See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/313965874 Case Conceptualization Chapter · January 2015 DOI: 10.1002/9781118625392.wbecp106 CITATIONS READS 7 43,231 2 authors: Samantha E John Daniel L Segal University of Nevada, Las Vegas University of Colorado Colorado Springs 56 PUBLICATIONS 507 CITATIONS 217 PUBLICATIONS 5,988 CITATIONS SEE PROFILE All content following this page was uploaded by Daniel L Segal on 16 October 2017. The user has requested enhancement of the downloaded file. SEE PROFILE Case Conceptualization Samantha John and Daniel L. Segal University of Colorado at Colorado Springs, U.S.A. For clinical psychologists, being able to devise a coherent and effective case conceptualization is arguably among the most important skill for effective clinical practice. Indeed, the case conceptualization is a critical link in the development of psychotherapeutic treatment decisions, serving as a bridge between the client’s concerns and the choice of specific interventions (Sperry, 2005). In general, the case conceptualization (sometimes called a case formulation) refers to the clinician’s collective understanding of the client’s presenting problems as viewed through a particular theoretical orientation; as defined by the biological, psychological, and social contexts of the client; and as supported by a body of research and practice that links a set of co-occurring symptoms to a diagnosis and, ultimately, a treatment plan. An informative case conceptualization is a required component leading to a successful course of psychotherapy. The case conceptualization will be incorporated into multiple clinical documents and typically evolves over time as the clinician’s understanding of the client grows or as new treatment approaches are explored. The purpose of this entry is to provide a discussion of the many key features, elements, and challenges of a case conceptualization. A strong case conceptualization is guided by the utilization of a theoretical orientation that provides a framework for the clinician from which to condense and synthesize multiple pieces of information into a coherent and well-developed narrative. This narrative aims to identify the original precipitating cause(s) of the client’s problems (usually including distal and proximal factors) as well as the forces at work, both internal and external to the client, that serve to maintain the problems. The narrative is supported by a body of research and theoretical literature that describes commonly observed patterns of behavior and reported symptoms that are associated with particular diagnoses. There are numerous different theoretical orientations to choose from, each prioritizing different client factors, utilizing different terminology, and encouraging the use of different psychotherapeutic strategies or interventions. Although they may differ in their origin, language, and view of the clinician’s role, each orientation strives to describe the territory of the client’s problems and to make sense of the client’s struggles and how they may disrupt his or her social and occupational functioning (Berman, 2010). Although a theoretical orientation facilitates the understanding of an often complex clinical picture, the unique aspects of each individual case are of equal importance when deciding on a diagnosis and treatment plan. Two clients may present with a similar set of symptoms but receive different diagnoses on the basis of relevant history, health and medical factors, cultural identity, gender, age, and/or social environment. Each of these elements must be considered in order to develop an effective course of treatment for a particular individual (Segal, 2007). There is no universally accepted theoretical orientation or set of intervention strategies for any given mental disorder. Both orientation and intervention should be comfortable for the client, and the strength of treatment choice is often reflected in the strength of the case conceptualization from which it originated. The case conceptualization is likely most often considered the heart of a client intake report. Indeed, an initial case conceptualization is typically provided in the report after a full description of the client’s presenting problem, the history of the presenting problem, a psychosocial history, and a mental status The Encyclopedia of Clinical Psychology, First Edition. Edited by Robin L. Cautin and Scott O. Lilienfeld. © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc. DOI: 10.1002/9781118625392.wbecp106 2 CASE CONCEPTUALIZATION examination (Segal, 2007). This initial case conceptualization provides a working hypothesis about the nature and origin of the client’s difficulties and leads to an initial treatment plan. However, the conceptualization will continue to inform treatment beyond the intake session and will appear, in some form, throughout multiple other clinical documents. Assessment reports, treatment contracts, client transfer or termination summaries, as well as some referral documents might all include a modification of the case conceptualization. In the instance of shared clinical communications, the document’s function moves beyond the purpose of increasing the clinician’s own understanding to the goal of conveying important information to other professionals involved in the coordination and delivery of care. For this reason, the case conceptualization should be considered a living document, one that changes over time and with new information and gained insight. It may also be necessary to modify the document to the reader. Use of psychological jargon may be acceptable for a fellow mental health professional, but a primary care physician (PCP) will benefit from a simplified description that avoids specialized terms and instead focuses on more objective language rooted in symptoms and signs. In contrast, a client may not respond well to a description of him or herself that neglects detail or seems to gloss over important historical events or significant character strengths. The language of the case conceptualization as seen by the client should match the language used by the clinician within their session. The language read by the PCP should reflect the needs of that profession and the goal of improving integrated health services. A comprehensive case conceptualization will contain many different features. Like a well-written persuasive argument, the case conceptualization should be supported by evidence from the client’s history, presentation, and self-report and should serve to unite information from several potential origins into a singular working hypothesis or explanation. Importantly, the case conceptualization will strive to describe and explain the client’s presenting problem in terms that can be clearly operationalized, including cognitive, affective, and behavioral aspects of the problems. The conceptualization will settle upon one set of diagnoses while also providing justification for ruling out competing diagnoses. When well argued, the choice of diagnosis and the explanation of the client’s pattern of thoughts, feelings, and behaviors serve to introduce the choice of treatment. Interventions follow from the description of the client, and they take into consideration the way that the client typically interacts with his or her world and the patterns of thinking, feeling, and behaving that contribute to the maintenance of current mental health struggles. Client strengths and existing coping strategies can be used to help shape interventions, and knowledge of the client’s history (including prior responses to psychotherapeutic treatment) will provide evidence of interventions that may be either preferable or ill-suited for a particular individual (Segal, 2007). The choice of psychotherapeutic intervention follows directly from the choice of theoretical orientation. The most common theoretical orientations include psychodynamic, cognitive-behavioral, interpersonal, existential, gestalt, humanistic, and integrative models that combine the best features of diverse paradigms into a unified and coherent perspective. Different theories may offer different conceptualizations, and each will utilize its own unique language; however, most theoretical orientations use unique language to describe the same processes. Many clinicians may have a single preferred orientation with which they are most comfortable and familiar, and certainly, familiarity with a model is an important piece in understanding the client. However, it is possible that some clients may not respond well to certain models and their associated interventions, and so the wise clinician must always consider the benefit to the client of using a particular model. The choice of orientation will help to guide the conceptualization by dictating the types of questions to be asked of CASE CONCEPTUALIZATION the client and the missing information needed in order to gain a full understanding of client processes (Segal, June, & Marty, 2010). The set of hypotheses generated by the clinician about the client will reflect the theory used through the emphasis given to different client features. In a practical sense, should a client respond well to psychotherapy, then no major modifications in the conceptualization are necessary. However, should a client appear to not make progress, or to regress during treatment, then the conceptualization should be revised. What biological, psychological, and social forces are impinging on the client that must be recognized or understood more fully to propel effective treatment forward? This is an important question upon which clinical psychologists must reflect when they perceive their clients as responding less well than expected to treatment or if the psychologists themselves feel confused about the direction of psychotherapy. Despite the importance of case conceptualization in clinical training and practice, the research base on this topic is surprisingly sparse. The following issues should be addressed by researchers. To what extent are case conceptualizations reliable or replicable across clinicians? We would hypothesize that conceptualizations drawn from more structured approaches to psychotherapy (e.g., cognitive behavioral models) would be more reliable than those from less structured approaches. What is the impact of case conceptualizations on objective treatment outcomes? And to what extent does this impact vary based on important client variables such as age, race, gender, education level, acculturation, level of insight, and presenting problem? How does case conceptualization impact the selection of specific assessment and treatment strategies, and what is the exact nature of the feedback loops in play? Finally, researchers should examine training models for teaching clinicians to improve their case conceptualization skills. In short, we hope the field matures in its progress toward evidence-based case conceptualizations. There is considerable variability regarding the extent to which clinicians share aspects of 3 the case conceptualization with their clients. Indeed, some specific theoretical models include the sharing of the conceptualization as an essential part of treatment. For example, according to the cognitive model, the cognitive case formulation includes a statement about core beliefs or schemas, automatic thoughts, errors in cognitive processing (cognitive distortions), compensatory strategies, and problematic behaviors that underpin and maintain the client’s current problems (Persons, 2008). During the early phase of treatment, the clinician typically educates the client about the cognitive model (e.g., relationships between thoughts, feelings, and behaviors; and the primacy of cognition in leading to distressing feelings and maladaptive behavior) and then shares certain aspects of the case formulation so that the client is prepared to identify and begin to challenge his or her own unhelpful thinking patterns. Practitioners of other models (e.g., psychodynamically based models) are generally less inclined to overtly share their ideas about the case conceptualization, although it certainly drives therapeutic decision making and responding. Despite these differences, little research has examined the impact of sharing or not sharing conceptualization with clients and the extent to which clients find the process of conceptualization useful. It is no small task for beginning psychologists to learn how to devise case conceptualizations and to become comfortable using the conceptualization to determine specific interventions. Graduate training programs in psychology take seriously the task of training students to craft and revise case conceptualizations. Courses in which aspects of conceptualizations are typically discussed include psychopathology, clinical interviewing, and, of course, any psychotherapy class. Clinical supervisors also typically help beginning practicum trainees learn to form initial case conceptualizations and then improve the sophistication and breadth of formulations as they progress in their training. A developmental model is preferable as it frames growth as an extended process over time in which earlier building 4 CASE CONCEPTUALIZATION blocks in the skills of case conceptualization are expanded upon by later knowledge and experiences as one matures as a clinician. It is indeed a challenge to learn the skill of case conceptualization, but it is one that we think is of utmost importance as it is a critical component of effective psychotherapy. SEE ALSO: Biopsychosocial Model; Common (Nonspecific) Factors in Psychotherapy; Mental Status Exam; Psychotherapy Integration; Clinical Interview, The References Berman, P. S. (2010). Case conceptualization and treatment planning: Exercises for integrating theory with clinical practice (2nd ed.). Thousand Oaks, CA: Sage. Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York: Guilford. Segal, D. L., & Hutchings, P. S. (2007). Writing up the intake interview. In M. Hersen & J. C. Thomas (Eds.), Handbook of clinical interviewing with adults (pp. 114–132). Thousand Oaks, CA: Sage. View publication stats Segal, D. L., June, A., & Marty, M. A. (2010). Basic issues in interviewing and the interview process. In D. L. Segal & M. Hersen (Eds.), Diagnostic interviewing (4th ed., pp. 1–21). New York: Springer. Sperry, L. (2005). Case conceptualizations: The missing link between theory and practice. The Family Journal, 13, 71–76. doi:10.1177/ 1066480704270104 Further Reading Hersen, M., & Thomas, J. C. (Eds.). (2007). Handbook of clinical interviewing with adults. Thousand Oaks, CA: Sage. Hersen, M., & Van Hasselt, V. B. (Eds.). (1998). Basic interviewing: A practical guide for counselors and clinicians. Mahwah, NJ: Lawrence Erlbaum. Needleman, L. D. (1999). Cognitive case conceptualization: A guidebook for practitioners. Mahwah, NJ: Lawrence Erlbaum. Oltmanns, T. F., Martin, M. T., Neale, J. M., & Davison, G. C. (2012). Case studies in abnormal psychology (9th ed.). Hoboken, NJ: John Wiley & Sons. Segal, D. L., & Hersen, M. (Eds.). (2010). Diagnostic interviewing (4th ed.). New York: Springer.
