To aid in the development of the cognitive case conceptualization, it may be useful for clinicians to diagram the conceptualization. Such a diagram can be useful in organizing the information available about the patient. J. S. Beck (1995) provided a Cognitive Conceptualization Diagram that we believe is particularly useful in mapping information about the patient. This diagram includes spaces for depicting the relationship between automatic thoughts, and emotional and behavioral reactions, as well as the relationship between automatic thoughts and deeper level beliefs, such as conditional assumptions and core beliefs.
Recently, J. S. Beck (2005) recommended expanding the Cognitive Conceptualization Diagram in working with patients whose complex difficulties include displays of therapy-interfering behaviors; that is, patients' beliefs and compensatory behavioral strategies are likely to occur in therapy just as they occur in other areas of their lives. For example, patients who rarely take risks or try new behaviors because of fear of failure may have a difficult time with homework that requires them to test out their beliefs by engaging in novel behavior. Similarly, patients who compensate for their belief that they are unlovable by trying to please others are likely to try to please therapists by following through with whatever homework is assigned, regardless of its perceived or actual benefit. Specifying problematic situations that occur in therapy, and identifying the automatic thoughts, emotional and behavioral reactions, and compensatory strategies that accompany these situations, may be useful for challenging or complex presentations of depression. Furthermore, J. S. Beck discussed ways of working with challenging behavior in CT that occurs in sessions (e.g., challenges involved in setting goals, structuring sessions, or modifying beliefs) and between sessions (e.g., challenges involved in solving problems and doing homework). Using the case conceptualization in anticipating and responding to such challenges is likely to improve outcome in working with depressed patients.
Whereas J. S. Beck's (1995) Cognitive Conceptualization Diagram is likely to be helpful in working with many depressed patients, including people with severe, chronic, or treatment-resistant depression, it does not specifically address co-occurring conditions. To aid in diagramming case conceptualization for patients with comorbid conditions, we have provided in Figure 2.2 a Case Conceptualization Diagram for Comorbid Conditions modeled after J. S. Beck's (1995) Cognitive Conceptualization Diagram.
However, to minimize the complexity of the diagram, we have chosen not to include the sections on conditional assumptions, compensatory strategies, and meaning of automatic thoughts. Furthermore, we have added Persons's (1989) terminology of underlying mechanisms and overt difficulties, so that the diagram is consistent with our earlier discussion of case conceptualization.
Following the recommendations of J. S. Beck (1995), the therapist begins diagramming the case conceptualization by providing several examples of typical situations in which the patient becomes upset. The therapist then fills in the automatic thought elicited by each situation, and the patient's subsequent emotional and behavioral responses. From these typical automatic thoughts, the therapist hypothesizes the likely deeper level (i.e., core) beliefs. Finally, therapist and patient work together in generating hypotheses to understand the origins of relevant childhood and developmental experiences that may have contributed to the development and maintenance of these core beliefs.
To address issues of comorbidity, the Case Conceptualization Diagram for Comorbid Conditions includes space for completing two parallel sets of overt difficulties representing the situations, automatic thoughts, emotions, and behaviors for each of the two conditions; additional diagrams may be used for additional conditions. Completing the diagrams in tandem encourages the therapist to consider ways the comorbid condition(s) may be associated with depression. For example, if each of the two conditions is conceptualized as having its own underlying cognitive mechanism (i.e., the associated liabilities model of comorbidity), then the therapist completes the underlying mechanism section for each disorder and draws a line connecting the two underlying mechanisms (cf. top panel in Figure 2.1). In comparison, if the two conditions are conceptualized as arising from a common underlying cognitive mechanism (i.e., the alternate forms model of comorbidity), then the therapist draws a line from one underlying mechanism to both sets of overt difficulties (cf. middle panel in Figure 2.1). Finally, if one condition is conceptualized as having caused the other condition, then a directional arrow is drawn from one condition to the other, depicting unilateral or bilateral direction of effect (cf. bottom panel in Figure 2.1). In each conceptualization, the simultaneous completion of multiple diagrams serves to encourage the therapist to generate hypotheses about how the conditions are related.
As in the case of the original diagram, the Case Conceptualization Diagram for Comorbid Conditions is "introduced to the patient as an explanatory device, designed to help make sense of the patient's current reactions to situations" (J. S. Beck, 1995, p. 143). The conceptualization is presented as a series of hypotheses, and the patient provides input as to the accuracy of the conceptualization. Based on the view that the more authentic and collaborative the understanding that develops between the patient and the therapist, the better the outcome is likely to be (Persons, 1989), completing the cognitive conceptualization together as a collaborative exercise should promote better outcome. As such, this diagram is useful for helping both therapist and patient develop a working, common understanding of the patient.
In addition to providing hypotheses about relationships among the patient's problems, the case conceptualization should ultimately provide information regarding selection of an appropriate treatment modality (e.g., individual, couple, or family therapy) and specific intervention strategies, and the pacing of therapy. Case conceptualization may also provide information about other contextual factors that are relevant to treatment (e.g., the therapeutic relationship). Finally, it should be noted that case conceptualization is not fixed at the beginning (or at any stage) of therapy. Although it begins with an initial assessment, conceptualization does not end with this assessment. Instead, case conceptualization is viewed as a fluid, working hypothesis of the person, which is revised as additional information becomes available.
Because case conceptualization is so closely linked to the treatment plan, the utility of the conceptualization is evaluated by the outcome of the intervention that follows from it. Therefore, if an intervention based on the conceptualization is successful, the conceptualization is supported. In comparison, if an intervention based on the conceptualization is unsuccessful or ineffective, then the conceptualization is not supported. In this case, the conceptualization would need to be modified and alternative interventions implemented. We turn now to a discussion of ways in which standard CT may be adapted in treating different presentations of depression.
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