A Simple Formula to Teach and Grow Case-Conceptualization Skills

["We call this "attribution creep" (Duncan, Hubble, and Miller 1997). A diagnosis once set in motion, creates an expectancy of hard going or poor outcome that is surprisingly resilient (Salovey and Turk, 1991.) Left unchecked the expectancy becomes the person. Should this occur, observers (non-professionals and clinicians alike) unwittingly distort information to conform to their expectations."]

-The Heroic Client: A Revolutionary Way to Improve Effectiveness Through Client-Directed, Outcome-Informed Therapy by Barry Duncan, Scott Miller, and Jacqueline Sparks

Now I want to make something very clear. Over the years as a therapist and clinical supervisor, I have come to believe that we don't have impossible cases, but rather the way in which we think and talk about our clients generates these pathways to impossibility.

Our assumptions kill our ability to conceptualize and assist our clients. It is impossible to "know" and remain curious about our clients. For that reason I have written this article to guide clinicians back to the needs of their clients, and away from the fears that result from being trapped in their head with all that "clinical knowledge."

The following is a set of questions taken from the solution-focused approach. I utilize this approach because it sees the client's goal as the driving force, not the goals of the therapist or clinical team.

The simplicity of the questions offers ways to quickly and effectively conceptualize clinical cases, and helps clinicians avoid emotionalism and their need to "expert" the cases they present. Using these solution-focused questions will also shed new light on the most difficult cases and open the doors once more to possibility.

QUESTION METHOD FOR CASE CONCEPTUALIZATION (to be used in group presentation format or case conference)

1.) “What is the client’s goal?” Virtually every time a problem case is presented, the client's goal is unknown, lost, or has actually been accomplished already. All questions need to be in relation to the client's goal to avoid personalization on behalf of the clinician. Our job as well as the therapeutic alliance is dependent upon our goal consensus with our client.

2.) “How do you know?” What difference does the client say the identified goal will have on their life? If we don't know what difference this "goal" will make, it's probably not the client's goal. Often times, especially with families and mandated clients, we can find that our client is responding to another goal in their system (parole, their mom, etc.) This needs to be taken into account.

3.) “What worked for this client?” What has been effective (even a little) in the past? ID the client's patterns of success. Also, times when the therapist has been successful with the client. Most of our success and that of our clients, can quickly fall out of our awareness.

4.) “Where are you stuck?” Where is the clinician struggling? This helps the rest of the clinical team know how to be supportive. In presenting cases sometimes, we can misrepresent ourselves or fail to communicate our needs to the team.

5.) “What have you already tried?” It is important to recognize that the clinician and client have already tried things. We don't want to repeat more of what isn't working.

6.) “What do you want from the team?”  This ensures that the clinician presenting the case receive the feedback they desire. Sometimes, clinicians just want to be heard, feel like they are burning out, or need to know what they are successful at.

Remember to trust and perfect the process. Feel free to add your own questions and create your own formula. Remember to have the courage to ask better questions. As clinicians we can't guarantee outcomes, but we can always perfect our "doing."

Do more of what's working.