Case conceptualization with highly shame-prone and self-critical clients may often be thought of as case re-conceptualization. That is, clients with high degrees of shame and self-criticism often arrive in therapy with their own conceptualization of their problems, one that is often driven by fusion with the story that they are broken, damaged, incompetent, stupid, or in some way inadequate. For example, the client may state, “I’m not doing anything with my life. I’m basically a failure.” Or they may present self-critical ways of relating to internal experiences, for example, “I just want to stop being sad. It’s pathetic,” or even, “I hate my anxiety.” The goal of case conceptualization is to develop a new viewpoint that that is not based on a critical view of a self that needs to be “fixed.” This conceptualization forms for the core of the subsequent therapy contract. Furthermore, a collaborative re-conceptualization process may serve to loosen fusion with self-related content and begin the development of a new perspective on oneself that is more flexible, warmer, and more conducive to living a valued life.
Case re-conceptualization serves a de-fusing and de-blaming function by developing a zoomed out perspective in which the client is able to recognize thoughts and feelings as thoughts and feelings, and to understand why those thoughts and feelings might have developed based on their learning history with shame and criticism, and their learning history, or lack thereof, with warmth and compassion. On a micro level, they can begin to understand instances of shame and self-criticism in terms of their antecedents and consequences and begin to identify opportunities for changing their relationship with themselves. The conceptualization process also includes identifying past relationships and experiences that can serve as resources in building a friendlier kinder relationship to oneself and others.
Our case conceptualization process is informed primarily by two scientific traditions: 1. Contextual Behavioral Science (e.g., Acceptance and Commitment Therapy or ACT) and 2. Affective science (e.g., basic research on emotions such as shame and compassion). Our goal is to bring the lessons learned in affective science more thoroughly into clinical practice and integrate these with the functional contextual viewpoint found in therapies such as ACT. As such, this case conceptualization framework should be useful to therapists in organizing how to work with highly shame prone and self-critical clients using principles they already know from other evidence-based therapies, such as exposure therapy, behavior therapy, CBT, compassion-focused therapy, dialectical behavior therapy, or ACT.
We’ve been working on this case conceptualization framework for over a year and have been posting pieces of it on the website as we’ve gone along. I’m sure we’ll continue work on it with feedback from the friends and colleagues and will post revisions as we make them. However, we feel like it’s fairly complete at this point and should be useable. We hope you find it helpful.
The case conceptualization process has four components
- Functional analysis of shame and self-criticism,
- Identifying key relationships or situations that contributed to the client’s sense of shame and self-criticism,
- Identifying key relationships or situations that have contributed to the client’s ability to experience warmth and compassion
- Using and debriefing self-report measures of shame, self-criticism, and self-compassion with clients.
You can download the complete case conceptualization
framework, along with client handouts here.
We’d love your feedback as you try to use it. Let us know on Facebook, Twitter, or via the website about any reactions or questions you may have or just like us to let us know you appreciate what we’re doing.