Instructor Commentary: Case Conceptualization

Instructor Commentary: Case Conceptualization

Sandra Collins

The purpose of this commentary is to provide a foundation for engaging in the process of case conceptualization throughout both GCAP 671 and GCAP 635. All of the skills, techniques, and strategiesin GCAP 671 and GCAP 635 function to support the overall counselling process of (a) understanding the client’s presenting concerns; (b) collaborating with the client to make meaning of their experiences; (c) coming to a shared understanding of both the problem and the client’s preferred outcomes; (d) setting relevant and appropriate goals for the counselling process; (e) collaborating to identify and implement appropriate change processes; and (f) evaluating progress toward, and celebrating attainment of, client’s preferred outcomes. However, it is easy to get lost in the treesand lose sight of the forest, as the client provides more information. Revising your evolving hypotheses and shared meanings related to case conceptualization throughout the counselling process is one way to ensure an intentional, collaborative, and outcomes-focused process.

Most clients come to counselling with a sense of their presenting concern(s). However, these presenting concerns are only a starting point for the dialogue between counsellor and client that results in culturally responsive, socially just, ethical, and effective case conceptualization and intervention planning. You may wonder why we spend a whole course (GCAP 671) getting to the place of being able to define a client’s problem and preferred outcomes. It is because there are many factors that influence client problems and many techniques and strategies that can enhance your ability to accurately conceptualize problems and preferred outcomes. Failure to take this time with a client can result in implementing an intervention that is either (a) unrelated to or inappropriate for the problem or (b) conceptually congruent with what the counsellor perceives as the problembut mismatched with the client’s perspective. The following quote from Sperry (2005) reinforces the importance of counsellor and client collaboration in case conceptualization:

Effective therapists are skilled at developing, eliciting, and negotiating case conceptualizations. Because meaning making and search for explanations characterize human persons it should not be surprising that clients develop their own “case conceptualizations.” While they may not consciously be aware of their conceptualizations, these conceptualizations are nevertheless powerfully operative in the treatment process. Effective therapists not only recognize the presence of these conceptualizations, but also elicit them, and then negotiate a common conceptualization with their clients. (p. 358).

One of the strengths of Paré’s (2013) text isthe emphasis on collaboration and co-construction of meaning between counsellor and client. As a result, the skills, techniques, and strategies presented foster a process of constructive collaboration on cased conceptualization. Paré promotes a client-focused process of case conceptualization in which the client’s values, perspectives, needs, desires, and preferences are centralized. Sperry (2005) contrasts this approach with both (a) symptom-focused models that reflect a more medical and diagnostic approach than is commonly used in counselling psychology or (b) theory-focused models in which the client’s presenting concerns are viewed through the lens of the counsellor’s particular theoretical orientation. One of the primary risks of a symptom-focused model is that it is very individualistic by nature and counsellors may fail to attend to the interpersonal, contextual, and systemic factors that impact client well being. Theory-focused models, on the other hand,may fall prey to the old adage when you have a hammer, everything looks like a nail.Parénotes “theory therefore strongly influences what we pay attention to, what we notice, and what we ignore” (p. 35). This doesn’t mean that theory is not important; it just means it takes a backseat to the co-creation of meaning with a particular client.Symptom-focused and certain theory-focused approaches to case conceptualization also tend to be founded in counsellor analysis of the question “Why did it happen” (Sperry, 2005). Thequestion above “How do the counsellor and client make meaning of what happened?” opens the door to a more holistic, client-centred, collaborative, and less diagnostic approach to case conceptualization.

Assuming a client-centred approach to case conceptualization influences not only our shared understanding of how we view client’s problems and preferred outcomes, it also influences howwe approach change. This does not mean that we should not pay attention to symptoms or ignore our theoretical knowledge; it simply means that we place each unique client in the foreground and actively negotiate shared understanding of problems, preferences, and change processes.

So, how do we actually engage in client-centred case conceptualization? What do we look for? What do we explore? What factors do we consider? How do we make sense of what we learn? How do we articulate this in a way that is meaningful to the client? There are numerous models of case conceptualization in the professional literature. They all rely on what Sperry (2005) refers to as some sort of pattern analysis, a way of integrating, synthesizing, and making sense of a wide range of information about the client, their presenting concerns, and the intrapersonal, interpersonal, contextual, and systemic influences on the problem. The problem with many of these models is that they cannot escape their theoretical origins, and they therefore shine the lens on certain elements of client experience and fail to attend to others.

One of the most common frameworks for pattern analysisis the A-B-C model that originated in behavioural psychology. Drawing on Cormier, Nurius, and Osborn (2013), it can be summarized as follows:

Antecedent / Events, contexts, experiences that occur immediately before a behaviour and are functionally related to that behaviour (e.g., increase or decrease the likelihood that the behaviour will occur).
Behaviour / Overt (actions, words, etc.) and covert (thoughts, emotions, etc.) either isolated or clustered together that reflect a response to the antecedent.
Consequences / Intrapersonal, interpersonal, or contextual events that serve to either increase or decrease the likelihood that the behaviour will recur.

The A-B-C model is an example of a theory-focused case conceptualization model. As you discovered in GCAP 631: Models of Counselling and Client Change, other theoretical orientations will have similar causal or at least explanatory models about how to understand the patterns in client experiences. Cormier, Nurius, and Osborn (2013) expanded on this model in their ABC and Person-in-Environment model adapted below.This model moves beyond a strictly behavioural focus to include other aspects of client experience: affective, somatic, and cognitive. They also reinforce the importance of the interpersonal, contextual, and systemic influences, which are highlighted by Paré(2013).

Cast a critical lens on this model, based on your reading of the first two chapters of Paré (2013) and the Culture-infused counselling model of Collins and Arthur (2015). What are the strengths and weaknesses? What is missing in terms of fully understanding human experience? What explanatory factors are not fully accounted for? What theoretical assumptions are embedded in the model?

Person (Individual)
What? / Environment (Systemic) Where? How?
Affective / Somatic / Behavioural / Cognitive / Contextual / Relational
Antecedent
Behaviour
Consequences

One of the major flaws in this model is that it assumes a particular causal view of client experiences that may or may not be a fit with the cultural identities of the client, presenting with a specific concern, within a unique sociocultural context. The process of multicultural case conceptualization, emphasized throughout this program, requires us to step outside the fundamental assumption of most models of counselling that the problem resides within the client. It necessitates a broader scope of assessment, opens the door to more possibilities for defining client problems and preferences, and invites consideration of different levels of intervention. Consider, for example a client who presents with depression. A symptom-focused approach might result in a prescription for anti-depressants; a theory-driven approach might favour changes to self-talk. A client-centred approach, however, invites curiosity about other interpersonal, contextual, and systemic factors (e.g., the death of family member, harassment at work, systemic barriers related to cultural identities). A culture-infused and socially just approach to case conceptualization also prioritizes the client’s unique and/or culturally embedded explanation of their lived experiences. Although they may not be able to fully articulate the meaning of their experiences at the outset of counselling, the process of constructive collaboration provides a means for the clients’ own case conceptualization to emerge.

The process of collaborative, culturally responsive, and socially just case conceptualization can be facilitated in a number of different ways. There is a movement in the current counselling literature away from more linear (causal) models to more holistic and flexible models that can be tailored to each individual client and counsellor. In GCAP 671, you will use the process of concept mapping to make meaning of the ethic of care as a relational process in one of your course assignments. Liese and Esterline (2015) introduced concept mapping as a supervision strategy to enhance case conceptualization for novice counsellors. You may want to have a look at the example they provide of a concept map. A similar diagrammatic approach to case conceptualization is illustrated by Passmore and Oades (2015). Shiflett andRemley (2014) explored various forms of art-based case conceptualization to enhance pattern analysis by counselling supervisees. A more detailed case conceptualization is illustrated in the chalkboard case conceptualization model of Ellis, Hutman, and Deihl (2013). What all of these examples of case conceptualization have in common is that they are unique to the individual client and reflect the client’s specific issues, experiences, strengths, challenges, identities, and contexts.I often engage my clients in collaborative activities as a process a case conceptualization – we draw diagrams, list issues/factors on sticky tabs and organize them on my office wall, write poetry or stories, or other creative forms of making sense of their experiences.

Begin to consider the factors and the relationships among factors that you see as important to case conceptualization. Returning to the original questions as a potential starting point, I invite you to begin to build your own conceptual framework for making meaning related to the stories you engage in with your clients. Remember to ask yourself:

What is the presenting concern?
How do the counsellor and client make meaning of what the presenting concern?
How would the client like things to be different?
How can things be changed?

References

Note I have made the main part of the references belowlink directly to the article in the AU library. The new APA format for doi’s takes you to the Internet location for these articles.

Ellis, M. V., Hutman, H., & Deihl, L. M. (2013). Chalkboard case conceptualization: A method for integrating clinical data. Training And Education In Professional Psychology, 7(4), 246-256.

Liese, B. S., & Esterline, K. M. (2015). Concept mapping: A supervision strategy for introducing case conceptualization skills to novice therapists. Psychotherapy, 53(2), 190-194.

Paré, D. A. (2013b). The practice of collaborative counseling & psychotherapy: Developing skills in culturally mindful helping. Thousand Oaks, CA: Sage.

Passmore, J., & Oades, L. G. (2015). Positive psychology techniques - Positive case conceptualisation. Coaching Psychologist, 11(1), 43-45. Retrieved from

Shiflett, C. L., & Remley, T. P. (2014). Incorporating Case Conceptualization Drawing in Counselor Group Supervision: A Grounded Theory Study. Journal Of Creativity In Mental Health, 9(1), 33-52.

Sperry, L. (2005). Case conceptualization: A strategy for incorporating individual, couple and family dynamics into the treatment process. The American Journal of Family Therapy, 33, 353-364.