Counseling and Psychotherapy Theory · Meaning • Defining problems according to the standards set...
Transcript of Counseling and Psychotherapy Theory · Meaning • Defining problems according to the standards set...
Week 2. Counseling and Human Change
Counseling and
Psychotherapy Theory
Understanding Client ‘Problems’
Scientific/Statistical Approach
Practical Approach
Understanding the ‘Causes’ of Client Problems
Rethinking about ‘Cause’
Three Dimensions for Understanding ‘Cause’
Understanding Client ‘Change’
‘Elimination of Problems’ vs. ‘Promotion of Growth’
Starting from ‘Big Change’ vs. ‘Small Change’
Contents
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Scientific/Statistical Approach
Pathological Diagnosis System
Statistical Cutoff Scores
Ⅰ. Understanding Client ‘Problems’
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Meaning
• Defining problems according to the standards set by a pathological diagnosis system.
DSM Criteria
• Diagnostic and Statistical Manual of Mental Disorders. •Current version: DSM-5 •American Psychiatric Association
ICD Criteria
•International Classification of Disease •Current version: ICD-10 (ICD-11 in 2018) •World Health Organization
Pathological Diagnosis System
Evolution of DSM
Version Publish Date Number of Categories
Number of Total Diagnosis
Axial System
DSM-I 1952 8 106 None
DSM-II 1968 10 182 None
DSM-III 1980 16 265 Multiaxial
DSM-III-R 1987 17 292 Multiaxial
DSM-IV 1994 17 297 Multiaxial
DSM-IV-TR 2000 17 297 Multiaxial
DSM-5 2013 20 ~300 Multiaxial system
abolished
Pathological Diagnosis System
DSM (category examples)
1 Neurodevelopmental Disorders 11 Elimination Disorders
2 Schizophrenia Spectrum and Other Psychotic Disorders
12 Sleep-Wake Disorders
3 Bipolar and Related Disorders 13 Sexual Dysfunctions
4 Depressive Disorders 14 Gender Dysphoria
5 Anxiety Disorders 15 Disruptive, Impulse Control and Conduct Disorders
6 Obsessive-Compulsive and Related Disorders
16 Substance Use and Addictive Disorders
7 Trauma- and Stressor-Related Disorders 17 Neurocognitive Disorders
8 Dissociative Disorders 18 Personality Disorders
9 Somatic Symptom Disorders 19 Paraphilic Disorders
10 Feeding and Eating Disorders 20 Other Disorders
Pathological Diagnosis System
DSM (subcategory examples)
(Example 1) Depressive Disorders
Subcategory Main diagnostic characteristics
1 Disruptive Mood
Dysregulation Disorder
- (3 or more times per week on average) persistently irritable or angry, sporadic temper outbursts
- Present for 12 or more months
- Age between 6-18; onset before age 10
2 Major Depressive
Disorder
- Depressed mood or loss of interest or pleasure
- Nearly every day for more than 2 weeks
Pathological Diagnosis System
DSM (subcategory examples)
(Example 1) Depressive Disorders
Subcategory Main diagnostic characteristics
3 Persistent Depressive Disorder
- Depressed mood for at least 2 years (in children and adolescents, at least 1 year)
4 Premenstrual
Dysphoric Disorder
- Various marked (physical, emotional, cognitive) discomforts before the onset of menses
Pathological Diagnosis System
DSM (subcategory examples)
(Example 2) Anxiety Disorders
Subcategory Main diagnostic characteristics
1 Separation
Anxiety Disorder
- excessive anxiety and fear concerning separation from major attachment figures that last for 6 months or more
2 Selective Mutism
- despite normal language development, failure to speak in a specific situation for one month or more
Pathological Diagnosis System
DSM (subcategory examples)
(Example 2) Anxiety Disorders
Subcategory Main diagnostic characteristics
3 Specific Phobia
- Fear and avoidance of a specific object (e.g. dog, cat, spider, snake) or situation (high places, water) that last for 6 months or more
4 Social Anxiety
Disorder
- Excessive anxiety and fear of social situations where one is evaluated by others that last 6 months or more
5 Panic Disorder - Recurrent panic attacks (abrupt surge of intense
anxiety and fear)
Pathological Diagnosis System
DSM (subcategory examples)
(Example 2) Anxiety Disorders
Subcategory Main diagnostic characteristics
6 Agoraphobia
- Fear, anxiety, and avoidance of certain places (e.g. shopping center, movie theater, sports field, elevator, subway) that last for 6 months or more
7 Generalized
Anxiety Disorder
- excessive anxiety and worry occurring more days than not for at least 5 months about various dangers that may or may not happen
Pathological Diagnosis System
DSM (subcategory examples)
(Example 3) Personality Disorders
Personality Cluster
General Features Subtype Main diagnostic characteristics
Cluster A the "odd,
eccentric" cluster
Paranoid • distrust and suspiciousness • vigilant and tense • malicious attitude
Schizoid • social detachment and isolation • restricted range of emotional expression • wishes to be alone
Schizotypal
• avoidance of interpersonal relationships • cognitive, perceptual distortions • eccentric appearance and behaviors and severe social isolation
Pathological Diagnosis System
DSM (subcategory examples)
Personality Cluster
General Features
Subtype Main diagnostic characteristics
Cluster B
the "dramatic, emotional,
erratic" cluster
Antisocial • breaking of social norms and rules
• disregard for the rights of others; lacking guilt
Borderline • intense & unstable moods; interpersonal anger
• impulsivity, psychological instability
Histrionic • Exaggerated emotional expression and seductive
behavior to draw affection and attention of others
Narcissistic
• overestimation about self
• desire for praise, sense of entitlement, arrogant behavior
Pathological Diagnosis System
(Example 3) Personality Disorders
DSM (subcategory examples)
Personality Cluster
General Features
Subtype Main diagnostic characteristics
Cluster C
the "anxious, fearful" cluster
Avoidant • Inhibition and avoidance of social activities
• Feelings of inadequacy, embarrassment, hypersensitivity to negative evaluation
Dependent
• Lack of independent living
• Need and desire to be taken care of by others
• fear of parting
Obsessive-Compulsive
• orderliness, perfectionism
• Preoccupation with control over mind and interpersonal relationship
Pathological Diagnosis System
(Example 3) Personality Disorders
Pathological Diagnosis System
Characteristics
Focused on medical and pharmacological interventions
Based on long, statistical research findings
Provided a basis for scientific research on psychosis
Widely used in the fields of medicine and clinical psychology
Limitations
Problem of over-diagnosis
• May assume clients (in need of diagnosis) as ‘problematic persons’
• Most counseling sessions deal with daily life, personal development, and decision making issues
[Example] - career issues
- interpersonal issues (not requiring medication)
- conflict between spouses
Pathological Diagnosis System
Limitations
Emphasis on the problem instead of the person
“If one does not understand a person, one tends to regard him as a fool.”
Differently put, if we properly understand a person, we may not regard him as a fool or a problematic person.
Pathological Diagnosis System
Carl Jung
Limitations
Pathological Diagnosis System
May confuse ‘symptoms’ with ‘causes’ At times, the problem's category is unrelated to intervention's category. Must be applied to counseling practice with caution
Meaning
Setting the scores in the extreme ends of the normal distribution curve as cutoff score
[Example] MMPI, CBCL - if any score is beyond the cutoff scores, we consider it as outliers and say that the person has a problem.
W SC AD SP TP AP DB AB
CELIAC MALE
CBCL Subscales
CB
CL
Tsco
re M
ean
80 70 60 50 40 30 20
Statistical Cutoff Scores
Characteristics
Allow us to achieve objectivity or reliability.
Cutoff scores do not correspond with adverse effect in real life.
- [i.e.] eccentric personality of an artist
A client with an extreme score may not be in distress.
Statistical Cutoff Scores
Limitations
Making a final decision based on just the test scores is dangerous.
Test scores serve as supplementary information for experts.
Example
- a score of over 70 on the scale 8 in MMPI does not mean the client has schizophrenia.
- need to comprehensively consider various resources such as interview results, client behaviors in daily life, subjective discomfort, biological characteristics, and responses to individual items on psychological tests.
Statistical Cutoff Scores
Practical Approach
Basing on Main Complaint
Gap between the Desired State
and the Current State
Ⅰ. Understanding Client ‘Problems’
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Meaning
Defining problems based on what client says his problem is.
(e.g.: Kim et al. (1994), Adolescent problem type classification system: Basic research)
• “I’m anxious (depressed).”
• “I can’t get along with my friends.”
• “I can’t focus on my study.”
• “I can’t control my anger.”
Basing on Main Complaint
Characteristics
Might mean that the client is just ‘uncomfortable’
The easiest way to define problems
Can easily explore client’s task at hand
Is modified as counseling progresses
• Because the initial complaint has been resolved
• Because the understanding about ‘real problem’ has changed
• “I can’t sleep well at night.”
Basing on Main Complaint
Limitations
Clients may not be aware of the existence or the true colors of the real problem
Clients may attribute the root of the problem to environment or others.
Causes, symptoms, and main complaints may get mixed up.
• "I'm so stressed. Please change my husband.“
• "My friends all hate me."
• “I don’t have any problem.”
• "My problem is that I cannot form close relationships with others," (when in reality, his problem is his anxiety)
Basing on Main Complaint
Limitations
Different problems; same term
“I am depressed”
Same problem; different terms
Attachment issues..
• Relationship loss • Repeated failure, helplessness,
fatigue • Self-blame and anger • Temperamental/biological
problem
• "It's hard to approach my friends"
• "I'm really upset at my parents."
Basing on Main Complaint
Meaning
Problem is defined as the gap between the desired state and the current state of each individual.
No matter what the client’s current status is, the goal can be ‘to become better (happier) than now’.
Gap between the Desired State and the Current State
desired state
current state
Problem
Characteristics
Highly applicable in counseling practice
Guards against the impression that the client's current state is abnormal
Can prevent misunderstanding about the cause
Can provide accurate understanding of what the client needs to do.
Does not give negative impression about counseling
Can normalize & validate clients
Gap between the Desired State and the Current State
Limitations
Difficult to secure objectivity for scientific research
Need a procedure for training counselors to transform clients' main complaint into a problem that can actually be dealt with in counseling
Gap between the Desired State and the Current State
Rethinking about ‘Cause’
Illusion Evoked by Language
Points to Consider When Thinking about ‘Problem’ and ‘Cause’
Ⅱ. Understanding the ‘Causes’ of Client Problems
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At times, language influences our thought and behavior
Example
• Perception & Performance research
• Research on the words “Vision/Future”
Illusion Evoked by Language
Language causes errors even in various helping activities
Psychiatry Psychology Counseling
Studies
Illusion Evoked by Language
Medicine
When we say, ‘I got sick’…
• ‘Germs (the cause) came into my body.’
So ‘I need to get rid of the germs.’
• ‘I am lacking something (nutrition, which I must have).’
So ‘I need to fill that in.’
Illusion Evoked by Language
Medicine
When we say, ‘I am injured’…
• Something is ‘ripped’, ‘broken(shattered)’
So ‘I need to fix it.’
Illusion Evoked by Language
Medicine
‘Cause’
• Virus that invades must get rid of
• Nutrition that is lacking must fill in
• Germ that infects must get rid of
‘must treat’, ‘must fix’
• ‘Contaminated’ (by germs) person
• ‘Broken’ person
• Person that needs ‘fixing’
Illusion Evoked by Language
Psychology
Psychological ‘problem’
• ‘There is a problem.’ So, ‘I need to get rid of the problem.’
‘Because of’ (problem, personality, symptom, trauma)
• He is behaving that way ‘because of his personality’.
(So in order to correct his problematic behavior/thought), his personality needs to be fixed.
Illusion Evoked by Language
Psychology
‘Cause’
• ‘Past trauma experience’ must eliminate (?)
• ‘(not experienced) parental love’ must fill in (?)
‘(Psycho)therapy’
• Person ‘contaminated (by germs)’, ‘broken’, ‘needs fixing’ (?)
• Temporal delay
• Cannot remove or delete experience from our body
Illusion Evoked by Language
‘because of personality’, ‘because of problem’
‘Because of … I behave ~~ way.’
• Could be synonyms repeated
• A series of behaviors make up personality
Example
• ‘I don’t meet friend because of my introverted personality.’
• ‘She feels down because of her depression.’
Illusion Evoked by Language
Need to be able to do something ‘now’
• Interventions about the past should also be transformed into something about the present.
Need to be able to intervene in the ‘mind’.
• It's not about removing something (like germs) physically.
• We cannot wipe out the traces left on the mind (or the body).
Points to consider
Should be careful so that it's not a repetition of synonyms.
• Error of saying ‘because my personality is introverted ~~’
‘Problems’ and ‘causes’ need to be defined in a way that can be solved. (“A Tidbit of Counseling" section)
Points to consider
Three Dimensions for Understanding ‘Cause’
Past vs. Present Factor
Deteriorating vs. Barrier-to-improvement Factor
Environmental vs. Internal Mechanism Factor
Ⅱ. Understanding the ‘Causes’ of Client Problems
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Past factor
• Assume past experiences, traumatic experiences to be the cause of present problems.
Meaning
• He is so because his parents were sadistic .
• He is so because he was sexually harassed.
• He is so because he came to distrust the world due to oral fixation .
[Example] A client who is full of anger.
Past vs. Present Factor
Past factor
Characteristics
(Due to the temporal delay), we cannot eliminate the past experience itself
Medicine Counseling
Typhoid Angry behavior
• Cause: typhoid germ* • Experience of an unhygienic
place where he got the typhoid germs in his body
• Internal mechanism that triggers anger
• Abuse experience that made internal mechanism for anger settled in his body*
VS.
Past vs. Present Factor
Past factor
Characteristics
At times, clients cannot remember their past experiences.
- Selective forgetting
- No trauma experience
- Gap between actual experience and memory
- Past memories are quite constructive
Past vs. Present Factor
Present factor
Meaning
Past vs. Present Factor
Assume factors that are currently hindering the client from getting better as the cause
Past vs. Present Factor
Past me Present me
Present factor
Characteristics
Cognitive Rigid thinking, dichotomous thinking
Psychodynamic Explosion of unregulated, suppressed anger
Experiential Weakened ability to contain anger
Environmental aspect
- People who stimulate anger
- Unjust social system
Psychological factors
Past vs. Present Factor
Present factor
Characteristics
• Different theories assume different things to be the cause
• Mainly looks at psychological factors
• Mainly look at at barriers to change and improvement
• Factors that can be dealt with now
• Comparison of adult vs. children/youth counseling
Adult counseling Children/youth counseling
Looks at client’s internal psychological mechanism
Looks at parental and environmental factors of the present
Past vs. Present Factor
Deteriorating factor
Meaning
- Assume something that triggered client problem to be the cause.
Example
- Parents’ abuse
- Trauma experience
Deteriorating vs. Barrier-to-improvement Factor
Deteriorating factor
Characteristics
• Usually past experiences
• Already delayed temporally
• Direct intervention is difficult
• ‘Reinterpreting’ or ‘reprocessing’ deteriorating factors is possible
Deteriorating vs. Barrier-to-improvement Factor
Barrier-to-improvement factor
Meaning
- Factor that makes the client to stay status quo without improving or growing
Example
- Angry client
Barriers when trying to calm down
- Client with relationship difficulties
Barrier when trying to form relationships
Deteriorating vs. Barrier-to-improvement Factor
Barrier-to-improvement factor
Characteristics
• Current intervention is possible
• Usually, internal psychological mechanism or experience
• Different ‘cause’ according to theory
Deteriorating vs. Barrier-to-improvement Factor
Barrier-to-improvement factor
Characteristics
Past me Present me
Deteriorating vs. Barrier-to-improvement Factor
Environmental factor
Meaning
- Looks for the factors that deteriorate and stop client from improvement from outside of client's mind.
Example
- Anger stimulating spouse/child
- Anger stimulating social structure
Environmental vs. Internal Mechanism Factor
Environmental factor
Past me Present me
Environmental vs. Internal Mechanism Factor
Environmental factor
Characteristics
• Counseling usually focuses on internal mechanism.
• Environmental factors are of interest in the field of social welfare.
Environmental vs. Internal Mechanism Factor
Internal mechanism factor
Meaning
- Looking at internal psychological mechanism of client problems
Example
- Rigidity of thinking
- Internal mechanism created by trauma experience
Environmental vs. Internal Mechanism Factor
Internal mechanism factor
Characteristics
• Typically emphasized in counseling
• Although environment is also important, we are more interested in the internal mechanism that was formed with the influence of the environment.
Environmental vs. Internal Mechanism Factor
‘Elimination of Problems’ vs. ‘Promotion of Growth’
‘Elimination of Problems’ Perspective
‘Promotion of Growth’ Perspective
Ⅲ. Understanding Client ‘Change’
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Meaning
• Sees that change can be facilitated by getting rid of the ‘problem’ or ‘cause’.
‘Elimination of Problems’ Perspective
Problem
Example
• Relieve ‘depression’
• Reduce ‘schizophrenia’
• Fix ‘personality’
• Fix ‘internet addiction’
• Fix ‘interpersonal relationship method’
‘Elimination of Problems’ Perspective
Characteristics
• Largely based on the medical perspective
• Prevalent among us
• Although past trauma experience cannot be taken away, it is often seen as the cause.
‘Elimination of Problems’ Perspective
Meaning
• Instead of fixing problems or removing the cause, this perspective seeks to discover client’s motivation (desire) to remove the barriers to improvement
‘Promotion of Growth’ Perspective
Past me Present me
‘Promotion of Growth’ Perspective
Meaning
“If one does not understand a person, one tends to regard him as a fool.”
Differently put, if we properly understand a person, we are able to refrain from regarding him as a problematic person.
Carl Jung
‘Promotion of Growth’ Perspective
Example
• Explores what the client (ultimately) seeks to do.
• (Although not expressed verbally), what the client is (ultimately) pursuing is discovered through client’s actions or emotional reactions
• When the client tries to move forward, he is helped to remove or combat any internal barriers.
‘Promotion of Growth’ Perspective
Characteristics
• Does not assume the client to be someone who has problems that needs to be fixed.
• Emphasizes and uses the client's strength to grow.
• Stresses the client's autonomy and choice
• Trusts the client’s inner wisdom
• Doesn’t order the client to go in a certain direction or to eliminate problems.
• Helps the client to see what he really hopes to pursue more clearly.
• Makes what the client is pursuing after clearer, and remove any barriers that he comes to face in the process of pursuing them.
‘Promotion of Growth’ Perspective
Starting from ‘Big Change’ vs. ‘Small Change’
‘Big Change’ ‘Small Change’ Perspective
‘Small Change’ ‘Big Change’ Perspective
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Ⅲ. Understanding Client ‘Change’
Meaning
Claims that we need to take care of client's core problems before his surrounding, trivial behavioral problems or habits can be resolved.
Example
Characteristics
‘Client's long-standing parent-child relationship needs to be mended before her recent problems naturally get solved.’
• Interested in client's personality structure or core emotions
• Appropriate for long-term counseling
Meaning & Characteristics
‘Big Change’ ‘Small Change’ Perspective
Meaning & Characteristics
Goal
Goal
‘Big Change’ ‘Small Change’ Perspective
Meaning
• Claims that we need to take care of smaller problems at hand to make a bigger change possible
Example
Characteristics
• ‘You get angry frequently. In what situation were you especially angry recently?’
• Emphasized in short-term counseling
• Stresses exploration of specific situations
Meaning & Characteristics
‘Small Change’ ‘Big Change’ Perspective
Other perspective (Watzlawick, Weakland, & Fisch, 1974)
‘Progression’
Sees client change as occurring progressively
‘Transformation’
Sees client change as innovative
transformation
vs.
first-order change second-order change
Other Perspective
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