Case Conceptualization
Shawnna Franz
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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.
He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.
Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.
He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.
Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.
Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing.
Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.
Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.
The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.
Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.
Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.
On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.
Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.
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Integrating recent research and developments in the field, this revised second edition introduces an easy-to-master strategy for developing and writing culturally sensitive case conceptualizations and treatment plans.
Concrete guidelines and updated case material are provided for developing conceptualizations for the five most common therapy models: Cognitive-Behavioral Therapy (CBT), Psychodynamic, Biopsychosocial, Adlerian, and Acceptance and Commitment Therapy. The chapters also include specific exercises and activities for mastering case conceptualization and related competencies and skills. Also new to this edition is a chapter on couple and family case conceptualizations, and an emphasis throughout on trauma.
Case Conceptualization: A Biblical Wellness (B-Well) Approach is intended for students, counselors, counselor educators, and other helping professionals who desire to operate from wellness and a Christian worldview when conducting a clinical case conceptualization. This book seeks to offer the student, practitioner, and educator a coherent case conceptualization process by bridging the gap between wellness and a Christian worldview.
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Objective: This study aimed to investigate the relationship between therapist competence in case conceptualization and outcome in psychotherapy. Method: Twenty-eight adults received Cognitive Behavioral Therapy (CBT) for depression. The Conceptualization Rating Scale (CRS) was used to systematically evaluate therapist competence in case conceptualization using ratings from 225 DVD recordings of live therapy in real time across the first ten sessions of treatment. Results: Multilevel modelling (MLM) analysis revealed that after controlling for time and other pertinent therapy influencing variables, therapist competence in case conceptualization explained 40% of within patient variance and 19% of between patient variance associated with significant and positive change on the BDI-II. Conclusions: This study provided evidence that increased therapist competence in using case conceptualization in CBT is associated with greater reductions in depressive symptomology. The implications for supervision, training, and practice are discussed.
The purpose of the current article is to present two separate, yet interrelated behavior analytic conceptual analyses to (1) revisit social validity and propose features of socially meaningful case conceptualization, and (2) introduce a corresponding structured risk-driven approach to ABA service delivery. The primary goal is to equip all ABA clients and stakeholders with a readily accessible resource for maximizing individualized desired outcomes and minimizing risk (BACB, 2020). Potential contributions and limitations are discussed, including implications for future related research and practice.
Wolf (1978) greatly contributed to the available resources related to best practices for case conceptualization, but several potential limitations have since emerged. For example, Wolf defined social validity with respect to strengthening goal significance by way of establishing more robust acceptability and satisfaction measures at the level of procedures and outcomes. However, as indicated by Leaf et al. (2022a, b) we may now be facing relatively far more concerns regarding service goal selection. Wolf defined goal significance in accordance with societal-level norms without reference to (1) the individual (i.e., client/recipient of services) or (2) minimizing individualized risks to desired outcomes. Significant developments over the past several decades call into question the value associated in identifying risks with a strong focus on societal values (especially given how many views are now relatively far more diverse and often diametrically opposed). Further, the field of ABA is defined according to that which is currently considered to be socially meaningful for a given individual, their immediate circle of support, and the community at-large. As such practitioners are obligated to continuously revisit previously established standards and related practices to determine necessary adjustments.
Figure 1 depicts the primary phases of TheRDA in accordance with the traditional progression of ABA services for a given individual (i.e., from the point of referral and initial intake through service transition/discharge). Across all aspects of service delivery, TheRDA process involves collaboratively determining potential risks to accessing an improved QoL (i.e., desired ABA service outcomes), and when identified, when a given risk can be (1) resolved or (2) mitigated. If the desired outcomes require environmental changes and adjustments (i.e., procedural arrangements) that necessitate substantial behavior change, ABA service recommendations must be designed in accordance with maximizing desired outcomes by minimizing risk (BACB, 2020). As an alternative, if an immediate solution is identified (i.e., an environmental change or adjustment that requires minimal corresponding behavior change) that risk does not require the development of corresponding mitigation strategies, influencing the overall ABA treatment dosage recommendations.
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