Supervisor Tips: Case Conceptualization

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Case conceptualization basically describes outlining treatment goals.

Think of this as getting into a car, and then deciding where to go. Once you have decided where you want to go, you need directions. So the goal of case conceptualization is basically to answer 2 questions:
  1. Where am I going?
  2. How do I get there?

With each client you serve, it is imperative to conduct thorough case conceptualization or your case will quickly dissolve into chaos, frustration, or poor quality treatment (the dreaded “cookie cutter” treatment).

I often find that newer staff/ newly certified staff struggle in this area, and have many questions about properly designing treatment. When supervising individuals for the BCBA exam, I love to give many opportunities to practice case conceptualization because it ties together so many important behavior analytic skills. It’s like reading a well written report from a clinician; when it’s done right, you feel as if you know everything vital about the client, their needs, their history, and their environment.

I see case conceptualization as more art than science, because 2 clinicians could have the same information from the same client, and “create” two completely different “treatment recipes”. Very similar to making a meal, two cooks could receive identical ingredients and yet create two separate, and amazing, dishes. It doesn’t mean one dish is wrong and one dish is right.
 I seek out and give feedback to colleagues all the time, mainly as just good clinical practice, but also because it’s fascinating and a learning experience to see how someone else would approach my clients…. Where would they begin with instruction? What barriers to parent involvement do they see? Am I missing any key setting events for problem behavior? If you don’t regularly have your work reviewed by colleagues, I highly recommend it. Its super helpful.

So here are some key points/tips that should have you conceptualizing treatment like a pro in no time!

  •         Conceptualization begins with a solid understanding of your client, their environment and/or the family system. Have you conducted a complete intake? Have you observed across settings for differences in behavior? Have you completed an appropriate assessment (which assessment to use will vary based on client functioning)? Have you conducted record review of the evaluation report, current IEP, any current or former Behavior Intervention Plans, etc.?
  •  Clearly identify the “problem”: WHY is the family/caregiver seeking services? What do they see as the main concerns? What specific changes do they expect ABA treatment to bring about. Do not skip this step, it is super important. I spend a lot of time during intake revealing misconceptions people have about ABA and explaining what they can expect from treatment, and what is unrealistic to expect from treatment. If you and the family (or whoever is hiring you) are not clear on the purpose of treatment, you'll end up just spinning in circles. 
  •  Please don’t forget client strengths! I was just talking to a colleague about this, but I regularly review/read over reports from various clinicians (the client’s OT, SLP, Psychiatrist, etc.) and sometimes I am blown away by how negative these reports can read. I can’t imagine as a parent what it would feel like to read report after report of your child’s lacks, deficits, and limitations. Accurate case conceptualization includes knowing your client’s deficits, of course, but what are they good at? What strengths do they bring to the table? Where can you highlight something positive? Treatment isn’t just about correcting deficits-- you can also build on strengths. 
  •   Be shortsighted and longsighted all at the same time. You will get your big, long term goals during intake (parent/caregiver input combined with clinician recommendations). But you can’t stop with just long term goals. For example, it is typical a parent will say something like “I want David to talk”. That’s great, but I can’t write a program that says “Within 6 months, David will talk”. Ummm, how will David learn to talk? How many words do I expect him to say? What function of communication am I focusing on (manding, labeling, etc.)? Answering these questions will lead you directly to your short term goals for treatment.
  •  Consider Treatment Mapping. I once worked for a company that required BCBA's submit treatment maps for 6 months out. If you are unfamiliar with these, it’s basically a way to visually outline where treatment is going. To me, it was like doing brainstorming in middle school. Remember that? You would write a topic, like “rainbows”, and then draw little lines out from the topic to start generating supporting ideas. Here is a very basic example of a treatment map, they usually are much larger than this. The cool thing about it is it basically takes everything out of your head, and gives you a concrete reference you can refer back to months down the line. If you are new to conceptualizing treatment, this is a tool that will take you some time, but could be very helpful for learning purposes.

*Recommended Reading:

Ingram, B. L. (2006). Behavioral and learning models. In B. L. Ingram, Ed., Clinical case formulations: Matching the integrative treatment plan to the client (pp. 157-190). Hoboken, NJ: John Wiley & Sons, Inc.

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