Little is documented concerning specific methods for training clinicians in case conceptualisation construction (Persons & Tompkins, 2007). However a number of common difficulties in training case conceptual skills have been identified (Persons & Tompkins, 1997). Firstly, clinicians frequently do not construct comprehensive problem lists, often omitting important information such as medical and other non psychological problems. Furthermore there is a tendency to over generalise and use jargon such as ‚co dependency‛ to describe problems rather than a specific functional analysis of the actual situation. These authors recommend that detailed discussions of the problem should be encouraged. Secondly it is reported that clinicians are often too cautious in generating a number of alternative hypothetical explanations for presenting problems, which can then be discussed and either
_________________________________________________________________________ applied or discarded as deemed appropriate. It is suggested that clinicians should be encouraged to generate multiple hypothesises and treatment interventions in the first instance and not be too concerned with the idea that there is only one ‚right answer‛. These writers also emphasise the need for the trainer to distinguish between two recurring questions asked by trainees namely, ‚How do I ?‛ and ‚What do I do if?‛ The second question is a question relating to the individualised case conceptualisation. Their final point is to stress the importance of the trainee clinicians being aware of the importance of applying disorder specific
conceptualisations when appropriate (individualised using the client’s
idiosyncratic information). In their view, teaching case conceptualisation requires, that in the first instance, the clinician is familiar with the model of psychotherapy used in conceptualising the problem, and that secondly they be given practice in generating and applying hypothesises in a situation where debate and discussion can occur. Familiarity with the model is dependent on traditional didactic teaching methods and the clinician’s own reading, research, and practice. These authors make no reference to the ‚therapist’s personal therapy‛ as a training mechanism.
Indeed, most methods of case conceptualisation see conceptualisation as a rational intellectual process, stipulating that trainees should familiarise themselves with the theoretical model and method of case formulation, practice on clients, read widely, and seek supervision. Familiarity with behavioural assessment, adult and child psychopathology, psychometrics, problem solving principles, developmental psychology, and interviewing skill are all emphasised as important in case conceptualisation (Nezu, Nezu, Friedman, & Hayes, 1997).
_________________________________________________________________________ Exceptions are, in Cognitive Analytic Therapy, where personal ‚non-time limited’ Cognitive Analytic Therapy is required for advanced trainees and first level
trainees would generally have had some form of dynamic therapy (Ryle & Bennett, 1997), which is assumed to be a necessary part of coming to grips with the case conceptualisation process. Similarly, as would be predicted, in most
psychoanalytic approaches therapists in training are expected to undergo their own dynamic therapy to develop the necessary clinical judgement to create a ‚complex dynamic formulation‛ (Messer & Wolitsky, 2007 p. 96). These
psychodynamic approaches are in line with the more generally recognised view of personal therapy which helps therapists identify blind spots and thus work more effectively with transference and counter transference issues.
Conceptualisation in Dialectical Behaviour Therapy (DBT) requires the therapist to ‚think like a behaviour therapist and experience like a Zen student‛ (Koerner, 2007 p. 365), with little clear direction as to how this could be achieved. However self- practice/self-reflection could be assumed to have a part to play in this instance, for example the DBT training program requires that trainees understand mindfulness and practice meditation (Linehan, 1993). In DBT the therapist’s awareness and sensitivity to his or her own emotional reaction to the client is emphasised as important in DBT case conceptualisation (Koerner & Linehan, 1997), once again this skill would seem amenable to the impact of structured self-practice/self- reflection.
Producing a CBT case conceptualisation of high quality requires that the clinician integrates a number of different strands of information about the patient such as the diagnosis, idiosyncratic patterns or cycles, triggering situations, thoughts,
_________________________________________________________________________ emotions, and behaviours. Relevant information is obtained through sensitive interviewing, interpersonal sensitivity, and the skilful application and
understanding of CBT interventions such as the dysfunctional thought record. Interpersonal understanding is essential in the conceptual use of the therapeutic relationship and requires a thorough understanding by the therapist, of his or her own beliefs and behaviours and their impact on the therapeutic relationship.
Information relevant to case conceptualisation, gained through more acute understanding of the therapeutic relationship includes identifying problematic systems of beliefs and behaviours (in both therapist and client), information about the ability of the patient to engage in therapy, motivation, possible obstacles which may be encountered, and the most appropriate interpersonal style needed to promote constructive engagement. Studies reporting on the effects of exposure to self-practice/self-reflection indicate that the clinician’s sensitivity to this kind of information may be facilitated by what Bennett-Levy and his research participants have called a ‚deeper sense of knowing‛. This facility, reported to be heightened by the interaction between self-practice/self-reflection is important in coming to grips with the complexity and richness of information conveyed in the
interpersonal transactions in psychotherapy.