L4: Case Conceptualization

Question 1

What is case conceptualization?

Answer 1

• a process
• for developing a hypothesis about,
• and a plan to address, (that is testable)
• the causes, preciptants, and maintaining influences of
• a person’s psychological, interpersonal, and behavioural problems
• in the context of that individual’s culture and environment

Question 2

What are the process and content aspects of case conceptualization?

Answer 2

• process aspects= refer to the therapists activities involved in elicitng the info necessary to formulate CC
• content aspects= refer to the problems identified, the diagnosis, the explanation of the problem, and the treatment

Question 3

What are event formulations and prototype formulations and how are they different from case formulations?

Answer 3

event formulation: seeks to explain a particular episode or event in therapy, not the entire treatment. its the therapist’s attempt in trreatment to understand unfolding events. ideally, it fits w the case formulation, is guided by it, and either confirms or disconfirms it.
prototype formulation: based on a theoretical conception of that disorder. can serve as starting point for an individual case formulation

Question 4

Why do we do case conceptualization? according to lecture

Answer 4

• taxonomy (DSM or HiTOP) is only descriptive not explanatory
• we need to take personal context, dev, and goals into account
• personal narratives & personal ideas on recovery are also not enough, we need to apply our general theories & scientific knowledge as experts
• we need to apply this knowledge to the specific case, and for this we need a good working theory and rationale in support of the “common factors” that are crucial in promoting good treatment outcome
• its a great tool to develop our clinical thinking & for supervision

Question 5

What are the 4 reasons why we do case conceptualization according to the book?

Answer 5

1. it guides treatment by helping therapist stay on track from one session to next, monitor progress, and notice changes in direction. its an overaching perspective of the treatment, a clear plan.
2. it increases treatment efficiency: because of this cldear plan, a time effective, evidence based route can be developed from start to finish
3. it tailors treatment to the specific circumstances a client is facing
4. it enhances therapist empathy, which contributes to treatment outcome

Question 6

How do we do case conceptualization?

What is it, and what is it not

Answer 6

not
- list of simple, certain, objective facts
- list of speculative, very unlikely, purely subjective hypotheses
what it is:
- working hypotheses developed in collaboration between therapist & client
- ask yourself: are the hypotheses credible enough? are they acceptable for the client? are they useful for treatment?
- sources for constructing hypotheses: theories & research, client experience & narrative, clinical experience of therapist

Question 7

What scientific knowledge do we have for creating valid conceptualizations?

Answer 7

• diathesis stress model (strong evidence)
• evidence based treatments (like cbt, exposure therapy, etc) (one isnt superior to another usually, and effects differ per person)
• “common factors” that influence treatment outcomes (strong evidence)
• theories (mostly partial evidence, but they help us dev ideas about the maintaining factors) & proposed mechanisms

Question 8

Describe the diasthesis-stress model?

Answer 8

heritable predispositions aka diasthesis (genotype, temperament) + early experiences aka stress (nurture, care, trauma, deprviation) -> strengths & vulnerabilities (schemas, attachment style, personality etc) -> support and stress (social, medication, thearpy etc) -> complaints & symptoms

Question 9

What are the common factors in thearpy?

Answer 9

• therapeutic alliance
• collaboration
• goal consensus (agreeing on a goal during conceptualization)
• adapting treatment to specific client characteristics
• empathy
• promoting treatment credibility
  etc

Question 10

How can we use the knowledge on common factors in case conceptualization?

Answer 10

• adapt CC to specific client needs & characteristics
• develop person-specific rational why certain therapy fits & works
• use validation & empathy
• take care of indications for alliance rupture
• create shared ground for setting goals
• create a starting point for adequate collaboration
  etc

Question 11

what are the 3 main sources of information for case conceptualization?

Answer 11

1. theory
2. evidence
3. expert practice

Question 12

How did case conceptualization come about?

History

Answer 12

• rooted in Hippocratic & Galenic medicine: viewed individual as a whole when diagnosing & encouraged clients participation in cure, as well as using reason & observation
• similarly case conceptualization depends on observation, holistic perspective, and considers a lot of context

Question 13

What 4 contemporary developments in psychology have influenced psychotherapy case conceptualization?

Answer 13

• conceptions of the nature and classification of psychopathology
• theories of psychotherapy
• the psychometric tradition
• the start of structured case formulation models

Question 14

How have the conceptions of the nature and classification of psychopathology influenced psych case conceptualizations?

Answer 14

• psychopathology is the content of case formulation
• so to make case formulations we need to define & classify psychopathology and thus define what is abnormal (socially constructed task but some common criteria are personal distress, behaviour that causes distress in others, personality inflexibility etc)
• these definitions & classifications are the reference point for understanding clients & generally formulating the case conceptualization
• DSM, ICD
• usually lacks either etiological models or descriptive models
• categorical or dimensional view on psychopathology influences your case conceptualization

Question 15

What is the categorical vs dimensional view on psychopathology?

Answer 15

• categorical: mental disorders are syndromal and qualitatively distinct from each other as well as from normal states. its the “medical model” view that assumes that all disorders have predictable causes, courses, and outcomes. dominant in the DSM & ICD. con: there are clients who do not meet the criteria but still meet some. pro: easier cause clinical decisions are often categorical in nature (treat or not, intervention a or b)
• dimensional: psychopathology lies along a set of continua from normal to abnormal. pro: reflects psychopathology as it exists in nature & dimensions can be measured more easily & capture more

Question 16

How have the theories of psychotherapy influenced psych case conceptualizations?

Answer 16

• a therapists theoretical orientation to psychotherapy provides a framework for explanation in case formulation
• behavioural: focus on symptoms & empiricism, reject case conceptualization
• psychodynamic: focus on the way the clients interpersonal & other issues outside of therapy may be enacted within therapy & general focus on unconsicous processes, defense mechanisms etc
• cognitive: focus on cognitive patterns, schemas, core beliefs etc specific to particular disorders
• humanistic & phenomonological: tend to reject case conceptualization, want to emphaize the person as w hole instead of a disorder, and sees therapist & client as equalts

Question 17

How has the psychometric tradition influenced psych case conceptualizations?

Answer 17

• psych testing involves a statistically informed frame of mind that is useful for case formulation (knowing about reliability, validity etc may improve quality of case conceptualization)
• but some ppl doubt its influence: they question whether psychotherapy & psychometric assessment are closely related

Question 18

How have the structured case formulation models influenced psych case conceptualizations?

Answer 18

• began in 1960s and 70s, ppl started making formal models for case conceptualization since ppl were inferring thing without actually observable proof for them, and many paradigms were disagreeing w each other
• theres many different ones, but they have in common: they identify prolems; infer maladaptive relationship transactions and concepts of self/others/the world; rely primarily on clinical observation; involve low level inference
• ex: the CCRT

Question 19

What is the CCRT?

Core Conflictual Relationship Theme

Answer 19

• aims to reliably & validly identify a clients central problematic relationship pattern
• focuses on narratives a client tells in therapy
• identifies 3 key components within those narratives: the individuals wishes, their expected responses of others, and their own responses to those expectaitions

Question 20

What are the 5 basic tensions inherent in case conceptualization?

Answer 20

1. immediacy - comprehensiveness: getting all the information vs using time wisely
2. complexity - simplicity: no need to get full complexity of case in the conceptualization vs enough complexity needed to serve goals of treatment
3. therapist bias - objectivity: impossible to be fully bias free vs but you need to try to manage it and maybe even use it to benefit therapy
4. observation - inference: theory free descriptive evidence gathered by careful watching & listening vs conclusion formed on the basis of observation. how much can you infer from observation without straying too far?
5. individual formulations - general formulations: focus on the individual and their context etc vs using the broad info about psychology & mental illness

Question 21

How is the case conceptualization model integrative?

Answer 21

• it is intended to apply to any theoretical apporach to psychotherapy
• it can be assimilated into different unitheoretical therapy modles
• it allows for different perspectives on therapy to be brought together into a coherent case formulation

Question 22

Why is it important that the case conceptualization model be integrative?

Answer 22

• an integrative orientation is widely prevalent among practising therapists (majority of therapists identify with more than one orietnation)
• allows therapist to tailor the therapy to the specific combination of problems a client brings
• meta-analyses show that no individual theoretical apporach consistently outperforms others. so what explains outcome are qualities shared by all forms of treatment (support, learning, and action or according to frank 4 different ones)

Question 23

What are, according to Frank, the 4 common factors in therapy that contribute to its outcome?

Answer 23

1. an emotionally charged & confiding relationship is developed between client & therapist
2. therapeutic relationship exists in a defined social context where theres clear roles to be played: client presents to therspist who client believes can help them. amoutn of sessions, time, price etc is all predetermined
3. a credible & persuasive account of the reasons for the clients symptoms & problems is collaboratively accepted by the client & therapist & a way to treat these problems
4. active participation of both client & thearpist

Question 24

Describe the Integrative, Evidence-Based, Case-Formulation-Guided, Psychotherapy

Answer 24

1. gather info
2. formulate conceptualization
   a. create problem list
   b. diagnose
   c. develop explanatory hypothesis
   d. plan treatment
3. treat
4. termination

at the same time monitoring of the progress is constantly happening
all these steps are closely intertwined and not sequentail as presented here

Question 25

Describe Step 2 of the integrative, evidence based, case formulation guided psychotherapy

Formulating conceptualization

Answer 25

1. create a problems list (including red flags (chemical dependence, domestic violence, suicidality, homicidality, neglect) and funciioning of self/interpersonal contact/ and social contact)
2. diagnose
3. develop an explanatory hypothesis: take the info gathered & use available empirical resources, theory, and clinical expertise (including cultural competency) to offer the best account of what is causing, maintaining, and precipitating (aka inducing) the problems.
   sources: evidence & theory; components: precipitants (inducing), origins (predisposing), resources (clients strenghts), and obstacles (clients obstacles that may interfere w treatment)
4. plan treatment: operationalize the explanatory hypothesis into a sequence of steps designed to guide treatment & resolve problems (may include set point considerations (reactance, preferences, culture, readiness), goal identification (process/outcome goals, short/long term goals) and plan interventions)

Question 26

Describe Step 1 of the integrative, evidence based, case formulation guided psychotherapy

Gather Info

Answer 26

Gathering info
- primarily in intake interview but continues throughout and uses other measures like tests & seeing other ppl in the clients life
- use free form: follow the clietns stream of thought
need
- specific categories of info like the complaint, psych/medical/family/developmental/social/education/work/legal history, mental status examination
- process info: how does the individual present themselves and how do you as a therapist experience them
- narrative info: descriptions of specific stories or episodes in their (social) life. can use the transactional “he-said-she-said” level of detail, or the chain analysis which esxamins moment to moment sequence of events and thoughts etc

Question 27

What is the difference between Step 2, Formulate, and Step 3, Treat in the I-EB-CFG-psychoterhapy model?

Answer 27

• treatment plan (formulate) is only a plan and will need to be changed and updated repeatedly (monitoring progress is essential for this)
• case formulation skills (formulate) are different from those involved in actually treating someone. its theory vs application
• treatment always involves a mix of theory/method & the personal contact with the client, so each treatment will be unique

Question 27

Describe the monitoring progress step of the integrative, evidence based, case formulation guided psychotherapy

Treat

Answer 27

• purpose: provide objective feedback so the therapist will know whether treatment is proceeding as planned or if updates are needed & tests the explanatory hypothesis
• should use objective measures
• enables therapist to test his/her outcomes against those in RCTs
• red flag issues like self harm should be monitored consistently
• improves outcomes
• but different aspects improve at different rateqs (first, symptoms improve, then social role functioning, then interpersonal functioning or according to another model: remoralization, symptom improvement, well-being improvement)