Case conceptualisation is central to psychological practice. It helps clinicians organise information, understand how a person’s difficulties may have developed and been maintained, and decide what treatment would be adequate. However, conceptualisations can become overly intuitive, static, or disconnected from both assessment evidence and treatment research. Christon, McLeod, and Jensen-Doss (2015) propose a science-informed approach designed to connect evidence-based assessment with evidence-based treatment. Their framework treats case conceptualisation not as a one-off written formulation completed at the beginning of therapy, but as an ongoing process of developing, testing, and revising clinical hypotheses. The model consists of five stages: clinicians identify presenting concerns and relevant contextual information; consider diagnostic questions; develop hypotheses about factors contributing to or maintaining the difficulties; select and plan treatment; and monitor progress to determine whether the conceptualisation and treatment plan remain accurate. The approach reflects an evidence-based psychological practice in which research evidence is integrated with clinical expertise and the individual characteristics, culture, values, and preferences of the client (APA Presidential Task Force on Evidence-Based Practice, 2006). Its aim is not to replace clinical judgement but to make clinical reasoning more explicit, systematic, testable, and responsive to new information.
Why case conceptualisation matters
Children and adolescents rarely present with one isolated and straightforward difficulty. Their emotional or behavioural concerns may be influenced by developmental stage, family relationships, school experiences, peer interactions, physical health, learning needs, cultural context, and previous experiences. Young people may meet criteria for more than one disorder or show clinically significant symptoms that do not fit within a diagnostic category. Case conceptualisation provides a way of organising this complexity. Christon et al. (2015) define it as a collaborative process through which information is used to generate hypotheses about the causes, antecedents, and maintaining influences associated with an individual client’s difficulties within a biopsychosocial context. Research has shown the limitations of relying exclusively on intuitive judgement, even when clinicians are experienced (Dawes et al., 1989). A science-informed conceptualisation therefore asks clinicians to use research, psychometrically assessment methods, and systematically collected information alongside their professional expertise. This does not mean reducing a young person to questionnaire scores or diagnostic labels. Instead, it means making explicit what the clinician currently believes, what evidence supports those beliefs, and what information might confirm or challenge them.
Evidence-based assessment as the foundation
Evidence-based assessment involves using research to guide what should be assessed, which methods and measures should be selected, and how assessment information should be interpreted and used (Hunsley & Mash, 2007). Christon et al. (2015) position evidence-based assessment as the foundation of their model. Assessment helps clinicians:
- Define the problems that require intervention
- Identify possible causal and maintaining factors
- Estimate diagnostic probabilities
- Select treatment targets
- Establish a baseline
- Monitor change
- Determine whether treatment should continue, change, or end.
Standardised measures can support this process when they are reliable, valid, clinically relevant, and feasible. Brief and freely available measures may be especially useful in services where time and financial resources are limited (Beidas et al., 2015). However, assessment should remain purposeful. The aim is not to administer every available questionnaire, but to collect information that contributes to a specific clinical decision.
Stage 1: identifying and quantifying the presenting problems
The first stage involves identifying the young person’s main difficulties, gathering information about possible causal, maintaining, historical, and contextual factors. This requires different informants since they may identify different concerns. A parent may focus on emotional outbursts, defiance, or avoidance, while the young person reports fear, sadness, embarrassment, or difficulties with peers. Teachers may observe inattention, disengagement, social isolation, or declining academic functioning that is less visible at home. Rather than immediately deciding which account is correct, the clinician should explore these perspectives and establish how the difficulties vary across situations. Relevant questions include:
- What exactly happens?
- How frequently and intensely does it occur?
- When did it begin?
- What tends to precede it?
- What happens afterwards?
- In which settings is it better or worse?
- How does it affect the young person’s functioning?
- What has the family already tried?
Standardised measures may help clarify symptom patterns and severity. Validated measures can assess anxiety and depressive symptoms across several diagnostic domains while also producing dimensional information (Chorpita et al., 2000). Some young people experience substantial functional difficulties without meeting the full criteria for a formal disorder. Research has shown that children with clinically important impairment can remain undiagnosed when assessment focuses too narrowly on diagnostic thresholds (Angold et al., 1999). A useful conceptualisation therefore considers both symptoms and their effect on daily life.
Stage 2: considering diagnosis
The second stage involves considering whether the available information supports one or more diagnoses. Diagnosis can be useful, providing a shared language, helping clinicians access relevant psychopathology and treatment research, and may supporting communication between services. Diagnostic information can also help identify established treatment options and alert clinicians to common co-occurring conditions. However, diagnosis is not the same as case conceptualisation. Two young people who meet criteria for the same disorder may differ substantially in their developmental histories, family circumstances, maintaining processes, strengths, and barriers to treatment. Christon et al. (2015) therefore place diagnosis within a broader process. Clinicians should consider established diagnostic criteria (American Psychiatric Association, 2013), but they should also assess symptoms dimensionally, examine functional impairment, explore alternative explanations, and consider co-occurring difficulties. Diagnostic reasoning should remain open to revision since early information may be incomplete, and some symptoms may be explained by more than one condition. A clinician may therefore need to maintain several competing hypotheses and gather additional evidence rather than prematurely committing to a single explanation. Using structured information can reduce the influence of cognitive biases and improve consistency. This is particularly important given evidence that unaided clinical judgement is not invariably more accurate than systematic approaches to decision-making (Dawes et al., 1989).
Stage 3: developing hypotheses
The third stage is the core of the conceptualisation process. The clinician uses the assessment information and relevant research to develop hypotheses about why the difficulties arose and what may be maintaining them. These factors may include:
- patterns of avoidance;
- reinforcement within family or school interactions;
- beliefs about the self, other people, or threatening situations;
- difficulties regulating emotions;
- parenting responses;
- family stress;
- peer rejection or conflict;
- developmental vulnerabilities;
- physical health or sleep difficulties;
- environmental demands;
- previous adverse experiences.
For example, a young person with anxiety may avoid feared situations, avoidance reduces distress in the short term but prevents the young person from learning that the situation is manageable, thereby maintaining the anxiety. Parents may understandably accommodate the avoidance, which can further strengthen the pattern. In another case, disruptive behaviour may be maintained by interaction patterns in which escalation allows the young person to escape a demand. The purpose of identifying this process is not to blame the young person or family, but to identify modifiable factors that can become targets for intervention. Personalise assessment is especially relevant at this stage, and involves measuring the particular behaviours, experiences, and contextual processes that matter for an individual client rather than relying solely on comparisons with population norms (Haynes et al., 2009). This may involve monitoring mood, avoidance, panic symptoms, family responses, sleep, school attendance, or other case-specific targets. The resulting conceptualisation should distinguish established facts from hypotheses. Statements such as “avoidance appears to be maintaining the anxiety” or “family accommodation may be reducing opportunities for exposure” make the clinician’s reasoning visible and testable.
Stage 4: selecting and planning treatment
The fourth stage connects the conceptualisation to treatment. Treatment should not be selected solely because it is familiar to the clinician or generally associated with a diagnosis. The clinician should consider:
- whether the treatment has evidence for the presenting problem;
- whether it targets the processes identified in the conceptualisation;
- whether it is developmentally appropriate;
- whether it is acceptable to the young person and family;
- whether practical barriers could prevent participation;
- whether adaptations are needed.
Research can help clinicians identify both complete treatment protocols and the common therapeutic components found across evidence-based interventions (Chorpita et al., 2005). This may be especially useful when a young person has multiple difficulties or does not fit neatly within the population studied in a single treatment trial. But individualisation should not mean abandoning the evidence base. Instead, an evidence-based treatment provides a starting framework, while assessment and conceptualisation help determine which targets should receive priority and how the intervention should be delivered. Approaches that present treatment outcomes probabilistically can support more individualised and transparent decision-making (Lindhiem et al., 2012). Treatment goals should be collaboratively defined and measurable. Broad goals such as “feel better” or “behave better” can be translated into observable outcomes, such as:
- attending school more consistently;
- completing previously avoided activities;
- reducing the frequency of panic attacks;
- improving sleep;
- decreasing aggressive incidents;
- increasing social participation.
Clear goals make it possible to determine whether treatment is producing meaningful change.
Stage 5: monitoring outcomes
The final stage involves monitoring progress and using the results to evaluate the conceptualisation. The initial conceptualisation is provisional, even when based on careful assessment and research evidence, it remains a set of hypotheses. Treatment provides an opportunity to test those hypotheses. When a young person improves after a proposed maintaining factor is targeted, this offers some support for the conceptualisation. When progress is limited, several explanations are possible:
- the intervention may not have been delivered as intended;
- the selected target may not be central to the problem;
- an important difficulty may have been overlooked;
- the young person may not find the treatment acceptable;
- environmental barriers may be interfering;
- the original diagnosis or explanatory hypothesis may require revision.
Progress should therefore be monitored throughout therapy rather than evaluated only at the end. Repeated standardised measures can be combined with idiographic indicators, goal-based outcomes, behavioural observations, and feedback from the young person, family, and school. Feasible measures are important because monitoring is more likely to occur when tools are brief, accessible, and directly relevant to clinical decisions (Beidas et al., 2015). When outcomes do not change as expected, the clinician should revisit the conceptualisation and treatment plan. This creates a continuous cycle: assess → hypothesise → intervene → monitor → revise.
Integrating evidence with individual needs
A major strength of the model is that it does not present evidence-based practice and individualised formulation as competing approaches. Research evidence helps clinicians identify reliable assessment tools, established risk and maintaining factors, and treatments likely to be helpful. Clinical expertise is needed to interpret the evidence, reconcile conflicting information, manage uncertainty, and adapt treatment appropriately. The young person’s and family’s characteristics, culture, circumstances, values, and preferences shape what is acceptable and feasible (APA Presidential Task Force on Evidence-Based Practice, 2006). Collaboration is therefore essential. The conceptualisation should make sense to the young person and family, and treatment goals should reflect outcomes that matter to them.
Implications for clinical practice
The paper offers several practical lessons. First, assessment should begin with clearly defined clinical questions and measures should be chosen because they help answer those questions. Second, diagnosis and conceptualisation should be distinguished. Diagnosis may guide access to research and treatment options, but it does not provide a complete explanation of the individual case. Third, hypotheses should be explicit and testable. Clinicians should be able to state what they believe is maintaining the problem and what evidence would support or challenge that belief. Fourth, treatment should target the processes identified in the conceptualisation while drawing on the best available intervention evidence. Fifth, goals should be concrete and measurable. Finally, assessment should continue throughout treatment, allowing clinicians to recognise improvement, detect stalled treatment, and revise the conceptualisation when the expected change does not occur.
Conclusion
Christon et al. (2015) present case conceptualisation as a bridge between evidence-based assessment and evidence-based treatment. Their five-stage framework moves from identifying and measuring presenting problems, through diagnosis and explanatory hypotheses, to treatment selection and ongoing outcome monitoring. The central message is that conceptualisation should be structured but flexible, evidence-informed but individualised, and sufficiently explicit to be tested and revised. A useful case conceptualisation is therefore not simply a polished document produced at the beginning of therapy, but a working model that helps clinicians determine what information matters, what should be targeted, whether treatment is helping, and what needs to change when progress does not occur.
Where next?
Join us on 08 for a fantastic event on ‘Psychotherapy: A 5-Step Approach to Case Conceptualization’ with Dr. Bryce D. McLeod, Ph.D.
This workshop will introduce a case conceptualization model to guide the treatment process from intake to termination. This model employs a hypothesis-testing approach informed by evidence-based assessment. We will explain the core principles of evidence-based assessment and the benefits of science-informed case conceptualization. Additionally, we will discuss practical applications in clinical care and present examples based on this model.
References
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
- Angold, A., Costello, E. J., Farmer, E. M. Z., Burns, B. J., & Erkanli, A. (1999). Impaired but undiagnosed.
- APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology.
- Beidas, R. S., Stewart, R. E., Walsh, L., et al. (2015). Free, brief, and validated.
- Chorpita, B. F., Daleiden, E. L., & Weisz, J. R. (2005). Identifying and selecting the common elements of evidence-based interventions.
- Chorpita, B. F., Yim, L., Moffitt, C. E., Umemoto, L. A., & Francis, S. E. (2000). Assessment of symptoms of DSM-IV anxiety and depression in children.
- Christon, L. M., McLeod, B. D., & Jensen-Doss, A. (2015). Evidence-based assessment meets evidence-based treatment.
- Dawes, R. M., Faust, D., & Meehl, P. E. (1989). Clinical versus actuarial judgment.
- Haynes, S. N., Mumma, G. H., & Pinson, C. (2009). Idiographic assessment.
- Hunsley, J., & Mash, E. J. (2007). Evidence-based assessment.
- Jensen-Doss, A., Hawley, K. M., Lopez, M., & Osterberg, L. D. (2009). Using evidence-based treatments.
- Lindhiem, O., Kolko, D. J., & Cheng, Y. (2012). Predicting psychotherapy benefit.