Advance Praise for The 15 Minute Case Conceptualization
This is it! This is the book for planning and implementing highly effective therapy. Use the five-steps strategy for a 15-minute case conceptualization that will guide your clients’ movement toward wellness. For a few minutes more, the eight step strategy will make the difference for those with more severe and debilitating conditions. Every practicum and internship student absolutely needs this book. And, if you missed case conceptualization in your training, this pattern-focused approach will make all the difference in how you practice after graduation.
James Robert Bitter, EdD East Tennessee State University
I’ve needed this book for 30 years! . . . Reading (it) has already helped me become better at teaching case conceptualization.
John Sommers-Flanagan, PhD from the Foreword
The 15 Minute Case Conceptualization: Mastering the PatternFocused Approach by Len and Jon Sperry is a must read for any mental health professional. Their practical five-step procedure for tracking clients’ nine behavioral markers, all illustrated with numerous case studies, makes mastery of case conceptualization easy. This unique, research-based approach is the most comprehensive approach to case conceptualization available and should be required reading in any academic mental health program.
Brian A. Gerrard, PhD Western Institute for Social Research and University of San Francisco
Len Sperry, MD, PhD, is a pioneer and one of the top experts in behavioral health case conceptualization in the world. Reading this book will be like having Len mentor and personally teach you his artful approach to recognizing personality-based patterns and case conceptualization and will improve your clinical assessment and practice. Len and his son Jon team up to offer this refined yet
inclusive approach that helps you understand your patient from multiple perspectives and puts you in a position to better help your patient. I benefitted from Len’s expertise in the classroom when he was first developing and teaching his case conceptualization approach, and it has had an incredible impact on my career and has helped me with everyone I have ever worked with. More importantly, my patients have all benefitted from it. I strongly recommend this mustread text and reference to all behavioral health professionals.
Jon A. Lehrmann, MD
Charles E. Kubly Professor and Chair of Psychiatry and Behavioral Medicine
Medical College of Wisconsin
Sperry and Sperry are pioneers in advocating for psychotherapy case conceptualization and providing practical tools for incorporating this critical skill into clinical practice. Their latest contribution sweeps away myths that case conceptualization is too cumbersome, time-consuming, or difficult. Learning their parsimonious 15-minute case conceptualization approach for more straightforward clients and their full-scale model for more complex clients would benefit any therapist. In short, this important book can help therapists achieve better outcomes.
Tracy D. Eells, PhD University of Louisville
In The 15 Minute Case Conceptualization, Drs. Sperry offer a remarkably timely, practical, easy to understand and implement case conceptualization approach for clinical and counseling students and professionals. Today, clinicians must provide evidence-based, practical, and accurate case conceptualizations and this book will certainly help them to do so. It highlights nine clear and easy to remember “behavioral markers” that anchor the process of case conceptualization. This book should be in the hands of every clinical student and practitioner, and surely it will be the go-to resource for case conceptualization.
Thomas G. Plante, PhD, ABPP Santa Clara University and Stanford University School of Medicine
The 15 Minute Case Conceptualization
Mastering the Pattern-Focused Approach
LEN SPERRY, MD, PHD AND JON SPERRY, PHD
3
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Library of Congress Cataloging-in-Publication Data
Names: Sperry, Len, author. | Sperry, Jon, author. Title: The 15 minute case conceptualization : mastering the pattern-focused approach / Len Sperry, M.D. Ph.D. & Jon Sperry, Ph.D.
Other titles: Fifteen minute case conceptualization
Description: New York, NY : Oxford University Press, 2021. | Includes bibliographical references and index.
Identifiers: LCCN 2021024152 (print) | LCCN 2021024153 (ebook) | ISBN 9780197517987 (paperback) | ISBN 9780197518007 (epub) | ISBN 9780197608715 (online)
LC record available at https://lccn.loc.gov/2021024152
LC ebook record available at https://lccn.loc.gov/2021024153
DOI: 10.1093/oso/9780197517987.001.0001
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Printed by Marquis, Canada
Foreword
I’ve needed this book for 30 years!
Just last month (before reading this book), I was standing in front of a Zoom camera, trying to teach the basics of case conceptualization to a group of 23 master’s and doctoral students. All of my fine-grained case conceptualization wisdom was being channeled into a single visual and verbal performance. “My left hand,” I said, “is the client’s problem.” Pausing briefly for dramatic effect, I then continued, “and my right hand is the client’s goal.”
My newfound nonverbal gestures are mostly a function of seeing myself on the screen, and therefore wanting to avoid seeing myself (and being seen by the class) as boring. To add spice to my case conceptualization gesturing. “Case conceptualization is simple,” I said. “All it is, is the path we take to help clients move from their problem state . . . toward their goal state” (I finished with a flourish, by wiggling the fingers on my raised right hand).
But boiled down truths are always partly lies. Despite my fabulous mix of the verbal and nonverbal, I was lying to my students. At the time, I had thought of it as a little white lie, all for the higher purpose of simplification. And although I still like what I said and still believe in the rough truth of my visual case conceptualization description, after reading Len and Jon Sperry’s illuminating work on case conceptualization, I better understand what I should have said.
Case conceptualization is not simple. As Sperry and Sperry describe in this book, case conceptualization—even when summarized well—includes multiple dimensions of human behavior along with clinician perception, judgment, and decision-making. I needed much more than a few wiggly fingers to communicate the detailed nuances of case conceptualization.
What these authors have done in this book is the gracious service that great writers do so well: They have done our homework for us. They’ve read extensively, taken notes, taught and field tested their approach, and gifted us with elegant summaries of dense and complex concepts. They’ve made it easy for us to understand and apply the principles and practices of case conceptualization.
What I like best is how they transformed a bulky and inconsistent literature into simple, therapist-friendly principles. They emphasize the explanatory, tailoring, and predictive powers of case conceptualization. I’ve never organized case conceptualizations using those “powers,” but doing so was like switching on a light bulb. Of course, case conceptualizations should explain the relationships between client problems and client goals and shine a bright light along the path, but rarely do theorists or writers make this linkage so efficiently. Their second principle, tailoring case conceptualization to individual and diverse clients is also essential. The whole idea of tailoring counters the all-too-frequent cookbook approach to case conceptualization. Tailoring breathes life into creating client-specific case conceptualizations. And of course, case conceptualizations need predictive power; the authors equip us with enough foundational predictive language to anticipate potential challenges and roadblocks in the treatment process so we can address them should they arise.
Many other examples of how elegantly Sperry and Sperry have done our homework are sprinkled throughout this book. Here’s another one of my favorite examples: In Chapter 2, they take us (in a few succinct paragraphs) from what Theodore Millon described as eight evolutionarily driven personality disorders to eight crisply described behavioral patterns. What I love about this is that Len and Jon’s wisdom transforms what might otherwise be viewed as a pathologizing personality disorder system into language that can be used collaboratively with clients to identify contextually maladaptive interpersonal patterns. This is a beautiful transformation because it spins psychopathology into something clients not only understand but also will feel compelled to embrace.
The process goes something like this:
1. Therapist and client engage in an assessment process that touches on the client’s repeating maladaptive behavior patterns. These behavior patterns are palpably troubling and far less than optimal for the client.
2. As all clinicians inherently know, touching upon clients’ repetitive maladaptive behavior patterns can activate client vulnerability. This is a primary challenge of all counseling and psychotherapy: How can we nudge clients toward awareness without simultaneously activating resistance? For decades, psychoanalysts managed this through cautious trial interpretations. Solution-focused therapists dealt with this by
never speaking of problems. Gently coaxing ambivalent clients toward awareness and change is the whole point of motivational interviewing.
3. When addressed in a sensitive and nonpathologizing way, deep maladaptive behavior patterns can be discussed without activating resistance or excessive emotionality. This is a critical and not often discussed part of case conceptualization. The authors illuminate a path for gentle, sensitive, and collaborative case conceptualization.
4. When clients can feel, recognize, and embrace their maladaptive behavioral patterns in the context of an accepting therapeutic relationship, insight is possible. When insight happens, client interest is piqued and motivational to change spikes. Good case conceptualizations articulate problem patterns in ways that compel clients to invest in change.
I’m not surprised that Sperry and Sperry have produced such a magnificently helpful book. If you dig into their backgrounds and conduct a case conceptualization of their personality patterns, you’ll discover they wholeheartedly embrace Alfred Adler’s work and, consequently, much of what they do is all about social interest. Len and Jon Sperry are in the business of helping others. Reading their book has already helped me become better at teaching case conceptualization. I appreciate their work, and, no doubt, the next time I begin waving my hands in front of my Zoom camera, my students will appreciate their work too.
John Sommers-Flanagan, PhD University of Montana
Introduction
In their first session, Jessie told her therapist, Jared, that her daughter was just diagnosed with a life-threatening medical condition. Jared then elicited her thoughts and feelings about the diagnosis. Jessie expressed guilt and anger for not seeking a medical consultation earlier. The remainder of the session focused on disputing these guilt-producing thoughts. At the end of the session, Jessie was more despondent as she scheduled a follow-up appointment. After processing this session in supervision, Jared was no longer surprised that Jessie did not keep their scheduled appointment. Their first and only session occurred near the end of Jared’s third week as an intern, and he had been eager to practice a brief cognitive disputation strategy just learned during a weekend workshop. When the supervisor asked if Jared had developed a case conceptualization that might have averted this premature termination, the answer was no. Because Jared had not learned case conceptualization in his formal graduate coursework, the supervisor facilitated Jared’s learning this competency.
This happened at a time when there was considerably less awareness of the clinical value of case conceptualizations than now. To aid in increasing such awareness, we published the first edition of Case Conceptualization: Mastering This Competency with Ease and Confidence in 2012. Since then, many other books, articles, and book chapters have been written. Today, the capacity to write credible case conceptualizations is considered essential in counseling and therapy practice. In fact, increasingly, case conceptualization is considered one of the most important of all clinical skills and competencies. Once understood as useful but optional, case conceptualization is now considered essential and required.
Today, there are a number of case conceptualization approaches. So, which one will you choose? When making such a decision, it is useful to determine which of these approaches are effective and, if effective, are they clinician friendly? Returning to the case of Jesse, even if Jared had developed a particular type of case conceptualization, there is no guarantee that premature termination would have been avoided. Why? Because most case conceptualization approaches emphasize the functions of explanation and guiding
treatment but seldom include a prediction function. This third function helps the clinician anticipate likely challenges and obstacles that if not proactively addressed are likely to result in therapy interference and/or premature termination, as with Jesse. Without such a predictive function, an approach cannot be effective.
In contrast, a case conceptualization informed by the pattern-focused case conceptualization approach—the approach described in this book—would have predicted that because of Jessie’s avoidant pattern, it is anticipated that a specific transference–countertransference enactment was likely, and if it occurred, she might drop out of treatment, as she did. The predictive function is as important as or more important than the explanatory function and the guiding or tailoring function. It is particularly important in determining the course and overall effectiveness of therapy. As the saying goes, clients can only succeed in therapy if they show up, and they make progress.
Despite the growing number of case conceptualization approaches, publications, and courses and workshops, a number of myths about case conceptualizations remain. Basically, these myths reflect the extent to which an approach is clinician friendly or not. Two such myths of case conceptualizations are that they are (1) too complex and difficult to learn and (2) too time-consuming to write. The approach described in this book can be learned in as little as a 2-hour training workshop, and as a result of this training, trainees and practicing clinicians can write credible case conceptualizations in just 15 minutes.
In short, the extent to which a case conceptualization approach is effective and clinically valuable and also clinician friendly are key criteria in evaluating a case conceptualization approach. Because trainees and practicing clinicians have shared with us that these are very important concerns for them, we have designed this book to focus on ease of use, practicality, and effectiveness.
So, can an accurate and complete case conceptualization actually be written in as little as l5 minutes? The answer is “yes”—if one follows our eight-step strategy. This strategy emerged from 10 years of teaching this approach to more than 1,000 mental health trainees and professionals as well as the results of a line of research on case conceptualization. This book will lead you through this eight-step strategy: You answer eight prompt questions with eight sentences and then string them together into a concise and complete case conceptualization statement.
The case conceptualization approach described in the following chapters is one of the very few evidence-based approaches. By evidence-based, we mean that six empirical studies have demonstrated its effectiveness with both graduate students and practicing clinicians. No other case conceptualization approach can make this claim.
Overview of the Book
Chapter 1 addresses the question of what constitutes a clinically valuable case conceptualization approach or what we hereafter refer to as a highly effective case conceptualization approach. We note that a paradigm shift is underway in the practice of medicine and suggest that a similar shift is underway in psychotherapy practice as it becomes increasingly informed by focused case conceptualization approaches.
Because our approach is pattern-focused, Chapter 2 focuses on pattern, which we consider the very heart of a highly effective case conceptualization. The chapter includes a clinical strategy for quickly identifying a client’s basic pattern. Then, eight of the most common patterns are described in terms of their characteristic behavioral markers.
Chapter 3 introduces the basic concepts of this approach. It discusses each of the nine P’s, which are the core behavioral markers of this approach: pattern, presentation, precipitant, predisposition, protective factors, perpetuants, personality–culture, plan, and predictive factors.
Chapters 4 and 6 offer the basic strategy of this approach for writing highly effective case. In Chapter 4 you will find the five-step, brief case conceptualization approach described and illustrated. In Chapter 6 you will find the eight-step, full scale case conceptualization approach described and illustrated with case material.
Chapters 5 and 7 provide additional case material to help you learn and begin to master this approach. Chapter 5 will help you practice developing brief case conceptualizations, and Chapter 7 provides exercises to help you develop full-scale case conceptualizations.
So far, we have described and illustrated our case conceptualization approach for working with individual clients. But what about working with couples and families? Is an individual case conceptualization sufficient or is more needed? Whereas formulating a conceptualization for individual clients is necessary, it is not sufficient with couples or families. Accordingly,
Chapter 8 provides additional behavioral markers to incorporate in developing effective couple and family case conceptualizations. A provocative and troubling case that received extended national attention illustrates our approach for incorporating individual, couple, and family patterns.
The question of how one goes about increasing one’s mastery of our approach is addressed in Chapter 9. Specific interventions such as deliberate practice and mindfulness are highlighted and specific exercises are included. The chapter also provides a scaffolded format that mental health educators can use to intentionally integrate the pattern-focused approach in various graduate courses. Finally, you may want to know about the line of research that supports the claim that our case conceptualizations approach is both brief and effective. We conclude the book with Chapter 10, which describes the origins of our approach and evidence for its briefness—15 minutes—and effectiveness. This chapter provides the history and the results of 10 years of experience utilizing it in teaching and supervising trainees and clinicians as well as the results of six research studies.
Some may wonder how this book differs from the authors’ other case conceptualization books. Whereas the two editions of Case Conceptualization: Mastering This Competency with Ease and Confidence emphasized integrating common case conceptualization elements with specific elements from five major theoretical orientations, this book is shorter and more practical. This book focuses solely on learning our pattern-focused format for writing concise, effective, and compelling case conceptualization in eight steps resulting in an eight-sentence case conceptualization statement. What about any connection between this book and Len Sperry’s Pattern Focused Therapy (2021)? Although both books emphasize the centrality of pattern, Pattern Focused Therapy describes and illustrates how an evidencebased, pattern-focused case conceptualization informs an evidence-based, pattern-focused approach to therapy in mental health and integrated care settings.
We anticipate that before long, readers will be able to write a credible case conceptualization in 15 minutes. It is our hope that you will be among the first!
1 The Pattern-Focused Case Conceptualization Approach
So, what is a clinically valuable—that is, highly effective—approach to case conceptualization? Generally, clinicians expect that a case conceptualization approach will help them (1) provide a useful explanation that will help clients understand why they are experiencing their presenting symptoms or conflict and (2) provide a useful guide in planning and implementing treatment. Some current case conceptualization approaches provide these. Although both are necessary, they are not sufficient conditions for clinical utility and therapeutic effectiveness. Often, these approaches fail to provide what is essential to achieve positive clinical change while avoiding premature termination: a prediction of the clinical challenges and obstacles that are likely to be encountered as the therapy process unfolds, starting with the first encounter. In contrast, the approach described in this book emphasizes this predictive function as well as the explanatory and the guiding functions. This chapter describes and illustrates these three functions, which are central to the pattern-focused approach described and advocated in this book. It describes the paradigm shift that precision medicine is making in medical practice, with its focus on precision and personalized treatments based on biomarkers, and a similar shift occurring in psychotherapy practice based on behavioral markers. Case conceptualization approaches based on behavioral markers and that can explain, guide, and predict treatment challenges as well as optimize treatment outcomes appear to be the future of the field. The pattern-focused case conceptualization approach that informs this book is one such approach. Key points are illustrated later in the case of Jill.
Pattern-focused case conceptualization approach: An approach to case conceptualization that offers an evidence-based strategy for understanding and explaining the client’s situation and maladaptive patterns, for guiding and tailoring treatment, for anticipating challenges and roadblocks in the treatment process, and for optimizing treatment
outcomes. As such, it is likely to exhibit high levels of explanatory power, tailoring power, and predictive power.
Case Conceptualizations That Explain, Guide, and Predict Challenges
The three key functions of a highly clinically valuable case conceptualization approach are described in this section. Three criteria are available for evaluating the adequacy and precision of a specific case conceptualization: explanatory power, tailoring power, and predictive power. Not surprisingly, high levels of explanatory, tailoring, and predictive power are the characteristics of a highly effective case conceptualization approach. Because all three functions are informed by and reflect pattern, a basic description of pattern is provided next.
Pattern
Our approach to case conceptualization is centered on pattern. We define pattern as the predictable, consistent, self-perpetuating manner in which an individual thinks, feels, copes, and behaves. We presume that pattern identification and pattern change are the “heart of a case conceptualization” (Sperry & Sperry, 2020, p. 34). Whether in therapy or not, most of us are comfortable with the notion of patterns and can learn to identify and change our own patterns. In fact,
Most patients readily accept the idea that there is a “pattern” underlying their behavior. The word is reassuring, for it suggests that there is order and meaning to behavior and experience. Educating patients about these patterns helps them to distance themselves from events and promotes selfobservation. At the same time, pattern recognition promotes integration connecting events, behaviors, and experience that were previously assumed to be unconnected. (Livesley, 2003, p. 274)
Chapter 2 focuses on patterns. The eight most common patterns that present for psychotherapy are described along with their origins. Maladaptive and adaptive versions of each pattern are described along with their
precipitant or trigger. Then each of the five potential therapeutic challenges or obstacles are listed.
Explanatory Function
An explanation is a statement that gives meaning to a set of circumstances that may be troubling. In terms of a case conceptualization, as a client’s maladaptive pattern begins to emerge, the clinician can provide an explanation for the factors that account for the client’s behavior and reactions in the past and present, particularly regarding the presenting problem. By explaining the client’s symptoms or relational conflict in terms of their maladaptive pattern, the client not only gains understanding but may also experience some measure of control over the situation. The explanation can also provide a rationale for the proposed treatment.
Explanatory Power
In our case conceptualization approach, pattern is the central concept. Accordingly, the degree to which a specific case conceptualization can explain the client’s maladaptive pattern in an accurate and compelling manner is essential to our approach. It is called explanatory power (Sperry & Sperry, 2020). Case conceptualizations have variable gradations of explanatory power, ranging from low to very high. The more accurate the predisposing factors, risk and protective factors, cultural factors, and specificity of the maladaptive pattern, the higher the level of explanatory power.
Guiding Function
Much of what you read or hear about the value of using case conceptualizations is that they help “guide” treatment. But what exactly does guiding treatment mean? Specifically, what does guiding mean for the particular client with whom you are working right now? In our experience, using any case conceptualization approach may be better than a case summary in making decisions to personalize and tailor treatment, but few of these approaches help you specifically tailor your interventions, much less help you anticipate the treatment issues and challenges and how to face them with specific clients.
This is exactly where the pattern-focused approach described in this book differs from other case conceptualization approaches. What is the difference? It is “precision” and “personalizing.” By focusing on precision and personalizing, medical practice has begun to rapidly change since the Precision Medicine Initiative was announced and began implementation (Collins & Varmus, 2015; Parker et al., 2016).
This initiative reflects the paradigm shift underway in the practice of medicine. Its distinguishing feature is the replacement of the trial-and-error strategy with the precision and personalizing strategy to optimize treatment outcomes (Parker et al., 2016). The precision medicine approach was first applied in cancer treatment to select the exact combination of cancer treatments that “best fit” a particular patient based on genetic biomarkers, instead of the traditional trial-and-error strategy. The result has been a quicker and optimal treatment response without the troubling side effects and wasted time associated with medical decisions based on trial and error.
This approach is now being applied to depressed individuals who would typically undergo an antidepressant trial (Musker & Wong, 2019). Given that only one-third of individuals experience a positive therapeutic response to first prescribed antidepressant, the trial-and-error strategy continues—sometimes for a year—until an effective medication is found. In contrast, the precision medicine approach utilizes an individual’s unique biomarkers—including genetic characteristics—to select which antidepressant will be the best fit for them.
Might the precision medicine approach be applicable as a personalizing and tailoring strategy in psychotherapy practice? The answer is “yes.” The strategy is dubbed precision medicine/mental health (Delgadillo & Gonzalez Salas Duhne, 2020), and recent research is promising. For example, researchers matched a treatment approach—cognitive–behavioral therapy or person-centered counseling—to some biomarkers and behavioral markers in patients with major depression. They found that those who received their optimal treatment match were twice as likely to improve significantly (Delgadillo & Gonzalez Salas Duhne, 2020).
Case conceptualization can be a powerful strategy in personalizing psychological treatment. Although there are yet no biomarkers for selecting the best fit of psychotherapeutic interventions, the nine “behavioral markers” identified in this book serve a similar function as biomarkers. We believe that a “precision-focused” case conceptualization is a particularly powerful strategy for planning and implementing the best fit treatment process for clients without trial and error. The pattern-focused approach that informs this book is such an approach.
Nine Behavioral Markers in Highly Effective Case Conceptualization Approaches
Presentation
Precipitant
Pattern
Predisposition
Perpetuants
Personality–culture
Presenting problem and characteristic response to precipitants
Triggers that activate the pattern resulting in the presentation
Predictable, self-perpetuating way of thinking, feeling, acting, and coping that underlies the presentation; is adaptive, flexible, and effective or maladaptive, inflexible, and ineffective
Biological, psychological, and social factors that foster adaptive or maladaptive presentation (symptom) and pattern functioning
Factors that maintain the presentation and pattern
Impact of cultural factors (identity, explanation, stressors, and acculturation) and personality on the presentation
Protective factors
Plan
Predictive factors
Elements that foster well-being and decrease the likelihood of developing a clinical condition
Stated treatment goals—including pattern change—and the therapeutic and cultural interventions to achieve them
Challenges in the treatment process anticipated from the pattern
Analogous to the trial-and-error in medicine are necessary modifications to the treatment process in psychotherapy that were not initially anticipated. Trainees learn early on that there is no guarantee that the initial therapeutic approach, including empirically supported treatments, will be effective with every client. Just as in medical practice, there are side effects in psychotherapy. These have been called therapy-interfering behaviors or factors (Linehan, 2015). The most common of these factors are breaches in the therapeutic alliance, a lack of treatment response, and dropout or premature termination (Sperry, 2021).
Although we are not proposing this evolving paradigm shift be called “precision psychotherapy” or something similar, we continue to advocate for the increased use of focused case conceptualization approaches that personalize and tailor treatment and optimize outcomes. This book represents our continuing effort to equip therapists and other mental health professionals with a proven set of skills for achieving the best fit and optimal clinical outcomes for specific clients.
Tailoring Power
In our case conceptualization approach, tailoring is a key concept. Treatment outcomes are likely to increase when a compelling explanation informs a treatment plan and its implementation. Case conceptualizations have variable gradations of being focused and tailored, ranging from low to very high. The treatment plan is rated based on the degree to which it reflects and “fits” a specific client’s predisposing factors and cultural explanation—as well as the client’s particular needs, goals, readiness, and willingness to engage in the treatment process—and leads to optimal treatment outcomes. It is called “tailoring power” and is integrally related to the guiding function.
Predictive Function
By prediction, we mean anticipating likely challenges and obstacles to the treatment process and outcomes, including the therapeutic alliance. Trainees find the prospect of making such predictions daunting until they learn about the consistency and enduring nature of patterns of personality and behavior. It is this enduring quality of specific patterns that facilitates prediction. For instance, clients with a passive–aggressive pattern are likely to demonstrate ambivalence or resistance when certain expectations are communicated. Furthermore, it would not be surprising for a client with an avoidant pattern to summarily refuse involvement in group-oriented treatment or for a client with a dependent pattern to find termination most difficult. In addition to pattern, the clinician would do well to consider the client’s developmental and social history, particularly early relational conflict and trauma. That a client has not experienced previous success in making small personal change suggests that failure may also be operative in therapy unless these dynamics are directly addressed. We teach trainees to start looking for clues about a likely pattern from the first encounter with the client and then ask questions to rule in or rule out that pattern.
Predictive Power
In our case conceptualization approach, anticipating and predicting the likely clinical challenges and obstacles to treatment progress is highly valued. The capacity to identify the five characteristic challenges associated with the client’s pattern, as well as other factors, is a marker of a clinician’s expertise. The ultimate test of a case conceptualization is its clinical value in identifying such obstacles and proactively planning a therapeutic response. This is referred to as its “predictive power” (Sperry & Sperry, 2020). Furthermore, highly predictive case conceptualizations are associated with optimal treatment outcomes. Effective treatment outcomes require that clinicians anticipate, recognize, and respond to these therapeutic challenges and related therapy-interfering behaviors. It is essential that they be included in the case conceptualization. Because such factors have been anticipated, the clinician can plan an appropriate response, including resolution strategies that can be implemented before or as these factors emerge in the treatment process.
Explanatory power: Extent to which a case conceptualization offers a compelling explanation to clients in making sense of the troublesome experiences they present in therapy; when high, increases client engagement in the treatment process
Tailoring power: Extent to which the treatment plan in a case conceptualization is personalized to a client’s unique pattern, needs, expectations, and readiness; leads to increased treatment engagement as well as trust and confidence in the clinician’s effectiveness, and optimal treatment outcomes
Predictive power: Extent to which a case conceptualization credibly anticipates challenges in the therapeutic process before they emerge and, when proactively addressed, optimizes treatment outcomes
Case of Jill
The case of Jill illustrates the process of prediction and planned response. The following is an excerpt of the case conceptualization that identifies her pattern, its unique triggers, and five characteristic challenges likely to surface in the treatment process.
Jill is a 29-year-old Caucasian female who is single, lives alone, and was referred to Marilyn Jackson, PhD, by her family physician for evaluation and
treatment of 3 weeks of low mood, tearfulness, and social isolation. The retirement of a close and trusted co-worker appears to have precipitated these symptoms. She was diagnosed with adjustment disorder with depressed mood and exhibits avoidant personality traits.
Two sets of treatment goals were established. The first set included reducing her depressive symptoms, increasing her interpersonal and friendship skills, and enlarging her social network. The second set involved developing a more adaptive pattern: to feel safer in connecting with others.
Case Conceptualization Excerpt
Jill’s developmental and social history reflects her maladaptive pattern: She avoids new encounters whenever possible, while conditionally relates to others except for the few that she trusts. Not surprisingly, she lacks some basic interpersonal skills and has a limited social network. Demands for close interpersonal relating, social appearances, and loss of trusted confidants are common triggers or precipitants for her pattern (pattern and pattern triggers).
Given her avoidant pattern, ambivalent resistance is likely in her efforts to engage in the treatment process. It can be anticipated that she would have difficulty discussing personal matters with clinicians; that she would “test” and provoke them into criticizing her for changing or canceling appointments at the last minute or being late; and that she might procrastinate, avoid feelings, and otherwise “test” the clinician’s trustability. Furthermore, her pattern of avoidance is likely to make entry into and continuation with group work difficult. Therefore, individual sessions can serve as a transition into group, including having some contact with the group practitioner who will presumably be accepting and nonjudgmental. This should increase Jill’s feeling of safety and make self-disclosure in a group setting less difficult (engagement). Transference enactment is another consideration. Given the extent of parental and peer criticism and teasing, it is anticipated that any perceived impatience and verbal or nonverbal indications of criticalness by the therapist (countertransference) might activate this transference (transference). Because engagement in a support group can foster social connectedness and skills, she may resist early efforts to involve her in group treatment until convinced it is reasonably safe. Accordingly, efforts to ease her into such group should come after she has formed a trust bond with at least one new acquaintance
(treatment progress). Finally, planning for termination should begin proactively early in the course of therapy. Otherwise, she is likely to cling to the clinician and insist on extending treatment as termination nears unless her social support system outside of therapy is increased (termination).
Case Commentary
Most approaches to case conceptualization focus primarily on the first set of goals, whereas the pattern-focused approach also focuses on the second set based on Jill’s basic pattern. As such, it can anticipate the unique obstacles and challenges in working with Jill. Based on her identification of these five behavioral markers, Dr. Jackson was able to anticipate and proactively respond to these predictable challenges in the therapeutic process. It is hoped that the precision of this case conceptualization can and will optimize Jill’s treatment outcomes.
So how might Dr. Jackson, or another clinician, have come to identify these anticipated challenges? She might have had extensive and successful experience working with avoidant clients. She might discuss the case with a supervisor, consultant, or knowledgeable colleague. Or, she might have taken a workshop or read one of our books that highlighted the challenges specific to avoidant clients. Chapter 2 provides a chart for the eight most common patterns in psychotherapy practice. Here is the chart for the avoidant pattern:
Engagement
Transference
“Testing” behavior—for example, changing or being late for appointments; fear of being criticized; difficulty with self-disclosure; premature termination
“Testing” clinician’s trustability; overdependence on clinician when achieved
Countertransference Frustration and helplessness; unrealistic treatment expectations of client
Treatment process
Fearful of making progress until they learn to feel safer around others; likely to resist involvement in group treatment until convinced it is reasonably safe
Termination Anxious and ambivalent about the prospects of termination
Case
Conceptualizations That Inform the Therapeutic Alliance
Some insist that the therapeutic alliance is the most important of all clinical skills, whereas others insist that specific treatment factors are more important. Based on our clinical and supervisory experience, we favor the therapeutic alliance view but in nuanced manner. We have come to believe that highly effective case conceptualizations can and do “inform” and personalize the therapeutic alliance. Such a conceptualization sensitizes the clinician to the client’s unique pattern, needs, and culture, and it fosters the development and maintenance of a clinically productive alliance. In this nuanced sense, then, case conceptualization is the most important clinical skill and competency.
A clinical example illustrates this point as well as the importance of the prediction function. Therapists in training are commonly taught the acronym SOLER (sit squarely, have an open posture, lean forward, make direct eye contact, and be relaxed) to remember the clinician behaviors that facilitate developing a good therapeutic alliance. Although this formula works for some, even many, it does not work for all clients. In fact, it may result in the client reacting negatively in the session or not returning (i.e., premature termination). Let’s take the likely impact of one of these behaviors—making direct eye contact—on particular clients. Clients who exhibit shy or avoidant patterns are likely to experience a therapist’s direct eye contact as uncomfortable, whereas those who show a wary or paranoid pattern may perceive the therapist as a threat and so react negatively in word or behavior. Similarly, clients from certain cultures may perceive direct eye contact as disrespectful or intimidating.
However, therapists utilizing a case conceptualization approach that emphasizes the predictive function and are mindful of the challenges in engagement for clients with an avoidant or paranoid pattern can be proactive and not engage with direct eye contact or other SOLER behaviors that may trigger client reactions that do not facilitate an effective therapeutic alliance. Instead, they may be more indirect, neutral, and reserved in initial encounters with such clients. In such instances, the predictive function of the case conceptualization alerts the therapist to anticipate and respond more effectively and therapeutically to those clients.
Specifically, a case conceptualization is directly linked to the development and maintenance of the therapeutic relationship, and the client’s pattern can
provide the clinician with a framework for how they might build or approach likely engagement challenges. Imagine meeting a 25-year-old client who reports a history of being pampered during childhood. She states that her siblings and parents consistently made choices for her and solved many of her personal problems throughout her childhood and even as a young adult. She informs you that her goal for therapy is “to be able to make decisions on my own and have my own voice.” You complete the initial assessment and determine that the client displays a dependent pattern, in which she moves toward others to elicit help and consistently avoids situations that require self-sufficiency and independence. Near the end of the meeting, you discuss scheduling a follow-up appointment and the client interrupts you and asks, “I really need your help, what do you think I should do?” Given your awareness that clients with dependent patterns often seek to please mental health professionals and often will elicit direct advice, you decide to refuse the invitation to solve the client’s problem. Instead, you engaged her in an empowerment process in which she develops some initial ideas. The decision to avoid advice-giving and to empower the client to participate in collaborative treatment goal setting is informed by a case conceptualization that considers her pattern. This is another example of how case conceptualization informs the therapeutic alliance.
The Pattern-Focused Case Conceptualization Approach
This is a book about a highly effective and clinically valuable approach to case conceptualizations. It is a very practical book in which you will learn and begin to master an accurate and effective approach to case conceptualizations with high levels of explanatory power, tailoring power, and predictive power (Sperry & Sperry, 2020). This approach is based on specific behavioral markers that include pattern and pattern triggers, as well as those that can predict likely challenges and facilitate the treatment process: engagement, transference, countertransference, treatment progress, and termination.
Conclusion
We have described and illustrated the three key functions of a clinically valuable case conceptualization approach. It explains the client’s presenting
