How to find one's theoretical orientation?

[PsychNLife]

So I know a bit about theoretical orientations, mainly this comes from my basic psychology courses as well as some of the surface stuff I've read online. Just basic knowledge about CBT, Psychoanalytic, a bit about humanistic and whatnot, a smidge of whatever else is available. However, I'm having trouble, especially when needing to prepare for future applications, with finding the orientation (or mixed-orientation) that works well for me. As far as I know, the field as a whole is pretty into CBT and cognitive-behavioral approaches right now, and it seems to be pretty effective in certain situations. I just don't entirely like the idea of being limited to only that, and I'm sure that CBT isn't the only single valid orientation that's worth looking deeper into. Love the idea of evidence-based stuff that's supported by research, but I feel like these other orientations wouldn't really be around if they weren't somewhat valid or beneficial to people. I know psychoanalytic theory has that Freudian bad rep... but is it entirely useless?

It almost feels like...well isn't the point of grad school to study these orientations in depth? How can I fully know what type of orientation fits me before diving super in-depth into them and using them in practice (which obviously I cannot do yet as a senior in undergrad).

How did other people find their specific orientation? Anyone use a mixed ones, and if so, which one's seem to compliment each other best?

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[R. Matey]

Treatments | Society of Clinical Psychology

www.div12.org

You might want to flip the question and look at what are evidenced based practices in psychology and how best to gain competence in using them. What I linked above is a good starting place.

 

[WisNeuro]

So I know a bit about theoretical orientations, mainly this comes from my basic psychology courses as well as some of the surface stuff I've read online. Just basic knowledge about CBT, Psychoanalytic, a bit about humanistic and whatnot, a smidge of whatever else is available. However, I'm having trouble, especially when needing to prepare for future applications, with finding the orientation (or mixed-orientation) that works well for me. As far as I know, the field as a whole is pretty into CBT and cognitive-behavioral approaches right now, and it seems to be pretty effective in certain situations. I just don't entirely like the idea of being limited to only that, and I'm sure that CBT isn't the only single valid orientation that's worth looking deeper into. Love the idea of evidence-based stuff that's supported by research, but I feel like these other orientations wouldn't really be around if they weren't somewhat valid or beneficial to people. I know psychoanalytic theory has that Freudian bad rep... but is it entirely useless?

It almost feels like...well isn't the point of grad school to study these orientations in depth? How can I fully know what type of orientation fits me before diving super in-depth into them and using them in practice (which obviously I cannot do yet as a senior in undergrad).

How did other people find their specific orientation? Anyone use a mixed ones, and if so, which one's seem to compliment each other best?

Not commenting on any orientation in particular, but this isn't a good way to judge if something in healthcare is valid or useful. Healthcare is full of pseudoscience or clinical lore that has zero empirical basis, but still persists. Just because something is done, doesn't validate it's usefulness or ability to produce an effect above placebo.

That being said, I would gravitate towards what has a good basis with the populations you work with. As a neuropsychologist who still does treatment work in anxiety (PTSD and panic), CBT is definitely the go to. However, it's always good to have multiple tools in your toolbox. I have several years of psychodynamic work and supervision that I occasionally draw from as well.

 

[PsychNLife]

Not commenting on any orientation in particular, but this isn't a good way to judge if something in healthcare is valid or useful. Healthcare is full of pseudoscience or clinical lore that has zero empirical basis, but still persists. Just because something is done, doesn't validate it's usefulness or ability to produce an effect above placebo.

That being said, I would gravitate towards what has a good basis with the populations you work with. As a neuropsychologist who still does treatment work in anxiety (PTSD and panic), CBT is definitely the go to. However, it's always good to have multiple tools in your toolbox. I have several years of psychodynamic work and supervision that I occasionally draw from as well.

Yes I know there's a lot of pseudoscience, I was mainly referring to the main categories of orientation (seems to be like Cognitive behavioral, psychodynamic, family systems, humanistic, etc). I don't want to do psuedoscience. However, it seems like more than one of these approaches to conducting therapy could be valid. Do you find that CBT approaches and psychoanalytic approaches can mesh cohesively for you in practice? It seems at first glance that the two could possibly conflict.

 

[WisNeuro]

Yes I know there's a lot of pseudoscience, I was mainly referring to the main categories of orientation (seems to be like Cognitive behavioral, psychodynamic, family systems, humanistic, etc). I don't want to do psuedoscience. However, it seems like more than one of these approaches to conducting therapy could be valid. Do you find that CBT approaches and psychoanalytic approaches can mesh cohesively for you in practice? It seems at first glance that the two could possibly conflict.

There is good evidence for some aspects of psychodynamic. Analytic... not so much. I also do not use projectives in my assessments, very limited usefulness and evidence base beyond some very narrow areas in which we already have better and quicker instruments for.

 

[Justanothergrad]

No one does just one theory. People generally integrate beliefs and this isn't an issue since, generally speaking, theories have distinct terms for most of the same ideas. Or concepts have just become accepted as general aspects of therapy (see, working alliance)

 

[PsychNLife]

No one does just one theory. People generally integrate beliefs and this isn't an issue since, generally speaking, theories have distinct terms for most of the same ideas. Or concepts have just become accepted as general aspects of therapy (see, working alliance)

Understandable, but I still would need to figure out what type of integration I like best (probably at least some level of CBT). I have some basic overview, but I feel like I just need more before committing to either one or a mixture on my applications/statements.

 

[Justanothergrad]

Understandable, but I still would need to figure out what type of integration I like best (probably at least some level of CBT). I have some basic overview, but I feel like I just need more before committing to either one or a mixture on my applications/statements.

Commitment is over-rated honestly. It encourages an end state, rather than active process of evaluation, reflection, and change. No training should be without exposure to all of the contemporary theories (BT, CT, Dynamic, Humanistic, etc). And frankly, you probably will. I get the problem you're in though, you want to look committed so you don't look without direction- how do you pick without knowing. Rest assured, the application process is forgiving to your development and don't stress too much. I'd emphasize the values and ideas you share with potential research matches to the degree to which you feel as though you understand the ideas and have been exposed to them- and remain open to learning and exploring the complexity of treatment and theory.

tl;dr, be adaptive and adaptive in your application while you identify common ground

 

[PsychNLife]

Commitment is over-rated honestly. It encourages an end state, rather than active process of evaluation, reflection, and change. No training should be without exposure to all of the contemporary theories (BT, CT, Dynamic, Humanistic, etc). And frankly, you probably will. I get the problem you're in though, you want to look committed so you don't look without direction- how do you pick without knowing. Rest assured, the application process is forgiving to your development and don't stress too much. I'd emphasize the values and ideas you share with potential research matches to the degree to which you feel as though you understand the ideas and have been exposed to them- and remain open to learning and exploring the complexity of treatment and theory.

tl;dr, be adaptive and adaptive in your application while you identify common ground

Yes this is exactly my conundrum. It's good to know there's a lot of room for growth. For some reason, I got it in my head that schools will heavily weigh your expressed interest in an explicitly stated orientation, and that would be a big deal when it came to my statements. If it's not a big deal, that's reassuring though.

 

[WisNeuro]

Yes this is exactly my conundrum. It's good to know there's a lot of room for growth. For some reason, I got it in my head that schools will heavily weigh your expressed interest in an explicitly stated orientation, and that would be a big deal when it came to my statements. If it's not a big deal, that's reassuring though.

Well, it should generally match the site. If you write all about how you're interested in psychoanalytic theory and want to practice it, and you're applying to a midwest program that hasn't had an analytic faculty for more than 30 years, it won't look great.

 

[AbnormalPsych]

Learn about them all. Be open to studying our field's history - the good and bad. Be smart in understanding what the healthcare system wants to see. Read a lot of peer-reviewed research in the disorders and population you most want to work with. Learn what smart people that do that kind of work do and why. A few years down the road, find a middle ground based on how you have learned to understand the human condition/experience, while utilizing science to back up how you intervene.

If you work with some specific disorders (e.g., PTSD) there will be a much narrower/clearer conceptualization as to what is going on, and thus intervention. Sometimes.

It will come in time.

 

[PsychNLife]

Learn about them all. Be open to studying our field's history - the good and bad. Be smart in understanding what the healthcare system wants to see. Read a lot of peer-reviewed research in the disorders and population you most want to work with. Learn what smart people that do that kind of work do and why. A few years down the road, find a middle ground based on how you have learned to understand the human condition/experience, while utilizing science to back up how you intervene.

If you work with some specific disorders (e.g., PTSD) there will be a much narrower/clearer conceptualization as to what is going on, and thus intervention. Sometimes.

It will come in time.

This could be good advice that I will use in the future. What I'm getting though is that, at least for applications, a general idea of values, surface background, and openness to learn will be acceptable to schools as opposed to "X is my orientation, this is why it's my orientation, etc"?

 

[AbnormalPsych]

For grad school apps? I would say yes in general and in an ideal world. And for some programs. Willingness to be open, synthesize, and learn is a value.

But, in reality, for some programs and some mentors doing very specific work, you are best served choosing the best answer. Specific phobia research? Definitely not time to talk up your knowledge of Gestalt principles or analytic tendencies.

 

[PsyDr]

As an applicant: your theoretical orientation is the orientation of whatever school to which you are applying.

 

[Fan_of_Meehl]

Treatments | Society of Clinical Psychology

www.div12.org

You might want to flip the question and look at what are evidenced based practices in psychology and how best to gain competence in using them. What I linked above is a good starting place.

Agreed. I also think it's important to remain up-to-date--as much as possible--with the empirical literature in the field as a whole (including theories of psychopathology, personality theory, etc.) especially as relates to core processes presumed to underlie dysfunctional patterns of thinking/feeling/behaving (holy trinity of CBT, so to speak). Breaking down reactions in cognitive behavioral terms (e.g., event --> thought --> emotion/physiology --> behavior (or impulse)) can be a foundation for collaboratively choosing interventions with clients but, most often, things in your session will not necessarily go the way that the example in Judith Beck's (or anyone else's) book says they will (or the treatment manual says they will). When you run into roadblocks to implementation of CBT tools/procedures, it's imperative that you have a good body of sound psychological theories (including, say the motivational interviewing stuff or even Millon's stuff on personality disorders) in mind to help you conceptualize and overcome roadblocks including problems in the therapeutic relationship itself.. Clinical Psychology Review is one of my favorite journals and I find a lot of stuff in there that is useful in conceptualizing and intervening with folks who have mental disorders and want to improve their lives.

 

[Fan_of_Meehl]

Understandable, but I still would need to figure out what type of integration I like best (probably at least some level of CBT). I have some basic overview, but I feel like I just need more before committing to either one or a mixture on my applications/statements.

If you want a good reference for CBT, I find that Tolin's 'Doing CBT' is a very good one. It's much more 'theory rich' than standard 'intro to CBT' books out there and does a good job of integrating up-to-date findings from research/theory into the nuts and bolts of the techniques.

Amazon product

 

[deleted343839]

This could be good advice that I will use in the future. What I'm getting though is that, at least for applications, a general idea of values, surface background, and openness to learn will be acceptable to schools as opposed to "X is my orientation, this is why it's my orientation, etc"?

It would be unreasonable to expect applicants to commit to a theoretical orientation in grad school applications. It seems irrational to ask someone with little to no training in the field to commit to a treatment philosophy. That comes a lot later, through training and experience, and frankly I think we tend to oversell the importance of orientation at any stage. I have a lot more respect for someone who expresses a knowledgeable commitment to evidence-based practice than to someone who aligns with a "camp."

 

[futureapppsy2]

A lot people say that they become behaviorists because “it just clicked for them (which is ironically mentalistic).

 

[ClinicalABA]

A lot people say that they become behaviorists because “it just clicked for them (which is ironically mentalistic).

Personally, I display behavior analytic behaviors due to a combination of learning history, current environmental contingencies, and genetic/species specific traits and abilities. In other words, it just clicked.

 

[ClinicalABA]

...I have a lot more respect for someone who expresses a knowledgeable commitment to evidence-based practice than to someone who aligns with a "camp."

This. Why is it not sufficient to just say "I do what I do because it's been shown to be effective and I'm trained to do it." Its a job. Bad things can happen when we make it part of our personal or philosophical identity (such as thinking that client outcomes are more related to who we are, than to what we've been trained to do and how we do it).

 

[EmotRegulation]

As a faculty member in a clinical psychology program, I can say that if someone were to describe an orientation in their application materials I would give it basically zero attention. OK, that's a bit harsh--I would read it for a sense of how the person communicates their thoughts and perspectives and perhaps an indication of some initial knowledge about orientation, but a person cannot know their orientation prior to doing clinical work. Hell, I work with graduate students up to internship applications who don't really have a sense of their orientation yet, and that's fine! An openness to learning, a desire to be trained in the model of the program and a general curiosity about human beings are what I look for far more than a stated theoretical orientation.

 

[Ollie123]

I think they want to see that you are being thoughtful about it and that you generally align with what the school can offer. Not that you know exactly what your now-and-forever theoretical orientation will be.

For what its worth, you have an essay specifically on what your theoretical orientation is for internship. I basically wrote mine about how theoretical orientations were bad and the question was stupid (in....not exactly those words). Think I landed 13/16 interviews, or something like that.

 

[conky124]

A lot people say that they become behaviorists because “it just clicked for them (which is ironically mentalistic).

not if you just call the "clicking" a behavior.

Pro tip: call everything a behavior that way you cant be wrong.
Pro tip2: just call your self a third wave ________[behaviorist or other orientation]

Also, in my experience, my orientation ended up being what my supervisors and training heavily emphasized which was ACT and other third wave CBTs. This was kind of a bummer at first because humanism and existentialism is what originally drew me in. At the end of the day, admissions people and jobs are looking for behaviorists because their methods are empirically supported and easy to study empirically. They also work.

 

[cara susanna]

Pro tip2: just call your self a third wave ________[behaviorist or other orientation]

I just came here to have a good time and I'm honestly feeling so attacked right now.

 

[R. Matey]

I basically wrote mine about how theoretical orientations were bad and the question was stupid (in....not exactly those words). Think I landed 13/16 interviews, or something like that.

Yeah, why is theoretical orientation still a thing? No one practices purely from one stance and it's clear (at least to me) that people have different reasons for integrating techniques from other schools of psychotherapy other than what those techniques purport to do. IMO, we need a data-driven model that's NOT everything works so it doesn't matter.

 

[Spydra]

This. Why is it not sufficient to just say "I do what I do because it's been shown to be effective and I'm trained to do it." Its a job. Bad things can happen when we make it part of our personal or philosophical identity (such as thinking that client outcomes are more related to who we are, than to what we've been trained to do and how we do it).

Yeah, why is theoretical orientation still a thing? No one practices purely from one stance and it's clear (at least to me) that people have different reasons for integrating techniques from other schools of psychotherapy other than what those techniques purport to do. IMO, we need a data-driven model that's NOT everything works so it doesn't matter.

Both of these have been on my mind as I finalize my internship application. It really seems sort of stupid to be expected to claim a commitment to one theoretical orientation out of the four choices that are allowed. I've been wondering if at some point this essay will evolve into something else that is of greater interest to internship sites.

 

[WisNeuro]

Both of these have been on my mind as I finalize my internship application. It really seems sort of stupid to be expected to claim a commitment to one theoretical orientation out of the four choices that are allowed. I've been wondering if at some point this essay will evolve into something else that is of greater interest to internship sites.

Well, many of us give the essays a quick glance and nothing more. Most people in this particular section will talk about their main theoretical orientation and discuss implementation of others methods as well. People make WAY too big of a deal of this than it is most places.

 

[Spydra]

Well, many of us give the essays a quick glance and nothing more. Most people in this particular section will talk about their main theoretical orientation and discuss implementation of others methods as well. People make WAY too big of a deal of this than it is most places.

That is the impression I got from talking to training directors at conferences. So if the whole point of the application is have applicants tell training directors about the things that are of interest it seems that the application would evolve periodically. It doesn't seem helpful to have applicants prepare a packet of materials that include sections that are of little interest. It seems the most important essays are the autobiographical and diversity and perhaps the other two can become supplementary materials for sites who are interested in them. I imagine research-focused or research-supportive sites would want to see the research essay and sites that are therapy heavy would be interested in the theoretical orientation one.

 

[WisNeuro]

That is the impression I got from talking to training directors at conferences. So if the whole point of the application is have applicants tell training directors about the things that are of interest it seems that the application would evolve periodically. It doesn't seem helpful to have applicants prepare a packet of materials that include sections that are of little interest. It seems the most important essays are the autobiographical and diversity and perhaps the other two can become supplementary materials for sites who are interested in them. I imagine research-focused or research-supportive sites would want to see the research essay and sites that are therapy heavy would be interested in the theoretical orientation one.

different sites and people will emphasize different things. I don't emphasize the essays at all. Your CV and letters of rec are the only things I really look at.

 

[chicandtoughness]

Yeah, why is theoretical orientation still a thing? No one practices purely from one stance and it's clear (at least to me) that people have different reasons for integrating techniques from other schools of psychotherapy other than what those techniques purport to do. IMO, we need a data-driven model that's NOT everything works so it doesn't matter.

Oh boy. This is the hill I will die on and I refuse to be ashamed. Technique and theory are completely different things and I find that the two get conflated way too often.

No one practices purely from one stance, but it is still good to have an underlying theory that informs your formulation and case conceptualization. Case in point, I'm psychodynamically oriented but given my patient population (low SES, eating disorders, substance abuse) I use a whole smattering of CBT, DBT, ACT, ERP, 12 Step, etc. My psychodynamic orientation helps me conceptualize how maladaptive behaviors may arise, but I concede that in the short term, some of the alphabet soup I've listed above is much better at symptom management than twice weekly on the couch therapy. With confused supervisees, I have likened this to having a religion or spiritualistic belief that guides your everyday moral compass, but also being open to others' interpretations and engaging respectfully in other traditions should the situation call for it. I've brought Christian friends to a Buddhist temple; that doesn't shake their underlying belief in their Christian faith (theory), but they accept that Buddhist "methods" (technique) have their usefulness as well.

 

[R. Matey]

Oh boy. This is the hill I will die on and I refuse to be ashamed. Technique and theory are completely different things and I find that the two get conflated way too often.

No one practices purely from one stance, but it is still good to have an underlying theory that informs your formulation and case conceptualization. Case in point, I'm psychodynamically oriented but given my patient population (low SES, eating disorders, substance abuse) I use a whole smattering of CBT, DBT, ACT, ERP, 12 Step, etc. My psychodynamic orientation helps me conceptualize how maladaptive behaviors may arise, but I concede that in the short term, some of the alphabet soup I've listed above is much better at symptom management than twice weekly on the couch therapy. With confused supervisees, I have likened this to having a religion or spiritualistic belief that guides your everyday moral compass, but also being open to others' interpretations and engaging respectfully in other traditions should the situation call for it. I've brought Christian friends to a Buddhist temple; that doesn't shake their underlying belief in their Christian faith (theory), but they accept that Buddhist "methods" (technique) have their usefulness as well.

Mmmm....I think you missed my point. I'm totally for case conceptualization. I hammer that nail pretty hard when I give supervision. What I question is this weird tradition in psychology and allied mental health professions to engage in inductive reasoning by first aligning themselves with a particular orientation and then applying said orientation to a number of problems regardless of the research base rather than taking a deductive approach and examining what works with most people and then apply that. CBT has a lot of support, so I claim if someone asks, but there's some weird s*** even in there. I got a cognitive psychologist in my department to laugh at me by explaining Beck's concepts of modes. Personally, I think a data driven approach would be better. If you follow the work of John Norcross or David Burns, this is stuff that they've been talking about for the past decade.

 

[conky124]

Mmmm....I think you missed my point. I'm totally for case conceptualization. I hammer that nail pretty hard when I give supervision. What I question is this weird tradition in psychology and allied mental health professions to engage in inductive reasoning by first aligning themselves with a particular orientation and then applying said orientation to a number of problems regardless of the research base rather than taking a deductive approach and examining what works with most people and then apply that. CBT has a lot of support, so I claim if someone asks, but there's some weird s*** even in there. I got a cognitive psychologist in my department to laugh at me by explaining Beck's concepts of modes. Personally, I think a data driven approach would be better. If you follow the work of John Norcross or David Burns, this is stuff that they've been talking about for the past decade.

Aren't psychodynamic case conceptualizations shown to be particularly useful even if you are doing CBT or some sort of behavioral therapy? I had a supervisor who was behavioral and he recommended using psychodynamic case conceptualizations as an option. Also it was my understanding that this is an evidence based approach that can be particularly useful for disordered personality features.

 

[R. Matey]

Aren't psychodynamic case conceptualizations shown to be particularly useful even if you are doing CBT or some sort of behavioral therapy? I had a supervisor who was behavioral and he recommended using psychodynamic case conceptualizations as an option. Also it was my understanding that this is an evidence based approach that can be particularly useful for disordered personality features.

Did you read this part?

I'm totally for case conceptualization. I hammer that nail pretty hard when I give supervision.

 

[conky124]

Did you read this part?

wow not sure how I missed that, my bad

 

[chicandtoughness]

Aren't psychodynamic case conceptualizations shown to be particularly useful even if you are doing CBT or some sort of behavioral therapy? I had a supervisor who was behavioral and he recommended using psychodynamic case conceptualizations as an option. Also it was my understanding that this is an evidence based approach that can be particularly useful for disordered personality features.

Ah, I gotcha. I misunderstood that you (and others) were trying to say that techniques/interventions should occur independent of the theory, which is yikes. That said, I do think that when you wield the hammer of a particular theory, it is hard not to see every problem as a nail that can be struck. It definitely takes conscious effort for me to put down the psychodynamic hammer and pick up another one that might be more effective. I think this problem is also more prevalent amongst graduate students who find a theory they like and are way too excited to throw it at every fire. I had a classmate who found narrative therapy and started asking all of his practicum patients to start writing letters to themselves, never mind that some of them could not even conceptualize this idea (he had an individual pretty far on the spectrum, who thought writing a letter to himself was the dumbest thing, and in that case I agreed with him!)

 

[Ollie123]

My biggest issue with orientations is in line with what R Matey said. We cling to them as identities. It's often 9 parts religion for every 1 part science. I use a lot of traditional CBT because it is what I was trained in and it (mostly) is effective for the populations I see. If tomorrow convincing evidence comes out saying X is reliably more effective, I would drop CBT like a hot potato in favor of X without so much as a second thought. I think this is how we, as a field, should be approaching these things but I definitely feel there is an implicit push to find an orientation as a "spiritual alignment" that in my view runs very counter to what modern practice should look like.

Perhaps I am misunderstanding, but it sounds like some folks are suggesting applying techniques from A, but conceptualizing with B and that there is even evidence to support this? If so, I would be interested to see it. I have never even seen a study that rigorously (to my standards) examined the importance of conceptualization vs technique, let alone one that looked at this when crossing theories. I don't doubt that it is done and can possibly be done effectively, but if there is actual literature on that I would be super interested to read it and I am finding nothing...

 

[R. Matey]

From now on if someone asks my theoretical orientation, I'm just going to say science.

 

[AbnormalPsych]

From now on if someone asks my theoretical orientation, I'm just going to say science.

 

[conky124]

From now on if someone asks my theoretical orientation, I'm just going to say science.

I'm going to say the book of latter day saints! (sorry mormons you are just an easy target)

 

[singasongofjoy]

I think it's important to be able to speak competently about what your preferred/most used approach is to the population you work with AND WHY- and also the limitations of it and when you might draw from other orientations and how you might do that. Nothing is wholesale excellent all the time for all cases. Think about the clients you're likely to work with, what works for them, what doesn't, and what kind of unexpected presentation might influence you to step back and draw some strategies / appraoches from different orientations AND WHY. As long as your and-whys are based in research that seems reasonably applied to your population, and you're able to speak competently about it, you don't need to worry too much what others are going to think. Or to take the more succinct route, as AbnormalPsych said: "Science."

 

[beginner2011]

Aren't psychodynamic case conceptualizations shown to be particularly useful even if you are doing CBT or some sort of behavioral therapy? I had a supervisor who was behavioral and he recommended using psychodynamic case conceptualizations as an option. Also it was my understanding that this is an evidence based approach that can be particularly useful for disordered personality features.

Given that:
1. the theory behind one's case conceptualization informs the intervention used
2. effectiveness of intervention is related to patient expectancies
3. patient expectancies are related to logical coherence and believability of the theory-based explanation of the presenting problem and proposed intervention

It seems pretty essential to me that case conceptualization be theory-based and consistent with the intervention. If I tell my patient with PTSD that I think we should do PE because my understanding of their presenting problem is that they have pervasive issues interpersonally due to unresolved central conflicts from childhood we're ... not going to have a good time...

 

[bcliff]

Given that:
1. the theory behind one's case conceptualization informs the intervention used
2. effectiveness of intervention is related to patient expectancies
3. patient expectancies are related to logical coherence and believability of the theory-based explanation of the presenting problem and proposed intervention

It seems pretty essential to me that case conceptualization be theory-based and consistent with the intervention. If I tell my patient with PTSD that I think we should do PE because my understanding of their presenting problem is that they have pervasive issues interpersonally due to unresolved central conflicts from childhood we're ... not going to have a good time...

Why? In that event, you could arrange a hierarchy where gradually increasing exposure to stimuli that occasion aversive childhood memories is the foundation.

I actually think that that scenario is a good example of how behavioral (e.g., avoidance of reminders of aversive childhood memories), cognitive-behavioral (e.g., catastrophic thinking about the perceived danger of painful memories), and dynamic (e.g., interpersonal/relational conflict caused by adverse childhood experiences) conceptualizations could all point towards an exposure-based intervention.

Having a theoretical conceptualization of why someone is experiencing distress doesn't preclude implementation of an evidence-based intervention that draws on different theoretical underpinnings -- I guess you could argue that I hold that flexible perspective because of my third-wave orientation, in which case maybe I rigidly adhere to flexibility

 

[beginner2011]

Why? In that event, you could arrange a hierarchy where gradually increasing exposure to stimuli that occasion aversive childhood memories is the foundation.

I actually think that that scenario is a good example of how behavioral (e.g., avoidance of reminders of aversive childhood memories), cognitive-behavioral (e.g., catastrophic thinking about the perceived danger of painful memories), and dynamic (e.g., interpersonal/relational conflict caused by adverse childhood experiences) conceptualizations could all point towards an exposure-based intervention.

Having a theoretical conceptualization of why someone is experiencing distress doesn't preclude implementation of an evidence-based intervention that draws on different theoretical underpinnings -- I guess you could argue that I hold that flexible perspective because of my third-wave orientation, in which case maybe I rigidly adhere to flexibility

That's assuming "unresolved central conflicts from childhood" = trauma that occurred in childhood the memory of which is related to presenting problem. I can see why you made that assumption, but that wasn't my original intent. Working with veterans so much I've just defaulted to index trauma occurring during adulthood (although, of course, this is not always true for veterans either). If I tried to talk to a veteran with a combat-related index trauma and PTSD about their "unresolved central conflicts in childhood" (such as, not being the favored child, etc.), and then proposed PE I think that would be a bad time.

In your example, certainly one could use a psychodynamic case conceptualization without there being obvious wires crossing, but I don't see how it would be at all additive (or even meaningfully different). That's a whole other conversation, though. I think there's a ton more overlap between much that happens in certain applications of psychodynamic psychotherapy and behavioral psychotherapy (e.g., the example you're giving here).

 

[conky124]

Given that:
1. the theory behind one's case conceptualization informs the intervention used
2. effectiveness of intervention is related to patient expectancies
3. patient expectancies are related to logical coherence and believability of the theory-based explanation of the presenting problem and proposed intervention

It seems pretty essential to me that case conceptualization be theory-based and consistent with the intervention. If I tell my patient with PTSD that I think we should do PE because my understanding of their presenting problem is that they have pervasive issues interpersonally due to unresolved central conflicts from childhood we're ... not going to have a good time...

Yeah of course, I wasn't trying to make a point there I was genuinely asking a question that turned out to be redundant. Don't worry I work with PTSD Vets at the VA too and am not about trying to get people to do psychodynamic therapy when PE is appropriate. Also, in my experience with PTSD clients they seem that they'd jump at an opportunity to avoid doing PE... I describe the experience to them to be like a root canal, painful and grueling but necessary and likely very effective.

 

[chicandtoughness]

If I tell my patient with PTSD that I think we should do PE because my understanding of their presenting problem is that they have pervasive issues interpersonally due to unresolved central conflicts from childhood we're ... not going to have a good time...

I usually don't share conceptualizations with my patients if it's not going to be useful. Doesn't mean I can't still have the theory underlying that conceptualization. In my process notes and my tx planning I may very well justify the use of PE in order to resolve childhood issues, but in the session room I will absolutely present it as a technique used to slowly become less activated by traumatic memories. Perhaps in the future, we can delve into the conceptualization, but the immediacy of the issue best treated by PE/CBT can be explained in simpler terms. I've explained this to a patient before in the form of Maslow's hierarchy - yes, we do have unresolved childhood issues and deeper things, but we don't have to focus on talk therapy for those items (further up the hierarchy) until we can get them performing ADLs without debilitation (lower on the hierarchy).