Case Conceptualization and Effective Interventions: Assessing and Treating Mental, Emotional, and Behavioral Disorders

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Lynn Zubernis & Matthew Snyder

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    Acknowledgments

    The authors wish to thank Dr. Rick Parsons and Dr. Naijian Zhang for their support and encouragement, and for allowing us to be part of the Sage Counseling and Professional Identity Series. We are grateful for their insightful comments and recommendations, as well as the input of our reviewers who contributed their expertise in order to help us find the right balance of depth and breadth in this book.

    Special thanks to our intrepid graduate assistant, Emma Harrison, who will be a fabulous counselor herself someday soon. And to Kassie Graves from Sage who shepherded us through the publication process with efficiency and good humor.

    Finally, we would like to thank our families (Emily, Jeffrey, and Kevlin, and Carrie and Adam) for allowing us the time and space to tackle an ambitious project—and for understanding our passion for counseling.

    SAGE wishes to acknowledge the contributions of the following reviewers: Wanda P. Briggs, Winthrop University; Mary J. Didelot, Purdue University Calumet; Franco Dispenza, Georgia State University; Carolyn F. Hester, Grambling State University; Lisa Hollingsworth, Purdue University Calumet; Jo Anne Jankowski, Pennsylvania State University Eberly; Karen Sue Linstrum, Northwestern Oklahoma State University Alva; Christine Sacco-Bene, Barry University; Anthony T. Strange, Winthrop University; Cory Viehl, Georgia State University; and Joshua C. Watson, Mississippi State University Meridian.

    Series Editors’ Foreword: Introduction to the Series Counseling and Professional Identity in the 21st Century

    As members of the Counseling Profession, we are committed to the promotion of wellness. Rather than curing disease, our Profession distinguishes itself among other helping professions by retaining a focus on development, prevention, client-environment interaction, and empowerment. The wellness and preventive perspective on assessment and treatment of mental health issues has made mental health counselors fully understand and highly value the need for engagement in remedial services.

    As counselors we are required to engage in a process of case conceptualization while providing professional services. The case conceptualization that includes data collection, data organization, and finding meaning, can either target remediation or prevention. This process not only becomes the foundation for the formulation and implementation of our interventions and treatment plans, but also establishes a clear and valid conceptualization. However, it is quite challenging to connect this conceptualization to a well-established and empirically supported intervention. This challenge is not only addressed, but also made easier to overcome, by the text you hold in your hands—Case Conceptualization and Effective Interventions.

    Case Conceptualization and Effective Interventions not only provides current research on mental, emotional and behavioral disorders found in the Diagnostic and Statistical Manual of Mental Disorders -5 (DSM-5) but also frames these disorders within a unique model for case conceptualization. The Temporal/Contextual (T/C) Model of case conceptualization created by Zubernis and Snyder is a comprehensive, practical, easy-to-apply framework for interacting with and understanding clients. Their extensive use of case illustrations and guided exercises helps counselors not only comprehend, but apply the model within their own practice. As noted within each chapter of the book, the T/C model of case conceptualization provides the counselor with the insight needed to formulate intervention and treatment plans, which reflects the evidence based on the most recent research valuing the uniqueness of the human condition in its diversity and individual variation. We believe Case Conceptualization and Effective Interventions is an essential tool for all counselors seeking informed, ethical and effective decisions in practice.

    As is obvious, one text or one learning experience will be neither sufficient for mastery of the process of case conceptualization, nor possible for the successful formation of your Professional Identity and Practice. The formation of both your Professional Identity and Practice will be a lifelong process – a process that we hope to facilitate through the presentation of this text and the creation of our series: Counseling and Professional Identity in the 21st Century.

    Counseling and Professional Identity in the 21st Century is a new, fresh, and pedagogically sound series of texts targeting counselors in training. This series is NOT simply a compilation of isolated books matching those which are already on the market. Rather, each book with its targeted knowledge and skills will be presented as part of a larger whole. The focus and content of each text serves as a single lens through which a counselor can view his/her clients, engage in his/her practice and articulate his/her own professional identity.

    Counseling and Professional Identity in the 21stCentury is unique not just in the fact that it ‘packaged’ a series of traditional texts, but that it provides an integrated curriculum targeting the formation of the counselor’s professional identity and efficient, ethical practice. Each book within the series is structured to facilitate the ongoing professional formation of the counselor. The materials found within each text are organized in order to move the counselor to higher levels of cognitive, affective and psychomotor functioning, resulting in his/her assimilation of the material into both his/her professional identity and approach to professional practice. As essential to the practice of counseling, each book in the series will emphasize the following:

    • the assimilation of concepts and constructs provided across the texts found within the series, thus fostering the counselor’s ongoing development as a competent professional;
    • the blending of contemporary theory with current research and empirical support;
    • a focus on the development of procedural knowledge, with each text employing case illustrations and guided practice exercises to facilitate the counselor’s ability to translate the theory and research discussed into professional decision making and application;
    • the emphasis on the need for and means of demonstrating accountability, and;
    • the fostering of the counselor’s Professional Identity and with it the assimilation of the ethics and standards of practice guiding the counseling profession.

    We are proud to have served as co-editors of this series, feeling sure that each text book, just like Case Conceptualization and Effective Interventions, will serve as a significant resource to you and your development as a professional counselor.

    Richard Parsons, Ph.D.Naijian Zhang, Ph.D.

    Preface

    As the profession of counseling continues to grow, counselors provide services in a wide range of settings, from community mental health centers to schools and hospitals. As a mental health counselor, you work with diverse populations of clients and help them deal with a wide variety of challenges. In order to do so effectively, an understanding of the process of case conceptualization is critical; to help your clients, you must be able to figure out what is standing in the way of their optimal development, help them set goals for how to achieve that optimal development, and identify the strengths and supports that allow them to get there.

    Case Conceptualization and Effective Interventions for Counselors provides the tools for you to accomplish your goal of becoming an effective counselor. We introduce an innovative new model for case conceptualization called the Temporal/Contextual (T/C) Model, which gives you a comprehensive, practical, easy-to-apply framework for interacting with and understanding your clients. Using case examples, you learn to use the T/C Model to gather information and generate hypotheses about a wide variety of clients. We also include a summary of the current information on mental, emotional, and behavioral disorders found in the Diagnostic and Statistical Manual of Mental Disorders (DSM). A complete reiteration of all the DSM criteria is beyond the scope of this text, and would be both overwhelming and redundant. Instead, we focus on presenting problems most often found in counseling settings and then summarize the information in an accessible, easy-to-understand format.

    In addition, we address the competencies identified by the Council for the Accreditation of Counseling and Related Educational Programs in their latest standards as essential to competent counseling practice in a multicultural society (CACREP, 2009). The current standards include an increased emphasis on the applied aspects of counseling, especially those that are evidence based. As you work your way through this book, each chapter brings the counseling experience to life by blending current theory and research with case illustrations that anchor the material in real-world experience.

    The first section of the book describes the process of counseling within the historical context of the profession and the unique professional identity of a counselor. Counseling is a complex process. Before we can effectively help our clients, we must have an understanding of who we are as counselors. What is our history, what are our goals, and what is our identity as counselors? In this section, we review the literature on counseling effectiveness, including skills, attributes, and theoretical orientation. Although these concepts are covered in introductory courses in most counseling programs, we apply them here to illustrate their use in the process of case conceptualization. Rather than including an exhaustive variety of theoretical approaches, the text briefly discusses the theories most often employed by counselors, emphasizing application in case conceptualization and treatment planning.

    An understanding of professional identity, history, skills, and theory provides the lens through which we encounter our clients, and the template which we use to make sense of clients’ challenges and strengths. In this section, you also learn and practice applying the T/C Model, which provides a framework to understand and help our clients. The T/C Model helps you become a reflective counselor, continually assessing the counseling process, and an intentional counselor, asking the questions and utilizing the tools which help you to help your clients.

    The second section includes chapters on the most common presenting problems in counseling settings, and includes empirically supported interventions to address these problems, which are both culturally and situationally responsive. Case Conceptualization and Effective Interventions provides a pathway for treatment of mental, emotional, and behavioral disorders based on the most recent evidence-based research, while at the same time recognizing that diagnosis and treatment are part of a dynamic and evolving field that embraces human diversity and individuality. Thus, the text is not designed to present a rigid formula for assessment, prevention, and intervention, but rather to help counselors make informed, ethical, and effective decisions to benefit their clients. The American Counseling Association’s code of ethics stresses the need to employ interventions with the greatest chance of success; therefore, the text focuses on research-based treatment strategies most often used for the disorders included.

    An in-depth discussion of specific interventions is beyond the scope of this text; rather, the most commonly employed empirically supported treatments are described, with links to more extensive training materials provided in the “Go Further” section at the end of each chapter. In addition, this book is not intended to teach general counseling skills. We assume that you already have the fundamental knowledge and skills to work effectively with clients; this book shows how to employ those skills more effectively with the application of the case conceptualization model presented here.

    Finally, the third section emphasizes the importance of integrating the information, principles, and practices of counseling within an evolving professional identity. As you go forward, the T/C Model that you learn in this book enriches your counseling practice by ensuring that the case conceptualization is carried out in context and that the process is an intentional one. In addition, this final section ties case conceptualization to the next steps with a focus on effective interventions that truly help clients.

    The Case of Katy

    Katy is a 23-year-old Korean American female. She sought counseling because of family and relationship issues. She graduated in May from college with a bachelor’s degree in English Literature and a grade point average (GPA) of 3.92, but has yet to find a job and lives at home with her mother, stepfather, and two younger half-brothers. She states that she is self-referred; however, she also says that she is seeking counseling because her on again/off again boyfriend made it a condition for getting back together. Prior to this visit, Katy sought counseling for a few sessions in college at the university counseling center when her main issue was feeling caught in the middle between her mother and stepfather’s frequent arguments.

    Katy reports high levels of depression and anxiety. She has trouble falling asleep because “my mind just won’t turn off.” When she does fall asleep, she often wakes up at 4:00 or 5:00 am and cannot go back to sleep. She often feels queasy, and says she “just isn’t hungry” a lot of the time. Katy hasn’t been to see a medical doctor, but admits that she’s gone down a few jean sizes and appears slightly underweight.

    In her first session with the counselor, Katy appears nervous. She speaks very rapidly, as though she just wants to get the words out. Her eye contact is sporadic; sometimes she glances at the counselor as if to gauge the counselor’s reaction, but then quickly looks away. At other times, she looks down at her hands, which she clasps and unclasps in her lap. Katy shifts position on the chair often, and generally appears uncomfortable.

    Katy describes her situation as “hopeless,” says that she is “a failure” who will “never find a job.” Her rocky relationship with her boyfriend has also made her doubt herself, and she fears she’ll be “alone all my life.” She is confused by what her next steps should be in life and feels “adrift,” now that she has graduated. Because she doesn’t have a job, she moved back in with her mother and stepfather three months ago. While they were fine with that decision, it’s clear they consider the arrangement to be temporary, and they expect Katy to find employment. Katy has been on several job interviews, but none were in her field, and she has received no job offers. She is beginning to feel hopeless about the prospect of getting a job, and is envious of her two best friends who are employed and living independently. Katy is certain that her parents and her stepparents are all looking at her with disapproval and consider her a failure.

    While Katy was never in trouble in high school or college, since she has graduated she mentions several instances of participating in risky sexual behaviors (one-night stands, unprotected sex, promiscuity), and says her friends would describe her as “crazy,” and “out of control.” She described a recent incident on a bus where she “just lost it.” She felt like she couldn’t breathe and that her heart was pounding out of her chest, and she started to feel dizzy. It got so bad that she had to have the bus driver stop to let her out before he reached the next bus stop. Since then, she has been avoiding public transportation. Unfortunately, she does not own a car, so she often feels “stuck” in the house during the day when her mother and stepfather are at work. On several other occasions, Katyexperienced the same feelings when she was in an unfamiliar place, and ended up leaving. The list of places she wants to avoid is growing, and the avoidance is starting to limit her daily life, especially when she booked a job interview for next week that she requires taking the bus.

    Katy’s parents divorced when she was six. Her mother and father have both remarried. Katy’s father is the owner of several neighborhood grocery stores. Her father grew up in Korea and immigrated to the United States as a young man. He opened his first store when he was 20 and now has four very successful stores. He was and still is very demanding and does not understand why Katy does not have a job yet. While Katy visited her father every weekend when she was younger, recently she has been avoiding going to see him because she expects a lecture.

    Katy’s mother and stepfather are currently separated, but still live together “for the sake of the children.” Katy’s stepfather, a tax accountant, is the parent she talks to the most and from whom she feels she receives unconditional love. When she was younger, Katy and her stepfather were quite close. Her stepfather is not home as much anymore, however, and Katy believes he may have a girlfriend. She misses their time together, but doesn’t want to rock the boat and risk him moving out completely.

    Katy reports having different “roles” depending on which parent she is with. Katy’s mother is a financial analyst. She has always expected A’s from her daughter, and held strict expectations for Katy about school and socializing. Katy describes her mother as “a worrier,” who didn’t let Katy go to sleepovers or to amusement parks because “bad things might happen.” Her mother tends to have a few drinks every night after dinner “to help me relax.” Katy remembers several periods of time during her childhood when her mother went out constantly, and she overheard arguments with her stepfather accusing Katy’s mother of cheating and “spending all their money.” During these times, Katy says she avoided her mother because “I never knew what would set her off and start her screaming and throwing things. She was crazy; it was horrible.” More than once, Katy says that she was hit by a thrown object, and her younger brothers have been as well. Other times, her mother just seemed withdrawn, and rarely smiled. Katy’s mother has never been affectionate, and Katy sometimes feels she needs to do negative things in order to get any attention from her mother.

    While Katy reports also being “a worrier” all her life, especially about her grades, she is usually quite social and enjoyed the new freedom to go out and socialize when she went to college. She was a member of a sorority as an undergraduate, and she enjoys going out with friends. She drank in college, but not to excess. Recently, however, when she does go out she frequently drinks to the point of blacking out. Her friends are worried about her, and Katy is concerned that they might stop inviting her to go out with them.

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    About the Authors

    Lynn Zubernis, Ph.D., is a licensed clinical psychologist and an associate professor at West Chester University of Pennsylvania. She has over 20 years of counseling experience in a variety of settings, including serving as the assistant director of a university counseling center and working as a school psychologist. Her experience also encompasses clinical work at inpatient psychiatric hospitals, community mental health organizations, eating disorder clinics, and juvenile detention facilities, and serving as coordinator for the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) for West Chester University’s fully accredited counselor education program. Dr. Zubernis has published numerous articles and books, and presented at national conferences on various topics, including counseling diverse populations, motivational interviewing, psychological understanding, positive psychology, and the psychology of being a fan.

    Matthew Snyder, Ph.D., is a licensed professional counselor, an associate professor, and department chair of Counselor Education at West Chester University of Pennsylvania. He has practiced in a number of diverse settings, such as working as a high school counselor, inpatient psychiatric specialist, university counselor, drug and alcohol counselor, university professor, and in private practice. He has over 20 years of clinical, teaching, and supervision experience. He has written several articles and presented at national conferences on motivational interviewing, treating adolescent depression, and counseling diverse populations.


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