you need to be a good psychotherapy super sleuth because if you conceptualize the presenting symptoms erroneously then your treatment approach may take you and your client in the wrong direction. Being a good mental health super sleuth is the difference between being a mediocre (at best) and excellent therapist.
Written by Cathi Spooner, LCSW, RPR-S
Any really great therapist will tell you that one of the foundational elements of providing excellent psychotherapy to clients is …
… Clinical Case Conceptualization.
Are you having flashbacks to graduate school and rolling your eyes at me as you read this? Well, hang in there with me for a minute. I LOVE, LOVE, LOVE , LOVE clinical case conceptualization. It’s like being a psychotherapy detective aka – super sleuth. Yes, that’s my guilty pleasure – watching detective shows. I love a good “who dunnit.” As a psychotherapy super sleuth, you begin an “investigation” to figure out what is going on underneath those symptoms and how to help your clients get better.
Here’s why case conceptualization is the backbone… (full disclosure – I’m passionate about this because I see it go wrong so often) …
…it’s the way in which you conceptualize what’s going on with your clients and then formulate a plan to help your clients overcome the problem they were seeking you to help them resolve. The same is true for play therapy and expressive arts. How you conceptualize the presenting problem determines how you plan to help your client overcome it. So, you need to be a good psychotherapy super sleuth because if you conceptualize the presenting symptoms erroneously then your treatment approach may take you and your client in the wrong direction. Being a good mental health super sleuth is the difference between being a mediocre (at best) and an excellent therapist.
What is clinical case conceptualization?
It’s the way in which you conceptualize what the presenting symptoms mean and how you’ll treat those symptoms. Clinical case conceptualization helps you figure out your “road map” for treatment – aka your treatment plan. Your clinical case conceptualization is based on collecting information about the frequency, duration, and intensity of the presenting symptoms in order to identify a diagnosis (even a non-DSM diagnosis of the problem) which helps you identify what treatment modality to use and what type of interventions are needed. The way in which you conceptualize the presenting issues also helps you determine how you will pace the sessions, aka – the frequency of sessions. You’ll also identify who needs to participate in treatment and what you’ll address with parents/family members.
Tips for developing your clinical conceptualization
Gathering a thorough history using a psychosocial assessment as well as a genogram model provides the information needed to fully understand what are the factors contributing to the presenting issue as well as the extent of the problem. For example, is there a family history of trauma, attachment, addiction, and/or mental health problems? The longer the problems have existed typically means the issue is more entrenched systemically. Since child and adolescent therapists work with children it’s important to understand them within the context of family, school, social network, and culture. When you’re gathering information from parents/guardians, and when appropriate the child/adolescent, it’s important to gather information about the presenting symptoms frequency, duration, and severity. How often do the symptoms occur, how long does the problematic behavior last, and how severe are the symptoms? I often ask clients to rate the severity of the symptom using a Likert scale of 0- 10 with “0” meaning no problem to “10” as the most severe. Having my clients rate the severity of their problem gives me information to see the problem through their eyes to get a better sense of how parents/caregivers and the child experience the problem. These are the “clues” I need for my “detective lens” that helps me better identify what’s going on with my client.
It’s also very important to ask about the child’s developmental and school history because this information gives clues to help me identify a potential learning problem or other developmental delays that may be impacting symptoms. It also helps me to get a sense of my client’s ability to manage stressors during significant transitions, such as the transition to school for kindergarten, middle school, and high school. These are big transition periods and it’s important to get a sense of how your young clients adjust to changes in their life. For example, the transition from elementary school to middle and middle school to high school can be problematic, and gathering this information may provide clues as to when problems began to get worse. I typically ask parents/caregivers if their child’s behavior began to gradually and steadily get worse or if there was an event that seemed to have activated the problematic behavior.
Frequency, duration, and severity of symptoms
Using a really good genogram focus to gather information about family history and family relationships provides a framework for collecting information about the broader context of the presenting symptoms and identifying resiliency resources. This provides information about potential genetic predispositions such as ADHD, learning problems, depression, anxiety, trauma, addiction, and other significant mental health challenges like bipolar disorder. It’s important to also identify potential resources to support positive growth and resiliency. Gathering information about the quality of family relationship patterns helps provide clues about parenting abilities and attachment patterns. As child/adolescent therapists, part of our treatment focus is to help parents/caregivers develop skills for supporting their child long after treatment ends. We need to build therapeutic rapport with parents/caregivers. Gathering information about family history and relationship patterns gives me clues about the acuity level of the family system in which my young client lives. All of this information provides clues to help me identify the “roots” of the presenting symptoms and conceptualize the treatment plan needed to help my client overcome their challenges.
What happens if you miss key components because you are not gathering “clues”?
Your “roadmap” will likely go to the wrong “destination” or you may get lost in treatment if you don’t have enough information to fully understand what is underneath (roots) your client’s presenting problems. For example, if you don’t gather information about school performance and school transitions, then you may miss a potential learning disability that warrants further evaluation by a clinical psychologist. Undiagnosed learning problems can often manifest as defiance, depression, anxiety, and poor self-esteem that may later contribute to substance misuse and/or dropping out of school. Perhaps you’ve gathered information about a traumatic event your client experienced but you didn’t gather a thorough family history and/or information about generational family attachment patterns. Children heal best within the context of their relationships because they need their parents/caregivers to help them navigate their world and their emotions. So, why would we leave parents out of the treatment process since they’re a significant part of the solution? Gathering information about family history and family relationship patterns provides information about parent/caregiver capacity to be the support their child needs them to be, and what type of support and interventions are needed to help parents provide healthy support. It helps us to figure out if a parent/caregiver has the ability and capacity to be a healthy part of the child’s healing process. If we fail to accurately identify the “roots” of the problem and positive resources available, the interventions you choose may not be effective because you didn’t identify what are the potential “roots” of the problem and how to effectively address those “roots.”
Here’s the thing … we don’t always get it “right” in the beginning because our clients are complex and it may take time to fully understand what are the factors contributing to the presenting problems. However, we do need to make sure we have a mindset of “mental health super sleuth” so that we are regularly looking for clues to the problem so that we can use that information for our clinical decision-making process and adjust the treatment approach as needed throughout the treatment process. This is critical to effectively help our clients and their families overcome their challenges.
Here’s a recap:
· Clinical case conceptualization is the way in which you identify what are the roots of the symptoms and conceptualize what treatment approach is needed. It forms the basis for your treatment “roadmap.”
· Gathering a thorough psychosocial assessment helps you identify the “roots” of the symptom frequency, duration, and intensity as well as identifying the severity of the problem within the context of the child’s life.
· If you miss key components you’ll be trying to figure out why your client may not be making progress and your roadmap will miss the mark for its effectiveness.
· We don’t always get it “right” and we may need time to gather enough information as well get to know our clients and their family. The key is that we need to ensure we are using our mental health super sleuth “lens” so we can accurately identify the “roots” of the problem and figure out how we’re going to integrate parents/caregivers into the treatment process.