Running toward the emotional fires

Jeffrey Karp, Psy.D., argues for a transtheoretical approach to conceptualisation.

Years ago, I had a patient who could not drive on highways or over bridges. She felt like she was going to die, and her body would shake so much she could not safely drive. Driving to a location that required going over a bridge was much harder than driving home along that same route. When I asked about her childhood she described her father as ‘abusive and scary’ and living two hours from her grandmother. Her mother was using drugs and unable to care for her. She recalled feeling terrified driving two hours on the highway, anticipating the abuse she would endure while living with her father, and the relief she felt driving back to the safety of her grandmother’s home. 

Understanding where her symptoms stemmed from changed her view of herself from ‘a weak person’ who cannot do something ‘normal people can do’ to someone who was experiencing a traumatic response. Early interventions focused on understanding how to use grounding techniques while driving, gradually building up to traveling over bridges. We were able to generate more specified coping skills from the knowledge that some of the anxiety she experienced driving as an adult came from feeling scared and alone traveling with her father. The patient found it helpful to think about a supportive family member saying calming phrases while tightly gripping then releasing her steering wheel. Understanding how the trauma she experienced as a child was impacting her physiologically and emotionally as an adult helped her feel capable of challenging her fears. Being able to use grounding techniques to help her feel safe and connected to supportive family members allowed her to start to create new associations with anxiety and driving over bridges. 


Regardless of a therapists’ theory of change (CBT, Psychodynamic, Family Systems, ACT, DBT, Behavioral, Person Centered etc.) a person’s early childhood experiences and relationships impact their development. Conceptualising patients should therefore include gathering a developmental history that focuses on early relationships with parents, caregivers, and any siblings. There are patients who push back at those types of questions, saying ‘I didn’t come here to blame my mother, I want to talk about me’. I typically respond by saying, ‘It’s not about blaming; it’s about understanding how that relationship impacted you’ – or more accurately, your maturing brain. 

Both genetics and environment begin to organise our neurons into a functioning brain: ‘...activation of neural networks – chains of neurons – allow us to think, feel, act...laugh, cry, hope’ (Perry, 2002, p.81). These networks, which allow us to create relationships, are the product of interactive processes that take place during our lifetime. However, our brains are most sensitive to experience – in positive or negative ways – in infancy and early childhood. A person’s early childhood relationships are external forces that significantly contribute to the creation of a person’s neuronal associations and brain development. The creation of those neural connections become the first ‘template’ of how we process emotions, understand interpersonal relationships, and understand ourselves. Those ‘templates’ become reinforced throughout our childhood, creating patterns of relating to others, and ourselves, that become our ‘default’ responses. 

Thinking about patients from this understanding can only deepen a therapist’s knowledge about their patient’s symptoms. A patient who presents to a therapist with a snake phobia will need some form of exposure and response prevention to decrease their fear of snakes. Taking a developmental history that includes early childhood relationships would only increase a therapist’s understanding of the patient and what interventions could be needed to challenge the phobia. The patient may have had a traumatic snake bite as a child or seen their mother or father display irrational fears about being bitten by snakes. Both of those hypothetical experiences would have formed memories (neuronal connections) that shape the way that person thinks about and relates to snakes. Part of the interventions needed might be remembering they are an adult and know how to better protect themselves than a child does. Or, they might remind themselves that Mom or Dad’s fears do not have to be their own. Those types of interventions could help a patient deepen their connection to the exposure work in therapy. 

A patient diagnosed with PTSD might need help managing symptoms, understanding how their trauma is impacting interpersonal relationships, and understanding how their trauma impacted their view of themselves. Patients who are actively having flashbacks and dissociating would need education about how to understand their symptoms and use grounding techniques to manage their anxiety. Once their symptoms are managed, some patients might want to understand why certain intrapersonal and interpersonal patterns repeatedly occur. Conceptualising with a focus on early child relationships allows the therapist to be able to shift from symptom management work to reshaping internal concepts of relationships. Patients with the same PTSD diagnosis may individually benefit from different interventions due to prior experiences in therapy, as well as their identified goals. 

Focus on the overlap

We are uniquely qualified to help people recognise and understand patterns of conflict in their lives. We give people opportunities to get ‘unstuck’ and move forward differently. This is what we trained for. When someone says, ‘I’m overwhelmed and feel out of control’ we say, ‘come on in, let’s talk about it’. When someone says, ‘my life is falling apart’ we say, ‘let’s figure this out together’. We run towards the emotional fire – or, more accurately, sit near it. 

Yet to me, there seem to be too many divisions within our profession. Too much focus on identifying how theories or approaches are in separate circles in the figurative Venn diagram, and not enough discussion about where those circles overlap. I believe that a more uniform approach to conceptualising patients, taking that developmental approach and focusing on early childhood relationships, would benefit both therapists and patients. 

Case conceptualisation is of course a pivotal component of therapy (Sperry, 2005), but there is a surprising lack of empirical research on ways to examine efficacy and mastery of that area (Flinn et al., 2014). The focus of a case conceptualisation ends up depending on the theoretical orientation of the therapist. Multiple therapists looking at the same case will inevitably focus on different areas of that case depending on their theoretical orientation (Flinn et al., 2014; Kuyken et al., 2005). Hill et al. (2017) offer similar sentiments, noting that therapists’ case conceptualisations vary so widely it is difficult, if not impossible, to view them outside the context of theoretical orientation. Further, reliability of case conceptualisations, within a specific theoretical orientation, is difficult to establish particularly when examining a case beyond presenting issues (Kuyken et al., 2005; Mumma & Smith, 2001). 

Conceptualising cases based on theoretical orientation limits a therapist’s understanding of the patient’s symptoms by only focusing on the area of the case that fits within their theory of change. Creating a more uniform approach to case conceptualization, focused on the overlap between theories, would allow therapists to broaden the way they understand patients’ symptoms to include important information that would not have been considered otherwise. 

Looking to the developmental approach for a common ‘therapy language’ – for social workers, counselors, therapists, psychologists, and others who ‘run toward the emotional fires’ – is not an eclectic approach to therapy. It’s the reality of how humans learn. Regardless of race, culture or religion, all people develop their understanding of how relationships work, who they are, and how to express emotions first as a child. Their understanding of what is normal, possible, and desirable begins with their first relationships and experiences. This remains the same whether their therapist views symptoms as learned behaviours or defences against unconscious conflicts. If people are going to change how they express or regulate their emotions and repair or create healthy relationships, they are going to need help understanding how their symptoms formed, and in sparking new patterns of relating to themselves and others. 

-       Jeffrey Karp is a licensed psychologist based in Cleveland, Ohio


Flinn, L., Braham, L., & dasNair, R. (2014). How Reliable are Case Formulations? A Systematic      Literature Review. British Journal of Clinical Psychology. DOI: 10.1111/bjc.12073

Hill, C. E., Spiegel, S. B., Kivlinghan, D. M., & Gelso, C. J. (2017). Therapist Expertise in   Psychotherapy Revisited. The Counseling Psychologist, 45(1), 1–47. 

Kuyken, W., Fothergill, C. D., Musa, M. and Chadwick, P. (2005). The reliability and quality of cognitive case formulation. Behaviour Research and Therapy, 43, 1187–1201.

Mumma, G. H. and Smith, J. L. (2001). Cognitive-behavioral-interpersonal scenarios: interformulator reliability and convergent validity. Journal of Psychopathology and Behavioral Assessment, 23, 203– 221.

Perry, B. (2002). Childhood Experience and the Expression of Genetic Potential: What Childhood Neglect Tells Us About Nature and Nurture. Brain and Mind, 3, 79-100.

Sperry, L. (2005). Case Conceptualizations: The Missing Link Between Theory and Practice. The Family Journal, 13(1), 71–76.

BPS Members can discuss this article

Already a member? Or Create an account

Not a member? Find out about becoming a member or subscriber