Evaluating the content and quality of cognitive-behavioural therapy case conceptualisations

Whilst case conceptualisation(CC) is considered a key Cognitive-Behaviour Therapy (CBT) competency, assessment and evaluation of the content and quality of CBT CC skills is not generally part of CBT training. In this paper, the content and quality of CCs produced by novice CBT clinicians was evaluated. Twenty-six novice CBT clinicians constructed CCs based on four clinical case vignettes. The content and quality of the CCs was evaluated using three rating scales, the Case Formulation Content Coding method, the Fothergill and Kuyken Quality of Cognitive-Therapy Case Formulation rating scale, and the CBT CC rating scale and benchmark conceptualisations. Descriptive statistical analysis of content displayed consistent distribution of subcategories of clinical information included, or omitted in the CCs. Underlying psychological mechanisms were emphasised. Information concerning biological, socio-cultural, protective factors, and the therapeutic relationship were generally omitted. As far as quality was concerned, between 50% -61 % of participants produced "good-enough" CBT CCs. The consistent pattern of clinical information evidenced in the participants' CCs highlighted strengths and weaknesses which have implications for improving training in CC CBT competency. Case Conceptualisation (CC), sometimes referred to as case formulation, is widely regarded as a core psychotherapeutic competency (Dobson & Shaw, 1993; Eells, 2007; Kuyken, Padesky, & Dudley, 2009; Persons, 2008). Notwithstanding the consensus regarding its importance, CC has been described in the literature as "poorly defined and taught" (Sperry, Gudeman, Blackwell, & Faulkner, 1992) and, "seldom systematically evaluated" (Eells, Kendjelic, & Lucas, 1998). The situation is gradually changing and, with the publication of two influential books, "The case formulation approach to cognitivebehaviour therapy" (Persons, 2008) and "Collaborative case conceptualisation" (Kuyken et al. 2009), there is evidence that a more systematic approach to developing, and effectively using a CC in clinical practice, is evolving. CC has proved a difficult area to research as it is a "principles driven" approach to treatment rather than a "treatment" per se (Persons, 2008). Key research questions have concerned the content, quality, reliability, validity, treatment outcomes positively correlated with individualised CC, and clinical utility (Kuyken et al., 2009). Consensus regarding the content of a clinically useful CC has been achieved over the past 30 years after the "consensus issue in psychoanalysis" had been named (Seitz, 1966, cited in Eells, 2007). Systematic models of CC generally include a description of presenting problems, the patient's developmental history, precipitating and maintaining factors, weaknesses, and suggestions regarding a treatment plan (Beiling & Kuyken, 2003). Over the past decade the evaluation of content and quality of CCs has been reported in a few studies (Eells, Kendjelic, & Lucas, 1998; Eells, Lombart, Kendjelic, Turner, & Lucas, 2005; Kuyken, Fothergill, Musa, & Chadwick, 2005). Further progress has been facilitated by the development of a number of structured CC formats such as the Judith Beck CBT CC form (Beck, 1995). To evaluate content and quality, the Case Formulation Content coding method (Eells et al., 1998) was developed and remains the only published manual differentiating categories of information contained in most case conceptualisation models. The Case Formulation Content Coding method has been shown to be a reliable measure of CC (Eells et al, 1998; Eells et al, 2005, Kuyken et al., 2005), which codes the content and quality of clinical information included in CCs across Psychoanalytic, CBT, and Humanistic models of psychotherapy. As far as reliability of CC is concerned, a number of studies have shown a greater degree of reliability for descriptive, rather than the explanatory, components of the CC (Kuyken et al. …