Case Conceptualisation II

The previous post considered a number of cognitive behaviour models for case conceptualisation. Clearly, at the centre of all these models is a case conceptualisation built around core beliefs, and how these impact on day-to-day cognitions, emotions and behaviour. These case conceptualisations do not provide a lot of space for comment on the relationship with the client, the client’s motivation or examine factors that may indicate the prognosis of therapy in general.

Consideration of these types of factors can considerably enhance your case conceptualisation. For example, use of psychological tests such as the Millon Clinical Multiaxial Inventory (MCMI III) can provide an Axis II picture of how the client is likely to react in general situations in their life as well as predicting how they are likely to interact in the therapy room.

The following factors are useful to consider:

• Motivation
• Capacity (psychological mindedness or insight).
• Ego strength.
• Intellectual ability.
• What social and emotional resources are available for supporting the client's positive changes?

Understanding the above factors can have a significant impact on the type of treatment and techniques that you utilise to work with the client. For example, a client with low psychological mindedness or insight, low ego strength and low intellectual ability may not respond well to techniques such as Socratic questioning and active thought monitoring. They may find extremely difficult to keep a thought diary. Their low intellectual ability may make it difficult for them to understand the logic behind Socratic questioning and challenging dysfunctional thought processes. Utilising these techniques with this type of client is likely to lead to frustration both on the part of the client and therapist. The value in assessing these aspects in a case conceptualisation means that you pitch your therapy to what the client can cope with and understand.

Clearly, the level of case conceptualisation, you can undertake to some degree relates to how much information you have gathered. In some situations, we only have a short period of time to gather information before implementing treatment. Where we may only have five or six sessions, then we may only have one session to gather data on which to base a case conceptualisation.

In these types of situations, consider using a psychological test such as the Minnesota Multiphasic Personality Inventory (MMPI-2), the Millon Clinical Multiaxial Inventory (MCMI III) or the Personality Assessment Inventory. Any of these tests will provide a wealth of data that will considerably enhance your case conceptualisation. Personally, I really like the Millon Clinical Multiaxial Inventory.

In particular usign it with the book on interpretation by Choca and Van Denburg: Interpretive Guide to the Millon Clinical Multiaxial Inventory (3rd Edition). This book has interpretation on up to three combined highpoint scales of Axis II Scales. The book then provides an outline of the personality traits as well as likely responses that the client will have to therapy and suggestions for how the therapist can manage this. I find this particularly helpful as it gives me many useful ideas about how to work with and manage the client in the therapy room. My approach with a client with compulsive traits is going to be quite different from my approach to a client with passive aggressive traits.

With a client with compulsive traits my approach is likely to reflect this in ensuring that I'm always on time, always finish on time, that the same room is used every and  time that we arrange a meeting at the same time every week. I am likely to focus more on cognitions and take an intellectual approach to begin with as this more likely to engage the client. With a client with passive aggressive traits then I am likely to be focusing more on motivational issues, and usually utilising techniques such as cost benefit analysis to ensure that the client is fully engaged in therapy.

In the last year I have come across a couple of papers with some new ideas to consider in formulation. The first of these by Grosse Holtforth and Castonguay provides a framework for analysing the client's motivations. Their primary focus, on need satisfying experiences of the client, is based around one of my favourite therapeutic sayings.

Nobody does nothing for no reason.

In more scientific terms: Any repeated behaviour by an organism is an attempt to meet a need for that organism

Grosse Holtforth and Castonguay assert that the identification of need satisfying experiences and utilising this knowledge to manage the therapeutic relationship leads to better outcomes. They make it clear that this type of case conceptualisation or analysis is an addition to the standard case conceptualisation from a cognitive approach outlined above.

They divide motivational goals up into approach goals and avoidance goals. Approach goals are those goals people actively seeks out in their environment. Each individual is likely to have a different hierarchy of motivational goals. They identify the following approach goals:

• Intimacy
• Affiliation
• Altruism
• Help
• Recognition
• Status
• Economy
• Performance
• Control
• Spirituality
• Self-confidence
• Self reward

They also identify the following avoidance goals:

• Separation
• Deprecation
• Humiliation
• Accusations
• Dependence
• Hostility
• Vulnerability
• Helplessness
• Failure

Identifying a client's primary approach and avoidance goals enables the therapist to tailor their interventions around assisting the client to meet these core needs.

Because human communication involves both issues of content and process, motivational achievement fostering the therapeutic bond also includes both non-verbal and para-verbal levels of the communication. For example, if close relationships are important for a client he or she is likely to prefer warm, close and caring non-verbal behaviour from the therapist. If, on the other hand, the client is irritated by seeing emotion in others a more distanced rational technical therapeutic stance might be indicated. If it is very important to the client to be autonomous, the therapist should leave as many decisions as possible in the client's hands. If the client values education and broad interests, the therapist might put in an extra effort towards providing explanations or theoretical models for the client problems.

For many clients their approach and avoidance goals will conflict. For example, many clients, a primary approach goal will be intimacy at the same time they may have strong avoidance goals around dependence and vulnerability. This can lead to them having very conflicted relationships with them getting close to someone and then pulling away when they feel vulnerable and dependent. This pattern of behaviour, not infrequently plays itself out in the therapy room.

Shahar and Porcerelli have a paper out in the latest Journal of Clinical Psychology. It is a case formulation method using what they called the action formulation. In this type of formulation, the client is seen as actively shaping and controlling their environment. The client is seen to some degree in as being responsible for what happens to them.

They identify four guidelines:

• Map the clients, social environment, focusing on sources of support, chronic interpersonal difficulties and negative and positive life events

• Identify how the clients in the context of their personalities, psychopathology and strengths actively influence their environment.

• Differentiate or identify maladaptive risk related interpersonal cycles and adaptive protective go to sleep based interpersonal cycles.

• Plan and tailor techniques to short-circuit maladaptive cycles and bolster the adapter protective cycles

As a therapist, one needs to approach case conceptualisation in a developmental manner. Start with a simpler model of conceptualisation such as the four Ps model. Once you've mastered this or try to set a few times and expand into utilising persons models as well as Beck’s and Leahy’s models.

To start with, these models are often developed in reflection and supervision or in discussion with other psychologists. As you become more adept at this and a more relaxed in the room you'll find yourself more able to begin to make these formulations as you're doing your initial assessments. This allows you to more actively test out some of your hypotheses as they immediately come to mind when you're working with the client.

The process of developing good case conceptualisations involves firstly, taking the time to think and reflect about what is happening with the client. Case conceptualisation is to be thought of as a developing hypothesis. There is a danger when the case is initially conceptualised that we lock into the first model that we put forward and then selectively attend to information that supports or or ignore information that doesn't support this hypothesis.

See also: Case Coneptualisation I

Comments

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Thanks for a great article - this has been very useful to me as I am undergoing supervision for registration and need to present a number of case studies which require case formulation/conceptualisation.
JCO

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