Psychotherapy © 2015 American Psychological Association

2015, Vol. 52, No. 2, 190 –194 0033-3204/15/$12.00 http://dx.doi.org/10.1037/a0038618

Concept Mapping: A Supervision Strategy for Introducing Case

Conceptualization Skills to Novice Therapists
Bruce S. Liese and Kate M. Esterline
The University of Kansas

Case conceptualization, a term synonymous with case formulation, is an essential psychotherapy skill.
Novice therapists enter into the practice of psychotherapy with limited case conceptualization skills.
Hence, an important goal when supervising novice therapists is to effectively teach these skills. Concept
mapping facilitates case conceptualization skills through the process of methodically creating graphic
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

representations of clients’ problems and dynamic relationships between these problems. This article
This document is copyrighted by the American Psychological Association or one of its allied publishers.

introduces a highly structured and practical 4-stage approach to supervision that effectively introduces
case formulation skills to novice therapists using concept mapping. It is assumed that concept maps,
when shared with clients, function as an intervention to facilitate insight and change.

Keywords: supervision, concept mapping, case conceptualization, case formulation

Case conceptualization, a term synonymous with case formula-
tion, is an essential information processing skill (Mayfield, Kar-
dash, & Kivlighan, 1999), foundational to the provision of psy-
chotherapy. It involves the collection, synthesis, organization, and
interpretation of client information. When shared with clients, case
conceptualization becomes part of the treatment process with
potential for facilitating insight and change. Eells (2007) defines
case formulation as the generation of hypotheses “about the
causes, precipitants, and maintaining influences of a person’s
psychological, interpersonal, and behavior problems” (p. 4). Ber-
nard (1997) describes case conceptualization as the “ability to
make some sense of the information that the client is presenting, to
identify themes, and to discriminate what is essential information
from what is not” (p. 311). Hill (2014) proposes that case concep-
tualization enables therapists to be focused in sessions, “instead of
just wandering aimlessly” (p. 240). Given the importance of case
conceptualization skills, novice therapists are likely to derive great
benefit from learning these skills in supervision. In this article, we
describe the use of concept maps as a means of teaching case
conceptualization skills to novice therapists.
Concept maps are diagrams that graphically organize relation-
ships between ideas, concepts, or problems. Facilitated by multi-
variate statistics (i.e., cluster analysis and multidimensional scal-
ing), concept mapping has been used in counseling psychology
research (Goodyear, Tracey, Claiborn, Lichtenberg, & Wampold,
2005), to understand therapeutic alliance (Bedi, 2006; Bedi &
Richards, 2011), common factors (Tracey, 2003), and helpful
events in group supervision (Carter, Enyedy, Goodyear, Arcinue,
& Puri, 2009). Mayfield et al. (1999) used concept mapping to
This article was published Online First March 2, 2015.
Bruce S. Liese and Kate M. Esterline, Department of Psychology,
University of Kansas.
Correspondence concerning this article should be addressed to Bruce S.
Liese, University of Kansas Medical Center, Mailstop 4010, 3901 Rainbow
Boulevard, Kansas City, KS 66160. E-mail: bliese@ku.edu
examine information processing differences between experienced
and novice counselors. They found that novice counselors tend to
use “superficial client-specific details” (i.e., surface-level princi-
ples) while experienced counselors use “essential deep-level psy-
chological principles” to conceptualize clients. Concept mapping
has also been applied, without statistical analyses, to teach nursing
care skills (Schuster, 2012).
Early in training and lacking experience, novice therapists are
likely to feel overwhelmed by the challenge of conducting psy-
chotherapy (Ronnestad & Skovholt, 1993, Rønnestad & Skovholt,
2003; Stoltenberg, 2005; Stoltenberg & McNeill, 2010). Concept
mapping, when integrated into a structured approach to supervi-
sion, has the potential to help novice therapists develop case
conceptualization and general psychotherapy skills by methodi-
cally identifying, organizing, and structuring information provided
by clients. It is at this beginning stage of professional development
that novice therapists need the kind of structure concept mapping
provides. Stoltenberg and McNeill (2010) explain that, “structure
removes some of the uncertainty from the [supervision] process
and helps limit the anxiety associated with early training” (p. 64).
According to Ronnestad and Skovholt (2003), “A life-saver for the
beginning student is to learn easily mastered, straightforward,
counseling/therapy methods . . . . that can be absorbed quickly
with focused effort and that hopefully can be applied to all clients”
(p. 12).
Concept Mapping in Supervision:
A Four-Stage Process
We have developed a four-stage supervision process that fo-
cuses on concept mapping. This process is described in the fol-
lowing paragraphs.
Stage I occurs during an initial psychotherapy session, with the
novice therapist and client collaboratively generating a problem
grid (see Table 1). To construct this grid, the therapist inquires
about the client’s problems and then lists them in the first column
of a four-column grid, with corresponding behaviors, feelings, and
thoughts listed in the remaining three columns.

190
 CONCEPT MAPPING IN SUPERVISION
Table 1
Joe’s Problem Grid, Including Associated Behaviors, Feelings, and Thoughts
Problem Behaviors
Depression • Withdraw from wife, other family members,
and friends.
• Withdraw from hobbies, social, and
recreational activities.
Anger, aggression • Become visibly angry.
• Raise voice.
• Slam doors.
Heavy alcohol use • Drink alcohol and pass out every night
while watching television.
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Cigarette smoking • Continue to smoke 2 packs of cigarettes per
day, despite the fact that wife has asked
him to stop on many occasions.
Marital problems • Anger, aggression towards wife.
• Raise voice at wife.
• Refuse to stop drinking, smoking.
Although this process may at first appear to be mechanical, it is
actually a dynamic exchange between therapist and client wherein
the therapist helps the client identify specific problematic behav-
iors and learn the subtle differences between thoughts and feelings.
In addition to providing data for the case conceptualization, this
process has the potential to strengthen the therapeutic alliance, as
therapist and client work together to establish a shared view of the
client’s problems.
To illustrate, consider a hypothetical client named “Joe” who
has just begun therapy. Like most psychotherapy clients, Joe has
multiple problems. He is a depressed, angry, heavy drinker, and
cigarette smoker with severe marital problems. Joe and his therapist
spend most of a session completing the problem grid in Table 1. The
following is an excerpt from Joe’s discussion with his therapist as they
compose the grid:
Ther: Joe, I understand that you’re depressed and angry
about your marriage. You say that your wife’s biggest
concerns are your drinking, smoking, and anger.
Joe: Yeah, that’s the way she sees it. She hates my drinking
and smoking.
Ther: How do you see it?
Joe: I admit that I drink a lot and I want to quit smoking
eventually, but I won’t be forced to do anything. [As
they talk, the therapist lists Joe’s problems in the first
column of the problem grid: depression; anger, aggres-
sion; heavy alcohol use; cigarette smoking; and mar-
ital problems.]
Ther: I can see that you are getting upset as we discuss these
problems. How do you feel when your wife says you
need to quit drinking and smoking?
Joe: I feel like she doesn’t understand that drinking and
smoking are my only pleasures. My life sucks, plain
and simple. I drink to relax and get away.
191
Feelings Thoughts
• Impatient • “My life sucks.”
• Restless • “Nothing works out.”
• Unhappy • “I’m tired of this.”
• Tense
• Annoyed • “Sometimes I just need to blow off
• Frustrated steam.”
• Angry • “People piss me off.”
• Tense until drinking begins • “I don’t have a drinking problem.”
• Relief after first drink • “I drink to relax.”
• Urges and cravings prior to • “I wish people would just get off my
smoking back about smoking.”
• Relief while smoking and for some • “I’ll quit when I’m good and ready.”
time afterwards
• Angry that his wife is critical of • “My wife doesn’t understand me.”
him • “My marriage sucks.”
• Furious when wife threatens to • “My wife is always on me about
leave something.”
Ther: So your thought is, “My wife doesn’t understand me.”
I’ll write that in the “thoughts” column. What emotion
do you feel when you have that thought?
Joe: I’m angry. I’m angry that she always criticizes me.
[Based on Joe’s input over the remainder of the ses-
sion the therapist continues to enter Joe’s behaviors,
thoughts, and feelings into the remaining columns of
the problem grid.]
During Stage II the therapist reviews the problem grid and uses
information contained in it to construct a concept map as home-
work (see Figure 1). In doing so the following guidelines are
followed: (a) the concept map is constructed soon after the prob-
lem grid is compiled, while its contents are still fresh in the
therapist’s mind; (b) the client’s name is placed in a circle at the
center of the concept map and the client’s main problems are
plotted in rectangles around that circle; (c) the client’s behaviors,
feelings, and thoughts are then plotted in circles around the prob-
lems associated with them; (d) the plotting is done so that related
problems are in close proximity to each other; and (e) arrows are
used to indicate dynamic relationships between problems, behav-
iors, feelings, and thoughts.
During this stage the therapist generates hypotheses about the
client’s functioning and thus begins the process of case conceptu-
alization. This process is designed to be transtheoretical (i.e.,
transcending any particular theory). As an example of a transtheo-
retical case conceptualization the therapist might conclude: “Joe
tends to create vicious cycles in which he gets depressed and then
uses alcohol to relieve depression, resulting in worse depression.”
If preferred, this process also provides an opportunity for the
therapist to generate specific theoretical explanations for problem-
atic behavior. For example, a cognitive– behavioral therapist might
hypothesize that Joe’s dysfunctional behaviors are a result of
faulty thinking. A psychodynamic therapist might hypothesize that
Joe has an avoidant insecure attachment style, evident by his
 192 LIESE AND ESTERLINE
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Figure 1. Concept mapping with a hypothetical client, Joe, whose problems include depression, chronic anger,
marital problems, cigarette smoking, and excessive alcohol use.
distancing himself from his wife and isolating himself during times
of stress.
The volume of material in the problem grid and concept map is
determined by various factors including the number, complexity,
and severity of problems the client presents. Some concept maps
will have many rectangles and circles while others will have just a
few. It is important to note that not all information on the problem
grid is included in the concept map. Only information most per-
tinent to the case conceptualization is included, and it is under-
stood that there are no right or wrong ways to construct the concept
map. It is also understood that the concept map may change as the
client presents new information in future sessions. These under-
standings help to alleviate novice therapists’ anxiety about com-
pleting the concept map “correctly.”
In Stage III, therapist and supervisor meet to review the concept
map. As the therapist presents the concept map, completed as
homework, the supervisor considers the therapist’s thought pro-
cesses and helps the therapist develop and strengthen case con-
ceptualization skills. In this stage the supervisor asks the essential
question: “What are the client’s various problems and how are they
related to one another?” The supervisor explains that the listing of
problems, behaviors, feelings, and thoughts is a surface-level pro-
cess, while examination of the dynamics between these is a deeper-
level process. For example, Joe’s cigarette smoking is a surface-
level problem. At a deeper, more dynamic level, Joe’s cigarette
smoking might be viewed as a compensatory strategy for emotion
regulation.
It is during Stage III that the supervisor has an opportunity to
teach deeper-level case conceptualization skills, consistent with
the supervisor’s own therapeutic framework. For example, a
cognitive– behavioral supervisor might focus on the impact of
Joe’s thoughts and beliefs on his subsequent emotions and behav-
iors. A psychodynamic supervisor might point out how Joe’s
reactions to his wife and to life stressors relate to his attachment
style. The following is an excerpt from the conversation between
Joe’s therapist and the supervisor during this stage.
Ther: I’m not exactly sure how to map Joe’s marital prob-
lems, his drinking, and his smoking. He doesn’t see
drinking or smoking as primary problems. He actually
thinks his marital problems are his wife’s fault. I do
believe that his drinking and smoking are related to
problems in his marriage.
Sup: I agree. How can we make these connections more
evident on this concept map?
Ther: Well, I already drew arrows connecting Joe’s drinking
and smoking to his marital problems, because he
knows his wife doesn’t like those behaviors. But I
guess his irritated thoughts about his wife probably
contribute to his anger, which in turn leads to more
problems in his marriage. [The therapist draws arrows
pointing from Joe’s anger and aggression to his mar-
 CONCEPT MAPPING IN SUPERVISION
ital problems and then adds arrows to and from Joe’s
negative thoughts, all resulting in a vicious cycle.]
Sup: I like what you’ve done there. On the surface it ap-
pears that Joe’s drinking and cigarette smoking are
important problems. Actually, on a deeper level, his
difficulty with emotion regulation might be consid-
ered his most important problem. When you next meet
with Joe you can encourage him to reflect on all of
these connections. Perhaps he will agree that many of
his problems are related to the central theme of mood
dysregulation.
It is also during Stage III that supervisors have an opportunity to
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
assess, evaluate, and provide feedback to therapists on a regular
This document is copyrighted by the American Psychological Association or one of its allied publishers.
basis regarding their case conceptualization skills. Recently the
American Psychological Association (APA) Council of Represen-
tatives approved guidelines for clinical supervision in health ser-
vice psychology (APA, 2014). These guidelines state, “Supervi-
sors aspire to provide feedback that is direct, clear, and timely,
behaviorally anchored, responsive to supervisees’ reactions, and
mindful of the impact on the supervisory relationship” (p. 20). By
integrating concept mapping into supervision as described above,
therapists engage in a structured method of conceptualizing clients
(concept mapping, completed as homework). This homework pro-
vides data that can be reviewed by a supervisor who is in a position
to provide direct, clear, timely feedback in response to the thera-
pist’s case conceptualization skills. For example, supervisors
might assess the extent to which therapists progress from surface-
level to deeper-level conceptualizations.
Stage IV of this concept mapping process takes place between
therapist and client in the next therapy session, as the therapist
presents the concept map to the client and they discuss it. This
discussion serves the following purposes: (a) it establishes a col-
laborative tone and conveys the message that both therapist and
client are equally important to the therapeutic process; (b) it
demonstrates that the therapist will work hard for the client, as
evidenced by the therapist’s preparation for the session; (c) it
provides the therapist with an opportunity to further understand
and expand the case conceptualization, based on client feedback;
(d) it ensures that both therapist and client have similar views of
the patient’s problems; (e) it potentially strengthens the therapeutic
alliance; (f) it enables the client to understand the therapist’s
thought processes and thus become better socialized to the dynam-
ics of therapy; (g) it gives the therapist an opportunity to teach
important concepts like the distinction between thoughts and feel-
ings; and (h) it facilitates the client’s insight about his/her own
problems.
The following is an excerpt from Joe’s session with his thera-
pist, as they review the concept map.
Ther: I have been thinking about your marital problems and
have actually drafted a diagram based on the problem
grid we compiled in our last visit. [Places the grid and
concept map side by side on the table in front of
them.]
Joe: [Appearing surprised] Wow, that’s pretty cool!
Ther: Good, I think it will be helpful. When we talked last
time you said that you and your wife disagree about
the causes of your marital problems.
193
Joe: Yeah. She thinks my drinking and smoking are caus-
ing our problems but I think she’s causing the prob-
lems with her nagging and griping at me.
Ther: Okay, so let’s look at this concept map together. You
can see that thoughts like “I wish my wife would get
off my back!” may be contributing to your anger,
which then contributes to your marital problems, as
you told me. At the same time, it seems that drinking
until you pass out and smoking are both habits your
wife doesn’t like, and that might also be contributing
to the problems in your marriage.
Joe: I guess I didn’t realize both of those things could be
true, but when I see it drawn out like this, it makes
sense.
In this exchange, Joe responds to his therapist’s conceptualiza-
tion in a positive, collaborative manner. Obviously this will not
always be the case. When the client disagrees with the therapist’s
conceptualization the two work together to restructure the concept
map so both can agree.
Summary and Conclusions
In this article, we have introduced concept mapping as the active
ingredient of a four-stage model of supervision. Concept mapping
provides a structured and practical approach to supervising novice
therapists. Consistent with an assumption of the integrative devel-
opmental model of supervision (Stoltenberg & McNeill, 2010), we
have observed that novice therapists appreciate this structured
approach to supervision. Consistent with Mayfield et al. (1999),
we have also observed that novice therapists initially conceptualize
clients with surface-level concepts. As they gain experience and
receive effective supervision, they increasingly conceptualize cli-
ent problems at deeper levels.
We believe that concept mapping, when integrated into super-
vision, benefits both therapists and clients. Accordingly, we pro-
pose the following questions for empirically testing concept map-
ping as part of the four-stage process described in this article: (a)
Do novice therapists view concept mapping as helpful in acquiring
case conceptualization skills? (b) Does concept mapping facilitate
surface, deep, or both levels of case conceptualization in novice
therapists? (c) Does the collaborative nature of concept mapping
facilitate the therapeutic alliance? (d) Does concept mapping fa-
cilitate client insight? (e) Conducted early in therapy, does concept
mapping improve commitment to therapy (e.g., by reducing the
likelihood of early dropout)? (f) Does concept mapping facilitate
client behavior change? As these questions are addressed in re-
search, strengths and weaknesses of concept mapping in supervi-
sion will be uncovered.
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kpg041
Received March 31, 2014
Revision received October 1, 2014
Accepted October 2, 2014 䡲