Case Conceptualization
The development of a case conceptualization is widely recognized to be a critical part of treatment planning in cognitive therapy (Persons, 1997, 2008). The development of a case formulation can be useful for
developing a case model to understand the patient and his or her behavior,
determining a priority sequence for solving problems,
predicting optimal treatment strategies and which interventions not to use,
developing the therapeutic relationship,
anticipating treatment outcomes and setting realistic change targets, and
understanding patient behavior over the course of therapy.
However, to be useful, a valid case conceptualization needs to meet several stringent criteria (Bieling & Kuyken, 2003). Specifically, it should have predictive validity, it should lead to improved outcomes relative to not having a conceptualization, it should improve the therapeutic alliance, and it should lead to enhanced treatment adherence by therapists. Research has not yet firmly concluded whether these criteria are met by most case conceptualizations (Kuyken, Fothergill, Musa, & Chadwick, 2005).
The heart of a case conceptualization is the description of the mechanism or mechanisms that the patient uses to create and maintain his or her problems. In this sense, a single patient may require distinct conceptualizations for the core beliefs that lie behind the problems that he or she presents in therapy. Since the cognitive model often involves a diathesis–stress process, in which the core beliefs represent the diathesis or vulnerability toward a problem and some life event or trigger is the stressor that precipitates the problems, the case formulation will usually delineate an interaction among one or more beliefs and one or more stressors. Once the process is begun, general behavioral strategies or behaviors such as avoidance may emerge, which in turn increase the likelihood of further stress, negative thinking, and the emotional and behavioral consequences of that negative thinking.
A case conceptualization can be diagrammed in a number of ways. The therapist can develop the first instance as a way to understand a new patient who is being evaluated. Over time, however, the patient is included in the development of the case formulation since he or she has information to elaborate certain elements or correct mistakes that the therapist may have made. As the case develops further, the therapist and patient together finalize the model and may develop experiments to gather information about less well-understood aspects of the case formulation.
A basic way to diagram the case conceptualization was presented in Figure 3.1. The bubble diagram is a concise form for sharing case conceptualizations and it is easily comprehended by most patients. It works best for single core beliefs. It does not present fully the process involved in most cases, as it does not include a space to conceptualize the developmental bases of the belief that is the focus of therapy. It also does not represent patterns of compensatory or maintenance behaviors that are employed by the patient to sustain his or her belief system. Thus, the bubble diagram may be more appropriate early in therapy, when the cognitive model is first described to the patient, then replaced with more elaborate models as the case develops.
Two other systems for case formulation have been widely promoted. Perhaps the best known was developed by Persons (Persons, 1989, 2008; Persons & Davidson, 2010). This formulation (see Figure 4.1) requires information about developmental considerations, current problems, core beliefs, stressors, the mechanisms that underlie the problems, and how these elements relate to each other. Case conceptualizations that use this model can include predictions about treatment goals, the strategies that seem to be indicated for the patient, planned techniques, and potential obstacles to treatment success.
