Bridging Case Conceptualization, Assessment, and Intervention

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Scott T. Meier

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    Preface

    Attempts to bridge the science and practice of clinical work in mental health have a long history (Hess & Mullen, 1995; Pepinsky & Pepinsky, 1954; Stricker & Trierweiler, 1995). Eldridge (1993), for example, noted that accountability (i.e., outcome assessment) had been proposed as the central issue confronting social workers during the 1970s; counseling educators have expressed concerns about students' ability to conceptualize clients for decades (Holloway & Wolleat, 1980; Nelson & Neufeldt, 1998). Yet many observers (e.g., Goldman, 1972) conclude that a science-practice integration has failed or at least failed to meet expectations. Potential explanations include:

    • The science-practice link has been strained because of the different purposes of scientists and practitioners. Researchers are typically concerned with discovering general laws, whereas practitioners focus on helping specific cases that consist of individuals, groups, and families (e.g., Fensterheim & Raw, 1996; Hess & Mullen, 1995; Stricker & Trierweiler, 1995).
    • Many students in the helping professions enter graduate school with vocational interests that are socially oriented and unrelated to research activities (Kahn & Scott, 1997). Beginning students, for example, often express a stronger desire to learn the what and how (i.e., techniques) of clinical work than the why; graduates in the helping professions seldom conduct or publish research. Expecting such individuals to change their vocational interests and abilities is unrealistic.
    • Clinicians have been resistant to evaluation efforts because of the additional workload and the potential for critical feedback involved (Nugent, Sieppert, & Hudson, 2001). Issues of accountability and effectiveness often hold more interest for administrators, funding agencies, and researchers than they do for clinicians. Thus, scientific methods have been perceived as having little to offer clinicians except negative consequences.
    • Scientific methods and clinical practice are typically taught in separate courses and seldom completely integrated (Meier, 1999; Stoltenberg, Kashubeck-West, Biever, Patterson, & Welch, 2000). Chwalisz (2001) noted that “the scientist-practitioner model, as currently enacted in psychology training programs, has not built a sufficient relationship between science and practice” (p. 265). Many training programs appear to assume that if graduate students receive separate courses in research design, testing and assessment, and reviews of counseling research, they will naturally integrate this information into their work with clients. My experience as a student and faculty member is that this is usually not the case: Many students differentiate research and practice into separate domains.

    This book approaches the science-practice problem by focusing explicitly on the links between case conceptualization, assessment, and analysis of intervention effects during clinical work. Observing the professional behaviors of neurosurgeons, Gladwell (1996) noted that “the complexity and mystery of the brain has … led to a culture that rewards intuition, and has thus convinced each neurosurgeon that [his or her] own experience is as valid as anyone else's” (p. 39). Like neurosurgeons, clinicians conducting psychotherapy typically receive little systematic feedback about the effects of their work and make many of their decisions intuitively. The approach described in this book attempts to present a balance between questioning and supporting clinical intuition by making clinicians' thoughts, decisions, and judgments explicit, and then checking them against other kinds of information (see Berman, 1997; O'Brien, 1995). By integrating this structured approach directly into the content of clinical, theoretical, and practicum courses, faculty can increase the likelihood that student clinicians will increase their confidence in using more systematic methods and thus actually use them (Meier, 1999).

    The most basic reason for investing in such an integrative approach is improving clinical outcomes. Failure to conceptualize and monitor treatment may be one of the contributing factors to treatment failure (Clark, 1999). In addition, by closely linking case conceptualization and assessment data with intervention decisions, students and clinicians can (a) be introduced to a standard of practice that moves beyond an eclectic, flying-by-the-seat-of-your-pants approach to therapy and (b) better understand why counseling is ineffective with some individuals and thus have a basis for adjusting treatment in those instances. A commitment to an integrative approach that increases professional reflection should also foster clinicians' professional development (Ronnestand & Skovholt, 2001; Skovholt & Ronnestand, 1995).

    Four basic themes form the foundation of this integrative approach. First, Lazarus (1971, p. xi) cautioned clinicians “not to forget the obvious fact that every individual is unique, and to tailor … therapy accordingly” (cited in Gottman & Leiblum, 1974). Many psychotherapy theories and clinical measures, however, treat clients as if they were largely interchangeable and not individual interpreters and creators of meaning. Although case conceptualization, clinical assessment, and intervention are built on nomothetic theories, they work best when focused on the relatively unique, idiographic aspects of each client.

    Second, this integrative approach differs from traditional methods of teaching counseling and psychotherapy in its emphasis on the inclusion of assessment data in the intervention process. For example, while many counseling texts provide information related to counseling process and intervention, and some explicitly relate this information to client conceptualization, few thoroughly and systematically connect conceptualization and intervention with assessment. Assessment tends to be taught in separate courses on measurement, intelligence testing, and personality testing. The extent to which assessment is integrated into the therapeutic process often depends upon the judgment and background of a particular supervisor in a practicum setting. In fact, the mental health professions appear to be lagging behind medicine and education in their use of assessment data as feedback in the intervention process (see Cross & Angelo, 1988; Mark et al, 1991).

    Third, structured feedback is critical to learning for both students and practicing clinicians. Experience becomes helpful when we have “systematic procedures for learning from our failures as well as our successes” (Gottman & Leiblum, 1974, p. 9). When clinicians closely examine the set of outcomes experienced by each client, they often find evidence of both success and failure. Thus, analysis of clinically relevant data is key to learning about and improving work with individual clients.

    Fourth, this approach focuses on the application of scientific methods, as contrasted with the exclusive use of specific theoretical knowledge or empirical results. The methods and procedures described in this book are transtheoretical in that they can potentially be applied by clinicians of any particular school of counseling and psychotherapy. The descriptions and examples provided here include a variety of modalities (e.g, individual, group, family) and therapeutic orientations (e.g., social learning, multicultural). Instructors should modify and employ these concepts with whatever therapeutic approaches they prefer, as well as adapt and introduce their particular techniques for case conceptualization, clinical assessment, and analysis of intervention effects.

    This book will be useful to graduate students in clinical fields, and postgraduate clinicians may benefit from a review of these concepts. Introductory courses in counseling theory (including theories of personality, psychopathology, and psychotherapy), measurement and assessment, and qualitative or quantitative analysis will help the reader make sense of these chapters. These materials are intended as an extension of or sequel to class texts, to be used in psychotherapy, counseling, and practical classes where the instructor wishes to bring scientific methods into the discussion of clinical issues. With its emphasis on concepts and procedure, the book's primary intended use is as a manual; those looking for discussions of philosophical foundations should consult sources such as Trierweiler and Stricker (1998). Because the focus of the book is the integration of conceptualization, assessment, and analysis of intervention effects, the treatment of each of these areas is necessarily brief; references are cited in each chapter for sources that provide a deeper discussion. When referring to the counselor or therapist, I prefer to use the word clinician, as it “is a general term used to refer to individuals who have obtained, or are in the process of obtaining, professional training in psychology, counseling, education, or social work departments at universities, medical centers, or training institutions” (Berman, 1997, p. xi). Given the diverse potential readership of the book, terms like psychotherapy and counseling are employed interchangeably.

    The book consists of six chapters. Chapter 1 provides an introduction to the key elements of conceptualization, assessment, and analysis, as well as a more thorough rationale for their integration. Chapter 2 introduces and guides the clinician through the steps necessary to select (a) process elements related to client etiology and intervention and (b) outcome elements for multiple and selected problems. In Chapter 3, the focus shifts to how to assess these process and outcome elements; the presentation includes an overview of assessment methods (including idiographic and behavioral assessment), construct explication, psychometric principles, guidelines for method selection, the use of baselines, and examples. Chapter 4 presents basic graphical, qualitative, and quantitative analytic techniques that can be used to address questions related to outcome, conceptualization, and assessment. Chapter 5 addresses common problems in conceptualization, idiographic assessment, and analysis, while Chapter 6 includes possible future directions for science-practice efforts in the helping professions.

    Portions of this book are based on Meier (1994, 1999); more detailed descriptions of teaching methods related to this material are in Meier (1999), and descriptions of measurement and assessment issues can be found in Meier (1994). Client and therapist names and characteristics have been altered to protect confidentiality; because the purpose of the data presented in this book is teaching, not research, some data have also been altered to protect confidentiality. I would like to thank the many graduate students (particularly Caroline Baltzer, Julie Nettina, Benson Hendricks-Hoffman, and Beth Wahlig) who provided creative (but sometimes uncited, to protect confidentiality) examples of clinical models and analytic displays. Finally, I would like to thank my graduate assistants, the latest including Ron Beebe, Benson Hendricks-Hoffman, Christine Messmer, Julie Nettina, and Erin Steck, for their considerable assistance and helpful feedback.

    —Scott T. Meier Ph.D., stmeier@acsu.buffalo.edu, http://www.acsu.buffalo.edu/~stmeier, University at Buffalo, August 19, 2002

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    About the Author

    Scott T. Meier is Professor and Co-Director of Training of the Program in Counseling/School Psychology, Department of Counseling, School, and Educational Psychology, University at Buffalo. His major research and teaching areas focus on psychological assessment and testing (particularly outcome assessment), research methods (particularly program evaluation), and counseling skills (particularly the integration of case conceptualization and assessment with intervention). He is a licensed psychologist who received his Ph.D. in Counseling Psychology from Southern Illinois University, Carbondale in 1984. He is also the author or coauthor of four books, including Elements of Counseling (Brooks/Cole, 2001), and 40 journal articles.


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