Image: Episode 494 artwork for Just a Hypothesis. The graphic shows a person writing with a blue pen at a desk, alongside a photo of guest Dr. Nikki Rubin.
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Just a Hypothesis: Case Formulation and Treatment Planning for Real-World Therapy – An Interview with Nikki Rubin, PsyD

Somewhere between the case conceptualization you stayed up until three in the morning writing in graduate school and the client sitting in front of you right now, the whole practice quietly fell away. You have techniques. You know what you are doing in the room most of the time. But if someone asked you to explain what you are targeting with this particular client and why, you might find yourself reaching into the toolbox instead of reaching for a map.

Curt and Katie talk with Nikki Rubin, PsyD, about what case formulation looks like when it is built for actual practice rather than for a graduate school assignment. Nikki’s central move is a small one with large consequences: a case formulation is a hypothesis. It is your best current guess about what is going on and what might help, written down so you can test it, and revised as the data comes in. Once you hold it that way, most of what makes formulation feel heavy falls off.

Nikki walks through the seven areas she assesses with every new client, how formulation and treatment planning are linked, why structure creates flexibility rather than limiting it, and what to do when you have five sessions and a parent who wants their kid fixed.

Transcript

Click here to scroll to the podcast transcript.

(Show notes provided in collaboration with Otter.ai and Claude AI.)

About Our Guest: Nikki Rubin, PsyD

Image: headshot of Nikki RubinNikki Rubin, Psy.D. is a licensed clinical psychologist specializing in Acceptance and Commitment Therapy (ACT) and other 3rd wave cognitive behavioral therapies. Dr. Rubin is passionate about mentorship in mental health training. She serves as an Associate Clinical Professor at UCLA where she trains doctoral students in ACT, and she previously served as an Adjunct Professor of Psychology at Columbia University’s Teachers College.

Dr. Rubin is a co-founder and the Chief Operating Officer (COO) of MindScience Collective, a continuing education company focused on providing high quality, evidence-based education on a beautiful, modern, and easy-to-use platform. Learn more at mindsciencecollective.com and drnikkirubin.com.

In this Podcast Episode: How to Build a Case Formulation You Can Test and Revise

Nikki describes case formulation as one large working hypothesis rather than a document you complete and file away. She walks through the seven areas she assesses with every new client, drawn from the work of Jacqueline B. Persons, PhD, and explains why the approach works across theoretical orientations rather than only within cognitive behavioral therapies. The conversation covers the traps clinicians fall into, how a formulation translates into specific target behaviors you can actually look for in session, what to do when the treatment stalls, and how to scale the whole thing down when you are working in a crisis setting or under session limits.

Key Takeaways for Therapists: Case Formulation, Treatment Planning, and Clinical Decision-Making

“When we’re in that [problem solving] mode, we’re actually missing things, because we’re so in our heads and in the weeds. We’re not paying attention to what’s happening in the room.”

— Nikki Rubin, PsyD

  • The formulation is a hypothesis. Writing down “this looks like it might be OCD-ish, I am not sure yet” is the work, not a lapse in rigor. An assumption declares what something is. A hypothesis says what it looks like for now and commits you to gathering more data.
  • Being afraid to guess is its own trap. Nikki names this one mid-list and then circles back to flag it, because it quietly produces the other problems. If a formulation has to be correct, you cannot start one.
  • Trying to know everything backfires. When you go into problem-solving mode about a client, your attention leaves the room. You stop testing things, stop asking questions, and stop learning through the work itself.
  • Narrowing onto one facet backfires too. Clinicians used to over-focus on diagnosis. Nikki now more often sees supervisees over-focus on sociocultural factors, which she reads as progress, but either way most of a person’s functioning is left out.
  • Formulation and treatment planning are inseparable. You formulate so that you can act. That means naming what you are targeting, operationalizing it so you can look for it in session, and starting with roughly three target behaviors.
  • Covert behaviors count. Clinicians reliably capture the behaviors they can see. Worrying, ruminating, and emotional suppression are behaviors too, and they often carry the compensatory function that explains everything else.
  • A stalled treatment is information, not a verdict on you. When behavioral activation does not move a mild depression, the hypothesis needs revising. You made a reasonable choice with the data you had, and now you have more data.
  • Structure is what creates room to move. Nikki holds this dialectically: commit to the framework, and stay present enough to amend it in real time as new information arrives.

“I’m very confident as a therapist because I’m really okay not knowing. I know some things, but if there’s a whole huge gap that I don’t know, I’m okay with that, because as we move through time, we’re going to gather more data and things are going to come into focus little by little.”

— Nikki Rubin, PsyD

The Seven Areas Nikki Assesses in a Behavioral Case Formulation

Nikki credits this framework to Jacqueline B. Persons, PhD, and emphasizes that you do not have to practice CBT to use it. Every item below is held as a guess rather than a finding, including the diagnostic one. At a high level, she assesses:

  • A problem list. Everything the client wants to work on. Nikki asks every patient to write a problems and goals list after the intake.
  • Diagnostic hypotheses. Your best current guesses, held loosely.
  • Precipitants. What was happening right before the current episode or problem.
  • Relevant sociocultural factors. Race, ethnicity, religion, gender identity, generation, military service, regional identity, and anything else that shapes context.
  • Current thoughts and beliefs. Including the ones the client has not said out loud yet.
  • Current behaviors, overt and covert. With particular attention to behaviors that serve a compensatory or regulating function.
  • Origins of the mechanisms. Learning history. How these beliefs and behaviors developed in the first place.

Nikki has all of this in mind before the first session, from the voicemail or the intake email onward, and describes the gaps as the useful part. You can see where the holes are, which tells you what to ask next.

Listen to the full episode for Nikki’s clinical examples and how she teaches this to second-year doctoral students who have never seen a client.

Structure Creates Space

Curt raises the concern most therapists have about formalized formulation, which is that it sounds rigid, and that early career clinicians in particular will anchor onto a hypothesis and refuse to move off it.

Nikki’s answer is that a hypothesis you can revise is not a cage, and then she uses building a house as an example. If you take everything that belongs in a house (a toilet, a couch, a sink, some paint) and dump it onto an empty lot, you do not have a house. The structure has to go up first, and the structure is what creates the rooms. Once the rooms exist, you can decorate them however you want, rearrange the furniture, redecorate, and remodel. The framework is what makes intervention possible, and any framework carries a risk of being held too tightly.

Katie builds on the metaphor twice. She scales it down to the studio apartment (below), and she extends it into long-term work: as the relationship deepens, you move from room to room, and sometimes you gut and rebuild a room entirely as the client’s values, circumstances, and goals shift. Nikki notes that in her experience the throughlines of a formulation stay fairly steady over years, while the treatment plan can change dramatically. Someone who came in for panic may be doing attachment work years later, off the same underlying hypotheses.

Case Formulation When You Do Not Have Time

Curt asks the practical question: what about therapists in structured settings, on session limits, or facing a parent who wants their kid fixed in five sessions?

Nikki is direct that a formulation done under those conditions will be less thorough, and that this is fine. The alternative most of us default to under pressure is pulling skills out of the toolbox and throwing them at the wall, which tends to get more distressing over time rather than less. Katie offers the image that makes this usable: some clients get the studio apartment version of a formulation, and some get the full complex of homes. Nikki adopts it on the spot and says she will be citing it when she teaches.

Her invitation is smaller than it sounds. Find a sliver of space, get curious about what is happening right now with this person, and let that inform how you respond. A partial hypothesis still beats no hypothesis.

Where to Start This Week

If you have not built a formulation since graduate school, Nikki suggests starting with a willingness to be uncomfortable, wrong, and in the murky for a while. From there, take a client you are already working with and walk the seven areas. What clinicians usually notice is that it is steadying rather than constraining, in a grounding way rather than a rigid one. You know more than you thought you did, and you can see exactly where the gaps are, which is where the next round of questions comes from.

Resources on Case Formulation, Treatment Planning, and Clinical Decision-Making

We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!

Relevant Episodes of MTSG Podcast

Meet the Hosts: Curt Widhalm & Katie Vernoy

Picture of Curt Widhalm, LMFT, co-host of the Modern Therapist's Survival Guide podcast; a nice young man with a glorious beard.Curt Widhalm, LMFT

Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com

Picture of Katie Vernoy, LMFT, co-host of the Modern Therapist's Survival Guide podcastKatie Vernoy, LMFT

Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com

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Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):

Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements)

… 0:00
(Opening Advertisement)

Announcer 0:00
You’re listening to the Modern Therapist Survival Guide, where therapists live, breathe, and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.

Curt Widhalm 0:15
Welcome back, Modern Therapists. This is the Modern Therapist Survival Guide. I’m Curt Widhalm with Katie Vernoy, and this is the podcast for therapists about the ways that we approach the work that we do. And I want to talk about going back to graduate school. Because in graduate school, professors looked at you dead in the eye with the intensity of a war general and said, “You must create a comprehensive, multi-axial case formulation for every human soul that crosses your threshold, and you sit there at 23 years old with zero life experience, thinking, “Yeah, I’m going to totally do that.” And cut to several years later, and you are now sitting across from somebody who is sobbing because their landlord’s cat looked at them oddly, and you realize I have no idea where I’m going. So today we are here to stop all of the madness. We are joined by the brilliant Dr. Nikki Rubin. She is a clinical psychologist and someone who actually knows how to build case formulations for the real world. So thank you so much for joining us.

Dr. Nikki Rubin 1:26
Thank you so much for having me, Curt and Katie, and and also say, and I you know I actually love building case formulations. Like I I don’t I don’t just know how I’m like psyched on building them. So you know, which I know is not usually a popular perspective, but that’s why hopefully I can I can bring some of your listeners into the the excitement of case formulation.

Dr. Nikki Rubin 1:51
Oh my goodness, a general?

Curt Widhalm 1:54
Maybe my professors, if my professors are listening, Hi Dr. Hall. But maybe my professor just took it really seriously.

Dr. Nikki Rubin 2:04
Yes.

Dr. Nikki Rubin 2:05
Well, I’m, I think this is all going to be either really exciting and fun, or somewhat boring. So let’s hope for the hope for the former.

Dr. Nikki Rubin 2:15
I’m going to hope for, I’m going to hope for the former, and also like a true, and and if it’s boring, also like no offense taken, like that’s okay. Like doesn’t have to be everybody’s jam. That’s fine.

Katie Vernoy 2:26
So before we get into the excitement that is case formulation, I want to ask you the question we ask all of our guests, which is, who are you, and what are you putting out into the world?

Dr. Nikki Rubin 2:38
Well, in addition to case formulations and treatment plans. So I’m a psychologist. I’m based in Los Angeles. I treat patients both here in California and also in New York. And I’m also a co-founder and the COO of Mind Science Collective, which is a continuing education platform. And I’m going to use our tagline, which I really like, which is it’s “Modern CEs for real world therapy,” so it kind of aligns with what we’re talking about today. Because, like, we want we’re we’re all you know in the trenches doing the work, right? Like, it’s not just like being in graduate school and you’re like, I got to come up with this rigid plan. We want to help therapists, you know, like do the work in ways that feel energizing, inspiring, and we think that CEs should reflect that and also be kind of fun.

Curt Widhalm 3:30
So the topic of case conceptualizations, the the way that we map out what’s going to be happening with the client, it’s not just treatment planning, and a lot of us were taught in grad school this really rigid formulation that it kept us up until three in the morning because we’re trying to understand every possible outcome of a human experience. That doesn’t really serve us.

Dr. Nikki Rubin 3:55
Nope.

Curt Widhalm 3:55
It’s, I know that the the honest answer to my first question here is not doing them at all, but I don’t want that answer. My question is, what are the common traps that therapists fall into when doing case formulation? So beyond not doing it, yeah, what traps do people fall into?

Dr. Nikki Rubin 4:17
Sure. So that’s a great question, and you’ve actually already named the first one, which is trying to figure out every possible problem, every possible solution. Basically, like trying to know everything, and you know, look, hopefully, you know, for most of us that have been practicing for a long time, we’re very well trained and honestly comfortable with not knowing things, like you know, certainly when we’re earlier in our training, that can feel a lot more unpleasant. But like all of us, myself included, we can, you know, we can feel anxious, like when we don’t know what’s happening in the room, like where to go, and so the tendency is, you know, just as with humans in general, is I got to figure it all out. I got to go into problem solving mode. I’ve got to dig through every single answer. And unfortunately, when we’re in that mode, we’re actually missing things because we’re so in our heads and in the weeds. We’re not paying attention to what’s happening in the room, and we’re not testing things out. We’re not asking questions. We’re not, you know, for lack of a better phrase, like learning through trial and error experiential process, right? So, so that’s really the first thing that I see is like people get way too heady about it, and you know, this is the problem with being being a human doing this human work. Is that, that’s where our minds like to go. We like to go really cognitive about things. So that’s really like I said, the first place. The second place that I see clinicians tend to get stuck, and this really spans, like honestly, novice to clinicians all the way to very experienced clinicians, is that I see folks get really kind of narrow in focusing on one or two facets of a person. So, like back when I was in graduate school, like that was more diagnostic. Like people would get overly focused, like on diagnosis. They come in with panic disorder and they’re just conceptualizing what are their symptoms. Like you know, how is it impacting their behavior? What are they avoiding? But they were ignoring everything else, right? They’re ignoring like family history, cultural factors. These days, I would say, like with my supervisees, I tend to see actually getting only stuck on socio cultural factors, which you know, in some ways, I view as progress because students are a lot more aware of the importance of that and integrating it into how they’re understanding the patients that they’re working with, but again, if we’re only focusing on one facet of a person’s experience, then we’re not paying attention to all of these other very, very expansive and multifaceted important parts of a person’s functioning.

Katie Vernoy 6:58
When we’re trying to sort through where to focus our attention, what are the things that help us to get that balance? Because I don’t want to not have any idea of what’s going on in the room, but I also don’t want to get it stuck in my head or focused on only one piece. So how do you how do you make sure that you’re touching on enough to have sufficient information to begin your case formulation.

Dr. Nikki Rubin 7:23
Such a good question, and I think the first step is actually starting with an orientation where you’re saying, as the clinician to yourself, “I’ve got to go in with eyes wide open, and I’ve got to be mindful to keep zooming out because I know what my brain’s going to want to do is like get in the weeds in one area. So I actually say to to clinicians I’m training, and again, both like experienced clinicians and novice ones, we want to kind of go in with this mindful approach, right? Where we’re saying, okay, I’m committing what I’m going into working with somebody new, and by the way, this includes the first contact somebody emails you, leaves you a voicemail. I have that hat on before I’ve even spoken to the person, and I’m saying, okay, holistically, I want to try to open up and take in as much data as possible. From there, I want to make sure that there are about seven areas that I want to assess. So I know that sounds kind of like a lot, right? And some people might be hearing that, going like, “Oh, I don’t know. How am I going to keep seven things in my mind at once?” But it’s seven areas that are about different, like I said, facets, factors of a person’s experience. And if you want, I can share those. Would that be?

Curt Widhalm 8:41
I think it would be detrimental if you introduce the concept of seven and then don’t talk about them at all.

Katie Vernoy 8:48
Or if you if you introduce it and then talk about like five and then all of a sudden we’re left wondering what it is.

Dr. Nikki Rubin 8:56
Just to keep everybody on the edge of their seats. Okay, great. So I’m okay. So and and I should mention this comes from Jacqueline Persons. So, Jacqueline Persons, Dr. Jacqueline Persons, a psychologist, actually up in Oakland, and she’s she’s kind of like the in the cognitive and behavioral family therapies guru when it comes to case formulation. So, you know, for listeners that aren’t practicing within that family, I want to make sure I’m clear. Like, what I love about this approach is that you actually don’t have to be a CBT therapist to be doing it. We’re trying to just be very, very holistic in how we’re understanding a person and then formulating a treatment plan. So, okay, so here are the seven things. All right, so the first is you want to identify a problem list or start to think about a problem list. This is actually something that you know you as the clinician are going to be thinking about, but you’re also going to be asking the patient about it. I actually ask every single patient after an intake to write a problems and goals list for therapy. We’re starting to identify why are you here? What do you want to be working on? So, this includes anything and everything. So I tell patients like anything and everything related to being a human is allowed to be talked about in therapy, right? Like therapy’s a place to, you know, learn to be a more effective human. So it doesn’t have to just be, you know, my panic symptoms. It can also be I’m struggling financially, or you know, of course, things like it might be things in childhood that they want to talk about. It could be something like trauma. It could also be difficulties in sibling relationships. Anything and everything you can think of, we want to try to identify from the get go. Then, as the clinician, we do want to identify diagnostically what’s going on as best we can, right? So these are hypotheses, right? So, like you might think, like I don’t know, this kind of feels like it might be OCD-ish, but I don’t know. Put it down, right? Like it’s it’s a guess. You’re just getting things going, and and I didn’t say this before, but I want to emphasize this: Case formulation is like one giant hypothesis, right? So I should have maybe added a third thing. Is where I see people get stuck is that they’re afraid to make guesses, right? It’s like I don’t want to be wrong. I don’t want to over assume. It’s like assumptions are saying this is what it is. This is a fact. That’s not what we’re doing, right? We’re creating hypotheses. We’re testing like scientists for like I don’t know, maybe it’s OCD. Maybe it’s not. But I’m gonna, that’s what it looks like for now. And I’m going to then proceed and gather more data. The next thing that you want to identify is you want to write down what Jacqueline Persons calls the precipitants to the current episode or problem. So basically, like what happened right before the thing that they’re struggling with, right? I kind of want to know recent history. What’s been going on that’s influencing why they’re coming in? We then want to identify relevant socio-cultural factors, and this includes, of course, things like race, ethnicity, you know, religion, gender identity, but it also includes things like if somebody’s in the military, for example. I used to say when I when I lived in New York, and I would tell my students, I’d like be like, “Look, guys, if you were writing a case formulation about me, you’d want to talk about my Californian identity. That’s pretty important to me. Like, that’s that’s different. You know, it’s like a different cultural context. So, any relevant socio-cultural factors, like you know, generational ones, for example, as well. You then want to actually go ahead and write down, and again, you don’t have to do this with the patient necessarily. This is like you as the clinician when you’re starting to formulate. What are some examples of current thoughts or beliefs that this that this person may have, and again, some of these may be guesses a little bit. Like, let’s say you’re working with somebody who comes in and they seem very over controlled. You know, they’re extremely put together. They’re you know 10 minutes early, like on the dot. You know, they they have a very clean and neat notepad. Maybe you they haven’t said these words to you, but you guess they have a belief around: I need to be perfect, right? Hypothesis. Okay. Okay, we’re almost done. Last two. It’s a lot, I know. You’re going to want to write down the current behaviors the person is doing. And you really, really want to give particular thought to behaviors that seem to have some kind of compensatory function, and what I mean by that is it’s something they’re doing to try to regulate their emotions or cope, right, or get through things. So it serves them in some way, you know. This one is where I get very dorky because I’m a behaviorist, I’m sorry. I like talking about behavior. As clinicians, we tend to primarily focus on overt behaviors, like things we could see somebody doing. So you might be like, “Oh yeah, this person’s they’re they’re drinking three glasses of wine a night. We’re putting that one down. Oh, they’re exercising for twice a day, seven days a week, right? Okay, those are definitely behaviors we want to identify, but you also want to make sure you’re identifying covert behaviors-the behaviors they’re doing inside of their body that you can’t see. Like, are they worrying? Right? Are they ruminating? Are they suppressing emotion? Right? So these are things that we want to target too, and we want to define them. And then lastly, we want to start to come up with some hypotheses about, as Jacqueline Persons says, the origins of the mechanisms. Like, how did these stories they have about themselves? How did these behaviors? How did these thoughts? How did they develop? Like, what’s their learning history? So, I know I just said so many things right now. Do you want to pause? But yeah, so it’s pretty thorough. What I’m thinking from the get go.

… 14:49
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Curt Widhalm 14:50
How quickly are you developing this? This sounds like something that you have obviously had a lot of practice with. I’m sure you’ve supervised and taught a lot of people. In real time, how does this look in session?

Dr. Nikki Rubin 15:05
Okay, so I guess I’ll start. I’ll say like what my experience is now at this stage, but also how I train. Because I’m doing this with like sometimes like second year therapists, like or sorry, second year doctoral students. They’ve never seen a patient before, right? So I’m doing this right away. These are the things that are in my mind. Like I said before, as soon as I get a call from somebody, right? As soon as I like hear the tone of their voice, what they’re asking about. Of course, there’s a going to be a lot of gaps, right? You know, so I’m not saying I have answers to all of these, but these are all in my zoomed out 30,000 foot view of like, okay, what do I know? I start to fill in the gaps, and then I also start to see what don’t I know yet, and then with each meeting, I’m going to start filling in the gaps. So it’s a little bit like a puzzle, right? You know, it’s like I can kind of see where the holes are. So, with students or folks that maybe are struggling with case formulation who’ve practiced for a long time, I also ask them to do this right away. And I’m really clear in saying, look, this is one of these practices that when you’re new to it in the short term, initially it feels really overwhelming, right? You’re like, how am I supposed to know all this? Like these are a lot of pieces, and I’m like, I promise you though, when you start with the harder thing, you start with this very holistic view. It’s going to make things easier because when you go the other way, and the other way is, I see people with a box full of techniques, right? But they don’t know when and how to apply them. It’s kind of like they pull one out and like throw it at the wall and see if it sticks, right? That actually, over time, actually over time, sometimes pretty quickly, gets much more distressing. So this is something I tell people: we want to start with this as soon as possible.

Katie Vernoy 17:02
This seems to make sense to me. I think part of it is I did get a lot of training in more of the behavioral CBT kind of case formulation and that good stuff when I was in agency work, and oftentimes it was structured in this way for the initial assessment. And so you went down a lot of these different categories, and you probably added a few other pieces that are like medical or, or those types of things. But it it makes a lot of sense. I guess the question I have is how does that turn into treatment planning and understanding the client holistically? Because I have a picture in my mind, and how I would use it, but I would love to have your description of how this comes together and and what it what it informs, and honestly, how it fits with other orientations. Because I think for folks who aren’t more behavioral, they may not align with this type of treatment planning or case formulation.

Dr. Nikki Rubin 17:59
It is a really good question. So I think that you know I’m I’m using the term behavioral case formation because that’s where it comes from. It comes from you know cognitive behavioral therapists that that utilizes it. That hopefully you can tell even in the components that I’m laying out, these are kind of like just things that we do as therapists that we think about. They’re aspects, facets of a person’s functioning. Like you know, just like a small story: When I was in New York, and I New York’s very psychoanalytic, and I was teaching at Columbia, and they were very psychoanalytic program. And this, and I taught the CBT practicum, and I remember the students would ask me things when we’d be going over case formulation, and they would ask me pretty like broad questions, and they would say, “Like, are you allowed to do this in CBT? I was like, “Are you a let? Like, you’re going to be a psychologist. Of course, you’re allowed to ask about their family or whatever, you know.” So, so I think some of this also requires reminding ourselves that you know across orientations, where we have like a thread of similar aims and objectives, which is to help somebody change, right? To help somebody evolve. And so, when we’re conceptualizing this approach, is really not limited to just behavioral interventions. We’re trying to just think really holistically. When we get to the interventions and the techniques, you can be utilizing actually any treatment orientation. So, you know, to come back to your question of what does this look like? Well, when we start to formulate in the beginning, what what we want to do is we start want to start to identify what are we targeting? You know, what are the things we’re, another way to say that in a less behaviorist way is like, what are we trying to change, right? And we want to operationalize that. We want to be specific so that we can look for it in the session. So, for example, if I might work with somebody who comes in andthey have a lot of self-critical thinking, right? And so I might say, “Well, one of my target behaviors is self-critical self-talk, right? I’m going to be looking out for that, and I want to help move them towards a behavior, shape them towards more self-compassionate self-talk. Now, every therapist does that in in some way, right? I could also have a target that’s more specific to if I’m working with OCD. You know, again, where I’m going to be targeting obsessions and compulsions, and I’m going to do ERP for that. But let’s say somebody is trying to increase insight, and they want someone’s insight to improve, right? Like, well, what would that look like? How do you know they’re they’re more insightful? So you want to start to identify what it is that you’re trying to to shape, to target, and be really specific about that from the get go. And we want to start relatively small with like three target behaviors.

Curt Widhalm 21:01
This sounds like it has the potential to be very rigid.

Dr. Nikki Rubin 21:04
Ah, interesting. I’m I’m curious why why that’s your, why that’s your reaction.

Curt Widhalm 21:09
The you’re just thinking about kind of the tendency for early career clinicians where you’re saying, I’m just picturing kind of this anchoring effect where people start to come up with these hypotheses and then can’t move off of them. That this, I guess, what I’m trying to lead you to is this is also not just a set it and forget it. This is an ongoing process.

Dr. Nikki Rubin 21:34
Yeah, it is. It is, and it’s um, you know, it’s it’s so, I mean, it’s very helpful to hear that reaction because, to me, because I live this, I’m like, oh, it’s very flexible. But you’re right, Curt, right? That when people are not accustomed to utilizing structure, they can get really sticky and attached to structure, right? And so, this is true with anything, and again, newer clinicians we see this a lot, right, in training, where they want to have a set of rules. This is what I do in the session. This is how I conceptualize. And so, I think, and I, I think this is also can happen with folks later in their careers that haven’t learned case formulation as thoroughly, where they can, you know, basically share your same concern. Like, if I do this, I’m going to get stuck, and so this is why I want folks that are listening not to be afraid of the structure because structure is just a framework. Structure is something that is going to orient us, but we’re not attached. Like, we’re humans doing this. We’re the ones that are coming up with the formulation. Like we have the freedom to change it, and we need to change it. So, my best analogy is kind of like building and decorating a house, right? So, if you you know if you’re going to build a house, like and you’ve got all the stuff, you go to an open lot. You don’t want to just have a toilet and a and a couch and a sink and some paint and throw it onto the onto the lot and you might have like all the things that go in a house, but that doesn’t make a house, right? We got to start with the structure. We need to build it, and what’s interesting about that is it’s the structure creates space. Actually, having the structure now you have this room with ceilings and room, and then then you can decorate it however you want. There’s all kinds of techniques and interventions we can do, and we can rearrange the furniture. We can redecorate. We can even remodel the house here, right? But I think that sure there is there there is the risk of rigidity, but that’s the risk of honestly, like utilizing any framework, is that we can get too attached to doing it the right way. This is about dialectically holding structure and at the same time saying, I need to be present, focused, and moment to moment, and take in the data that I’m getting in real time and amend as necessary.

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Dr. Nikki Rubin 24:03
With the foundation and all of the information that’s gathered. I feel like there’s both the the concern that Curt brought up, which is this rigidity, but I think there’s also potentially the the house could be like a hoarder house. I think there’s so much information that we can continue to gather, and at some point it becomes less useful. And we can get caught in that day to day, week to week. We’re just gathering more and more information. We’re learning more about them, and so how do you know that the the formulation is is going to rest, kind of be in that moment, and we get to target behaviors. We get to those types of things. How does this help? Because it it’s something where I think I do a lot of this in my head. I’ve I’ve done a lot of this, so I don’t think it’s it’s something that’s new to me. But writing some of this stuff down as I, you know, as I’m in perimenopause, I need to write this stuff down. But I think that there’s a lot where I don’t write it down, and it just I have the things to attach it in my brain, and so it continues to to evolve and and all of that. But it it seems like you’re saying if we get a little bit more structured with it, it can really help us with our work, and so I guess I’m I’m saying again, how do what does this look like, and how does this help?

Dr. Nikki Rubin 25:28
Yeah. So and look, to be fair, the longer you practice utilizing case formulation, you’re going to be writing things down less. You are going to be doing more in your head, right, and being able to sort of, in you know, do it on the fly a little bit more, but all of us hopefully write things down in the beginning, right when we’re doing an doing an intake, you know. So I’m going to say another dialectic, right? Which is, and this is this is the case and how we we do therapy, unless you’re, and I guess unless you’re in a maybe in like a clinic or a community mental health center where they require a certain amount of sessions where you’re just doing intake, but it’s kind of like both things are happening at the same time. You’re conceptualizing, you’re gathering data, and you’re intervening simultaneously, right? So writing things down isn’t about like again, it’s not a linear process of now I gather all of the data, and once I gather all of the data, you know, after X amount of sessions, then I’m allowed to start targeting behavior. You know, I would I would ask listeners think about like when someone comes in for a first session, or again, usually before, you know, when you’re you’re talking to somebody on the phone and doing a phone consult, you’re usually providing some psycho education, for example, right about what you’re going to socialize them to the treatment that you do and like how you work, and you know like one of your episodes I remember you were talking about like you know how do you get to the office and those kinds of things right so so there’s some there’s some shaping that’s happening you’re already targeting some behaviors right and then internal you’re also starting to think as a clinician like what are they sharing with me? What are some of the things that they’re saying that they’re struggling with, and then I’m also starting to identify what don’t I know, right? So I think your question, Katie, is about what do we do when we feel that pull to keep gathering, keep gathering, keep gathering, which really gets us stuck from doing. And part of this is honestly about being willing as the clinician to take a risk, right? To take some risks where you’re you’re trying some things, you’re testing things out, you’re beginning to collaborate with the person that you’re working with to see if what you’re doing is having a consequence that is impactful and effective, right? So, you know, case formulation is not a is not just an academic exercise. Like, you know, we’ve been talking about treatment planning, sort of in and out during this conversation, and I think it’s really important to say, like, they are inherently linked; they go together. We we do case formulation so that we can enact the treatment, and part of enacting treatment requires saying, “Okay, like these are some things I know. I’m going to start testing things out, and I also don’t know a bunch of stuff, and I don’t know how that’s going to go. And I’m going to trust that I’m going to get information when I try something. Like, let’s say, you know, if somebody is very comes to you very depressed, and you say, you know, oh, I’m going to start with you know what the science says. I’m going to start them on behavioral activation. They’re going to start. I’m going to have them shower daily, and they’re going to get out for a walk once a day because their symptoms seem kind of mild, and then maybe that’s like not working at all, you know, and you’re surprised about it, and you’re like, “Huh, this, you know, this isn’t working. I don’t know why it’s not working.” Well, okay, so you’re going to have to ask more questions. You’re going to have to try different things. You might need to consult or collaborate with a psychiatrist, but that doesn’t mean you did the wrong thing, you know, from the data that you had, you’re you’re making a choice to start to move the treatment forward.

Curt Widhalm 29:06
This is something that can be very ingrained with a lot of practice and can be very natural, as you’re describing, for being able to both kind of gather this information as well as doing some of the interventions. For therapists who are in the position where they don’t have a lot of time, I’m thinking VAP therapists, people who are structured in network that needs a lot of insurance jargon. Parents of child clients are saying, fix my kid in the next five sessions. We want, How does how do you manage to do this kind of stuff where there are the time constraints?

Dr. Nikki Rubin 29:47
Yeah. So, look, I think that what’s tempting for all of us when we are in a a position where there is a lot of pressure to move things very quickly. When there’s honestly very real in the examples you’re giving time limited sessions you know there you may be working in a crisis situation of course you’re going to have a less thorough case formulation. That’s the best way I can say it. It’s not going to be as thorough, but what I would want your listeners to consider is that does using the approach of okay, I’m just going to keep throwing things at the wall, like people are, you know, I’ve got to keep this going. I’m just going to go with the toolbox that I have, and I’m going to like, you know, I had a supervisor once use the example of saying it’s kind of like you get a skill and you get a skill. You’re just like tossing them out, you know, and and we can feel, we can even be being told, you know, sometimes by you know organizations we’re working for that’s what we need to do. And what I would encourage therapists to consider is like, where can I slow down even a smidge, right? Like I tell patients this a lot. Like I’m, you know, I’m an act therapist, so you know, mindfulness is very interwoven into what I do. And I’ll say, you know, sometimes things are extremely busy, but it’s like, where can you even find like a sliver of a pause, right? Just a little bit of space where you can get curious about what’s happening right now. What might work right now? What am? How is this person functioning right now? And case formulation is related to that kind of approach. So it may not be the most thorough case formulation you’ve ever done, right? But I would like gently encourage and challenge folks listening. Say, well, I wonder what would happen if I just tried to slow down just a little bit to think about what’s going on in this moment with this person, and maybe that helps inform how I’m responding in a way that might work better.

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Katie Vernoy 31:57
It seems like there’s an opportunity to have the studio apartment case formulation, and then I’m thinking about longer term clients where maybe it’s a whole you know complex of homes.

Dr. Nikki Rubin 32:12
That is, you know what I got to tell you, no one’s ever said that that way to me before, but I’m kind of obsessed with what you said. I I will cite you from here to eternity when I’m teaching students, but that’s right. It’s a that’s a wonderful way of saying it. You can have a studio apartment version of the case formulation, and you can and you can work with that.

Katie Vernoy 32:30
And I think the thing for me, when I keep coming back to it, it it feels like for clients where you’re really wanting to make progress very quickly, maybe you start there and then you you add on, you you continue to go forward because, especially, I think with folks who are very in a high level of crisis, I don’t think spending a lot of time navel gazing around their family origin is where they want to go anyway.

Dr. Nikki Rubin 32:55
Correct.

Katie Vernoy 32:56
And so I think it’s that that element, unless that’s the trauma, but I think the element that is that is really clear is that there’s there’s a need to have at least a a beginning level conversation, a a session or or a good portion of a session that’s really dedicated to filling out this foundation. And I’m curious your experience around when you now are remodeling, adding on wings to the house that can occur because of the the deep, long standing relationships. Because I I do long term work, and it seems like the the the goal of case formulation shifts as you get to know the client really really well.

Dr. Nikki Rubin 33:39
Yeah, it’s you know, and in in that case, it’s like you would expect some of it’s some of the case formulation is the same, and then some of it’s different, right? Like even as you know, I was I’m telling students, I’m like, look, we’re meeting patients as they’re as they’re moving through time. You know, it’s like literally like we’re moving through time, so things happen, experiences happen, they’re developing, evolving. So, I don’t think I’ve ever had a wildly different conceptualization of somebody that I’ve worked with for a long time. You know, like I think that in a lot of ways, you know, there’s some steady throughlines that exist, and as they’ve changed and their life circumstances have changed, aspects of the formulation, and then of course the treatment plan shift, and and that’s actually important to say too is that sometimes the formulation is, can be relatively steady for a while, that but the treatment looks very different, right? So maybe somebody comes to you, again initially for some kind of like short-term problem, like I used before, like panic disorder. But you, you know, you do a full intake, so you get a little, you get some information about their family and you know their job and you know hopefully like their values are, their hopes and dreams, those kinds of things. But you’re just treating the panic disorder. But maybe if you work with them for many years, far down the line, maybe you’re really getting into attachment work. Maybe that’s something that you’ve been thinking about this whole time, but the treatment looks very different because of where they’re at and what their needs are at that at that moment in in the therapeutic work.

Katie Vernoy 35:19
I’m having this picture of like all these different rooms, and so this is the the you know the the room where the the career room, the family room, and and this is the other rooms. And and as you are in the relationship with the client longer, you just move from one room to the next, and/or you completely remodel or redecorate the room because of of how the work has continued, and and their values, goals, dreams shift, even if in small ways.

Dr. Nikki Rubin 35:47
Yeah, you’ve taken the metaphor that I use and made it so much better. I like. I’m not joking when I’m saying I’m very excited to be to be using this. I will give you full credit.

Dr. Nikki Rubin 35:59
All right, sounds good.

Curt Widhalm 36:00
For any of our listeners that haven’t done case conceptualizations since grad school, whether that be five minutes or five years or more, what is your advice for them to start implementing today?

Dr. Nikki Rubin 36:17
Yeah, so I would say, first of all, start by practicing a willingness to be uncomfortable because it’s going to be uncomfortable, and that includes a willingness to make mistakes, a willingness to be wrong, a willingness to kind of be in the murky for a while, right? And from that place, I would say start with the questions that I outlined. You know, and you can it can be with somebody you’re already working with. And I think what what I tend to find is that when I do this exercise with again, like I said, novice clinicians up until more experienced clinicians, it very quickly becomes anchoring, not in a rigid way, but like in a studying, grounding way, because it’s like, oh right, I do know some things here, you know. Maybe I don’t know a lot of stuff, but I do know some things. And then I would encourage folks, and you know, and this is something I also share with my students is like to get practice being confident and not knowing things, you know. So, like, I I tell my students that like I’m very confident as a therapist because I’m really okay not knowing. I’m really okay. I know some things, but if there’s a whole huge gap that I don’t know, I’m okay with that because I know as we move through time, we’re gonna gather more data and things are gonna come into focus little by little.

Curt Widhalm 37:51
Where can people find out more about you, your practice, and all the wonderful work that you do?

Dr. Nikki Rubin 37:57
They can find me at mindsciencecollective.com and. also drnickirubin.com.

Curt Widhalm 38:06
And you have a special offer for our listeners.

Dr. Nikki Rubin 38:10
I do. So at Mind Science Collective, mindsciencecollective.com, your listeners can get 10% off. So it’s going to be MTSG10 number 10 one zero,

Curt Widhalm 38:23
and we will include links to all of Nikki’s work in our show notes over at mtsgpodcast.com. Follow us on our social media, join our Facebook group, the Modern Therapist Group, to continue on with this and other conversations. And until next time, I’m Curt Widhalm with Katie Vernoy and Dr. Nikki Rubin.

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