The Case of "Kate" and Her Pseudohallucinations from the Perspective of Interpersonal Defense Theory: An Example of Using Case Formulations as the Key Guide for Understanding Patients' Problems and Making Treatment Decisions

Abstract

Shapiro, Bussing, and Nguyen’s (2014) case study of the treatment of Kate, a 16-year-old girl with pseudohallucinations, is instructive in two ways regarding the importance of going beyond a symptom-/diagnosis-based approach to psychotherapy. First, the case supports this point because the authors found it necessary to move away from their initial focus on Kate’s hallucinations to successively broader viewpoints on Kate’s problems, which involved shifting from a primary emphasis on medication to employing certain cognitive-behavioral interventions and then to taking a psychodynamically-oriented approach to Kate’s individual therapy coupled with addressing family dynamics in adjunctive parent therapy. I maintain that in large measure we can attribute the gains that were made in the treatment to the authors’ efforts (as therapist and supervisors) to move away from their initial symptom-based approach in these ways. However, I also maintain that the case study is instructive regarding the key point for a second, very different reason. I suggest that the authors could have moved further away from a symptom-/diagnosis-based approach by adopting an approach that takes case formulation based on theoretical principles about processes as the basis for clinical work and uses those principles to organize the clinical data, including information about symptoms and diagnoses. I offer a tentative formulation of the case based on interpersonal defense theory (e.g., Westerman, 2011b; Westerman & Muran, 2014; Westerman & Steen, 2007) as an example of such an approach. I use that formulation as the basis for identifying limitations in the individual therapy with Kate and the work with Kate’s parents and suggesting a number of ways in which the treatment might have been enhanced.