CASE CONCEPTUALIZATION: Therapist Compass, Clarifying Lens, Medical Model Envy ... or a Jumping-off Point for Something Completely Different
A discussion paper by Don Edwards, Ph.D., Jude Johnston, MSW, Julia Balaisis, Ph.D.,Valeri Belyanin, Ph.D. & Inese Gravlejs
CASE CONCEPTUALIZATION (CC): an assessment of the client and their presenting concerns in order to devise a treatment plan or treatment approach. This assessment includes client skills, environmental stressors and supports, cognitive, emotional and behavioural patterns. According to Padesky & Greenberger (1995), case conceptualization consists of identifying the issue or concern with the most leverage in the context of all other contributing and mitigating factors. This issue or concern may not be one that is initially figural for the client, but if not correctly identified by the therapist, the direction of therapy and its outcome may be compromised.
A well-prepared case conceptualization is intended to facilitate communication between professionals, systematize client records, and may help the therapist maintain a consistent frame of reference as well as track and review progress with the client even if the CC is not shared with the client. CC can also link the facts of the case to therapeutic interventions and may suggest areas of psycho-education as well as a session direction if the client does not raise areas of concern. In this era of heightened 'accountability,' 'cost effectiveness' and 'managed health care,' treatment plans, which are more and more demanded by non-practitioner administrators and professional regulatory bodies, are predicated on CC. However, as we will explore, CC's are not without their limitations.
FACTORS INFLUENCING HOW A CASE IS CONCEPTUALIZED:
- therapist's theoretical orientation:
The theoretical focus of a therapy shines the spotlight on aspects of the client's psychological functioning that the therapy seeks to improve. Every therapy is based on a set of assumptions about what is important. These assumptions manifest in the case conceptualization. For example, a therapy such as Psychoanalysis, based on a developmental stage model, will seek to address developmental arrests. A relational therapy such as Gestalt Therapy will seek to improve the relational skills of the client – the ability to create and experience contact in Gestalt terms. CBT seeks to correct cognitive distortions that affect the emotional functioning and behaviour of the individual and might consider factors such as “schema interference” that would not figure in conceptualizations based on other therapeutic models. Bound up in the theoretical orientation are other fundamental premises that become reflected in how a case is conceptualized:
- CC is a solution-focused notion that fits in the medical model. CC can be 'diagnosis lite.' Not all therapies embrace this view of the nature and purpose of psychotherapy. Gestalt therapy in its purest form, for example, regards the client's concerns and blocks as emergent. The client is not treated according to some assessment or diagnosis conceived by the therapist in the early stages of therapy.
- notions of where the 'neurosis' is held: in the body (Maté, 2004) as reflected in Reichian (Totton & Edmondson, 2009) and other somatic therapies and those that focus on energetics
- the definition of healthy or wellness inherent in the therapist's theoretical orientation
- the influence of culture as part of the individual's field (Lewin, 1952), lived experience, meaning making, imposed identities or identifications as reflected in an existential stance (e.g., Yalom, 1980) or an anti-oppression orientation (e.g., Aguinaldo, 2008)
type of therapy (brief/depth): Clearly conceptualizing a case is limited by the amount of data that can be collected. If the therapy is single session as in a drop in centre, the presenting data is shallow and may be the only basis for conceptualization other than the therapist's intuition and professional acumen. Also elaborate conceptualizations have questionable utility of the therapy is going to be of short duration.
therapeutic method, not to be confused with theoretical orientation: to paraphrase, If all you have time for is a hammer, every problem is a nail. These days due to heavy case loads most psychiatrists reach for the prescription pad. If you cannot prescribe medication, medication will only be part of your treatment plan if a prescribing physician is part of the treatment team. Without these medical resources, case conceptualization will be limited to psychodynamic, cognitive and behavioural elements. If you are an ardent CBT practitioner, the whole person may not figure as large in the conceptualization; body language may be noticed and conclusions drawn about it, but interventions are not likely to begin with the body as movement-based therapists would. A Reichian practitioner would begin with somatic energy blocks.
presence of medical issues, addictions, trauma, pervasive disorders, psychosis. The DSM IV-TR multi-axial system is one way or organizing this set of criteria into an efficient heuristic or checklist:
- Axis I: All diagnostic categories except mental retardation and personality disorder
- Axis II: Personality disorders and mental retardation (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)
- Axis III: General medical condition; acute medical conditions and physical disorders
- Axis IV: Psychosocial and environmental factors contributing to the disorder
Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia.
Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.
CC is not without limitations and drawbacks. The above factors influencing how a case is conceptualized are also potential limitations:
- within the therapist's paradigm of practice, a blindered view of the case is a considerable risk
- inherently a CC is imposed on the therapeutic relationship and fosters hierarchy in the relationship
- if the CC is not allowed to evolve over the course of therapy, it may become out-dated, and the therapy is at risk of becoming sterile, non-organic and irrelevant. Even if the CC evolves, it remains narrowing, though some may think of this as 'focusing.' This focusing can either help or hinder the therapeutic process by either making more figural those aspects that are truly influential or alternatively limit content and vocabulary or and narrowing perspective.
CAN WE DO BETTER? BEGINNING CONSIDERATION OF A TRANSCENDENT VIEW OF CC
A case conceptualization is a snap-shot of the client from the perspective of a therapist or treatment team. Even if it evolves and is rethought from time to time, we still will have only a set of snap-shots that are static rather than process-based and not matrixed in the larger context of the client's experience which includes the therapy itself. Some criteria for next generation CC that is less susceptible to the above noted limitations might include:
- shift toward a process orientation: patterns and dynamics versus labels and static facts
- added focus on relationality: include the impact of therapeutic relationship, by abandoning the car mechanic model of therapy and recognizing that the therapist is person, not just a technical resource, in the client's social matrix, notwithstanding all the tried and true wisdom concerning the maintenance of professional boundaries.
- more openness to cross-disciplinary integration by including professionals using other modalities or disciplines:
- know when to bring other practitioners onto the team. Psychotherapy does not address everything that may be contributing to the client's presenting concern and we do the client a disservice trying to make therapy into a panacea.
- special focus: explore (with the assistance of other practitioners if necessary) the important role of food and diet
- know when the client's problem does not fit within the therapists frame of reference: recognizing when the limits of one's training and expertise have been reached
integration the influence of culture, including religion, ceremony and ritual
shift the professional attitude of the CC as a plan (somewhere the therapist is taking the client) to a biography (therapist as more respectful observer or co-traveller)
Aguinaldo, J. P. (2008) "The social construction of gay oppression as a determinant of gay men's health: homophobia is killing us." Critical Public Health, 18(1), pp.87-96.
Lewin, K. (1952) Field Theory in Social Science. London: Tavistock.
Maté, G. (2004) When the Body Says No. Toronto: Knopf/Vintage.
Padesky, C. & Greenberger, D. (1995) Clinician's Guide to Mind Over Mood. New York: Guilford.
Totton, N., & Edmondson, E. (2009 ) Reichian Growth Work: Melting the blocks to life and love. London: PCCS Books.
Yalom, I. (1980) Existential Psychotherapy. New York: Basic Books.