Tag Archives: Therapist in training

Value of Case Formulation

I recently started at a new practicum placement, and the agency assessment form includes a case formulation.  I haven’t done this before, so I’m not sure how to write it and how I can use it in my work with clients.  

A case formulation, also called a clinical or case conceptualization, is a theoretically based explanation for the client’s presenting problems and symptoms.  You use the concepts from your chosen theoretical perspective to describe why this client has developed the particular issues that are the focus of treatment.  The formulation follows your diagnosis and assessment and guides development of your treatment plan.  Chapter 8 of my book is devoted to the topic of case formulation, including an illustration of a case formulation written from three different theoretical perspectives for the same case.

The case formulation model I present in my book includes the following five aspects of the case:

  • Symptoms and presenting problems—Begin with a brief summary of the reason for treatment, both from the client’s initial presentation as well as additional issues that may be emerged from the assessment.
  • Developmental history and recent events relevant to the symptoms—Summarize the life events that are relevant to the client’s symptoms.  These would include traumatic events, losses, and significant psychosocial stressors that occurred in the past as well as recent precipitants that have contributed to the client’s current presentation.
  • Factors that contribute to the symptoms—This is the core of your case formulation, making clinical inferences about the links between your client’s life events and symptoms.  It is best to use one theoretical orientation as the basis of your formulation, in order to have a cohesive guide for your treatment.  Sample statements are “client developed a core belief of that she is unworthy of love and attention” or “the early disruption in client’s family life led him to develop an avoidant attachment to his mother.”
  • Cultural issues—Describe how cultural identities and other cultural factors impact the client’s symptoms and will be relevant in the treatment.
  • Strengths and resources—Review the internal and external factors that will assist in lessening the client’s symptoms and will enhance the client’s progress in therapy.

Regarding the question of how you can use a case formulation in your work, it can enhance your work in several ways.  When you hold and communicate an accurate understanding of the client’s difficulties, you are able to convey a deeper level of empathy than is possible based only on the client’s presenting symptoms themselves.  Your case formulation also guides your choice of treatment goals and interventions, allowing you to target more specifically the underlying source of the client’s problems.  Last, you are able to organize new clinical material more readily when you have a case formulation that structures your knowledge of the client’s present and past experiences.

I hope this model for case formulation enables you to develop clinically useful descriptions of the links between your clients’ symptoms and history.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Awareness of Cultural Influences

counselingI am a female therapist working with a young woman in her 20’s. She has an opportunity for a promotion which would involve business travel a couple times a month, and would be a good career move for her. However, she is considering turning down the promotion because she helps her parents care for her grandmother who has many health problems. It’s hard for me to see my client sacrifice her professional success for this family obligation. How can I help her with this decision?

This is an example of the influence of cultural values in psychotherapy. You and your client are both female, but you may be different in other cultural identities such as age, ethnicity, social class, sexual identity, religious affiliation, and immigration status. Our values and our views of relationships are shaped by the combination of cultural factors that make up our identity, and these differences between you and your client lead you to different cultural values. The topic of cultural issues in psychotherapy is covered in Chapter 4 of my book.

It is important for you to recognize that you have formed an opinion about what is best for your client based on your values, but she is letting you know that she views her situation differently. Assuming that she needs to come around to your point of view interferes with the understanding that can develop when you are curious and interested in her perspective. Take time to encourage her to explore and reflect on the values she is expressing by pursuing a career and by caring for her grandmother so she can become more clear about the dilemma she is facing. As you are more open to considering her point of view, you will be able to empathize with her complex feelings and to support her making a decision in line with what is most meaningful to her.

Be aware that your client may be making assumptions about what is and isn’t acceptable to her family, and she may not have discussed her decision openly with her family. Our beliefs about ourselves and relationships are often internalized early in life and may not be fully within her awareness or part of recent family conversations. Once you have helped your client become aware of her values, you and she can examine them together to see the extent to which they inform her decision. It may also be useful for her to talk with others in her cultural community to see whether there is more diversity of opinion than she assumes or than she believes based on her individual experience in her family. Getting consultation, especially from someone who is familiar with your client’s cultural influences, will be helpful in managing your feelings as she arrives at her decision.

In addition to your client’s values, examine the practical issues that may influence her decision to take this promotion. The immigration status of her parents and grandmother, the family’s financial resources, and the presence of other support in the community are all factors that may make it more or less difficult for your client to prioritize her career, if that is what she wishes to do. It may take time for her to disclose some of these details to you, depending on the extent to which she holds cultural values that consider such matters as private, not to be shared outside the family.

This career decision may be the beginning of numerous situations your client will face and need to discuss in therapy. Whatever she decides about this promotion, continuing to talk with her about her cultural values will be helpful in her developmental progress. It is likely that she will face similar choices in the future as she navigates her career and family commitments. If you recognize your values and assumptions as culturally influenced and develop an authentic interest and curiosity in your client’s perspective, the therapy is likely to develop into a deeper and richer relationship. You have an opportunity to provide your client with the experience of empathy, understanding, and respect that will build her confidence in making this and future decisions.

If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

 

Education as a Therapeutic Intervention

I’ve been seeing a client for about six months, and she recently told me about witnessing domestic violence between her parents when she was young. I used to volunteer at a DV family shelter, so I have a lot of information about how she may have been affected by this. Is it appropriate for me to share what I know as part of her therapy?counseling

This is a good question and brings up a common situation in therapy. You have information that may be useful for the client in understanding and resolving the difficulties that led her to seek therapy, and you are wise to think through the decision to take an educational role. I will share some of my thoughts about the factors to consider in deciding how and when to bring educational information into therapy.

First, I would affirm your sense that providing education can be a useful therapeutic intervention. As mental health professionals, we have knowledge about trauma, relationships, communication, human development, family dynamics, and many other topics that are relevant to our clients’ concerns. This particular client has introduced the topic of domestic violence, and it could be empowering for her to gain knowledge that she can apply to her life.

As you consider talking with your client about the impact of witnessing domestic violence as a child, pay particular attention to the timing of her decision to share this with you and to your countertransference feelings in learning this new detail of her history. She chose to wait six months before telling you about this powerful and traumatic experience, so this means she has been waiting to feel a sufficient level of trust before disclosing this to you. Think about what it means for her to have chosen this moment in the therapy to share the domestic violence and reflect on what she wants and needs from you in response. Notice how you felt when she told you and what you feel as you anticipate giving her educational information. There may be an intense emotion you are avoiding or attempting to modify by introducing psychoeducation, especially if it represents a shift from your usual therapeutic style. Consider the possibility that your client will benefit from education about the impact of domestic violence at a later time in the therapy after you and she have talked about the meaning and feelings she has about telling you now.

Another factor to consider in your decision is your client’s culture and what this means for her expectations of you and the therapy. She may view you as an expert who has knowledge that she is lacking, and it may be more therapeutic for you to work on developing a more collaborative alliance before you adopt an educational role. Alternatively, it is possible that conforming to her expectations of your role may help her to feel more safe and trusting. Reflection on the therapeutic process so far and consultation with your supervisor will help you to sort out the cross-cultural implications of sharing your knowledge about this topic. If your client comes from a different cultural community than you, also give thought to her cultural values and norms for family relationships and the presence of physical violence in the home. Providing education requires sensitivity to cultural differences and to her current relationship with the cultural values of her childhood.

Last, I would recommend thinking about your client’s general description of her relationship with her parents and how your use of education may provide a different experience for her. If she experienced her parents as unavailable and preoccupied, you will provide a different experience by being engaged and attuned to her needs and questions. If she experienced her parents as intrusive and acting on their own agenda, it will be helpful to introduce your ideas tentatively and ask for her responses and thoughts about the information you provide.

I hope you found this blog post helpful in considering the use of psychoeducation in therapy. Please email me with comments, questions, or suggestions for future blog topics.