Case Conceptualization
(Definition)
- A Case Conceptualization is an explanatory hypothesis for understanding a patient’s problematic feelings, thoughts and/or actions, grounded in a specific psychological model or theory.
- Such models include:
- Cognitive-Behavioral
- Family Systems
- Interpersonal
- Psychodynamic
Case Conceptualization
(what does it do…why do it)
- A way to organize and integrate client material in a meaningful story.
- Helps the therapist make sense of the patient’s symptoms/difficulties
- Helps the therapists understand the forces shaping the patient’s experience
- Helps the therapist develop a treatment plan
Case Conceptualization
(Components)
- Identify the patient’s symptoms and problems
- Identify the precipitating stressors or events
- Identify the predisposing life events or stressors
- Develop an hypothesis that explains why the patient’s problems developed, and what maintains them, based on the data above
Case Conceptualization
(factors)
(name them)
- Predisposing factors
- Precipitating factors
- Perpetuating factors
- Protective factors
Predisposing factors
risk factors in the individual’s history and their respective hypothesized effects that have produced an increased vulnerability or proclivity to developing problems, difficulties, and/or symptoms.
Precipitating factors
Circumstances/events that triggered the onset of the current problems for which for which the client is seeking treatment and/or that increased the severity of preexisting problems to a clinically significant level
Perpetuating factors
Presently-operating factors that are maintaining the current problem(s), thus causing them to persist.
Protective factors
The client’s strengths, resources, and assets that can moderate his or her problems and assist in treatment.
Three Step Process
(name them)
- DESCRIBE
- Review
- LINK
Three Step Process
(DESCRIBE)
the patient’s presenting problems and patterns
Three Step Process
(LINK)
the problems and patterns to the history using organizing ideas
Psychodynamic
Case Conceptualization
- Includes
- Ideas (aka hypotheses) about how unconscious thoughts and feelings might affect patients’ problems
- Ideas (aka hypotheses) about how those unconscious thoughts and feelings might have developed, and how it might be that they are maintained
Case Conceptualization
(parts)
- Part 1: Summarizing Statement
- Part 2: Description of Nondynamic Factors
- Part 3: Psychodynamic Explanation of Central Conflicts
- Core Psychodynamic Problem
- Childhood experience(s)
- Recent experience(s)
- Strengths
- Biological vulnerability
- Part 4: Predicting Responses to the Therapeutic Situation
- Prognosis
Case Conceptualization (Summers & Barber, 2010)
- Grounded in the patient’s history (historical timeline)
- Consider the following across the developmental trajectory
- Infancy, childhood, adolescence, adulthood, etc.
- Seminal life events (across developmental trajectory
- Key subjective experiences, psychiatric sxs
- Neurobiological factors, syndromal pathology
- Psychodynamic themes (drive, ego, object, self)
- Loss, dependency, gilt, conflict, separation, self-esteem, impulsivity, etc.
- Previous treatments and response
Components of a Psychoanalytic Case Conceptualization
- Fixed Attributes: Demographics, genetics, physical/medical illness, brain conditions, substances abuse, external circumstances, temperament, etc.
- Developmental Themes: Why this issue, now? Consider history, circumstances of the problem in the past; early childhood separations, losses, disruptions; school/work history; sexual history; whether problem indicates an unconscious conflict vs. developmental arrest; attachment style, etc.
- Defensive Pattern: Consider types/levels of defenses, whether characterological versus situational, etc.
- Affects: Consider appropriateness, range, intensity of affect, etc.
- Identifications: Consider [transference, introjection, intersubjective], cultural identity, etc.
- Relational Patterns: Consider the quality of the person’s relationships/intimate relationships
- Self-Esteem: Consider the stability/fragility of self-image, identity, etc.
- Pathogenic Beliefs: Can be approached in the framework of cognitive schemas; what are this person’s beliefs that are causing this person to suffer?
Consider Early Relational Experiences
- Repeated, “schemas” become templates for future relationships and behaviors
- Relational Schemas
- The person may identify with and take on any role in the system
- e.g., victim or aggressor
- Self-Schemas
- Self-soothing
- Impulse control
- Motivation
- Stability
Consider Domains of Personality Functioning
- Interpersonal relating
- Trust in benign motives and desires of others
- Realistic appraisals of others’ intentions/motivations
- Capacities to create positive, supportive, intimate interactions with others
- Capacities for empathy, perspective taking
- Capacities to see others and self as multidimensional and separate
- Capacities for flexibility and collaboration
- Self-functioning
- Coherent and realistically positive (and stable) sense of self
- Capacities for self-regulation/emotional regulation and coping, impulse control, and motivation
Treatment Focus
- Therapist and patient agree on the problem
- i.e., the patient’s needs and conflicts, that the patient can do something about
- Distinct from goal(s),which is/are what the patient wants to have happen
- Consider: not all goals are obvious, or even known
- p. 180, Danielle, who wanted “a life…advice, support and pushing to make it happen.” vs. fantasies about being a small child—”She mourned the difference between what she wanted and would always want, and what was more realistic and achievable”
Conscious vs Unconscious Goals
(quote)
“ A good psychotherapist must accept the patient where she is, respecting her stated goals, listening carefully for the unstated ones, and expect as much growth and change as possible” (p. 181).
Defining a Focus: Five Factors
- Formulation (or conceptualization)
- Wide v. narrow focus
- Ambition and motivation
- Level of the problem
- Intrapsychic/individual
- Relational/systemic
- Life cycle/developmental (through transitions, life stages)
- Adaptation to neurobiology (e.g., temperament, an “Axis I” disorder, etc.)
- Patient’s personality characteristics (and resources)
- Curiosity, intelligence, introspection, capacity for closeness
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Class 125
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Class 222
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Class 3: Object relations and Attachment theories38
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Class 4: Self Psychology and Relational and Interpersonal Theories33
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Class 5: Adlerian20
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Class 6: Short-term Psychodynamic Therapy and Models of Change and The Therapeutic Alliance12
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Class 7: Core Psychodynamic Problems26
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Class 8: Case Conceptualization20
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Class 9: just extra cpp of obsessionally7
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Class 10: The Therapist’s Experience21
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Class 11/12: Time-Limited Psychodynamic Psychotherapy22
