Conceptualization in Psychotherapy

The Models Approach

Frederick M. Levine, Evelyn Sandeen

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780898595499
• Edition: 1
• eBook ISBN:
  9781134927012
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Published in 1985, Conceptualization in Psychotherapy is a valuable contribution to the field of Psychotherapy.

1

Introduction

A 42-year-old married female client enters the therapist’s office and describes herself as having a “phobia of leaving the house.” She states that she has had various fears since shortly after she was married 20 years ago, but that these feelings of anxiety surrounding leaving her home have become so intense that she has rarely left the house in the last 3 years. How does the therapist go about determining the appropriate treatment for this client? Certainly most therapists would agree that further information-gathering about the woman’s situation is necessary. But how does one go about assessment in a systematic manner so that the information obtained can lead to treatment decisions? In the current stage of the development of psychotherapy, the crucial work of selecting a treatment for a particular client is, unfortunately, frequently based on a combination of one of two factors: the diagnostic category into which the client’s symptoms fall, and the theoretical predilections of the therapist. Thus, many therapists would diagnose this woman’s problems as “agoraphobia,” and, depending on their theoretical affiliation, they would select a treatment popularly acknowledged (within their affiliation group) to be effective with “agoraphobia.”

Therapeutic Approaches

The therapist trained in the Freudian psychoanalytic approach may see the woman as suffering from an unconscious conflict about sexuality; since sexual impulses may emerge by being exposed to the outside world, she reduces her anxiety by avoiding going outside. The analytic therapist would select intensive psychoanalysis to make this woman aware of her currently unconscious motivations as the therapy of choice. If the therapist is a medically-oriented psychiatrist, the physical components of the anxiety as well as the woman’s suitability for medication will be thoroughly assessed, and the treatment of choice will probably center on medication to combat the anxiety keeping her in the house.

To those therapists trained in a Pavlovian classical conditioning approach, the woman is assumed to have had an anxiety-provoking experience out of the house. This has caused her to become conditioned to not only the specific stimuli associated with her trauma, but through stimulus generalization, to other situations occuring outside of the house. Such a therapist would recommend a counterconditioning procedure such as systematic desensitization or in vivo desensitization to treat this problem.

The therapist with a Skinnerian-operant approach to therapy may look for the reinforcers that keep this woman in the house. She may hate shopping and her phobia then would serve to help her avoid this unpleasant task; she may have a jealous husband who questions her in great detail after each trip out of the house in an aversive and punishing manner; or in combination with the Pavlovian explanation, she may be reinforced by the anxiety reduction that takes place by avoiding a situation that had previously been associated with anxiety. Thus the preferred treatment of a Skinnerian therapist would be a contingency-management program in which the woman was rewarded for going out of the house while not rewarded for remaining inside.

A cognitive therapist would be selectively interested in the woman’s dysfunctional cognitions which maintain her fear and avoidance, and would treat her by attempting to change these cognitions to more functional ones. Therefore, a cognitive restructuring program would be instituted with this client.

On the other hand, the therapist with a social perspective may ask about the conditions outside of the house; this woman may live in a high-crime area. She may be at real physical risk by leaving the house since her neighborhood is replete with incidents of mugging and rape. This therapist then concentrates on concrete strategies the woman could use to increase her safety.

An eclectic therapist may choose some sort of treatment “package” for agoraphobia, including elements of most or all of the above mentioned treatments. Frequently this choice is made by searching the therapy literature for “agoraphobia treatments” and picking one with the greatest researched effectiveness. However, the therapy literature says very little about the type of person who will benefit most from a particular treatment, so this choice would be made independently of specific client characteristics other than symptomatology.

This case shows that there is not a single treatment for agoraphobia, since in psychopathology, unlike medicine, accurate diagnosis does not dictate treatment. In fact, we have seen cases of people who fit the diagnostic category of agoraphobia who have met each of the descriptions given above, and responded to the appropriate treatment. It is the role of the therapist to carefully assess the facts surrounding the specific case, and make a conceptualization of what psychological process is producing the symptomatic behavior. Only after an accurate conceptualization has been made can a treatment be effectively selected for an individual. The important question of how to conceptualize in terms that will lead to treatment decisions has been largely ignored. This book is an attempt to guide therapists in the essential task of conceptualization in psychotherapy. We shall briefly explore the historical pressures which have led to the failure to address conceptualization before explicating our approach.

The Problem of Therapeutic Schools

As the practice of psychotherapy enters its second century, a large number of therapeutic approaches have been established. The very fertility of the field threatens to impede its progress. We are exposed to a wide variety of approaches to treatment with each claiming superiority over the others. Although many of these approaches are based on important theories, there seem to be few attempts to define the limits of the theory. Instead, therapists identify with a given treatment technique, or set of techniques, and attempt to expand the area of applicability of these techniques. For example, reinforcement procedures were initially found to be powerful interventions of changing disruptive behavior of psychotic patients on hospital wards (e.g., Ullman & Krasner, 1965). Proponents of the operant approach then applied their therapeutic viewpoint to problems of weight control (Ferster, Nurnberger, & Levitt, 1962); smoking (Ober, 1968); depression (Lewinsohn, 1974; Lewinsohn & Atwood, 1969; Lewinsohn & Graf, 1973; Lewinsohn & Libet, 1972); and marital problems (Azrin, Naster, & Jones, 1973; Jacobsen & Margolin, 1979). Therapists who follow the cognitive approach, in a similar manner, try to expand their “domain.” There are cognitive approaches to similar problems (e.g., Baucom, 1981; Beck, Rush, Shaw & Emery, 1979; Ellis, 1972, 1977a; Emery, Hollon, & Bedrosian 1981; Meichenbaum, 1977; Shaw & Beck, 1977).

Clinical research is often directed at obtaining data supporting the superiority of a given technique. Frequently, there is selectivity in the gathering of such data. Thus, in a process labeled “academic tribalism” by DiLoreto (1971), different “schools” of therapy have historically generated data supporting their beliefs (e.g., Bandura, Blanchard, & Ritter, 1969; Paul, 1966; Rogers, 1967; Sloane, Staples, Cristol, Yorkston, & Whipple, 1975). Such “comparative” research projects were not designed to elucidate, as much as to confirm what was already believed (e.g., that behavior therapy is superior to insight therapy).

In a review of outcome research in marital therapy, Beach and O’Leary (1985) state their opinion that such “‘horse race’ comparisons [between different treatment approaches] could lead us to inappropriately discard therapeutic approaches which are valuable for some subgroup … [p. 771].” We feel that this is indeed what has occurred with this approach to outcome research. Additionally, research within schools usually has not challenged the prevailing assumptions of the school. Research is typically published only in journals which share the theoretical predilections of the researcher. Therefore, different schools of therapy evolved with little or no thought as to how each might fit with other established schools. Practitioners often feel allegiance to a particular therapeutic tribe, and are likely to treat all their patients according to the lore and data of that modality (Kelly, 1961). London (1964) clearly articulates the dilemma produced by such a state of affairs:

Now if this plentitude of treatments involved much variety of techniques to apply to different persons under different circumstances by different specialists, there would be no embarrassment of therapeutic riches here, just as there is not within the many specialties of medicine or law or engineering. But this is not the case…. One hardly goes to a psychoanalyst to be cured of anxiety and a nondirective therapist to be treated for homosexuality, as he might to a cardiologist for one condition and a radiologist for another. Nor does the same doctor use Freudian therapy for psychogenic ulcers and Rogerian treatment for functional headaches, as a physician might use medicine for one ailment and surgery for another. On the contrary, being a certain kind of psychotherapist has little bearing on treating a certain kind of problem, but refers rather to the likelihood of treating all problems from the vantage of a certain system [pp. 30–31],

The current state of psychotherapy is comparable to what Starr (1982) describes as the situation in medicine between 1850 and 1900. During this chaotic time, there were feuds between the allogenic and homeopathic schools of treatment. The homeopathic school believed that the body had natural healing mechanisms, such as fever, which medicines should promote, while the allogenic school felt that these processes were abnormal and should be suppressed. The theoretical convictions on both sides of the debate prevented each one from asking the question of, for example, under what circumstances is fever healing, and under what circumstances must it be controlled. Parenthetically, as is occurring in psychotherapy today, there were intense disputes during that tumultuous period regarding the necessary training and educational requirements for membership in the healing profession.

The Rise of Eclecticism

Recently, grumbling has been heard within the psychotherapeutic community, indicating dissatisfaction with a “schools” approach in treating clinical problems. Garfield and Kurtz (1974), in a survey of clinical psychologists, found that—compared to an earlier survey (Kelly, 1961)—fewer clinicians identified themselves exclusively with the psychoanalytic, neo-Freudian, or Sullivanian schools of therapy, and more were self-identified “eclectics.” Therapists of many orientations have been confronted with the inadequacies of a narrow, monolithic approach to therapy (Franks, 1976; Goldfried, 1980; Goldfried & Padawer, 1982). This dissatisfaction has expressed itself in different forms.

Some therapists respond to the inadequacies of a narrow ideological stance by greatly broadening the techniques they are willing to use and the forms of behavior and experience they will investigate (e.g., Lazarus, 1970, 1981). Others advocate “rapprochement,” attempts to identify the commonalities between different theoretical schools and to incorporate these commonalities into a new and improved therapeutic system (e.g., Goldfried, 1982; Marmor & Woods, 1980; Wachtel, 1977). Many of these innovative thinkers identify themselves as “eclectics,” as do a surprisingly large number of practicing clinicians: 55% of those surveyed by Garfield and Kurtz (1974). There have been attempts at structuring the eclectic approach (e.g., Beutler, 1983; Dimond, Havens, & Jones, 1978; Goldstein & Stein, 1976). We view these moves as positive responses to the rigidity of the previous therapeutic zeitgeist. However, while the weakening of dogmatic schools is doubtless a positive occurrence, eclecticism without theoretical guidelines is incomplete.

One problem of eclecticism is that once the theoretical underpinnings of a “school” are taken away, leaving the practitioner with a purely pragmatic stance, the ability to understand and predict the effect of interventions can be attenuated. The clinician may be reduced to an attempt at matching a patient’s diagnosis (e.g., “depression”) to treatments for that disorder which have been reported in the psychotherapy literature (e.g., increasing reinforcement experiences, Lewinsohn, [1974]; attribution retraining, Abramson, Seligman, & Teasdale, [1978]; cognitive restructuring, Beck et al., [1979]). Such treatment reports tend to be technique-oriented without giving information on how to determine whether such an intervention would be appropriate in a given case (Meyer & Turkat, 1979). Although it is undoubtedly true that successful eclectic clinicians evolve their own “theory” (cf. Garfield & Kurtz, 1977), one can only speculate about the efficacy of those who are not capable of doing so. As Goldstein & Stein (1976) point out, it is a difficult task to develop and practice a “skilled eclecticism.” Without the theoretical background provided by a school of therapy to guide them in making treatment decisions, eclectics must rely on trial and error, attempting to match a patient’s disorder (e.g., “depression” or “phobia”) with a treatment technique.

A second problem of eclecticism is actually one faced by all psychotherapy: What is the method for selecting treatments? Some therapists would recommend substantially similar treatments for all clients. As an example, traditional psychoanalysis may differ in content for different individuals, but would be the treatment of choice for all patients, according to some analysts. Even those who employ a variety of treatment techniques (such as behavior therapists) have failed to clearly state in what cases different techniques are to be used (Meyer & Turkat, 1979).

Eclecticism emphasizes freedom in the choice of treatments. While we agree with that concept, simply expanding our selection of treatment techniques still leaves us with the fundamental question: Under what conditions are we to use a given technique? In order to answer this question, it is important to first direct attention to the problem of conceptualization in psychotherapy. This book is a guide to conceptualizing clients’ problems in the terms of established psychological principles. Its purpose is to help the therapist go beyond treatment by diagnosis or treatment by ideological predilection and instead, conceptualize cases in a manner which will generate effective points of intervention.

The strategy presented is idiographic because each case is analyzed individually, and treatments are designed to fit the particular person’s problems. In this respect, it bears similarities to the behavior-analytic approach (Flasher, Maistro, & Turkat, in press; Meyer & Turkat, 1979; Turkat & Maisto, in press; Turkat & Meyer, 1982). Since the strategy is idiographic, we would assert that diagnosis per se should never dictate the treatment. The categorization of persons according to the third Diagnostic and Statistical Manual (DSM III) (American Psychiatric Association [APA], 1980) is of little help in guiding treatment, especially for non-psychotic disorders. At best, a DSM III diagnosis gives the therapist clues to what should be investigated closely during assessment. Although diagnosis has a function in aiding communication between professionals (Spitzer, 1975), the fact that a client meets the criteria for a certain diagnostic category should not, in itself, determine what treatment strategy should be taken. For example, depression is a disorder that is beginning to be viewed as a heterogeneous category (Beach, Abramson, & Levine, 1981). From our clinical experience, we have seen that some depressions are biological and respond to drugs or diet changes; some are related to boredom and respond to increasing environmental reinforcers; some depressions are related to cognitive deficits subsumed under “learned helplessness”; some are a result of dysfunctional handling of anger; some are manipulations of the environment; some are due to grief. It would obviously be foolish to treat these disparate problems—all correctly labeled “depression”—with a single treatment (e.g., antidepressant medication) and expect the same recovery pattern from each.

The Models Approach

The systematic approach we propose for conceptualizing clinical cases we call the models approach. We define a model, as used in the context of psychotherapy, as a sufficient explanation of the data of a client’s situation based on empirically tested psychological principles. A model is the psychological mechanism behind a particular symptom or set of symptoms. The model refers to the process by which a symptom is developed and maintained. In the following chapters we will discuss several models that we have found to be present (singly or multiply) in most clinical cases, and will demonstrate how conceptualizing these cases in terms of models guides the therapist to which interventions to use with which client.

The models we present are: the biological, which emphasizes the role of biological functioning upon behavior; the limited capacities, which emphasizes the match between what the person is capable of and the demands of the environment; the operant, which emphasizes the role of reinforcement upon the problem areas; the respondent, which views associations of experiences in the development and maintenance of problems; the cognitive, which looks at how thoughts and beliefs influence the person; and the social-context model, which emphasizes the effects of social forces on the individual. The models discussed in this book are intentionally broad in scope. They were chosen on the basis of their combined explanatory capability, in our experience, when applied to clinical cases, and on the basis of their empirical support. It is certainly true, however, that a models approach could be employed using different or more specific models. The concern is with the approach—i.e., systematically conceptualizing cases in terms of psychological principles—rather than the choice of a particular model.

Within the models approach, the task of assessment is to find which model fits the data of the case best to direct us in our intervention strategy. Thus, assessment and therapy become a process of testing hypotheses about what factors are maintaining the problem behaviors and what factors we as therapists can introduce to produce change.

A flowchart of the conceptual analysis approach to assessment and intervention within the models approach has been included. (See p. xii–xiii at the beginning of this volume.) It is designed to provide rough guidelines for the therapist in determining points of intervention. Although the order of assessment generally goes from internal determinants of behavior (i.e., the biological and limited-capacities models) to more situational determinants of behavior, the experienced therapist will often shorten the procedures. Frequently, the therapist will quickly pick up information that allow rapid assessment without systematically having to rule out alternative models. The flowchart should be used as a guideline for the development of conceptual hypotheses. Once a model has been hypothesized to be active in a given case, the therapist must look at the capacities of the client for change, in the direction dictated by the model. As an example, a client may be depressed because of a stressful and unrewarding job. The limited-capacities model would suggest that this stress be eliminated by finding a new job. However, the client may have limited options vocationally and may become even more depressed without a job. Often stressful situations represent the best available opportunity for individuals at some point in time. Once the model, the treatment goal, and the individual’s capacities for change are determined, the flowchart points out some of the many therapeutic techniques available to achieve the therapeutic goals.

A model is initially chosen because it “fits” the data of the case relatively well and the data are congruent with the given model. The model then serves as a working hypothesis with which we collate further data and initiate intervention. Our original conceptualization of the problem is retained or changed to another model (working hypothesis) on the basis of the client’s response to intervention, as well as on the basis of other data gathered. The best treatment in a particular case may be one commonly acknowledged to be effective with the diagnostic entity the person displays; or it may be a totally different treatment, depending on the model operating behind the set of exhibited symptoms.

Phobias, for example, are frequently treated by systematic desen...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgements
• Flow Chart for the Models Approach
• Chapter 1: Introduction
• Chapter 2: The Biological Model
• Chapter 3: The Limited-Capacities Model
• Chapter 4: The Respondent or Classical-Conditioning Model
• Chapter 5: The Operant Model
• Chapter 6: The Cognitive Model
• Chapter 7: The Social-Context Model
• Chapter 8: Case Studies
• Chapter 9: Armchair Speculations on the Models Approach
• References
• Author Index
• Subject Index