Therapist Use of a Case Formulation is Associated with the Resolution but not Prevention of Episodes of Symptom Deterioration and Lack of Progress During Cognitive Behavior Therapy

We evaluated whether the decision support tools (written case formulation, list of treatment goals, plot of progress monitoring data) of the case formulation approach to cognitive behavior therapy (CBT) predicted the prevention and resolution of episodes of symptom deterioration and lack of progress during treatment and the relationship of these episodes to dropout and end-of-treatment symptoms. Participants were adults who received naturalistic CBT for symptoms of depression ( n = 314) measured with the Beck Depression Inventory (BDI) and/or anxiety ( n = 398) measured with the Burns Anxiety Inventory (BurnsAI). We defined a not-on-track (NOT) episode as a reliable worsening of symptoms (deterioration) or a period of five or more sessions without reliable improvement compared to intake (lack of progress). The research team rated the presence of each decision support tool in the clinical record and the therapist rated whether dropout was premature or uncollaborative. NOT episodes predicted increased end-of-treatment BDI and BurnsAI scores. Resolution of NOT episodes predicted decreased end-of-treatment BDI and BurnsAI scores and lower likelihood of premature dropout. Positive effects of the resolution of NOT episodes were larger than their negative effects. No decision support tool predicted reduced occurrence of NOT episodes. The case formulation predicted resolution of NOT episodes defined by BDI scores. The large positive effect of the resolution of NOT episodes on end-of-treatment symptoms suggests the resolution of NOT episodes can strengthen the treatment. Therapist use of a case formulation appears to contribute to that helpful process.