In their first session, the intern learned in his first session that Jane's son had been diagnosed with a brain tumor. The therapist then excited the client's thoughts and feelings regarding her son's diagnosis. Jane expressed guilt and the thought that this would never have happened to her son if she had done more about the early symptoms. Upon hearing these feelings of guilt, the intern spent much of the remainder of the session denying them. When the session ended, the client was more desperate.
After completing this session under supervision, the intern was no longer surprised that Jane had not kept a follow-up appointment. The first session took place towards the end of the intern's second week and she endeavored to practice cognitive disputation, which she found appropriate in this case. When asked by supervisors why she completed this, the intern replied that "it felt right".
The supervisor was not surprised by this answer, as the intern had not developed a case conceptualization. With one, the intern could have foreseen the importance of instantly building an effective and collaborative therapeutic alliance and processing Jane's emotional stress gently enough before delving into her guilt-producing thoughts.
This failure to develop an adequate and appropriate case conceptualization is not just a lack of trainees. It is also common enough among experienced advisors.
What is case conceptualization?
Basically, a case conceptualization is a process and a cognitive map to understand and explain the presentation problems of a client and to control the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood of achieving treatment goals.
We will use the definition from our integrated case conceptualization model to operationalize the term and explain how this process can be used. Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client's situation and mismatching patterns, guiding and focusing treatment, anticipating challenges and obstacles, and focusing on a prepare for successful completion.
We believe that case conceptualization is the most important counseling skill, besides developing a strong therapeutic alliance. If our beliefs are correct, why is this skill so rarely taught in graduate schools, and why do counselors in training strive to develop this skill? We believe that the conceptualization of cases can be taught in graduate training programs and that on-site counselors can develop this competence through ongoing training and targeted practice.
This article describes a method for practicing case conceptualization.
The eight Ps
We use and teach the eight-P format of case conceptualization because it is short, quick to learn, and easy to use. Students and counselors in the community who have attended our workshops say the step-by-step format helps them create a mental picture – a cognitive map – of the client. They say it also helps them make treatment decisions and write an initial assessment report.
The format is based on eight elements to articulate and explain the nature and origin of the presentation and subsequent treatment of the customer. These elements are described in terms of eight Ps: presentation, predisposition (including culture), precipitating agents, protective factors and strengths, patterns, perpetuators, (treatment) plan and prognosis.
Presentation
The presentation refers to a description of the type and severity of the client's clinical presentation. This usually includes symptoms, personal concerns, and interpersonal conflicts.
Four of the Ps – predisposition, triggers, patterns, and perpetuators – provide a clinically useful explanation of the client's concern.
Assessment
Predisposition refers to all factors that make a person susceptible to a clinical condition. Predisposing factors usually include biological, psychological, social, and cultural factors.
This statement is influenced by the theoretical orientation of the consultant. The theoretical model is based on a system for understanding the cause of suffering, the development of personality traits and a process of how change and healing can take place in counseling. A biopsychosocial model is used in this article because it is the most commonly used model by mental health providers. The model includes a holistic understanding of the client.
Biological: Biological factors include genetic, familial, temperamental and medical factors such as the family history of a mental or substance use disorder or a cardiovascular disease such as high blood pressure.
Psychological: Psychological factors can include dysfunctional beliefs that include inadequacy, perfectionism or over-dependency and further predispose the individual to a disease such as coronary artery disease. Psychological factors can also include limited or exaggerated social skills such as a lack of friendship skills, indeterminacy, or over-aggressiveness.
Social: Social factors can be early childhood losses, inconsistent parenting styles, an overly entangled or disconnected family environment, and family values such as competitiveness or criticality. Financial stressors can further exacerbate a client's clinical presentations. The “social” element in the bio-psychosocial model includes cultural factors. However, we separate these factors out.
Cultural: Of the many cultural factors, three are particularly important for the development of effective case conceptualizations: degree of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture that is different from the original culture. Adjusting to another culture is usually stressful, and this is known as acculturative stress. Such adjustment is reflected in acculturation levels that range from low to high.
In general, clients with a lower degree of acculturation are more exposed than clients with a higher degree of acculturation. Differences in the level of acculturation within a family are found in conflicts over expectations of language use, career plans, and adherence to the family's eating habits and rituals. Acculturative stress differs from acculturation-specific stresses such as discrimination, second language skills and microaggressions.
Precipitation
Precipitants refer to physical, psychological and social stress factors that can be causative or coincide with the occurrence of symptoms or relationship conflicts. These can be physical stress factors such as trauma, pain, side effects from medication or withdrawal from an addictive substance. Common psychological stress factors are losses, rejections or disappointments that undermine the feeling of personal competence. Social stressors can result in loss or rejection that undermines an individual's social support and status. Includes illness, death, or hospitalization of a significant other, downgrading, loss of social security benefits for the disabled, etc.
Protection factors and strengths
Protective factors are factors that reduce the likelihood of developing a clinical condition. Examples of this include coping skills, a positive support system, a secure attachment style, and the experience of leaving an abusive relationship. It is useful to think of protective factors as the opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition). Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm, and thoughts of suicide.
Related to protective factors are strengths. These are psychological processes that consistently allow individuals to think and act in ways that benefit themselves and others. Examples of strengths are mindfulness, self-control, resilience, and self-confidence. Since professional counseling highlights strengths and protective factors, counselors should feel supported in identifying these elements and incorporating them into their case conceptualizations.
Pattern (badly adapted)
Pattern refers to the predictable and consistent style, or the way in which an individual thinks, feels, acts, manages and defends the self in both stressful and non-stressful circumstances. It reflects the basic functions of the individual. The pattern has physical (e.g. sedentary and corona-prone lifestyle), psychological (e.g. dependent personality or disorder), and social characteristics (e.g. collusion in a relative's marital problems). The pattern also encompasses the individual's functional strengths, which offset functional disorders.
Perpetuants
Perpetuants refer to processes by which an individual's pattern is reinforced and affirmed by both the individual and the individual's environment. These processes can be physical, such as B. Impaired immunity or habituation to an addictive substance; psychological problems such as losing hope or fear of the consequences of recovery; or social, such as consulting family members or agencies promoting limited dysfunctional behavior instead of recovering and growing. Sometimes triggering factors continue and become perpetuators.
Plan (treatment)
Plan refers to a planned treatment intervention, including treatment goals, strategy and methods. It includes clinical decision-making and ethical considerations.
Forecast
The prognosis relates to the expected response of the patient to the treatment. This prognosis is based on the mixture of risk factors and protective factors, customer strengths and willingness to change as well as the experience and specialist knowledge of the advisor in making therapeutic changes.
Case study
To illustrate this process, we'll provide a case vignette to help you practice, and then apply the case to the format of our eight Ps. Ready? Let's try it out.
Joyce is a 35 year old doctoral student. Student at an online university. She is white, identifies as straight, and reports that she has never been in a love affair. She is self-referred and seeks counseling to reduce her chronic and social fears. She recently started a new job in a bookstore – a stressor that led her to counseling. She reports that she is very concerned when speaking in her online classes and in social settings. She is concerned that she will not be able to cope with her fear of her new job because she will take on a leadership role.
Joyce reports that she has been very worried since childhood. She denies any past psychological or psychiatric treatment, but reports that she recently read several self-help books about anxiety. She also manages stress by spending time with her close friend from class, spending time with her two dogs, drawing and painting. She seems highly motivated for counseling and explains that her therapy goals are, “My fear to cope with and reduce, to strengthen my self-confidence and finally to enter into a romantic relationship ”.
Joyce describes her childhood as lonely and herself as "introverted to be extroverted". She states that her parents were successful lawyers who valued success, achievement, and public recognition. They were very critical of Joyce when she struggled with academics or was shy in social situations. As an only child, she often played alone and spent her free time reading or drawing by herself.
When asked how she sees herself and others, Joyce says: "I often don't feel good enough and don't belong. Usually I expect people to be self-centered, critical and judgmental."
Overview of the case conceptualization
We propose to develop a case conceptualization with an overview of the key phrases for each of the eight Ps. This is what these sentences could look like for Joyce's case. These sentences are then put together into sentences that form a case conceptualization statement that can be imported into your first assessment report.
Presentation: Generalized symptoms of anxiety and social anxiety
Precipitant: New job and concerns about dealing with your fear
Pattern (maladaptive): Avoids Cl Weakness in order to avoid perceived damage
Assessment:
Biological: Fatherly story of fear
Psychological: regards himself as insufficient and others as critical; Deficits in assertiveness, self-calming and relationship skills
Social: Few friends, a story of social anxiety and parents who were very successful and critical
Cultural: No acccultural stress or cultural stress, but from the socio-economic status of the upper middle class, i.e. from a privileged background – access to services and resources
Perpetuants: Small support system; believes that she is not competent at work
Protective factors / strengths: compassionate, creative interaction, determined, hardworking, has
access to various resources that are motivated to give advice
Plan (treatment): Supportive and strengths-based counseling, mind test, self-monitoring, mindfulness practice, down arrow technique, coping and relationship skills training, referral to group counseling
Prognosis: Good, given your motivation for treatment and the extent to which your strengths and protective factors are integrated into the treatment
Explanation of the case conceptualization
Joyce presents with generalized symptoms of anxiety and social anxiety (presentation). A recent triggering event includes her new job at a local bookstore. She fears that she will make mistakes and have high levels of fear (triggers). She presents herself with an avoidant personality or attachment style and usually avoids close relationships. She has a close friend and has never been in a love affair. She usually distances herself from others in order not to be criticized, judged or rejected (pattern). Some ongoing factors are her small support system and her belief that she is not competent at work (perpetuants).
Her protective factors and strengths include being compassionate, using art and music to deal with stress, being determined and hardworking, and working together in the therapeutic relationship. Protective factors include having a close friend from school, access to university services such as counseling services and student clubs and organizations, motivated to seek advice, and health insurance (strengths and protective factors).
The following biopsychosocial factors try to explain the symptoms of anxiety and the avoidable personality style of Joyce: a fatherly fear story (biological); She sees herself as inadequate and others as critical and judgmental and struggles with deficits in assertiveness, self-calming skills and relationship skills (psychological). She has few friends, a history of social anxiety, and parents who have been very successful and critical of her (social). Given Joyce's upper-middle class upbringing, she was born into a life of opportunity and privilege. Their claim to a preferred and comfortable life could therefore also explain their challenges in dealing with life stress (culturally).
In addition to facilitating an extremely supportive, empathetic and encouraging counseling relationship, the treatment also includes training in psychoeducational skills to develop assertiveness, self-calming skills and relationship skills. These skills are implemented through modeling, session rehearsal and role play. Your challenges in relation to relationship skills and interpersonal patterns will also be addressed with a referral to a therapy group at the university counseling center. The negative self-talk, interpersonal avoidance, and anxiety symptoms of Joyce are addressed with Socratic questions, mind tests, self-monitoring, mindfulness practice, and the down arrow technique (plan treatment).
The result of the therapy with Joyce is judged to be good because of her motivation for treatment, if her strengths and protective factors are included in the treatment process (prognosis).
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Notice how the treatment plan targets the presenting symptoms and pattern dynamics of Joyce's case. Each of the eight Ps has been identified in the case conceptualization and you can see the flow of each element and its connections to the other elements.
Tips for writing effective case conceptualizations
1) Contact a peer or supervisor for feedback on your case conceptualizations. Often times, a different perspective will help you understand the different elements (eight Ps) you are trying to conceptualize.
2) Be flexible with your hypotheses and therapeutic assumptions when putting together case conceptualizations. Sometimes your guesses are accurate and sometimes you are far from the goal.
3) Ask the customer how they would explain their presentation problem. We start with a question like, "How can you explain the (symptoms, conflict, etc.) that you are experiencing?" The client's perspective can reveal important predisposing factors and cultural influences and their expectations of treatment.
4) Be okay with being imperfect or completely wrong. This process requires practice, feedback, and monitoring.
5) After each initial recording or assessment, write down the presentation dynamics and guess its cause or etiology.
6) Have a solid understanding of at least one theoretical model. Read some of the landmark textbooks or watch counseling theory videos for a comprehensive assessment of a particular theory. Understanding the basic ideas of at least one theory will help you conceptually piece together the information you've gathered about a customer.
We recognize that putting together case conceptualizations can be a challenge, especially at the beginning. We hope you find this approach works for you. Best wishes!
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For more information and ways to learn and use this approach to case conceptualization, see the recently published second edition of our book Case Conceptualization: Mastering This Competence with Ease and Confidence.
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Jon Sperry is Associate Professor of Clinical Psychological Counseling at Lynn University in Florida. He teaches, writes and researches the conceptualization of cases and conducts workshops around the world. Contact him at [email protected].
Len Sperry is Professor of Counseling Education at Florida Atlantic University and a member of the American Counseling Association. He has long been committed to helping counselors learn and apply case conceptualization, and his research team has completed eight studies on it. Contact him at [email protected].
Knowledge-sharing articles developed from sessions presented at American Counseling Association conferences.
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It should not be assumed that opinions or statements in articles appearing on CT Online represent the opinions of the editors or guidelines of the American Counseling Association.
