Q&A, Part Two: Authors of the Transdiagnostic Road Map to Case Formulation and Treatment Planning

Editor’s Note: This is part two 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. For part one, click here.

Which modalities have been most notably influential in the development of this approach, and is it necessary that users of the book have a background in any particular treatment modality (i.e. ACT, DBT, etc.)

RIF: At its core the transdiagnostic road map is a case formulation model that allows therapists to individualize assessment and treatment to the needs of each patient. While we draw heavily from theoretical and applied constructs within cognitive behavioral therapy and the other evidence-based treatments in which we are trained, this book is a stand-alone reference for any therapist (both novice and experienced) who is interested in learning more about psychological mechanisms, and how to identify and target them across a wide range of patient problems to alleviate the suffering of those individuals and improve their functioning and quality of life.  Since our description of clinical interventions is intended as a brief overview for the purposes of illustrating how they flow from the transdiagnostic formulation, we do intend that, per ethical and professional standards across mental health disciplines, readers will receive adequate training in any assessment and treatment strategies they implement with their patients.

JD: It will be helpful to have a fundamental understanding of CBT. Ideally, readers will have some knowledge of, or at least an interest in, some of the evidence-based treatments from which transdiagnostic mechanisms and interventions are derived. While the book may be quite helpful to readers who have some familiarity with ACT and DBT, it can also be a good introduction to learning more about these and other treatment approaches. We hope this book points all readers in the direction of learning more about possible transdiagnostic mechanisms in case formulation and treatment planning and about the protocols and treatment approaches from which they are derived.

Who is this book for?

RF & JD: This book is for any clinician—from novice to experienced—interested in treating patients with symptoms spanning different diagnostic categories or struggling to keep up with the growing number of disorder-based protocols and underlying psychological mechanisms described in the literature. While seasoned clinicians may be familiar with case formulation and the many mechanisms and interventions described in the book, our road map offers a much-needed guide to learn about a full range of mechanisms and interventions and how they can be mapped to the presenting problems of specific clients. Academic faculty and clinical supervisors can use this book to guide their students and trainees; and students and trainees can directly benefit from this book because it covers the fundamental principles of good clinical practice and components of CBT and other evidence-based practices, while guiding readers in developing and implementing transdiagnostic case formulations. We did a lot of groundwork so that all clinicians could benefit from our review of the literature and develop ideas about how to integrate research on transdiagnostic mechanisms into their actual work with clients.

One of the many benefits of a case formulation approach like the transdiagnostic road map is that it tailors interventions to the specific needs of individual patients while maintaining fidelity to the evidence-based treatment protocols generating those interventions. This is explained in the section on flexibility within fidelity in Chapter 4. Can you expand on this concept a bit more here?

RIF: “Flexibility within fidelity” is a longstanding concept in cognitive behavioral therapy. It refers to the necessity of adhering to the overarching theoretical and structural caveats that govern specific treatment protocols, while being somewhat flexible in how you tailor them to the needs of each patient. For example, we might alter the ordering of session content to address a specific problem that arises during treatment, or we might focus on specific elements within a treatment module (e.g. emphasizing self-soothing as a distress tolerance skill for someone lacking self-compassion) while de-emphasizing others (e.g., making contributions, which might be helping that same person avoid attending to their own emotions and needs). Similarly, thought records may be modified to incorporate relevant constructs (such as mindfulness-based responses, physical sensations, or efforts to suppress thoughts and feelings), while including the basic elements of situation, thoughts, emotions, and behaviors. Again, we intend that readers obtain proper training in whatever road map methods they are incorporating into clinical practice.

JD: This is important. The risk when using an individualized case formulation and treatment plan that draws from multiple treatment approaches targeting multiple mechanisms is that the formulation and treatment plan can become muddled. When you stay true to the scientific understanding and intent of treatment approaches, your patient benefits from the research and theory behind those approaches. Otherwise your treatment may become haphazard and inconsistent with the rationale on which interventions are based.

If you don’t have the necessary training to implement treatment components in a manner that is consistent with the theory and purpose behind them, and consultation or supervision is not enough, you should consider referring clients to other clinicians who do have that training and experience. Very few, if any, therapists are confident in their ability to adequately address all TDMs or implement every clinical intervention available to us. Conducting a good clinical assessment, developing formulation hypotheses, and considering appropriate treatment planning options may lead you to make a referral, and this may be the best use of a transdiagnostic case formulation if it helps the patient get the best help available to meet their needs!

Another important piece of the transdiagnostic road map is skillful creativity, which is described in the book as a concept that “breathes life into the road map and truly individualizes treatment by incorporating the unique blend of each therapist-patient dyad’s talents, skills, and creative ideas into clinical interventions. Please expand on this. 

RIF: Skillful creativity is perhaps one of the more rewarding aspects of clinical work. I never cease to be amazed at the many different creative, innovative, and ingenious ways that people take ownership of their treatment and make it personally meaningful by incorporating their talents, knowledge, and skills into interventions—which also makes those interventions so much more effective. I often am quite humbled by my patients’ depth of creative talent, and feel privileged that they are willing to share it with me. For example, I have seen clients use artwork, crafts, music, narratives, poetry, imagination, and humor to tackle some of the most painful experiences of their lives, and to enhance their ability to benefit from different clinical interventions. I also enjoy bringing my own personal and creative talents to my work, whether it’s my sense of humor, my appreciation of music and cooking, or my efforts at different sports and activities, which I share with clients to illustrate mechanisms (yes, we also have TDMs to tackle in our daily lives!). It’s the unique blending of my skills and talents with each patient’s own diverse attributes that makes every collaborative journey such a rewarding, fulfilling, and cherished one of my own.

JD: You’re already thinking outside the box when you use a case formulation approach, for it requires you to think creatively. As we all know, every individual is different, which necessitates a degree of creativity when working in collaboration with patients who bring diverse backgrounds, experiences, values, and goals to treatment. When making choices about interventions to target underlying mechanisms, it is important to stay true to the function that the interventions should serve. When it comes to the specifics about how you choose to implement those interventions, creativity will help you and your patient individualize the intervention to best suit their needs. I encourage patients to be creative when designing therapy homework plans that work best for them. While one patient might like recording problematic situations and new responses to automatic thoughts and behaviors on an electronic device, another patient might like to draw diagrams or cartoons of them. Behavioral experiments can require great creativity when one is carrying out plans to test assumptions and expectancies. Choosing how to design interventions or monitor progress can be a very creative process even as it still adheres to the function that those interventions and monitors should serve. Like Shelly pointed out, creativity allows patients to take on a greater level of ownership of their treatment and maintenance plans.

Helping people reduce symptoms, learn new skills and life strategies, and live the life they want to live is what makes my work so rewarding. Using creativity in the process of achieving those goals is what makes my work so enjoyable. When I was in graduate school I was concerned that I had chosen a career path that would prevent me from pursuing my creative interests. A very wise woman told me, “Helping others requires the greatest form of creativity.” Those words ring true now even more than they did when I was a student. Clinical work builds on science and a strong foundation in clinical skills. Yet it is not a cookie-cutter type of profession. It can’t be since we are working with different human beings to alleviate different types of suffering. I am challenged every day to bring the creative aspects of myself to my work and to encourage my patients to bring their creativity to the table so that we can best implement treatment components to meet their needs and achieve their goals.

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