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Theory and Design in Counseling and Psychotherapy
Susan X Day , Iowa State University and University of Houston
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CHAPTER 2: Theory and Case Analysis
Chapter Review
A theory is a set of related principles that describes phenomena or facts and can be used to make predictions about how the phenomena will occur in the future. Checking the accuracy of predictions can test the theory, and if the forecasts are born out, the theory can help us comprehend how events happen, guiding our actions for similar situations. Counseling theory organizes, articulates, and integrates the factual knowledge and experience of a number of people in the field. Theories are never fully proven empirically, though they can be disproven, and testing across situations is necessary.
Experience allows clinicians to contextualize and situate the client so irrelevant information is excluded and important information is parsimoniously used to look at deeper, essential client themes. Theory is made up of such insights, offering a coherent structure that can be trusted as plausible. Theory illuminates the underlying links and potential causes of client dynamics. Conceptual systems explain the vagaries of twists and turns in therapy, providing clues when the process has derailed and showing how to get back on track. Knowing theory helps therapists choose alternative techniques within a framework that can be explained and trusted by the client.
Case conceptualization is basically a mini-theory about a specific client describing the client's presentation, both healthy and unhealthy behavior, relevant descriptive information, the presenting concern, appropriate historical experiences, interpersonal style, environmental factors, and personality characteristics. With a full client description, theory offers explanations for client dynamics and what change is needed to deal with difficulties.
Some conceptualizations are taken from personality theory such as Kelly's constructs that summarize how people psychologically construe their views of the world. The client's social setting and relationship network includes a person's background perspective of intimate relationships, cooperative activities, social themes and patterns, acceptable climates for complaints, and roles played that support others. External social influences include how others see the person, group identifications, political and social issues, and areas where the person is included or excluded. Patterns of speech and versatility of thought and activities are other social identifiers. The person's economic resources affect psychological constructs including those dependencies that define the individual's basic lifestyle requirements. Finally, turning points in a person's life force the individual to change constructs during transitional periods.
In determining conceptualizations, a number of aids help clarify and expand counselor thinking. Predictions about clients are kept in therapists' personal notes, rather than in permanent records. Diagrams of the client's cognitive structure can be helpful. Brainstorming possible hypotheses and thinking in metaphors facilitate creative explanations. Psychological tests
organize the multiplicity of variables to consider. It can also be useful to collect client materials such as journals, drawings, and the like. Counselors bring to mind loose associations about the client during free moments and sometimes gain new conceptualizing insights. However, it is important to remember that the counselor's inferences, drawn from her life experience, may not be applicable to the client's life. Keeping in mind differences and similarities between the counselor and the client prevents misinterpretations. Protecting notes with appropriate security measures is also critical.
DSM diagnoses are helpful, not to categorize the client, but to help the clinician consider relevant factors for disorders. Diagnostic questioning defines the severity of problems and offers clues for some treatment planning, if not full conceptualizations. DSM categories include Axis I for presenting problems; Axis II for personality disorders; Axis III for medical conditions; Axis IV for environmental or psychosocial difficulties; and Axis V for GAF, 0-100 scale for a global assessment of functioning.
Therapists observe client characteristics and behavior and make inferences regarding the client's personality and psychological issues. A clear, undistracted focus on the client's appearance, nonverbal behavior, facial expressions, and common themes builds a picture of the client as a person. However, when making inferences, it is easy for the counselor to make errors in interpretations, such as inferring that client problems have a single cause to the exclusion of other factors, diagnosing based on the counselor's new learning or personal experiences, selecting evidence to confirm bias, attributing behavior to character flaws without factoring in external influences, and making unsubstantiated correlations. However, the possibility of inferential errors does not mean clinicians can afford to avoid all inferences, since case conceptualizations require searching for underlying patterns. The study of theory informs clinicians so inferences have some basis from knowledge in the field.
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