Practice in Action: Case Conceptualization Remix

Today, we’re throwing it back to one of our most popular episodes, “Case Conceptualization: What is it Good For? Absolutely Everything.” This comprehensive episode combines insights from a two-part series, exploring the critical role of case conceptualization in therapy across various orientations like CBT, psychodynamic therapy, and behavior therapy. We dive deep into the art of case conceptualization. We explore how understanding a client’s preferences for therapy, identifying their triggers, and considering their developmental stage can significantly improve treatment outcomes. We discuss practical strategies to tailor interventions effectively and delve into how we can create effective, individualized treatment plans by truly listening to and learning from our clients’ experiences. 

But that’s not all—we’re excited to announce the upcoming launch of our Continuing Education Program! Soon, professionals will be able to earn CE credits from listening to select podcast episodes, with accreditation from the APA and more on the way. Stay tuned for more updates and enjoy the full episode! 

Updated link for download: https://www.psychedtopractice.com/course/case-conceptualization

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Transcript

 Hey everyone and welcome to the Psyched to Practice Podcast your one stop for practical and useful clinical information. Masterful insights from experts in the field and A Guide to Daily Living. I'm your host, Paul Wagner. And today we have a bit of a throwback for you. And it's one of the episodes that we have noticed has just been garnering a lot of attention. And so it was a four part two series. So we thought, why not work to combine these and also use it as an opportunity to announce that coming soon, we will be launching a continuing education program for professionals in the field to gain continuing education credits. So far we have been accredited from the APA and working on further accreditation and we'll be launching with a video library as well as an approved home study, which is exciting because that gives us an opportunity to review past podcast episodes and the ones that meet criteria. We can offer a course with an accompanying exam and you can actually earn CSU credits from listening to the podcasts. So keep an eye out on social media as we announce more information and what's coming around the corner for site to practice. But until then, we hope you enjoy the full episode case conceptualization. What is it good for? Absolutely everything. Say it again. All right, Paul. So back for another practice, an action episode. And I have to say, I'm kind of excited about the topic we're going to do today because it's one of kind of really focused on in my career, I've done some writing in and and that's case conceptualization. Yeah, I think you might have me beat in terms of familiarity, but I think we can both agree it's a really important topic and one that I don't know that is talked about or really understood as well as it should be. So I think a really hopefully a valuable episode for our listeners, you know, it's not that it's a new topic. Yeah. I mean I think case conceptualization or a form of that has been around for, for a while. And I think what's so important about talking about the use of case conceptualization, it doesn't matter. You know, we're going to talk a lot about CBT, but there are versions for psychodynamic therapies. You know, I think they use maybe the term case formulation instead of case conceptualization. And in kind of behavior therapy, maybe they use the term functional behavior assessment. But I think all orientations of therapy have a version of this. And so the idea of kind of talking about what do we need to do to really understand people I think is going to be important and something I hope maybe we can help people get into practice. Yeah, and I think a lot of times some of the traps that clinicians can fall into is we focus so heavily on the symptoms and I think the symptoms are such an important piece. I mean, that's that's why someone is oftentimes coming in, talking with us and working with us is they're experiencing symptoms but we can't just focus on the symptoms. And actually, you've shared a few different times, you know, off Mike, some of the the important piece of that. And I was wondering like for you, rea, like how would you conceptualize case conceptualization. Yeah. Yeah, it's so, you know, it's interesting, I have followed this kind of for a while and you know, I, I really got into it really when I was studying my, my doctoral program. And, you know, we've said kind of similar stories in the past or something. I read I read this article from the Journal of Journal of Consulting Psychology, and there was an article by a guy, Gordon Paul, who was a professor in Houston. And he was he in his kind of article, he wrote this idea of what he called the ultimate question. And and essentially the ultimate question is this what treatment by whom is effective for this individual with that specific problem under which set of circumstances? And how does it come about? Which is a mouthful. Right. And that was super condensed. Yeah, but it's it's complex. But I think that's an important piece because therapy is complex and treatment is complex. And if we think about it in too linear of a way, we miss out on the full experience of therapy if we only are focusing on the symptoms are like too linear of a perspective, right. You know and it's yeah I mean it is such a complex thing, but I think that the part that got distilled from that ultimate question piece was this idea that our role as health care providers or clinicians is trying to, that it's more important to really understand the patient who has a disorder or who has a difficulty rather than understanding the disorder or difficulty the patient has. And I, I always kind of like that term because it really kind of puts that it's not just about what their diagnosis is like. I mean, we, we can get there, but we've all probably had people that we've seen with the same diagnosis and maybe are similarities in our treatment, but how we make that unique to treat that person is is really the most, I think the most important. And and it it gets us beyond this idea that diagnosis is going to give us the right treatment options. I think diagnosis gives us access to the research that we can pull from. And so if I know somebody has a generalized anxiety disorder, in my mind I can go, okay, I know the research about what treatments work with that. But that doesn't tell me what treatment works with that person. And I think this is really the beauty of case conceptualization is that we really. We can be thoughtful about a person, we can understand the person and really make it a more personal, personable treatment. And I know look in my work and I'd be interested in your thoughts. Is that when I've done that with someone? Their connection in therapy is different and we use the term connection often. And I think part of the difference in me just talking about exposure from a very research, this works with this disorder. When I talk about it and put it into the context of what that person's experiencing, their ability to to have kind of an ownership in using that if that intervention or a willingness to use that or intervention I think is greater. I think some of the actually quite a few of the master's and practice episodes that we've done, we've talked about this and with our most recent episode with Dr. E, you know, that was a huge part of what brought her into this. What made her that master. But even, you know, when we were talking with Terrie and she gave that story of someone coming into her office and sharing about, you know, hey, this is what happened and this is where I'm at and this is why, you know, my suicidal ideation is there. And she was talking about. Right, we know it helps. We know, you know, where we want them to be. But if I were to just share that and, you know, I think the example was they had just broken up with significant other. It's like, well, the thing that helps is being more connected then with a different group. But I just say that, that that's missing the piece. We need to help guide them there. And I think that's the case conceptualization. That's the knowing the person and making it fit for them rather than just being, you know, a one stop shop of, you know, just sharing the same information and regurgitating it back. Yeah, it's I you know, this is not a unique comment to me. I know other people have other versions of it and I have kind of stolen and maybe tweak the comment about, you know, it's really this idea of moving away from one size fits all treatment and moving to what size fits you treatment and and which, you know, I think is important is that and it does I think it helps that that connection and when we really think we're doing good therapy, I think that that happens. And, you know, whether it's CBT or anything else, it also opens up a door for something else we've talked about in the past. And that's sometimes we get to go beyond our our orientation. We're focusing in and we have to go, hey, this person needs something a little different. And yes, maybe they have ICS disorder that responds to this treatment. But for this individual, there's other stuff that's happening that we need to to bring into it. So yeah, I mean, I think the watt of case conceptualization is really this idea of how do we understand people? I mean, that's beyond diagnosis. How do we really bring that human element and that relationship and connection? When you were just sharing that last you know, this last piece here, I kept getting the mental imagery of having a suit tailored and my wedding is coming up soon. So that that's kind of on my mind, right? There's a I'm going to butcher this quote. The idea of you can look better in a cheap suit that you have tailored rather than an expensive suit that isn't. Yeah. And the idea of like integrating these different therapeutic backgrounds and styles of treatment, we might not be familiar with them that, you know, it might feel like we kind of have that cheaper suit if we can make sure that we're tailoring it to the person, you're going to walk away with a better fit. And you know, that's what we're doing. We're tailoring treatment to the person and trying to have the best fit that we can. I love that. I think the word tailor is perfect, right? I think that that really does kind of summarize where it's at. And when we do that, I don't know that we can go wrong in that approach. And I think an important factor where if for people new to case conceptualization is the idea that this isn't like an assessment, that's a one stop. I got this data and this is what's happening. What I like about the idea of case conceptualization is we're really weaving this through therapy and my case conceptualizations honestly kind of change through the process. I have kind of my initial hypotheses about what's happening with people, but as they uncover new things through therapy, it helps me think about their case different. And so it really is this fluid dance that kind of happens where, you know, we have our ideas based on our maybe initial interview or first few sessions and we have our treatment plan. But as time goes on, it really does have all that. It makes it we're it's not this static treatment approach. And so yeah, I mean, we're tailoring it and then people are gaining weight and losing weight and we're adjusting and tailoring, you know, dynamic with it. We're dynamic with that's a great, you know, great word with it. So yeah, I think that that's important because it just. It makes us personalize and I just keep kind of going back to that. You know. So I guess, Paul, what are your thoughts about? We know being personal with people helps, but how do you think that helps drive treatment? You kind of. What's your thoughts on why case conceptualization can make the treatment process better? I think it develops a better sense of buy. And, you know, if I'm thinking about, you know, what are the things that help me, you know, feel can really kind of be myself and it's heard and it's seen in it's accepted what you know what a powerful relationship that can be if you're able to develop that in therapy where your therapist hears you, sees you and truly, you know, to the best of their ability, understands where you're at, what you've been going through, how this is impacting your life. And, you know, with that taking their knowledge. So, you know, the therapist can kind of meet you. So, you know, like there's a quote that I had in grad school. The patient is the expert in them. We need to be the expert and helping them to be better. And so it takes this like we are really trying to be the best clinician. Again, it's impossible to have a cookie cutter approach. Right. Even if they're similar. There's subtle differences. You know, there's been times before where I've treated siblings, you know, and I even had twins and it was a different treatment approach. And so, you know, just even the personality that had those different variations that, hey, I can't just regurgitate the same thing I just said, you know, to their sibling, you know, in our last session. And it was about different things, but that that treatment approach still felt very important to make sure that they were feeling like an individual. Because if you just feel like I'm just a number or, you know, I'm just I'm your 10:00 session and that's all right, then what's the point of coming back? Because you can have a 10:00 session. You're always going to have a 10:00 session. Like what makes me different? And I think if we can understand that from the client's perspective, it helps us to feel more motivated to really connect and integrate with them, to make this this unique experience that ideally helps them to walk away better. Yeah, I agree. I think connection is definitely one of the reasons we do it. And, and, you know, when I kind of write about this, I always kind of. Talk about the connection, but also this idea that case conceptualization really helps us gather and organize information. And I know we're going to talk about that next episode about how we do that. But I think it's important that we're really gathering and organizing information to understand the patient's situation and their current problems. So it really, again, kind of builds that connection and helps us understand a little bit. You know, for me, I think the other piece that I think adds value is good case conceptualization, guided treatment. Yeah. You know, and so even down to what's the right interventions for the person beyond just the research, you know, it's, you know, it really is this blend of the the science of of psychology and mental health treatments and the art of understanding people and how we kind of can take both of those and mash them together. But when we do that, it lets us again be more thoughtful in the approaches that we're going to take. I think that's hard. And I think that, you know, one thing, I don't want to make it sound easy. I think being good at case conceptualization requires work. I mean, I, I start my day looking at my schedule and thinking about what I'm doing with, with people. I think about them before sessions. I think about it after sessions. It really is this, this kind of part of really thinking about what we're doing and being thoughtful and what we select and having the acceptance that we might select the wrong thing sometimes. And we make a hypothesis and we go, I think this is going to work. And maybe it didn't go as well as we thought, but then we kind of reconceptualize and come up with maybe alternative hypotheses as well, which will let us go a different path. So again, I like that selecting good interventions, but also gives us that that way to adjust. I came out of grad school with this broad idea of what it was, but not really how to do it, or at least how to do it effectively. And so you just sort of through my own kind of personal or professional readings, trying to adapt, trying to learn that. And even it's a few months ago I finished one of the islands books. I read a few of his email over the past year and I'm blanking on the exact one. It was he it was kind of a a narrative story following a psychoanalytic therapist. And one of the things that he had written in there was that this therapist would start each session by, you know, before they went and got the patient out of the waiting room. Through my understanding of this person, what is the thing that I can do that's going to be the most helpful for them in reaching their goal or making the situation better for themselves? And I think if if we can really capture that, like, you know, that is like, you know, what we want to do and why? Because it's, you know, it's understanding and it's taking that understanding and applying it and making it better because and I think we've all had, you know, we've all at some point felt like a number or felt like, you know, just another person. But, you know, when we have that individualized specific treatment, it is that tailored fit for us because it was made for us. And it then allows us as clinicians to be that and that fluid approach that maybe this. Nope, that didn't work. Okay. But it's this. We're constantly, I think, communicating with our clients as well about it. And I think if we can have an open dialog about our conceptualization and sharing that with them, you know, again, they're the experts on them. They're going to be able to share that. So as much as I think it's this personal experience for me as a clinician, they think, okay, what is my thought here? It's also bringing them into the fold as well and saying, you know, this is where this is my working hypothesis or this is, you know, my understanding of what's going on. How does this fit for you? And it's we're just kind of trying on those different fits until they get one that that they're like, you know, that that yes, that that's exactly the thing that we're talking about. So and and those are the good moments, I think. Yeah, I like that. I like that, y'all. I'm quite I think Mom's written actually a lot of his books kind of hit on the idea of case formulation in some ways. And and, you know, you mention about the psychoanalytic, I think really, you know, there's a lot of strong roots that come out of that orientation, you know, and kind of going back on what you you said about the working hypothesis, which is really the word we use in CBT, I think maybe, you know, in psychoanalytic it's more providing insight for people or there's other terms that we kind of use. But I think that's where, where psychoanalytic has done such a great job in, in using case formulation in how to give that back to the questioner or the patient and helping them find that insight and understand those problems. It's interesting when I you know, I, I said I think of case conceptualization throughout treatment. That's just part of how my training has been. And I'm always. It always feels good for me when I kind of I'm listening. I'm pulling all these pieces together and, you know, being thought of when it and when I do give that back to the person in front of me and say, you know, so we got all this information and let me kind of distill it down to what I think is kind of maybe happening. And I kind of want your opinion about this and I I'll give kind of my hypothesis to them and their eyes open, you know, and they give you this look like, oh, my gosh, yes, like that. That's that's like that's what that's what I'm experiencing. And it doesn't always go that way. I mean, I've had so, you know, I've had times where I've said something. They went, get the sideways look. Yeah, I don't think that's right and that's okay. Like that's but that what a great opportunity for me to go. Okay, like, what am I missing? Like what? What about this? Can we talk about to give me a different understanding so there's such a powerful give and take with it, but watching people get it and go, Wow, you took all this stuff and it came to us. It gives them a nice little summary and it gives us kind of a base that we can kind of keep going back to. So I, I, I, I remember the first time, I really didn't, I had a little, little bit of case conceptualization when I did my master's degree. But it really it was my doctoral training that, you know, they really I mean, that was something that from day one we were constantly talking about. And I remember when I finally started getting better at it and had that moment with someone and I went, all right, like this was good. Like I got this. It really it helped me understand the person had helped me move treatment. You know, I think the other value and and research I think supports this is that when we do good case conceptualization, we also not only is it personalized treatment, the effectiveness and the efficiency of therapy is better that, you know, yeah we can we can pinpoint some things and and help people move to better outcomes in a more efficient way. Maybe it's not going to take 40 sessions. Maybe it's 18 or 20 and a little shorter time frame, or maybe it's even less than that in some cases. So I think it also helps us with figuring out what the outcome you're going to be is on track and in therapy. The other thing I'm going to kind of add is I, I think case conceptualization. Case conceptualization also helps us maybe predict some of the challenges. Yeah, I think sometimes if we, we just think of diagnosis and treatment, we miss the fact that there are a lot of variables in people's lives that are going to either make treatment maybe more difficult or harder for some follow up. And it lets us kind of predict that and helps with treatment adherence. Yeah. And I think this comes up a lot, especially if I'm working with, like children or adolescents, even teens who. Just doing things after school and like the, the, the rotation that can come along with like, oh, it's, you know, football season, then it's wrestling season, then it's track and field season or like and it's like, oh, you know, this is, has practices every other night of this one the entire week. And it just like that then changes the way that, you know, that we are even able to meet. But it changes their routine. It changes like what is, you know, what is going on for them, the stress load, the you know, how physical they're being, you know, all of these different pieces. So like it's a very clear cut. Here's a change that's coming up that we can protect. And so, hey, this works really well because you have this break in time after school, but in like five weeks, you're not going to have that break in school anymore. What are we going to be doing then? Because, you know, if we're setting you up for success right now, then we're kind of setting you up for failure when you're not gonna be able to have this. So what does this look like and how do we make it adaptable now? So that way come, you know, whatever season it might be, were then able to adapt the treatment or adapt the measure. Or are we saying, let's wait until we're actually there before starting because, you know, we want you to be able to. We don't want to start it when it's easy. And I think we talked a little bit about that with like setting goals. You don't set a goal when it's the ideal moment. One, when is there ever truly an ideal moment, but also the moment that changes? We haven't really set ourselves up to deal with those challenges. And so I think case conceptualization absolutely helps us predict because if we know that person, we know their interest or we know what's coming up for them, then we can be we can again make the treatment dynamic and make it, you know, make it this fluid process that can adapt around whatever obstacles are coming. Whether that's externally or internally, you know, if it's hey, this is a difficult anniversary that's coming up or, you know, I'm dreading going into shape like just these different internal pieces as well. Yeah. And I even think of it is there's, there's parts that I do when I interview people that will kind of. Bleed into some of my case conceptualization. And a lot of it comes really. I mean, John Norcross has done some incredible work and this is over at University of Scranton, I believe. But, you know, his his work's been like things like, you know, how we ask people questions about, you know, what kind of therapy are you interested in? Do you want is would you benefit more from something more direct? You want something that, you know, is is maybe a less direct approach and really kind of getting their preferences for treatment. And, you know, how we utilize that information. Then in understanding the person you cite, I use those questions early in my my interview, which says a whole nother could be a whole nother episode talking about that But like some of those questions that we ask, those are the things we want to bring in that will help with with areas like who I ask upfront, you know, how are you going to do in therapy with me giving you between session work or homework or whatever we want to call it? How's that going to work for you? Like, is that something you think you can manage? What time are you going to be able to have available for those things? And I ask that and then I pull that into understanding what I can do as far as my treatment and make that part of that conceptualization. We don't have the barriers later on. You know, there's a great book I read years ago. I don't think they ever did a second edition, but it's the book's actually I think just called treatment adherence and it's by Donald Mike and bomb and. Kirk is the last name of the other author. It's a brilliant book and they talk a lot about that, like how our best way to avoid difficulties in any treatment is and to have better adherence is to identify what those challenges are really and make that part of our understanding of the person. Because if you have a person up front says, Yeah, I'm not going to be really good at doing some of these between session works. We have to find ways to work around that to still give them that practice between sessions. So all of these little things I think add to case conceptualization and ultimately better treatment. Rae With this being like such an important piece that maybe goes unseen or unused or maybe. Maybe it is not really fully recognized. I think a lot of clinicians do this often, but they might not do it and maybe to the full capacity that they can. And you know, I know in our next episode we're really wanting to break down the how, but I think there's you know, with this one, we were wanting to capture a little bit of what is case conceptualization and why is it important? But I'm also like, who is it important for? Or who can really benefit from utilizing case contextualization, do you think? Yeah, you know, I think that's one of the the great parts that I mean, honestly, any helping profession is going to be able to use case conceptualization to help the process of those they're working with, whether you're a school psychologist, working with students and trying to understand situation for them to make some better interventions for them. Or if you're a physician and trying to help a patient or a counselor or social worker. I think really the idea of case conceptualization really crosses so many fields, which is is is really, I think, interesting. And with it, again, it's, you know. Well, most of our professions that are helping professions, bird lending, you know, the science and the humanistic aspects together. And this is a way to do it in a really thoughtful manner. So I guess I would challenge anybody that is working with people to start thinking about people and how these different factors in their life. Kind of come together in the work that we're doing. And and I'm excited about the next time we'll be talking about some of the things. And, and there's a lot of models out there. I mean, there's tons of books that you can read on it. You know, I'll share some of the things I've written about and things that, you know, you put into practice, but there's no one perfect way for it. I think that's the other thing. There's, you know, I think we can share some of the artifacts, but there's other resources that I think people can pull together and there's no perfect way. It really it's work fits your practice. And, you know, just to give somebody and give people another way to kind of think about things. So we have to be individual and unique in the way we're trying to tailor individual and unique treatments. Yeah, I mean, we use that as a quote. Yeah. Well, then we hope to talking about case conceptualization as being able to get you psyched up. And we really hope you're coming back. And next week, as we're really talking about how you know how to do case conceptualization. But until then, be well. Stay psyched. Well, Paul, we're back for kind of the extension of our last episode on Case Conceptualization and and really kind of talking today more about, I guess how we do it or what's the parts of it. Yeah. Round two, round two. And we hope that you will listen in on our part one episode. If not, you know, would probably encourage you to give this one a pause and go back and listen. Because in that episode we really talk about, you know, what case conceptualization is and why it's so important. And so, you know, as you said in this one, really wanted to talk about like, hey, now that we know that, how do you do it? Right. And so, Rae, maybe starting off sharing like because you have quite a bit of background talking about and you've been writing about case contextualization. So for you, if you had to kind of give a broader thing, you know, a broad direction there, how do you do case conceptualization? It's been something I've been really kind of passion about through my career, being able to to write and present on and, you know, so we're maybe let's go through kind of a model that actually Ruminative and I put together, gosh, many, many years ago. I'm almost 20 years now. I want to just kind of come off of our last episode. You know, we kind of ended talking about what we're going to talk about, not the only way. And I just want to reiterate that I think again to people is we're and give you kind of of the things that we look at and kind of the model that that I often teach and present about, but know that there's other models out there. I really encourage anybody read about different models, see what kind of fits for you. And, you know, there's there's no perfect way to do this. It really does get kind of individualized. So, you know, so you talking about case conceptualization maybe maybe poll can do is I'll talk about maybe some of the areas that we look at and maybe we can just kind of discuss each of these as we kind of go back and you know, so it's interesting of Rohan, I just made some changes in kind of a we're writing right now kind of a revision to our case conceptualization model. And one of the things we kind of put to the front of this is, you know, years ago and I shared this with with you, Paul, is that and we I would when I was doing training, I would sit in on case conferences. In case conferences were always, you know, you kind of had to know how to present a case. So it was I have an eight year old boy who is presenting with a generalized anxiety disorder who has these symptoms. And it was this very formal kind of process. And one of the things over time that I started challenging is I never understood why we don't talk about the kid first. Like, why don't we say like, Hey, there's this eight year old kid that's coming into my office who's really into Star Wars and Marvel Comics and is into all these activities. But he also has an anxiety disorder where we kind of get to understand him as a kid first and then understand the kid that has a problem. And that will make sense when you listen to the first episode like we want to understand the person with the problem. So one of the things that we kind of have in our case, conceptualization, which I think is kind of unique compared to other models, is this idea of who is this individual as a person, essentially what makes them tick, what are they into? So we start with that humanistic, personal piece, which I don't think we can ever go wrong with. So that's kind of our start point, which doesn't sound very clinical. I think that's maybe what makes it so effective or so important is because, you know, we're starting with this fuller picture of life. So when we start talking about the anxiety or the symptoms we're seeing, the way that it's impacting, rather than just talking about the symptom itself, if it's impacting sleep, if it's impacting, great. If it's impacting these other areas, what were they you know, was there a time before anxiety where that wasn't impacting it? And how much of a difference is there? It's always, you know, right now anxiety is keeping them up. But before it was video game, so they weren't really ever sleeping beforehand. So, you know, those different pieces that can play such an important role in saying how influential is this diagnosis or this symptomology versus, you know, just focusing on, oh, well, there's a disturbance in sleep with anxiety, right? Yeah. It's really getting that. It's, you know, that person. I think the other part of that. Really is interesting. As we've kind of evolved, our motto is, you know, with all of the things and we've done episodes on this about helping use pop culture and, you know into our treatment and how we use certain metaphors that are going to connect. If we understand what makes people tick, whether it's kids or adults, it gives us a better way to connect all of those interventions down the line and to really, you know, be thoughtful in the metaphors that we use. You know, so I think all of that kind of goes together really well. So that's our start point. And then we move more into then talking about kind of the concerns. And when we talk about case conceptualization, we talk about concerns across, you know, those functional areas, whether it's score or work or home or community, trying to look at how different symptoms or problems might present across different areas. I think, again, starting with the person that can be really valuable because you're seeing them what is being taken away or what is lost. So like when you're thinking of the concerns, I guess, how nuanced do you get with that? Like are you trying to get very specific or is this just kind of a general conceptualization? Yeah, I mean, yes. I mean, I think that for the conceptualization part, I kind of try to make it more summary of symptoms. And rather than listing out this laundry list of all these different things that happen, I think we have to kind of pull some things together. So it's really kind of taking all that information from that interview that we've done and the information that we get from people and really kind of summarize those those reported concerns. And one of the things I'm writing about right now is this the idea of not only asking when the problems curb. You know, one of the things I often ask is tell me when you do your best, tell me when you're not anxious or tell me about the times when you are depressed or don't feel depressed. I think knowing those times are also important in understanding the concerns because most people don't feel that way 100% of the time. There's always some times that may are a little better. It doesn't mean they're healthy times that they're doing it, but it's so important for us to know, you know, we don't have an episode coming up with John Murphy, who does solution focused therapy, and he does a lot of work around understanding where people, you know, what are the times that were there, their behaviors or their moods or the past. So it will be interesting to kind of hear his take on it because I think he does that very well. But yeah, I for for me, I kind of make it more of a summary. I'm really looking at reporting concerns conceptually. What are definitely those that we see across multiple settings as being the ones that we want to really kind of target first versus, you know, if they only get anxious in one setting and not and they're finding every other setting that we will want to target that. But if they have other behaviors across all settings, we want to target that one area. So that's how I summarize. It's almost like looking at the data like a one raw data point versus trying to make, you know, distilling down good information from many data points and trying to then, you know, formulate like, you know, a trend rather than just one potential outlier data point or something along those lines, right? Yeah, I agree. Yeah. Next we kind of next area we kind of talk about is understanding the antecedents and triggers, which is a very behavioral therapy kind of view, but definitely something important. And, you know, I find knowing what those trigger points are for people when things are the most difficult for them does help give me a good understanding. So really kind of having a little summary about that I think is important as well. We talked a bit about this, you know, in the last episode, but some of the some of the value of knowing what's coming up for someone or for identifying those particular instances of what brings this on, we can then talk about it or we can even kind of engage with it in interventions in different ways. You know, if we can identify this trigger, then like, hey, let's, let's have an imagined or a role play, you know, these interactions and saying, you know, let's break it down step by step or frame by frame and let's see, like, what does this look like? And, you know, how would you imagine this going on if this was actually in the moment? So if we missed that piece, we kind of are at a loss. Like what? Really? What's the starting point? And we just plop ourselves down right in the middle of it, which can then almost be disorienting if if we don't have it that direction. Yeah, it's a shame. I just had a case I was with the other day that we were talking to the individual who was an adult and very severe anxiety. And it was interesting because primary anxiety is essentially about functioning at work. Like that's where the primary is, which she came in for. But as we talked, there were other kind of these peaks of of anxiety that happened that which was kind of these reported concerns when they happened. But the interesting part is with the in a sense is I think it also helps us distill down to in this individual's case, it wasn't the situations that were the trigger or the antecedent. The antecedent was the thought that she would be criticized. So when we think about this more and actually it's you know, so for me, like if I was just treating her work anxiety or just treating her anxiety driving or just treating her anxiety when she has to help her daughter with homework or whatever it might be, those individual situations, they don't necessarily matter. The antecedent is she's afraid she's going to be wrong or criticized that when she gets that thought and gets that feeling of, Oh my gosh, I'm putting myself in a situation that this could happen. It doesn't matter what the location or where she's at, it result in the same level of anxiety. So I think we got to dig into those antecedents a little bit. They kind of help to uncover maybe some of the more like core concepts or the core belief systems there that that drive the anxiety. So again, you're missing it if we don't take the time to focus on it. Right. And then some in some cases we will go, I think, down to that fight. And I think other times maybe it is just situational. You know, I've had kids especially who, you know, the transition times are difficult for them and it really isn't it doesn't have any necessarily thought tied to it. It's just that the act of transition is overwhelming for them. So yeah, I think we just have to look at them a little deeper and you know, gosh, there's tons written on antecedents and triggers, but it's definitely something we have to think about as part of our conceptualization. Yeah, well, and I think this, this next step you were sharing with me earlier, and I'm interested to hear how this plays a role and maybe kind of sharing like the application piece for I think it was developmental considerations. Yeah. Yeah. So, you know, it's, it's interesting this, you know, so this again, we're this is not unique to us but you know, really understanding and this isn't just for kids. So even with adults understanding developmental considerations, it's not like, okay, when did they walk and talk like that kind of development? We really view it kind of theoretically in that, you know, we have a lot of wonderful theories and development that help us understand people, whether it's something like Piaget's cognitive factors and really kind of saying, okay let me understand this person, you know, is this a person I need to be really concrete with in my examples, or is this a person that's going to want this challenge and move up into these kind of higher thinking and higher order processes as a developmental consideration? It's not about intelligence, so we just have to understand the person. I mean, and that makes me again, when I understand that there are some people I say really practical in my interventions and some we get pretty heady about what we ask about. But thinking about that lets me help tailor that treatment. But also things like, you know, Maslow's theory of hierarchy of needs falls into that. I know I really love Eric Erickson's work on, you know, these developmental conflicts and kind of where people were at and have written a little bit about that over time is that, you know when we think about things like Erickson, there always happen in these stages. And I always kind of viewed them more as this fluid kind of process. Like, I don't think we just hit these stages and move up. I think we are always vulnerable to fall back a few stages at times. You know, I when I talk to patients, I always use the metaphor of skiing and I'm like, if you're skiing, you can have developed to a point where you're a good skier and you're going down the slopes and you're kicking your skis back and forth, and you're doing all kinds of great slides and throwing snow and doing all those things. But as soon as you get to a mountain. That becomes overwhelming. We all have the tendency to go back to these old snowplow behaviors. You know, how we first learned, like we we go back and we refer to an earlier stage of our development. When we think of developmental considerations, that's that's kind of how we think about it, is that there is a little flow with it that we have to pay attention to with Mars. I think Maslow's things I mentioned that is, I think really one of the the more important ones that we should consider, you know, knowing where people are at in these basic needs. Here we have a child that's depressed. They're also homeless. And we really I think conceptually with this person, what's the things we need to really target first? And so, yes, when we think about development, that's that's kind of how I use it. What are your thoughts on it? You I mean, you just shared like so much like, I think really good information. I'm sitting here digesting it for a moment, but I think it it allows us to reflect back like what is what is the thing that truly helps this individual. And even if like, you know I having I liked your term heti I often get how do you think it ends as well but if there's someone who can have the best, you know really dense concept for this and trying to share this with someone, but if they're not there and if they're not really, you know, interested or seeing it and viewing it in that way, then then it's not a good or an effective treatment process. I mean, I keep coming back to this like, you know, how do we do the thing that helps the child who is homeless? You know, if we try to then talk about like talking about resiliency and talking about, you know, how do we try to adapt to really challenging circumstances versus a let me be a more accurate identifier of like threats, but is it, you know, in in a threatened situation? So, you know, to try to dismiss that or to try to challenge it, that's not an effective tool or resource in that moment. So, you know, it goes back to that dynamic tailoring idea or concept where, you know, we are really trying to fit and meet the person with where they're at. And I think developmentally, if we can keep those, you know, we went through our developmental classes for a reason. If we can get those theories in mind and we can really try to apply them, then we're not just sitting in a classroom having to take a test on Piaget or for guys, you know, for all of those theories. But rather we're kind of seeing them come to life and seeing what does this actually look like in the therapy setting? Yeah. And, you know, I think they're doing training with people. They're always like, well, is there a rating scale for this? Is there now? It really is. Just, you know, this is a trying to find the perfect science is trying to say, okay, these are just spikes I have to think about for this person and consider. And and it really is, I think, doing this. And I was lucky in my training that I was told to do this very early. Was it really changed how I think about things like I just had a teenage guy that I just saw who kind of want to go back to Maslow that that seems to be a really go to for me sometimes. But, you know, he's a kid who's really struggling with some anxiety and depression, but, you know, he's been it's three or four therapists before me. I'm, you know, I guess number three or four or five here. And he's and everybody he's treating the depression. And conceptually with this kid, you know, through asking questions like, you know, he's sleeping 2 hours a night is video gaming all night and I know that's you know, that happens. But we have a kid who's sleep deprived. We have a kid who's physically is needs are not at a level that me asking him for is his thoughts about anxiety and depression aren't words that we have to talk about sleep hygiene with this kid. And it's and and honestly it was a mistake when I think where therapy didn't work for this kid is without thinking about those needs that he has from a physical standpoint which I you know kind of lump in the developmental piece is that is we can't get him to start thinking about his thoughts and we had to really sit down and talk to parents and say, we need to really start with some basics here. Let's start with just some sleep hygiene and let's get him up to 4 hours of sleep a night. And how do we regulate this and how do we do these things? And getting him on board to do that. And, you know, maybe 4 hours don't sound like why, but it's better than to double. Yeah, and we'll hopefully get to more than that. But you know, my approach was I can't treat the depression if we don't get him to a point where physically he's in a better place. And I'm going to work with you on that first. No, we're only a few sessions and we're. Far enough that I am going to can predict outcomes but is sleeping more actually rather than four it jumped up to actually about six. We have really, really kind of specific behavioral things in place. His mood's already improved. We've never talked about depression or anxiety yet. That's why I think these things are important. It lets us things to think about, things that ultimately, if we don't address or we don't think about, might impact our outcomes. And it's funny you talking about Sue. I had someone that I was working with even just last night and it was actually it was it him and his wife? They were we were talking about what are some healthier just lifestyle changes that can be made. And sleep came up and, you know, she was sharing her concerns about, you know, him staying up too late. And, you know, as he was talking about this, he was talking about how, you know, in the morning, he always has like he's always feeling groggy. He's always just not feeling good. And he's really frustrated, upset with last night him. But by the time he gets to that, you know, that the next night it's always this. I worked so hard for everyone else all day, you know, why can't I do something for myself? And one of my comments back to him was, Sleep is something for yourself. You know, it's not you in that moment. It's it's morning you in the morning you. That's always ticked off at night. You like this? This is something for yourself that both of those are the same person. We need to really connect that and not have it feel like it's I'm not doing anything. For me, this is a really good thing to do for me and this is me really taking care of myself and putting myself first. Right. And he had just kind of stopped and took a moment there. But it's that understanding that just said if I was like, ahead, get more sleep. Like, that's not going to be the effective treatment approach without really understanding why. And if we can connect some of those, the barriers there can be make it then more effective for them. Yeah, I mean, it is you know, again, all of this kind of ties together for people and it's, you know, you know. So yeah, we've all had these developmental classes like let's not put them to waste. We paid good money for those classes, so let's use let's use that. So I think using that I think is really helpful. And, you know, we, we then kind of go into the kind of ethno racial and cultural considerations that we have to kind of put into therapy as well. And, you know, this is kind of an area I think just keeps evolving for us as long as we get better at understanding different factors that are, you know, people are affected by. And this covers a for us kind of a broad piece of it. It's it's, you know, really understanding culturally, just simply, you know, beliefs about mental health could play a part in that. Are there different things in their cultures that are important for us to understand when we're thinking about treatment? But also, you know, I think what we've done better is understanding the experiences of different groups and different, especially marginalized groups and how that impacts how we do treatment and understanding that, you know, we can we can have different people from different racial backgrounds, gender or whatever it may be. All have to be in the same situation and all have very different experiences. And that's really what we're trying to, to target there. You know, it's yeah, I, I feel like I'm learning so much always in this area. But, you know, just even when we use kids for an example, I, I've been in situations where I've treated five kids in the same high school at the same time and all of them being of different either racial backgrounds or some type of, you know, cultural differences and. They all had very different experiences based on their background and having them teach me about that and really trying to understand that man. It's just been so good at really helping connect with them, but also helping me view how we're going to use interventions differently. And we I'm excited. We have an episode coming up here soon with a guy who I had an opportunity to see is named Ryan Dunlap, who I think is doing some of the best work in this area. He taught me so much in just a few hours of of training, doing a training workshop with him. I'm excited to get more of his view on this, but definitely something we have to, you know, think about and really think about those experiences that people have that are different than what we experience and. You know, we can travel like I'm really excited just to hear from her. I've heard some really good things in your from your your training with him. But even just like, you know, my own, like I've and came back to diversity courses and how that just being aware of you know, the privilege or you know. Yeah. Just the privilege that certain individuals have, which then means that other other individuals are at this disadvantage. And if we just take those things for granted, you know, especially if we're out therapies and taking some things for granted of our experience, then it discounts and discredits and really can make someone feel marginalized. And, you know, it's really kind of like that that idea of like feeling smaller, feeling like, you know, having to fit, you know, having to fit a certain description. And like, if you're not, then you're less than right. And that's not really an effective area for growth. And so through developing a really conscientious understanding of that, again, giving that person permission to be themselves and letting them be the educator. I love the idea of, you know, they are the expert in them. So, you know, let's listen and learn from them and their beliefs, their views, their experiences, all of those different pieces. So we can get a better understanding of what's the specific perspective and lens that they're viewing things through. Yeah, I mean, I, I think it's absolutely important and really, you know, it's I think we're seeing better information and better ways of approaching, you know, any type of cultural differences in treatment. Yeah, I'm I would say my training was mediocre at best. And when I was kind of going through it was a lot of theory. You know, it was like, oh, here's what you should know about, you know, these different groups. But really how that applies in session and how those those different understandings can influence treatment. I think that's what we're getting better at. And I know that just taking the time to understand the experiences that people have and the perceptions that come from that and having real conversations with people about it, you know, I mean, I think it's so easy to just blow over it and to not have the conversation and it might be uncomfortable. Yeah. I mean, it's but to really say, like, listen, I don't know a whole lot. I need you. I need you to help me understand this experience. And, and how is your experience different than mine and really listening to that. And I think it's made me a better therapist. And and that doesn't matter, you know what? Racial background, cultural background, then any of that, you know, I do it the same with everyone, you know, even even if it's, you know, somebody who's a white individual who comes in, they have a cultural experience, they have a racial experience We really need to look at this across everyone that we work with to really get that better understanding. I do think we're getting better at it. I got a long way to go, but it's something we have to think about when we're conceptualizing and helping really understand people. And it's funny, I think my graduate program did a really good job with showing diversity privilege, like, just like those different cultural consideration pieces. And probably, I mean, one of the, one of the courses that just really stands out to me is like that opened up my eyes, one just like I knew about privilege, but that was the one that actually made me understand privilege, I think. Yeah. And so being able to then I think it makes us better listeners and it makes us, you know, we then are able to cut through a lot of our biases that we have and just, you know, really hear what the person's experience is instead of trying to color it or shade it in our own personal perspective or you know what we just assumed their experience was. Yeah, yeah. It really it's it's it's it's an area I think we, we can continue to look at. And and again, I'm going to keep throwing Ryan the last name out there. I mean, I think this is a guy who he and his wife have been collaborating on this this model. And it's exciting to see it really put some some real meaning in training on how we use stuff and especially your experience definitely different than mine. I mean, just generationally where when I was in training we said it was a it was part of a curriculum because I think it was thought to be part. That was a great thing to be part of a curriculum. I've gained more probably in the last five years in this area of just doing my own kind of, you know, going to workshops and reading and than I ever did in graduate training. So I, I look forward to seeing more how this evolves with, with how we do treatment and, and seeing some real practical things be put in place to to make it meaningful. Absolutely. Yeah. So next kind of area I guess we go into is wellness and resiliency factor. So we also we know when we're trying to conceptualize it. Case. You know, we often can't just talk about the problems, like what are the things that are going well for the person? What are things maybe that they have in place that are going to be good factors to build resiliency? Maybe that's they do have good connections with people or they're involved in a lot of activities or maybe a supportive family. But even, you know, things like maybe there are people who do get great night's sleep or they exercise or they eat a balanced diet, all of those wellness things I think we have to take into consideration. And sometimes there's little gems in those resiliency factors that we can really pull from and I think make part of treatment So I think knowing all of kind of what's going well for people is important to ask. And I think it can also be a really valuable, I guess lends some valuable insight with. How severe could this actually be? And they're just adapting to it. Well, because of these resiliency features and doctors and so someone who has a good sleep routine, you know, who's working out, who has a good diet, and they are then struggling with this in a way that maybe feels like it's only presenting in certain areas, but only because they're taking care of themselves in these ways. And there could be more severe, significant things happening that were just that just aren't, you know, coming up to the surface that, you know, if we just discredit or discount that, then we may not be seeing the full picture. So and the value and the resiliency and the strength base aspect, but also kind of like. Because they're there adding then we might. We don't. Just because they're adding doesn't mean that we're taking something away. You know, it's there can both be these positive features and negative features that are present? Yeah. And I think it's and it's definitely, you know, we use the wellness and resiliency factors as the term because we don't want to just ask people like, tell me what your strengths are. It's just so superficial no one ever gives you, you know? So in caring. Yeah. Right. And it's just this laundry list. And I don't want to know about that. I want to know about, like, water, you know, tell me about what you do that helps you take care of yourself. What are these good things that happen? And I'm treating a physician right now who works know, 12 to 14 hour days. Tough, tough schedule and great physician. And, you know, it was interesting because I said, you know, tell me a little bit about what what do you do for a wellness? What's that look like for you? What are the things that you think how things would be better in your life? And it was funny because her first thing was she was, you know, when I come home every day, spend time with my kids and I spend 2 hours playing Call of Duty, I didn't expect that. So she's like, you know, she's probably mid-forties. And I went and I'm sure I gave a funny look and I went. But you know, and she went, Yeah, she's like that. She was. I need something that's mind numbing. I need to just take a break. I need something. And she's like, I find that it's a little escape for me. And, you know, so maybe the first time in a long time I wrote Call of Duty as a wellness factor for her. But for her, it was it was that finding a way to just let herself reset. And it was an important factor that we had. And she said, she's like this. I've tried relaxation. I've tried going to the gym. She's like, I run all day long on my job. She goes, I seriously want to sit down and do something that's just I don't have to think about it. So I think she used the word it feels very carnal for her. And it's like this really just and I think it's interesting. So when we talk about these things, you know, they're unique to people sometimes. You know, it's I don't know that I would have thought of that. But for her, she's like me. And when I reset, then I'm okay and my husband and I get some time together and then I get to sleep. I get a good night's sleep. And she has this wonderful routine that is. Is great for her. And I think we have to. I said we can't make judgment. Like I said, I made kind of a little bit like, okay, that's the first time wellness was in Call of Duty came in the same sentence, but it was unique for her and an important act for her, something she needed to have part of her day So I think we can we have to let it be a little unique and. So I guess on the other end of the wellness pieces, we also include in kind of what we think through is barriers and what are the barriers to progress? What are some things you see with people you work with? A lot of times I think I like to think of it in terms of internal barriers and external barriers. So like barriers in terms of if I have a thought process that says this is how it's always going to be, you know, then we have a bit of that self-fulfilling prophecy coming in or we get stuck in these negative feedback loops without challenging them. So we are kind of putting these these barriers of these limits upon ourselves, and it's then working to really kind of it's an important piece to understand because we can put, you know, all of these different interventions in place. But if I don't think any of them are going to work, I'm not going to buy into it. Right. So that being a barrier versus the external barriers, which might be, you know, changes in an environment, changes in routine, you know, certain individuals that are, you know, that end up going back to triggers are just things that we know that are happening in their lives that are going to be challenging. Yeah, you know, I can think of one individual who they know that they're going to lose their job here soon, you know, just kind of like. They're about 90% confident. And that is now very true because for one insurance, you know, they're going to lose their insurance coverage. They're going to lose, you know, some of that. So we're talking about how do we adapt? How do we kind of prepare for this? But, you know, that is going to be a huge change and a barrier for them to make progress. And so it's you know, that's something that is external. They're not you know, they're not internally. You know, I'm not I'm not going to be able to keep my job. But I know that it's unfortunately, they're going to be laid off, not, you know, not fired. But it's it's something that. The real part of their lives that they're then having to adapt with. So I think the barriers in that way because I think then the way that we try to intervene with them or address them can be, again, more tailored or unique. Yeah, yeah. I think barriers come in all different forms. I mean, it can be from work schedules to finances to everyday life, transportation. All of those things can kind of get in the way. So, you know, again, knowing about them, thinking about them, thinking about how they affect treatment, that's really why we put it in this piece. You know, I never want to react to a barrier. I always want to be proactive with a barrier, if that makes sense. And I like I oftentimes will talk about this with parents, too, like when we're trying to kind of talk about like, okay, like working with a child and then like trying to say, how do you adapt this in the home? And I talk like I recognize I have an hour on, I have 40, 40 to 50 minutes of uninterrupted. We're just sitting down, we're focusing and we're talking and it's so effective in here. And then when you get home, your other children are going, you know, you have your running, right? Like these are different environment that is a barrier, you know, so you're not going to be as successful in this as I might be because of those factors. And so how do we have to keep that in mind? So a lot of times I can joke around, I was like, and I'm going to talk to you about this. Like, it's the ideal, I realize. Easier said than done. So I want to first get it out there as a concept and then let's talk about how do we apply this specifically for, you know, what this could look like or we just make the best out of it that we can sometimes. Yeah, yeah, I agree. It's the same thing for me. I mean, I think any way we can kind of approach it, whether it's parents or the patients themselves I think is important. Yeah, I think that leads into even the next area, which is readiness to change factors. And again, that's unique to us by any means. I love readiness to change research that's out there. It's been something I've kind of followed throughout my career, but really, you know, this idea of where the person is meeting them, where they're at, and just because everybody else in their life wants them to be at the action phase doesn't mean they're going to be. And we we can't jump to that either. So, you know, nothing here out of the traditional readiness to change model and just kind of thinking about that and trying to find where the person's at so that we can maybe treatment match a little better. And I think we've talked about this in other episodes, you know, the stages of change. And, you know, if we're trying to if we're trying to push someone, like you said, into action or even into preparation when they're really even in pre contemplation right now, that's not going to be effective. Right. So, again, you know, such an important feature of meeting the person where they're at and how do we help them transition so that way we can get to to meet into them being successful in maintenance. Yeah. And and then the other piece we add in our model is we have relevant assessment data. And this is really, I think, something that it really depends on who we're seeing. We might put some unique things in this area where we're talking about things that maybe came out of the interview that didn't fit anywhere else. But we also think think of things like rating scales. Maybe we've given some, you know, like aq9 or something where we're trying to look at some symptom severity. That's information we'd kind of kind of put in this section and think about how it developed out. Like is that it also like applicable in terms of like grades or kind of like workplace, like work review, like performance reviews and things like that that are going on, you know, not even necessarily in the in the therapy session or setting itself, but like assessments that are going on outside that they're being kind of held to And I have to revise this chapter. I'm writing it all and then think about that. But I like that that's I think that's a great point. And yeah, I think that data piece, right. Yeah. I mean, I think grades fit in that, right. I mean, I think there's, you know, in some ways that's such a great functional assessment, you know, knowing what we're seeing on their grades or work performance or yeah, I think any data that helps us understand the person at or we should put there. Yeah, I think sometimes I guess I think too psychometric and I think of how we're eating skills and and things. But yeah, no, I think that's an excellent point. I mean, I think I would encourage people anything that you have, like as we should be looking at and considering if we have access to it. And I always love like when expressed again, children I think are have an easier time with this just because there's more adults and involved in their lives. But behavior charts, you know, if they're earning on green more often or they're ending on yellow red or you know, hey, we we put a been I have one family that we talked about there's a successful morning. They put a bean in a jar and once they fill up the jar, then, you know, they were right and they earned something and it's, hey, how many beans you get this week? So like again, so to date, an odd assessment scale that it's the bean assessment scale, but it's an important one. It's an important one. And it and again, it doesn't it doesn't have to be these big, nationally normed scales. I mean, sometimes that data's just good data. In real time, though, we have to always consider things. So with with case conceptualizations, we had all these little areas of information, you know, we kind of maybe now move into more of this wrap up of it. And what do we do with all these variables that we've talked about? And, you know, so kind of the goal case conceptualization is this concept of of developing a working hypothesis. But considering all these things, what do we think is happening with this person and why it's happening at this time under these circumstances? You know that that kind of a big and I've thought of or big question of you know why is it going on and how can we summarize it so it can help us develop treatment also? I love the term working hypothesis mainly for the first part of it, the working piece. And and you know, I was always taught and in my work that it's a working hypothesis because it is change. It will change. And sometimes after our first few sessions we get a hypothesis and we move down a direction and maybe treatment's not going the way we think. And we have to go back and revisit that hypothesis and and make adjustments to it. And it is a fluid piece and I wish I could say I am right every time on my first attempt with working hypothesis, but I'm not. Yeah, I mean I think that's that's the part of therapy we, we make we take information, we make the best kind of hypothesis we can and then we use time and data to modify that and to adjust treatment as necessary. And one, I think as a clinician like to have those aha moments. I mean I think that feels good for us. And you know, if we're right every time it makes those aha moments much harder to have. Yeah. And there's other times I know when I've been working with someone for quite a while and then they drop a bombshell on me. It's like, Oh yeah, I know this has been going on for years and it's like, Yeah, well, this changes everything, you know? So we have to throw the old hypothesis, how's it play out? And like, you know, we're kind of well, not that, but we, we have to update it, we have to adapt it. And sometimes it can skew things drastically. You know, substance use, I think, is one that a lot of times doesn't get disclosed initially. And then later on down the road, it's like, oh, you know, I get high every night. What? Right. You know, why haven't we talked to you know, I don't want you to tell. You know, I didn't want you to tell my parents. I didn't want you to tell anyone. It's like, all right, you know, I understand where you're coming from. Amanda That's a really important piece that we didn't have now. And so, you know, again, like, it's, it's putting everything together and updating as needed. Yeah. And, you know, I'll say you kind of said something and then took it back was like, what? You scrap it. And I think that happens sometimes. Yeah. I mean it's, you know, I don't think that happens often. But, you know, I remember a case years ago where I had a gentleman I was seeing and I mean, we usually we kept modifying the hypothesis, just couldn't get to it. And I regretfully were probably maybe six months into treatment. And he automatically discloses that he had some significant physical and sexual abuse when he was a child, but he never disclosed in in earlier sessions. We scrapped a lot like him. It was like it was a complete and I said like, wow, okay. Now it makes sense why we haven't maybe made the perfect why don't we really need to address this a different way? So I think it's okay to describe sometimes I think we sometimes we have to I don't think that happens often. I mean, I probably on two hands in 28 years I can't think of. Yeah. I don't think I can fill two hands of cases, but it does happen. Well, and maybe I should have said scrapping the hypothesis, but not the conceptualization, because all the other issues are really valuable and important. But it might just change how we put it all together. That's right. Yeah. It's all the other stuff still important, but this new variable may have changed it the the hypothesis completely, you know. And so with all of this, we're really trying to get this hypothesis, which then leads, I think, to our last kind of two pieces And and that is, you know, is there a relevant diagnosis for the person? And while I don't think diagnosis drives treatment, I do think diagnosis helps us understand and bring in some research data to help develop our treatment. And then really looking at how do we take this hypothesis to form good goals and determine how frequently somebody needs to be seen. And we could probably do a whole episode on how we use data to determine the level of service somebody needs. I mean, I think that's really over time, I think we get better at that know younger clinicians. I think sometimes that that's at least the feedback I get from people is like, should I see them every week or should I see them every other week or should it be twice a week? Like knowing that level is sometimes a hard decision. I think that gets easier when we go through our career. But, you know, so the end of, of, of creating a conceptualization is taking the hypothesis to now drive treatment goals, treatment plans and interventions. Yeah, it's fine. And I agree. I think we probably could be, as you said, that I do as a past supervisor that I had. And you would always talk about acuity, you know, what's the acuity for? You know, spend some time, look over your caseload. And it's like one thing he would repeat was. Is this client receiving a disservice by not seeing you as often, or are they receiving a disservice by seeing you too often? And really, that whether that's in safety, whether that's in, you know, the availability for progress, the availability for them to actually take these things and put them into place. And so, you know, it is something, I think, that develops over time. But it's funny, as you said, that's a wonderful question. I mean, I think, you know, is yeah. I mean, I think that because it can like what is really the right balance for this person. And and again, I don't think that's disorder specific. I know there's research that would maybe indicate like it should be this around the sessions or this often, but it is really individual like I have I have two people that are really very close and what I'm seeing them about and I have one that I see every week we need to see every week. If we go beyond that, it's not a good fit. And I have the other that we see about every 2 to 3 weeks, and that individual needs the time to practice what we work on and a week's not enough. So when they come back into session, they're like, Oh, I don't know if it's really working or not. So that spreading it out gives them time to really and they're great at it. They're like people. They're the ideal person to go and do the interventions, like they're following through on everything, but they need the time, you know and it's so really, you know, making that decision. Based on what's best care. And I like that question from your supervisor. I would remember that. Yeah. So with all this, you know, how do we put this stuff in practice? So it sounds like a lot of information and I, you know, so we are going to just kind of call out for those of you who are really interested in this, if you go to our website on the first page, there's a little area that says sign up for the practice squad, which is just kind of our term for those of you who listen. And if you go in there and enter your name and email, we will send you. We actually have a case conceptualization worksheet that is something that continually evolves, something developed by me and one of my colleagues and I would be absolutely willing to share that with you. So go online. If you put your information in, we'll send you that worksheet. That really is something just to help people who haven't done conceptualization. Help organize your thoughts to help you get thinking about cases differently as people evolve in case conceptualization, I think you don't necessarily have to have a worksheet to fill out every time I like using it when I do supervision with people because it helps me then kind of look at their thought processes. But I will say, you know, early in my career I use something similar and you've kind of said morphed it into a whole bunch of different areas now, but feel free to use it. It's an easy way to just take this information, jot some thoughts down as you're going through your interview and help you kind of pull everything together at the end. So feel free to download it. And you know, I think this is an episode the. Might be worth a realist. Like, I think like each of those different steps and stages like to go back and like really just kind of sit with each maybe, you know, have the worksheet there. Yeah. You know, we kept it at the end so that we had to go back and we listened. But yeah, but no, to, to really kind of stop and share like, hey, like what is, you know, what do each of these stages really represent? And to pull back on our, I think from the first episode or the part one. Is this something that works well with me or is this something I'm looking for? A different way of conceptualizing? How do I know and you know? Or do I adjust and adapt as to really kind of be a tailored fit for me? So I think a really valuable resource and hoping that they take us up on it. Yeah, absolutely. And and we will over time as some with some new references we're working on come available, we will get them on the website and put underneath this episode. Some of the things like the chapters we're working on are currently just in in progress. So when that comes available, keep an eye on it. We will post them on there. That way you all can take a look and I will put some other books that are not our model that you can take a look at, because there's a lot of great work beyond what I've been involved in in this area, and I know they're all valuable resources for me, so hopefully you all can check them out. So just so much good information. And you know, if after listening to these two episodes you have any doubts, then, you know, I'll certainly go listen again by case conceptualization. Just an important piece to be that even just an effective clinician but just to to be an effective provider you a provider of support and services for others because it helps us really get in touch with the individual. So we hope you enjoyed this episode. We'd love to hear that feedback. Please reach out if you'd like that worksheet. But until next week, you will stay psyched. The information contained in this podcast and on the site. The practice website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, educational or medical advice, diagnosis or treatment. Please note that no professional patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host guest and listeners of this podcast. If you need the qualified advice of a mental health professional or practitioner, please contact services in your area. Similarly, if you need supervision on clinical matters, please locate a supervisor with experience to fit your professional needs.