Counseling and Psychotherapy Theory Week 2. Counseling and Human Change
Contents 1 2 3 Understanding Client Problems 1 2 Scientific/Statistical Approach Practical Approach Understanding the Causes of Client Problems 1 2 Rethinking about Cause Three Dimensions for Understanding Cause Understanding Client Change 1 2 Elimination of Problems vs. Promotion of Growth Starting from Big Change vs. Small Change
Ⅰ. Understanding Client Problems 1 Scientific/Statistical Approach 1 Pathological Diagnosis System 2 Statistical Cutoff Scores
Pathological Diagnosis System 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 1 2 Subcategory Disruptive Mood Dysregulation Disorder Major Depressive Disorder Main diagnostic characteristics - (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 - 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 3 4 Subcategory Persistent Depressive Disorder Premenstrual Dysphoric Disorder Main diagnostic characteristics - Depressed mood for at least 2 years (in children and adolescents, at least 1 year) - Various marked (physical, emotional, cognitive) discomforts before the onset of menses
Pathological Diagnosis System DSM (subcategory examples) (Example 2) Anxiety Disorders 1 2 Subcategory Separation Anxiety Disorder Selective Mutism Main diagnostic characteristics - excessive anxiety and fear concerning separation from major attachment figures that last for 6 months or more - 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 3 4 Subcategory Specific Phobia Social Anxiety Disorder Main diagnostic characteristics - 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 - 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 6 Agoraphobia Main diagnostic characteristics - 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 Cluster A General Features Subtype Main diagnostic characteristics the "odd, eccentric" cluster Paranoid Schizoid Schizotyp al distrust and suspiciousness vigilant and tense malicious attitude social detachment and isolation restricted range of emotional expression wishes to be alone avoidance of interpersonal relationships cognitive, perceptual distortions eccentric appearance and behaviors and severe social isolation
Pathological Diagnosis System DSM (subcategory examples) (Example 3) Personality Disorders Personality Cluster General Features Subtype Main diagnostic characteristics Antisocial breaking of social norms and rules disregard for the rights of others; lacking guilt Cluster B the "dramatic, emotional, erratic" cluster Borderline Histrionic Narcissistic intense & unstable moods; interpersonal anger impulsivity, psychological instability Exaggerated emotional expression and seductive behavior to draw affection and attention of others overestimation about self desire for praise, sense of entitlement, arrogant behavior
Pathological Diagnosis System DSM (subcategory examples) (Example 3) Personality Disorders Personality Cluster General Features Subtype Main diagnostic characteristics Avoidant Inhibition and avoidance of social activities Feelings of inadequacy, embarrassment, hypersensitivity to negative evaluation Cluster C the "anxious, fearful" cluster Dependent Obsessive- Compulsive Lack of independent living Need and desire to be taken care of by others fear of parting orderliness, perfectionism Preoccupation with control over mind and interpersonal relationship
Pathological Diagnosis System Characteristics Based on long, statistical research findings Focused on medical and pharmacological interventions Provided a basis for scientific research on psychosis Widely used in the fields of medicine and clinical psychology
Pathological Diagnosis System 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 Carl Jung 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 Limitations 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
Statistical Cutoff Scores CBCL Tscore Mean 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. 80 70 60 50 40 30 20 W SC AD SP TP AP DB AB CELIAC MALE CBCL Subscales
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.
Ⅰ. Understanding Client Problems 2 Practical Approach 1 2 Basing on Main Complaint Gap between the Desired State and the Current State
Basing on Main Complaint 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 I can t sleep well at night. 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
Basing on Main Complaint Limitations Clients may not be aware of the existence or the true colors of the real problem 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) Clients may attribute the root of the problem to environment or others. "I'm so stressed. Please change my husband. "My friends all hate me." Causes, symptoms, and main complaints may get mixed up.
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."
Gap between the Desired State and the Current State 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. desired state Problem current state
Gap between the Desired State and the Current State 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
Ⅱ. Understanding the Causes of Client Problems 1 Rethinking about Cause 1 2 Illusion Evoked by Language Points to Consider When Thinking about Problem and Cause
Illusion Evoked by Language 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.
Points to consider 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)
Ⅱ. Understanding the Causes of Client Problems 2 Three Dimensions for Understanding Cause 1 2 3 Past vs. Present Factor Deteriorating vs. Barrier-to-improvement Factor Environmental vs. Internal Mechanism Factor
Past vs. Present Factor Past factor Meaning Assume past experiences, traumatic experiences to be the cause of present problems. [Example] A client who is full of anger. 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.
Past vs. Present Factor Past factor Characteristics (Due to the temporal delay), we cannot eliminate the past experience itself Medicine Typhoid Cause: typhoid germ* Experience of an unhygienic place where he got the typhoid germs in his body VS. Counseling Angry behavior Internal mechanism that triggers anger Abuse experience that made internal mechanism for anger settled in his body*
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 Assume factors that are currently hindering the client from getting better as the cause
Past vs. Present Factor Past me Present me
Past vs. Present Factor Present factor Characteristics Environmental aspect - People who stimulate anger - Unjust social system Psychological factors Cognitive Rigid thinking, dichotomous thinking Psychodynamic Explosion of unregulated, suppressed anger Experiential Weakened ability to contain anger
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 Looks at client s internal psychological mechanism Children/youth counseling Looks at parental and environmental factors of the present
Deteriorating vs. Barrier-to-improvement 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 - Client with relationship difficulties Barriers when trying to calm down 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
Environmental vs. Internal Mechanism 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.
Ⅲ. Understanding Client Change 1 Elimination of Problems vs. Promotion of Growth 1 2 Elimination of Problems Perspective Promotion of Growth Perspective
Elimination of Problems Perspective Meaning Sees that change can be facilitated by getting rid of the problem or cause. Problem
Elimination of Problems Perspective 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.
Promotion of Growth 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. Carl Jung Differently put, if we properly understand a person, we are able to refrain from regarding him as a problematic person.
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.
Ⅲ. Understanding Client Change 2 Starting from Big Change vs. Small Change 1 2 Big Change Small Change Perspective Small Change Big Change Perspective
Big Change Small Change Perspective Meaning & Characteristics 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 Client's long-standing parent-child relationship needs to be mended before her recent problems naturally get solved. Characteristics Interested in client's personality structure or core emotions Appropriate for long-term counseling
Big Change Small Change Perspective Meaning & Characteristics Goal Goal
Small Change Big Change Perspective Meaning & Characteristics Meaning Claims that we need to take care of smaller problems at hand to make a bigger change possible Example You get angry frequently. In what situation were you especially angry recently? Characteristics Emphasized in short-term counseling Stresses exploration of specific situations
Other Perspective Other perspective (Watzlawick, Weakland, & Fisch, 1974) Progression Sees client change as occurring progressively vs. Transformation Sees client change as innovative transformation first-order change second-order change
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