Cognitive Case Conceptualization

A Guidebook for Practitioners

Lawrence D. Needleman

• Publisher: Routledge
• Year: 1999
• eBook ISBN: 9781135692667
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

For cognitive therapy to be successful, therapists must identify the key factors that contribute to their clients' problems. Effective cognitive case conceptualization necessarily precedes appropriate targeting and intervention selection. It requires the integration of the results of a comprehensive assessment into a strong conceptual foundation.

Solidly grounded in recent research, and focusing particular attention on important new theoretical developments, this book first offers a comprehensive overview of the contemporary cognitive model of therapy. It then lays out detailed, easy-to-follow procedures for assessing within a cognitive framework, developing effective individualized cognitive case conceptualizations, and implementing state-of-the-art interventions based on them. A step-by-step guide for concisely summarizing and representing the salient features of a client's presentation is included. Extensive case histories bring to life the entire process of cognitive therapy--assessment, conceptualization, and intervention--for several clients with a variety of complex clinical problems: panic disorder with agoraphobia, obsessive-compulsive disorder, and chronic or recurrent major depressive disorder.

Cognitive Case Conceptualization will become an indispensable desk reference for many experienced clinicians as well as trainees.

1

Introduction to Case Conceptualization

1.	How Case Conceptualizations Facilitate Successful Treatment
	a.	Conceptualizations Guide Selection of Interventions
	b.	Conceptualizations Facilitate Intervention Implementation
		i.	Conceptualizations Help Clients Understand Their Problems and Rationales for Interventions
		ii.	Conceptualizations Help Therapists Predict Potential Obstacles to Treatment
		iii.	Conceptualizations Help Clients Increase Their Motivation
		iv.	Conceptualizations Help Therapists and Clients Establish an Effective Therapeutic Relationship
	c.	The Conceptualization Process Can Help Therapists Further Their Understanding of Psychopathology
	d.	The Conceptualization Process Can Help Scientist-Practitioners Develop Relevant Research Questions
2.	Guidelines for Developing Case Conceptualizations
	a.	Format of the Case Conceptualization
		i.	Identifying Information, Presenting Problem, and Precipitants of the Presenting Problem
		ii.	Exhaustive List of Problems, Issues, and Therapy-Relevant Behaviors
		iii.	Relevant Beliefs
		iv.	Origins of Core Beliefs
		v.	Vicious Cycles/Maintaining Factors
		vi.	Treatment Goals, Possible Obstacles to Treatment, and Treatment Plan
	b.	Therapist’s Perspective on Modifying the Conceptualization
	c.	Client–Therapist Collaboration as Part of the Conceptualization Process
	d.	Potential Threats to the Accuracy of Clinical Data
3.	An Example of a Case Conceptualization Illustration
4.	An Example of a Completed Case Conceptualization Summary Form
5.	How This Book Is Organized

In brief, cognitive case conceptualization refers to the process of developing a parsimonious understanding of clients and their problems that guides effective and efficient treatment (Sacco & Beck, 1995). When developing a case conceptualization of a client, the therapist incorporates the following elements from the cognitive model:

1. the integrated cognitive, affective, and behavioral responses to triggering circumstances;
2. the client’s underlying belief system that determines the client’s responses;
3. the circumstances that activate maladaptive responses;
4. the environment’s responses to the client’s behavior;
5. the negative events that precipitated the client’s problems; and
6. the learning history that contributed to the client’s vulnerability to specific problems (Beck, Freeman, et al., 1990; Persons, 1989; Sacco & Beck, 1995).

To maximize a conceptualization’s usefulness, therapists should attempt to find the fewest number of underlying beliefs and processes that can comprehensively explain the client’s behavior and problems (Persons, 1989). By linking together relevant elements of the clinical material, conceptualizations enable therapists and clients to see the “big picture.” Drawing an illustration that links various elements of the conceptualization and writing a summary of the relevant elements are invaluable methods for illuminating important connections. Without using these tools, therapists are more likely to miss some of these connections. Thus, case conceptualizations help therapists think about clients’ problems clearly and efficiently.

When therapists develop individualized case conceptualizations, they integrate information from three sources. These sources are (a) knowledge of the intricacies of the cognitive model (see chap. 2), (b) a comprehensive assessment of the client (see chap. 4), and (c) research and theoretical literature related to the client’s problems.

First this chapter describes how case conceptualizations facilitate the selection and effective implementation of interventions. Next, it presents guidelines for developing conceptualizations. Finally, it presents examples of conceptualizations.

How Case Conceptualizations Facilitate Successful Treatment

An accurate conceptualization of the mechanisms that determine the client’s problematic responses allows the therapist to predict the client’s behavior and responses to interventions. By helping therapists make accurate predictions, conceptualizations facilitate successful treatment. Most important, for our purposes here, the conceptualization process guides therapists’ selection and implementation of cost-effective interventions. However, the case conceptualization process also can help therapists further their understanding of psychopathology and can help scientist-practitioners develop relevant research questions that may lead to advances in clinical psychology.

Conceptualizations Guide Selection of Interventions

Beck, Emery, and Greenberg (1985) suggested that case conceptualization involves placing a psychological problem in its context. Understanding the context in which a problem arises permits appropriate selection of interventions. Although novice therapists may be aware of many techniques for addressing a particular clinical problem, they often choose inappropriate approaches. This results from failing to have a clear understanding of the underlying mechanisms that produced the problem.

Consider several individuals who had a common overt problem, chronic difficulties completing tasks in a timely manner. The first client, Latoya, believed, “Everything I do must be perfect.” When she worked on projects, this belief resulted in anxiety, urges to check her work for errors, and repeated, overt checking behavior. Her repeated checking dramatically slowed her performance. Another individual with difficulties completing tasks was Byron. He held the belief, “I shouldn’t have to do mundane tasks.” He felt angry when people asked him to complete tasks. When they did, he had an urge to angrily refuse the request. However, this urge was tempered by his belief that he would be punished if he expressed his anger directly. As a result, he worked on projects, albeit slowly and carelessly. A third individual, Ava, believed, “I can’t do anything right; I’ll probably mess up.” She felt anxious and had urges to escape. She avoided attempting tasks by feigning physical illness. A fourth individual, Jim, was depressed, had little energy, and believed, “Nothing really matters.” When required to do a task, he wondered, “Why bother?” and did not attempt it. Clearly, understanding the idiosyncratic mechanisms responsible for a problematic response is necessary for selecting appropriate intervention strategies for the individual.

It should be noted that cognitive case conceptualizations are useful despite the availability of effective cognitive-behavioral treatment approaches for various disorders. Outcome studies have found that disorder-specific cognitive therapy approaches have been effective for several disorders. These include depression (Beck, Rush, Shaw, & Emery, 1979), panic disorder (Beck, Sokol, Clark, Berchick, & Wright, 1992; Clark, 1986; Clark et al., 1994; Sokol, Beck, Greenberg, Wright, & Berchick, 1989), agoraphobia (Hoffart, 1995; Marchione, Michelson, Greenwald, & Dancu, 1987; Sharp & Power, 1996), obsessive-compulsive disorder (Freeston, Rhéaume, & Ladouceur, 1996; Salkovskis, 1985, 1989, 1996; Salkovskis & Kirk, 1989; Steketee & Foa, 1985; Steketee & Shapiro, 1993; Turner & Beidel, 1988; van Oppen & Arntz, 1993), social phobia (Chambless & Hope, 1996), and bulimia nervosa (Fairburn, Marcus, & Wilson, 1993). Then, why bother developing individualized case conceptualizations for clients with these disorders?

There are several compelling reasons for doing so. First, even for clients with disorders for which effective interventions are available, successful implementation of treatment packages depends on the therapist’s having an accurate understanding of the client’s idiosyncratic cognitive, affective, motivational, and behavioral responses (Layden, Newman, Freeman, & Morse, 1993).

Consider how the treatment approach for panic disorder was tailored to two clients having this disorder. During his panic attacks, Jeff focused on feelings of dizziness and unreality and had the catastrophic cognition that he would lose control and “go crazy.” To prevent himself from going crazy during attacks, he typically touched the ground to literally “feel grounded and make sure everything is still real.” In contrast, Janie focused on her chest pain during her panic attacks and believed that she would have a heart attack and die. She believed the reason she had not actually had a heart attack was that she always lay down and tried to relax when she had panic attacks. Both clients received the same treatment components—cognitive restructuring, paced breathing, relaxation training, procedures for refocusing attention, and intentional exposure to the sensations of panic (see chap. 6 for a detailed description of the procedures for treating panic disorder). However, their treatment was individualized based on idiosyncratic features of their case conceptualizations.

For Jeff, cognitive restructuring targeted his belief that he was at risk for going crazy when he experienced panic attacks. Resulting from guided discovery (see chap. 3), Jeff generated compelling evidence that he was not in danger of going crazy (e.g., despite having hundreds of panic attacks, he never had hallucinations or delusions or exhibited grossly inappropriate behaviors; he had no family history of psychosis or mania). The therapist recorded the reasons on an index card that Jeff referred to during attacks. Regarding exposure to panic sensations, Jeff was exposed to dizziness by spinning around in a swivel chair and hyperventilating. He was not allowed to “ground” himself during these therapist-induced “attacks.” The purpose was to teach him that even when pushed to the limit, he would not lose control and go crazy.

Based on Janie’s cognitive case conceptualization, cognitive restructuring focused on her catastrophic belief that she was having a heart attack. To expose her to sensations of panic so that she could understand that her fear was unfounded, her therapist had her exercise vigorously during the therapy session. Janie was discouraged from resting and in fact was urged to exercise beyond the point at which she believed she must stop. (These procedures were cleared with her cardiologist first.) Frequently repeating...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of Cases
• Foreword
• Acknowledgments
• 1. Introduction to Case Conceptualization
• 2. The Cognitive Model
• 3. The Therapeutic Relationship
• 4. Assessment and Information Integration
• 5. Cognitive Therapy Interventions
• 6. Panic Disorder (PD) With Agoraphobia
• 7. Obsessive-Compulsive Disorder (OCD)
• 8. Chronic or Recurrent Major Depressive Disorder
• Appendix: Blank Forms
• References
• Author Index
• Subject Index