Case Conceptualisation I

Case conceptualisation is one of the areas that many beginning therapists and interns seem to have difficulties with.

As with many concepts, we psychologists like to define case conceptualisation using a complex set of words:

Case conceptualisation is the process of using sound theoretical frameworks to organise interview data, observational data and assessment data to formulate hypotheses that may explain the underlying dynamics of presenting problem in order to formulate an appropriate treatment plan.

Another definition of case formulation:

Case formulation aims to describe a person is presenting problems, and his theory to make explanatory inferences about causes and maintaining factors that can inform interventions. First, there is a top-down process of cognitive behavioural theory providing clinically useful descriptive frameworks. Second the formulation enables practitioners and clients to make explanatory inferences about what caused and maintains the presenting issues. Thirdly case formulation explicitly and centrally informs intervention. Case formulation is a cornerstone of evidence-based CBT practice. For any particular case of CBT practice, formulation is the bridge between practice and theory and research. It is the crucible, where the individual particularities of a given case relevant theory and research synthesise into an understanding of the persons presenting issues in CBT.

In more simple terms. What's going on and what are we going to do about it.

The longer definition above is from a paper by Willem Kuyken and others, looks at the reliability and quality of cognitive case formulation. It is an interesting aside, that manualised approaches work better for beginning therapists than individualised case conceptualisation approaches and that there is not always a high degree of agreement on inferential aspects of case conceptualisation, even amongst experienced clinicians

There are a number of case conceptualisation models put out by various cognitive behavioural therapy writers. I have outlined a few of them below and provided a sample conceptualisation for some of the models.

The Fours Ps model is probably the simplest of all the case conceptualisation models. I don’t know where this comes from. If anybody knows the original reference or who conceived this one let me know.

• Predisposing factors.
• Precipitating factors.
• Perpetuating factors
• Protective factors

Predisposing factors are the historical or genetic elements that contribute to the current problem. The precipitating factors are the current triggers i.e. what sets off this problem or behaviours. Perpetuating factors are the internal and external thoughts and behaviours that maintain the problem. Protective factors are the strengths, social supports and positive patterns of behaviour.

Judith Beck's Cognitive Case Conceptualisation

• Relevant childhood data
• Core beliefs.
• Conditional assumptions, beliefs or rules.
• Compensatory strategies.

• Specific situation.
• Automatic thought.
• Meaning of the automatic thought.
• Affect or emotion
• Behaviour

Here is an example of Beck’s case conceptualisation.

Leahy's Cognitive Case Conceptualisation .

• Developmental history.
• Personal schema .
• Schema about others.
• Automatic thoughts
• Maladaptive assumptions.
• Conditional beliefs.
• Coping strategies.

Here is an example of Leahy’s case conceptualisation.

Leahy’s and Beck’s model are very similar. Leahy splits the core beliefs up into schema about the self and schema about others. He also provide room t consider the maladaptive assumptions. Both of these models are narrowly focussed on the cognitive processes alone and do not take account of relational or motivational factors to any significant degree.

Judith Beck's book, Cognitive Therapy: Basics and Beyond, has an excellent chapter covering cognitive case conceptualisation.

Stenhouse and Van Kessel nicely summarise how to complete Beck’s case conceptualisation diagram.

Beck suggests it is best to start with the bottom half of the conceptualisation diagram, where the therapist records three typical situations in which the client has experienced a high level of negative affect. For each situation the therapist fills in the automatic thoughts, the meaning of the key automatic thought, and the client's emotional and behavioural reactions. The meaning of the key automatic thought for each situation should be logically connected with the Core Belief box near the top of the diagram. To complete the top of the conceptualisation diagram the therapist identifies how the core beliefs) originated and how they were maintained. The data obtained in this box may often include significant childhood events such as parental divorce, sexual abuse, or other adverse life conditions such as growing up in poverty, facing racial discrimination and so on; or may be more subtle, such as a child's perception that they were less favoured as a child, or the perception that a child did not live up to the expectations of significant others.

Core Beliefs are written in the box below relevant childhood data, and are unconditional beliefs about the self, world, and others. The next box in the diagram is for intermediate beliefs (rules, attitudes, or underlying assumptions), which help the patient to cope with the painful core belief. And finally to complete the top half of the formulation diagram the therapist identifies compensatory strategies/behaviours which again allow the client to cope with the core belief. Beck points out that the conceptualisation diagram needs to make logical sense to the therapist and client, and should be continually updated and refined as additional data are collected. The conceptualisation is shared and explored with the client in a collaborative process.

Robert Leahey in his book, Cognitive Therapy Techniques: A Practitioner's Guide, does not provide nearly as much detail on how to go about implementing a case conceptualisation. However it does have a short section on possible problems that may arise with developing a case conceptualisation with the client.

Although case conceptualisation is often a powerful intervention that helps patients make sense of current problems, it may raise concerns are some. For example, some patients may believe there are hopeless cases because they were "ruined" by their childhood experiences. These concerns about fundamental defects can be challenged by asking patients to consider if they have ever had any beliefs. They subsequently changed ruined any new behaviours, since we are learning and changing daily, knowing that old habits and beliefs were established early on may be the first step in changing them now. A good question to ask is.

Since some of the beliefs that bother you now were established when he was six years old would you want to continue believing things he learnt as a child?

Another question might be::

When you learnt this belief as a child, you did not have the ability to think as an adult. Now you can challenge these ideas with all the benefits of being older and wiser.

Persons' in her book;Cognitive Therapy in Practice: A Case Formulation Approachoutlines a model of conceptualisation that has eight core components and moves beyond just a cognitive formulation.

• Problem list.
• Core beliefs.
• Precipitating and activating situations
• Origins
• Working hypothesis.
• Treatment plan.
• Predicted obstacles
• Strengths, supports and assets

Persons’ model is more developed in my view. It includes the cognitive conceptualisation of the above models but asks the clinician to make a treatment plan based on these. It asks the clinician to think about the therapeutic relationship to some degree by identifying problems and obstacles to therapy that may occur. It also asks the clinician to consider the strengths and supports the client brings to therapy. In my view something often missed by clinicians focussing just on the client’s problems. The identification of strengths and support can help you as a clinician tailor your CBT much more effectively.

See also: Case Conceptualisation II

Comments

[Abby H]

The 4P's case formulation model comes from:

Weerasekera, P. Multiperspective Case Formulation: A Step Towards Treatment Integration. Melbourne, Fla: Krieger Publishing, 1996.

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This theme has interested me! Thirdly case formulation explicitly and centrally informs intervention. Case formulation is a cornerstone of evidence-based CBT practice. For any particular case of CBT practice, formulation is the bridge between practice and theory and research. It is the crucible, where the individual particularities of a given case relevant theory and research synthesise into an understanding of the persons presenting issues in CBT.