Case conceptualization is a foundation of cognitive-behavioural therapy (CBT) because it describes and explains clients' presentations in ways that inform interventions. Yet the evidence base challenges the claimed benefits of case conceptualization. This paper reviews the rationale and evidence base for case conceptualization and outlines a new approach that uses the metaphor of a case conceptualization crucible in which a client's particular history, experience and strengths are synthesized with theory and research to produce an original and unique account of clients' presenting issues. The crucible metaphor illustrates three key defining principles of case conceptualization. First, heat drives chemical reactions in a crucible. In our model, collaborative empiricism between therapist and client provides the heat. Second, like the chemical reaction in a crucible, conceptualization develops over time. Typically, it begins at more descriptive levels, later a conceptualization incorporates explanatory elements and, if necessary, it develops further to include a longitudinal explanation of how pre-disposing and protective factors influence client issues. Finally, new substances formed in a crucible are dependent on the chemical characteristics of the materials put into it. Rather than simply look at client problems, our model incorporates client strengths at every stage of the conceptualization process to more effectively alleviate client distress and promote resilience.

Cognitive behavioral therapy has often been criticized for ignoring the role of the therapeutic relationship. In this article, I outline several dimensions for case formulation and intervention that suggest that the cognitive-behavioral approach can be a powerful theoretical model for understanding the causes of and the strategies for overcoming impasses in therapy. I review how the clinician and patient can collaborate in understanding the importance of case conceptualization, validation, emotional philosophies, victim resistance, schematic resistance, schematic mismatch, sunk-cost commitment, and self-handicapping. The relevance of these factors for both patient and therapist are discussed. During the last decade there has been increased interest in the nature of the therapeutic relationship in cognitive behavioral therapy (Gilbert, 1992; Safran, 1998; Safran and Muran, 2000; Greenberg, 2002; Leahy, 2001; Gilbert and Irons, 2005; Leahy, 2005; Bennett-Levy and Thwaites, 2007; Gilbert and Leahy, 2007). Cognitive behavioral therapists have proposed that the therapeutic relationship reflects interpersonal schemas, earlier attachment problems, emotional processing, failures in validation and compassion, and a variety of processes underlying non-compliance or resistance. Resolving “ruptures” in the therapeutic relationship provides an often essential opportunity for using the relationship as a means to modify cognitive and emotional problems (Safran, Muran, Samstag and Stevens, 2002; Katzow and Safran 2007). In light of the emphasis on “empirically supported treatments” (such as CBT) there is the risk that the alliance in therapy may be foreshadowed by the techniques and protocols used in CBT, perhaps giving credibility to Mahoney's (1991) earlier claim that therapy can become “technolatry”.

Behavioural and Cognitive Psychotherapy is an international multidisciplinary journal for the publication of original research, of an experimental or clinical nature, that contributes to the theory, practice and evaluation of behaviour therapy. As such, the scope of the journal is very broad and articles relevant to most areas of human behaviour and human experience, which would be of interest to members of the helping and teaching professions, will be considered for publication.

Cognitive-behavioural therapy (CBT) supervision has traditionally been presented as an extension of the therapy, a reflexive strategy that includes a commendable commitment to a principled approach. However, a critical review suggests that this strategy has not been implemented with fidelity. Furthermore, this strategy overlooks potentially valuable ideas from the wider field of clinical supervision, runs counter to CBT's empirical roots, and under-values supervision as a discrete professional specialization. For these reasons, it is argued that new developments should be grafted onto the current approach. In future, this augmented version of CBT supervision should be subjected to the same kinds of research and development (R&D) activity as CBT. Initially, this could include developing a manual to specify and operationalize this innovative approach, evaluation of manual-based training, and N = 1 research to assess its effectiveness. Examples of preliminary work are provided, and future R&D directions identified.