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


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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


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


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



(Example 1) Depressive Disorders


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



(Example 2) Anxiety Disorders


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





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)





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



(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



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




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




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


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.


Carl Jung

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

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


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.


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.


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.”


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.”


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)


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."


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


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


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”


Language causes errors even in various helping activities

Psychiatry Psychology Counseling

Studies


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.’


Medicine

When we say, ‘I am injured’…

• Something is ‘ripped’, ‘broken(shattered)’

So ‘I need to fix it.’


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’


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.


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


‘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.’


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 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 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


Present factor

Meaning


Assume factors that are currently hindering the client from getting better as the cause


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


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


Deteriorating factor

Meaning

- Assume something that triggered client problem to be the cause.

Example

- Parents’ abuse

- Trauma experience


Deteriorating factor

Characteristics

• Usually past experiences

• Already delayed temporally

• Direct intervention is difficult

• ‘Reinterpreting’ or ‘reprocessing’ deteriorating factors is possible


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



Characteristics

• Current intervention is possible

• Usually, internal psychological mechanism or experience

• Different ‘cause’ according to theory



Characteristics

Past me Present me


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



Past me Present me



Characteristics

• Counseling usually focuses on internal mechanism.

• Environmental factors are of interest in the field of social welfare.


Internal mechanism factor

Meaning

- Looking at internal psychological mechanism of client problems

Example

- Rigidity of thinking

- Internal mechanism created by trauma experience


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.


‘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’.


Problem

Example

• Relieve ‘depression’

• Reduce ‘schizophrenia’

• Fix ‘personality’

• Fix ‘internet addiction’

• Fix ‘interpersonal relationship method’


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.


Meaning

• Instead of fixing problems or removing the cause, this perspective seeks to discover client’s motivation (desire) to remove the barriers to improvement


Past me Present me


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


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.


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.


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



Goal

Goal


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


‘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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Counseling and Psychotherapy Theory · Meaning • Defining problems according to the standards set...

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