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
It will support the reader in making the transition from the lecture theatre to the consulting room. The approach incorporates a contemporary perspective on the multiple roles of clinical psychologists within a competitive health care market, where professional psychologists not only need to be accountable for their outcomes and efficient in achieving them, but also need to be conscious of the social and political context in which psychology is practised. Chapters are organised around the acquisition of key competencies and linked within an evidence-based, science-informed framework. Case studies, handouts, graphics and worksheets are employed to encourage the implementation of the skills described. This book should be read by all those enrolled in, or contemplating, postgraduate studies in clinical psychology. 