Evidence-Based Practices in CognitiveBehaviour Therapy (CBT) CaseFormulation What Do PractitionersBelieve is Important and What DoThey DoPenelope Huisman and Maria KangasCentre for Emotional Health Department of Psychology Macquarie University Sydney New SouthWales Australia

Objective In cognitive behavioural therapy (CBT) case formulation (CF) is anintegral process in ensuring cliniciansrsquo work is grounded in evidence-based practice(EBP) The objective of this study was to evaluate psychologistsrsquo perceptions andself-reported applications of CBT-CF and whether these differed according toclinician experience training and professional accreditation Method A scale wasdeveloped to assess CF beliefs and applications by clinicians who had been practisingCBT for a minimum of 6 months The development of scale items was based ontwo CBT-CF conceptual models Seventy-nine psychologists registered in Australiatook part in this online survey Results Psychologistsrsquo beliefs pertaining to CBT CFsupported a three-factor model On average psychologists perceived all activitiesrelated to CF at least moderately important and were implemented at least someof the time However activities related to use of external evidence were rated asless important and less frequently implemented Clinical psychologists endorsedtheory and EBP in structuring CF as more important which also translated into self-reported practice of CF CBT implementation relative to generalist psychologistsConclusions The findings indicate some gaps in the knowledge and applicationof CF CBT in clinical practice and has implications in strengthening cliniciantraining in CF CBT

Keywords case-formulation CBT clinical training assessment

Evidence-based practice (EBP) in psychotherapy has been defined as lsquothe integrationof the best available research with clinical expertise in the context of patient charac-teristics culture and preferencesrsquo (American Psychological Association PresidentialTask Force on Evidence-Based Practice 2005 p 5) It has been suggested that usingEBP in psychological treatment enables clinicians to ensure that they make recom-mendations about treatment that offer the maximum chance of treatment benefit withthe minimum risk of harm to clients more broadly EBP can ensure that costs of de-livered treatments are acceptable given their likely benefit (Australian PsychologicalSociety 2010)

Address for correspondence Associate Professor Maria Kangas Centre for Emotional Health Department ofPsychology Macquarie University AustraliaEmail MariaKangasmqeduau

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Penelope Huisman and Maria Kangas

In the implementation of psychological therapies it has been proposed that EBPhas three core components (Lilienfeld Ritschel Lynn Cautin amp Latzman 2013) Thefirst component is the clinicianrsquos ability to identify and use the best available evidenceregarding treatment enabling selection of the treatment demonstrated to be mosteffective for a client presentation and an understanding of why a treatment is effectiveSuch evidence includes treatment efficacy studies in research settings effectivenessstudies in lsquoreal-worldrsquo settings and research into psychological processes relevant totherapies (Lilienfeld et al 2013) The second component of EBP entails the cliniciansrsquoexpertise comprised of clinical skills and experience Lilienfeld et al (2013) argue thatclinical expertise is a necessary part of decision making in psychological therapies aslsquodata simply are not available to dictate every decision within a psychotherapy sessionrsquo(p 886) The third component of EBP comprises cliniciansrsquo knowledge of client valuesand preferences as these may have an impact on choice of therapy for instance atreatment found to be effective for a clientrsquos problem may not be acceptable to a client(Lilienfeld et al 2013)

Despite the suggested benefits of EBP in delivering psychological therapy researchsuggests that a substantial proportion of clinicians offering psychological therapies donot adopt all components of EBP relying predominantly on their clinical expertisewith resistance to EBPs most consistently related to use of external evidence (egCowdrey amp Walller 2015 Gyani Shafran Myles amp Rose 2014 Lilienfeld et al2013 Pilecki amp McKay 2014 Safran Abreu Ogilvie amp DeMaria 2011) A numberof reasons for this finding have been proposed including clinicians (1) not findingresearch relevant or applicable to their practice (Kazdin 2008 Safran et al 2011)(2) not updating their knowledge of research (Gyani et al 2014) or (3) lacking famil-iarity with the theory underpinning treatments (Pilecki amp McKay 2013) Lilienfeldet al (2013) proposed that while many clinicians agree that external research-basedevidence is useful in therapy practice other sources of information (most consistentlytheir own clinical experience) are endorsed as most useful and used more frequently

Allegiance to a therapeutic approach may play a role in influencing clinician at-titudes toward using research Studies have indicated that clinicians using cognitivebehavioural therapy (CBT) regularly are more likely to be positive about EBPs com-pared to clinicians who apply other theoretical orientations (Gyani et al 2014) CBTapproaches also have a comprehensive evidence base in terms of theoretical conceptstreatment methodologies and validation (Tarrier amp Calam 2002 Nezu Martell ampNezu 2014) Therefore clinicians using CBT may be more aware of EBPs or morelikely to implement EBPs in their practice

Within the practice of CBT a specific therapy process suggested to play an integralrole in incorporating evidence into individual treatments is case formulation (CFDudley Kuyken amp Padesky 2011 Nezu Nezu amp Lombardo 2004 Persons 20062008) It is during the CBT CF process that the clinician can integrate the lsquoindividualparticularities of a given case relevant theory and researchrsquo (Kuyken 2006 p 12)By incorporating empirical findings into the CF the clinician is prompted to identifyaspects of the individualrsquos presentation that correspond with theoretical models andthat could be targeted in treatment (Persons Roberts Zalecki amp Brechwald 2006)

Despite the importance of CF to the practice of CBT surprisingly there is apaucity of research regarding clinician practice of CF In one of the few studies to focuson clinician perspectives regarding CBT CF Flitcroft James Freeston and Wood-Mitchell (2007) aimed to identify the essential features of CBT CF for depression usinga Q-sort methodology Twenty-eight CBT clinicians were asked to order in terms of

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Evidence-Based Practices in CBT Case Formulation

importance expert-developed statements describing CBT CF processes and then toselect three statements that they perceived represented what was most essential toCF and three statements representing what was least essential Flitcroft et al (2007)identified that the descriptive statements rated as most important referred to theformulation as (1) explaining how problems are maintained (2) being acceptable tothe client and others (3) helping to make sense of what the client was experiencingand (4) guiding possible interventions Their analysis of results identified a three-factormodel which Flitcroft et al (2007) argued represented three different viewpoints ofwhat is most important in CF However this outcome should be interpreted withcaution as many of the statements appear to cross-load on the three factors makinginterpretation of factor structure difficult Moreover the factor extraction methodused in this study the Kaiser criterion has been criticised as one of the least accuratemethods for selecting the number of factors to retain (Costello amp Osbourne 2005) asit may lead to identification of too many factors (Velicer amp Fava 1998) The findingsfrom Flitcroft et alrsquos (2007) study were also likely affected by the very small sampleof participants (N = 28) well below the sample suggested as the lowest numberacceptable for factor analysis (Velicer amp Fava 1998)

More recent research by Nattrass Kellett Hardy and Ricketts (2014) evaluatedthe content of CFs presented by eight clinicians to 29 clients who received CBT-oriented treatment for obsessive compulsive disorder In the 70 sessions analysed Nat-trass et al identified that clinicians appeared to focus on information about symptomsand maintaining factors with most frequently mentioned content being descriptionsof the behavioural and cognitive components of the clientrsquos psychological difficultiesHowever the authors concluded that their focus on analysing the CF content as pre-sented to the client did not enable them to examine the complexity of CF over time

Neither of these aforementioned studies provide specific information about whatpractices CBT clinicians consider important to CF what practices they report im-plementing and whether this incorporates use of EBP Accordingly the overarchingobjective of the current study was to address this gap in the literature notably to ex-amine which practices CBT clinicians report are important to CF and which practicesthey report implementing

The CF process itself has been proposed to comprise three stages (Eells 2007)First the clinician gathers information about the clientrsquos current thoughts emotionsbehaviours and contextual and historical factors in order to identify what clientdifficulties are to be the focus of treatment (Eells 2007) In the second stage usinginformation from the client and knowledge of the theoretical basis of treatment theclinician develops hypotheses about how the clientrsquos current psychological difficultiesand problems are maintained (Eells 2007) These hypothesised relationships can thenbe used to develop an initial treatment plan (Eells 2007) In the third stage both theCF and the treatment plan based upon it are evaluated and revised by the clinicianas treatment progresses (Eells 2007) A possible integration of EBPs as outlined byLillenfeld et al (2013) and as applied to the practice of CF as described by Eells (2007)is presented in Table 1

Study Aims and HypothesisConsidering the notable paucity of research that has focused on clinician perceptionsand applications of CBT CF the aim of the current study was to investigate whetherclinician responses regarding what they believed was important in CBT CF and

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Penelope Huisman and Maria Kangas

TABLE 1

Synthesis of the Three Steps of Case Formulation and Evidence-Based Practices

Case formulation processlowast Relevant evidence-based practicelowastlowast

Gather information from the client todescribe presentation

Knowledge of client preferences

Identificationuse of best available evidencerelating to presentationtreatment

Develop hypotheses about maintenanceof problems may include diagnosis

Clinical expertise

Use of best available evidence relating topresentationtreatment

Evaluate hypotheses and adjust iftreatment does not progress

Clinical expertise

Knowledge of client preferences

Note lowastBased on Eells (2007) lowastlowastBased on Lilienfeld et al (2013)

what practices they implemented reflected Eellsrsquo (2007) grouping of CF activitiesinto three stages For the purposes of the current study the Nezu et al (2004 2007)and Persons (2006 2008) CF models were selected as the basis for investigating CFbeliefs and practice among clinicians as these models provide guidance on usinginformation from the three sources defined by Lilienfeld et al (2013) as comprisingEBP In particular the approaches by Nezu et al (2007) and Persons (2006 2008)provide specific guidance regarding how to incorporate empirical findings and relevantexternal evidence into the CBT CF process

Four specific hypotheses were tested First on the basis that (a) research hasshown that clinicians tend to rely on their experience existing skills or consultationwith colleagues when engaged in activities such as selecting treatments and thatthere is resistance or reluctance to incorporate external evidence in clinical practice(eg Stewart Stirman amp Chambless 2012) and (b) studies have further shown thatless experienced CBT clinicians may not identify all problems relevant to treatment(Haarhoff Flett amp Gibson 2011) and struggle to identify relevant theory-drivencomponents of CF (Dudley Park James amp Dodgson 2010) it was first hypothesisedthat clinicians would report that practices related to incorporating external evidencewere less important and that these practices were less likely to be implemented Sec-ond it was predicted that more experienced clinicians would be more likely to endorsepractices related to using evidence in CF as these practices may reflect higher levelsof skill using theory to inform practice Furthermore research has documented thattraining also seems to improve CBT-based CF skills (eg Dudley Ingham Sowerbyamp Freeston 2015 Haarhoff Gibson amp Flett 2011 Zivor Salkovis Oldfield ampKushir 2013) Accordingly the third hypothesis tested was that clinicians with higherlevels of training would endorse more practices related to use of external evidence onthe basis that use of external evidence may be considered a more advanced CF skillFinally it was also hypothesised that participants with higher levels of professionalaccreditation would also endorse more practices related to use of external evidence

Method

Participant CharacteristicsA sample of 79 psychologists registered in Australia with the Psychology Board ofAustralia at the time of recruitment took part in an online survey The participants

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Evidence-Based Practices in CBT Case Formulation

were predominantly female (N = 68 86) while the average age of the samplewas 40 years (SD = 1123 range 26ndash69 years) Participants were required to meetthe following inclusion criteria (1) had completed their professional registration asa psychologist in Australia (2) applied CBT at least monthly in their current workand (3) had more than 6 monthsrsquo experience using CBT with clients Of the 79participants who started the survey 9 did not complete all sections

MeasuresThe online survey completed by participants consisted of items regarding partici-pantsrsquo demographic characteristics including professional title highest level of pro-fessional qualification current work setting characteristics (ie own practice out-patient or inpatient settings) current client caseloads (eg anxiety PTSD) yearsof experience using CBT training in CF and encouragement to use CF in theworkplace

Following a review of the published literature for CBT-based CF two CBT CFmethodologies were identified that contained specific guidance relating to use ofexternal evidence during the CF process (Nezu et al 2004 Nezu Nezu amp Cos 2007Persons 2006 2008) These published methodologies were used to develop statementsrelated to general practice in CBT CF and statements related to EBP in CBT CFStatements were developed based on this literature given no validated questionnaireassessing beliefs and practices related to CF in CBT could be identified CF surveyitems derived from the aforementioned CBT CF methodologies described differentactivities associated with the three steps of CF outlined by Eells (2007) In summarythese steps related to (1) the clinician assessing and describing the clientrsquos presentingproblems (2) generating hypotheses about how the presenting problems are beingcaused or maintained and (3) evaluating these hypotheses Within each of thesethree stages activities relating to use of externally derived evidence were identifiedand described

These statements were incorporated into the survey For clinician beliefs aboutCBT CF activities 13 statements focused on participantsrsquo belief in the importanceof different CF activities (see Table 4 for items) Participants were asked to rate theextent to which they agreed an activity was important in CF on a 5 point scale with ascore of 1 representing not important to case formulation a score of 2 equivalent to of littleimportance to case formulation 3 representing moderately important to case formulationa score of 4 denoting important to case formulation and scores of 5 representing veryimportant to case formulation

A further 13 statements (see Table 5) assessed how frequently participants reportedimplementing these activities in their current CF practice (where current practice wasdefined as lsquothe last 8 weeks of practicersquo) Frequency was indicated using a 5-point scalewhere a score of 1 represented I never do this as part of case formulation 2 equivalent toI rarely do this as part of case formulation 3 represented I sometimes do this as part of caseformulation 4 represented I usually do this as part of case formulation and a score of 5represented I always do this as part of case formulation Three final statements assessedhow participants used CF in their current practice This was scored using a 5 pointscale identical to the activity item score (ranging from a score of 1 representing Inever do this to 5 equivalent to I always do this)

Following institutional ethics approval the survey was piloted with two psychol-ogists (a generalist psychologist and a clinical psychologist) Following feedback one

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Penelope Huisman and Maria Kangas

question relating to psychology registration was rephrased to ensure that only provi-sional psychologists were excluded from completing the survey

ProcedureAn email invitation was circulated to a variety of relevant professional networksand organisations throughout Australia These included the Australian Psychologi-cal Society (APS) Australian Clinical Psychology Association (ACPA) AustralianAssociation for CBT (AACBT) Headspace offices Primary Health Networks andvarious Facebook groups used by psychologists in Australia to discuss professionalconcerns A snowball approach was also utilised requesting that psychologists whocompleted the survey to also consider inviting colleagues to participate

Data AnalysisData were analysed using SPSS Version 22 to derive descriptive statistics chi-squarecomparisons repeated measures t tests to evaluate whether differences emerged be-tween responses to survey items related to using external evidence and other surveyitems and independent sample t tests to compare participantsrsquo responses by profes-sional title and years of experience with CBT As the survey on CBT CF beliefsand practice was developed for this study exploratory factor analysis revealed ad-equate internal consistency with Cronbachrsquos alpha coefficient reported at 080 forthe 13 items related to CF beliefs and 079 for the 13 items related to CF practicesTo assess whether a three-factor model could be derived from belief and activityitems confirmatory factor analysis was conducted Based on recommendations in theliterature on factor analysis (Costello amp Osborne 2005 Fabrigar Wegener Mac-Callum amp Strahan 1999) data reduction was conducted using principal axis factoranalysis and oblique rotation Results indicated that items relating to beliefs aboutimportance of activities could be explained by a three-factor model but reduction ofitems relating to implementation of activities did not produce coherent latent vari-ables Given this outcome individual statements were used to explore the aims ofthe study

Results

Analyses relating to participant characteristics were conducted prior to hypothe-sis testing Sixty-one percent of the participants categorised themselves as clinicalpsychologists and 39 as general psychologists About half of participants (53)had a masterrsquos degree as their highest qualification with 32 reporting they had adoctorate-level qualification Due to the small number of participants with certificatediploma or bachelor studies as their highest level of qualification these categories werecombined representing 14 of the total sample As most participants with doctoralqualifications also held masters-level qualifications these groups were not consideredsufficiently different to compare a finding confirmed by preliminary analysis Thenumber of participants with certificatediplomabachelor degrees as their highest levelof qualification was small As such planned comparisons using qualifications couldnot be conducted

Participants reported clinical experience using CBT ranging from less than 2 yearsto more than 5 years Due to the small number of participants with less than 2 yearsrsquoexperience the categories of lsquoless than 2 yearsrsquo experiencersquo and lsquo2ndash5 yearsrsquo experiencersquowere combined Almost two-thirds (63) of participants reported having more than

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Evidence-Based Practices in CBT Case Formulation

5 yearsrsquo experience using CBT in their work and 38 reported having 5 yearsrsquoexperience or less The professional characteristics of the total sample are summarisedin Table 2 Participants with more than 5 yearsrsquo experience were significantly olderthan participants who had less than 5 yearsrsquo experience t(77) = -561 p = 003they were also more likely to have a doctoral qualification χ2(2) = 699 p = 032There were no significant differences in work settings or client characteristics whenexperience formed the basis for comparison (all ps gt 005)

In comparing accreditation status clinical psychologists were found to be signif-icantly older t(77) = -285 p = 006 more likely to have completed doctoral levelstudies χ2(2) = 2407 p lt 001 and had more years of experience using CBT thanpsychologists χ2(2) = 1002 p = 002 Comparisons between psychologists and clini-cal psychologists revealed no significant differences in relation to current work settingage of clients or client presentations (all ps gt 05)

Participantsrsquo responses regarding specific training in CF indicated that there wereno significant differences when responses were compared for psychologists and clinicalpsychologists or when comparing responses for participants with more than 5 yearsrsquoor less than 5 yearsrsquo experience (all ps gt 005 see Supplementary material onlineTable 1) Overall the most common source of CF training was self-directed (egreading books and articles) with 89 of participants endorsing this option Eighty-sixpercent of participants reported they had received training in CF during their studiesand 75 stated they had received training in CF at work (eg from a supervisoror from work-sponsored training) The majority of participants endorsed receivingtraining from all three sources Participants were also asked to report whether theycurrently received encouragement to use CF in their workplace Again no significantdifferences emerged between groups when compared by professional title or years ofexperience Overall 78 of participants reported they were encouraged to use CFskills by their supervisor and 68 agreed they were encouraged to use CF skills bywork colleagues

Factor Analysis of Beliefs and Practices DataResponses to items about beliefs in importance of CF activities (N = 79) and CFactivities implemented (N = 72) were reduced to identify whether a three-factorstructure emerged that reflected the grouping of CF activities as described by Eells(2007) Measures of sampling adequacy indicated that both sets of data were suitablefor data reduction (KMO Measure of sampling adequacy = 074ndash077 Bartlettrsquos testof sphericity significance = 0000 all anti-image correlations gt 050) Based onrecommendation of Costello and Osbourne (2005) only items with correlations above32 with a factor were retained

Data reduction of item responses regarding beliefs in importance of CF activitiesindicated that a three-factor structure could be derived (see Table 3) Each factorcontained three or more items loading above 5 on the factor which Costello andOsbourne (2005) suggest is the minimum factor loading that can be considered stableFactor 1 was moderately correlated with both factor 2 (r = -34) and factor 3 (r =+34)factors 2 and 3 were weakly correlated with each other (r = -14) Data reduction ofitems related to activities implemented resulted in less coherent groupings of itemswith lower item loadings on factors and cross-loading of items on multiple factorsFactors 1 and 3 were moderately correlated (r = =37) and factor 2 was weaklycorrelated to Factor 1 (r = +11) and Factor 3 (r = -07)

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Penelope Huisman and Maria Kangas

TABLE 2

Sample Demographics and Professional Details

Total General Clinical

sample psychologist psychologist

(N = 79) (N = 31) (N = 48) p value

Gender

Female 861 870a 854b 0044

Male 139 129a 146b

Highest level of study

Certificatediplomabachelors

139 290a 004b 0000

Masters 532 677a 438b

Doctorate 329 32a 521b

Years experience using CBT 0002

Less than 5 years 367 581a 229b

5 years or more 633 419a 771b

Work setting (total sample)

Inpatientoutpatient setting 355 375 0058

Own practice 258a 479b 0051

Government funded ornot-for-profit service

484 292 0084

Privately funded or for profitservice

323 229 0359

Client age groups

Child (up to 11 years) 342 355 333 0844

Adolescent 532 581 500 0483

Adult 949 903 979 0133

Client presentations

Anxiety 1000 1000 1000 NA

Depression 1000 1000 1000 NA

PTSD 949 903 979 0064

Eating disorder 873 839 896 0053

Addiction 886 871 896 0202

Bipolar 924 903 938 0135

Schizophrenia 924 903 938 0883

Personality disorders 937 903 958 0090

Developmental disorders 899 903 896 0951

Impulse control disorders 911 806 958 0261

M (SD) M (SD) M (SD)

Age 400 357 (SD = 427 (SD = 0006

(1123) 1002)a 111)b

Note Some participants endorsed more than one work setting Superscript a and b indicate p lt 05

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Evidence-Based Practices in CBT Case Formulation

TABLE 3

Factor Analysis of Items Related to Importance of Activities to CBT CF

Factors Factors

Belief scale Practice scale

Item 1 2 3 1 2 3

Seeking information about clientfactors which may negativelyimpact treatment

085 048

Consulting theory or evidencerelevant to a clientrsquos presentingproblems

065 042 043

Seeking information about clientstrengths which appear helpful tothe client or therapy

063 041

Identifying the clientrsquos goals inseeking treatment

061 054

Identifying how to evaluateexplanations relating to causal andmaintaining factors and theirrelationship to presenting problems

ndash081 038 066

During therapy evaluatingexplanations relating to causal andmaintaining factors and theirrelationship to presenting problems

ndash073 072

Using a structured case formulationto guide case formulation such as aCBT case formulation template

ndash072 037

Identifying the clientrsquos currentpresenting problems

065 076

Developing explanations about howthe clientrsquos thoughts behavioursand affect are related to thepresenting problems

059 049

Identifying client thoughts andbehaviours associated withpresenting problems

051 041

Seeking information aboutdevelopmental experiences whichappear related to the clientrsquospresenting problems

041 058

Identifying factors which appear tomaintain or worsen the clientrsquospresenting problems

041 075

Using assessments such as self-reportquestionnaires to identify thoughtsemotions and behaviours

Noloading

049

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Penelope Huisman and Maria Kangas

Beliefs and Practices in CBT CFTo test the first hypothesis for the full sample (N = 79) means were calculatedfor each item that assessed the importance given to different CF activities and thefrequency with which participants reported engaging in these activities (see Tables 4and 5 respectively) Mean scores indicated that the activities described were seen asrelevant to CBT CF with all activities achieving mean scores above 3 Participantsrsquoscores for frequency of implementation of activities for the full sample (N = 72)indicated slightly more variation in responses compared with belief ratings but overallactivities all achieved mean scores above 3

To compare responses on items describing activities related to use of externalevidence paired-sample t tests were conducted The mean of five items in the surveyon beliefs (these items are summarised in Table 4) was compared to the mean ofthe eight items describing other activities Cronbachrsquos alpha for the scales indicatedacceptable internal consistency of scale item (see Supplementary Table 2) Results ofscale comparisons indicated that participants rated items related to use of externalevidence as significantly less important compared to their ratings of importance ofother CF activities t(78) = 10901 p lt 001 The mean of the five items describingimplementation of practices related to use of external evidence was compared to themean of the eight survey items describing other practices the five items relating to useof external evidence are presented in Table 5 Cronbachrsquos alpha for the scale relatedto use of external evidence was adequate but questionable for the eight-item scaleParticipants reported significantly less frequent implementation of activities relatedto use of external evidence compared to their implementation of other activitiest(71) = 10070 p lt 001

Beliefs and Practices in CBT CF Comparisons Between GroupsParticipantsrsquo responses related to beliefs and practices in CF were compared using dif-ferences in years of experience with CBT and differences in professional accreditation(general psychologist vs clinical psychologist) A Bonferroni correction was used toadjust p set at p lt 025 for this set of analyses

For the full sample comparisons of responses about beliefs relating to CF indicatedfew differences Participants with less than 5 yearsrsquo experience using CBT rated someactivities as significantly less important to CBT CF including evaluating explanationsduring therapy t(77) = -272 p = 01 consulting theory or evidence relevant to aclientrsquos presenting problems t(77) = -300 p lt 001 and using a structured caseformulation t(77) = -232 p = 02 Few significant differences emerged when clinicalpsychologists and generalist psychologists were compared Generalist psychologistsrsquoratings of the importance of consulting theory or evidence were significantly lowerwhen compared to ratings given by clinical psychologist t(77) = -234 p = 02as were generalist psychologistsrsquo ratings of the importance of using a structure caseformulation t(77) = -241 p = 018

Comparisons of responses relating to frequency of implementation of CF practicesalso indicated very few overall differences with no significant differences identifiedwhen participants with differing levels of experience were compared Psychologistsreported less frequent implementation of evaluation of their hypotheses about causaland maintaining factors t(70) = -268 p = 01 and less frequently consulting theoryor evidence relevant to the clientrsquos presenting problems t(70) = -235 p = 02compared to clinical psychologists

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Evid

ence-B

asedPractices

inC

BT

Case

Form

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TABLE 4

Beliefs about Importance of CF Methods

Full sample(n = 79)

Comparisongroup

Item Mean (SD) Comparison mean (SD) t (df) p d

Identifying the clientrsquos current presentingproblem(s)

485 (0395) 5 years + 484 (037)024 (77) 081 005

lt5 years 486 (044)

Clin psych 481 (039)100 (77) 032 023

Psychologist 490 (040)

Identifying factors which appear to bemaintaining or exacerbating the clientrsquospresenting problems

481 (0455) 5 years + 480 (050) 026 (77) 080 006

lt5 years 483 (038)

Clin psych 479 (050) 045 (77) 066 011

Psychologist 484 (037)

Identifying client thoughts and behavioursassociated with the presenting problem(s)

467 (0548) 5 years + 478 (042) minus211(4026)lowastlowast

004 053

lt5 years 448 (069)

Clin psych 463 (061) 093 (77) 036 021

Psychologist 474 (045)

Developing explanations about how the clientrsquosthoughts behaviours and affect are related tothe presenting problem(s)

457 (0710) 5 years + 470 (058) minus19843(4314)lowastlowast

005 049

lt5 years 434 (086)

Clin psych 460 (074) minus054 (77) 059 011

Psychologist 452 (068)

Identifying the clientrsquos goals in seekingtreatment

449 (0766) 5 years + 456 (061) minus090(4091)lowastlowast

032 022

lt5 years 438 (098)

Clin psych 440 (084) 1422 (77) 016 034

Psychologist 465 (061)

Beh

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Penelo

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Hu

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TABLE 4

(Continued)

Full sample(n = 79)

Comparisongroup

Item Mean (SD) Comparison mean (SD) t (df) p d

Seeking information about client strengthswhich appear helpful to the client or therapy

435 (0863) 5 years + 442 (081) minus089 (77) 038 020

lt5 years 424 (095)

Clin psych 431 (095) 054 (77) 059 013

Psychologist 442 (072)

Seeking information about developmentalexperiences which appear related to clientrsquospresenting problems

422 (0842) 5 years + 426 (088) minus062 (77) 054 014

lt5 years 414 (079)

Clin psych 427 (084) minus073 (77) 04748 017

Psychologist 413 (085)

Seeking information about client factors whichmay negatively impact treatment

420 (0758) 5 years + 430 (068) minus151 (77) 013 035

lt5 years 403 (087)

Clin psych 421 (082) minus008 (77) 093 003

Psychologist 419 (065)

Evaluating explanations relating to causal andmaintaining factors and their relationship topresenting problems during therapyˆ

419 (0877) 5 years + 438 (081) minus272 (77) 001lowast 063

lt5 years 386 (083)

Clin psych 427 (087) minus106 (77) 051 025

Psychologist 406 (081)

12

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Evid

ence-B

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inC

BT

Case

Form

ulatio

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TABLE 4

(Continued)

Full sample(n = 79)

Comparisongroup

Item Mean (SD) Comparison mean (SD) t (df) p d

Consulting theory or evidence relevant to aclientrsquos presenting problems for instance toassist identify relationships betweenpresenting problems causal or maintainingfactorsˆ

403 (0877) 5 years + 424 (074) minus300 (77) 000lowast 067

lt5 years 366 (097)

Clin psych 421 (087) minus234 (77) 002lowast 056

Psychologist 374 (082)

Identifying how to evaluate explanationsrelating to causal and maintaining factors andtheir relationship to presenting problemsˆ

403 (0974) 5 years + 418 (098) minus188 (77) 006 044

lt 5 years 376 (091)

Clin psych 408 (109) minus066 (77) 051 015

Psychologist 394 (077)

Using assessments such as self-reportquestionnaires to identify thoughts emotionand behavioursˆ

343 (0957) 5 years + 346 (089) minus08(77) 072 008

lt 5 years 338 (108)

Clin psych 344 (099) minus08 (77) 094 002

Psychologist 342 (092)

Using a structured case formulation to guidecase formulation such as Beckrsquos CBT caseformulation template or ACT formulationtemplateˆ

327 (1106) 5 years + 348 (111) minus232 (77) 002lowast 055

lt 5 years 290 (101)

Clin psych 350 (111) minus241 (77) 0018lowast 057

Psychologist 290 (101)

Note ˆactivities described as incorporating or using external evidence according to Nezu et al (2004 2007) and Persons (2006 2008)lowastp lt 025 lowastlowastPopulation variances unequal t statistic df and p results reported with equal variances not assumed Clin psych = Clinical psychologist

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TABLE 5

CF Activities Implemented

Full sample(n = 72)

Comparisongroup

Item Mean (SD) Comparison Mean (SD) t (df) p d

I identify the clientrsquos presentingproblem(s)

489 (0519) 5 years or more 489 (061) 000(70) 100 000

Less than 5 years 489(032)

Clinical psychologist 487 (063) 047(70) 064 012

Psychologist 493 (027)

I identify factors which appear to bemaintaining or exacerbating theclientrsquos presenting problem(s)

476 (0489) 5 years or more 467 (060) 026 (70) 079 005

Less than 5 years 470 (054)

Clinical psychologist 473 (050) minus100 (70) 032 023

Psychologist 459 (069)

I identify client thoughts andbehaviours associated with thepresenting problem(s)

468 (0577) 5 years or more 487 (034) minus207(3527)lowastlowast

0046 055

Less than 5 years 459(064)

Clinical psychologist 476 (053) 019(70) 085 004

Psychologist 478 (042)

I develop explanations about how theclientrsquos thoughts behaviours andaffect are related to the presentingproblem(s)

453 (0804) 5 years or more 458 (066) minus104(70) 030 025

Less than 5 years 441 (069)

Clinical psychologist 464 (053) minus1967(3905)lowastlowast

006 049

Psychologist 430 (082)

I identify the clientrsquos goals in seekingtreatment

451 (0671) 5 years or more 453 (087) minus008 (70) 094 001

Less than 5 years 452 (070)

Clinical psychologist 451 (092) 023 (70) 082 005

Psychologist 456 (092)

14

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Evid

ence-B

asedPractices

inC

BT

Case

Form

ulatio

n

TABLE 5

(Continued)

Full sample(n = 72)

Comparisongroup

Item Mean (SD) Comparison Mean (SD) t (df) p d

I seek information about clientstrengths which appear helpful tothe client or therapy

433 (0787) 5 years or more 429 (079) 062 (70) 054 015

Less than 5 years 441 (080)

Clinical psychologist 436 (077) minus031 (70) 076 008

Psychologist 430(082)

I seek information aboutdevelopmental experiences whichappear related to clientrsquos presentingproblems

428 (0876) 5 years or more 424 (088) 012 (70) 068 010

Less than 5 years 433 (088)

Clinical psychologist 427 (089) 014 (70) 089 003

Psychologist 430 (087)

I seek information about client factorswhich may negatively impacttreatment

419 (0833) 5 years or more 433 (080) minus186 (70) 054 045

Less than 5 years 396 (085)

Clinical psychologist 436 (071) minus217 (70) 003 051

Psychologist 393 (096)

I evaluate explanations relating tocausal and maintaining factors andtheir relationship to presentingproblems during therapyˆ

400 (1138) 5 years or more 404 (122) minus043 (70) 067 01

Less than 5 years 393 (100)

Clinical psychologist 427 (094) minus268 (70)lowast 001 062

Psychologist 356 (131)

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Penelo

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Hu

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Maria

Kan

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TABLE 5

(Continued)

Full sample(n = 72)

Comparisongroup

Item Mean (SD) Comparison Mean (SD) t (df) p d

I consult theory or evidence relevantto a clientrsquos presenting problemsfor instance to assist identifyrelationships between presentingproblems causal or maintainingfactorsˆ

381 (1043) 5 years or more 393 (101) minus135 (70) 018 033

Less than 5 years 359 (108)

Clinical psychologist 402 (097) minus235(70)lowast 002 056

Psychologist 344 (109)

I identify how to evaluateexplanations relating to causal andmaintaining factors and theirrelationship to presentingproblemsˆ

358 (1230) 5 years or more 364 (135) minus054 (70) 059 018

Less than 5 years 343 (101)

Clinical psychologist 380 (114) minus197 (70) 005 047

Psychologist 322 (131)

I use assessments such as self-reportquestionnaires to identify thoughtsemotion and behavioursˆ

357 (1098) 5 years or more 344 (112) 033 (70) 022 031

Less than 5 years 378 (105)

Clinical psychologist 353 (110) 036 (70) 072 009

Psychologist 363 (112)

I use a structured case formulation toguide case formulation such asBeckrsquos CBT case formulationtemplate or ACT formulationtemplateˆ

312 (1363) 5 years or more 331 (140) minus151 (70) 014 041

Less than 5 years 281 (101)

Clinical psychologist 331 (140) minus151 (70) 014 037

Psychologist 281 (127)

Note ˆactivities described as incorporating or using external evidence according to Nezu et al (2004 2007) and Persons (2006 2008)lowastp lt 025 lowastlowastPopulation variances unequal t statistic df and p results reported with equal variances not assumed

16

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Evidence-Based Practices in CBT Case Formulation

Discussion

This study was the first survey conducted with psychologists (generalist and clinicalpsychologists) pertaining to CBT CF Before the main aim and hypotheses could betested an initial goal was to identify whether participantsrsquo responses reflected thethree-step model of CF suggested by Eells (2007) which grouped CF activities intothose (1) that describe presenting problems (2) activities aimed at generating hy-potheses about presenting problems and (3) activities aimed at evaluating hypothesesFactor analysis of item responses related to beliefs about importance of activities inCBT CF supported a three-factor model but the factors identified did not appear tosupport Eellsrsquo (2007) model in its entirety Factor 1 consisting of four items appearedto comprise activities in which the clinician seeks contextual information relevant toplanning treatment such as finding out about client factors that may help or hindertreatment consulting theory or evidence relevant to the presenting problems andidentifying the clientrsquos goals for treatment Factor 2 comprising three items relatedto activities used by clinicians to structure or check CF Factor 3 which included fiveitems comprised activities related to the clinician describing and hypothesising aboutthe clientrsquos presenting problems including maintaining factors

The three factors indicated that clinician responses grouped activities related tounderstanding client presenting problems (including hypothesising about those prob-lems) separately from activities related to understanding psychosocial factors that mayhave an impact on treatment and that were distinct from activities related to struc-turing and checking hypotheses These results imply that clinicians view structuringand evaluation of hypotheses as a discrete activity in CBT CF as suggested by Eellsrsquo(2007) model However these findings also indicate that clinicians may perceive thedistinction between activities related to description and hypothesis generation as lesssalient These results should however be interpreted with caution While loading ofthe items on factors can be described as adequate the sample size can only be consid-ered modest (Costello amp Osbourne 2005) Furthermore this pattern of item loadingswas not reflected in data reduction of items describing reported practice of activitiesFactor analysis of practice-related items provided support for grouping items related touse of external evidence as items related to consulting theory evaluating hypothesesand using assessments were related Overall however the factor structure for theseitems did not appear to reflect Eellsrsquo (2007) description or suggest an alternativecoherent pattern

The specific aim of this study was to investigate clinician beliefs and practicesrelated to EBP in CBT CF On the basis of prior studies (Lilienfeld et al 2013) it washypothesised that CF activities derived from published CBT CF methodologies thatexplicitly involved reference to external evidence would be seen as less important andwould be less frequently implemented by clinicians and the findings supported thisprediction Participants rated consulting theory or evidence related to the presentingproblem using third-party assessments (such as self-report questionnaires) to identifyrelevant constructs (thoughts or behaviours or feelings) using a structured case for-mulation identifying how to evaluate hypotheses and then evaluating hypothesesduring therapy as less important These activities were also less frequently imple-mented compared to activities related to describing and explaining the presentingproblem and activities related to understanding factors that could affect treatmentHowever it should be noted that the absolute differences were not large That is al-most all activities were reported at least moderately important and were implementedat least sometimes during CF

Behaviour Change

17

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Penelope Huisman and Maria Kangas

Furthermore in line with our predictions more experienced clinicians reportedevaluating hypotheses during therapy and consulting theory related to the presentingproblems and using a structured CF to guide their CF as significantly more importantthan less experienced clinicians However no significant differences were identifiedin reported frequency of implementation of any CF activities between cliniciansaccording to experience This outcome indicates that while experience was related toclinicians endorsing practices related to use of external evidence as more importantto CF this did not translate into observed differences in their reported practice

Not surprisingly in the current study registered clinical psychologists endorsedhigher levels of training (including having participants with a greater proportion ofdoctoral qualifications) and experience compared to general psychologists Howeverfew differences in ratings of importance of CF activities emerged between generalistpsychologists and clinical psychologists Clinical psychologists rated consulting theoryor evidence relevant to presenting problems and using a structured CF to guide CF assignificantly more important compared to psychologistrsquo ratings of the importance ofthese activities and they reported consulting theory or evidence related to the clientrsquospresenting problem with significantly higher frequency than registred generalist psy-chologists These findings provide only partial support for the hypothesis that traininglevel and experience influence use of external evidence in CBT CF

Interestingly however when comparing participants with more or less experienceresults indicated no significant differences in reported implementation of CF activi-ties Thus it is possible that observed differences in reported practice between clinicalpsychologists and generalist psychologists may be due to differences in training back-ground although this explanation can only be considered tentative While clinicalpsychologists had higher levels of training overall a substantial proportion (67)of general psychologists reported having a mastersrsquo qualification and it is likely thata number of those participants who marked the general psychologist category werein the process of working towards endorsement as clinical psychologists under theAustralian regulatory frameworks Moreover given the structure of many doctoratedegree programs in Australia it is likely many of the clinical psychologists who com-pleted doctoral-level qualifications had also completed a mastersrsquo degree within thatqualification As such it is difficult to draw distinctions between the two groups inrelation to differences in university-based training

Given that clinical psychologists were identified to be significantly more expe-rienced than psychologists this may in part have contributed to difference in theirCF practice However it is also possible that clinical psychologists are more likelyto work in organisational contexts where such CF practices are encouraged andorhave supervisory roles that encourage modelling of certain behaviours or that clientcharacteristics also play a role (eg greater client complexity or comorbidity neitherof which were assessed in this study may be related to greater reliance on theoryor external evidence when planning treatment) Therefore further exploration ofthe role of professional accreditation in contributing to observed differences in CFpractice is warranted to determine the possible contributions of factors associatedwith accreditation including training and work setting as well as considering clientcharacteristics

The results from this study indicate that CF practices related to using externalevidence are more likely to be endorsed as important and more frequently put intopractice by clinical psychologists and clinicians who have more experience This find-ing has several implications First it supports the view that using external evidence

18

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Evidence-Based Practices in CBT Case Formulation

effectively in CF is a clinical skill that can be developed As such it is encouraging thatmost participants in this survey indicated that they received training in CF throughmultiple formats including university training workplace training and through self-directed learning While self-directed training is to be encouraged evidence indicatesthat it needs to be carefully directed to be an effective form of training in CF (Haarhoffet al 2011) and that more extensive training with supervision is more likely to re-sult in improved skills (Zivor et al 2013) Moreover the significantly lower rateof endorsement of activities related to use of external evidence all of which werederived from published CBT CF methods (and are therefore accessible to clinicians)indicates that current training approaches used may not be effective in helping clin-icians develop specific skills related to use of external evidence to supplement theirunderstanding of the clientrsquos presentation generate CF hypotheses and identify andimplement evaluation of those hypotheses

A further implication of participantsrsquo responses is the finding that clinicians withless experience and lower levels of accreditation who it could be argued are mostin need of the guidance offered by empirical research are less likely to believe itis important and may be less likely to use it These clinicians are also less likely tohave developed significant clinical expertise and yet these results indicate that theymay be likely to rely on their limited clinical experience in relation to CBT CF withclients Research indicates that clinicians with less skill in CF are more likely torate themselves as competent and are less able to identify low quality formulations(Zivor et al 2013) therefore it is possible that clinicians with less experience andtraining may not be aware of the gap between their perceived and actual competencein relation to CF As such they may be less likely or less able to use external evidenceas a way to compensate for reduced competence This has implications for training ofpsychologists in terms of their ability to develop and assess their CBT CF competencyas well as to learn strategies that can mitigate low competency levels

This study has several limitations that should be taken into account when inter-preting the findings First while the psychometric properties of the survey items onCF beliefs and practices were adequate (both with an alpha above 07) the measurestill needs further validation in future research The relatively small differences inresponses to both belief and practice items may reflect that the scales used to capturedifferences did not do so adequately or may reflect that in fact there is relativelylittle variation in perceived importance and implementation of CF activities Captur-ing responses from a larger and more varied sample is therefore warranted in futureresearch A further limitation of this study was the difficulty in assessing differencesin training level of participants given the various current pathways to registration asa psychologist in Australia Researchers Zivor et al (2013) and Kuyken FothergillMusa and Chadwick (2005) sought to resolve this difficulty by testing participantswho took part in a workshop on CBT CF either before or after they completed theworkshop and comparing responses but acknowledged this approach also had lim-itations It appears that future research in CBT CF would benefit from more robustmethods of delineating training level to assist in identifying what training and howmuch training results in improvements in CF skills

Notwithstanding these limitations the current study was the first to investigatecliniciansrsquo beliefs and practices related to CBT CF and use of external evidencewithin the CF using activities derived from literature on CBT CF methodologiesResults indicate that clinicians focus on describing the client presentation and devel-oping explanations relating to that presentation Beliefs and practices related to use of

Behaviour Change

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Penelope Huisman and Maria Kangas

external evidence and evaluation of the CF appear to be seen as less important andare less likely to be implemented These findings indicate that further research is war-ranted on barriers to use of external evidence and evaluation in the CBT CF processClinician skills related to use of external evidence to develop their understandingof the clientrsquos presenting difficulties and evaluate that understanding are essential ifpsychologists are to confidently claim that their practice is fully evidence-based

Supplementary material

To view supplementary material for this article please visit httpsdoiorg101017bec20185

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Report of the 2005 presidential task force on evidence-based practice Washington DC AmericanPsychological Society

Australian Psychological Society (2010) Evidence-based psychological interventions in the treatment ofmental disorders A literature review Washington DC Author Retrieved August 27 2016 fromhttpswwwpsychologyorgauAssetsFilesEvidence-Based-Psychological-Interventionspdf

Cowdrey ND amp Waller G (2015) Are we really delivering evidence-based treatments for eatingdisorders How eating-disordered patients describe their experience of cognitive behaviouraltherapy Behaviour Research and Therapy 75 72ndash77 doi101016jbrat201510009

Costello AB amp Osbourne JW (2005) Best practices in exploratory factor analysis Four recom-mendations for getting the most from your analysis Practical Assessment Research amp Evaluation10 1ndash9 Available online httppareonlinenetgetvnaspv=10ampn=7

Dudley R Ingham B Sowerby K amp Freeston M (2015) The utility of case formulation intreatment decision making The effect of experience and expertise Journal of Behaviour Therapyand Experimental Psychiatry 48 66ndash74 doi101016jjbtep201501009

Dudley R Kuyken W amp Padesky CA (2011) Disorder specific and trans-diagnostic case con-ceptualisation Clinical Psychology Review 31 213ndash224 doi101016jcpr201007005

Dudley R Park I James I amp Dodgson G (2010) Rate of agreement between clinicians on thecontent of a cognitive formulation of delusional beliefs The effect of qualifications and experi-ence Behavioural and Cognitive Psychotherapy 38 185ndash200 doi101017S1352465809990658

Eells TD (Ed) (2007) Handbook of psychotherapy case formulation (2nd ed) New York NY TheGuilford Press

Fabrigar LR Wegener DT MacCallum RC amp Strahan EJ (1999) Evaluating the useof exploratory factor analysis in psychological research Psychological Method 4 272ndash299doi101007s10803-009-0816-2

Flitcroft A James IA Freeston M amp Wood-Mitchell E (2007) Determining what isimportant in a good formulation Behavioural and Cognitive Psychotherapy 35 325ndash333doi101017S135246580600350X

Gyani A Shafran R Myles P amp Rose S (2014) The gap between science andpractice How therapists make their clinical decisions Behaviour Therapy 45 199ndash211doi101016jbeth201310004

Haarhoff B Flett R amp Gibson K (2011) Evaluating the content and quality of cognitive-behavioural therapy case conceptualisations New Zealand Journal of Psychology 40 104ndash114

Haarhoff B Gibson K amp Flett R (2011) Improving the quality of cognitive behaviour ther-apy case conceptualization The role of self-practiceself-reflection Behavioural and CognitivePsychotherapy 39 323ndash339 doi101017S1352465810000871

20

Behaviour Change

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Evidence-Based Practices in CBT Case Formulation

Kazdin AE (2008) Evidence-based treatment and practice New opportunities to bridge clini-cal research and practice enhance the knowledge base and improve patient care AmericanPsychologist 63 146ndash159 doi1010370003-066X633146

Kuyken W Fothergill CD Musa M amp Chadwick P (2005) The reliability andquality of cognitive case formulation Behaviour Research and Therapy 43 1187ndash1201doi101016jbrat200408007

Kuyken W (2006) Evidence-based case formulation Is the emperor clothed In N Tarrier (Ed)Case formulation in cognitive behaviour therapy The treatment of challenging and complex cases (pp12ndash35) New York NY RoutledgeTaylor amp Francis Group

Lilienfeld S Ritschel L Lynn SJ Cautin R amp Latzman RD (2013) Why many clinicalpsychologists are resistant to evidence-based practice Root causes and constructive remediesClinical Psychology Review 33 883ndash900 doi101016jcpr201209008

Nattrass A Kellett S Hardy GE amp Ricketts T (2014) The content quality and impactof cognitive behavioural case formulation during treatment of obsessive compulsive disorderBehavioural and Cognitive Psychotherapy 1ndash12 doi101016jcpr201209008

Nezu CM Martell CR amp Nezu AM (2014) Specialty competencies in cognitive and behaviouralpsychology Oxford England Oxford University Press

Nezu AM Nezu CM amp Cos TA (2007) Case formulation for the behavioral and cognitivetherapies A problem-solving perspective In TD Eells (Ed) Handbook of psychotherapy caseformulation (2nd ed) New York NY The Guilford Press

Nezu AM Nezu CM amp Lombardo E (2004) Cognitive-behavioural case formulation to treatmentdesign A problem-solving approach New York NY Springer

Persons JB (2006) Case formulationndashdriven psychotherapy Clinical Psychology Science and Practice13 167ndash170 doi 101111j1468-2850200600019x

Persons JB (2008) The case formulation approach to cognitive-behaviour therapy New York NY TheGuilford Press

Persons JB Roberts NA Zalecki CA amp Brechwald WAG (2006) Naturalistic outcomeof case formulation-driven cognitive-behaviour therapy for anxious and depressed outpatientsBehaviour Research and Therapy 1041ndash1051 doi101016jbrat200508005

Pilecki B amp McKay D (2013) The theory-practice gap in cognitive-behaviour therapy BehaviourTherapy 44 541ndash547 doi101016jbeth201303002

Safran JD Abreu I Ogilvie J amp DeMaria A (2011) Does psychotherapy research influence theclinical practice of researcherndashclinicians Clinical Psychology Science and Practice 18 357ndash371doi101111j1468-2850201101267x

Stewart RE Stirman SE amp Chambless DL (2012) A qualitative investigation of practicing psy-chologistsrsquo attitudes toward research-informed practice Implications for dissemination strategiesProfessional Psychology Research and Practice 43 100ndash109 doi101037a0025694

Tarrier N amp Calam R (2002) New developments in cognitive-behavioural case formulationEpidemiological systemic and social context An integrative approach Behavioural and CognitivePsychotherapy 30 311ndash328 doi101017S1352465802003065

Velicer WF amp Fava JL (1998) Affects of variable and subject sampling on factor pattern recoveryPsychological Methods 3 231ndash251 doi1010371082-989X32231

Zivor M Salkovskis PM amp Oldfield VB (2013) Formulation in cognitive behaviour therapy forobsessive-compulsive disorder Aligning therapist perceptions and practice Clinical PsychologyScience and Practice 20 143ndash151 doi101111cpsp12030

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