A section headed “Process Issues” in the current special issue of Behavioural and Cognitive Psychotherapy contains a couple of important articles about conceptualization, a component of CBT that many therapists find difficult, and some would prefer to do without.
In Evasions, I looked at some supposedly new techniques that have unfortunately, in my view, become associated with CBT. The core CBT process that some therapists would like to evade is known as case conceptualization, or formulation. It’s the process that maps the patient’s difficulties on to cognitive theory. That conceptual mapping provides the therapist with ways to approach therapy for that individual patient — a treatment plan.
CBT does not depend on diagnosis, because diagnosis is not specific enough to each patient to generate a CBT treatment plan. A diagnosis mostly describes a cluster of symptoms, a syndrome. For example, the term “depression” does not really define an illness. People who are perfectly well can be depressed, sometimes severely, and sometimes for an extended period.
Even a more specific term like “major depressive episode with mood-congruent psychotic features (296.24)” is still only descriptive. Such a description is useful to convey some information between professionals, but it does nothing to describe the patient’s inner world of emotion, which is where a therapist must meet the patient in order to understand how to treat the problem.
The first of these articles, The Science and Practice of Case Conceptualization, is built around a case study:
Consider the case of Beth (age 20), admitted to a residential unit following an escalating pattern of self-injury. Her presenting issues included self-injury, post-traumatic stress disorder (PTSD) and depression.
Notice how describing Beth’s difficulties requires multiple diagnostic terms, and how the writers of this article base it primarily on the practice of psychotherapy, not primarily on academic research. A discussion of conceptualization in research identifies several important ways in which researchers have failed to capture conceptualization and the whole active and dynamic nature of CBT.
The outcome of a successful case conceptualization is often not what you might expect, because it derives from an exploration of the patient’s entire emotional world, in which the therapist and the patient work together to make sense of things. As a result, the focus of therapy can turn out to be pretty much unrelated to the patient’s symptoms and diagnosis.
For Beth, the most important discovery was her resilience:
Beth had what she called “attitude” and what the therapist described as a willingness to take on challenges, question authority and “fight her corner”.
This turned out to be the key to her recovery.
Unfortunately, the authors of this article struggle to explain the process of conceptualization as an actual process. The best they can do is to describe it metaphorically in terms of a crucible:
…a crucible is a strong container in which different elements go through a process of substantive and lasting change…
The elements that go in the crucible are the various factors affecting the patient (protective, pre-disposing, triggering and maintaining factors), together with the patient’s symptoms, other experience and strengths, and whatever CBT theory and research applies. The “heat” under the crucible is said to be “collaborative empiricism”.
I find this metaphor profoundly lacking, because the idea of just mixing a whole lot of things together and melting them feels quite unlike the way I would conceptualize a case. Can I create a better metaphor? Perhaps one day I’ll try.
On the other hand, such a simple metaphor usefully illustrates that conceptualization is not a formal or consciously complicated process, even though it can draw on a lot of elements. Perhaps the crucible is a useful way to encourage therapists and researchers who currently evade conceptualization to try it for themselves.
Although the article lacks precision, it’s certainly a rare and welcome potshot at the dumbing down of CBT.
The second of these articles, The Therapeutic Relationship in Cognitive-Behavioral Therapy, examines some aspects of the collaborative relationship, the therapeutic alliance, between patient and CBT therapist, with a focus on how a successful alliance can be used to overcome obstacles to therapy.
It’s very clear that the author (Robert L. Leahy) knows what he is writing about, and not just as an academic concept:
It is important to think of the therapeutic relationship or alliance as an on-going process, rather than an achievement that is fixed at one point in time, since the relationship is interactive and iterative, reflecting the patient’s response to the therapist’s response to the patient.
And Leahy also makes it clear that he understands conceptualization is problematical:
These skills, considered to be important regardless of therapeutic modality, may often be overlooked in training cognive behavioral therapists, since emphasis is often placed on techniques and processes…
But what he doesn’t do is describe the alliance in process terms, what actually happens, where you start, how you get there. So unless you already know, its like reading tourist information about a wonderful city, its castles and palaces, shopping centres and concert halls, without any clue about where this city is or how to get there.
As a second potshot at the dumbing down of CBT, though, this article is as welcome as the previous one.