Case Conceptualization Outline epsy 6325 Theories of Counseling



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Case Conceptualization Outline

EPSY 6325 Theories of Counseling

Department of Educational Psychology, University of Houston



Consuelo Arbona Ph.D.

Case conceptualization refers to the process in which we make sense of a client's presenting concerns in the context of a theoretical framework. In other words, it refers to how we explain or understand the client's symptoms, personality characteristics, cognitions, feelings, and behaviors in light of a particular theory or integration of theories. Such understanding should lead to the formulation of counseling goals and intervention strategies.


At this stage we will conceptualize the client's case from one theoretical orientation at a time. The content of the conceptualization of the same case will differ according to the various theories depending on the aspect of human experiencing that each theory emphasizes.
The case conceptualization process (as with the counseling process itself) starts with an understanding of the clients' presenting concerns from the perspective of the client.
Therefore, Step 1 addresses the question


  • What does the client say her or his problems are?

In Step 2, following an exploration process in collaboration with the client, the counselor starts formulating a framework from which to explain the origins of the stated problems, guided by the following questions:




  • How is it that this person came to have these particular problems?

  • Where are these problems stemming from? (e.g., Intra-psychic issues, early relationships, learned behaviors, faulty cognitions)

  • What are this person’s strengths?

And in Step 3,




  • Goals for counseling are identified, and

  • Specific interventions are used to address the problems identified by the counselor and the client.

Conceptually, the various theories differ in (a) the questions they ask clients as part of the exploration process, (b) the answers they provide to the questions posed in Step 2 and, (c) the interventions selected in Step 3.


This paper provides an overview of the salient characteristics of three theoretical approaches -- Psychodynamic, Humanistic, and Behavioral. The discussion emphasizes the aspects of each approach that distinguish it from the other two. The presentation of each approach is followed by an application of the approach to conceptualize Richard’s presenting concerns.

Salient Characteristics of Theoretical Approaches, and

Case Conceptualization

Psychodynamic Approaches

The psychodynamic approaches (Object Relations Theory and Adler) will not take the client’s presenting concerns at face value. Instead, psychodynamic counselors will assume that these concerns are symptoms of deeper seated problems. To explain the origins of the clients’ stated difficulties (Step 2), psychodynamic counselors are likely to explore experiences that happened in the early life of the person (from childhood on) when his/her sense of self was formed. The psychodynamic counselor will expect that at least in part, the feelings and thoughts associated with early problematic experiences will be in the unconscious or pre-conscious part of the self.


Therefore, from the perspective of the psychodynamic theories, before moving on to help clients solve their presenting concerns, the counselor needs to obtain developmental information to form hypothesis regarding the origins of the presenting concerns, since there may lie the real problem that needs to be addressed. This developmental information will also help the counselor form hypothesis regarding the sense-of-self the person formed in the context of these early experiences.
In addition to capturing (or describing) the client’s sense of self (e.g. resilient, brittle, well organized, rigid, flexible, with high or low self-regard), from the psychodynamic perspective the counselor will identify the mechanisms of defense the person developed early on to deal with anxiety in the context of early problematic experiences and examine to what extent the person still uses the same defenses in interpersonal relations and in times of stress.
Most likely, the counselor will discover patterns of behavior (in relation to others and the world) that help explain how the client’s sense of self and early experiences lead to their current conflicts. The counselor may also identify specific stages of development (a la Erikson) that were not resolved appropriately.
Object relations theory pays special attention to issues of attachment and autonomy to maternal and paternal figures in clients’ development of a sense of self and consequent problems.
From the Adlerian perspective, to explore the contributions of early experiences to current problems (stage 2) the counselor will likely ask clients’ about their life-style (role they played in family constellation and early recollections) to identify the content of the private or faulty logic they developed in their attempts to strive for significance in the context of their family constellation.
The Adlerian counselor also will pay attention to the clients’ level of social interest (since this is a sign of healthy mental functioning) and will identify current problems in terms of clients’ neurotic symptoms. Part of the goal of therapy will be to help clients become aware of how they use their neurotic symptoms as excuses to engage in specific life-tasks. In this process, the counselor will help the client move out of their discouragement and become encouraged to meet the life tasks.

Once a theoretical framework has been applied to explain the particulars of a client's case, interventions are implemented to help the client solve the presenting concerns. In the case of the dynamic approaches, this will entail exploring (gaining insight, analysis of the transference) and resolving (e.g. catharsis; corrective emotional experience) the early conflicts that trigger the current problems and identifying the defenses the person developed to cope with these early conflicts and still uses today.


Next, information regarding specific constructs from Object Relations is presented. The emphasis will be in steps II and III of the case conceptualization process: exploration and formulation of a framework from which to explain the origins of the stated problems, and establishment of counseling goals and implementation of therapeutic interventions.
Object Relations Theory
Gathering information to generate hypothesis regarding the origins of the clients' current problems.


  1. Explore current and early relationships as they relate to issues of attachment and autonomy. This includes gaining an understanding of how the client understands the world and his/her relationships with others (that is the clients’ mental representations of others and the world based on internalized objects). Understanding the clients’ internal frame of reference will help the counselor understand the clients’ behaviors.




  1. Describe the ideas and feelings about self that the client might have developed in the context of these early relations (internalized objects).




  1. Discuss how experiences and behaviors developed in early life have shaped the clients' sense of self and have contributed to his/her current problems; identify conflictive patterns from the past that the client may be repeating in current life; explore to what extent current experiences trigger in the client emotional reactions elicited by past experiences (relieving the trauma).




  1. Discover specific defense mechanisms embedded in clients’ presenting concerns and other symptoms and explain how each defense mechanism relates to the clients’ current difficulties and past experiences.



Goal Setting and Interventions

In the dynamic approaches the information provided in the conceptualization process leads to specific counseling processes or goals such as:




  • Re-experience earlier conflicts, from an emotional and a cognitive perspective

  • Gain insight regarding how past experiences relate to present problems

  • Resolve the early conflicts, with the help of the therapist

  • Reconcile split-off aspects of the self and move to a more integrated sense of self

  • Modify negative aspects of the self

  • Facilitate the development of positive aspects of the self in the context of the therapeutic relation

  • Change aspects of the persons' sense of self (e.g. feeling unlovable)

  • Work through conflicts in relation to attachment and autonomy in intimate relations

Interventions may include:




  • Free association

  • Dream analysis

  • Confrontation

  • Interpretation

  • Gaining insight

  • Analysis of the transference


Richard’s Case Conceptualization: Psychodynamic/Object Relations Theory


Hypothesis based on theory’s concepts

Richard’s history suggests that he did not have the opportunity to form adequate attachment bonds with his mother or father (he reports both parents as alcoholic and absent). It appears that he also lacked other adult figures in his environment (relatives, siblings) with whom to form significant relations (he was an only child and reports being very lonely and isolated as a child). Because of this deprivation of any significant nurturing relationship, as a child Richard must have felt great pain; together with the pain he likely experienced great anger both towards himself (blaming himself for his pain, feeling inadequate) and towards others (primarily maternal/paternal figures for failing to meet his needs). He might have concluded that he was not loved because he is defective and, therefore, not lovable, developing a negative sense of self. In order to avoid this pain, it is possible that early on, as a defense mechanism, Richard disconnected himself to a certain extent from his emotional self. This disconnect from his own emotions allowed him to survive emotionally as a child (adaptive quality of the defense). However, as an adult being disconnected from his own emotions has made it difficult for Richard to connect with others, feel empathy and develop intimate relationships (a defense that was adaptive in early life, continues to be used in adulthood with negative consequences)


The early experiences of abandonment may have led Richard to develop a sense of self as an adult characterized by the beliefs that he is not lovable, he doesn’t have much to offer emotionally to others, and that he cannot trust others to meet his needs (he appears to fluctuate between believing that he doesn’t deserve other’s attention and care and believing that others are mean and will not give of themselves). He seems to feel that he needs to always be on the defensive because this is “a dog eats dog” world. This pattern of relating to others most likely emerged in the context of his early relationship with parents, where his basic emotional needs of nurturing, affection, and security were not met. The anger he experiences now may have originated earlier in his life as a way of coping (defense) with the intense pain generated by this early emotional deprivation. Deprivation that he internalized and therefore, perpetuates in his life by his inability to bond with others (in other words, Richard repeats in his adult life the negative patterns of early relations with his parents). His failures in current relationships make him feel angry toward himself (because of his perceived inadequacies) and towards others (for not benign perfect and meet his needs) all over again.
This negative view of self and his detachment from his own emotions (in order to avoid the pain - defensive behaviors) makes it difficult for Richard to develop emotionally satisfying intimate relationships. He is probably scared and overwhelmed by the idea of getting too close to another person. Because of his inability and fear to get close to others, Richard has chosen to establish superficial, short relationships with women; he does not allow the other person to really come close to him, nor does he truly give of himself. At some level, it is almost as he feels that he does not have anything to give, except his pain (which he cannot really face) and his anger (which may feel overwhelming and scary). With his behaviors, Richard ends up pushing other people away, which serves to confirm the ideas of him and the world that he formed in his early years– that either he is not good enough or that others are mean to him- which makes him feel angry, and father distances him from people. In this way, Richard may be responding to others not only according to who and what they are, but also according to the negative objects (unresponsive and uncaring significant others) that he internalized early in life, when his sense of self was formed.

Richard seems to be wrapped up in himself – which is labeled by the psychodynamic approach as a narcissistic personality trait. The lack of adequate emotional support and care as a child had an impact on the sense of self Richard developed. Because he was not able to fully resolve the issues associated with the normal narcissistic stage experienced by infants (as described by object relations theory), emotionally he is “stuck” on that early stage.


In terms of defense mechanisms, Richard seems to be experiencing some degree of splitting between his cognitive and emotional selves, which leads to intellectualization, and expression of contradictory, rigid ideas (because the two aspects of the self are not integrated, he is not able to manage contradictory information about self and others). For example, he says that he desperately needs a woman in his life to be happy, but describes all women as “bitches”; he professes to love his ex-wife Connie and feels sorry for her because she must be suffering, but at the same time he is extremely angry and would like to have the opportunity to yell his anger at her. In some ways Richard’s negative perceptions of others result from his projection (defense mechanism) of his anger and negative view of himself on others. In the development of his sense of self, Richard internalized the negative relationships he had early on with his caretakers, who did not meet his basic needs of nurturance and emotional security as “bad me” (internalization of bad objects). Richard is likely to feel unworthy of others’ attention and care, which are likely very painful feelings. One way to protect himself from this pain is to resort to the defense mechanism of splitting – which allows him not to connect with these feelings of low self-worth and own them. Instead, he projects the feelings of negative self-worth onto others seeing them as flawed, not good enough and ultimately responsible for his misery.
To compensate (defensive behavior) for his negative perception of himself, Richard is in search of the “perfect” woman that will lead to the “perfect” relationship. At some level (probably unconscious) Richard may believe that being with a perfect woman will compensate for his profound sense of inadequacy -- being with someone perfect will make him acceptable and good. Since perfect women do not exist, the goal of finding one is also a defensive behavior that protects Richard from allowing women to come close to him (true intimacy is difficult for him), which perpetuates the cycle of loneliness, pain, and anger. The unavailability of a “good enough” woman gives him an excuse to being alone, excuses that masks his true feelings and fears.
In addition, Richard’s difficulties with intimacy may stem from his great emotional neediness. According to Objects Relation theory, lack of proper attachment has likely impaired his ability to form an autonomous self, which may contribute to his fear of intimacy. When Richard allows someone to come close to him, he does not know how to keep a healthy boundary and may feel overly dependent emotionally on the other person. At the same time, he may project his deep fears of abandonment on the partner, and fear that the partner may leave him. Richard’ emotional over-dependency on Connie may be inferred from the fact that even though he reports that towards the end they had very poor communication and a relatively hostile relationship, Richard still feels that by leaving the marriage, she took everything away from him.
Goals for Counseling
From a psychodynamic and object relations perspective, the goal of therapy is to help Richard connect with his emotional self. If he has enough ego resiliency (something the counselor most ascertain first), the goal of therapy would be for Richard to allow himself feel the pain/anger associated with his early negative experiences (catharsis) and gain insight regarding how these early experiences are related to his problems in relationships. It is expected that by forming a close emotional bond with the therapist, Richard may learn how to experience fulfilling closeness in relationships, while maintaining appropriate boundaries.
Interventions
Establishing the relationship - Given Richard’s lack of significant nurturing relationships in his life, issues of trust were particularly difficult with him. This was addressed, in an empathic way, early on in the relationship – I told him that I recognized and understood that it would likely be difficult for him to trust me, the therapist, but that as he felt comfortable it was important for him to develop some trust on me so that the therapy may work. I also encouraged him to communicate to me how he felt regarding being or not being able to trust me, even if it felt uncomfortable for him to talk about trust issues. Initially Richard was very guarded, tended to make jokes or become hostile with me when the counseling came close to painful issues for him. In some of these instances I pointed out his behavior and asked him what he was feeling about himself and about me in the here-and-now just before he said the remark (immediacy of the relationship). Sometimes, instead of asking, I reflected to him feelings of discomfort or anger that I picked up in relation to the issues we were discussing. Sometimes, I shared with him (immediacy of the relationship) how his jokes and/or angry remarks made me feel in the relationship with him (e.g. “when you respond in that way – make a joke about something serious we are talking about or respond angrily at me – it makes me feel like you are pushing me away,”). And, using parallel process, other times I wondered out loud to what extent others in his life may feel like me—pushed away-- when he makes angry remarks or “not very funny” jokes.

Analysis of transference - I helped Richard recognize and process when he was pushing me away. In these instances I asked him to stay with and explore the feelings that he was experiencing - which often included fear of being rejected, anxiety, pain, disbelief that the therapist cares. As he was able to recognize and label these feelings, I encouraged him to remember or connect with other times in his life when he had felt in similar ways. As I described above, these intervention entailed confronting Richard with what was happening in the here-and-now of the counseling relationship.
With some time, Richard experienced the connection between his early experiences of abandonment and his current difficulties. He allowed himself to experience and accept the pain of his lost childhood, and the anger he felt toward his parents for the constant fighting in the house and for not loving and caring for him. During these times I assured Richard that, regardless of the parents’ problems, their behavior had been wrong and that as a child he deserved better. This served as a corrective emotional experience – he was able to feel that his anger was justified and that another person, the therapist, was able to accept him with his anger, whereas in the past he interpreted his feelings of anger as further proof of his badness and feared that if the parents (and now others) knew of this anger they would further reject him.
Insight - As part of the therapy process Richard came to understand how his early deprivation, which was not his fault, led him to not trust himself or others and feel bad about himself, and how these feelings have made it very difficult for him to enter in close relationships with others.
In summary this process involved both emotional and intellectual insight. With the support of the therapist, he allowed himself to get in touch - feel - the pain generated by his early deprivation, which lies beneath the strong anger that he feels today.
During this process in my role as a therapist I provided emotional support, helped Richard “hold” and “contain” the strong pain and anger that had been pent up in him for so long, and accepted him as he was. I often assured him that his feelings were reasonable given the experiences he had had, and communicated to him (verbally and non-verbally) that it was ok to express his feelings to me and that I was not overwhelmed by his pain, anger, and fear. In some ways, he was able to re-live his painful childhood experiences in the context of a relationship where he felt accepted, and psychologically taken care of. These experiences constituted a “corrective emotional” experience that allowed him to develop acceptance of self and learn about appropriate boundaries in close relationships.
With this new insight and corrective emotional experiences, Richard started to be less defensive and more open in relationships with women. He realized that his search for the perfect women was in part an effort to cover his strong sense of inadequacy (insight). However, the search for the perfect woman also served to keep others away, and “protected” him from engaging in an authentic intimate relationship with women (Engaging in an intimate relations with a woman was scary and painful for Richard, because a desire for closeness triggered in him the sense of inadequacy he developed in the context of lack of proper nurturance form parents or other adult figures). The insight he gained regarding the motivation for his search for a perfect woman, helped Richard to work towards accepting himself as he is and others as they are, with good and not so good things – in other words, he developed a more flexible view of himself and the world.
Adlerian Theory
Next, information regarding specific constructs from Adlerian theory is presented. The emphasis will be in steps II and III of the case conceptualization process: exploration and formulation of a framework from which to explain the origins of the stated problems, and establishment of counseling goals and implementation of therapeutic interventions.
Gathering information to generate hypothesis regarding the origins of the clients' current problems.


  1. Identify how presenting concerns relate to client's ability to successfully meet specific life tasks (society, work, sex, spiritual, coping with oneself).




  1. Explore family constellation to discover experiences that might have led client to develop his/her specific faulty logic. Describe the content of this faulty logic and the sense of self the client developed in the context of these experiences.




  1. Help clients establish a connection between the content of the client’s faulty logic and: (a) experiences in the family of origin, (b) problems in current life, and (c) the sense-of-self in relation to the world that the client developed (gain insight).




  1. Identify the underlining purpose of the client's problematic behaviors and describe how the client uses the symptoms as an excuse to engage in meeting specific life tasks.


Goal Setting and Interventions
In the Adlerian approach the information provided in the conceptualization process leads to specific counseling goals such as:


  • Identify and modify faulty logic

  • Gain encouragement to face life-tasks

  • Develop social interest

  • Identify the underlining purposes of symptomatic behaviors

  • Make a commitment to behavior change

Interventions may include:




  • Life-style assessment

  • Interpretation to lead to insight

  • Paradoxical Intention

  • Spitting in the Soup

  • Catching oneself

  • Acting as if

  • Task setting


Richard Case Conceptualization: Adlerian
Hypothesis based on theory’s concepts
From and Adlerian perspective, one would say similar things about working with Richard but using slightly different language. In the context of his family constellation Richard was not able to achieve a place of significance because his parents seemed to be immersed on their own problems and basically neglected him. His inability to find a place of significance within his family led to the development of strong feelings of inadequacy. In this context he developed a life-style characterized by feelings of unworthiness, the belief that nobody will care for him (overgeneralization), and that he has little to offer to others. These experiences and feelings have generated significant levels of anger in Richard. He often finds a place for himself in the world by asserting his anger (e.g. situations at work with female co-worker). He has also come to believe that in order to be significant (to be ok and accepted by others) (self-ideal) he must achieve a perfect relationship with a perfect woman, which constitutes a misperception of life demands.
These faulty beliefs have led him to have difficulties in meeting the life tasks. Because of his lack of nurturing relationships in his family constellation, Richard has developed a very poor sense of himself, he does not accept himself and has difficulty accepting others for who and what they are. He is having, and has had throughout his life, major difficulties with the life task of forming intimate relationships. Because of his inability to trust others, and his belief that he does not deserve others to be there for him (faulty logic), he does not seem to allow the women he dates (or the woman he married) to come emotionally close to him. At the same time, he is not able to give of himself in these relationships. His problems in relating to others and the pent-up anger he feels have also affected his worker life task. He has had various interpersonal problems at work that have led to him being fired. He also is having difficulty in finding meaning in his life. At times he feels suicidal because all his pain and suffering seem worthless. He also lacks social interest. Until very recently, Ricahrd felt that this is a “dog eat dog” world and that he needed to be ready to strike first. He feels very discouraged to face a new relationship and life in general. His recent divorced have heightened these feelings to the point of making them unbearable.
Goals for Counseling
Goals for counseling include helping Richard (a) identify and change the faulty beliefs (about himself, others in general and women in particular) that he developed in his family of origin (b) identify and stop his self-defeating behaviors regarding his difficulties in relating to others (his anger), and (c) develop social interest.
Interventions
From an Adlerian approach, I helped Richard to identify and change his faulty beliefs - that nobody will care about him, that he has nothing to offer to others, and that there is something wrong with him. As part of this process I gently confronted him with the underlining purpose (or secondary-gain) of his anger. Mostly, his anger prevents others from getting close to him. This is a defensive maneuver, because desire for or the experience of closeness unconsciously triggers in him the early conflict and its associated pain and feelings of inadequacy (generated by the deprivation and neglect he experienced in his family of origin). Using immediacy, I encouraged Richard to explore what he was feeling and what he wanted to accomplish when he got angry at me in the session – e.g. (push me away, change the topic). I helped him see that this anger prevents others from coming close to him, something that he desperately wants but is also very afraid of. I brought to his attention the importance of developing social interest. I encouraged him to think about a project he could get involved to help others. As therapy progressed, Richard volunteered with a mentoring program in his company, where he served as a mentor to a child who experienced difficulties at home. This helped him feel better about himself and allowed him to start discovering good things about himself that he can give others.
I also encouraged Richard to revise his beliefs about women, which seemed to include very negative thoughts and expectations. He understood how he was projecting on all women the anger and distrust he felt towards his mother (in Adlerian language, he was operating from the faulty logic that all women are selfish, angry, likely to reject him and, therefore, at fault for the pain he feels). The search for the perfect woman led him to keep women at an emotional distance and allowed him to reject them before the women had a chance to reject him. This, of course, prevented him from forming a stable, open relationship with any woman. As we discussed these issues, Richard realized that one way he distanced Connie from him was by being sarcastic when he felt put down or threatened by her. Slowly, he accepted responsibility for his contribution to the problems in his relationship with Connie.
To help Richard control his anger, and discover the connections between his anger and his negative feelings about self, I encouraged him to catch himself when he started feeling angry toward another person and stop to explore other feelings he may be experiencing underneath the anger. This was hard for him to do at first, but slowly he started to recognize how he often interpreted the behaviors of others as rejection or putting him, and how these interpretations triggered his anger. Using immediacy I challenged him to explore the reasons and feeling underneath his anger, when he felt angry at me in counseling. For example, in one occasion when I was pointing to him with role in distancing women from him, he became very sarcastic. I confronted his sarcasm by telling him that I felt he was angry at me, and using spitting in the soup, suggested that maybe his he was being sarcastic instead of expressing directly the anger that he was feeling toward me. When he was able to recognize and accept his anger, I asked him to act as if he could share with me other feelings he was having (e.g. hurt, fear of rejection, and sadness). By “acting as if” he can allow himself to enact behaviors that are not comfortable to him, but that may be more adaptive in managing his emotions.

Humanistic Approaches

The Humanistic approaches de-emphasized the importance of early experiences in life and of unconscious processes. These approaches emphasize the clients’ here-and-now experiences, their strengths and abilities to cope. The Humanistic approaches also highlighted the importance of the real, here-and-now relationship between client and counselor (as opposed to the transference relationship).

From a Rogerian perspective, the counselor will assume that client’s presenting concerns emerged because internalized conditions of worth have lead clients to disconnect from parts of themselves. This disconnects, in turn, (a) has resulted in feelings of incongruence and anxiety, (b) has impaired their internal locus of control and (b) as thwarted their self-actualizing tendency.
The Rogerian counselor may also examine the discrepancy between the client’s self-concept and ideal self-concept. Since the theory proposes that given the presence of adequate facilitative conditions (empathy, positive regard, and congruence) in the counseling relationship, clients will be able to reconnect with themselves and find their own way, the theory does not offer much in terms of a framework to explain the origin of the client’s presenting concern. The Rogerian approach is more a theory of the change process itself than a theory of personality development.
Richard Case Conceptualization: Rogerian
Gathering information to generate hypothesis regarding the origins of the clients' current problems.
The counselor’s goal is to create safe, trusting relationships so that clients will be able to:


  • Explore the parts of themselves that they have denied or distorted.

  • Recognize and give up the internalized conditions of worth

  • Develop and internal locus of evaluation,

  • Become more open to experience,

  • Achieve self-trust.


Goal Setting and Interventions
Counselor’s role is to help clients set their own goals. The Intervention is for the most part is the relationship in itself, which must include three conditions:

  • Congruence or genuineness Positive regard Accurate empathic understanding

Specific counselor’s behaviors to facilitate the relationship and foster client change include:



  • Reflection of feeling

  • Paraphrasing, rephrasing

  • Questions for clarification


Existential
From the Existential approach one would explore to what extent the clients' difficulties are related to their efforts to avoid facing the normal anxiety generated by specific givens of existence (Death, Meaning, Freedom, Isolation). For example, to what extent problems are related to the client’s refusal to accept responsibility for self or to face aloneness. Individuals’ efforts to avoid normal anxiety, labeled, mechanisms of defense, lead to neurotic anxiety and/or guilt \ and other problems in living.
The Humanistic approaches are not very rich in terms of specific interventions. They emphasize the importance of the therapeutic relationship, the shared journey, as a way to help individuals find within themselves the solutions to their problems. Rogers focuses on the qualities of the therapeutic relation that are conducive to change and the existential approach focuses on healthy coping with the givens of existence
Gathering information to generate hypothesis regarding the origins of the clients' current problems.


  1. Identify how presenting concerns (problem behaviors/cognitions) relate to specific givens of existence.




  1. Discover how the client uses specific mechanisms of defense to avoid facing the normal anxiety generated by specific givens of existence (Death, Meaning, Freedom, Isolation).




  1. Describe how each mechanism of defense (a) helps the client avoid anxiety, and, (b) prevents the client form taking responsibilityfor self and/or live an authentic existence.




  1. Describe how these defensive behaviors have led the client to experience neurotic anxiety and/or neurotic guilt and the relation of the neurotic anxiety and/or guilt relate to the presenting concerns.



Goal Setting and Interventions
In the existential approach, goals may involve to:


  • Help clients gain awareness of the choices they are making in their lives

  • Encourage clients to face the givens of existence that they may be avoiding and helping them become aware of the defenses they are using to avoid the normal anxiety generated by the givens of existence.

  • Help clients become aware of the negative effects these defensive behaviors/cognitions have in their lives and to recognize how these defensive behaviors are related to their presenting concerns

  • Help clients find adaptive ways of facing the anxiety generated by specific givens of existence

  • Encourage client to take responsibility for their lives and make active choices regarding the life situations they are facing

Interventions may include:




  • Confrontation

  • Process interpersonal dynamics of the counseling relationship, attending to the emotions generated by the counseling process in the context of the-here-and now relationship with the counselor.

  • Paradoxical intention

  • Situational reconstruction

  • Compensatory self-improvement

Richard Case Conceptualization:Existential
Hypothesis based on theory’s concepts
From the Existential perspective, Richard seems to have most difficulty dealing with the givens of existence in the areas of isolation, freedom-responsibility and meaning. Primarily he is struggling with inter-personal and intra-personal isolation. Borrowing from the psychodynamic approaches, the existential psychotherapist would observe that Richard is estranged form parts of himself and that this disconnect serves as a defense to protect himself from his profound pain. Because he is disconnected from his emotional self, Richard has difficulty “wishing” which makes it difficult to construct meaning (given of existence) in his life, and also is not able to engage emotionally with others to form real and meaningful relationships. Instead, he seems to be using women to help him cope with his existential isolation and lack of meaning in life. Because he is not really in touch with himself, and as a way to avoid the pain of looking inwards, Richard tends to blame others for his problems, and therefore avoids responsibility for himself and his actions (freedom, given of existence). His estrangement from his emotional self (intra-personal isolation) and his related inability to form deep, real relations with others (inter-personal isolation) makes him feel empty and his life lacks meaning. The failure of his marriage has been a boundary situation that has led Richard to look at himself and seek counseling.
Goals for Counseling
From the existential perspective, Richard needs to (a) connect with his emotional self, (b) confront his intra- and inter-personal isolation and learn to accept himself (b) become aware of how he contributes to his own problems (freedom and responsibility issues)
Interventions
As therapist I provided a real relationship to Richard to facilitate his exploration of the difficulties he has experienced in relationships and his pain and anger (process similar to the one desceibed under the object relations theory). I used the intervention of compensatory self-improvement to help him cope with the pain of the loss of his marriage and motivate him to use this crisis to improve parts of himself he has control of (e.g. career-wise, personally; something that he seems to be already doing suggested by his willingness to come to therapy, and his embarking in anew career). The issues described in the psychoanalytic approach related to helping him become aware of how he behaves toward others in general and women in particular would also be consistent with the Existential goal of helping clients become aware of the choices they are making in life
Cognitive -Behavioral Approaches
From the Behavioral and Cognitive Behavioral perspective counselors tend to take the client's presenting concerns at face value (a clear difference form the psychodynamic approach); that is, as the problems that need to be solved. From a strictly behavioral approach, the focus will be in the environmental contingencies that are believed to trigger the unwanted behaviors that lead to the problems (a stimulus-response paradigm). From the cognitive behavioral perspective, clients’ presenting problems are primarily understood as the product of specific faulty learning, which has led to irrational thoughts or faulty cognitions (e.g. Beck's maladaptive patterns of thinking - arbitrary inference, selective abstraction, overgeneralization, etc.) while also taking into account environmental contingencies in the behavior change process. The exploration process primarily entails identifying the antecedent behaviors and cognitions that trigger the maladaptive thoughts and behaviors.
Once a theoretical framework has been applied to explain the particulars of a client's case, interventions are implemented to help the client solve the presenting concerns. In the cognitive-behavioral approaches, interventions help clients un-learn past negative behaviors and cognitions (e.g. desensitization training, self-control) and learn new, more adaptive ones (e.g. skills training).
Next, information regarding specific constructs from the Cognitive Behavioral approaches is presented. The emphasis will be in steps II and III of the case conceptualization process: exploration and formulation of a framework from which to explain the origins of the stated problems, and establishment of counseling goals and implementation of therapeutic interventions.


Behavioral/Cognitive Behavioral



Gather information to generate hypothesis regarding contingencies of clients' problems.


  1. Relate the presenting concerns to faulty learning, irrational thoughts, and/or faulty cognitions.




  1. Identify client's irrational thoughts (Ellis) and/or specific faulty cognitions or maladaptive thought patterns (Beck) and illustrate how these lead to the problematic behaviors.




  1. Describe the antecedent behaviors and cognitions that trigger the client's maladaptive behaviors and thoughts (behavioral assessment).


Goal Setting and Intervention
To resolve the presenting concerns by:

  • Learn new behaviors,

  • Change environmental conditions, and

  • Replace irrational thoughts and/or maladaptive cognitive schemas with rational thoughts or adaptive schemas.

Interventions may include:



  • Modeling

  • Behavioral rehearsal

  • Skills development training (e.g. assertiveness, social behavior)

  • Self control or self-monitoring

  • Stimulus control

  • Contingency contracting

  • Systematic desensitization

  • Recognizing and changing irrational thoughts

  • Cognitive restructuring to change maladaptive thought processes

  • Learning a new internal dialogue

  • Relaxation training


Richard Case Conceptualization: Cognitive Behavioral Approaches

Hypothesis based on theory’s concepts
Richard’s feelings of depression and anger are primarily caused by how he interprets the events in his life. He has irrational thoughts such as I must find the perfect women to be happy; Connie took everything from me, if I am alone I feel miserable.

Goals for Counseling
Have Richard (a) identify his irrational thoughts and mistaken assumptions and replace them with more adaptive rational thoughts and (b) identify and rehearse new behaviors that will allow him to relate better to others and overcome his depression. At the behavioral level, start with small, specific changes that he is likely to have success with (e.g. what to do when he feels lonely on Saturday afternoons, how to relate to a co-worker)
Counseling Interventions
Use Socratic dialogue and guided discovery (Beck) to help Richard identify irrational thoughts and mistaken assumptions such as “others are responsible for me”, “I will only be happy in a relationships with women who is perfect,”“without a woman in my life I am unhappy and miserable,”” the failure of the marriage with Connie means that I will never be able to form a satisfying relationship with a women.” Once identified, I disputed (Ellis) Richard’s self-statements to help him develop the ability to disprove these irrational thoughts for himself and replace them with rational thoughts (e.g., it is sad and inconvenient that the marriage ended but it is not a catastrophe). Give Richard homework such as what to do when he feels lonely and sorry for himself on Saturday afternoons. I used modeling to show Richard how he could communicate appropriately feelings of anger, fear, or pain and positive feelings. Later on I encouraged him to rehearse those behaviors by openly expressing his feelings to me. We also role-played responses to situations he was facing with co-workers and acquaintances in which he would practice communicating his feelings without becoming angry and sarcastic. In a slowly and painstaking process, Richard became more aware of feelings underlining his anger and more adept at disputing the irrational thoughts associated with such feelings and sharing them with me and others.


(Revised 8/13)



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