A FORMAT FOR CASE

CONCEPTUALIZATION
The authors developed a format for case conceptualization to foster the systematic collection and
integration of clinical data. The format is intended to complement training in counseling
techniques.

Many professional and personal challenges confront practicum students as they work with
clients. For example, students must establish a counseling relationship, listen attentively, express
themselves clearly, probe for information, and implement technical skills in an ethical manner.
Those counseling performance skills (Borders & Leddick, 1987) center on what counselors do
during sessions. At a cognitive level, students must master factual knowledge, think
integratively, generate and test clinical hypotheses, plan and apply interventions, and evaluate
the effectiveness of treatment. Those conceptualizing skills, within the cognitive operations used
to construct models that represent experience (Mahoney & Lyddon, 1988), show how counselors
think about clients and how they choose interventions. It is highly desirable for instructors of
practica to have pedagogical methods to promote the development both of counseling
performance skills and conceptualizing skills. Such methods should be diverse and flexible to
accommodate students at different levels of professional development and with distinct styles of
learning (Biggs, 1988; Borders & Leddick, 1987; Ellis, 1988; Fuqua, Johnson, Anderson, &
Newman, 1984; Holloway, 1988; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987).

RATIONALE FOR THE FORMAT

In this article, we present a format for case conceptualization that we developed to fill gaps in the
literature on the preparation of counselors (Borders & Leddick, 1987; Hoshmand, 1991).
Although many existing methods promote counseling performance skills, there are few
established methods for teaching students the conceptualizing skills needed to understand and
treat clients (Biggs, 1988; Hulse & Jennings, 1984; Kanfer & Schefft, 1988; Loganbill &
Stoltenberg, 1983; Turk & Salovey, 1988). We do not discount the importance of counseling
performance skills, but we believe that they can be applied effectively only within a meaningful
conceptual framework. That is, what counselors do depends on their evolving conceptualization
of clients; training in that conceptualization matters.

Given the large quantity of information that clients disclose, students have the task of selecting
and processing relevant clinical data to arrive at a working model of their clients. Graduate
programs need to assist students in understanding how to collect, organize, and integrate
information; how to form and test clinical inferences; and how to plan, implement, and evaluate
interventions (Dumont, 1993; Dumont & Lecomte, 1987; Fuqua et al., 1984; Hoshmand, 1991;
Kanfer & Schefft, 1988; Turk & Salovey, 1988). Although systematic approaches to collecting
and processing clinical information are not new, the case conceptualization format presented
here, as follows, has several distinguishing features:
 1. The format is comprehensive, serving both to organize clinical data (see Hulse &
Jennings, 1984; Loganbill & Stoltenberg, 1983) and to make conceptual tasks operational
(see Biggs, 1988). The components of the format integrate and expand on two useful
approaches to presenting cases that are cited often and that are linked to related literature
on supervision: (a) Loganbill and Stoltenberg's (1983) six content areas of clients'
functioning (i.e., identifying data, presenting problem, relevant history, interpersonal
style, environmental factors, and personality dynamics), and (b) Biggs's (1988) three
tasks of case conceptualization (i.e., identifying observable and inferential clinical
evidence; articulating dimensions of the counseling relationship; and describing
assumptions about presenting concerns, personality, and treatment).

In addition, the format makes explicit the crucial distinction between observation and inference,
by separating facts from hypotheses. It advances the notion that observations provide the basis
for constructing and testing inferences. Thus, the format fosters development of critical thinking
that is more deliberate and less automatic than the ordinary formation of impressions. The
approach is compatible with recommendations that counselors receive training in rational
hypothesis testing to reduce inferential errors (Dumont 1993; Dumont & Lecomte, 1987;
Hoshmand, 1991; Kanfer & Schefft, 1988; Turk & Salovey, 1988).

• 2. The format can be adapted to the developmental stage of students by its focus on stage-
appropriate components and implementing those components in stage-appropriate ways
(Ellis, 1988; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993;
Stoltenberg & Delworth, 1987). As an example, beginning students use the format to
organize information and to learn the distinction between observation and inference,
whereas more experienced students focus on using the format to generate and test
hypotheses.
• 3. The format is atheoretical, thereby permitting students to incorporate constructs from
any paradigm into their case conceptualizations. In this sense, the format resembles the
cognitive scaffolding described in the constructivist perspective (Mahoney & Lyddon,
1988). Rather than being an explicit template through which observations are filtered to
conform to an imposed representational model, the format provides an abstract set of
cognitive schemas. With the schemas, the student actively fashions a conceptual
framework from which to order and assign meaning to observations. Simply put, the
format is a generic structure that the student uses to construct his or her "reality" of the
case.

COMPONENTS OF THE FORMAT

The format has 14 components, sequenced from observational to inferential as follows:

background data, presenting concerns, verbal content, verbal style, nonverbal behavior, client's
emotional experience, counselor's experience of the client, client-counselor interaction, test data
and supporting materials, diagnosis, inferences and assumptions, goals of treatment,
interventions, and evaluation of outcomes.

Background data :includes sex, age, race, ethnicity, physical appearance (e.g., attractiveness,
dress, grooming, height, and weight), socioeconomic status, marital status, family constellation
and background, educational and occupational status, medical and mental health history, use of
prescribed or illicit substances, prior treatment, legal status, living arrangements, religious
affiliation, sexual preference, social network, current functioning, and self-perceptions. Initially,
students are overwhelmed by the data that they assume need to be collected. Guidance must be
provided on how students are to differentiate meaningful from inconsequential information. In
our program, for example, we ask students to evaluate the relevance of background data, for
understanding clients' presenting concerns and for developing treatment plans. We advise
students to strive for relevance rather than comprehensiveness.

Presenting concerns consist of a thorough account of each of the client's problems as viewed by
that client. This task might begin with information contained on an intake form. We assist
students in developing concrete and detailed definitions of clients' concerns by showing them
how to help clients identify specific affective, behavioral, cognitive, and interpersonal features of
their problems. For example, the poor academic performance of a client who is a college student
might involve maladaptive behavior (e.g., procrastination), cognitive deficits (e.g., difficulty in
concentrating), negative moods (e.g., anxiety), and interpersonal problems (e.g., conflict with
instructors). Counseling students should also explore the parameters of presenting concerns,
including prior occurrence, onset, duration, frequency, severity, and relative importance. We
further suggest that students explore how clients have attempted to cope with their concerns and
that they examine what clients expect from treatment, in terms of assistance as well as their
commitment to change. In addition, students should assess immediate or impending dangers and
crises that their clients may face. Finally, we instruct students in identifying environmental
stressors and supports that are linked to presenting concerns.

Verbal content can be organized in two ways. A concise summary of each session is appropriate
for cases of limited duration. Alternatively, verbal content can include summaries of identified
themes that have emerged across sessions. Occasionally, those themes are interdependent or
hierarchically arranged. For example, a client may enter treatment to deal with anger toward a
supervisor who is perceived as unfair and, in later sessions, disclose having been chronically
demeaned by an older sibling. We teach students to discriminate central data from peripheral
data through feedback, modeling, and probing questions. Students need to focus their sessions on
areas that are keyed to treatment. For instance, we point out that clients' focal concerns, along
with the goals of treatment, can serve as anchors, preventing the content of sessions from
drifting.

Verbal style refers to qualitative elements of clients' verbal presentation (i.e., how something is
said rather than what is said) that students deem significant because they reflect clients'
personality characteristics, emotional states, or both. Those elements can include tone of voice
and volume, changes in modulation at critical junctures, fluency, quantity and rate of
verbalization, vividness, syntactic complexity, and vocal characterizations (e.g., sighing).

Nonverbal behavior includes clients' eye contact, facial expression, body movements,
idiosyncratic mannerisms (e.g., hand gestures), posture, seating arrangements, and change in any
of these behaviors over time and circumstances. Instructors can assist students in distinguishing
relevant from unimportant information by modeling and providing feedback on how these data
bear on the case. As an example, neglected hygiene and a listless expression are important
nonverbal behaviors when they coincide with other data, such as self-reports of despair and
hopelessness.

Clients' emotional experience includes data that are more inferential. On the basis of their
observations, students attempt to infer what their clients feel during sessions and to relate those
feelings to verbal content (e.g., sadness linked to memories of loss). The observations provide
insights into clients' emotional lives outside of treatment. We caution students that clients' self-
reports are an important but not entirely reliable source of information about their emotional
experience. At times clients deny, ignore, mislabel, or misrepresent their emotional experience.
Students should note the duration, intensity, and range of emotion expressed over the course of
treatment. Blunted or excessive affect as well as affect that is discrepant with verbal content also
merit attention. To illustrate, a client may report, without any apparent anger, a history of
physical abuse.

Initially, students can be assisted in labeling their clients' affect by using a checklist of emotional
states. We have found it helpful to suggest possible affect and support our perceptions with
observation and logic. Empathic role taking can also help students to gain access to clients'
experience. Instructors may need to sensitize students to emotional states outside of their own
experience or that they avoid.

Counselor's experience of the client involves his or her personal reactions to the client (e.g.,
attraction, boredom, confusion, frustration, and sympathy). We strive to establish a supportive
learning environment in which students can disclose their genuine experiences, negative as well
as positive. Students often struggle to accept that they might not like every client. But students
should be helped to recognize that their experience of clients is a rich source of hypotheses about
feelings that those clients may engender in others and, thus, about the interpersonal world that
the clients partially create for themselves. The "feel" of clients often provides valuable diagnostic
clues (e.g., wanting to take care of a client may suggest features of dependent personality
disorder). Sometimes students need assistance in determining whether their reactions to clients
reflect countertransferential issues or involve "normative" responses. We draw on parallel
process and use-of-self as an instrument to help clarify students' feelings and to form accurate
attributions about the origins of those feelings (Glickauf-Hughes & Campbell, 1991; Ronnestad
& Skovholt, 1993).

Client-counselor interaction summarizes patterns in the exchanges between client and counselor
as well as significant interpersonal events that occur within sessions. Such events are, for
example, how trust is tested, how resistance is overcome, how sensitive matters are explored,
how the counseling relationship is processed, and how termination is handled. Thus, this
component of the format involves a characterization of the counseling process. Students should
attempt to characterize the structure of the typical session--specifically, what counselors and
clients do in relation to one another during the therapy hour. They may do any of the following:
answer questions, ask questions; cathart, support; learn, teach; seek advice, give advice; tell
stories, listen; collude to avoid sensitive topics. Taxonomies of counselor (Elliott et al., 1987)
and client (Hill, 1992) modes of response are resources with which to characterize the structure
of sessions.
At a more abstract level, students should try to describe the evolving roles they and their clients
play vis-a-vis one another. It is essential to assess the quality of the counseling relationship and
the contributions of the student and the client to the relationship. We ask students to speculate on
what they mean to a given client and to generate a metaphor for their relationship with that client
(e.g., doctor, friend, mentor, or parent). Client-counselor interactions yield clues about clients'
interpersonal style, revealing both assets and liabilities. Furthermore, the counseling relationship
provides revealing data about clients' self-perceptions. We encourage students to present
segments of audiotaped or videotaped interviews that illustrate patterns of client-counselor
interaction.

Test data and supporting materials include educational, legal, medical, and psychological
records; mental status exam results; behavioral assessment data, including self-monitoring;
questionnaire data, the results of psychological testing, artwork, excerpts from diaries or
journals, personal correspondence, poetry, and recordings. When students assess clients, a
rationale for testing is warranted that links the method of testing to the purpose of assessment.
We assist students in identifying significant test data and supporting materials by examining how
such information converges with or departs from other clinical data (e.g., reports of family
turmoil and an elevated score on Scale 4, Psychopathic Deviate, of the Minnesota Multiphasic
Personality Inventory-2 [MMPI-2; Hathaway & McKinley, 1989]). Assessment, as well as
diagnosis and treatment, must be conducted with sensitivity toward issues that affect women,
minorities, disadvantaged clients, and disabled clients, because those persons are not necessarily
understood by students, perhaps due to limited experience of students or the "homogenized"
focus of their professional preparation.

Diagnosis includes students' impression of clients' diagnoses on all five axes of the Diagnostic
and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, American Psychiatric
Association, 1994). We guide students' efforts to support their diagnostic thinking with clinical
evidence and to consider competing diagnoses. Students can apply taxonomies other than those
in the DSM-IV when appropriate (e.g., DeNelsky and Boat's [1986] coping skills model).
Instructors demonstrate the function of diagnosis in organizing scattered and diverse clinical data
and in generating tentative hypotheses about clients' functioning.

Inferences and assumptions involve configuring clinical hypotheses, derived from observations,
into meaningful and useful working models of clients (Mahoney & Lyddon, 1988). A working
model consists of a clear definition of the client's problems and formulations of how
hypothesized psychological mechanisms produce those problems. For instance, a client's primary
complaints might be frequent bouts of depression, pervasive feelings of isolation, and unfulfilled
longing for intimacy. An account of those problems might establish the cause as an alienation
schema, early childhood loss, interpersonal rejection, negative self-schemas, or social skills
deficits.

We help students to elaborate on and refine incompletely formed inferences by identifying

related clinical data and relevant theoretical constructs (Dumont, 1993; Mahoney & Lyddon,
1988). We also assist students in integrating inferences and assumptions with formal patterns of'
understanding drawn from theories of personality, psychopathology, and counseling (Hoshmand,
1991).
As with their instructors, students are not immune from making faulty inferences that can be
traced to logical errors, such as single-cause etiologies, the representative heuristic, the
availability heuristic, confirmatory bias, the fundamental attribution error, and illusory
correlations; (Dumont, 1993; Dumont & Lecomte, 1987). As an example, counselors tend to
seek data that support their preexisting notions about clients, thus restricting the development of
a more complete understanding of their clients. We alert students to the likelihood of bias in data
gathering, particularly when they seek to confirm existing hypotheses. Furthermore, we
demonstrate how to generate and evaluate competing hypotheses to counteract biased
information ]processing (Dumont & Lecomte, 1987; Kanfer & Schefft, 1988). Instructors,
therefore, must teach students to think logically, sensitizing them to indicators of faulty
inferences and providing them with strategies for validating clinical hypotheses as well as
disconfirming them (Dumont & Lecomte, 1987; Hoshmand, 1991). The proposed format can
accomplish this task because it separates inferences from the clinical data used to test inferences
and thus "deautomatizes" cognitive operations by which inferences are formed (Kanfer &
Schefft, 1988; Mahoney & Lyddon, 1988). We have found it beneficial to have students compare
their impressions of clients with impressions that are independently revealed by test data (e.g.,
MMPI-2); this exercise permits the correction of perceptual distortions and logical errors that
lead to faulty inferences. Although students' intuition is an invaluable source of hypotheses,
instructors need to caution them that intuition must be evaluated by empirical testing and against
grounded patterns of understanding (Hoshmand, 1991).

We also model caution and support for competing formulations and continued observation. This
approach fosters appreciation of the inexactitude and richness of case conceptualization and
helps students to manage such uncertainty without fear of negative evaluation. With the
development of their conceptualizing skills, students can appreciate the viability of alternative
and hybrid inferences. Moreover, they become more aware of the occasional coexistence and
interdependence of clinical and inferential contradictions (e.g., the simultaneous experience of
sorrow and joy and holistic concepts such as life and death). The increasingly elaborate
conceptual fabric created from the sustained application of conceptualizing skills also enables
students to predict the effect of interventions more accurately.

Goals of treatment must be linked to clients' problems as they come to be understood after
presenting concerns have been explored. Goals include short-term objectives along with long-
term outcomes of treatment that have been negotiated by the client and trainee. Typically, goals
involve changing how clients feel, think, and act. Putting goals in order is important because
their priorities will influence treatment decisions. Goals need to be integrated with students'
inferences or established theories and techniques of counseling. In their zeal, students often
overestimate the probable long-term aims of treatment. To help students avoid disappointment,
we remind them that certain factors influence the formulation of goals, including constraints of
time and resources, students' own competencies, and clients' capacity for motivation for change.

Interventions comprise techniques that students implement to achieve agreed-on goals of

treatment. Techniques are ideally compatible with inferences and assumptions derived earlier;
targets of treatment consist of hypothesized psychological structures, processes, and conditions
that produce clients' problems (e.g., self-esteem, information processing, family environment).
Difficulties in technical implementation should be discussed candidly. We provide opportunities
for students to observe and rehearse pragmatic applications of all strategies. Techniques derived
from any theory of counseling can be reframed in concepts and processes that are more
congruent with students' cognitive style. To illustrate, some students are able to understand how
a learned fear response can be counterconditioned by the counseling relationship when this
phenomenon is defined as a consequence of providing unconditional positive regard. In addition,
we teach students to apply techniques with sensitivity as well as to fashion a personal style of
counseling. Finally, legal and ethical issues pertaining to the conduct of specific interventions
must be made explicit.

Evaluation of outcomes requires that students establish criteria and methods toward evaluating
the outcomes of treatment. Methods can include objective criteria (e.g., grades), reports of
others, self-reports (e.g., behavioral logs), test data, and students' own judgments. Instructors
must assist students in developing efficient ways to evaluate progress over the course of
treatment given the presenting concerns, clients' motivation, and available resources.

USES OF THE FORMAT

We developed the :format for use in a year-long practicum in a master's degree program in
counseling psychology. Instructors describe the format early in the first semester and
demonstrate its use by presenting a terminated case; a discussion of the format and
conceptualization follows. The first half of the format is particularly helpful when students
struggle to organize clinical data into meaningful categories and to distinguish their observations
from their inferences. The focus at that point should be on components of the format that
incorporate descriptive data about the client. Later in their development, when students are
prepared to confront issues that influence the counseling relationship, components involving
personal and interpersonal aspects of treatment can be explored. As students mature further,
components that incorporate descriptive data are abbreviated so that students can concentrate on
the conceptualizing skills of diagnosis, inferences and assumptions, treatment planning and
intervention, and evaluation. When conceptualizing skills have been established, the format need
not be applied comprehensively to each case. Rather, it can be condensed without losing its
capacity to organize clinical data and to derive interventions.

The format can be used to present cases in practicum seminar as well as in individual supervision
sessions. It can also be used by students to manage their caseloads. Also, the format can be used
in oral and written forms to organize and integrate clinical data and to suggest options for
treatment (cf. Biggs, 1988; Hulse & Jennings, 1984; Loganbill & Stoltenberg, 1983). For
example, practicum seminar can feature presentations of cases organized according to the format.
As a student presents the data of the case, participants can construct alternative working models.
Moreover, the format compels participants to test their models by referencing clinical data.
Written details that accompany a presentation are also fashioned by a student presenter according
to the format. The student presenter can distribute such material before the presentation so that
members of the class have time to prepare. During the presentation, participants assume
responsibility for sustaining the process of case conceptualization in a manner that suits the class
(e.g., discussion, interpersonal process recall, media aids, or role play).
Supervision and case notes can also be structured more flexibly with the use of the case
conceptualization format to give students opportunities to relate observation to inference,
inference to treatment, and treatment to outcome (Presser & Pfost, 1985). In fact, supervision is
an ideal setting to tailor the format to the cognitive and personal attributes of the students. In
supervision, there are also more opportunities to observe students' sessions directly, which
permits instruction of what clinical information to seek, how to seek it, how to extract inferences
from it, and to evaluate the veracity of students' inferences by direct observation (Holloway,
1988).

FUTURE APPLICATIONS AND RESEARCH

The format is a potentially valuable resource for counselors to make the collection and
integration of data systematic when they intervene with populations other than individual clients.
Application of the format to counseling with couples and families might seem to make an
already conceptually demanding task more complex. Yet counselors can shift the focus from
individuals to a couple or a family unit, and apply components of the format to that entity. By
targeting relationships and systems in this way, the format can also be used to enhance
understanding of and improve interventions in supervision and with distressed units or
organizations.

Although research has been conducted on how counselors collect data, few studies have
investigated how counselors process information when testing hypotheses (e.g., Strohmer, Shivy,
& Chiodo, 1990). Empirical evidence of the effectiveness of various approaches to the
conceptual training of counselors is long overdue. Avenues of inquiry include determining
whether the format contributes to the acquisition of conceptualizing skills and to facilitative
conditions and techniques thai: may be mediated by such skills (e.g., empathy and clear
communication). There are several written measures available with which to evaluate students'
conceptualizing skills. Examples of those measures are the Clinical Assessment Questionnaire
(Holloway & Wolleat, 1980); Intentions List (Hill & O'Grady, 1985); and Written Treatment
Planning Simulation (Butcher, Scofield, & Baker, 1985). Interpersonal process recall of
audiotaped and videotaped sessions, case notes (Presser & Pfost, 1985), and direct observation
can also be used.

Other promising directions for research include comparing the effect of the format with other
approaches to training, isolating components of the format that produce the greatest gains in
conceptualizing skills, and determining the outcomes when the format is implemented with the
use of different instructional strategies and with students at varying levels of development.
Finally, investigation into how the format produces cognitive and performance gains would be
valuable, particularly if integrated with literature on cognitive development and effective
learning strategies.

Nonetheless, the format has several limitations. Although students will eventually learn to apply
the format more efficiently in their professional practice, it remains cumbersome and time
consuming. Explicit and comprehensive application of the format in supervision and in the
routine management of individual caseloads is particularly awkward. In those contexts, the
format must be applied tacitly as a heuristic, with specific components used more deliberately
when obstacles to progress are encountered. For example, focus on a client's affective experience
can promote accurate empathy in the student and lead to more helpful interventions.

Moreover, given the differences in the cognitive development of students (Biggs, 1988; Borders
& Leddick, 1987; Ellis, 1988; Fuqua et al., 1984; Ronnestad & Skovholt, 1993; Stoltenberg &
Delworth, 1987), the format cannot be applied rigidly or uniformly as a pedagogical tool.
Beginning students and those who think in simple, concrete terms seem to profit most from
learning environments in which instructors provide direction, expertise, feedback, structure, and
support. Conversely, more experienced students and those who think in complex, abstract terms
learn more readily when instructors fashion autonomous, collegial, flexible, and interactive
environments (Ellis, 1988; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993;
Stoltenberg & Delworth, 1987). Hence, the format must be applied creatively and tailored to
students' capabilities, to avoid needless discouragement, boredom, or threats to personal integrity
(Fuqua et al., 1984; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993;
Stoltenberg & Delworth, 1987).

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~~~~~~~~

By MICHAEL J. STEVENS and STEVEN J. MORRIS

Michael J. Stevens is a professor of psychology and director of the master's degree program in
Counseling Psychology and Steven J. Morris is an assistant professor of psychology, both at
Illinois State University, Normal, Illinois. This article was presented at the annual meeting of the
American Psychological Association, Washington, DC, in August 1992. Correspondence
regarding this article should be sent to Michael J. Stevens, Department of Psychology, Illinois
State University, Campus Box 4620, Normal, IL 61790-4620.

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