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Collaborative Case Conceptualization
 Collaborative Case
Conceptualization
Working Effectively with Clients
in Cognitive-Behavioral Therapy

Willem Kuyken
Christine A. Padesky
Robert Dudley

THE GUILFORD PRESS

New York London
© 2009 Willem Kuyken, Christine A. Padesky, and Robert Dudley
Published by The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com

All rights reserved

Except as indicated, no part of this book may be reproduced, translated, stored

in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, microfilming, recording, or otherwise, without
written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED PHOTOCOPY LICENSE

These materials are intended for use only by qualified mental health
professionals.

The publisher grants to individual purchasers of this book nonassignable

permission to reproduce the Aid to History Taking Form. This license
is limited to you, the individual purchaser, for personal use or use with
individual clients. This license does not grant the right to reproduce
these materials for resale, redistribution, electronic display, or any other
purposes (including but not limited to books, pamphlets, articles, video-
or audiotapes, blogs, file-sharing sites, Internet or intranet sites, and
handouts or slides for lectures, workshops, webinars, or therapy groups,
whether or not a fee is charged). Permission to reproduce these materials
for these and any other purposes must be obtained in writing from the
Permissions Department of Guilford Publications.

Library of Congress Cataloging-in-Publication Data

Kuyken, W. (Willem), 1968–

Collaborative case conceptualization : working effectively with clients in
cognitive-behavioral therapy / Willem Kuyken, Christine A. Padesky, Robert
Dudley.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60623-072-5 (hardcover : alk. paper)
1. Cognitive therapy. 2. Psychiatry—Case formulation. I. Padesky,
Christine A. II. Dudley, Robert (Robert E. J.) III. Title.
[DNLM: 1. Cognitive Therapy. 2. Cooperative Behavior.
3. Psychological Theory. WM 425.5.C6 K965c 2009]
RC489.C63K89 2009
616.89′1425—dc22
2008042357
 WITH LOVE TO

Halley, Zoe, and Ava

— W. K.

Tim, for the origins,

and Kathleen, for our evolution
— C. A. P.

Joy, Jessica, James, and Samuel

— R. D.
 About the Authors

About the Authors

Willem Kuyken, PhD, is Professor of Clinical Psychology at the Uni-

versity of Exeter, United Kingdom; Cofounder of the Mood Disorders
Centre; and a Fellow of the Academy of Cognitive Therapy. His primary
research and clinical interests are case conceptualization and cognitive-
behavioral approaches to depression, and he has published more than
50 articles and book chapters. Dr. Kuyken is a recipient of the May
Davidson Award from the British Psychological Society.

Christine A. Padesky, PhD, is a Distinguished Founding Fellow of the

Academy of Cognitive Therapy and recipient of its Aaron T. Beck Award.
She is an internationally renowned speaker, consultant, and coauthor
of six books, including the bestselling Mind Over Mood. Dr. Padesky’s
numerous awards include the Distinguished Contribution to Psychology
Award from the California Psychological Association. Through her web-
site, www.padesky.com, she produces audiovisual programs on case concep-
tualization and other topics that provide CBT training for therapists in
more than 45 countries.

Robert Dudley, PhD, is a Consultant Clinical Psychologist for the

Early Intervention in Psychosis Service at the Northumberland, Tyne,
and Wear Mental Health NHS Trust, United Kingdom. He is currently
serving as a Beck Institute Scholar at the Beck Institute for Cognitive
Therapy and Research. Dr. Dudley’s primary clinical and research focus
is the understanding and treatment of psychotic symptoms. As a clini-
cian, trainer, and supervisor, he developed an interest in case conceptu-
alization and has undertaken several research projects in this area.

vii
 Preface
Preface

Preface

ognitive-behavioral therapy (CBT) is both art and science. Nowhere

C is this truer than during case conceptualization, when therapists stay
attuned to clients’ unique experiences while also attending to the sci-
entific theories and research that underpin CBT. Like many cognitive
therapists, we deeply appreciate CBT precisely because it bridges art and
science, practice and theory, idiosyncratic experiences and the common-
alities encapsulated by cognitive and behavioral theories of emotion. We
stand on this bridge with our clients working together to relieve distress
and build resilience.
The three of us first met in 2002 in Warwick, England, at a CBT
conference symposium entitled “Case Conceptualization: Is the Emperor
Clothed?” The conference organizers had scheduled the symposium in
a relatively small seminar room. The topic generated so much interest
that the room was full, with many people standing at the back or sit-
ting in the aisles. Rather like Hans Christian Andersen’s allegorical tale
alluded to in the symposium’s title, the symposium highlighted several
important “facts.” First, case conceptualization is considered a funda-
mental therapy skill. Even so, many therapists lack confidence in how
to conceptualize. Second, therapist interest in case conceptualization
outstrips the sparse evidence base. Third, the little research that exists
challenges assumptions about the positive value of CBT case concep-
tualization. The symposium concluded that the case conceptualization
emperor appeared to be unclothed!
At the end of the symposium the three of us lingered in conversa-
tion and began talking about case conceptualization. As we talked, we
realized we shared a keen interest in case conceptualization and each of
us brought different, valuable, and complementary perspectives to the
topic. While the three of us teach, supervise, consult, and conduct CBT
research, each of us has acquired special expertise in at least one of these
areas. Robert offers keen clinical insights gleaned from his years of expe-
ix
x Preface

rience as a therapist and supervisor working with complex clinical cases.

Christine is an internationally recognized CBT instructor and innovator.
Willem is a leading case conceptualization researcher and teacher. We
thought this combination of experience and knowledge could advance
understanding of how to make case conceptualization more effective in
CBT.
This book is the result of an ongoing collaboration that began at
that conference. Our ideas evolved in stages over the past 6 years. First
we made explicit the unresolved implicit research and clinical challenges to
case conceptualization. These are summarized for the reader in Chapter
1. As we jointly struggled with how to respond to these challenges, we
realized many of our solutions were insufficient. We generated fresh ideas
and tested these out with each other; in discussions with peers; in our
clinical work; in our work as supervisors, consultants, and instructors;
and in relation to the emerging research. We distilled useful ideas down
to their simplest form using collaborative empiricism as a check and
balance to guard against heuristic biases. After a few years, we reached
consensus on a model for case conceptualization that we felt adequately
addressed the existing challenges.
Our model is described in Chapter 2 along with three principles
to guide its practice: collaborative empiricism, incorporation of client
strengths, and evolving levels of conceptualization. This model has its
roots in the conceptual and empirical traditions of Aaron T. Beck, the
founder of CBT as well as a mentor and friend to each of us. We draw
on the rich empiricism of behavioral therapy, especially functional analy-
sis. In addition, our ideas are informed by contemporary research on
resilience and strengths. Throughout, our aim is to provide a conceptu-
alization approach that therapists can use collaboratively with clients to
more effectively relieve distress and build resilience.
This book teaches our approach to case conceptualization and
brings it to life with case examples, practical clinical tips, and sample
dialogues. Step by step, we show how to develop a conceptualization
that first describes client presenting issues and then deepens in explana-
tory power as treatment progresses. Client strengths are identified and
harnessed throughout the process of conceptualization to help create
effective and lasting improvement. We describe how therapist and client
can truly collaborate to explicitly co-create and test conceptualizations
throughout the course of therapy.
Chapter 3 delineates our first conceptualization principle, collab-
orative empiricism, and shows readers how a collaborative and empirical
approach to therapy leads to effective resolution of a number of concep-
tualization challenges. In Chapter 4 we show how our second principle,
incorporation of client strengths, expands the emphasis of case conceptual-
 Preface xi

ization to encompass goals of restoring and building client resilience.

Chapters 5 through 7 illustrate our third principle, levels of conceptualiza-
tion, by following a client, Mark, over the course of therapy as he tackles
depression, obsessive–compulsive disorder, health worries, work difficul-
ties, and family struggles.
Although Mark is a composite of many clients, his case portrays
a common clinical presentation that requires individualized conceptu-
alization: he experiences high levels of distress in the context of many
overlapping diagnostic issues. Readers learn how Mark and his therapist
progress from simpler, descriptive case conceptualizations (Chapter 5),
to explanatory conceptualizations of what triggers and maintains his
presenting issues (Chapter 6), to a longitudinal account of what predis-
posed him to this particular set of presenting issues and what strengths
protected him from worse difficulties (Chapter 7). Mark’s in-depth case
illustration demonstrates how our approach can simultaneously help
decrease psychological distress and promote resilience.
As CBT instructors, supervisors, and consultants we observe that
learning to use case conceptualization effectively is one of the biggest
challenges faced by therapists. In Chapter 8 we demystify the learning
process and suggest a systematic approach for therapists and instructors
to learn and teach case conceptualization skills. In our closing chapter
we consider some of the issues therapists might face in using our model
in a variety of therapeutic settings. Consistent with our commitment to
empiricism, we also propose a program of research to test the assump-
tions and principles central to our model.
One of the measures of a worthwhile collaboration is how engaged
the parties remain throughout the process. By this standard, our collabo-
ration as authors has held great value. Each of us is even more enthusi-
astic and interested in case conceptualization now than we were at the
outset of this project. We have done our best to capture for readers the
essence of the spirited discussions and debates that infused our interac-
tions over the last several years. Now this book is in readers’ hands. We
hope it enhances your understanding of case conceptualization, shows
you how to actively collaborate with your clients during these processes,
and stimulates research to evaluate our ideas. In the years ahead we
look forward to a broader conversation that includes many of you as
we continue to explore the boundaries and depths of collaborative case
conceptualization.
 Acknowledgments
Acknowledgments

Acknowledgments

A number of people have shaped and contributed to this book and we

gratefully acknowledge their input. At various stages we have tested the
ideas in this book on colleagues whose opinions we greatly value. The
book has benefited from the ideas and comments of Peter Bieling, Gillian
Butler, Paul Chadwick, Tracy Eells, Melanie Fennell, Mark Freeston,
Kevin Meares, Kathleen Mooney, Ed Watkins, and Kim Wright. We
are grateful for the artistic talents of Bruce Lim, who created original
illustrations throughout the book, including the case conceptualization
crucible, an image central to our model. We thank Bibiana Rojas for her
excellent graphic design work on the figures. We appreciate Seymour
Weingarten at The Guilford Press for his constructive support of this
work at every stage of its development. Finally, we are indebted to our
Guilford editor, Barbara Watkins, whose professional and insightful
commentary on a series of drafts significantly enhanced the clarity and
cohesion of the book.
—WILLEM KUYKEN, CHRISTINE A. PADESKY, ROBERT DUDLEY

I am grateful to my mentors, collaborators, and clients, who have helped

me cross the divide between science and practice so many times that I no
longer regard it as a divide but rather as a creative dialectic! I thank Profes-
sors Aaron T. Beck, Chris Brewin, Tony Lavender, and Paul Webley, who,
in different and important ways, provided inspiration, challenge, and
support during my professional development. I have been very lucky to
be able to work with superb collaborators, including Peter Bieling, Sarah
Byford, Paul Chadwick, Tim Dalgleish, Emily Holden, Rachael Howell,
Michelle Moulds, Eugene Mullan, Rod Taylor, Ed Watkins, Kat White,
and the World Health Organization Quality of Life (WHOQOL) Group.
Collaboration is at the heart of my professional work. In my opinion,
the challenges faced by clinical researchers are often best met by multi-
disciplinary teams. I am fortunate to have had productive collaborations
xiii
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