A FORMAT FOR CASE CONCEPTUALIZATION
Stevens, Michael J., Morris, Steven J., Counselor Education & Supervision, Sep 1995, Vol. 35, Issue 1
The authors developed a format for case conceptualization to foster the systematic collection and integration of clinical data. The format is intended to complement training in counseling techniques.
Many professional and personal challenges confront practicum students as they work with clients. For example, students must establish a counseling relationship, listen attentively, express themselves clearly, probe for information, and implement technical skills in an ethical manner. Those counseling performance skills (Borders & Leddick, 1987) center on what counselors do during sessions. At a cognitive level, students must master factual knowledge, think integratively, generate and test clinical hypotheses, plan and apply interventions, and evaluate the effectiveness of treatment. Those conceptualizing skills, within the cognitive operations used to construct models that represent experience (Mahoney & Lyddon, 1988), show how counselors think about clients and how they choose interventions. It is highly desirable for instructors of practica to have pedagogical methods to promote the development both of counseling performance skills and conceptualizing skills. Such methods should be diverse and flexible to accommodate students at different levels of professional development and with distinct styles of learning (Biggs, 1988; Borders & Leddick, 1987; Ellis, 1988; Fuqua, Johnson, Anderson, & Newman, 1984; Holloway, 1988; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987).
RATIONALE FOR THE FORMAT
In this article, we present a format for case conceptualization that we developed to fill gaps in the literature on the preparation of counselors (Borders & Leddick, 1987; Hoshmand, 1991). Although many existing methods promote counseling performance skills, there are few established methods for teaching students the conceptualizing skills needed to understand and treat clients (Biggs, 1988; Hulse & Jennings, 1984; Kanfer & Schefft, 1988; Loganbill & Stoltenberg, 1983; Turk & Salovey, 1988). We do not discount the importance of counseling performance skills, but we believe that they can be applied effectively only within a meaningful conceptual framework. That is, what counselors do depends on their evolving conceptualization of clients; training in that conceptualization matters.
Given the large quantity of information that clients disclose, students have the task of selecting and processing relevant clinical data to arrive at a working model of their clients. Graduate programs need to assist students in understanding how to collect, organize, and integrate information; how to form and test clinical inferences; and how to plan, implement, and evaluate interventions (Dumont, 1993; Dumont & Lecomte, 1987; Fuqua et al., 1984; Hoshmand, 1991; Kanfer & Schefft, 1988; Turk & Salovey, 1988). Although systematic approaches to collecting and processing clinical information are not new, the case conceptualization format presented here, as follows, has several distinguishing features:
1. The format is comprehensive, serving both to organize clinical data (see Hulse & Jennings, 1984; Loganbill & Stoltenberg, 1983) and to make conceptual tasks operational (see Biggs, 1988). The components of the format integrate and expand on two useful approaches to presenting cases that are cited often and that are linked to related literature on supervision: (a) Loganbill and Stoltenberg's (1983) six content areas of clients' functioning (i.e., identifying data, presenting problem, relevant history, interpersonal style, environmental factors, and personality dynamics), and (b) Biggs's (1988) three tasks of case conceptualization (i.e., identifying observable and inferential clinical evidence; articulating dimensions of the counseling relationship; and describing assumptions about presenting concerns, personality, and treatment).
In addition, the format makes explicit the crucial distinction between observation and inference, by separating facts from hypotheses. It advances the notion that observations provide the basis for constructing and testing inferences. Thus, the format fosters development of critical thinking that is more deliberate and less automatic than the ordinary formation of impressions. The approach is compatible with recommendations that counselors receive training in rational hypothesis testing to reduce inferential errors (Dumont 1993; Dumont & Lecomte, 1987; Hoshmand, 1991; Kanfer & Schefft, 1988; Turk & Salovey, 1988).
2. The format can be adapted to the developmental stage of students by its focus on stage-appropriate components and implementing those components in stage-appropriate ways (Ellis, 1988; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987). As an example, beginning students use the format to organize information and to learn the distinction between observation and inference, whereas more experienced students focus on using the format to generate and test hypotheses.
3. The format is atheoretical, thereby permitting students to incorporate constructs from any paradigm into their case conceptualizations. In this sense, the format resembles the cognitive scaffolding described in the constructivist perspective (Mahoney & Lyddon, 1988). Rather than being an explicit template through which observations are filtered to conform to an imposed representational model, the format provides an abstract set of cognitive schemas. With the schemas, the student actively fashions a conceptual framework from which to order and assign meaning to observations. Simply put, the format is a generic structure that the student uses to construct his or her "reality" of the case.
COMPONENTS OF THE FORMAT
The format has 14 components, sequenced from observational to inferential as follows: background data, presenting concerns, verbal content, verbal style, nonverbal behavior, client's emotional experience, counselor's experience of the client, client-counselor interaction, test data and supporting materials, diagnosis, inferences and assumptions, goals of treatment, interventions, and evaluation of outcomes.
Background data includes sex, age, race, ethnicity, physical appearance (e.g., attractiveness, dress, grooming, height, and weight), socioeconomic status, marital status, family constellation and background, educational and occupational status, medical and mental health history, use of prescribed or illicit substances, prior treatment, legal status, living arrangements, religious affiliation, sexual preference, social network, current functioning, and self-perceptions. Initially, students are overwhelmed by the data that they assume need to be collected. Guidance must be provided on how students are to differentiate meaningful from inconsequential information. In our program, for example, we ask students to evaluate the relevance of background data, for understanding clients' presenting concerns and for developing treatment plans. We advise students to strive for relevance rather than comprehensiveness.
Presenting concerns consist of a thorough account of each of the client's problems as viewed by that client. This task might begin with information contained on an intake form. We assist students in developing concrete and detailed definitions of clients' concerns by showing them how to help clients identify specific affective, behavioral, cognitive, and interpersonal features of their problems. For example, the poor academic performance of a client who is a college student might involve maladaptive behavior (e.g., procrastination), cognitive deficits (e.g., difficulty in concentrating), negative moods (e.g., anxiety), and interpersonal problems (e.g., conflict with instructors). Counseling students should also explore the parameters of presenting concerns, including prior occurrence, onset, duration, frequency, severity, and relative importance. We further suggest that students explore how clients have attempted to cope with their concerns and that they examine what clients expect from treatment, in terms of assistance as well as their commitment to change. In addition, students should assess immediate or impending dangers and crises that their clients may face. Finally, we instruct students in identifying environmental stressors and supports that are linked to presenting concerns.
Verbal content can be organized in two ways. A concise summary of each session is appropriate for cases of limited duration. Alternatively, verbal content can include summaries of identified themes that have emerged across sessions. Occasionally, those themes are interdependent or hierarchically arranged. For example, a client may enter treatment to deal with anger toward a supervisor who is perceived as unfair and, in later sessions, disclose having been chronically demeaned by an older sibling. We teach students to discriminate central data from peripheral data through feedback, modeling, and probing questions. Students need to focus their sessions on areas that are keyed to treatment. For instance, we point out that clients' focal concerns, along with the goals of treatment, can serve as anchors, preventing the content of sessions from drifting.
Verbal style refers to qualitative elements of clients' verbal presentation (i.e., how something is said rather than what is said) that students deem significant because they reflect clients' personality characteristics, emotional states, or both. Those elements can include tone of voice and volume, changes in modulation at critical junctures, fluency, quantity and rate of verbalization, vividness, syntactic complexity, and vocal characterizations (e.g., sighing).
Nonverbal behavior includes clients' eye contact, facial expression, body movements, idiosyncratic mannerisms (e.g., hand gestures), posture, seating arrangements, and change in any of these behaviors over time and circumstances. Instructors can assist students in distinguishing relevant from unimportant information by modeling and providing feedback on how these data bear on the case. As an example, neglected hygiene and a listless expression are important nonverbal behaviors when they coincide with other data, such as self-reports of despair and hopelessness.
Clients' emotional experience includes data that are more inferential. On the basis of their observations, students attempt to infer what their clients feel during sessions and to relate those feelings to verbal content (e.g., sadness linked to memories of loss). The observations provide insights into clients' emotional lives outside of treatment. We caution students that clients' self-reports are an important but not entirely reliable source of information about their emotional experience. At times clients deny, ignore, mislabel, or misrepresent their emotional experience. Students should note the duration, intensity, and range of emotion expressed over the course of treatment. Blunted or excessive affect as well as affect that is discrepant with verbal content also merit attention. To illustrate, a client may report, without any apparent anger, a history of physical abuse.
Initially, students can be assisted in labeling their clients' affect by using a checklist of emotional states. We have found it helpful to suggest possible affect and support our perceptions with observation and logic. Empathic role taking can also help students to gain access to clients' experience. Instructors may need to sensitize students to emotional states outside of their own experience or that they avoid.
Counselor's experience of the client involves his or her personal reactions to the client (e.g., attraction, boredom, confusion, frustration, and sympathy). We strive to establish a supportive learning environment in which students can disclose their genuine experiences, negative as well as positive. Students often struggle to accept that they might not like every client. But students should be helped to recognize that their experience of clients is a rich source of hypotheses about feelings that those clients may engender in others and, thus, about the interpersonal world that the clients partially create for themselves. The "feel" of clients often provides valuable diagnostic clues (e.g., wanting to take care of a client may suggest features of dependent personality disorder). Sometimes students need assistance in determining whether their reactions to clients reflect countertransferential issues or involve "normative" responses. We draw on parallel process and use-of-self as an instrument to help clarify students' feelings and to form accurate attributions about the origins of those feelings (Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993).
Client-counselor interaction summarizes patterns in the exchanges between client and counselor as well as significant interpersonal events that occur within sessions. Such events are, for example, how trust is tested, how resistance is overcome, how sensitive matters are explored, how the counseling relationship is processed, and how termination is handled. Thus, this component of the format involves a characterization of the counseling process. Students should attempt to characterize the structure of the typical session--specifically, what counselors and clients do in relation to one another during the therapy hour. They may do any of the following: answer questions, ask questions; cathart, support; learn, teach; seek advice, give advice; tell stories, listen; collude to avoid sensitive topics. Taxonomies of counselor (Elliott et al., 1987) and client (Hill, 1992) modes of response are resources with which to characterize the structure of sessions.
At a more abstract level, students should try to describe the evolving roles they and their clients play vis-a-vis one another. It is essential to assess the quality of the counseling relationship and the contributions of the student and the client to the relationship. We ask students to speculate on what they mean to a given client and to generate a metaphor for their relationship with that client (e.g., doctor, friend, mentor, or parent). Client-counselor interactions yield clues about clients' interpersonal style, revealing both assets and liabilities. Furthermore, the counseling relationship provides revealing data about clients' self-perceptions. We encourage students to present segments of audiotaped or videotaped interviews that illustrate patterns of client-counselor interaction.
Test data and supporting materials include educational, legal, medical, and psychological records; mental status exam results; behavioral assessment data, including self-monitoring; questionnaire data, the results of psychological testing, artwork, excerpts from diaries or journals, personal correspondence, poetry, and recordings. When students assess clients, a rationale for testing is warranted that links the method of testing to the purpose of assessment. We assist students in identifying significant test data and supporting materials by examining how such information converges with or departs from other clinical data (e.g., reports of family turmoil and an elevated score on Scale 4, Psychopathic Deviate, of the Minnesota Multiphasic Personality Inventory-2 [MMPI-2; Hathaway & McKinley, 1989]). Assessment, as well as diagnosis and treatment, must be conducted with sensitivity toward issues that affect women, minorities, disadvantaged clients, and disabled clients, because those persons are not necessarily understood by students, perhaps due to limited experience of students or the "homogenized" focus of their professional preparation.
Diagnosis includes students' impression of clients' diagnoses on all five axes of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, American Psychiatric Association, 1994). We guide students' efforts to support their diagnostic thinking with clinical evidence and to consider competing diagnoses. Students can apply taxonomies other than those in the DSM-IV when appropriate (e.g., DeNelsky and Boat's  coping skills model). Instructors demonstrate the function of diagnosis in organizing scattered and diverse clinical data and in generating tentative hypotheses about clients' functioning.
Inferences and assumptions involve configuring clinical hypotheses, derived from observations, into meaningful and useful working models of clients (Mahoney & Lyddon, 1988). A working model consists of a clear definition of the client's problems and formulations of how hypothesized psychological mechanisms produce those problems. For instance, a client's primary complaints might be frequent bouts of depression, pervasive feelings of isolation, and unfulfilled longing for intimacy. An account of those problems might establish the cause as an alienation schema, early childhood loss, interpersonal rejection, negative self-schemas, or social skills deficits.
We help students to elaborate on and refine incompletely formed inferences by identifying related clinical data and relevant theoretical constructs (Dumont, 1993; Mahoney & Lyddon, 1988). We also assist students in integrating inferences and assumptions with formal patterns of' understanding drawn from theories of personality, psychopathology, and counseling (Hoshmand, 1991).
As with their instructors, students are not immune from making faulty inferences that can be traced to logical errors, such as single-cause etiologies, the representative heuristic, the availability heuristic, confirmatory bias, the fundamental attribution error, and illusory correlations; (Dumont, 1993; Dumont & Lecomte, 1987). As an example, counselors tend to seek data that support their preexisting notions about clients, thus restricting the development of a more complete understanding of their clients. We alert students to the likelihood of bias in data gathering, particularly when they seek to confirm existing hypotheses. Furthermore, we demonstrate how to generate and evaluate competing hypotheses to counteract biased information ]processing (Dumont & Lecomte, 1987; Kanfer & Schefft, 1988). Instructors, therefore, must teach students to think logically, sensitizing them to indicators of faulty inferences and providing them with strategies for validating clinical hypotheses as well as disconfirming them (Dumont & Lecomte, 1987; Hoshmand, 1991). The proposed format can accomplish this task because it separates inferences from the clinical data used to test inferences and thus "deautomatizes" cognitive operations by which inferences are formed (Kanfer & Schefft, 1988; Mahoney & Lyddon, 1988). We have found it beneficial to have students compare their impressions of clients with impressions that are independently revealed by test data (e.g., MMPI-2); this exercise permits the correction of perceptual distortions and logical errors that lead to faulty inferences. Although students' intuition is an invaluable source of hypotheses, instructors need to caution them that intuition must be evaluated by empirical testing and against grounded patterns of understanding (Hoshmand, 1991).
We also model caution and support for competing formulations and continued observation. This approach fosters appreciation of the inexactitude and richness of case conceptualization and helps students to manage such uncertainty without fear of negative evaluation. With the development of their conceptualizing skills, students can appreciate the viability of alternative and hybrid inferences. Moreover, they become more aware of the occasional coexistence and interdependence of clinical and inferential contradictions (e.g., the simultaneous experience of sorrow and joy and holistic concepts such as life and death). The increasingly elaborate conceptual fabric created from the sustained application of conceptualizing skills also enables students to predict the effect of interventions more accurately.
Goals of treatment must be linked to clients' problems as they come to be understood after presenting concerns have been explored. Goals include short-term objectives along with long-term outcomes of treatment that have been negotiated by the client and trainee. Typically, goals involve changing how clients feel, think, and act. Putting goals in order is important because their priorities will influence treatment decisions. Goals need to be integrated with students' inferences or established theories and techniques of counseling. In their zeal, students often overestimate the probable long-term aims of treatment. To help students avoid disappointment, we remind them that certain factors influence the formulation of goals, including constraints of time and resources, students' own competencies, and clients' capacity for motivation for change.
Interventions comprise techniques that students implement to achieve agreed-on goals of treatment. Techniques are ideally compatible with inferences and assumptions derived earlier; targets of treatment consist of hypothesized psychological structures, processes, and conditions that produce clients' problems (e.g., self-esteem, information processing, family environment). Difficulties in technical implementation should be discussed candidly. We provide opportunities for students to observe and rehearse pragmatic applications of all strategies. Techniques derived from any theory of counseling can be reframed in concepts and processes that are more congruent with students' cognitive style. To illustrate, some students are able to understand how a learned fear response can be counterconditioned by the counseling relationship when this phenomenon is defined as a consequence of providing unconditional positive regard. In addition, we teach students to apply techniques with sensitivity as well as to fashion a personal style of counseling. Finally, legal and ethical issues pertaining to the conduct of specific interventions must be made explicit.
Evaluation of outcomes requires that students establish criteria and methods toward evaluating the outcomes of treatment. Methods can include objective criteria (e.g., grades), reports of others, self-reports (e.g., behavioral logs), test data, and students' own judgments. Instructors must assist students in developing efficient ways to evaluate progress over the course of treatment given the presenting concerns, clients' motivation, and available resources.
USES OF THE FORMAT
We developed the :format for use in a year-long practicum in a master's degree program in counseling psychology. Instructors describe the format early in the first semester and demonstrate its use by presenting a terminated case; a discussion of the format and conceptualization follows. The first half of the format is particularly helpful when students struggle to organize clinical data into meaningful categories and to distinguish their observations from their inferences. The focus at that point should be on components of the format that incorporate descriptive data about the client. Later in their development, when students are prepared to confront issues that influence the counseling relationship, components involving personal and interpersonal aspects of treatment can be explored. As students mature further, components that incorporate descriptive data are abbreviated so that students can concentrate on the conceptualizing skills of diagnosis, inferences and assumptions, treatment planning and intervention, and evaluation. When conceptualizing skills have been established, the format need not be applied comprehensively to each case. Rather, it can be condensed without losing its capacity to organize clinical data and to derive interventions.
The format can be used to present cases in practicum seminar as well as in individual supervision sessions. It can also be used by students to manage their caseloads. Also, the format can be used in oral and written forms to organize and integrate clinical data and to suggest options for treatment (cf. Biggs, 1988; Hulse & Jennings, 1984; Loganbill & Stoltenberg, 1983). For example, practicum seminar can feature presentations of cases organized according to the format. As a student presents the data of the case, participants can construct alternative working models. Moreover, the format compels participants to test their models by referencing clinical data. Written details that accompany a presentation are also fashioned by a student presenter according to the format. The student presenter can distribute such material before the presentation so that members of the class have time to prepare. During the presentation, participants assume responsibility for sustaining the process of case conceptualization in a manner that suits the class (e.g., discussion, interpersonal process recall, media aids, or role play).
Supervision and case notes can also be structured more flexibly with the use of the case conceptualization format to give students opportunities to relate observation to inference, inference to treatment, and treatment to outcome (Presser & Pfost, 1985). In fact, supervision is an ideal setting to tailor the format to the cognitive and personal attributes of the students. In supervision, there are also more opportunities to observe students' sessions directly, which permits instruction of what clinical information to seek, how to seek it, how to extract inferences from it, and to evaluate the veracity of students' inferences by direct observation (Holloway, 1988).
FUTURE APPLICATIONS AND RESEARCH
The format is a potentially valuable resource for counselors to make the collection and integration of data systematic when they intervene with populations other than individual clients. Application of the format to counseling with couples and families might seem to make an already conceptually demanding task more complex. Yet counselors can shift the focus from individuals to a couple or a family unit, and apply components of the format to that entity. By targeting relationships and systems in this way, the format can also be used to enhance understanding of and improve interventions in supervision and with distressed units or organizations.
Although research has been conducted on how counselors collect data, few studies have investigated how counselors process information when testing hypotheses (e.g., Strohmer, Shivy, & Chiodo, 1990). Empirical evidence of the effectiveness of various approaches to the conceptual training of counselors is long overdue. Avenues of inquiry include determining whether the format contributes to the acquisition of conceptualizing skills and to facilitative conditions and techniques thai: may be mediated by such skills (e.g., empathy and clear communication). There are several written measures available with which to evaluate students' conceptualizing skills. Examples of those measures are the Clinical Assessment Questionnaire (Holloway & Wolleat, 1980); Intentions List (Hill & O'Grady, 1985); and Written Treatment Planning Simulation (Butcher, Scofield, & Baker, 1985). Interpersonal process recall of audiotaped and videotaped sessions, case notes (Presser & Pfost, 1985), and direct observation can also be used.
Other promising directions for research include comparing the effect of the format with other approaches to training, isolating components of the format that produce the greatest gains in conceptualizing skills, and determining the outcomes when the format is implemented with the use of different instructional strategies and with students at varying levels of development. Finally, investigation into how the format produces cognitive and performance gains would be valuable, particularly if integrated with literature on cognitive development and effective learning strategies.
Nonetheless, the format has several limitations. Although students will eventually learn to apply the format more efficiently in their professional practice, it remains cumbersome and time consuming. Explicit and comprehensive application of the format in supervision and in the routine management of individual caseloads is particularly awkward. In those contexts, the format must be applied tacitly as a heuristic, with specific components used more deliberately when obstacles to progress are encountered. For example, focus on a client's affective experience can promote accurate empathy in the student and lead to more helpful interventions.
Moreover, given the differences in the cognitive development of students (Biggs, 1988; Borders & Leddick, 1987; Ellis, 1988; Fuqua et al., 1984; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987), the format cannot be applied rigidly or uniformly as a pedagogical tool. Beginning students and those who think in simple, concrete terms seem to profit most from learning environments in which instructors provide direction, expertise, feedback, structure, and support. Conversely, more experienced students and those who think in complex, abstract terms learn more readily when instructors fashion autonomous, collegial, flexible, and interactive environments (Ellis, 1988; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987). Hence, the format must be applied creatively and tailored to students' capabilities, to avoid needless discouragement, boredom, or threats to personal integrity (Fuqua et al., 1984; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987).
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By MICHAEL J. STEVENS and STEVEN J. MORRIS
Michael J. Stevens is a professor of psychology and director of the master's degree program in Counseling Psychology and Steven J. Morris is an assistant professor of psychology, both at Illinois State University, Normal, Illinois. This article was presented at the annual meeting of the American Psychological Association, Washington, DC, in August 1992. Correspondence regarding this article should be sent to Michael J. Stevens, Department of Psychology, Illinois State University, Campus Box 4620, Normal, IL 61790-4620.