road map walks therapists through a collaborative process allowing them to identify which TDMs are in play for any given patient, to develop treatment goals that are based on those TDMs and client-specific outcome goals, and to select interventions that will target those TDMs and achieve desired outcomes. More importantly, once patients understand the concept of TDMs and the specific vulnerability and response mechanisms that are relevant to them, the transdiagnostic road map arms them with effective tools for dealing with problems throughout their lives, long after therapy is done.
JD: The concept of psychological mechanisms underlying presenting problems across diagnoses has long been at the heart of CBT case formulation. Jackie Persons’s case formulation approach, which she developed in the 1980s, focuses on mechanisms, and those mechanisms cut across diagnoses. Other case formulation approaches do the same and integrate various considerations, such as patient strengths. Currently, with so much research targeting the role that specific underlying psychological mechanisms play across a range of problems, many of which derive from disorder-specific protocols, our field has coined terms for numerous specific psychological constructs. As a result, multiple terms have been used to describe these constructs, including “transdiagnostic processes.”
We combined the research on psychological mechanisms and transdiagnostic processes, and referred to the resulting construct as a transdiagnostic mechanisms, or TDM. We are moving beyond a broad category in case formulation, called “mechanisms,” to now defining those mechanisms in much more specific terms based on the burgeoning research. We chose the common psychological mechanisms described in the literature as determined by an extensive review of the empirical database, to list in this book.
Deciding how to list so many transdiagnostic mechanisms in this clinical road map was a daunting task. We saw a pattern in the function that they played and thus arrived at a two-column approach to list them: vulnerability and response mechanisms. Vulnerability mechanisms are what may underlie and drive problematic responses in current situations; response mechanisms are the actual patterns of those problematic responses in current situations which help maintain presenting problems; and both interact in constant feedback loops. Vulnerability mechanisms include neurophysiological vulnerabilities, negative schemas, patterns of behavioral responses learned earlier in life, and constructs such as intolerance of uncertainty and perfectionism, among others. They contribute to problematic responses used in current situations. Response mechanisms are the actual problematic responses used in current situations. For example, a person might struggle with intolerance of uncertainty, a vulnerability mechanism, and may respond to situations that trigger it by engaging in response mechanisms such as avoidance behaviors, compulsions, or worry behaviors.
We'll post the scond half of this Q&A tomorrow. Stay tuned!