In my own defense…..

It is September 21st, 2017, my birthday, and I’m officially 48-years-old: an old fart…

Its 11:25 in the morning and I just had an appointment with my psychiatrist and took time to review where I’m at now. Honestly, I’ve been too busy. While I’m grateful to be on track, everything is happening at fast pace and at the rate I’m on going I won’t get a day off until I can move to a different schedule for my weekend job. I’m trying my best to carve out time out for myself whenever I have a spare minute. However, I realize this schedule can continue for very long.

I’m in the car right now trying to make the most of this drive time, and I’m dictating this post on a handy-dandy app I downloaded onto my phone….



I have this theory that life comes with its bitter pill we must swallow. I know this sounds a bit “Debbie Downer” of me, but bear with me. As I see it, this bitter pill represents an undeniable yet ugly truth of our lives. If we face it directly it causes us more pain then we’re prepared or willing to feel. So what we do is we engage in a willful denial of facts and create a reality that deletes these ugly truth out of the equation. The problem with this, is we end up perpetuating what we deny
We seek answers in the wrong places and end up chasing our tails like a hamster on a wheel. As a reformed-fuck-up, I’ve come to understand that the only way out is through. The truth will set you free.

(I realize I’ve said this elsewhere on this blog before. However, it bears repeating here.)

I feel like that kid in the emperor has no clothes fable who points out that the king is naked and gets in trouble for simply stating facts.

It’s truly a crazy making experience to be told that I’m supposed to treat truth as bullshit and bullshit is truth. Its as if those in my past expected me to help them deny what they hated to see. I was expected to collude with others in the maintenance of the pretty, self-deceptive realities we shared.  Unseen facts were my crosses to bear and theirs to benefit from since I was too young to know better.

If you’re a first-time visitor I’m sure this makes absolutely no sense. In this case, I suggest you read through my blog. I’m frankly not in the mood now to provide a detailed accounting of this experience.

My point is, I have this life to look back upon that is very lonely in the truest sense of the word. This loneliness – (in part at least) – meant my daily life was lacking in meaningful companionship, interaction, and belonging.  I’m at a point in my life now where I am not  willing to pay a price for the ignorance of others – even if this does mean I must watch them hurting. I must speak my truth and can’t afford to save others at my expense. I do not expect others to change or if knowledge my truth.

In this blog post I want to tell my side of the story: (or at least the Cliff Notes version of it)

As I write these words my mind is filled with memories of a childhood where I felt like a defendant in the court of public opinion. I was deemed guilty before I had a chance to speak on my behalf.  Nobody took time to understand what I was going through.  It’s not that they didn’t give a fuck or pretending not to notice….

…they just had more “pressing matters” to deal with and I wasn’t exactly high on their list of priorities.

Today when I speak with people who knew me as a kid – (whether family, friends or acquaintances) – it’s like a bad acid trip.  Through the eyes of all those who know me, I am able to see a version of myself that is always distorted and never flattering.  Instead, it is stereotypical and glossed over.  When viewing these preconceived versions of me side-by-side, I feel I’m walking through a hall of mirrors
No one took time to understand where I was coming from, when they drew their conclusions. Instead they acted as judge and jury.  I was screwed from the outset. You see, acknowledging me has meant facing ugly truths previously swept under the rug.  My only regret is I did not stand up for myself sooner in life.
 As that man in a monkey suit, I struggle to break free, but the zipper is stuck. I ask someone to help me but they don’t notice my inner struggle.  You see I’m just a stupid monkey. I urge them from within to look inside but they can’t see behind this frickin mask.  All I say and do is contextualized within this preconceived notion.  These preconceptions render the truth of who I am essentially invisible to all – including myself.  All that can be seen is this thick layer of bullshit ideas thrown my way.

There’s a standard and legal profession that I’m sure you’ve heard before: beyond a reasonable doubt. So they’ll does this mean?

So in my defense, what facts can be brought forth the produce doubts about the conclusions mad about me in the court of public opinion?  What follows is listing of unacknowledged facts – in no particular order that provide a solid argument against these judgments rendered upon me in the court of public opinion:

To continue click the links below


When examining the origins of my pathological naivety I must say it comes down to the fact that life developed a one-sidedness based on others’ opinions and my inability to see beyond them.

I have had to examine my own personal narrative to include information that had been previously overlooked. This idea of me being not good enough has haunted and perplexed me much of my life. And until I was willing to confront the traumas of my past, I had no idea why people reacted to me as they did. I just knew it was hurtful and made no sense. With no one guiding me there to help me, I naturally blamed myself. Within me was the thought I’m worthwhile person. Around me everyone had these terrible things to say coming out of left field
As far back as I can remember, I’ve always been an optimal target for bullies. In fact, as the “girl with the cooties”, bullying has always been a constant issue: from kindergarten at St. Agnes up through high school graduation. Admittedly, the bullies changed from year to year, but they all saw me the same way. I was the perfect target: I am highly sensitive and don’t fight back….For those who have never been bullied, you’d be surprised to learn that the actual bullying isn’t the worst of it. The collateral damage it sustains upon your social life is devastating. You see, when you get picked on often enough at school people start to notice and a reputation develops. Now a “loser”, you’re essentially walking around with a scarlet letter tattooed to your forehead. Hapless bystanders, silently observe the altercations but do nothing. Instead they pretend not to notice. Fearing for their own well-being and hoping to retain their status within the social hierarchy, you’re now a social leper. A “dork-by-association” rule starts to govern all social interactions with you. Should someone dare say “hi” or strike up a conversation, they’ll hear about it later: “what the hell are you doing hanging out with that wierdo?!?!”

 

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Validation What is it Exactly?

PART #1:  Validation vs Invalidation:

“I’ve talked to nearly 30,000 people on this show and they had one thing in common: they all wanted validation” – Oprah

What is Invalidation???

While I haven’t been a therapist for very long, I have noticed that Oprah definitely has a point.  Every individual I’ve seen thus far simply seeks validation.  In fact, it appears to be a critical factor in the development of a therapeutic relationship.  From the outset, it seems my clients are asking themselves: “does this lady get it at all?” So with this in mind, I find myself asking the question, how can I learn to effectively communicate validation with my clients?  However, before I can answer this question, it may be essential to first start with defining the concept. Here a few useful quotes that tell us what validation “is not”:

Pervasive invalidation occurs when, more often than not, caregivers treat our valid primary responses as incorrect, inaccurate, inappropriate, pathological, or not to be taken seriously. Primary responses of interest are persistently squelched or mocked; normal needs for soothing are regularly neglected or shamed; honest motives consistently doubted and misinterpreted. The person therefore learns to avoid, interrupt, and control his or her own natural inclinations and primary emotional responses. Like a creature in a chamber with an electrified grid for the floor, he or she learns to avoid any step that results in pain and invalidation. (Koerner, 2012, p28-29)
How others understand your feelings when reacting with invalidation

How others treat your feelings when reacting with invalidation

Linehan, (1993), adds that invalidating responses cause us to feel others are ignoring, minimizing and/or punishing our inner emotional experiences. What are the consequences of emotional invalidation? A pervasive distrust of one’s own emotions, thoughts, and perceptions are inherently flawed. From within this preconceived vantage point it is nearly impossible to develop any sense of personal agency or sense of worth.  The predefined lens through which one enters life is defined by shame and self-invalidation. “self-invalidation refers to the adoption by an individual the characteristics of the invalidating environment” (71-72, linehan, 1993)

“in Invalidating Environments a person learns to avoid, interrupt, and control his or her own natural inclinations and primary emotional responses.  Like a creature in a chamber with an electrified grid for the floor, he or she learns to avoid any step that results in pain and invalidation…we avoid personal thoughts, sensations, or emotions that put you at risk of experiencing an invalidating event with someone else….”(Koerner, 2012, p. 6).

“Pervasive invalidation creates exquisite sensitivity. The slightest cue can set off emotional pain, the equivalent of touching third-degree burns…Because the individual cannot control the onset and offset of events that trigger emotional responses, the person can become desperate for anything that will make the pain end” (Koerner, 2012, p. 7)

Click here to read my post titled, “Shame, Invalidation & a Little Baggage”

So what is validation then?

validating responses teach us to use emotion to understand what is happening within and outside our skin as a moment-to-moment readout of our own state and our needs with respect to the environment. In an optimal environment, caregivers provide contingent, appropriate soothing for strong emotions. They strengthen and help the individual refine the naturally adaptive, organizing, and communicative functions of emotions. None of us get the perfectly optimal environment, of course. (Koerner, 2012, p. 28-29)

The essence of validation is this. The therapist communicates to the client that her responses make sense and are understandable within her current life context or situation. The therapist actively accepts the client and communicates this acceptance to the client. The therapist takes the client’s responses seriously and does not discount or trivialize them. Validation strategies require the therapist to search for, recognize and reflect to the client the validity inherent in her response to events. With unruly children parents have to catch them while they’re good in order to reinforce their behavior, similarly, the therapist has to uncover the validity within the client’s response, sometimes amplify it, and then reinforce it (Linehan, 1993, pp 222-223)
How others understand your feelings when reacting with validation

“A validating response occurs when a person expresses his or her private experience to another person and this expression is met with understanding, legitimacy, and acceptance of this experience (Linehan, 1997). A validating response does not directly seek to change or alter a person’s emotional experience. Instead, it seeks to highlight the emotional experience in order to facilitate an individual’s acceptance and experiencing of the emotion. This validation can influence individual emotion regulation in several ways. First, validating responses are believed to minimize the frequency, intensity, and duration of an emotional reaction, especially those involving negative affect, making regulation more likely. Second, validating responses promote the learning of skills for regulating emotions because they promote more disclosures of emotional states which facilitate the experiencing of an emotion and consequently its expression and regulation” (Fruzzetti & Shenk, 2008).
Validation promotes learning of emotional regulation skills.

Empathy vs. Validation.

“Whereas empathy is the accurate understanding of the world from the client’s perspective, validation is the active communication that the client’s perspective makes sense (i.e., is correct). To validate means to confirm, authenticate, corroborate, substantiate, ratify, or verify. To validate, the therapist actively seeks out and communicates to the client how a response makes sense by being relevant, meaningful, justifiable, correct, or effective. Validating an emotion, thought, or action requires empathy, an understanding of the particular or unique significance of the context from the other person’s perspective. However, validation adds to this the communication that the emotion, thought, or action is a valid response. Were the client to ask, “Can this be true?” empathy would be understanding the “this” whereas validation would be communicating “yes” (Koerner & Linehan, 2004, p. 456).

Empathy, What is it?

What is DBT?

Part #2: How to Validate…

In part one , I provide a “Cliff’s Notes Overview” to know about validation and information from various sources that can help us discern what validation is not.  In this section, I would like to review information from another resource that describes how we do validate others…

QUESTION ONE:  “What do we validate???”

Based on information reviewed thus far, its certainly clear that validation is a critical component in the therapeutic process.  However, the question which naturally arrises is “what should I validate?”  As a therapist, it would be a disservice to my clients to validate everything they say without question.  So what does it mean to validate?

With this in mind it is important to consider what we should validate as therapists.  Koerner & Linehan provide the following clarification:

“Validation means the acknowledgement of that which is valid.  It does not mean the “making” of something valid.  Nor does it mean making validating that which is invalid.  The therapist observes, experiences and affirms but does not create validity.  That which is valid pre-exists the therapeutic action” (Koerner & Linehan, 2004, p. 477).  
In other words, therapists affirm those aspects of a client’s experience that hold validity.

Treating invalid perceptions as correct and accurate is a disservice to our clients.  So how can we uncover and discern the grain of truth in a client’s viewpoint?  In the next section I will review a few suggestions from Koerner & Linehan (2004).

QUESTION TWO: How do we find  valid elements in a client’s exeriences?

Something can be valid based on an assessment of the empirical facts.

For example, I’ve had always had conflicting feelings about being biracial.  I don’t feel I’m accurately perceived am, due to the random characteristics that define my meat suit.  I also have quite a bit of baggage from my childhood due to racist and ethnocentric attitudes in my extended family. I try to validate my own personal sense of identity as a biracial person by reminding me of the empirical facts.  I have a Filipino mother and a white father.  Therefore, I am biracial.  Nobody’s opinions can render these facts invalid.

Sometimes a client’s perspective can be valid in terms of the pre-existing causal factors they describe.

One day, my sister and I were talking about various childhood memories and she made the observation that I could have handled the bullying differently.  I was too sensitive and isolated myself.  At the time she said this I was quite hurt, (this was several years ago). Based on an objective empirical assessment of facts – my sister certainly had a point.  However the problem with empirical assessments is that they are based on logic and external observation.  Left out of the equation were unique pre-existing causal factors that she overlooked.  Failing to understand my own subjective experience is failing to understand me.

Sometimes a client’s perspective can be valid in terms of their long term goals and the observed consequences of their actions.

“The client’s response may be valid in terms of past learning history…or current circumstances.. But her response may be simultaneously invalid in that it may be ineffective to her long-term goals” (Koerner & Linehan, 3004, p. 458).

QUESTION THREE:  When is validation contraindicated?

“The only true contraindication is that therapists should not validate invalid behavior. That is, the therapist does not want to validate responses that are dysfunctional and incompatible with progress toward the agreed-upon therapeutic goals” (Koerner & Linehan, 2004, p. 459),  Keep in mind, validation is a form of reinforcement.  It is a form of communicated acceptance that can act as a counterbalance to any chance strategies that are utilized.

QUESTION FOUR- How does one validate?

Step #1:   Know your client.

Know your client’s biopsychosocial history and the nature of their psychopathology.  Be aware of what is valid and invalid for the specific client with this information in mind.  “Does the response move the client toward his or her immediate or ultimate goals?” (Koerner & Linehan, 2094, p. 479)

Step #2:  Telling it like it is.

If something is valid affirm this fact to be client.  If something is not valid address this issue at the appropriate point in time, (depending on the quality of the therapeutic relationship.

“Step 3: Validate at the Highest Possible Level” (Koerner & Linehan, 2004, p 461).

What does this mean? Koerner & Linehan, (2004) are alluding to the idea that it isn’t just what you say but how you say it.  In other words, actions speak louder than words.

  1. The first step in validation is the listening to and observing what the client is saying, feeling, and doing as well as a corresponding active effort to understand what is being said and observed” (Linehan, 1997, p. 360)
  2. The second level of validation is the accurate reflection back to the client of the client’s own feelings, thoughts, assumptions, and behaviors” (Linehan, 1997, p. 360)
  3. ”In level three of validation, the therapist communicates to the client his or her understanding of aspects of the client’s experience and response to events that have not been communicated directly by the client.” (Linehan, 1997, p. 364)
  4. “At level four, behavior is validated in terms of its causes. Validation here is based on the notion that all behavior is caused by events occurring in time and, thus, in principle, is understandable…feelings, thoughts, and actions make perfect sense in the context of the person’s current experience” (Linehan, 1997, p. 367)
  5. ”At level five, the therapist communicates that behavior is justifiable, reasonable, well-grounded, meaningful, or efficacious in terms of current events, normative biological functioning, and the client’s ultimate life goals.” (Linehan, 1997, p. 370).
  6. “In level six, the task is to recognize the person as he or she is, seeing and responding to the strengths and capacities of the individual while keeping a firm empathic understanding of the client’s actual difficulties and incapacities” (Linehan, 1997, p. 377).

References

Gilbert, P. (Ed.). (2005). Compassion: Conceptualisations, research and use in psychotherapy. Routledge.

Koerner, K (2012). Doing dialectical behavior therapy: A practical guide. New York, NY: Guilford Press.

Koerner, K., & Linehan, M. M. (2004). 68 VALIDATION PRINCIPLES AND STRATEGIES. Cognitive behavior therapy: Applying empirically supported techniques in your practice, 456-462.

Leahy, R. L. (2005). A social–cognitive model of validation. Compassion: Conceptualisations, research and use in psychotherapy, 195-217.

Linehan, M. M. (1997). Validation and psychotherapy. Empathy reconsidered: New directions in psychotherapy, 353-392.

McKay, M., Wood, J. C., & Brantley, J. (2010). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, Emotion regulation & distress tolerance. Oakland, CA: New Harbinger Publications

Neff, K. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and identity, 2(2), 85-101.

Newell, J. M., & MacNeil, G. A. (2010). Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue. Best Practices in Mental Health, 6(2), 57-68.

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MCC 670 – Psychodynamic Models

Psychodynamic model hypotheses are based on the work of Freud, Jung, & Adler. They focus on unconscious mechanisms and early childhood experiences.

internal parts (p1)

overview & key concepts

“The problem can be explained in terms of Internal Parts that need to be understood, accepted or modified and coordinated.” (Ingram, 2912, p. 289) In other words, there exists a lack of awareness of how subconscious thought processes and/or childhood experiences create conflict in our lives. Treatment centers around resolving this inner conflict and addressing this resistance. Ingram, (2012), discussed concepts within transactional analysis as highly relevant here.

when is hypothesis a good match

“you can only work productively using this hypothesis when the client can reflect on different parts as aspects of one’s personality, and be able to take a playful, ‘as if’ attitude when speaking with the voice of an inner part. This requires the maturity to take a metacognitive perspective.” (Ingram, 2012, p292)

treatment planning ideas

Treatment planning involves the resolution of our missing pieces as areas of conflict. In DBT, the outcome of this would be wise mindedness. In transactional analysis it would be an identification if inner parts and resolution of inner conflict.

example #1: overcome stuckness

“Resistance is often explained as a battle between inner parts: one part wants to change, while the other does not – out of fear of the risks or enjoyment of the benefits of staying the same (secondary gains)”. (Ingram, 2012 p234).

example #2: gestalt 2-chair technique

Therapist guides client to talk back and fort between two parts, each spatially linked to a different chair. The therapist’s role is to clarify. (Ingram, 2012, p296).

recurrent parts (P 2)

overview & key concepts

“A Recurrent Pattern, possibly from early childhood, is causing pain and preventing satisfaction of adult needs…Insights may not be enough, the client may need to experience and learn to tolerate painful emotions.” (Ingram, 2013, p301). We generally tend to utilize the most effective solutions based on past experience. Ingram, (2012), discusses attachment theory and family of origin here.

treatment planning

“you need to be specific about what exactly is being reenacted and offer your hypothesis about how, specifically, the pattern occurs in current functioning.” (Ingram, 2012, p305)
Avoid blaming and focus on promoting insight and provide validation. Be aware of countertransference.

deficiencies in self & relational capacities (P3)

overview

“The client demonstrates Deficits in Self and Relational Capacities and seems to be functioning at the maturity level of a young child.” (Ingram, 2012, p. 312). Ingram, (2012), goes into great detail on various theories that discuss stages of childhood development.

treatment planning

Ingram, (2012) suggests holding off until you can understand their developmental level relationally. Psychoanalytic strategies can might involve a therapist being as a “selfobject [for purposes of] learning vicariously” (Ingram, 2012, p302). Humanistic theories can address these issues by enabling client’s to be less reliant on approval from others.

unconscious dynamics (p4)

“client suffers from irrational, self-defeating behaviors or distressing symptoms that do not respond to ordinary interventions. These may stem from unconscious conflict or self-protective responses to traumatic events. Defense mechanisms function to keep the conflict unpleasant affects out of awareness” (Ingram, 2012, p.325). This hypothesis utilizes some Freudian concepts that I’m not a fan of.

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MCC 670 – Cognitive Models

“Cognitive hypotheses can be applied with every client because the content and process of thought is an element in all problems and solutions” (Ingram, 2012, p. 191). This hypothesis is based on psychodynamic, humanistic, existential, and CBT models.

Metacognitive Model (C1)

Metacognition refers to thinking about thinking. In other words, you are focusing on your thoughts and feelings without identifying or reacting to them. Critical thinking is the ability to evaluate thinking and requires the following skills:

  1. Able to separate self from thoughts
  2. Not give power or control to thoughts
  3. Evaluate one’s thinking in terms of goals
  4. Taking the role of executive over one’s thoughts.
  5. Non reactivity to inner experience

is this hypothesis a match?

This hypothesis is useful in achieving emotional regulation, achieving goals, & harmonious relationships. It is useful for OCC, PTSD, depression or substance use.

treatment planning

Step one involves psychoeducation of the fundamental nature of metacognitive beliefs. Homework assignments that allow us to apply this skill and engage in self-monitoring of our thoughts. Ingram, (2012) also mentions clarifying questions as useful to understand her thinking. Ongoing efforts to build metacognitive skills and practice mindfulness & acceptance activities are also discussed by Ingram, (2012).

Limitations of Cognitive Map (C2)

overview

This hypothesis is useful when a “person’s cognitive map (e.g. beliefs, schemas and narratives) are causing problems or preventing solutions” (Ingram, 2012). Maladaptive belief systems act like “self-fulfilling prophecies that need to be identified, evaluated, and challenge” (Ingram. 2012).

key concepts

cognitive map

“deep structures of thinking, such as schemas, rules, or cultural worldviews. They provide meaning and purpose, a rulebook for how to behave the world” (Ingram, 2011, p. 195).

limiting narratives

“a cognitive map that is extended through time” (Ingram. 2012, p. 292). We all tend to arrange life experiences sequentially and create story around these experiences for sense of continuity and meaning. We can address them by understanding simply that our stories define our life.

lifestyle

“Adler used the term lifestyle for “the convictions individuals develop early in life to help them organize experience, to understand it, to predict it, and to control it” (Ingram, 2012, p. 198).

ABC Model

[A] Event -> [B] Thinking -> [C] Feelings
[A] Event -> [B] Causes -> [C] Feelings

Deficiencies of cognitive processing (C3)

overview & key concepts

“the client demonstrates Deficiencies in Cognitive Processing, poor reality testing, and an inflexible cognitive style” (Ingram, 2012) This hypothesis is useful with depression, anxiety disorders, or psychosis, as an example.

information processing

Ingram, (2012), discusses information processing and describes concepts of input, processing, and output. Input consists of how we intake information. (i.e. Attentional mechanisms). Processing consists of how we imbue this data with meaning (i.e. Perception). Output consists of our behavioral response.

Beck’s Errors in Thinking

  1. Overgeneralization – (always or never)
  2. Personalization (assumption that external events r/t you)
  3. All-or-Nothing Thinking – Polarizing thoughts black/white
  4. Arbitrary inference – Jumping to conclusion.
  5. Mind Reading – Assuming you know what others are thinking
  6. Emotional Reasoning – thinking with feeling

blocks to listening

Ingram, (2012), discusses filtering, dreaming, prejudging, and rehearsing and identifying. The MBTI describes cognitive styles & the MMPI describes defensive styles.

treatment planning

Ingram, (2012), discusses the concepts of Socratic dialogue, collaborative empiricism, confrontation, CBT, and homework assignments….

Dysfunctional self-talk (C4)

overview & key concepts

DYSFUNCTIONAL SELF-TALK (C4) – The problem is triggered and/or maintained by Dysfunctional Self-Talk, (i.e. automatic thoughts, internal tapes, or interior monologue). Sample problem areas can include anxiety, depression, impulsive behavior, healthy eating, substance abuse (Ingram, 2012).

treatment planning

It starts with promoting self awareness and gaining an understanding of our thoughts and belief systems. Deciding to change and enacting a plan to make it happen are final steps.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment ​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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Mcc670 behavior & learning models

Overview of Hypotheses

“The Hypotheses in this chapter apply models of learning from experimental and social psychology: operant conditioning, respondent conditioning and social learning theory.” (Ingram, 2012). I’ve reviewed these elsewhere for the NCE exam.

Antecedents & Consequences (BL1)

Overview & Key Concepts

The treatment plan should be based on an analysis of Antecedents (triggers) and Consequences (reward and punishment). “Interventions based on functional analysis of behavior. Strategies of behavioral change based on studies from operant conditioning” (Ingram, 2012, p. 158). B.F Skinner’s theory stated behavior is a function of its consequence. Triggers are stimuli that causes behavior to happen. Positive and negative reinforcement allow us to control behavior. Applied behavioral analysis allows us to gather data based on these concepts and design interventions accordingly. Useful with children (i.e. Autistic child with disruptive mood disorder)

Step #1: Define Problem Behavior

What are the problem behaviors? Is it related to a skill deficit or trigger? Can you clarify the behavior in a clear and measurable fashion?

Step #2: Identify Antecedents

What stimulus occurs before the specific behavior? It can be a biological condition, emotional state, or cognitive trigger.

Step #3: Identify Consequences

What sort of rewards and/or punishments serve to explain why the individual engages in the specific behavior? How is behavior reinforced?

Step #4: Examine Sociocultural environment

What cultural norms exist and how would you characterize the client’s support system. In what way do these factors also play a role in the client’s behaviors.

Step #5: conduct a cost/benefit analysis

This involves examining how the above factors weigh in the client’s decisions to behave? Clarify the weight and sequence of these factors play in the overall decisional equation. Ingram, (2012) defined functional analysis as an “analysis of specific contingencies that maintain problem behaviors along with an analysis of the necessary contingencies for the desired behavior to replace the problem behavior.” (Ingram, 2012). The payoff can be a means of escape from something negative. Or it can provide a tangible reward (i.e. Sensory and/or attention-getting benefit). These steps allow us to develop a treatment plan.

The Treatment Plan

The goals of this hypothesis are fairly straightforward and involve either increasing desired behaviors or decreasing undesirable behaviors. Homework assignments between sessions are useful alongside the gathering of data that the client can examine to clearly see the benefits of all interventions. Ingram, (2012) also discusses common strategies such as +/- reinforcement, contingency contract, etc. Finally, if the client remains noncompliance, it may be useful to utilize another hypothesis (p4 or p1).

Conditioned Emotional Responses BL2

Overview & Key Concepts

This hypothesis is based on Pavlov’s theory and concepts such as conditioned/unconditioned responses or extinction. Conditioned Emotional Responses are often at the core of extreme distressful responses or maladaptive behaviors. “There is an intense emotional response that is not justified by the stimuli in the current environment, along with a lack of cognitive mediation, we can infer that prior learning involved classical conditioning” (Ingram, 2012, p. 172).

is this a good match

“There are many situations where extreme emotional reactions are justified, as with traumatic events (discussed under C2), deaths and other losses (C4), and social injustice (SCES). Similarly, intense emotional reactions accompany developmental transitions (CS3), loneliness and social isolation (SCE3), and changes in one’s social environment and required social role (SCE4)” (Ingram, 2012, p. 173)

Treatment Planning

Usually involves some form of systematic desensitization of anxiety-producing situations where the trigger is paired with relaxation responses. However, beforehand this should first include some relaxation training. Followed by the development of a fear hierarchy from lowest to highest. This can then allow the therapist to utilize a gradual exposure plan.

Skill Deficits (BL3)

Overview & Key Concepts

This hypothesis is useful if skill deficits exist and the client requires to gain competency in a particular area. The treatment goals tend to center around providing opportunities for learning. Sample problem areas can include anger management or social skills. This hypothesis is based on Bandue’s conditioning principals which state that we learn by observing and mimicking others.

treatment planning

“It may be helpful to orient the client to the ‘learner role’, which requires an acceptance that achievement of proficiency requires effort, practice, and acceptance of mistakes” (Ingram, 2012). The first step involves the evaluation of the client’s skill level. This requires an identification and clarification of the problem then brainstorming solutions. Graduated tasks and homework are essential with the utilization of a step-by-step plan. Behavioral rehearsal is an essential component of this process. Ingram, (2012), suggests that interpersonal therapy or DBT.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment ​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Sociocultural & Environmental Factors

CHAPTER 14 “Social, Cultural & Environment Factors” in Ingram, (2012) discusses his hypotheses that look outside of the individual for explanations and solutions.  Draws from systems theory and varied disciplines. The table below comes from (Ingram, 2012, p, 285).

This post is part of an excruciatingly frustrating list of posts where I take old notes from a class. In order to expedite matters, I’m doing the cliff notes version. Above, is key info on the hypotheses. Below, are examples of these hypotheses applied to my own life…

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Existential & Spiritual Models

“By applying the hypotheses in this category, the therapist refuses to pathologize, medicalize, or objectify the patient. Clients do not have a ‘disorder’ but are struggling with inevitable problems of human existence….The personhood of the therapist and the egalitarian, genuine quality of the therapeutic relationship may be more important than other therapeutic ingredients.” (Ingram, 2012, p, 257).

This post is part of an excruciatingly frustrating list of posts where I take old notes from a class. In order to expedite matters, I’m doing the cliff notes version. Above, is key info on the hypotheses. Below, are examples of these hypotheses applied to my own life…

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

 

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MCC 670 – Body & Emotions

Body & Emotion Hypotheses

These hypotheses are based on the idea that the body and mind are interconnected as two integral components of our overall well-being. “There are physiological causes for mental symptoms, psychological causes for physiological changes and psychological and biological factors that co-vary without our understanding the direction of causation.” (Ingram, 2012).  For example, anxiety can be a byproduct of a thyroid condition, or it can be a part of life stressors where the body/mind connection is at play.  This section talks about two hypotheses…

Biological Cause (BE1)

Overview and Key Concepts

“A wide range of physiological conditions can produce psychological symptoms. Psychosocial assistance is needed with coping with these issues” (Ingram, 2012). Examples of this might be strokes, brain tumors Alzheimer’s, fetal alcohol syndrome, endocrine disorders, vitamin deficiency, AIDS.  What follows is a listing of key ideas to keep in mind:

  1. Does the individual have a medical diagnosis.  Need to contact physician for purposes of care oordination.  
  2. Is there a medical emergency that can cause death, serious injury, or disability?
  3. Are there medically unexplained symptoms? (Somatization disorder?)
  4. is there a co-occurring medical illness and mental disorder 

Is this hypothesis a good fit?

Examples of problems that fit a biological cause hypothesis:

  1. Inadequate self-care
  2. Difficulties coping with health problem
  3. Compassion fatigue.
  4. Problem associated with terminal illness 
  5. Problems associated with drug addiction 

When should a therapist refer their case to a medical professional?

  1. “A need for medical referral is recognized by such data as impaired memory, concentration, consciousness, changes in appetite, weight, sleep patterns, mood and personality traits” (Ingram, 2012).
  2. “Events that require referral: poor grooming, neglect, loss of competence, delirium, dementia, amnesia, stroke, head trauma” (Ingram, 2012). 
  3. Finally, it is important to be aware of the fact that medical problems can masquerade as mental health issues

Finally, Ingram (2012), discussed two issues in detail that are an ideal fit for this hypothesis:  substance abuse and adapting to disability.

substance abuse.

An MSE, biopsychosocial assessment and CD eval are all essential.  Should assess history, quantity and frequency of consumption.  Also need to understand how addiction has affected life/relationships.  Keep in mind, the biological components:

  1. Intoxication: produces changes and impairments in client’s mental status.
  2. Dependence is a physiological and psychological  issue
  3. Affects of an addictive substance can mimic psychological disorders 

Coping with disability

Biological conditions can “affect an individual’s emotional, biological, spiritual and cognitive well-being” (Ingram, 2912).  How does this issue overwhelm an individual’s ability to cope? Acceptance, understanding and self-education are useful in learning to cope with irreversible medical issues.  Examining opportunities for prevention and healing require individuals to closely examine their lifestyle.

Treatment Planning

Assess the client’s understanding of the nature of their condition and prognosis.  Education and radical acceptance may be in order

  1. Do not forget ethical issues (I.e mandatory reporting laws) & remain within scope of care, utilizing referrals where necessary.
  2. Help client work through a system of self management that includes addressing ADL’s and making adaptations as needed.  
  3. Provide time for the client to work through psychological and relational and issues.
  4. It will be essential to function as part of an interdisciplinary team to coordinate care.  
  5. be aware of family involvement in treatment discussions.

with terminally ill clients:

  1. hospice or palliative care?
  2. Kubler-Ross stages
  3. spiritual & existential issues
  4. EOL decisions 
  5. assess/address quality of life.

Alcohol and Drug Treatment

Initial Phase requires detoxification under medical supervision.  Residential programs are the next phase.  Then client’s enter outpatient treatment and participate in 12-step programs

Finally, Ingram (2012) lists the following hypotheses as useful alongside this one:
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  • Limitations of Cognitive Map (C2) 
  • Antecedents and Consequences (BL1) 
  • Conditioned Emotional Responses (BL2)
  • Loss  and Breavement (CS4)
  • Spiritual Dimension (ES3) 

Medical Interventions (BE2)

Overview and Key Concepts

“The primary application of this hypothesis will be when the use of psychotropic medication is indicated for a psychiatric disorder” (Ingram, 2012, p. 78).  For example, someone has a gastric-bypass and needs help adhering to new diet and coping with lifestyle changes.  Ingram, (2012), caution against giving medical advice and stay with scope of practice.  What follows is a list of sample treatment considerations:

  1. Referral & coordination of care
  2. promote adherence with doctor’s recommendations 
  3. CBT (i.e. Cost-beneft analysis).
  4. Know basic psychopharmacology

Is this Hypothesis a good fit?

“…for severe disorders, such as Schizophrenia and Mania, psychopharmacological treatment is not considered optional, but is rather a part of the ‘standards of care'” (Ingram, 2012, p. 80). Referrals and care coordination are essential in such cases.  Ingram lists the following as reasons for seeking psychiatric referral:

  1. “symptoms are interfering with basic ADL’s
  2. The client is a suicide risk
  3. diagnosis exists which needs medication.
  4. The symptoms persist with medications.
  5. The client is self-medicating
  6. Psychotropic medication worked in the past.

Treatment Planning Ideas

The basics of treatment are discussion, psycho-education, assistance with decision-making, referral, and coordination of care with a medical practitioner.

DISCUSSING PSYCHOTROPIC MEDICATION:

  1. What are Side-effects r/t medications
  2. Reasons for non-compliance (why?)
  3. Problems emerging after symptom management increases.  (I.e. Suicide risk, ADL issues, & interpersonal problems).

Mind-Body Connections (BE3)

Overview and Key Concepts

“A holistic understanding of Mind-Body Connections leads to treatment for psychological problems that focus on the body and treatment for physical problems that focus on the mind. This hypothesis is a good fit for clients classified as somatizers, for many types of stress and tension complaints, and for sexual disorders. Clients often need to increase their awareness of and control over their bodies and to develop a somatic awareness of feeling” (Ingram, 20-2, p. 88).

  1. Healing mind also heals the mind
  2. Improvements in physical help improve psychological function.
  3. Stress is a mind-body issue.  

How you determine fit?

  1. “Stress and anxiety tension reduction 
  2. Problems with eating, sleeping and sexual function
  3. Medical complaints
  4. Chronic pain
  5. Body image problems
  6. Performance problems
  7. Restricted and rigid personality styles” (Ingram, 2912).

Treatment Planning Ideas

  1. SUD scale & mind/body awareness
  2. Relaxation and stress management
  3. methods that stress mind/body connection.

Emotional Focus (BE4)

Overview and Key Concepts

This hypothesis focuses on helping the “client improve awareness, acceptance, understanding, expression and regulation of feelings” (Ingram, 2012).  Key concepts

Emotions Defined:

“complex set of interactions mediated by neurons and hormones giving rise to affective experiences that generate cognitive processes, activate physiological adjustments, and lead to behaviors not always adaptive.” (Ingram, 2012).

Emotional Reactivity

how much affective arousal a client diaplays (i.e. Intensity & duration). Need to help canine a client’s emotional development.

Finally, Ingram, (2012) also discusses Carl Rogers’ Humanistic Psychology, culture & emotion as well as emotional competencies.

Treatment Planning:

“Bring in an emotionally connected relationship based on empathetic attunement and support enhances the person’s capacity to feel without needing to develop strategies to minimize or numb emotions. (Ingram, 2012).”  Client needs to develop an ability to accurately understand their feelings and express them in a healthy way.  Gestalt and EFT discussed here.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment ​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Attachment Interventions

Attachment Theory Overview

Based on the work of John Bowlby and Mary Ainsworth, Attachment Theory states that early experiences with primary caretakers during infancy provide a “working model [of oneself] and others” (Broderick & Blewitt, 2006). It is also worth noting that the concept of attachment, as described here does not pertain to a specific set of observable behaviors. Instead attachment is a system of beliefs that sure the purpose of an emotional bond known as “proximity maintenance…[in addition to a] safe haven…[and]…secure base” (Broderick & Blewitt, 2006, p125) with which to interact with one’s world Instead have profound effects throughout one’s lifetime. It is for this reason, an individual’s early attachment experiences have profound affects that last a lifetime. ​It is in the early social interactions with primary caregivers during infancy that we first learn trust others and develops a capacity for emotional regulation. Mary Ainsworth’s research utilized a measure called the “strange situation test” (Broderick & Blewitt, 2006, p126). Based on her observations four types of attachment styles have been observed. Babies with secure attachments show distressed when separated with a caregiver and are easily comforted upon her return so they are able to return to their play activities (Broderick & Blewit, 2006; Ingram, 2012). Anxious-Ambivalent attachments, like securely attached babies are distressed when their caregiver leaves. However, when they return, they are more anger and resistant to their caregivers attempts to provide comfort (Broderick & Blewit, 2006; Ingram, 2012). Infants with Avoidant Attachments do not cry when separated from their caregiver and ignore them when they return in the room (Broderick & Blewit, 2006; Ingram, 2012). Finally Disorganized Attachments are seen in an infant’s tendency to avoid a caregiver when they approach while seeking them out if stressed (Broderick & Blewit, 2006; Ingram, 2012).

Goals for Attachment Interventions​

A primary goal of attachment theories, regardless of one’s developmental stage is the consistent availability and access to an attachment figure (Cassidy & Shaver 1999). However it is important to note that an individual’s “assessment of availability” (Cassidy & Shaver, 1999, p39). changes throughout life. For example, during infancy availability is equated to physical proximity and consistent responsiveness from a primary caregiver. As we mature, the perception of availability pertains to communication and the cognitive appraisal of responsibility to relationship and emotional needs (Cassidy & Shaver, 1999).

For purposes of intervention in order to address disruptions in attachments it is important to assess the individual’s “current appraisal (Cassidy & Shafer, 1999, p39) of their attachment. As a current working model that influence’s one’s relationships, this construct varies and changes in response to relationship experiences throughout life (Cassidy & Shafer, 1999, p39). Intervention goals vary in accordance with: (1) an individual’s current relationship experiences and (2) their developmentally relevant methods of assessment of an attachment figures availability and inherent trustworthiness. Overall, goals center around the disruptions in present attachments and their long-term consequences for a relationship (Cassidy & Shafer, 1999).

Attachment Theory Interventions

One example of a Parent-Child Attachment Intervention is the “Steps Toward Effective Enjoyable (STEEP) Program” (Cassidy & Shafer, 1999, p565). The primary interventional goal for this program is to address a mother’s “working model of attachment by focusing on her feelings, attitudes and representations of the mother-child relationship” (Cassidy & Shafer, 1999, p565). Involving regular home visits staring around the later trimesters of a woman’s pregnancy and into early infancy. It takes a proactive approach. Participants include those who are at greater risk for parenting issues based on prior history. Individual and group sessions allow the individual to alter their beliefs about self and relation to others in order to prevent repeat experiences of old family history.
​Attachment Interventions for adults in individual psychotherapy can include, for example the work of Mary Main who describes three types of parental attachments towards children: “autonomous, dismissing and preoccupied” (Cassidy & Shafer, 1999, p565). Interventions utilized in Mary Main’s approach include metacognitive exercises that ask individuals to consider the working models and belief systems guiding their parental efforts. “Reflective functioning” (Cassidy & Shafer, 1999, p581), is an example of another intervention that involves reviewing life events and evaluating it from everyone’s perspective. Finally, interventions can also be aimed at allowing mothers to develop an understanding of their mental state and a child’s needs (Cassidy & Shafer, 1999).

Attachment Assessments

One convenient example of attachment assessments in early infancy, includes the work of Mary Ainsworth, as described earlier. With this in mind, they involve analysis of child-parent interactions and the stability of observable behaviors over time. As individual’s progress assessments such as “The Cassidy-Marvin System” (Cassidy & Shafer, 1999, p297), are useful. This assessment involves categories of attachment styles similar to Ainsworth’s but for individuals in early child and more diverse display of behavioral responses (Cassidy & Shafer, 1999). Attachment assessments for adolescents and adults, according to the Handbook of Attachment (Cassidy & Shafer, 1999), include a series of narrative interviews. The main goal in this respect is to examine the mental constructs they utilize in current relationships and behavioral responses to these preconceptions (Cassidy & Shafer, 1999).

FINAL QUESTION: “Would a goal of therapy be to increase healthy forms of attachment? Is this possible?”

In a nutshell, based on this book review and overview of interventions/assessments/goals I believe it is possible to work on attachments. An overview of my own attachment history and my husband, shows how fundamentally important this personal construct is in all relationships throughout one’s lifetime. I also believe, in this respect, that addressing it is a worthwhile and fruitful endeavor. One ideal example of the possibility of change is my own husband. His mother was an alcoholic, who died in her forties. Married 8 times in her life, she wasn’t a source of stability for him. Additionally, my husband’s father was never around. Despite this history, and after taking time to address these issues in his own life, he is an amazing husband and wonderful father. He is motivated to create the family he never had. Therefore, I would love to address this issue in my future practice

References

Broderick, P. C., & Blewitt, P. (2006). The life span: Human development for helping professionals. Boston MA: Pearson.
Cassidy, J & Shaver P.R. (1999). Handbook of Attachment. New York: The Guilford Press.
Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Crisis & Trauma

In chapter eight, Ingram (2012) describes five hypotheses that are useful in addressing crises that require “immediate…intervention” (p117). Each of these hypotheses is described below:
  1. An Emergency Hypothesis (CS1), is a situation in which an individual is experiencing homicidal and/or suicidal ideation. An example might be if you are seeing a new client for the first time, and they state they are experiencing suicidal thoughts. A careful assessment in this situation is essential, and the patient’s safety becomes a priority alongside mandatory reporting considerations.
  2. Situational Stressors (CS2) refer to life situations and/or stressors that are in excess of an individual ability to cope. One example might be a very contentious divorce. The loss of a significant relationship, financial strain and restructuring of a family environment can be overwhelming.
  3. Developmental Transitions (CS3) – refer to crises associated with normal human development. Erickson’s developmental theory is useful here as an underlying theoretical perspective for this hypothesis.
  4. Loss and Bereavement (CS4) – As someone who has works in healthcare I’m aware of the crisis associated with the death of a loved one. The grief and morning process occur in stages very much as Kubler-Ross describes
  5. Trauma (CS5) – As I understand trauma, it is an experience that changes how an individual perceives oneself and the world around them. Examples can include anything from rape, natural disaster, combat experience, child abuse, or even vicarious trauma experienced by emergency service worker.

The First Decision….

“Is this someone who needs an immediate, active intervention in order to prevent harm in the client or to others, or can I safely conduct my usual intake and therapy procedures.  There are two errors that must be avoided: (1) failing to prevent serious consequences, including death, destructive actions, and long term pathology by not promptly responding in crisis mode and, (2) pathologizing a condition that, while painful and debilitating, is best understood as a normal, expectable response to the stressors, transitions, and traumas of daily life (Ingram, 2012, p. 117)”  

A careful reading of the five hypotheses in chapter eight is useful in determining the nature of a client’s “crisis” and the associated needs. For all individuals, it is essential to assess for the presence of an emergency situation that produces a concern for the client and/or others. In the instance that a client expresses homicidal and/or suicidal ideation a thorough assessment is necessary. An examination of relevant stressors, suicide plan, presenting symptoms and past history, are key elements of a suicide risk assessment (Ingram, 2012, p120). Homicidal ideation also requires careful assessment and raises mandatory reporting concerns. Finally, evidence of child abuse also requires careful assessment and mandatory reporting. In order to adhere to all legal and ethical obligations, it is essential to be knowledge of the laws in your state and the ACA code of ethics.

In the event that a situation is not a true emergency, guidelines for the situational stressors and trauma hypotheses are useful.  Ingram, (2012) states these to hypothesis are based on crisis intervention literature which notes that “distressing impairment” (p. 117) of this magnitude are a byproduct of either situational stressors or developmental transitions.    Crises of this nature can be described as developing in the following stages:

  1. “STAGE ONE:  Rise in tension & stress.
  2. STAGE TWO: Unsuccessful coping.
  3. STAGE THREE:  Unsuccessful mobilization of emergency solutions.
  4. STAGE FOUR:  Disorganization & Crisis (Ingram, 2012, p. 118).”

Finally, while bereavement may be classified as a developmental transition Ingram, (2012) notes that there are theoretical models specifically designed to address this issue.  Trauma is also addressed as a separate hypothesis in acknowledgement of the obvious fact that stress and trauma are different things.

Emergency (CS1)

Summary & Key Ideas

In this instance, “the client presents an emergency [and] immediate action is necessary.  [It] must always be considered in first session to prevent serious consequences of not taking action”  (Ingram, 2012).  What follows are examples of situations in which this hypothesis may be applicable:

  1. Homicidal & Suicidal Risk.
  2. Mandated Reporting Requirements [i.e. abuse].
  3. Grave illness requiring immediate medical care.
  4. impaired judgment/disability & unable to care for basic needs.

In other words, is the client a danger to himself and/or others?  Are they unable to perform basic ADL’s? Ingram, (2012), suggests that practitioners know the mandatory reporting laws in their state, and how this pertains to confidentiality limits.  Additionally, when feasible consulting with a colleague or supervisor is essential.

Is this Hypothesis a Good Match

This hypothesis is ideally suited for situations in which a person is a danger to self and/or others.  It is also useful in situations where someone is unable to care for their own basic needs.  This hypothesis should be considered during the first session due to the potential negative consequences.

Treatment Planning

Ingram (2012) admits that when making a clinical decision, your best course of action is never  entirely clear!  Human beings are, by nature, complex.  Predicting someone’s future action is ultimately a your best-educated guess.   Two rules of thumb for the newbie: (1) better safe than sorry & (2) seek guidance from your clinical supervisor.  Generally speaking, this hypothesis focuses on people who (1) are a danger to themselves, (2) are a danger to others or, (3) are unable to meet their basic needs.  What follow is a quick-&-dirty list of issues you may need to wrestle with.

  1. Should I hospitalize?
  2. How can I maintain a therapeutic alliance while ensuring safety?  
  3. Risk Assessments
  4. Reporting violence & abuse 
  5. Ensuring client safety and well-being
  6. Mandatory reporting rules of law

Situational stressors – (CS2)

Summary & Key Ideas…

With this hypothesis it is important to examine whether or not the client’s symptoms are proportional to the level of stress they experience?  What are the specific stressors they are struggling with?  How well are they able to cope with the stress?  Examine any risk and/or protective factors that influence their ability to cope with stress.

Is This Hypothesis a Good Match

How does the situational stressor influence the client’s ability to cope?  Examine behavioral, cognitive, and emotional reactions to the stress.  How does the stress affect the individual’s overall well-being.  A convenient example you might compassion fatigue.

Treatment Planning

FIRST PRIORITY  Resolve the Situational Stressor that overwhelms the client’s ability to cope.  Ingram (2012), lists the following as steps for crisis intervention.

  1. “Instill Hope and give reassurance” (Ingram, 2012, p. 129).
  2. “Be in charge of the interview, provide structure, and present yourself as a problem-solving expert” (Ingram, 2012, p. 129).
  3. “Assess the crisis” (Ingram, 2012, p. 129) and help the client make sense of their situation.
  4. Allow the client an opportunity to prcess their thoughts and feelings.  
  5. Help the client to re-examine their perspective of things, (i.e. cognitive restructuring).
  6. “Develop a plan of action” (Ingram, 2012, p. 129) and help the client improve their coping skills and support system.
  7. Finally, monitor the client’s progress and plan with discharge in mind.

Developmental Transitions (CS3)

Summary & Key Ideas…

This clinical hypothesis is based on the developmental lifecycle theories that stress how humans progress through a series of stages in life!  Each stage builds on the one before it and involves a key challenge to overcome, (i.e. midlife crisis).  What follows is a list of terms and key ideas from theories upon which this clinical hypothesis is based.  It tends to focus on an individual model of development that normally occurs over a life span.  However, this developmental model must be placed within the proper cultural and historical context to be relevant to the client.  Gender differences also influence this process.

  1. “MATURATION: through the lifespan involves change, tension, stress and disruption of harmonious living, followed by periods of consolidation and stability
  2.  DEVELOPMENTAL – transitions are triggered by physical growth, psychological maturation, and social pressures and expectation
  3. STAGE – implies a fixed, linear sequence where one stage is completed before the next begins (i.e. Erickson and his concepts of disequilibrium/equilibrium).” (Ingram, 2012)

Is this hypothesis a good fit?

How does one determine if this hypothesis is a good fit?  Ingram, (2012), cautions gains utilizing this model as a preconceived model of growth but as a useful perspective upon which to evaluate an individual’s life history.  it can help us develop an understand the individual’s opportunities for growth and examine issues that were unresolved from previous developmental stages.  What follows are a few examples of common problems that this hypothesis may be a good fit for according to Ingram, (2012).

  1. “Major life decisions” (Ingram, 2012) – (for example having a baby). It can be difficult to make these decisions clearly at times.
  2. “Relationship problems” (Ingram, 2012) – working through relationships problems that develop and/or change as we grow is another developmental issue.
  3. “Cultural Deviation Distress” (Ingram, 2012) – sometimes if a person is deals with negative judgments from a culturally deviant lifestyle.  

Treatment Planning Ideas

Treatment planning should consider the person’s stage of development.  Ingram, (2012), suggests that psychoeducation be provided to help normalize the stress individuals feel when encountering a new stage in life.  Skills training can be helpful in allowing individuals to address new challenges (i.e. parenting challenges) if a skills deficit is uncovered (BL3).  Examining the client’s personal beliefs and feelings regarding the new stage in life is also useful.  Finally, where necessary, films, books, and community resources may be useful.

Loss and Bereavement (CS4)

Summary & Key Ideas…

The next crisis-related clinical hypothesis in the Ingram, (2012) textbook pertains to loss of a loved one or a catastrophic injury (quadriplegic).   Loss of this kind are both internal and external.  Knowledge about the stages of grieving is useful, however Ingram, (2012) cautions therapists to not a “rigid model of grieving”.  Hospice care, bereavement groups, are a few examples of resources that may be utilized.  Initial stages tend to involve feelings of shock and disbelief.  Over time feelings of pain, despair and depression can take over.  Resolving the loss can also involve swinging between denial and despair. What follows are a few related concepts…

  1. Key tasks in the grieving process:  
    1. “Accepting the reality of loss
    2. Working through the pain of grief
    3. Adjust to an environment that includes memory of loss
    4. Emotionally relocate that which was lost and move on…(Ingram, 2012)”
  2. Dual process theory for bereavement: As stated earlier, bereavement means working through feelings of shock, pain, disbelief, and despair.  It requires working through and processing feelings of loss alongside learning to cope and continue moving forward in the world.  This theory describes it as a loss orientation and restoration orientation.  
  3. Three types of complicated bereavement
    1. Chronic Type – too much focus on loss and lack of progress in restoration tasks
    2. Delayed, Inhibited / Absent – too little focus on loss with exclusive focus on restoration tasks.
    3. Traumatic type – intense and persistent confrontation with loss combined with avoidance.

Is this hypothesis a good fit?

Ingram, (2012) begins by providing a list of risk factors that are commonly associated with a complicated bereavement process: (1) the type of relationship with the deceased, (2) circumstances of death, (3) how the person copes with death, (4) other life stressors, and (5) inadequate social support.  Ideal circumstances in which to utilize this hypothesis include when an individual has difficulty coping with the loss and they are experiencing an incomplete recovery.  Examples of situations in which it may be useful can include; (1) divorce, (2) miscarriage, (3) death,(4) infertility, or (5) terminal illness.

Treatment Planning ideas…

  1. Evaluate the client’s level of distress, while providing empathy and room to process the feelings…
  2. Examine skills deficits in how the person is coping.  Consider DBT/CBT skills
  3. Provide psychoeducation on the grieving process. 
  4. Help the client cope with current relationships and life responsibilities.
  5. Restoring the client can involve revisiting experiences and promoting sense of connection to deceased. 
  6. Bereavement groups, CBT/existential/Psychodynamic (Ingram, suggestions). 

Trauma (CS5)

Summary & Key Ideas…

Click here to read a brief explanation of PTSD.  This clinical hypothesis focuses on trauma survivors who experience persistent distressing impairment as a result of traumas they have experienced. Treatment interventions can involved group therapy, spiritual interventions, EMDR, exposure therapy and CBT/DBT.  Ingram, (2012) states: “the concept of PTSD implies an etiologic process whereby pathogenic memory produces involuntary, distressing recollections in the form of intrusive thoughts, nightmares, flashbacks…etc…These recollections heighten emotional arousal….This…in turn, motivates attempts to avoid anything that might trigger recollections.”

  1. Risk factors:  “Severity of stressor, Prior vulnerability factors, Subjective Threat level, Lack of Social Support.” (Ingram, 2012).
  2. Protective factors: “effective coping skills, social support, spiritual factors, sense of self.” (Ingram, 2012).
  3. Cultural context: “Ethnocultural variables are important when assessing trauma history of survivors. Cultural factors can interfere and prevent effective interventions” (Ingram, 2012)..

How To Determine fit?

Ingram, (2012) begins by noting that trauma is harmful regardless of whether a person has symptoms of a diagnosis.  With this in mind, addressing the client’s problem first involve examining the specific symptoms they are experiencing, (trouble sleeping, emotionally numb, depressed, etc).  Then gather data about their trauma history, “avoid extremes in neglecting the topic and addressing it with insensitivity” (Ingram, 2012).

Treatment Planning Ideas…

“WARNING BEFOREHAND: Trauma interventionists need special training, competent supervision or consultation, and ongoing professional support. The need to be aware of the risk of vicarious trauma….” (Ingram, 2012).  With this in mind, my textbook provides an overview of three categories of interventiosn…

  1. “Critical stress debriefing immediately after trauma” (Ingram, 2012).
  2. “Treatment of PTSD Symptoms” (Ingram, 2012).  
  3. Treatment of complex PTSD” (Ingram, 2012). 

Treatment of PTSD requires multiple clinical hypotheses:  (1) Medical Interventions (BE2), (2) Mind-Body Connections (BE3), (3) Emotional Focus (BE4), (4) Conditioned Emotional Responses (BL2), (5) Cognitive (C1-4), (6) Spiritual Dimension (ES3), (50 Social Support (SC3).  Education/Medication/Exposure/CBT/EMDR/Relational psychotherapy.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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