The Process of Therapy - The Counseling Relationship - Case formulation

Question 1

What is the “process”?

Answer 1

(a) Any activity involving change can be described as being a ‘process’, since what happens in therapy is not static, and there is some sort of sequence of events that takes place.
(b) A very wide set of factors that may promote or inhibit therapeutic effects in clients. The contrast between ‘process’ and ‘outcome’: therapeutic ‘processes’ are the ingredients that contribute to outcomes.
(c) An essential human quality of being and becoming (Humanists)
(d) The way that clients in therapy attempt to comprehend or assimilate
difficult experiences in their lives. For instance, the emotional processing model employed by Greenberg et al. (1993) involves ‘doing
things’ to and with emotions: naming them, expressing them, reflecting on their meaning.

Question 2

Different

types of units - process

Answer 2

1. The speaking turn (interaction unit), encompassing the response of one speaker surrounded by the utterances of the other speaker. This can be regarded as a microprocess that lasts for perhaps no
   more than one or two minutes.
2. The episode, comprising a series of speaking turns
   organized around a common task or topic. This
   process unit is sometimes described as a therapeutic
   event, and can last for several minutes.
3. The session.
4. The treatment: the entire course of a treatment
   relationship.

Question 3

What happens in the begining phase of therapy?

Answer 3

• Negotiating expectations and preparing clients for 
counselling
• Assessment
• Case formulation and contracting
• Establishing a working alliance

Question 4

What happens in the middle phase of therapy?

Answer 4

Middle phase’
• Assimilation (understanding) of problematic experiences
• Process as: (a) as a gradual unfolding of new awareness or mastery of new skills and behaviours OR (b) a series of
significant change events= moments when ‘something
happens’?
• Client and counsellor need to work productively together to achieve a deeper understanding of the issues that brought the client to counselling, and to translate that understanding into
strategies and action that will allow the client to achieve his or her life goals: a counsellor should be responsive to the client’s needs, way of communicating, and style of problem- solving
• Using structured exercises and interventions- homework tasks.

Question 5

What happens in the ending phase of therapy?

Answer 5

The consolidation and maintenance of what has been achieved
The generalization of learning into new situations
Using the experience of loss and/or disappointment triggered by the ending
as a focus for new insight into how the client has dealt with such feelings in other situations.

Question 6

Which is the counseling basic tool?

Answer 6

The relationship!
• The basic tool of counselling is the person of the counsellor.
• Who the counselor/therapist is and the way he/she interacts with the client is at the heart of what counselling is about.
• Irrespective of the knowledge and the use of different theories and
techniques, the fact remains that theory and techniques are delivered through the presence and being of the counsellor as a person.
• Even if different approaches to counselling make sense of the client–therapist relationship in different ways they all agree that effective
counselling depends on how this kind of relationship operates, what happens when it goes wrong and how to fix it.

Question 7

How is the therapeutic relationship in psychoanalysis?

Answer 7

The relationship becomes the “container”, a place within which the most painful and destructive feelings of the client
can be expressed and acted out, because they are held safe there.
• This container has boundaries, or frame, and they need to be clearly defined that the client knows that they are there.
• Within this context of a personal relationship transference develops (i.e. reactions toward the therapist that have their
origins in unresolved childhood conflicts, desires and emotional needs, which are now finding expression, years later, in the safe environment of the therapy session) and the
patient typically becomes dependent on the therapist as an authority, teacher and mentor. Through the emotional and cognitive understanding of the transference healing occurs.

Question 8

How is the therapeutic relationship in client-centered therapy?

Answer 8

The core conditions
The principal relationship qualities suggested by these ideas are presence and contact.
It is through being present, in the current moment, with the client that the counsellor is able to be empathic, accepting and congruent.
The image of the therapeutic relationship as being distinctive in its level of authentic presence lies at the heart of the humanistic
tradition in psychology and psychotherapy.

Question 9

How is the therapeutic relationship in CBT?

Answer 9

• Although the relationship between client and counsellor needs to be ‘good enough’ to enable these interventions to be applied appropriately, the focus of CBT is mainly on the interventions, rather than the relationship.
• The primary aim of CBT is to help the person to change their performance in
social situations in the external, ‘real’ world, typically through using
structured exercises and interventions.
• The image that pervades much cognitive–behavioural practice is the counsellor–client relationship as similar to that of a coach or teacher and student.
• Some CBT therapists, and many cognitive therapists, regard their role as being like that of a scientist or philosopher, who is trying to challenge the basic, dysfunctional beliefs and cognitive schemas held by the client.
• A central theme: collaboration. The counsellor and client work alongside
each other to find solutions to a problem that is ‘out there’.

Question 10

How is the therapeutic relationship in integrative models?

Answer 10

Α functioning working alliance between a therapist and a client comprised by three features: an agreement on goals; an assignment of a task or series of tasks; and the development of a bond. Αll forms of therapy were built around goals, tasks and bonds, even if the relative weighting of each element varied in different approaches.

Question 11

Directiveness and

supportiveness in integrative models (therapeutic relationship)

Answer 11

● High direction/low support. The therapist is in charge of what is happening. This
style is appropriate when the client is unwilling or unable to move him/herself toward the goals of therapy.
● High direction/high support. The therapist adopts a teaching/psycho-educational role, in relation to a client who has indicated a willingness to learn. This is relational style commonly found in CBT approaches.
● Low direction/high support. The therapist using this style is essentially
accompanying a client who is engaged in a process of exploration and growth.
This is the relational style associated with person-centred counseling.
● Low direction/low support. The therapist functions mainly as an observer of the
client’s progress. This relational style is characteristic of classical psychoanalysis.

Question 12

What is case conceptualization?

Answer 12

• Case conceptualization: looking deeply into someone and making
sense of what you see.
• Sometimes it is referred to as “assessment”

Question 13

What is the difference between case conceptualization and assessment?

Answer 13

“assessment” refers to 2 different counseling tasks:
1. A case conceptualization approach to assessing individual and family
dynamics, also referred to as a “theory-informed assessment”, OR
2. A diagnostic approach to assess client symptoms, also called “clinical
assessment”.

Question 14

Importance of case formulation

Answer 14

• The different counseling theories provide therapists/psychologists/
clinicians the unique lenses to understand a client. They allow us to view clients and their problems through a larger context and help us
put the different pieces of the puzzle of a client’s life together.
• BUT, no theory is value-free, and every theory does not work well for every client.

Question 15

Does case formulation ends?

Answer 15

Case formulation never ends
• As a hypothesis, a case formulation is also subject to revision as new
information emerges, as tests of the working hypothesis indicate,
and as a clinician views the patient through the lens of an alternate theoretical framework.
• Case formulation involves both content and process aspects.

Question 16

Which are the content aspects of case formulation?

Answer 16

• Content aspects comprise several components that together paint a holistic picture of the individual and his or her problems.
• The treatment plan may include details such as the type of therapy or
interventions recommended, the frequency and duration of
meetings, therapy goals, obstacles toward achieving these goals, a prognosis, and a referral for adjunctive interventions such as
pharmacotherapy, group therapy, substance abuse treatment, or a medical evaluation. Alternatively, interventions other than
psychotherapy, or no interventions at all, might be recommended.

Question 17

Case formulation - Psychoanalysis

Answer 17

Significant psychoanalytic concepts (psychic determinism and the dynamic unconscious; the symbolic meaning of symptoms, ego defense mechanisms as
maintainers of psychic equilibrium, etc). The 3 contributions of Freud to case formulation:
(a) Freud provided us with an expanded view of the psychotherapy interview.
Before Freud, the psychiatric interview was viewed similarly to an interview in a medical examination, highly structured and focused on obtaining a history and
mental status review, reaching a diagnosis, and planning treatment.
(b) Since Freud, therapists recognize that patients often enact their psychological
problems, and especially interpersonal problems, in the course of describing them to the therapist. The interview process itself became an important source of information for the formulation, paying attention to the manner in which patients organize their self-presentations and thoughts, approach or avoid certain topics, and behave nonverbally and it has become part of what the therapist formulates.
(c) A third contribution of psychoanalysis to formulation is its emphasis on the case study.

Question 18

Case formulation - Humanistic therapy

Answer 18

Carl Rogers (1951): “psychological diagnosis . . . is unnecessary for [client-centered] psychotherapy, and may actually be detrimental to the therapeutic process” (p. 220). Rogers was concerned that formulation places the therapist in a “one up” position in relation to the client and may introduce an unhealthy dependency into the therapy relationship, thus impeding a client’s efforts to
assume responsibility for solving his or her own problems.
• Assumption: the practice of “psychological diagnosis” places the therapist and
client in a noncollaborative relationship in which the formulation is imposed
rather than reached jointly and modified as necessary. Contemporary exponents of phenomenological therapies are less rejecting of formulation than was Rogers but tend to emphasize formulation of the moment-to-moment experiences of the client (e.g. EFT, experiential therapies).
• Contributions of humanistic psychology to case formulation: its emphasis on
the client as a person instead of a “disorder” that is “treated,” its focus on the
here-and-now aspect of a human encounter rather than an intellectualized
“formulation,” and its view of the therapist and client as equals in their relationship. Humanistic psychology also takes a holistic rather than a
reductionist view of humankind.

Question 19

Case formulation - Behavior Therapy

Answer 19

Focus on a “functional analysis” of behavior, which involves identifying relevant characteristics of the individual in question, his
or her behavior, and environmental contingencies or reinforcement, then applying behavioral principles to make
alterations.
• Emphasis on symptoms as the problem and aim directly at symptom relief.
• They have emphasized empirical demonstrations to support the effectiveness of their approaches.

Question 20

Case formulation - Cognitive Therapy

Answer 20

• Specific mechanisms have been theorized for specific disorders. These formulations emphasize a set of cognitive patterns, schemas, and faulty information processes, each specific to the type of disorder (Beck et al,).
• More recently, there is increased interest on individualized formulations.

Question 21

Differences between approaches to case formulation

Answer 21

1. The nature of the behaviour that therapy should change;
2. Which independent variables are important in a case formulation;
3. The role of history in a case formulation;
4. How to use the case formulation with the client;
5. The role of psychiatric diagnosis, if any, in case formulation; and
6. How prescriptive the definitions of case formulation are (Sturmey,
   2009, p. 8)