**Discussion post of 350 words** Conceptualization skills provide the counselor with a rationale and a  framework for his or her work with clients, and with today's greater  focus on evidence-based pr

Case Conceptualization That Works

Introduction

As the prior chapters make clear, counseling is a complex process, requiring an understanding of professional identity and history, knowledge of theory and research, and certain skills and attributes. In turn, this understanding provides the lens we use to encounter our clients, and the template used to conceptualize clients’ challenges and strengths. Counseling is also an intentional and purposeful process, as the counselor helps a client move toward growth and change. Before a treatment plan can be developed and in order to guide the counseling process, the counselor must come to a deeper understanding of the client by gathering information and weaving all that they know about a client’s life and history together.

Case conceptualization is the process counselors use to understand the client’s symptoms, thoughts, emotions, behaviors, and personality constructs and to make sense of a client’s presenting problems. Effective case conceptualization entails thinking integratively, developing and testing hypotheses, and planning treatment based on those hypotheses. The model presented in this book (the Temporal/Contextual Model of case conceptualization, or T/C Model) is atheoretical, allowing students to incorporate constructs from various theoretical paradigms into their case conceptualizations. The model provides a framework or template for counselors to focus their observations and generate inferences about meaning.

In this chapter, we look at three components of the counseling process and how these components are integrated: diagnosis, where the counselor identifies and describes the client’s presenting problem and needs; case conceptualization, where the counselor comes to an understanding of the client’s needs and situation; and treatment planning, where the counselor develops strategies and interventions to address the client’s needs and move the client toward change. While we often think of diagnosis and case conceptualization as preceding treatment planning, in reality the three components may occur simultaneously as the counselor listens to the client and develops a deeper understanding of the client’s issues. Assessment and evaluation also occur throughout the process of counseling, and effective counselors are continuously hypothesizing and revising their understanding based on additional information.

Diagnosis and Problem Identification

In order to help a client, the counselor and client together need to define the problem that’s getting in the client’s way. While some clients come to counseling with an idea of the issue, others do not. Clients may feel down or have a vague sense that “something’s wrong” without a clear understanding of just what that signifies. The process of defining this problem is referred to as “diagnosis” in the medical and psychiatric professions. Depending on the setting where they practice, counselors may call this process diagnosis or problem identification. Because this text identifies problems based on the Diagnostic and Statistical Manual (DSM-5), we use the terms interchangeably. Even if a counselor is not practicing in a setting which requires a formal diagnosis, an understanding of the DSM codes is essential in order to collaborate with other helping professions and provide the best care.

The process of diagnosis is based on the client’s presenting problem—the reason the client provides for why he or she was referred or is seeking counseling from the viewpoint of the client. Problem identification addresses the basic question, “How does the client describe their problem?” The initial session with a client also includes a brief history of the problem and a description of attempted solutions and their outcomes. Sometimes a written or computer generated intake form is used to collect this information, or a symptom checklist is filled out by the client or counselor. A client interview then helps clients identify specific problems, as well as explore the onset, severity, and frequency of symptoms and whether the client has previously experienced similar symptoms.

For mental health professionals in the United States, diagnosis most often refers to the identification of symptoms using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). The DSM uses observable features to identify criteria for a wide variety of mental and emotional disorders, categorizing these based on symptom patterns. The DSM-5 is the most widely accepted diagnostic standard, although the World Health Organization’s International Classification of Diseases (ICD10) is also commonly used. The DSM-5 and ICD10 codes are often used together in practice. In this text, we concentrate on the DSM-5 system to categorize client issues.

The diagnostic formulation also allows the counselor to identify the most appropriate means of service delivery for the client. A client in crisis or who is suicidal may need to be hospitalized; a client with substance abuse issues may benefit from a drug and alcohol treatment facility; outpatient treatment may be most appropriate for other clients.

Based on the medical model which ties symptoms to an underlying physiological or biological problem, the DSM takes a categorical approach to understanding and treating mental health issues, as opposed to the more dimensional approach which counselors often use in understanding client problems. There remains some controversy about using a categorical approach which forces a dichotomy between health and pathology. Many counselors, reflecting the history and values of the profession, view wellness as a continuum with clients’ issues not fitting into rigid categories. The newest version of the DSM, published in 2013, moves in a more dimensional direction, attempting to build in some flexibility to the diagnostic categories.

While acknowledging the limitations of a categorical approach, nevertheless a diagnosis is crucial in order to communicate effectively with other mental health professionals, and provides a method for objectively describing a client’s presenting problems. Furthermore, integrating the categorical and dimensional approaches can help the counselor fully understand the nature of the client’s issues as well as the context within which the problems develop and are maintained, as we see in the next task, case conceptualization.

Clients may already have a diagnosis when they present for treatment; however, there may be other issues impacting the client and different clinicians may disagree about appropriate diagnoses. In later chapters, we discuss in more depth the diagnostic criteria for some of the issues most commonly encountered by counselors.

Case Conceptualization

As the counselor engages in a collaborative exploration with the client and identifies a diagnosis, the counselor begins to develop a framework to explain the etiology of the problem. How did the problem begin and what situational contexts contributed to its development? What is sustaining the problem? Conversely, what strengths and resources does the client have which can be mined to create hope and produce change? There are multiple lenses through which to conceptualize a case, and each individual counselor will use a different lens which emphasizes different aspects of the client’s life and history. Case conceptualization, therefore, is not an exact science nor is there one way to conceptualize a case. After all, counseling is an ongoing and continuously unfolding relationship with both the counselor and the client bringing to the table their own unique strengths and attributes. The effective counselor continually assesses their own effectiveness, and reviews the research on case conceptualization and intervention on a regular basis.

Seligman (2004) describes the case conceptualization process as allowing the counselor to more fully understand the client’s needs and situation and providing a “blueprint” for how to interact with, listen to, and help. An articulated model of case conceptualization is particularly important in today’s health care climate, which values efficient, cost effective, evidence-based treatment (Wampold, 2001). Case conceptualization has been identified as integral to quality and effective counseling (Sperry, 2010) and is considered a core competency for counselors (Betan & Binder, 2010). As we have seen, forming a therapeutic alliance with the client is a crucial skill; the alliance then informs and is part of the case conceptualization process. The trust and rapport established between counselor and client allows the client to be open to sharing critical information. The counselor then bases the conceptualization on this information, as we illustrate with the case of Katy in Chapter 1 and Chapter 2.

The way that a counselor conceptualizes a case influences the entire process of counseling—what questions to ask, how to interpret the answers, what hypotheses to develop, and how to test them. The case conceptualization tells the counselor where the client has been, and provides an understanding of where the client might be able to go. Neukrug and Schwitzer (2006) define case conceptualization as a tool for observing, understanding, and integrating a client’s thoughts, feelings, actions, and physiological status. They define three related processes: evaluation, organization, and orientation.

Evaluation

As the counselor begins to develop a case conceptualization, the counselor assesses and measures observable behaviors. These include the symptoms associated with the presenting problem. For example, a client experiencing anxiety may have difficulty sleeping, irrational fears associated with certain situations, or physiological symptoms, such as gastrointestinal problems or rapid heartbeat. Evaluation goes beyond the diagnosis of presenting symptoms to assess the client’s situational context. What is the client’s family context, work or school situation, interpersonal relationship status?

Specifically, the counselor working with Katy in the initial session observes her rapid speech and that she appears nervous, twisting her hands in her lap. Katy makes some eye contact with the counselor, but only sustains it for a moment before glancing away or down at her hands. The counselor takes note of her difficulties with sleeping, changes in appetite, anxiety attacks, depressed mood, and her risk-taking behavior. However, evaluation goes further. The counselor also takes into account the stress that Katy is currently experiencing, the reality of her conflicted relationships with her family and her boyfriend, the fact that she is in a time of developmental transition, and her confusion about selecting a career.

Sometimes evaluation is by informal interview; in other cases, formal measures and assessment instruments supplement the counselor-client conversation. Katy’s counselor might ask her to fill out a depression symptoms inventory, such as the Beck Depression Inventory, or might use a structured assessment of drug and alcohol use.

Background information gathered includes sex, race, ethnicity, age, socioeconomic status, medical history, prior mental health treatment, religious background and spirituality, sexual orientation, gender identity, family background, relationship history, marital status, educational background, employment data, substance use, peer relationships, trauma and abuse history, and physical appearance. Katy’s counselor already knows that she is the child of Korean immigrants, but will need to find out more about her cultural background, acculturation status, and family roles and values. As you can see from the description of background variables, there is a great deal of information that Katy’s counselor does not yet have about her client.

In addition, precipitating events that preceded the development of the client’s presenting problem, such as life transitions, recent losses, romantic breakups, job transitions, or developmental challenges, should be assessed. It is also important to assess suicidal ideation or experiences. Katy mentioned her boyfriend’s condition for staying in the relationship as dependent on Katy seeking counseling; her counselor will want to find out more about that relationship, as well as past romantic breakups. Katy’s parents’ divorce and her mother and stepfather’s conflict are possible past and current stressors that should be evaluated as well. An effective counselor will also take into account the client’s developmental stage and any recent transitions. As a young adult just out of college, Katy has just weathered a major transition and is facing another: finding a job. Developmental theory can be helpful in understanding the impact of such a transition on a 22-year-old young woman (Chickering & Reiser, 1969; Erikson, 1994).

The evaluation phase of case conceptualization also includes determining the client’s readiness for change. Has the client come in on his or her own, or is someone else in their life more motivated than they are to change? Has the client already spent time thinking about what changes might be beneficial, or even started to take small steps in that direction? Or is there still a great deal of ambivalence around the possibility of change, perhaps because the task seems overwhelming or the payoff is not yet clear? In Katy’s case, how much was counseling her idea, and how much was it to appease her boyfriend?

A variety of tests and assessment instruments can be used to amass client data. Behavioral and self-report questionnaires; intellectual, achievement, psychological, and personality tests; and medical, educational, and legal records are all sources of information. In addition, artwork, journals, poetry, songs, videos, and other creative works that clients produce can provide insight.

Box 3.1 provides an overview of a biopsychosocial assessment with some examples of areas to be assessed in particular domains.

While the evaluation process seems like merely a collection of facts, the way that counselors process and record the information has an impact on the subsequent phases of counseling (Anderson, 1997; O’Hanlon & Weiner-Davis, 1989). The counselor’s choice of words and the order of recording facts result in differences in meaning which then become part of the counselor’s conceptualization of the client. Since we know that hope and expectancy are related to client outcome (Lambert, 1992), it seems clear that when the counselor develops a positive conceptualization of the client from the start, the client is more likely as well to be hopeful about change. Therefore in this early phase of counseling, assessing and documenting the client’s strengths and resources should be a significant part of the evaluation; some researchers suggest that these should be at the top of the record, not near the end, because this creates a sense of optimism in the counselor. Describing the client’s abilities, successes, positive personal qualities, social and community supports, and spiritual resources can be a source of hope for both client and counselor.

As we saw in Chapter 1, Katy’s counselor has already begun to point out her strength and resilience, and to communicate that positive regard to Katy. As the evaluation process continues, the counselor’s evaluation of Katy’s challenges will be balanced against her strengths, providing a clearer and more hopeful picture of Katy the individual.

BOX 3.1 Biopsychosocial Assessment

table 6

Organization

The organization stage is the inferential phase of the case conceptualization process where the counselor organizes observations, measures, and assessments from the evaluation phase with the goal of making inferences and identifying themes or patterns. A case conceptualization provides an understanding of etiology as well as maintenance. How did the client’s problem develop, and how is the problem being sustained? The conceptualization provides a framework for how the counselor will engage the client throughout the counseling process, allowing the counselor to develop a theory of problem formation and resolution.

As we saw with the case of Katy, clients often arrive at their first counseling session with a great deal to say. They may have waited a long time to be heard, and thus may convey a lot of information in a short period of time. This can lead to a feeling of catharsis for the client, but the amount of information can also be overwhelming to both client and counselor. During this phase of conceptualization, the counselor begins to discriminate central information from peripheral information, and to focus the session on those areas which are connected to the client’s core issues. Clinical hypotheses are drawn from observations and assessments, and working models are generated of how the client’s problems developed and the mechanisms sustaining them (Stevens & Morris, 1995).

Case conceptualization calls for the counselor to identify themes in the client’s story, and to begin to make sense of the problematic patterns which the client is experiencing. The counselor develops hypotheses about what the client’s core issues might be, and then uses intentional questions and reflections to explore and clarify. These underlying concerns are often connected to multiple concerns and problem situations; the counselor gains leverage in focusing on core issues, more effectively helping the client. These patterns and themes then inform the client’s goals for change.

For example, as the counselor listens to Katy’s story in the initial session, she develops hypotheses about why Katy is currently feeling depressed and anxious. At first, the counselor might attribute Katy’s problems to the conflict in her relationship with her boyfriend. As she continues to listen, however, the counselor modifies that hypothesis as additional information is added to the conceptualization. Perhaps Katy’s depression is related to feelings of loss around her parents’ divorce. What role have her mother’s outbursts and disapproval played in Katy’s symptoms? How do her mother’s and father’s choice of career impact Katy’s current struggle to find her own profession?

In this phase of case conceptualization, the counselor pulls together the diverse threads of information obtained from the client and from assessment instruments and other sources into a coherent understanding of the client’s core issues, patterns, and life themes. For example, the counselor may ask questions about the first time and any subsequent times that a client noticed a particular symptom, and when (if ever) the symptom lessens. The counselor develops an explanation of when the client’s problem started, how it developed, what’s keeping it in place, and how the client is attempting to cope with the problem. Once all the information is integrated, a map of the client’s life story is created, which then guides action plans and goal setting. Having an articulated case conceptualization also helps the counselor anticipate and prepare the client for possible challenges and roadblocks to change (Sperry, 2010).

Concurrently, the counselor develops a cultural formulation of the client’s problem in order to understand how the client’s culture and broader sociological context impact the issues. An assessment of the client’s cultural context includes such diverse factors as gender, ethnicity, socioeconomic status, geographic region, sexual orientation, and many other elements that influence how a client views themselves and others. For example, poverty can be as influential in sustaining depression as irrational ways of thinking or a serotonin imbalance. Diversity often brings both challenges and resources that are necessarily reflected in the case conceptualization process. Marginalized groups can experience trauma and abuse; they may also develop strong and supportive social networks.

The counselor working with Katy will want to explore her family’s Korean heritage, including the impact of immigration on her parents, her relationship with extended family, and the norms and values that her family holds. For example, what are her family’s and her culture’s beliefs about gender roles or about adult children living with their parents? Because norms vary between cultures, they are important to understand as the counselor develops a case conceptualization.

In addition to the verbal content of the client’s story, counselors pay attention to tone of voice, changes in modulation and volume, rate of speech, and syntactic complexity (Stevens & Morris, 1995). Observation of nonverbal behavior also helps the counselor decide what is important and what is not—eye contact, body posture, facial expressions, gestures, and proxemics all convey information that add meaning to the client’s story.

Katy’s counselor will take note of how rapidly she’s speaking, her sporadic eye contact, and the way she clasps and unclasps her hands, as well as the way she constantly shifts position. During the case conceptualization process, the counselor makes meaning from all her observations. Perhaps she concludes that Katy is anxious, and that she may have a difficult time trusting the counselor. On the other hand, she seems eager to share her story, possibly because she doesn’t feel heard by the important people in her life. Would you agree with the counselor’s assessment? What are some other explanations for Katy’s presentation?

As the counselor considers observations and integrates information, insight into the client’s emotional experience emerges, further contributing to an understanding of problem areas. Specifically for clients who are cut off from their own emotional experience by trauma or ineffective coping strategies, and thus are less able to talk about their experience than Katy, counselors can use emotion checklists to help clients uncover and label their own emotions. However, even with a checklist the relationship between the client and the counselor allows the client to begin to share. As the counselor listens and validates what the client is expressing, trust builds, and the client becomes more comfortable sharing what he or she really feels.

As you will discover, the T/C Model facilitates the process of evaluation and organization, providing a clearly articulated framework to begin to understand the client’s context. The Model is also a reminder to the counselor of those domains which are important to assess, as some information may be left out of the client’s initial description or may get lost in the outpouring of information.

Another important source of information to include in the evaluation is the counselor’s own reactions to the client, which can be used to generate hypotheses about how others in the client’s life may react to them. The counselor’s emotional experience of the client may give support to particular hypotheses. For example, a counselor in a community mental health center met with a new client, a young man who is having trouble making friends at a community college. The client repeatedly stresses to the counselor that he is “too smart to be in a community college” and “doesn’t belong there.” The counselor finds himself thinking that the client isn’t very likable, and doesn’t seem all that intelligent either. A reflective counselor recognizes his own emotional reaction as information to include in the case conceptualization. If the counselor’s initial reaction was negative, perhaps that has been the reaction of the client’s new classmates too.

Awareness of this “parallel process,” where the experience of counselor and client in session mirror the client’s experience with others outside the session, is an important source of information (Ronnestad & Skovholt, 1993). Some training programs encourage students to characterize the nature of the counselor-client relationship in a metaphor (friend, parent, mentor, protector, etc.) in order to understand the relationship in a more useful way.

Orientation

Embedded within the case conceptualization process is the counselor’s understanding of how problems develop, how they are sustained over time, and what causes them to change. Counselors tend to develop a theoretical orientation over time, a collection of beliefs about what is needed to create change. Counselors use these assumptions as a frame for mapping problems and for interpreting what happens during a client session.

During the process of case conceptualization, the counselor uses a theoretical orientation to interpret and analyze the information gathered about the client, integrating their own observations with assumptions drawn from formal theories of counseling. While counselors’ intuition is a valuable asset in making inferences and generating hypotheses, nevertheless intuition must be grounded in empirically tested patterns of understanding (Hoshmand, 1991). Applying a theoretical framework allows the counselor to make sense of the factors that contributed to the development and maintenance of the client’s problem. The information which is most important to consider depends on the theoretical perspective selected.

In the previous chapter we briefly reviewed various theoretical approaches; counselors are expected to match the appropriate theory (or theories, in the case of integrative or eclectic approaches) to client needs (Corey, 2009; Dattilo & Norcross, 2006; deShazer & Dolan, 2007; Wampold, 2001). The techniques used by the counselor vary according to the theory, and are connected to how the counselor engages the client and develops the case conceptualization. While empirical research has not demonstrated the superiority of any particular model, nevertheless, having a theoretical orientation allows the counselor to organize the counseling process and guide the sessions. Counselors need to find the theoretical orientation which is the best fit for them, as well as to decide whether an integrative or eclectic approach is compatible with their personal view of human development and change.

As we discuss, case conceptualization is not an exact science, nor is one theoretical model prescribed by research. After thirty years of studies comparing the efficacy of different types of counseling and therapy, there is still controversy about the so-called “dodo bird effect.” This is the colorful name for the idea that different types of psychotherapy are similarly effective. The alternative view is that there are specific therapies that are more effective for a particular diagnosis. Some researchers contend that the meta-analyses supporting the dodo bird verdict rely on methodology which makes it difficult to uncover significant differences (Budd & Hughes, 2009).

In this text, we already presented the idea that all therapeutic models act as vehicles through which the common factors of therapeutic change operate (Sprenkle & Blow, 2004). Recall that research shows that all theoretical models are impacted by the extratherapeutic factors which occur outside the counseling relationship, and account for 40% of client change, and all models value the therapeutic alliance, which accounts for approximately 30% of client improvement (Lambert, 1992). When the counselor is confident and hopeful about the outcome of treatment, client expectancy and hope are also raised, accounting for another 15% of client outcome, with the remaining 15% explained by the use of a theoretical model (Lambert, 1992).

At the same time, there is a great deal of research exploring the effectiveness of a particular counseling intervention for a specific diagnosis (“empirically supported treatments”). In Part II of this text, we look at some of this research as we examine the presenting issues commonly encountered in counseling settings, and discuss treatment options. Counselors are most effective when they keep in mind the research on common factors and how these are incorporated into case conceptualization, while also using the literature on empirically supported treatments. Equally important, counselors must continually assess the effectiveness of the counseling process, from case conceptualization to intervention to follow-up.

Notably, the counselor’s theoretical orientation does have an impact on the way the counselor evaluates and understands the client, and on the strategies chosen to help the client change; the questions asked during the evaluation and organization process vary depending on theoretical orientation. In the next section, we briefly review the theoretical approaches most commonly used by counselors, and examine the focus, questions, assessments, and strategies a counselor with that orientation might employ. This chapter is not intended to be a comprehensive review of counseling theory, but we do include an overview of theoretical orientations as they relate to case conceptualization.

Solution Focused Brief Therapy (SFBT)

Based on the principles of exploring what happened in the client’s life before the problem situation developed, solution focused counselors look at the client’s past successes and clarify the strengths and resources that clients are already employing (deShazer & Dolan, 2007, deShazer, 1991). A solution focused counselor might ask questions that help the client identify and own their strengths and successes as the case conceptualization process unfolds, encouraging “self-complimenting” (Delong & Berg, 2008). The therapeutic alliance is built around the counselor’s “cheerleading” and supporting of the client’s new awareness of their strengths and successes, and the focus on positives increases the client’s sense of hope and expectancy and helps move them from a focus on problems to a focus on solutions.

For example, Katy’s counselor might give her some feedback after listening to Katy tell her story:

Counselor: “It sounds like you were dealing with a lot of family stress while you were at college, and yet you managed to graduate Summa Cum Laude! How did you manage to do that?”

Reminding Katy of her intelligence, perseverance, and resilience will help her use those strengths as she works through her current challenges.

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) was first described by Aaron Beck (Beck, 1976). A CBT case conceptualization looks at the client’s cognitions and how they impact behavioral decisions, physiology, and emotions. Counselors come up with hypotheses about the cognitive mechanisms that are causing the client’s problems, how these came about from the client’s life experience, and the environmental triggers producing and maintaining them (Beck, 1995; Persons, 1989, 2012). Such mechanisms include cognitive distortions, negative thoughts, or schemas that are maladaptive. According to researcher Judith Beck (1995), the cognitive model of case conceptualization proposes that distorted or dysfunctional thinking is common to all psychological disturbances.

Recall from your theories class that one of the earliest and most basic cognitive models is Ellis’ ABC model of Rational Emotive Therapy (Ellis, 1961). According to the ABC model, the client experiences an Activating Event (A) that acts like a stimulus to interpret or think about what is happening. Our understanding and interpretation of this event leads to specific Belief(s) about the event, ourselves, and our environment. Once we develop this belief, we experience emotional Consequences. These consequences, in turn, impact the ways in which a client responds. Subsequently, the goal of counseling is for clients to understand their cognitive processes so that distortions and misconceptions are identified in a more realistic manner. We eventually develop core beliefs and assumptions about ourselves, others, and the world which shape how we experience day to day events and trigger what Beck referred to as automatic thoughts. These automatic thoughts, especially when negative, can have a significant impact on our emotional state and our behavioral choices.

A counselor working with Katy from a CBT perspective would try to identify any dysfunctional thoughts and beliefs that are impacting her current situation.

Counselor: “You said that your situation was hopeless, and that you would never find a job. Can you tell me more about that?”

Katy: “Nothing ever works out for me. Why should this be any different?”

Counselor: “That’s a really painful way to feel. But, I remember a few minutes ago, you told me that when you went to college, you were dealing with the stress of being stuck in the middle between your parents, and yet you were still able to succeed academically. It sounds like maybe one thing worked out for you—and a pretty big thing too!”

During the case conceptualization process, the counselor listens for any automatic thoughts and beliefs that are getting in Katy’s way. At the same time, she searches out any evidence that challenges Katy’s thinking so that Katy can begin to see herself and her future more realistically. These conceptualizations are done in collaboration with the client and can then lead to goal formulation based on the information and insight provided.

Psychodynamic Approaches

Psychodynamic case formulation revolves around the inherent motivation for people to search for and maintain meaningful relationships. The counselor looks for commonalities and themes across relationships, places, and perceptions. Clients’ problems are conceptualized as maladaptive patterns of thinking and acting that stem from early childhood experiences and are maintained in the present. The early experiences and perceptions can turn into schemas through which the client views their lives, and can negatively impact the interpersonal relationships that clients have in the present (a process referred to as circular causality). These same patterns are acted out within the counseling relationship, so the counselor can use the dynamics which play out during the sessions to formulate hypotheses about the rest of the client’s experience and self-perceptions. The “here and now” interactions between client and counselor, and the transference and counter-transference reactions each have to the other, inform the conceptualization process.

A counselor conceptualizing the case of Katy from a psychodynamic perspective would want to know more about her early life experience. For example, Katy’s parents divorced when she was quite young, and she may have been unable at the time to make sense of a traumatic event for her. Now in young adulthood, she may be trying to make meaning of that trauma and struggling to do so in order to establish romantic relationships herself. A psychodynamic case conceptualization might focus on that early loss experience, and how a sense of being abandoned may be influencing Katy’s relationship with her partner.

Humanistic Approaches

Humanistic counseling emphasizes liberating clients from negative assumptions and attitudes that are incapacitating. A counselor working from a humanistic perspective views human nature as basically good and believes that clients have an innate potential to create healthy, meaningful relationships. The focus is on present processes and responsible self-actualization rather than past experiences or cognitive distortion. Carl Rogers (1951) believed that formal diagnosis was not necessary, and in fact might sometimes be unwise. As we have seen, Rogers greatly influenced the counseling field, and many counselors emphasize the importance of the relationship over diagnosis. When conceptualizing with a humanistic focus, counselors emphasize “unconditional positive regard” and respect for the client, and prioritize helping clients make their own choices. A humanistic counselor tries to empower the client toward self-actualization and positive growth.

For example, a counselor working with Katy from this perspective would listen without judgment, and convey valuing of the client.

Counselor: (warm tone of voice): “You’ve been through a lot, Katy. And yet here you are, a college degree under your belt, having the courage to start figuring out where you go from here.”

Existential Approaches

The existential formulation is focused on clients finding philosophical meaning by thinking and acting authentically. According to this perspective, some of the principal difficulties clients face revolve around existential concepts, such as despair, loneliness, and lack of meaning. Problems stem from not exercising choice and judgment well enough to build meaningful and fulfilling lives. In the face of this anxiety and suffering, clients work with counselors toward leading more meaningful lives through creativity, love, authenticity, and conscious choice. The focus of counseling then becomes helping the client create meaning in life and making choices in agreement with their values and beliefs. In addition, there is an exploration of environmental factors that are limiting the client’s ability to exercise this choice and live a meaningful life.

Katy seems to be facing an existential crisis as she comes to counseling. She is at a transition point in her life, no longer moving forward with the structure of a college curriculum and college residence hall. Without that structure or a clear plan for the future, Katy seems to be drifting, searching for meaning in both her career goals and her relationships. A counselor working from an existential perspective would focus on this crisis of meaning, and help Katy clarify her values and beliefs in order to make informed choices for her future.

Family Systems

As you might expect, a counselor working from a family systems perspective would focus on the client’s family and other systems in their lives. The counselor might, for example, use a genogram to gain a deeper understanding of the client’s family dynamics and interpersonal relationships. Genograms are structural diagrams that chart family relationships across three or four generations, explicating roles, norms, communication patterns, and significant life events that impacted the client. Some counselors use genograms to gather and chart detailed information about the client’s life and history, while others select a few important types of information to chart. Making patterns and themes visual can help clients talk about and understand their family history and its impact on the present—both strengths and challenges can be made tangible, helping the client understand both. Genograms fit well into a bioecological model of client assessment (such as the T/C Model), as they encourage both client and counselor to take into account multiple spheres of influence across time (Carlfred & Broderick, 1993; Kaslow, Broth, Smith, & Collins, 2012; Lewis, Beavers, Gossett, & Phillips, 1976; Nichols & Schwartz, 2004).

A counselor working from this perspective would explore Katy’s family background in more detail. Her parents’ relationship and breakup, her mother’s dating and marriage to her stepfather, her grandparents’ and great-grandparents’ history, and Katy’s relationship with her half-brothers would all provide important information for the case conceptualization. An understanding of who Katy is closest to in the family helps identify sources of support, while patterns of conflict help the counselor develop hypotheses about how anger and conflict are handled in the family. Intergenerational patterns and ways of coping, such as alcohol or drug use, divorce, and vocational values, can also be identified, and might be useful in working with Katy.

Postmodern Approaches

Postmodern theories of counseling include narrative, feminist, and social justice approaches as well as the multicultural focus discussed in Chapter 2. Narrative counseling is a postmodern approach based on a view of the self which is changeable and fluid and that opens up the possibility for change—as Carl Rogers said, we are all engaged in the process of “becoming” (Rogers, 1961). Developed by Michael White and David Epston (1990), counselors working within a narrative paradigm help the client focus on times when their dominant (problem) life story was not their primary narrative (White, 2007). Narrative theories of change assume that we all construct personal stories that organize and give meaning to our experience. We are all the narrators of our life stories, and they script the way we relate to others and form identities (Stewart & Neimeyer, 2001). When clients’ narratives are limited by sociocultural ideas related to power and gender, or influenced by past traumatic experiences, counselors help the client revise and re-author their life story (Meekums, 2005).

Similar to the solution focused idea of identifying exceptions, helping the client uncover and value an alternate narrative can help the client see themselves in a more positive way. The therapeutic alliance is built through what White (2007) called a “conversational partnership” as the client and the counselor together explore and discover meaning in the client’s alternative life story. The counselor practicing narrative therapy does not take the position of expert, but rather is a collaborator discovering the alternate narrative along with the client. The alternative life story is more hopeful and less problematic, thus helping the client view themselves and their future more positively.

In her first session with her counselor, Katy tells her life story as one of repeated loss and challenge, ignoring instances of her own success and instead including only stories of failure. A counselor working within a narrative perspective would begin to question this version of her life story, helping her to explore those more positive chapters and eventually to rewrite a more realistic, and more hopeful, narrative.

Feminist, multicultural, and social justice approaches also fall under the category of postmodern theories of counseling. There is increasing recognition that the traditional counseling theories are limited due to their basis on Euro-centric White male perspectives and values, and some researchers believe that these traditional theories may be inappropriate for minority clients (Ivey, D’Andrea, Ivey, & Simek-Morgan, 2007).

Multicultural, social justice, and feminist approaches emphasize that working to reduce social injustice, oppression, discrimination, marginalization, and economic inequality are critical to client mental health (Crethar, Torres Rivera, & Nash, 2008). Counselor education programs are beginning to address issues of privilege and social injustice which impact the lives of all clients, and there is increasing recognition of the impact of context on client mental health. Counselors who work from these perspectives are committed to fostering positive change for their individual clients while at the same time advocating for positive changes in their clients’ sociopolitical contexts (Arredondo & Perez, 2003; Arredondo & Toporek, 2004).

Feminist counseling, which grew out of the women’s moment in the 1960s and 1970s, focuses on the importance of interconnectedness for women, an idea that is often de-emphasized or even pathologized in more traditional theories. Feminist theories also question the acceptance of traditional social roles for women and aim to help women rediscover their authentic selves (Wastell, 1996). Empowerment is a primary goal of feminist counseling. Feminist counselors believe that clients know what is best for them, and view individual problems as embedded within sociopolitical and cultural contexts, often impacted by gender-based discrimination and violence. The feminist counselor works to educate clients about social activism, emphasizing that individual change occurs through social change (Remer, 2008). Similarly, social justice and multicultural counselors also promote social, political, and cultural change instead of focusing solely on intrapsychic issues. Individual symptoms are seen as a result of larger sociocultural forces. The relationship between client and counselor in these approaches is egalitarian, with issues of power discussed openly. Counselors work collaboratively with clients to expand clients’ awareness of the effect of sociopolitical factors on their lives.

A counselor working with Katy from a feminist, multicultural, or social justice perspective would want to explore the gender role messages that Katy has absorbed both from her family and from the broader culture. Where does her fear of being alone come from, and how does that impact her relationship with her on-again-off-again boyfriend, and her fear of being alone? What experiences has Katy had as a Korean American? Have Katy or her family experienced instances of discrimination, prejudice, or stereotyping? An understanding of the various sociocultural factors impacting Katy’s view of herself and her world will be helpful as she moves forward and figures out who she wants to be and where she wants to go.

Biopsychosocial Approaches

A biopsychosocial perspective can be useful in considering the diverse contextual influences that impact all of us. Bronfenbrenner’s (1979) model of contextual development describes the reciprocal relationships which contribute to development, including the individual, the proximal (immediate and face-to-face interactions), and distal (more removed, but nevertheless having an impact) environments, and the interactions that occur within those environments. At the most proximal level, interactions with family, peers, school, and work take place in each of these domains, which Bronfenbrenner called “microsystems.” The interrelationships between those microsystem spheres make up the “mesosystem,” which also impacts the individual. Finally, the more distal systems comprise the “exosystem,” influencing the client in a less direct way. In modern society, “macrosystem” influences are more influential than ever, with technology conveying cultural norms and messages in a more immediate and continuous manner. Bronfenbrenner acknowledged these influences as part of the individual’s “chronosystem,” the evolution of the client’s context over time, through developmental transitions and the changing world we live in.

A biopsychosocial perspective is particularly helpful when looking at the client as embedded in multiple systems of influence, and encourages counselors to conduct comprehensive assessments that take into account cultural and social factors. The T/C Model of Case Conceptualization we introduce in this text incorporates a biopsychosocial perspective. In the next section of this book, we apply the T/C Model to various clients, and scaffold you to begin the process of case conceptualization yourself.

Readiness for Change

As mentioned previously, an important aspect of the case conceptualization process is a client’s level of motivation and readiness for change. The most well-known and researched theory of the change process is Prochaska’s Transtheoretical Model of Change (Prochaska & DiClemente, 1986; Prochaska, DiClemente, & Norcross, 1992). The theory centers around four core constructs: the processes of change, decisional balance, self-efficacy, and temptation. The model describes change readiness progressing through six stages (precontemplation, contemplation, preparation, action, maintenance, and termination) and recommends that interventions should be tailored to the current stage of the client.

A client’s advancement through these stages is facilitated by what Prochaska called processes of change. These processes of change can be overt behaviors or covert cognitive shifts that help the client gain insight into their problems and find motivation to modify their behaviors toward more positive outcomes. Decisional balance refers to the client weighing the pros and cons of any specific behavioral change. Self-efficacy is the client’s confidence that they can sustain the change and that it will result in the desired outcome. Temptation represents the client’s urge to go back to their previous behaviors, and is the counterpart to self-efficacy.

As you develop a case conceptualization, it is important to not only gather information about a client’s presenting problem, but also get an idea of their motivation toward change. It is also valuable to gain an understanding of what the client has tried already—what has worked and what hasn’t. You also need to know what internal and external resources the client can employ to help them with the difficult process of change; to gain a full understanding of our client we have to gather information about resources and positives as well as deficits. This helps the counselor not only develop a conceptualization, but can be crucial for choosing goals and selecting the most effective intervention techniques.

See Figures 3.1 and 3.2 for more information on the stages of change.

The T/C Model: An Integrative Approach to Case Conceptualization

As is evident from our discussion so far, developing a case conceptualization is a multi-faceted process. Counselors need to establish the relationship; listen attentively; gather relevant information; reflect and provide feedback, validation, and encouragement; assess readiness for change; and start to engage in hypothesis testing and problem solving. Not only do counselors need to be experts in process, they need to be able to formulate a working hypothesis of the presenting problem, think thematically, and help the client set appropriate goals for change. Conceptualizing skills enable the construction of a model that represents the client’s world and experiences. It is only from this understanding that counselors can be truly effective in helping clients establish goals and select appropriate intervention strategies.

Figure 1

Figure 2

The T/C Model introduced here acts as a road map for gathering client information and exploring client problems and strengths. The model draws from various theoretical approaches commonly used in counseling, including the theories we reviewed above. In formulating this model, we specifically incorporate aspects of Padesky’s Five Aspect Model (Greenburg & Padesky, 1995), Bronfenbrenner’s bioecological model (Bronfenbrenner, 1979), and Prochaska’s stages of change (Prochaska, DiClemente, & Norcross, 1992). The T/C Model expands on these existing theories, however, taking a holistic approach and not only encompassing the internal mechanisms of personality, but also taking into account external influences both past and present. The model, while drawing from diverse theoretical approaches, is itself atheoretical. This allows counselors who practice from multiple theoretical perspectives to use the model effectively. In addition, the T/C Model is practical in its implementation, designed to facilitate goal setting and intervention, as well as conceptualization. The model’s developmental approach reflects the complexity of the client’s experience while at the same time allowing the counselor to focus on targets for change. An additional characteristic which sets the T/C Model apart is its ability to be applied both situationally (to describe a specific event in the client’s life) and globally (reflecting the entirety of the client’s experience in a holistic manner). The various constructs depicted in the Model are interrelated and interdependent, and are not intended to be exclusive categories.

Importantly, the T/C Model itself is both flexible and comprehensive. Not only does the model assist counselors in gathering information about client problems, but the breadth of the model encourages counselors to focus on clients’ strengths, resources, and past successes beginning in the first session. This creates a mindset in both client and counselor that focuses on the future and incorporates hope. Consequently, the model provides a path to change. Interventions are then selected based on existing research, the information gathered, and the path identified. In the following chapters, we apply the model to various case studies, identifying pathways, selecting interventions, and employing these in order to best help clients.

Figure 3.3 Temporal/Contextual Model of Case Conceptualization

Figure 3

Overview of the Model

All counselors recognize the importance of case conceptualization; however, there are few models of case conceptualization which provide an articulated framework of the process. The T/C Model is visually rendered in such a way as to facilitate the counselor’s understanding of the client. Highlighted within the model are the client’s internal world, including attitudes, values, and belief systems; the client’s external world, including environment, relationships, and culture; and the important processes of interaction between the internal and external worlds (behaviors, symptoms, readiness for change, coping skills, and life roles). In addition, the model uses the timeline concept, which allows a focus on past experiences and future goals, as well as the here and now of the present counseling experience.

In the next section, we explore each component of the T/C Model. Finally, we revisit the case of Katy and use the T/C Model to develop a conceptualization of Katy’s strengths and challenges.

The Triangle

In Figure 3.3, the triangle represents the three major elements of human experience and expression: behavior, cognition, and affect (emotion). In other words, the triangle represents the client’s internal world, both psychological and physiological. Represented within, and expressed by these three elements, is the client’s personality. The client’s personality embodies the internal personality constructs (“IPCs”) that form the client’s values and beliefs, self-concept, and worldview. These internal personality constructs also include the client’s attachment style, sense of self-efficacy, and self-esteem. In turn, the internal personality constructs impact the way that the client perceives their environment, how well they cope, and the client’s readiness for change.

Cognition includes how the client perceives and interprets information from the environment. Interpretation occurs through the filters of the client’s interpersonal schemas and internal working models, as well as through their beliefs about self, others, and the world (both rational and irrational). These beliefs are influenced by attachment and relationship style, and by the norms and values that the client absorbed, from gender roles to cultural beliefs to spirituality (Sperry, 2001). The client’s internal world is developed through interaction with the environment, and colored by past experience (at times creating mistaken beliefs and misperceptions).

Behavior encompasses what clients “do”— eating, sleeping, activity level, and withdrawal, as well as the counselor’s observations of the client in session, in the here and now. Is the client fidgeting? Sweating? Avoiding eye contact? Keep in mind that the client’s behavior and all the constructs in the model interact, reflecting reciprocal relationships between constructs. The client’s choices, beliefs, and feelings all impact behavior. It’s important for counselors to understand WHY clients do what they do, and not just interpret behaviors at face value.

Affect includes the client’s ability for emotional regulation, as well as awareness and expression of emotions. Again, affect does not exist in a vacuum—emotions are tied to thoughts and experience. Clients vary in their capacity for emotional regulation, which is influenced by parenting and attachment history. Counselors can be most effective by keeping in mind the interrelationships between constructs, in order to understand and empathize with clients.

The client’s biological experience is also an internal construct. Physiology and biology takes into account clients’ individual differences as well as strengths and vulnerabilities in physical health and constitution. This construct also includes an understanding of genetic predispositions and temperament, reaction to stress, biochemical differences in neurotransmitter function, and other brain chemistry factors. These important factors are sometimes neglected in counseling models of case conceptualization.

These genetic and physiological factors influence the client’s thoughts, emotions, and behavior, the points of the triangle. For example, the client’s beliefs, developed from the interaction of personality, biology, and experience (environment) create “hot thoughts” which are directly connected to affect. For example, Katy’s belief that her situation is hopeless is tied to her anxiety and depression. The link between cognition and behavior is also important—for example, without the belief that she can succeed (self-efficacy), Katy is unlikely to change her behavior.

The Inner Circle

The inner circle represents the boundary between the client’s internal and external worlds, the space where the client interacts with the environment and the environment is in turn impacted by the client. Symptomology is the first and perhaps most obvious construct on the inner circle. Both somatic symptoms and psychological symptoms must be assessed and understood before moving forward to a diagnosis or goal setting. Once again, the interrelationships between symptoms and internal and external constructs is important to understand. For example, somatic symptoms may be associated with emotional response; in Katy’s case, her anxiety and depression are expressed behaviorally as difficulty sleeping and eating. Katy’s symptoms are a reflection of her internal conflicts and discord, which are in turn impacted by her current circumstances and her way of thinking about those circumstances.

Also included in the inner circle are the client’s coping skills and strengths. As we’ve seen, assessment of the client’s strengths is as important as a thorough understanding of the client’s challenges. Uncovering the client’s strengths and supports that often are initially outside the client’s awareness is vital so that these can be applied as the client moves forward into the process of change. In addition, the client’s current readiness for change impacts the counselor’s conceptualization and how to proceed with goal setting and planning. These coping strategies, client strengths, and motivation for change are located on the inner circle, since they can impact the development of either symptoms or healthy adjustment.

The final construct in the inner circle is an understanding of the client’s life roles. We all play multiple roles in life—mother, daughter, sister, coworker, accountant, friend—and each role influences both what we do and how we view ourselves. Life roles are depicted along the inner circle, since these impact the way the client responds to stressful environmental events. Accordingly, life roles are influenced by the norms, values, attitudes, and beliefs that the client has absorbed as well as the individual’s attachment style, once again emphasizing the interconnectedness of the T/C Model and the client’s real-life experience. The client’s negotiation of multiple and sometimes conflicting roles has an influence on identity development, and can impact the client’s self-esteem and stress levels that are all relevant issues in counseling.

The Outer Circle

The outer circle represents the multiple environmental and relational influences that impact the client (and are in turn impacted by the client). These include the client’s interpersonal relationships (family, peer, and romantic), culture, socioeconomic status, community, social structures, and societal norms that influence identity and experience. An important relationship which impacts the client going forward is the counselor-client relationship. As we have seen, the therapeutic relationship is closely related to client outcome.

Again, keep in mind that the interrelationships between constructs are reciprocal. Environment, for example, plays a critical role in how the client’s IPCs are constructed, and various environmental conditions have differential impact depending on the client’s developmental stage. Within the environment reside the precipitating stressors which may have brought the client to counseling. Symptoms occur when the person’s risk factors and vulnerabilities overwhelm their strengths and coping strategies, and are depicted in the diagram as located in the intersection between person and environment.

The counseling relationship is also a unique and influential part of the client’s environment. Through our interactions with the client, we can help the client explore how the environmental influences of their past continue to impact their present and future. The therapeutic relationship plays out in the here and now allowing a comprehensive assessment and interpretation of the impact of all the components in the model. The relationship itself is a powerful means of gaining understanding and insight.

Timeline

The line at the bottom of the model represents time: past, present, and future. The timeline implies both context and setting, and reminds both counselor and client that events which happened in the past can be interpreted differently in the light of the present. The T/C Model is contextual in nature, and can be implemented with a focus on the past, present, or future depending on the counselor’s theoretical orientation and the needs of the client.

Environmental factors from the client’s past may have shaped the cognitions and self- concept the client has in the present. Thus, it may be important to explore the client’s early family experiences in order to gain insight into whether certain cognitions are distorted or behaviors are maladaptive. All of us learn some irrational beliefs as part of the socialization process of childhood (Corey, 2009). The incorporation of the timeline allows counselors to be flexible in assessing a client’s current circumstances by examining a client’s identity across time, and focusing on the future. The client’s understanding of the past can be used to imagine a future self, with fewer problems and a healthy, positive identity. This imagined future is the source of both future goals and motivation to move toward those goals. The client’s past and current experience impact readiness for change. Finally, counselors need to take into account the client’s behaviors, thoughts, and feelings in the present by using a here and now focus to clarify and correct whatever is getting in the client’s way.

Applying the T/C Model

Depending on the theoretical approach taken, different aspects of the T/C Model are expanded on and emphasized. Once a thorough case conceptualization is developed, a deeper understanding of the client’s problems and strengths emerges, which leads to the trust and rapport that allows an effective counseling relationship and serves as a bridge to goal setting and treatment planning.

Let’s take a moment to apply the T/C Model of Case Conceptualization to Katy’s situation. What do we know about the various domains represented in the model, and what do we still need to find out? Using the T/C Model as a framework allows you to fill in the blanks, while also making clear the gaps in your knowledge. In subsequent chapters, we will again apply the model to cases. While the cases are necessarily brief, in actual practice you will have more information to create a detailed case conceptualization using the model.

The Case of Katy

Example of T/C Case Conceptualization Model Outline

  (* Areas that the counselor believes require more information)

Presenting Problem: family and relationship conflict, high levels of depression and anxiety

Internal Personality Constructs and Behavior:

Self-efficacy: low, dismisses past history of academic success in the midst of challenge; dismisses past social success at sorority and at college; details of academic history*

Self-esteem: low

Attitudes/Values/Beliefs: beliefs about success and what is important in life*; gender roles and beliefs*; religious or spiritual beliefs*; sexual attitudes and relationship values*; sexual orientation

Attachment Style: possible insecure anxious ambivalent attachment with mother*, separation from father*

Biology/Physiology/Heredity: 23-year-old young adult; female; sexually active; medical history*; details of parental history of anxiety and alcohol use (mother)*

Affect: depression, anxiety

Cognition: confusion, feeling adrift, “mind won’t turn off”

Hot Thoughts: “It’s hopeless.” “I’m a failure.” “I’ll never find a job.” “My parents think I’m a failure.”

Behavior: weight loss, job search, sporadic eye contact, wringing hands, restless, alcohol use, risk taking; details of alcohol use and risk taking*

Symptomology: difficulty sleeping, lack of appetite, panic attacks

Coping Skills and Strengths: intelligent, has friends, mother and stepfather are financial supports, stepfather is emotional support

Readiness for Change: contemplation (aware of need for change, but ambivalent)

Life Roles: negotiating transition from student to prospective employee with difficulty; daughter; friend; girlfriend

Environment:

Relationships: recent breakup with boyfriend, conflict with mother; past relationship history*; relationship with father not well understood*; relationship with stepfather possible strength*; relationship with friends*; relationship with siblings*

Culture: Korean family background; specific cultural information*; acculturation status*

Family Norms and Values: parental expectations for career; parental expectations for academic success; gender roles and beliefs*; family values*; religious or spiritual beliefs*

Societal Influences: socioeconomic expectations*; societal norms around alcohol use*

Timeline:

Past Influences: Parents’ immigration*; parents’ divorce*; partner breakup*; mother and stepfather conflict*; parents’ remarriages*; mother’s anxiety; mother’s drinking; mother’s possible infidelity*; academic and social success at college; sorority membership

Present Influences: conflict with boyfriend; graduation; transition to living at home; conflict with mother; separation from father, and less involved with stepfather

Future Goals: job interview*; career goals unexamined*; relationship goals unexamined*

Question: What else would you want to ask, to complete this case conceptualization?

Treatment Planning

In the course of the case conceptualization process, the counselor begins to understand and develop hypotheses about the etiology of the client’s problem, the larger systems impacting the client, and how the symptoms are being sustained. Once you have an understanding of what caused the problem, figuring out what to do about it is much simpler. Thus, the treatment planning process is based on the case conceptualization.

In this phase, the information collected and the analysis of that information is integrated into specific interventions. The treatment plan is a map for how the client can make changes and achieve their goals based on the information gathered, the patterns identified, and the theoretical approach applied to that understanding (Seligman, 1993). Interventions selected and techniques chosen should be compatible with the inferences and assumptions arrived at in case conceptualization, since treatment plans flow from the conceptualization.

Treatment planning for most counseling approaches includes a behavioral definition of the presenting problem; identification of specific achievable goals; selection of intervention strategies; and outcome measures to examine progress. During each stage of treatment planning, the client’s readiness for change, available resources and support, level of dysfunction, and cultural and family context are considered. Goals are set with these factors in mind, to optimize the client’s chance of success and allow the restoration of hope and self-efficacy. The counselor’s knowledge of common factors, best practices, and evidence-based treatment options, as well as the counselor’s ability to select an appropriate theoretical orientation for the client, inform the intervention strategies in the treatment planning stage.

As we’ve reviewed, assessment of effectiveness is useful not just at the termination of counseling, but throughout the process. There is an emphasis on accountability in the mental health field today, so the development and application of outcome measures is crucial to demonstrate effectiveness (Seligman, 1996). The phases of counseling are not static; rather, effective counselors are constantly reassessing, testing, and modifying conceptualizations, and revising and updating treatment plans as needed.

Counseling Keystones

Case conceptualization is the process by which counselors make sense of a client’s presenting problems and come to understand the client’s symptoms, thoughts, emotions, behaviors, and personality constructs.

Three integrated processes of counseling can be identified: diagnosis, where the counselor identifies and describes the client’s presenting problem and needs; case conceptualization, where the counselor comes to an understanding of the client’s needs and situation; and treatment planning, where the counselor develops strategies and interventions to address the client’s needs and move the client toward change.

The Diagnostic and Statistical Manual (DSM-5) is widely used for diagnosis, using observable features to identify criteria for a wide variety of mental and emotional disorders, categorizing these based on symptom patterns.

During case conceptualization, the counselor begins to develop a framework to explain the etiology of the client’s problem.

An articulated model of case conceptualization gives counselors a lens through which to understand their clients, which provides a blueprint for how to interact with, listen to, and help.

The case conceptualization process includes: evaluation, in which the counselor assesses and measures observable behaviors and catalogs symptoms; organization, during which the counselor organizes observations and assessments to make inferences, identify themes and patterns, and develop hypotheses; and orientation, in which counselors employ a particular view of how problems develop and how people behave (a theoretical orientation).

Another important aspect of the case conceptualization process is a client’s level of motivation and readiness for change, as described by Prochaska’s Transtheoretical Model of Change.

The Temporal/Contextual Model of case conceptualization (T/C Model) is an atheoretical model that provides a framework or template that counselors can use to focus their observations and generate inferences about the meaning of client presenting problems.

The T/C Model is flexible and comprehensive, takes a holistic approach, encourages an early focus on client strengths, and not only encompasses the internal mechanisms of personality, but also takes into account external influences both past and present.

The treatment planning process is based on the case conceptualization, during which the information and analysis is integrated into specific interventions.

There is an emphasis on accountability in the mental health field today, so the development and application of outcome measures are crucial to demonstrate effectiveness, with counselors constantly reassessing, testing, and modifying conceptualizations, and revising and updating treatment plans as needed.

Exercises

Exercise 3.1 Writing Your Job Description

Having a job description is crucial for any profession; the job description defines the scope of responsibilities and the expectations for the position, detailing both what roles are appropriate and (equally important) what roles are inappropriate.

CLASS EXERCISE: Small group discussion, followed by large group discussion.

Question 1: If you were asked to write a job description for a professional counselor, what would it say?

Question 2: What are the main components of the job?

Exercise 3.2 Where Do You Begin?

The first session with a new client sets the stage for the way that the therapeutic relationship develops.

CLASS EXERCISE: Large group discussion.

Question: When starting a counseling relationship, what are some opening questions you might ask?

Exercise 3.3 What’s the Focus?

The way in which counselors process and record information can have an impact on the subsequent phases of counseling. The counselor’s choice of words and the order in which questions are asked can result in differences in meaning which then become part of the counselor’s conceptualization of the client.

CLASS EXERCISE: Students work individually to brainstorm information needed, followed by large group discussion.

Question 1: Brainstorm the information you want to know about a client during your information gathering process?

Question 2: What elements are you focusing on and why?

Exercise 3.4 Asking the Right Questions

There is certain specific information you need to gather in order to make a diagnosis and formulate a case conceptualization.

CLASS EXERCISE: Discuss in small groups, followed by large group discussion. Write down five questions you might ask under each of the following areas:

Past experiences

Present behaviors

Thoughts

Environmental stressors

Resources or areas of strength

Physical symptoms

Emotions

Values and beliefs

Exercise 3.5 The Pros and Cons of Diagnosis

The DSM-5 is widely used across the helping professions to provide a diagnosis for clients, which then guides treatment and reimbursement from insurers.

CLASS EXERCISE: Students discuss in small groups, followed by large group discussion.

Question l: When you think of being given a diagnosis yourself, what thoughts come to your mind?

Question 2: How might your client view his or her diagnosis?

Exercise 3.6 What Lens Best Fits You?

You read about the different theoretical lenses used in case conceptualization.

CLASS EXERCISE: Large group discussion.

Question 1: Which theoretical lens do you feel best fits you? Why?

Exercise 3.7 Stages of Change

Determining a client’s stage of readiness for change can help you decide where to start to help you and the client set appropriate and achievable goals.

CLASS EXERCISE: Students discuss in small groups, working with the Stages of Change Model presented earlier in the chapter, followed by each group presenting their assessment and a discussion of the basis for that assessment.

Question 1: Think about the case of Katy. What stage of readiness for change do you think Katy is in? Why?

Go Further

Mind Over Mood: Change How You Feel by Changing the Way You Think by Dennis Greenberger and Christine Padesky (1995) Guilford Press

Systems of Psychotherapy: A Transtheoretical Analysis by James O. Prochaska and John C. Norcross (2009) Cengage Learning

Making Human Beings Human: Bioecological Perspectives on Human Development (The SAGE Program on Applied Developmental Science) by Urie Bronfenbrenner (2004) SAGE