Case Conceptualisation Rules – Should It?

Most clinicians match clients to their prototypes of disorders. But how much information should you collect before matching ? ‘Since Persons (1980) and Judith Beck (1996) ‘Case Conceptualisation’  rules. But there has been no demonstrated added value of ‘case conceptualisation’ .

Prior to these authors there was simply ‘case formulation’ [see for examples of formulations of most disorders] which was the way in which a person was an exemplar of a particular disorder e.g a person with panic disorder might say that in their 1st panic attack they t0ok their palpitations as evidence that they were having a heart attack, but though nothing untoward physically happened they became hypervigilant over bodily sensations and avoided provoking  any such symptoms. Applying Clark’s cognitive model of panic disorder the key dysfunction is catastrophising  and avoidance of opportunities to disconfirm the catastrophic cognitions. A case formulation requires 1st of all a reliable diagnosis, what they are a ‘case of’  and an example of the mechanism by which this disorder is brought about. As such there are clear limits of the range of information that is pertinent to a ‘case formulation’. Making it usually a manageable task for the clinician at 1st interview  and  to set a pertinent homework exercise. Contrast this efficient use of time, with a real-world impact, with what happens when the focus is on ‘case conceptualisation’.

With case conceptualisation  there is no control of information variance, the therapist likely assembles information under a number of headings,  but this information does not speak for itself



Case conceptualization Kuyken 2009

The therapist arbitrarily selects a piece/s of information and  claims it/they are pivotal  e.g their father was alcoholic, they were involved in a life threatening incident. The descriptive information of itself is not prescriptive of a mechanism. One could assemble information under the above headings ‘until the cows come home’ it would make no difference, it is arbitrary to stop at any particular point. In this context clinicians easily succumb to ‘formulation nausea’ a condition arising from a bewildering array of arrows. Presented with such a picture clients can easily feel a victim and or blameworthy and disempowered. They are unlikely to have any success experience any time soon, homework is delayed. Therapy becomes an exercise in the acquisition of meaningless data, with the client likely to default. In fairness Judith Beck ( Centre for Cognitive Therapy 2018) does retain diagnosis in her case conceptualisation but this appears to be lost in translation, at least in UK CBT courses. 

It is 15 years since Kuyken et al produced their seminal work on Case Conceptualisation, recognising the evidence base for it was lacking but expressing confidence that this would be repaired. But no such further evidence has been forthcoming [Easden and Kazantis (2018)] and state that ‘the efficacy of case conceptualisation in CBT has yet to be demonstrated’.What has actually happened is that the framework of Case Conceptualisation, minus the diagnosis component, has been passed on to training courses and taken as gospel. Thus whilst there is a consensus about the importance of case conceptualisation there is a conspicuous lack of evidence, at least about what is customarily put into practice. Better returning to simply effective CBT [Scott (2009)]

The Kuyken model of case conceptualisation, suggests that the latter is an emergent property of a ‘soup’ , into which everything is thrown in,  genetic predisposition, precipitants of episodes etc. But this is reminiscent of the claim that life emerged from a ‘primordial soup’, there is no specificity of mechanism.  It is claimed that case conceptualisation is at another level of abstraction to case  formulation. This may well be the case, but there is no evidence that the former helps the latter. Contrast this with the multidimensional description of patients difficulties in DSM IV axis 1 disorders e.g depression, PTSD axis 2 disorders personality disorders, axis 3 physical disorders, axis 4 psychosocial stressors and  axis 5 judgement of overall functioning .   Applying this framework to a person in Gaza with likely PTSD symptoms would greatly change the therapeutic approach. It might well be concluded that the ‘toxic environment’ precludes psychological treatment at this point in time 

Dr Mike Scott