Current Studies

The case formulation helps therapists resolve but not prevent episodes of symptom deterioration and lack of progress during cognitive behavior therapy

Jacqueline B. Persons, Garret G. Zieve, and Griffin Kreit 

Objective: We studied the case formulation approach to CBT, which was developed to strengthen treatment by personalizing it and providing decision support tools (the written case formulation, the list of treatment goals, and the plot of progress monitoring data) to help the therapist solve problems that occur during treatment. We tested the hypothesis that the decision support tools of the therapy prevent and help the therapist resolve not on track (NOT) episodes of symptom deterioration and lack of progress. To lay the groundwork to test these hypotheses, we first evaluated the relationship between NOT episodes and their resolution to end-of-treatment severity of symptoms of depression and anxiety and to dropout in naturalistic treatment.

Method: Data for the study were drawn from an archival database that contains information collected from 1470 adults who received naturalistic case formulation-driven CBT in a private practice setting. Patients gave written informed consent for the use of their data in research. We assessed end-of-treatment symptom severity using the Beck Depression Inventory (N = 314) and the Burns Anxiety Inventory (N = 398), whether the patient was rated by the therapist as dropping out of treatment prematurely (N = xx) or uncollaboratively (N = xx), and presence in the clinical record of the three decision support tools. We defined a not on track (NOT) episode of symptom deterioration as a reliable worsening of symptoms compared to intake symptom severity based on the reliable change index, or a period of five or more sessions in which there was no reliable improvement over the intake BDI or BurnsAI score. To account for the nested structure of the dataset (patients nested within therapists), we analyzed data using a hierarchical generalized liner model framework. We used hierarchical linear regression to analyze continuous outcomes (e.g., end-of-treatment symptom severity scores on the BDI and BurnsAI) and hierarchical logistic regression to analyze binary and proportion outcomes (e.g., occurrence of NOT episodes, proportion of NOT episodes resolved).  

Results: NOT episodes predicted increased end-of-treatment symptom severity on the BDI and the BurnsAI. Resolution of NOT episodes predicted decreased end-of-treatment symptom severity on the BDI and the BurnsAI and a lower likelihood of premature dropout. Resolution of NOT episodes was associated with symptom changes in a positive direction that were larger than the negative effects of the NOT episodes before resolution. Therapist use of the decision support tools of the therapy did not predict the occurrence of NOT episodes. One of the decision support tools, the written case formulation, predicted resolution of NOT episodes defined by BDI scores and had a marginally significant relationship to the resolution of NOT episodes defined by BurnsAI scores.  

Conclusions: Resolution of NOT episodes had a larger positive effect on symptoms than the negative effect of the original NOT episodes, indicating that the occurrence of NOT episodes can provide useful information that helps therapists resolve the episodes. Therapist use of a case formulation appears to contribute to that helpful process.

Title: Effectiveness, Efficiency, and Acceptability of Cognitive Behavior Therapy in Private Practice

Paper submitted for presentation at the conference of the Association for Behavioral and Cognitive Therapies in New Orleans in November, 2025

Authors: Stephanie L. Haft, Ph.D., postdoctoral fellow at UCSF and Jacqueline B. Persons, Ph.D. at the Oakland CBT Center

The "treatment prevalence paradox" refers to the puzzling observation that, despite increased availability of treatments for depression, the prevalence of depression in the general population has remained largely unchanged. One proposed explanation is that the effectiveness of treatments demonstrated in randomized controlled trials (RCTs) may not fully translate to “real-world” clinical practice. While several studies have examined how outcomes from RCTs compare to those in routine care settings, limited research has focused specifically on psychotherapy outcomes in private practice settings. This gap is significant given that over one-third of individuals who receive mental health care do so through private practice. Understanding the degree to which RCT findings align with treatment outcomes in private practice is essential for identifying potential barriers to effectiveness, optimizing treatment delivery, and ensuring that evidence-based interventions remain both applicable and accessible in diverse clinical contexts.

The goal of this presentation is to discuss a study that compares findings from RCTs of Cognitive Behavioral Therapy (CBT) for depression to outcomes observed in a private practice clinic. This study will investigate how the effectiveness (Aim 1), efficiency (Aim 2), and acceptability (Aim 3) of CBT for depression in this private practice setting compares to results from RCTs of CBT for depression. We hypothesize that effect sizes observed in this private practice sample will be comparable to effect sizes from RCTs and other clinical practice settings (Aim 1). We expect that the time (number of sessions) to achieve reliable change in this private practice sample will be comparable to time to achieve reliable change observed in RCTs, and that treatment duration (total number of sessions) in this private practice sample will be longer than in the RCTs (Aim 2). Finally, we hypothesize that patient dropout rates in this private practice sample will be comparable to other clinical settings but higher than the RCTs.

To address our aims, the study relies on a robust dataset of routine outcomes monitoring collected over the course of over 40 years from approximately 1500 clients. Clients provided written informed consent to the use of their progress monitoring data in research. This study is pre-registered, and data analyses are underway. 

Longitudinal study of the patient outcomes of a single practitioner over 35 years 

Authors: Stephanie Haft, Sarah Coe-Odess, Cannon Thomas, Caroline Harris, Letian Li, and Jacqueline B. Persons

Empirical study in progress

This study examines patient outcomes over the course of Dr. Persons’ career, and examines whether her outcomes improved as she acquired years of experience, whether her efficiency (time taken for the patient to achieve a reliable improvement in symptoms), and her use of the decision support tools of the case formulation approach to CBT (the case formulation, the list of treatment goals, and the plot of progress monitoring data) changed over the years of her career.

Anhedonia changes more slowly than other symptoms of depression during cognitive behavior therapy

Authors: Ann Kring, Garret G. Zieve, Griffin Kreit, and Jacqueline B. Persons

Empirical study in progress