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the functional analysis. There are several strategies for As with the marker-variable strategy, concurrent
estimating functional relations for clients’ behavior administration of different assessment devices permits
problems, which will be discussed below. the behavior assessor to identify many potential
causal functional relations with a minimal investment
of clinical resources. Causal inferences derived from
Marker-Variable Strategy this method must be held very tentatively, however,
A marker variable is an easily obtained measure because the data are correlational in nature. Thus, it is
that is reliably associated with the strength of a func- difficult to determine which events came first.
tional relation in the natural environment. For
example, a client’s psychophysiological reaction to a
Behavioral Observation
short laboratory public-speaking task can serve as a
marker for his or her psychophysiological reaction and Self-Monitoring of Naturally
to real-world speaking tasks (e.g., giving a lecture to Occurring Context-Behavior Interactions
a class). Empirically validated marker variables can A third procedure to estimate causal relations is
be derived from self-report inventories specifically systematic observation of naturally occurring context-
designed to identify functional relations, as well as behavior interactions. Most commonly, clients are
structured interviews, psychophysiological assess- observed or are asked to self-monitor some dimension
ments, and role-playing exercises. A major advantage (e.g., frequency or magnitude) of a behavior problem,
of the marker-variable strategy is the ease with which along with one or more contextual or response contin-
it can be applied. This method enables an assessor gency factors that are hypothesized to affect the target
to identify many potential causal functional relations behavior.
with a very limited investment of time and effort. Self-monitoring and direct observation of naturally
Generalizability and validity are the most signifi- occurring functional relations can yield data that are
cant problems one must consider when using marker relevant to causal hypotheses. However, these meth-
variables. The extent to which unvalidated marker ods have three practical limitations. First, clients or
variables (e.g., client reports during an interview or observers must be adequately trained so that all events
responses to a self-report inventory, responses to lab- are recorded as accurately and reliably as possible.
oratory stressors, and observations of in-session set- Second, as the number and/or complexity of events to
ting-behavior interactions) correlate with “real-life” be observed increases, accuracy and reliability often
causal relations is often unknown. In addition, for decrease. Third, it is difficult to exclude the possibil-
those situations in which empirically validated marker ity that other variables may be affecting the data.
variables are available, the magnitude of correlation Taken together, these limitations suggest that system-
between the marker variable and “real-life” causal atic observation methods are best suited for situations
relations can vary substantially across clients. in which the behavior and contextual variables are
easily quantified and few in number.
Concurrent Administration of
Different Assessment Instruments Experimental Manipulation
Concurrent administration of different assessment The fourth method that can be used to estimate
instruments is a second method that can be used to casual relations is experimental manipulation. Experi-
derive hypotheses about potential functional relations. mental manipulations involve systematically modify-
For example, an assessor may observe that a client ing hypothesized causal variables and observing
reports (a) that several negative life events (e.g., death consequent changes in behavior in the clinic or natu-
of a parent) occurred within the past year on a ralistic settings. Experimental manipulation has
self-report inventory, (b) high daily levels of marital received renewed interest in recent years because it can
conflict on self-monitoring forms, and (c) symptoms be an effective strategy for identifying response con-
of depression during a behavioral interview. Given tingencies that may strengthen behavior problems,
these data, it may be plausible to hypothesize that the as well as settings and stimuli that can elicit such
individual’s depression is caused by family difficulties problems. Yet despite the potential treatment utility of
and increased life stressors. experimental manipulations, several questions remain
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90———Behavioral Case Formulation

unanswered. First, the reliability and validity of some by a punishment is less likely to reoccur. Furthermore,
experimental analog observation methods remain an individual learns that reinforcement is more likely
unexplored. Second, the incremental benefits of to occur for certain behaviors in certain circumstances
experimental analog observation for treatment design than in others. This means that behavioral case for-
and outcome have not been adequately estimated. mulation involves a careful assessment of the context
Finally, most demonstrations of the treatment utility within which a behavior occurs, along with develop-
of analog observation have been limited to a very ing testable hypotheses about causes, maintaining
restricted population of clients who were presenting factors, and treatment interventions.
with a restricted number of behavior problems. Behavioral case formulation is, philosophically as
—William H. O’Brien, well as practically, based in the experimental method.
Mary E. Kaplar, and Stephen N. Haynes Traditionally, the scientific method has involved four
steps: (1) observing a phenomenon, (2) developing
See also: Behavioral Assessment (Vols. II & III); Virtual hypotheses, (3) testing hypotheses and observing out-
Reality Therapy (Vol. I) come, and (4) revising hypotheses. For the clinician,
observation mirrors the assessment period; develop-
Suggested Readings ing hypotheses is the treatment-planning phase; test-
Bellack, A. S., & Hersen, M. (1998). (Eds.). Behavioral ing hypotheses is the implementation of the treatment
assessment: A practical handbook. Boston: Allyn & Bacon. plan; and revising the hypotheses is assessing the
Dougher, M. J. (2000). Clinical behavior analysis. Reno, NV: treatment review. (See Figure 1.)
Context Press.
Garb, H. N. (1996). Studying the clinician: Judgment research
and psychological assessment. Washington, DC: American Observation: Assessment
Psychological Association.
Haynes, S. N., & Heiby, E. M. (Eds.). (2003). Behavioral The assessment phase of behavioral case formulation
assessment. New York: Wiley. is integral to behavioral case formulation and involves
Haynes, S. N., & O’Brien, W. H. (2000). Principles and prac- assessment of both adaptive and maladaptive behav-
tice of behavioral assessment. New York: Kluwer. iors along with antecedents and consequences with
O’Brien, W. H. (1995). Inaccuracies in the estimation of func- possible functional properties. The following section
tional relations using self-monitoring data. Journal of addresses a variety of methods for collecting informa-
Behavior Therapy and Experimental Psychiatry, 26,
tion, identifying observable treatment targets, opera-
351–357.
Ramsay, M. C., Reynolds, C. R., & Kamphaus, R. W. (2002).
tionally defining treatment targets, and assessing the
Essentials of behavioral assessment. New York: Wiley. behavioral context.

Data Collection Methods

BEHAVIORAL CASE FORMULATION Direct observation of the client’s behavior is often

touted as the best method of behavioral assessment.
Several entries in the volume detail possible methods
DESCRIPTION OF THE STRATEGY
of direct behavioral observation. Although this type of
The process of providing a clear theoretical explana- assessment does reduce the potential bias involved in
tion for what clients do and why they do it is termed verbal report, it is rarely used in real clinical settings
case conceptualization. Case formulation, from a with adult clients. First, for adult clients who are not
behavioral perspective, implies that the “what” will be intellectually compromised, direct observation is often
observable behaviors and the “why” will be explained undesirable. Second, the observer’s presence may dra-
by learning principles. Within behavioral theory, both matically change the context of the target behavior.
adaptive and maladaptive behaviors are acquired, Third, since most behaviors occur in a variety of con-
maintained, and changed through the functional rela- texts, observation of all possible permutations is not
tionships with the events that precede and follow possible. Finally, and probably most important, direct
them. More specifically, behavior that is followed by observation is prohibitively expensive and time inten-
a reinforcement is more likely to reoccur, whereas sive. Taken together, these disadvantages to direct
behavior that either fails to be reinforced or is followed observation often lead clinicians to use a number of
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Behavioral Case Formulation———91

2. Develop Hypotheses
Cause
Maintenance
Intervention

1. Observe 5. Revise
(interview, assessment Hypotheses
instruments, objective 6. Test New 3. Test
observation) Hypotheses Hypotheses

4. Observe Results
(ongoing assessment)

Disseminate Findings

Figure 1 Scientific Method for the Scientist-Practitioner

alternative data collection methods, including the reliance on client verbal report, loss of validity over
clinical interview, self-report questionnaires, self- repeated administrations, and that many clinicians and
monitoring, and naturalistic video or audiotaping. clients dislike adding more paperwork.
The clinical interview, using either the client or Despite the fact that observation by an objective
informants, is one of the most common methods. observer may be impractical and problematic, teaching
Compared with direct behavioral observation, it is non-intellectually-impaired clients to be observers of
often more desirable, feasible, and cost-effective. It their own behavior may provide a good alternative. Self-
also has the advantage of allowing therapists to monitoring usually involves tracking variables such as
observe in-session behavior and begin establishing the intensity, frequency, duration, context, timing, and so
therapeutic rapport through mutual reinforcement. on of a target behavior. Having clients or accessible
The primary disadvantage of the unstructured clinical others observe clients’ behaviors is inexpensive and prac-
interview is that interrater reliability tends to be quite tical and may also have therapeutic value. Researchers
low. Structured clinical interviews such as the func- have also found that self-monitoring can lead to behav-
tional analytic interview may increase the reliability ioral change, even when no other treatments are used.
of both therapist and client verbal behavior. Less frequently used methods of observation include
Self-report questionnaires often augment the naturalistic or laboratory taping of behaviors, and physi-
clinical interview. In contrast to the clinical interview, ological measures of behavior. Clients may, for example,
self-report questionnaires represent stable stimuli, set up a video to record times when spousal arguments
and clinician subjectivity is minimized. Questions are are likely to occur to collect data on antecedents, behav-
asked in the same way each time, and the scores are ior, and consequences. Both spouses may also wear heart
typically computed according to specific instructions. rate monitors to assess physiological reactivity during
These questionnaires also allow clinicians to collect a arguments. These data may aid in assessing possibilities
great deal of information with little time and expense for interrupting the behavioral chain.
as well as providing data regarding how a client
compares with published norms for the measures.
Identifying and Describing Target Behaviors
Although this type of assessment is practical and has
increased reliability over interview data collection Early behavioral theorists emphasized the impor-
methods, there are several downsides, including tance of focusing only on observable behavioral
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92———Behavioral Case Formulation

targets. Internal experiences were discounted in lieu of accurate, careful diagnoses (i.e., use structured
externally observable behavior. Thus, for a client who interviews whenever possible; make sure that all diag-
reports feeling anxious, the treatment targets might be nostic criteria are met; use least severe diagnosis that
shaking, sweating, flushing, and avoidance of feared accurately describes problem; take cultural issues into
stimuli, rather than the subjective experience of anxi- account).
ety. More contemporary behavioral theorists such as
Aaron Beck and David Barlow have added internal Functional Assessment: Assessing the Context
experiences, such as mood and thought, to the list of
The final key assessment area for the Observation
important behavioral treatment targets. Examples of
Phase of behavioral case formulation is the context
externally observable treatment targets include verbal,
within which the target behavior occurs. The context
nonverbal, and motoric behaviors. More covert treat-
includes past as well as current factors that contribute
ment targets include thinking or believing, feeling,
to the cause and maintenance of the presenting con-
imagining, and physical sensations. Most behavioral
cerns. According to behavioral theory, an understand-
case formulations for adults will involve both exter-
ing of the instrumental variables that precede and
nally observable and covert behaviors.
follow the target behaviors is essential to developing
With this broadening of acceptable foci for behav-
an effective treatment intervention.
ioral case formulation, the necessity of accurate
The remote context refers to history, especially
operationalization has intensified. So, even for inter-
biological, psychological, or social events that may
nal behaviors, such as mood or thought, externally
have been functionally related to earlier episodes or
observable signs often become the focus of assess-
approximations of the current behavior. Although the
ment and treatment. That is, the behavioral manifes-
actual cause of a problem is elusive because it can
tations of the internal state will be assessed (e.g.,
never be truly known or tested, identifying setting
shaking, sweating, avoidance as external manifesta-
events may help in developing hypotheses about cur-
tions of subjective anxiety), as well as the frequency,
rent maintenance factors. All aspects of the biopsy-
intensity, and duration of internal experiences.
chosocial assessment are relevant for understanding
Behaviors best depicted by intensity, such as moods or
historical context.
feelings, may be characterized by a 0 to 10 intensity
scale. Behaviors best depicted by frequency, such as

Learning and modeling. An understanding of
thoughts or overt behaviors, may be characterized as
the types of behavior for which the client has been
the average frequency per day or week during that
reinforced and punished in the past may help to
time period. Duration may be assessed using an aver-
develop hypotheses about current functional relation-
age (i.e., daily, weekly, monthly) for the duration of
ships. In addition, knowledge of the behavior of
episodes of the target behavior. Finally, a timeline
important role models may shed light on current
should be retrospectively constructed to highlight
behaviors.
precipitating events, as well as more immediate
antecedents and consequences.

Life events. Both recent and past life events
A third step in describing the problem is to decide
may play a significant role in setting the stage for the
on the best-fitting diagnostic category. Although
current behavior. These may be singular or repeated
many behavioral theorists eschew diagnosis because
events and may be either traumatic or pivotal in some
of the negative effects of labeling coupled with a
way. Knowledge of significant events may alert the
perceived lack of utility in identifying functional rela-
therapist to important antecedents or consequences
tionships, diagnosis remains a centerpiece of treat-
for the current behavior. For example, if a woman
ment planning within the managed-care framework.
who experienced panic attacks cued by the smell of
For these reasons, some basic guidelines for conscien-
cologne had also experienced child sexual abuse by a
tious diagnosis that maximize the potential for benefit
man who wore heavy cologne, treatment may take a
and minimize the potential for harm include (a)
different direction than if no such history existed.
involving the client in the diagnostic process (i.e.,
explain how and why; explain that diagnoses are
Genetic factors. Most research suggests that the
descriptions of behavior rather than illness; diagnoses likelihood of developing mental health concerns
lead to choices of effective treatments) and (b) making increases when first-degree relatives also have mental
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Behavioral Case Formulation———93

health difficulties, even when afflicted parents do not behavior will occur are labeled as antecedents. A
rear the children. Thus, it is important to assess for stimulus becomes an antecedent when the target behav-
familial history of psychological and substance abuse ior has been reinforced immediately following the
problems. antecedent in the past and is strengthened with each
resultant reinforcement. Much like behavioral targets,

Physical factors. Any number of physical fac-
antecedents may be internal (physical, emotional, or cog-
tors may be involved in causing, maintaining, and/or
nitive) and/or external (behavioral or environmental).
exacerbating presenting problems. Depressed mood
may, for example, be sequelae of endocrine dysfunc-
Consequences. The instrumental events that follow
tion, such as hyper- or hypothyroidism. Panic attacks
the target behavior are labeled as consequences.
may be caused or worsened by heart conditions such
Consequences are those internal or external events
as mitral valve prolapse. An initial evaluation that
that either increase or decrease the probability that
includes thorough questioning about possible physical
the behavior will occur again. Consequences, like
conditions coupled with a recent physical examination
antecedents and target behaviors, may be internal
and medical records is essential so that serious or
(physical, emotional, or cognitive) and external (behav-
complicating physical factors are referred for appro-
ioral or environmental). At the most basic level, con-
priate care.
sequences that increase the target are called

Drugs or substances. A variety of substances reinforcers; those that reduce the target are called
may be related to mental health conditions, including punishers. More specifically, reinforcement or pun-
alcohol, prescription drugs, illegal drugs, over-the- ishment can be positive or negative depending upon
counter drugs, and alternative medications. Thorough whether an increase or decrease in the consequence,
assessment of current medications in all of these cate- respectively, leads to a change in the target behavior.
gories is vital to evaluating the extent to which a That is, with positive reinforcement, an increase in a
recent substance initiation, increase, decrease, or dis- consequence leads to an increased probability that the
continuation may fully or partially account for current target behavior will occur in the future, whereas with
symptoms. negative reinforcement, a decrease in an aversive con-
sequence leads to an increased probability that the

Sociocultural factors. Gender, age, ethnic her-
target behavior will occur in the future. Similarly, for
itage, religion, socioeconomic status, education, and
positive punishment, an increase in a consequence
so on may all be related in idiosyncratic ways to pre-
leads to a decreased probability that the target behavior
senting concerns. Behavioral theorists are most inter-
will occur in the future, and with negative punishment,
ested in the ways that social and cultural factors may
a decrease in a consequence leads to a decreased prob-
affect the learning history and the available punishers,
ability that the target behavior will occur in the future.
reinforcements, models, and beliefs. Such information
It is essential to note here that clients may not
may help to form hypotheses about behavioral and
always be good observers or reporters of these contin-
cognitive interventions that may be especially helpful.
gent relationships. First, clients may lack awareness of
the actual contingencies. Second, clients’ verbal reports
The recent context refers to the current antecedents may be influenced more by the in-session contingen-
and consequences that are maintaining the target cies than the actual events they are reporting on. Thus,
behavior. More specifically, the context of most inter- they may be unsure about the contingencies and unwit-
est in behavioral case formulation is the functional tingly base their responses on actual (e.g., head nods,
relationship between internal and external events that “uh-uh’s”) or anticipated (e.g., beliefs about social
precede and follow the target behavior. The focus of desirability) therapist reinforcements. Third, clients’
this assessment should be on behaviors as they usually beliefs about the consequences of reporting contin-
occur and/or a recent, specific example of the behav- gencies may also deter them. Clients who receive dis-
ior. Both may be important in developing hypotheses ability payments for chronic pain conditions may not
about treatment. reveal (or acknowledge to themselves) that these pay-
ments provide both positive and negative reinforcement
Antecedents. The events that immediately precede for avoidance. Taken together, these problems highlight
target behavior and increase the probability that the the importance of approaching functional analytic
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94———Behavioral Case Formulation

interviewing as a hypothesis-generating endeavor rather self-monitoring data are also important in generating
than a fact-finding mission. This is where it is important these hypotheses.
for the clinician to have a good grasp of behavioral There is an extensive empirical literature on the fac-
theory and some probable types of consequences that tors that tend to maintain certain types of presenting
may be maintaining a behavior to augment the infor- concerns. Because depression and anxiety are the most
mation offered verbally by the client. See the section common reasons that adult clients seek help in outpa-
below on “Developing Hypotheses About Maintenance” tient psychology clinics, those will be addressed
for common types of functional relationships with briefly here. Depression tends to be maintained with
certain presenting concerns. behavioral factors, such as a reduction in pleasurable
Observation is classically considered to be the first or mastery activities or a preponderance of aversive
phase of the scientific method. For practicing scientist activities (e.g., difficult social interactions, lack of con-
clinicians, however, this process continues throughout tingent relationship between behavior and outcomes).
therapy, as will be evident in the later discussion on Behaviors that tend to reduce depression are the reverse
“Testing Hypotheses and Revising Hypotheses.” of these behavioral deficits or excesses. Cognitive vari-
ables that tend to increase depression are unrealistic
predictions and labels or standards about self, others,
Developing Hypotheses: Treatment Planning or the world that focus on themes of helplessness,
The Observation Phase is followed by the Develop- hopelessness, and worthlessness. Anxiety, in contrast,
ing Hypotheses Phase of the scientific method. Once tends to be maintained by the negative reinforcement
the phenomena or the presenting concerns are inherent in escape; when individuals escape the anxi-
observed in behavioral case formulation, then testable ety-provoking stimulus, they experience profound
hypotheses as to cause, maintenance, and treatment relief. This relief then increases the escape response
are developed. The goal is a consolidation of informa- and reinforces beliefs that the stimulus is catastrophic
tion gained during the initial assessment with subse- (e.g., “It was so bad, I had to get out of there or I would
quent data collection (e.g., self-monitoring) and have died”; “If I hadn’t avoided thinking about it,
research literature. I would have completely lost it!”). Having knowledge
of the empirical findings regarding common contingen-
cies of presenting concerns also may aid in evaluating
Hypotheses About Cause
the accuracy of client reports.
Behaviorists have often shied away from the con-
cept of cause, focusing instead on currently observable
Hypotheses About Treatment
variables. While the value of current behavior and
contingencies cannot be underestimated, hypotheses The final step is to develop hypotheses about treat-
regarding the role of historical events and circum- ment. These hypotheses should flow logically from
stances may provide important hints about salient information collected in the Observation Phase as well
contingencies and genetic endowments that might not as the hypotheses developed about cause and mainte-
be available in a present-only-based functional assess- nance. In the behavioral tradition of empiricism, devel-
ment. The variables that would typically be addressed oping hypotheses about treatment also should also
in hypotheses about cause include those assessed in the take into account the empirical literature on effective
biopsychosocial assessment, specifically learning and treatments. Furthermore, from a pragmatic perspec-
modeling, life events, genetic factors, physical factors, tive, good hypotheses about treatment should address
substances and drugs, and sociocultural factors. cost-effectiveness, affordability, therapist competence,
client preference, and client stage of change.
First, the functional relationship between the target
Hypotheses About Maintenance
behaviors and the potential contingencies should be
The functional analytic interview is the centerpiece considered. If changing hypothesized contingencies
for hypotheses about maintenance. However, because does not lead to a change in the targeted behavior,
clients may not always be accurate observers of the then these hypotheses are probably in error.
contingencies for their own behavior, behavioral The second step in deciding on a treatment direc-
theory, the empirical literature, and any additional tion is a literature review of effective treatments
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Behavioral Case Formulation———95

specific to the client’s presenting condition. While a The treatment plan should include goals that are
comprehensive, critical literature review for each and consistent with hypotheses about treatment and that
every client may be beyond the capability of many are sufficiently specific to allow for evaluation of
practicing clinicians, some excellent resources sum- treatment hypotheses. The goals should meet the
marizing empirically supported interventions are following SMART criteria: (a) Specific: targeting
included in the suggested readings below. The treat- specific variables with observable referents that are
ment manuals used for these empirically supported relevant to the client’s presenting concerns (e.g.,
interventions are also readily available. intensity of depressed mood; frequency of panic);
Third, pragmatically, any treatment chosen must (b) Measurable: including an observable, objective
address priority concerns cost-effectively, affordably, scale of measurement that is meaningful to the client
and within therapist range of competence. Treatment (e.g., on a scale of 0–10; daily frequency); (c) Anchored:
choices should aim to maximize effectiveness while including the current and desired level of functioning
minimizing cost. In addition, the treatment must be (e.g., intensity of depressed mood will be reduced
viable within the client’s financial and time con- from a daily average of 9 to a daily average of 5);
straints, and clinicians must have adequate training (d) Realistic: considering client’s current and past
and/or supervision in the approaches they use. functioning as well as available treatment time; and
Finally, treatment should also be plausible, attrac- (e) Timeline: including a target date for the goals to be
tive, and tailored to the client’s readiness to change. If accomplished.
it is not, the client may be unlikely to either stay in or To assess whether hypotheses about treatment are
benefit from therapy. Thus, a treatment plan should correct, an intervention plan should be outlined, with
address the client’s primary presenting concerns first, a clear relationship between goals and interventions.
in the absence of factors that may contraindicate it Interventions should target the hypothesized func-
(e.g., significant risk issues such as suicidal ideation, tional relationships and be grounded in the empirical
homicidal ideation, violence, substance abuse, etc.). literature, if possible.
Similarly, clients’ readiness for change should be con- Assessment of client progress is essential to both
sidered in the choice of interventions. Four basic ethical practice and hypothesis testing. Without
stages have predictive validity for attrition and thera- measurement, clinicians cannot adequately evaluate
peutic success: precontemplation (i.e., does not recog- whether progress is being made. Here again, measure-
nize that there is a problem), contemplation (i.e., ments should have an objective, observable compo-
recognizes that problem exists; unsure whether bene- nent and directly reflect goals. Both standardized and
fits of change outweigh the costs), action (i.e., ready to idiographic measurements are recommended to assess
change and has already made steps toward changing), client outcome relative to a relevant population and
and maintenance (i.e., has successfully altered prob- themselves.
lem and is trying to maintain gains). Clients in early
stages of change may benefit most from interventions
that focus on increasing awareness of problem behav- Testing and Revising the
iors, such as giving feedback about assessments or Hypotheses: Conducting Treatment
self-monitoring, whereas clients in later stages of The final stages of behavioral case formulation are
change may make the most change through action- Testing and Revising Hypotheses by conducting treat-
oriented interventions, such as goal setting and cogni- ment and measuring outcome according to the plan. If
tive restructuring. data generated suggest that hypotheses were incorrect
or that methods were insufficient to test hypotheses,
Treatment Plan the client and clinician return to the Observation
Phase to develop new hypotheses and a revised plan.
After hypotheses about cause, maintenance, and
treatment are generated, a treatment plan that defines
specific goals, interventions, measurements, and a RESEARCH BASIS
timeline is developed collaboratively with the client. Although behavioral case formulation has not been
This collaborative treatment plan should enable clini- extensively researched as a specific treatment strategy,
cian and client to test hypotheses regarding treatment. a plethora of research has addressed the effectiveness
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96———Behavioral Case Formulation

of behavioral treatment interventions. These treatment after a change in spousal behavior fails to change the
interventions are typically based in behavioral case pain report does it become apparent that the primary
formulation. Based on the American Psychological functional variables may be positive reinforcement of
Association’s criteria for empirically supported treat- disability payments and negative reinforcement of
ments (i.e., at least two randomized controlled clinical relief from work. Second, actual hypothesis testing is
trials by more than one research group or a series of often difficult in community settings, because early
single-subject designs demonstrating either superior- changes to treatment plans are commonplace due to
ity over a placebo or comparable effectiveness to changes in client report of presenting concern (e.g.,
another well-established treatment with manualized client initially reports depression as primary concern
treatments and well-defined subjects), 19 of the 22 and later identifies marriage as focus of treatment);
well-established treatments for 21 different disorders changes in client life circumstances (e.g., client
are behavioral or cognitive-behavioral. This finding loses job or becomes homeless); crises (e.g., new
suggests that behavioral case formulation may be at emergence of suicidal ideation); changes in case
the core of effective treatment. In addition, research formulation (e.g., a variety of life problems originally
on functional assessment techniques more exclusively conceptualized as needing problem-solving training
has found success with a variety of adult clients may later appear to be a pattern of worry that would
presenting concerns. respond best to worry exposure); or attrition. Finally,
when the hypothesis-testing approach is adhered to
too rigidly, inaccurate hypotheses may be generated
RELEVANT TARGET
prematurely and maintained at the expense of patient
POPULATIONS AND EXCEPTIONS care. Although these complications can never be fully
Behavioral case formulation is a versatile method for eliminated, the steps outlined above are not designed
formulating a treatment direction and evaluating its to be finite, mutually exclusive entities. Rather, they
effectiveness. This method has demonstrated effec- are part of a fluid process with overlap and often
tiveness with adults, and older adults at varying levels several iterations.
of psychological, behavioral, and intellectual impair-
ment. Although behavioral case formulation is applic-
CASE ILLUSTRATION
able with most clinical populations, methods may
vary according to setting and intellectual capacity of Observation of Mr. X
client. Behavioral case formulation with intellectually
“Mr. X,” a 27-year-old, unemployed computer pro-
compromised clients may involve more use of infor-
grammer, the married father of three young children,
mants and live observation than with nonimpaired
presented with a primary problem of 10 to 15 daily
clients. Similarly, applying this method in nonclinical
episodes of feeling very panicky and tearful accompa-
settings such as schools or workplaces for problem
nied by hyperventilation, heart racing, nausea, sweat-
behaviors that do not reach diagnostic threshold may
ing, shaking, dizziness, and feeling that he was going
require omission of clinical diagnosis.
crazy. A secondary problem was a 5-year history of
ongoing depression. He requested help with resolving
COMPLICATIONS the panic and was ambivalent about treatment for
depression. He was participating in current psycho-
Although behavioral case formulation is unlikely to
tropic treatment for his depression and anxiety when he
result in serious negative consequences for any client,
presented for treatment. He reported that the medica-
complications that may arise in application include
tion had helped to reduce his depression to a “tolerable
difficulty identifying functional variables, disruption
level” but that the panic had not been helped.
in treatment, or premature treatment planning. First,
the central, and perhaps most difficult, element of
behavioral case formulation is an accurate definition
Defining Target Behaviors
of the problem and its functional antecedents and con-
sequences. Initial assessment may, for example, point For Mr. X, his panic attacks and depressed mood
to spousal statements of concern as reinforcers for a were operationalized through queries about the behav-
client’s subjective reports of severe back pain. Only ioral manifestations and impacts, as well as the
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Behavioral Case Formulation———97

frequency, intensity, and duration of the depression. Regarding physical factors, Mr. X was convinced that
According to self-monitoring and the interview, Mr. X physical problems were at the root of his problems;
reported that the average daily intensity for anxiety however, none of myriad medical tests (e.g., ECG,
and depression was an 8 (on a 0–10 point scale, with EKG, CAT scan, blood workup) had revealed any
larger numbers representing greater severity), with an physical problems. Furthermore, substances did not
average of 11 daily panic attacks. An assessment of appear to be causal. Mr. X denied any alcohol or illicit
the historical timeline indicated that within the past drug use. Although he had consumed up to three beers
4 years, Mr. X reported five separate episodes of a week prior to the panic onset, he had since discon-
severely depressed mood with durations ranging from tinued all substance use because he feared that alcohol
2 weeks to 2 months. Between these episodes, his might elicit an attack. The medication had produced
depressed mood was in the moderate range. Within some depression relief; however, the anxiety had been
the past 6 months, his panic attacks had increased unchanged. Socioculturally, Mr. X’s status as a young,
steadily from 0 per day to 10 to 15 per day. Diag- middle-income, professional, Caucasian male expe-
nostically, the following were identified: riencing depression and anxiety along with recent
unemployment had led to some aversive responses
Axis I: 300.21 Panic disorder with agoraphobia from family and peers who expected him to be suc-
cessfully earning a wage. He also reported some
296.33 Major depressive disorder, recurrent, severe beliefs about himself, based on his perceptions of cul-
without psychotic features, without full interepisode tural values for young, professional men, such as, “I
recovery must be the primary breadwinner in my family”; “A
Axis II: V71.09 No diagnosis sign of economic failure is a sign of personal failure”;
and “I should deal with this alone and not let anyone
Axis III: Noncontributory physical problems see how distressed I am.”
Axis IV: Unemployment due to depression and
panic Recent Context
Axis V: 50 Functional assessment Mr. X reported that the panic attacks had begun
about 6 months previously and had increased in sever-
ity and frequency since then. He could not identify
Remote Context
anything unusual about the time that the panic began.
Assessment of Mr. X’s history suggested that he He stated that the onset, as well the daily occurrences,
may have learned or modeled some of his current seemed to “come out of the blue.” Events that were
behaviors. According to Mr. X, his parents’ marriage likely to elicit panic attacks were (a) being somewhere
was intact. However, both parents had strict rules and where escape was difficult (e.g., mall, store, theater,
frequently worried about his safety (e.g., curfews, fre- bus, tunnels) and (b) having very negative thoughts
quent calls to make sure he was okay). His only sib- about himself (e.g., “I am worthless,” “I am crazy,” “I
ling, a 23-year-old sister, had also been diagnosed am a bad father,” etc.). He reported that his most
with agoraphobia. These life events as well as others effective coping strategy was to escape the evocative
may also be setting events for Mr. X’s current anxiety situation or distract himself as quickly as possible. He
and depression. Mr. X reported that his childhood was reported that the desire to escape was intense and the
stressful because his parents were so strict, but he relief after escape acute.
denied any specific events or overt abuse. Instead, he Depression also had no clear precipitating event
reported his work as a police officer to be traumatic other than some reported general difficulty dealing
because he often dealt with tragic situations (e.g., with the “human tragedies” that accompanied his pre-
hopeless people, car accidents, murders, domestic vious job as a police officer. He had been involuntar-
violence) over which he felt powerless to control. As ily retired from his job after being hospitalized for
for genetics, although Mr. X reported that his parents depression 4 years ago. He stated that his depression
had not been diagnosed with mental health concerns, had been constant since that time. He stated that the
his description of them suggests his mother and father depression had worsened since the onset of the panic
may both meet criteria for generalized anxiety disorder. and that over the past month, he had sat at home
B-Hersen.Vol.1.qxd 11/25/2004 2:36 PM Page 98

98———Behavioral Case Formulation

because he felt “too depressed to move.” He reported relief of these strategies was actually exacerbating his
depressed mood most of the day nearly every day, conditions long-term. Given these data about Mr. X,
accompanied by low interest, difficulty sleeping, feel- the following hypotheses about maintenance were
ing very guilty most of the time, low energy, difficulty developed:
concentrating, increased appetite, and visible slowing Mr. X’s panic is worsened by:
of speech and movements. He admitted to suicidal
ideation 4 years ago when hospitalized but denied any
Occurrence of antecedents in which he has
current ideation, plan, or intent. little control

Beliefs that he will die while having a panic
attack (e.g., at the first physiological sign of an
Developing Hypotheses for Mr. X attack, he says to himself, “Oh no! I really am
Hypotheses About Cause going to die this time!”)

Beliefs that he must be in control at all times
Given the biopsychosocial assessment for Mr. X,

Negative reinforcement (relief) he experi-
it appears that learning/modeling, genetic factors, life
ences when he escapes an anxiety-provoking
events, and sociocultural factors may play causal roles.
situation
Examples of hypotheses about cause that may be

Negative reinforcement (relief) he experiences
generated for Mr. X include the following:
when dismissed from household and parenting
responsibilities

Mr. X learned at an early age, through modeling
and reinforcement, that the world is dangerous and
Mr. X’s depression is worsened by:
that cautiousness is rewarded.

Simultaneously, Mr. X’s family history of anxi-
Occurrence of panic attacks
ety may have genetically predisposed him to manifest
A reduction in pleasurable and mastery activity
his responses to stress in similar ways. due to avoidance of anxiety-provoking activi-
ties (interaction between anxiety and depres-

While Mr. X. was a police officer, he witnessed
sion) and low motivation
traumatic events that challenged his central beliefs

Beliefs that he should not be experiencing
regarding importance of safety and the role of control
“weak” emotions, such as anxiety and sadness,
(e.g., “As long as I am always careful, I and others can
and that he should be gainfully employed
always be safe”). Instead, he learned that there are

Positive reinforcement he experiences when
some events over which he has no control. This led to
his wife inquires compassionately about his
feelings of panic when not in control.
sadness

The majority of men in Mr. X’s ethnocultural
Negative reinforcement (relief) he experiences
group are employed and do not have depression or when dismissed from household and parenting
anxiety disorders. Instead, the societal expectation is responsibilities
that young married men will contribute financially to
their families and maintain a modicum of mental
Hypotheses About Mr. X’s Treatment
health. Mr. X may have experienced feelings of shame
and fear as a result of not living up to society’s expec- Functional Relationships. For Mr. X, hypotheses
tations for him. These expectations are contributing to about maintenance point to the importance of cata-
the cause of his current intractable depression. strophic beliefs and avoidance for his panic attacks.
Although his depression is more long-standing, it
appears that the panic attacks may account for the
Hypotheses About Maintenance
recent depression exacerbation through the side
Although Mr. X reported that anxiety was effects of anxious avoidance (i.e., reduction in activ-
improved by escape and depression was improved ity, unemployment, and reinforcement of beliefs about
through inactivity, knowledge of the empirical litera- worthlessness). Treatment, therefore, should address
ture as well as typical behavioral conceptualizations the both behavioral (i.e., avoidance) and cognitive
of anxiety and depression suggested that the immediate variables (i.e., catastrophic beliefs).
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Behavioral Case Formulation———99

Empirical Literature. With regard to Mr. X’s present-
Panic treatment that includes education, relax-
ing problems, empirically supported interventions ation, cognitive restructuring, and exposure to
exist for both panic and depression. Based on at least the physical symptoms of panic (extinguishing
one meta-analysis of 43 controlled clinical trials for the escape response) will effectively reduce
panic disorder with agoraphobia, treatment packages Mr. X’s panic symptoms because it:
including education, relaxation, cognitive restructur-
ing, and exposure to the physical symptoms of panic is consistent with the hypothesized pertinent
(interoceptive exposure) were the most effective inter- functional relationships;
ventions available. Furthermore, interventions involving has the best data to support its effectiveness
interoceptive exposure were superior to medication or with panic symptoms;
cognitive-behavioral therapy without interoceptive is unlikely to be negatively affected by the
exposure. Recent reviews of depression interventions depressive symptoms;
suggest that cognitive-behavioral interventions are
is cost-effective and feasible for client and
among the most effective and durable treatments
therapist; and
available. The treatment outcome literature on comor-
bid panic disorder and depression generally supports addresses the client’s priority concerns first
treating panic prior to treating depression. It appears with action-oriented interventions to meet
that depression does not deter panic treatment and, him in the action stage.
furthermore, that depression symptoms may improve
Depression symptoms will improve during
during panic treatment. In the reverse, active panic panic treatment.
may actually hinder depression treatment.

Pragmatism. For Mr. X, among the most cost- Testing Hypotheses

effective interventions are 12 to 20 session cognitive- and Observing Results for Mr. X
behavioral treatments. They are feasible within his Treatment was conducted according to plan and
insurance allotment of 20 sessions yearly, and the standardized and idiographic outcomes for depres-
therapist’s primary training is in cognitive and behav- sion and anxiety were collected. See Figure 3 for the
ioral interventions. Mr. X identified a strong prefer- outcomes.
ence for targeting his panic symptoms first. Although As can be seen, hypotheses about anxiety and panic
his depression was severe, he was not experiencing were supported, whereas hypotheses regarding depres-
suicidal ideation or other conditions that would man- sion were not. Consistent with hypotheses, the appli-
date priority attention. He expressed tentative interest cation of cognitive-behavioral interventions targeted at
in later addressing the depressive symptoms if they reducing panic attacks effectively eliminated Mr. X’s
did not remit in the course of panic treatment. His panic attacks, agoraphobic avoidance, and average
stage of change was informally identified as action; daily intensity of anxiety. Contrary to hypotheses,
he had begun making changes in his life to reduce although Mr. X’s depression scores diminished some-
his panic symptoms, including seeing a psychiatrist, what over the 12 sessions, his depression was moder-
beginning regular relaxation practice, and reading ately severe at the conclusion of the treatment plan.
self-help books about panic attacks. Taken together, these findings suggest a need for revis-
After reviewing functional relationships between ing the predictions regarding depression.
target behavior and contingencies, empirical litera-
ture, and pragmatic concerns, the following hypothe-
Revising Hypotheses
ses about treatment were developed along with the
treatment plan in Figure 2: The final phase of the scientific method is often
iterative. For Mr. X, the hypothesis regarding the

Treatment will be effective if panic treatment responsiveness of his depression to interventions tar-
precedes depression treatment due to the client geted at panic was unsupported. Therefore, the func-
preference and empirical evidence support- tional assessment of depression was reviewed. Mr. X
ing the effectiveness of panic treatment with reported that his depression had returned to baseline
comorbid panic and depression. moderate level for the preceding 4 years. A subsequent
B-Hersen.Vol.1.qxd 11/25/2004 2:36 PM Page 100

100———Behavioral Case Formulation

Client: Mr. X Primary Therapist: Dr. Truax Current Date: 1/5/04 Target Date: 3/23/04

Primary Presenting Concerns:

Panic attacks, anxiety, and depression. Mr. X presents with a 5-year history of recurrent depression without interepisode
recovery and a 6-month history of generalized anxiety and panic attacks. Current average intensity for both anxiety and
depression is an 8 (0–10 point scale with larger numbers representing greater severity), and he averages 11 panic
attacks daily. As a result, his occupational functioning is severely impaired (i.e., he is unemployed) and he avoids nearly
all activities that involve leaving the house.
Diagnoses:
Axis I: 300.21 Panic Disorder with Agoraphobia
296.33 Major Depressive Disorder, Recurrent, Severe without Psychotic Features, Without Full
interepisode recovery
Axis II: V71.09 No diagnosis
Axis III: Noncontributory physical or medical problems
Axis IV: Unemployment due to depression and panic
Axis V: Current functioning = 50
Primary Goals:
1. Reduce frequency of panic attacks from 11 times daily to 3 times daily.
2. Reduce intensity of daily anxiety from an average of 8 to an average of 5.
3. Reduce severity of avoidance from the severe range to the mild range.
Secondary Goals:

4. Reduce intensity of depressed mood from daily average of 8 to an average of 4.

5. Reduce severity of depression from the severe range to the mild range.

Interventions:

1. Relaxation Training: diaphragmatic breathing, progressive muscle relaxation, cue-controlled relaxation, and recall
relaxation (Goals 1 & 2).
2. Cognitive Restructuring: identifying activating events, alarming beliefs, consequences, more reassuring beliefs, and
more adaptive coping (Goals 1–5).
3. |nteroceptive Exposure: developing a hierarchy and conducting graded exposure to physiological symptoms of panic.
(Goals 1, 2, & 3).
4. In Vivo Exposure: developing a hierarchy and conducting graded exposure to avoided situations due to panic (Goals 1–5).

Measurements: Schedule
Self-monitoring of frequency of panic attacks (Goal 1) Daily
Self-monitoring of average daily intensity of anxiety on a 0-10 scale (0 = no anxiety, 10 = most Daily
anxiety imaginable) (Goal 2)
Mobility Inventory (Goal 3) Monthly
Self-monitoring of daily intensity of depression on a 0-10 scale (0 = no depression, 10 = most Daily
depression imaginable) (Goal 4)
Beck Depression Inventory-II (Goal 5) Monthly
Agreement:
By signing this plan, I agree to complete the above outlined treatment plan. This will entail participating in weekly
therapy sessions and regular completion of tasks outside the session. If either client or therapist is concerned
about the progress of therapy, the concerned party will address the issue in session as soon as possible.
Prioritized summary and time frame:
12 weekly sessions targeting goals 1–3 (Sessions 1–8: Relaxation Training and Cognitive Restructuring; Sessions 5–12:
Interoceptive Exposure; Sessions 8–12: In Vivo exposure
Client Signature: Therapist Signature:

Figure 2 Treatment Plan for Mr. X

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Behavioral Case Formulation———101

12

10

0
1/5 1/12 1/19 1/26 2/2 2/9 2/16 2/23 3/2 3/9 3/16 3/23
Intake 2 3 4 5 6 7 8 9 10 11 12

Sessions

Average Daily Frequency of Panic Attacks

Average Daily Intensity of Anxiety (0-10)
Average Mobility Inventory-done alone (1-5)
Average Daily Intensity of Depression (0-10)
Beck Depression Inventory-II (Total/10)

Figure 3 Mr. X’s Progress on Standardized and Idiographic Anxiety and Depression Measures

functional assessment of the current depression sug- and observe results (Testing Hypotheses Phase), and
gested that important antecedents to worsened depressed revise the treatment plans if necessary (Revising
mood were inactivity and self-depreciating thoughts Hypotheses Phase). Through conscientious, compas-
regarding competence and unemployment. Based on this sionate attention to pinpointing concerns, understanding
functional assessment, Mr. X’s preferences, and a review contexts, and systematically implementing empiri-
of the empirical literature, new hypotheses regarding cally supported interventions, therapists may offer
Mr. X’s depression were generated: their clients the maximum opportunity for meaningful
improvement in psychotherapy.

Mr. X’s depression is exacerbated and main- —Paula Truax
tained by a paucity of pleasurable and mastery
activities (especially unemployment) and thoughts See also: Applied Behavior Analysis (Vol. I); Behavioral
of incompetence and ineptitude. Assessment (Vol. III); Case Conceptualization (Vol. II)

Interventions should focus on increasing plea-
surable and mastery activities while reducing Suggested Readings
self-depreciating beliefs.
Barlow, D. H. (2001). The clinical handbook of psychological

Cognitive-behavioral treatment that includes disorders (3rd ed.). New York: Guilford Press.
education, increasing activity through goal set- Cormier, S., & Cormier, B. (1998). Interviewing strategies
ting, career counseling, and cognitive restruc- for helpers: Fundamental skills and cognitive-behavioral
turing will effectively reduce Mr. X’s symptoms interventions. Pacific Grove, CA: Brooks/Cole.
of depression. Division 12 Task Force. (1995). Training in and dissemination
of empirically validated psychological treatments: Report
and recommendations. The Clinical Psychologist, 48, 3–23.
SUMMARY Gould, R. A., Otto, M. W., & Pollack, M. H. (1995). A meta-
In summary, a framework for behavioral case formu- analysis of treatment outcome for panic disorder. Clinical
Psychology Review, 15(8), 819–844.
lation through applying the scientific method to the
Leahy, R. L., & Holland, S. J. (2000). Treatment plans and
clinical setting has been presented. Much like the interventions for depression and anxiety disorders.
scientist, the clinician must assess clients (Observa- New York: Guilford Press.
tion Phase), develop treatment plans (Developing McConnaughy, E. A., DiClemente, C. C., Prochaska, J. O., &
Hypotheses Phase), implement those treatment plans Velicer, W. F. (1989). Stages of change in psychotherapy: A