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The American Journal of Family Therapy, 33:353364, 2005

Copyright Taylor & Francis, Inc.


ISSN: 0192-6187 print / 1521-0383 online
DOI: 10.1080/01926180500341598

Case Conceptualization: A Strategy for


Incorporating Individual, Couple and Family
Dynamics in the Treatment Process
LEN SPERRY
Florida Atlantic University and the Medical College of Wisconsin

While market and regulatory forces have made case conceptualizations essential in individual, couple and family therapy, therapists,
trainees, and supervisors are increasingly recognizing the clinical
value and utility of case conceptualizations in everyday practice.
This article describes and critically analyzes three main types of
case conceptualization and argues that the client-focused type is
the most appropriate in addressing theoretical and clinical considerations. A client-focused type with a phenomenological and systematic emphasis, called pattern analysis, is described. A detailed
case study illustrates pattern analysis.

For better or worse, market forces and statutory and regulatory decisions
have had and likely will continue to impact the practice of psychotherapy
and marital and family therapy. The success of one of the first books on case
conceptualization (Sperry et al., 1992) was due largely to the new managed
care requirement for written treatment plansa key component of a case
conceptualization. This powerful market force engendered a spate of similar
publications, continuing education seminars and curricular changes in the
graduate program to make case conceptualization and treatment planning a
core clinical skill and competency (Eells & Lombart, 2003). In contrast, before
the managed care requirement, there seemed to be only minimal interest
in case conceptualization among most clinicians and educators. Similarly, a
recent regulatory decision has significantly impacted licensure in at least one

A truncated version of this article appeared in Volume 33, Issue 3. We regret this error
and are pleased to present the article in full.
Address correspondence to Len Sperry, M.D., Ph.D., Professor and Coordinator of the
Doctoral Program in Counseling, Florida Atlantic University, 7776 Glades Road, Boca Raton,
FL 33431.
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state. Passing an intense oral examination involving case conceptualization


and treatment planning is now required for licensure as a marital and family
therapist in the state of California.
While outside forces have proactively made case conceptualization and
treatment planning a basic requirement and core clinical competency in individual, couples, and family therapy (Falvey, 2001), inside forces, that is,
the psychotherapy and marital and family therapy field, has been largely reactive and even resistant to such initiatives. Perhaps much of this resistance
reflects the values and practice patterns of the culture of therapy prior to
the era of accountability and managed care (i.e., therapist independence,
treatment decisions based on need rather than cost, subjective assessment of
treatment progress, etc.) (Sperry et al., 1997). Whatever the reason, the field
is less than enthusiastic about these initiatives, and there is little consensus
on basic considerations such as definitions, processes, and models of case
conceptualization, much less of training methods and research. Until such
consensus is reached there is a need among trainees and clinicians for a
straightforward, clinically useful strategy for quickly and easily incorporating
individual, couple, and family dynamics in the treatment planning process.
The purpose of this article is to describe and illustrate the use of the case
conceptualization strategy called pattern analysis for planning, sequencing,
and implementing treatment with individuals, couples, and families. First,
case conceptualization is defined and its components are described. Then,
its clinical value and the three types of case conceptualization are described.
This is followed by a description of pattern analysis in deriving a case conceptualization. Finally, a detailed case example illustrates the use of case
conceptualization as a strategy for formulating, sequencing, and implementing treatment.

CASE CONCEPTUALIZATIONS
A case conceptualization is a method and process of summarizing seemingly
diverse case information into a brief, coherent statement or map that elucidates the clients basic pattern of behavior. The purpose of a well-articulated
case conceptualization is to better understand and more effectively treat a
client or client-system, namely the couple or a family. In short, a case conceptualization is a clinicians theory of a particular case.

Three Components
Essentially, a case conceptualization consists of three components: a diagnostic formulation, a clinical formulation, and a treatment formulation (Sperry
et al., 1992). A diagnostic formulation is a descriptive statement about the nature and severity of the individuals psychiatric presentation. The diagnostic
formulation aids the therapist in reaching three sets of diagnostic conclusions:
whether the clients presentation is primarily psychotic, characterological, or

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neurotic; whether the clients presentation is primarily organic or psychogenic


in etiology; and, whether the clients presentation is so acute and severe that
it requires immediate intervention. In short, diagnostic formulations are descriptive, phenomenological, and cross-sectional in nature. They answer the
what questionWhat happened? For all practical purposes the diagnostic
formulation lends itself to being specified with DSM-IV criteria and nosology.
A clinical formulation, on the other hand, is more explanatory and
longitudinal in nature, and attempts to offer a rationale for the development and maintenance of symptoms and dysfunctional life patterns. Just as
various theories of human behavior exist, so do various types of clinical
formulations exist: psychoanalytic, Adlerian, cognitive, behavioral, biological, family systems, and biopsychosocial. Clinical formulations answer the
why questionWhy did it happen? In short, the clinical formulation articulates and integrates the intrapsychic, interpersonal, and systemic dynamics
to provide a clinically meaningful explanation of the clients pattern, that
is, the predictable style of thinking feeling, acting, and coping in stressful circumstancesand a statement of the causality of their behavior. Not
surprisingly, the clinical formulation is key component in a case conceptualization and serves to link the diagnostic and treatment formulations.
A treatment formulation follows from a diagnostic and clinical formulation and serves as an explicit blueprint governing treatment interventions.
Informed by both the answers to the What happened? and the Why did
it happen? question, the answer to the how questionHow can it be
changed? is the basis of treatment formulation. A well-articulated treatment
formulation provides treatment goals, a treatment plan, treatment interventions as well as predictions about the course of treatment and its outcomes.

Clinical Utility and Value


Clinically useful case conceptualizations are those which emphasize the
unique context and the needs and resources that the individual, couple,
or family brings to treatment. They are integrative case conceptualizations
in that they incorporate these factors in all three formulation dimensions:
diagnostic, clinical, and treatment
In addition, case conceptualizations have value for various stakeholders
in the therapy process. Therapists typically utilize case conceptualizations
because third-party reimbursement requires an explicit treatment plan. Similarly, many, if not most, clinics and treatment programs require written plans.
Even if not required, some clinicians find developing a detailed written plan
most helpful in guiding treatment, while other seasoned clinicians quickly
and informally derive such formulations while not necessarily committing
them to writing. Typically, trainees and interns are required to develop
case conceptualizations in graduate and other training programs. Supervisors
rely on case conceptualizations as a basis for discussing specific cases with
trainees. They also serve to monitor and document trainee progress in their

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clinical work with specific clients. As implied earlier, case conceptualizations


have value to MCOs and other third-party payers. Case conceptualizations
provide these payers with a basis for decisions about approving treatment, for
monitoring it, and for evaluating its efficacy and cost effectiveness. Presumably, case conceptualizations can have value for clients, particularly when
therapists elicit clients own conceptualization and endeavor to engage them
in a collaborative process to achieve mutually agreed upon treatment goals.

Three Types
Three general types of case conceptualizations can be described and differentiated: symptom-focused, theory-focused, and client-focused.
SYMPTOM-FOCUSED

CONCEPTUALIZATIONS

This type of conceptualization derives from the medical and behavioral


models of human behavior and is favored by managed care organizations
and other third-party payers. It identifies symptomatology and functional
impairment and then specifies treatment goals and associated interventions
for reducing symptoms and increasing functioning. This symptom-focused
approach to case conceptualization emphasizes measurable objectives that
are stated in behavioral terms. The obvious limitation of this type of conceptualization is its focus on symptoms and its unstated assumption that only the
what [diagnostic formulation] and how[treatment formulation] questions
count and that the why question [clinical formulation] is unimportant and
the answer is not clinically valuable. Such a symptom focus is believed to
engender accountability and positive treatment outcomes because symptomfocused treatment goals are relatively easy to measure and monitor.
From an individual therapy perspective that recognizes individual
psychodynamics are essential in understanding and changing behavior, a
symptom focus is quite limiting. From a family therapy perspective the
symptom-focused approach is also viewed as limiting. Besides the behavioral family therapy models, systemic approaches have little interest in individual symptoms and tend to view individual symptoms as reflections of
larger contextual dynamics. Despite these limitations, many clinics, inpatient,
and residential treatment programs require this type of case conceptualization. There are several treatment planning manuals that emphasize this type
of conceptualization for bothindividual therapy (e.g., Jongsman & Peterson,
1999) and family therapy (e.g., Jongsman & Datillo, 2000).
THEORY-FOCUSED

CONCEPTUALIZATIONS

In addition to recognizing symptoms and impaired functioning, theoryfocused conceptualizations can provide a compelling explanation for them.

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This type of conceptualization derives from a therapists theoretical or therapeutic orientation and this orientation serves as the basis for treatment goal
setting and implementation. Thus, a theory-focused case conceptualization
will reflect a dynamically oriented, existential-humanistic-oriented, cognitively oriented, or one of many systemic approaches to therapy. Such a conceptualization involves fitting a specific theory to a client or client system.
Not surprisingly, from a theory-focused perspective the why question
is the most important of the three primary, orienting questions of a case conceptualization. Beyond a mere description of symptoms and functioning, it
is believed that the richness and texture of an individuals, a couples, or a
familys life can be more fully captured by a psychoanalytic, structural, intergenerational, solution-focused, narrative, theoretically guided explanation,
(i.e., clinical formulation). Because the various theoretical orientations attend
to intrapersonal, relational, cultural, systemic, and other contextual factors,
the explanation of the source or cause of reported symptoms can aid both
the therapists and the clients or client systems understanding.
There is considerable value and support for theory-focused conceptualizations. First, trainees and practicing clinicians with specialized training in
a given therapeutic orientation have been trained by instructors and supervisors to conceptualize human behavior through the prism of a particular
theoretical framework. Thus, developing a clinical formulation can both be
compelling cconceptually but also clinically useful in specifying treatment
goals and selecting compatible treatment interventions for achieving goals
above and beyond symptom relief.
The downside of theory-focused conceptualizations is that they are primarily therapist-centered and may not sufficiently reflect the clients or client
systems own conceptualization of the problem or concern. The result can be
limited client commitment to the treatment plan and process since the goals
and plan are more meaningful to the therapist than the client. There are several books detailing single theoretical approaches to case conceptualization
and treatment planning (Persons, 1989; McWilliams, 1999), there are a couple of books that compare several theory-focused approaches to individual
therapy (Berman, 1997) and family therapy (Gehard & Tuttle, 2003).
CLIENT-FOCUSED

CONCEPTUALIZATIONS

This type of conceptualization derives primarily from the clients or clientsystems experience, needs, and expectations rather than the therapists therapeutic orientation. Rather than fitting a particular theoretical approach to
a specific client or client system as in the theory-focused approach, this approach constructs a theory that fits the client or client system. Thus, such
a client-focused type of conceptualization is compatible with social constructivists models ranging from the Adlerian to the narrative approach. The
emphasis of this type of case conceptualization is tailored treatment and

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maximizing the fit between a clients or client systems issues or symptomatic presentation and the treatment interventions provided.
After a brief discussion of client conceptualizations, the remainder of this
article describes one such approach to case conceptualization, called pattern
analysis with applicability to individual therapy (Sperry, 2000) and couples
and family therapy (Sperry, 2000, 2005).

Case Conceptualizations of Therapist and Client


Effective therapists are skilled at developing, eliciting, and negotiating case
conceptualizations. Because meaning making and search for explanations
characterize human persons it should not be surprising that clients develop
their own case conceptualizations. While they may not consciously be
aware of their conceptualizations, these conceptualizations are nevertheless powerfully operative in the treatment process. Effective therapists not
only recognize the presence of these conceptualizations, but elicit them, and
then negotiate a common conceptualization with their clients. These personal conceptualizations closely resemble the structure of the professional
conceptualizations described earlier. First, the clients or client systems description of their presenting problem or concern, including their symptomatic
distress and their rating of their impairment in the various areas of life functioning, is analogous to the therapists clinical formulation. Similarly, the
clients explanatory model of their condition or presenting problem and the
clients expectations for treatment is analogous to the therapists treatment
formulation. The greater the similarity between the two conceptualizations,
the more likely that collaboration will occur leading to positive treatment
outcomes. The effective therapists task then is to elicit the clients or clients
systems case conceptualization and reconcile differences between the two
explanations. This typically involves an educational and negotiation process
resulting in a mutually agreeable focus for treatment and expectations about
goals, roles, and treatment outcomes.

PATTERN ANALYSIS AND CASE CONCEPTUALIZATION


The basic premise of pattern analysis is that specificity in understanding the
what and why of the clients or client systems situation is essential in
answering the how questiontreatment formulation considerations. This
approach involves a detailed inquiry and understanding of patterns: specific
triggers, specific individual and relational patterns, specific individual and
systemic responses, specific perpetuants, and so on. Thus, it is more a phenomenonological and an open systems approach than a single theory-based
approach. Rather than dismissing symptoms and levels of functioning as of
minor importance, both are taken seriously as they reflect the patterns.

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TABLE 1 Four Elements in Pattern Analysis


Precipitant
Presentation

Perpetuants
Predisposition

The triggers or stressors that activate the pattern


The clients characteristic response to precipitants. The type and severity of
symptoms, history, course of illness, diagnosis, and individual, relational
and systemic behaviors including collusion, coalitions, communications,
and level of well-being.
Processes by which a clients pattern is reinforced and confirmed by both
the client and the client environment
All the intrapersonal, interpersonal, and systemic factors, including
attachment style and trauma, which render a client vulnerable
to maladaptive functioning

As noted earlier, pattern is described as the predictable and consistent


style or manner of thinking feeling, acting and coping, and defending self in
stressful and non-stressful circumstances (Sperry et al., 1992). Pattern analysis
is the process of examining the interrelationship among four elements or factors: precipitating factors, predisposing factors, perpetuating factors, and presentation factors, including relational response factor (as shown in Table 1).
In other words, a clients pattern or predicable style of behavior and
functioning reflects and is reflected in all four factors: precipitant, presentation, perpetuants and presdisposition. While it may appear that predisposing
factors such as traumatic events, maladaptive beliefs or schemas, defenses,
personality style, or systems factors primarily drive ones thoughts, feelings,
and actions, the contention is that both individual and systemic dynamics are
a function of all four factors, and thus should be included in a pattern analysis. Because pattern analysis includes all these and associated individual and
systemic dynamics, it is provides a systemiatic and comprehensive basis for
developing and articulating a clinically useful clinical formulation.

CASE EXAMPLE
Presenting Problem and Background Information
Leslie is a 12-year-old fraternal twin and son of a separated Euro-American
couple. He was referred for a family evaluation and treatment before discharge to the childrens hospital affiliate in an academic medical center. He
was hospitalized for diabetic coma. Leslie had been treated for juvenile-onset
diabetes since he was 7, although his older twin, LeRoy, has not received that
diagnosis nor been treated for it. It is noteworthy that until recently Leslies
diabetes was reasonably well controlled with diet and daily insulin injections
and blood sugar checks which he did himself. Other than this chronic medical problem, his health was good. He is the younger of two siblings, his
sister being 8 years older. His mother admits that Leslie was an unplanned
pregnancy and that her moderate social drinking during her pregnancy might

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have had some bearing on his diabetic condition. Leslie had done reasonably
well in school, had a few friends at his school and was quite involved with
both scouting and coin collection. Leslies sister is married and living out of
state. His parents separated about 7 months ago, and Leslie has been living
with his mother in the family home, although he spends most weekends with
his father who is living in a nearby apartment. Leslies father continued the
affair that had led to the separation and Leslies mother had begun dating.
Needless to say, Leslie was confused and frightened by these changes. LeRoy,
on the other hand, reports he is fine with this parent things; let them do
what they want. Caroline, their older sister by 9 years, apparently has not
been negatively impacted by the parents decision to separate and remarry.
Three weeks prior to the evaluation Leslies father said that he was
planning on getting married in 6 weeks. Later that day Leslie stopped taking
his insulin and went off his diet. Two days later he was found unconscious
in his room by his mother who rushed him to the emergency room where
he was diagnosed with diabetic ketoacidosis, treated and released. Leslies
parents immediately rushed to his bedside, putting their animosity aside, and
planning how they could support Leslie as best they could. His father moved
back into the family home and spent all his free time with Leslie. The family
was back together again, at least for a while. As things stabilized his father
moved back to his apartment and went forward with his wedding plans. The
next day, Leslie was taken by ambulance to the hospital where he was treated
for a diabetic coma. The pediatric endocrinologist who consulted on the case
told the parents that Leslie had nearly died and that his body was unlikely to
sustain another incident such as this. Recognizing that family dynamics were
involved, the doctor made the referral.

Case Conceptualization
DIAGNOSTIC

FORMULATION

In terms of DSM-IV-TR Leslie met criteria for the diagnosis of an Adjustment


Disorder and a V-Code of Parent-Child Problems. Of more value from an
assessment and formulation perspective is the pattern analysis summarized
in Table 2.
CLINICAL

FORMULATION

Pattern analysis reveals that when his parents begin talking of divorce and
remarriage Leslie responds by going off his diet and stopping his insulin.
The result is diabetic ketoacidosis which can result in coma and death if not
aggressively treated. An evaluation of individual dynamics reflect his selfview of being weak and physically defective in a world that is dangerous
and the unexpected happens and where people try to be caring but let him

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Case Conceptualization
TABLE 2 Pattern Analysis: Case of Leslie and Family
Pattern Factors
Precipitating
Factor(s)
Predisposing
Factor(s)
Presentation/
Personal
Presentation/
Family/Relational
Perpetuants

Formulation/Treatment Targets

Interventions/Sequence

Parents talk of divorce and remarriage

1. Parental coaching

Leslies defectiveness and rejection


schemas; familys everyone takes
care of themselves narrative
Leslies blood sugar drops and diabetic
coma
Parental temporary mobilization
attending to Leslies health
Leslies schema; family narrative

3. Schema work (Leslie);


Re-storying (family)
4. Health counseling
2. Parental coaching
3. Schema work (Leslie);
Re-storying (family)

down and hurt him. His strategy is to seek comfort and safety using whatever
means and at any cost to him. His self-harming behavior is his way of drawing his family back together where he can feel secure, connected, and cared
for. In terms of systemic dynamics, it appears that the familys narrative is
one of independence and self-reliance wherein everyone is expected to take
care of themselves and their own needs. This narrative permits the parents
to find other partners and go on with their individual lives if the marriage
doesnt work out. Similarly, it is acceptable that Leslies sister is living on
her own in another state. Unfortunately, Leslies schemas are a poor fit with
family narrative. Even his hobbies reflect his need for security (coin collecting) and connectedness and caring (scouting) rather than independence and
self-reliance.
TREATMENT

FORMULATION

Based on the clinical formulation above, the following short-term and longerterm treatment goals can be specified. Table 2 summarizes these interventions
and their potential sequencing. Note that the numbering represents the order
in which interventions are sequencedparental coaching is first and third,
while schema work and re-storying are second, and so on.
Given that Leslies health behaviorblood sugar drops and diabetic ketoacidosis and coma is relationally specific, to his parents talk of divorce
and remarriage and have not generalized, a conservative treatment strategy
would be to focus on the short-term goal of reducing or modifying this trigger. This could involve a few sessions with parents in which they are coached
to reduce triggering future health crises. It had been elicited that the parents no longer spoke with each other but would channel information about
themselves through Leslie and so the therapist would help them understand
the overall pattern and find ways of communicating directly with each other
[Intervention/Sequence 1].

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Next, treatment would include individual sessions with Leslie with a focus on his defectiveness and rejection schemas and sessions including his parents in which the family schema or narrative of independence/self-reliance
would be addressed. Coming from the narrative therapy tradition, restorying involves focusing on previously unexamined or unemphasized aspects of
those experiences (White & Epston,1990). The resulting story includes pieces
of meaning and understanding that are new or different and that allow for
a positive shift in the original family narrative. In this case, re-storying involved a bit less emphasis on the independence and self-reliance and more
on caring and connectedness with one another [Intervention/Sequence 2].
In addition, the parents would be coached about the value of regularly
scheduling time togetherat least once a weekwith Leslie to show their
support and caring for him. Even if divorce and remarriage occurred, this
planned family time together was preferable to emergency meetings in the
hospital, and certainly less life threatening [Intervention/Sequence 3]. Efforts
to achieve such family time would likely fail if this intervention preceded
work on the family narrative.
Finally, health-focused counseling (Sperry et al., 2005) is directed at
maintaining stable blood sugar levels and adherence to diet and insulin
regimen. Attempts to provide this kind of counseling prior to parent coaching
and prior to modifying Leslies schemas would most likely have been futile
[Intervention/Sequence 4].

Case Commentary
In this example, the case conceptualization did guide treatment planning
and implementation. The parents were quite responsive to parent coaching sessions and work on the family narrative, as was Leslie. The result
was that Leslies health stabilized and has remained stable for two years.
Although his father did remarry about a year ago, the family regularly continues to meet weekly. It is noteworthy that the pattern analysis provided
a framework not only for planning interventions based on the clinical formulation, but just as importantly, it offered a strategy and rationale for sequencing the interventions. As was previously noted, it is counterintuitive
to offer health counseling interventions last rather than first as this case
illustrated.

CONCLUDING NOTE
This article began by describing the emergence of case conceptualization
and treatment planning as a core competency for those practicing individual, couples, and family therapy. It was noted that while market and regulatory/statutory forces have been largely responsible for the thrusting case

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conceptualization in the limelight, the psychotherapy and marital and family


communities must now become proactive in this area. There are many concerns to be addressed which include: developing consensus on definitions
and models of case conceptualizations, articulating and evaluating strategies
for developing effective and clinically useful case conceptualizations, establishing training methods of clinicians and supervisors in the conceptualization
process, and initiating additional research and theory-building efforts in this
area. The clinical value and utility of case conceptualization for therapists,
trainees, supervisors, managed care reviewers, and clients is increasingly
evident. Three main types of case conceptualization were described and critically analyzed, and it was argued that the client-focused type was the most
appropriate in addressing theoretical and clinical considerations. A clientfocused type with a phenomenolgical and systematic emphasis called pattern
analysis was described. A detailed case study illustrated how pattern analysis
provides a systematic framework for conceptualizing individual, couples, and
family dynamics in terms of diagnostic, clinical and treatment formulations,
and how treatment interventions can be tailored and sequenced to optimize
treatment outcomes with clients and client systems.

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