Theoretical Integration: A bio-psycho-social-spiritual ... · Liberty University . ... A simulated psychological evaluation and treatment plan accompany ... Case conceptualization

Running head: THEORETICAL INTEGRATION 1

Theoretical Integration:

A bio-psycho-social-spiritual model

John Harrichand

Liberty University

THEORETICAL INTEGRATION

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Abstract

This paper is completed with the purpose of evaluating and synthesizing a theoretical grid

for counseling clients; it is divided into four sections, labeled A to D. Section A, provides

a bio-psycho-social-spiritual model of counseling from assessment to termination.

Section B, provides a discussion of the model in reference to Partner Relational Problem

outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text

revision, DSM-IV-TR, American Psychiatric Association, 2000). Section C, provides

descriptions of empirically-based treatment recommendations from emotionally-focused

couples therapy, behavioral marital therapy, and insight-oriented marital therapy. Finally,

Section D provides a simulated session-by-session protocol of a Partner Relational

Problem case study. A simulated psychological evaluation and treatment plan accompany

this paper in an Appendix.


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Introduction

No one theory in counseling and psychotherapy provides all the answers to the

myriad of problems characteristic of the human experience that clients present (Gilliland

& James, 1998). According to Archer and McCarthy (2007), integration and eclecticism

are the directions in which counseling and psychotherapy is moving towards, which is

partly due to the influence of common factors in psychotherapy (Hubble, Duncan, &

Miller, 1999). Halbur and Halbur (2006) stress the importance for counselors to have a

theoretical orientation/conceptual framework from which they can understand and meet

the therapeutic needs of their clients. It is important to understand that clients are not

blank slates; clients come into counseling and psychotherapy with life experiences,

expectations, intentions, and important information regarding their present struggles

(Heppner, Wampold, & Kivlighan, 2008). For the counselor to understand the clients

he/she interacts with in therapy, the counselor must view clients holistically, by focusing

on each client’s background, development, family origins, and experiences throughout

the counseling process (Seligman, 2009). Examination of the “biological, psychological,

social-environmental, and spiritual-theological spectrum” (Clinton & Ohlschlager, 2002,

p.56) of the client, better positions the counselor to assist his/her clients in therapy.

This paper introduces an ethically and theoretically grounded bio-psycho-social-

spiritual model that can be used throughout the counseling process. It also discusses the

model in relation to Partner Relational Problem as outlined in the DSM-IV-TR (2000),

and provides descriptions of empirically-based treatments, particularly emotionally-

focused couples therapy, for this condition. Finally, this paper outlines a session-by-

session protocol of a simulated case study based on partner relational problem.


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Section A: The Bio-Psycho-Social-Spiritual Model

The Model: What is it?

According to the bio-psycho-social-spiritual model, promoting the mental health

of an individual (client) involves (the counselor’s) integrative work that spans the

biological, psychological, social, and spiritual domains of the individual (Hatala, 2013).

This model provides the counselor with “a fuller understanding of what it means to be a

unified human being…[and it allows for the development of]…a more realistic and

holistic view of pathology and recovery” (Jones, Miguelez, & Butman, 2011, p. 70). The

bio-psycho-social-spiritual model integrates psychopharmacology, developmental

psychotherapy, cognitive-behavioral, person-centered, and family systems theories, with

Christian beliefs and biblical practices. This model involves the counselor being sensitive

to the client’s cultural and ethnic background, and how these constructs influence the

personhood of the client (Sperry, 2010). More so, this model focuses on the client’s

strengths and supports by actively incorporating them in the therapeutic process (Hays,

2008). This section will cover the bio-psycho-social-spiritual model in terms of

assessment, case conceptualization, treatment planning, and treatment and aftercare.

The Model: Assessment

Assessment can be thought of as the vehicle that provides client data, which is

evaluated by the counselor and guides the therapeutic process (Meier, 2003); spanning

the duration of counseling. Assessment is used to build the therapeutic alliance, and

develop trust and rapport between the client and counselor. Using the bio-psycho-social-

spiritual model, the counselor engages the client using the following steps: 1) obtaining a

history of the client, including personal information, chief complaint, present and past


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psychiatric and medical history (individual and family), and social and developmental

history; 2) the client’s mental status, including their appearance, behavior, speech,

emotion, and cognitions; 3) the collection of auxiliary data, including information on the

client’s family and social support, medical/laboratory tests (if any), and standardized

assessments; 4) summary of the principle findings concerning the client; 5) a multiaxial

diagnosis; 6) a prognosis; 7) case formulation/conceptualization; 8) the development and

implementation of a treatment plan (Maxmen, Ward, & Kilgus, 2009).

The biological domain of the model first seeks to gain information from a medical

physician’s examination to determine the presence/absence of any medical related

problem(s) (Maxmen et al., 2009). Assessments in the biological domain are obtained

using psychopharmacology and developmental psychotherapy. Psychopharmacology

assesses the effects of drugs, including medication, on the client’s brain. It provides the

counselor with information related to the client’s brain chemistry and specific emotional

and behavioral effects that accompany prescription and non-prescription medications

(Archer & McCarthy, 2007). Developmental psychotherapy assesses the client’s ego

development in relation to their regulatory processes: hypersensitivity, underreactivity,

and stimulus-seeking-impulsive-aggressive behaviors; and their capacity to engage,

relate, and maintain intimate relationships. It also assesses the client’s interpretation of

self in relation to intentional boundary-defining gestures, behaviors, and affects, as well

as more complex patterns of communication between self (the client) and others; and the

client’s representational capacity and differentiation (Greenspan, 1997).

The psychological domain is assessed using cognitive-behavioral therapy,

wherein counseling is viewed as a collaborative enterprise. The counselor assesses the


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client’s information-processing system to understand how the client creates meaning for

him/herself and the world around him/her. It focuses on biases, and negative and

dysfunctional schemas of the client leading to pathological thoughts, feelings and affects

(Clark, Hollifield, Leahy, & Beck, 2009); as well as effective and ineffective behaviors

learned through conditioning and reinforcement (Halbur & Halbur, 2006).

The social domain is assessed using person-centered and family systems theories.

Developed by Rogers (1961), person-centered therapy enables the counselor to develop a

relationship with the client characterized by genuineness, care, and empathy (Gilliland &

James, 1998). Person-centered therapy allows the counselor to assess the client’s view of

reality: who he/she is in relation to self and others (Rogers, 1961). Family systems

theory, Bowen’s (1976) model, allows the counselor to assess the degree of anxiety and

self-differentiation of the client in his/her family, the client’s family relationships, social

supports and socioeconomic status (Hatala, 2013). A family is seen as an emotional

unit/system, governed by relationships influenced by past generations, all of which affect

an individual’s (client) anxiety and differentiation (Archer & McCarthy, 2007).

The spiritual domain is assessed by collecting a spiritual history of the client,

asking him/her questions related to the presence/absence of a relationship with

God/transcendence, and their conscience- apart from cognitive values. A spiritual life

map is also used to assess the client’s relationship with God, providing a diagrammatic

representation of the client’s life in relation to where they came from, where they

presently are, and when they see them self headed in the future (Hodge, 2005).

The Model: Case Conceptualization


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Case conceptualization using the bio-psycho-social-spiritual model, provides the

counselor with a framework for understanding the client’s symptoms. It focuses on

understanding “the cause of the symptoms, the role the symptoms play in the person’s

experience and treatment strategies to help the person improve” (McMinn & Campbell,

2007, p. 145). Depending on the presenting problem of the client, the counselor can

conceptualize the problem along four modes: affective, cognitive, behavioral, and

systemic (Hackney & Cormier, 2009). The core theories will aid the counselor by

providing explanations for the client’s present problem(s), and answers related to

changing and/or resolving those problem(s).

Psychopharmacology will aid in observing the helpful/harmful effects of

using/possibly using psychotropic medication, as well as the client’s attitude regarding

the use of medication (Archer & McCarthy, 2007). Cognitive-behavioral therapy, will aid

the counselor working in conjunction with the client, to confirm the presence of cognitive

distortions which would be attributed to dysfunctional schemas/modes of thinking

(Archer & McCarthy, 2007), as well as noting the presence/absence of abnormal/erratic

behaviors relating to the self and other, attributed to behavioral dysfunction (Martell,

2007). A lack of self-differentiation, the presence of triangulation, family projection,

multigenerational transmission, and cut off, and negative societal factors will be

attributed to the client’s psychopathology at the social level, using Bowen’s family

systems theory (Murdock, 2007). The spiritual domain of the client will be

conceptualized using attachment theory, where the client’s discrepant representation of

God as being negative, distant, and/or controlling, will be attributed to his/her relational

representations based on the primary caregiver(s) responses during the client’s infancy


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(Noffke & Hall, 2008). In addition, developmental psychotherapy will provide an

overarching understanding of the bio-psycho-social-spiritual domains of the client, where

problems in regulation (biological), attachment (psychological and spiritual),

differentiation (social), and representational capacities (social and spiritual) can be

attributed to deficits in ego development (Greenspan, 1997).

The Model: Treatment Planning

Treatment planning focuses on partnering with the client, so he/she can take

ownership and responsibility regarding his/her outcome in therapy; it involves the

development of long- and short-term goals (Berman, 2010).

At the biological domain, the counselor works with the client employing

psychopharmacology to determine (depending on the seriousness of the client’s problem)

if medication can aid in achieving their goals (if no medication is being used), or if

medication needs to be revised due to possible negative effects (if medication is presently

being used). This might involve the counselor referring the client to a psychiatrist (Archer

& McCarthy, 2007); it also focuses on the client’s cultural values in relation to using

medication (Hays, 2008). Along the psychological domain, the counselor will use

cognitive-behavioral therapy to meet the goals of identify and later changing the client’s

maladaptive cognitive schemas, biased information processing systems, negative

automatic thoughts and images, and compensatory strategies (Clark et al., 2009). Along

the social domain, the counselor will use family systems theory to achieve the goal of

identify and changing triangulating relationships, negative social factors, and family

projections and transmissions that are contributing to the client’s present circumstances

(Murdock, 2007), as well as distorted cultural beliefs and practices (Hays, 2008). Along


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the spiritual domain, the counselor will seek to achieve the goal of identifying and

transforming the client’s distorted insecure representation(s) of God based on

maladaptive mental models using attachment theory and emotional informational

processing theory (Noffke & Hall, 2008). Developmental psychotherapy will be applied

at all the domains. It will achieve the goal of improving the client’s ego development by

collaboratively working with the client to move up their development ladder in relation to

regulation, attachment, behavioral and affective interactions, and representational

elaboration and differentiation (Greenspan, 1997).

The Model: Treatment and Aftercare

Treatment and aftercare will make use of the identified core theories of the bio-

psycho-social-spiritual model, and techniques from other theoretical approaches with the

express purpose of meeting the client’s identified goals (Archer & McCarthy, 2007).

At the biological level, psychopharmacological techniques including medication

referrals and psychoeducation on the use and abuse and biological effects of medication

will be employed (Archer & McCarthy, 2007). At the psychological and social levels,

cognitive-behavioral techniques including guided discovery, recognizing mood shifts,

imagery and role-play, checklists for automatic thoughts, and thought recording will be

used to identify automatic thoughts. While examining the evidence, applying reattribution

techniques, identifying cognitive errors, and using thought change records will be

employed to modify automatic thoughts. The downward arrow technique, identifying

repetitive patterns of automatic thought, and using schema checklists will be employed to

identify schemas; schemas will be modified using examining the evidence, generating

alternatives, cognitive rehearsals, and compiling a list of advantages and disadvantages


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(Bermudes, Wright, & Casey, 2009). In addition, cognitive-behavioral treatment will

include the use of situational analysis, interpersonal discrimination and interpersonal

transference hypothesis exercises, and significant-other lists to modify the client’s

information processing system (Friedman & Thase, 2009). Family systems theory will

also be employed at the social level using genograms, the process of detraingulation,

humor, family sculpting, parts parties, and paradoxical tasks to assist the client in better

understanding the self, his/her family system, and society at large (Poorman, 2003).

Integrating social and cultural strengths and supports will also be facilitated in client

treatment (Hays, 2008). Developmental psychotherapy will be employed to assist the

client in expanding his/her descriptions of their behavioral patterns by describing and

regulating physical sensations they experience within their body; and developing an

awareness of abstracted affects associated with their bodily sensations to the point that

the client can begin representing, elaborating, and differentiating affects (Greenspan,

1997). At the spiritual level, the counselor will create and facilitate an adaptive

attachment experience throughout therapy allowing the client to differentiate early

negative internalized relational representations of God based on an insecure attachment

with their primary caregiver(s). It will allow the client “to begin to consolidate images of

themselves as lovable [both the Christian and non-Christian client] and/or of God as

loving” (Noffke & Hall, 2008, p. 68); the counselor’s overarching theme of therapy.

In relation to aftercare, the counselor will inform the client that future services are

available (should he/she need it), and explain ways they can contact the counselor. This

will establish a bridge, connecting the client’s present state and future needs; allowing the

counselor to keep track of the client’s progress post-therapy to determine if the client is


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achieving his/her goals, while providing information of the counselor’s therapeutic

intervention-a self assessment. Aftercare will also include making a referral (if

necessary), when further therapy/ expertise in a particular area is required by the client

that the counselor doesn’t possess (Hackney & Cormier, 2009).

This section focused on explicating the bio-psycho-social-spiritual model in terms

of assessment, conceptualization, treatment planning, treatment and aftercare. The next

section will apply this model to a DSM disorder: Partner Relational Problem.

Section B: The Bio-Psycho-Social-Spiritual Model and Partner Relational Problem

The previous section provided a detailed description of the counselor’s bio-

psycho-social-spiritual model. Now, this model will be applied to Partner Relational

Problem as outlined in the DSM-IV-TR (APA, 2000), but first some preliminary

information will be provided on Partner Relational Problem.

The DSM Disorder: Partner Relational Problem

Communication, is the vehicle within a relationship that is the point of focus for

all therapists (Nichols, 2011); most couples coming for counseling initially indicate some

problem in establishing interpersonal boundaries (Weeks & Treat, 2008). In the DSM-IV-

TR, Partner Relational Problem (V61.10) is a diagnosis given when clinical attention

focuses on “a pattern of interaction between spouses or partners characterized by negative

communication… distorted communication… or no communication… associated with

clinically significant impairment in individual or family functioning or in the

development of symptoms in one or both partners” (APA, 2000, p. 737).

The Bio-Psycho-Social-Spiritual Model’s Interpretation of Partner Relational

Problem:


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Although communication, problem solving, financial, child guidance, and the

regulation of closeness and distance are problems presented for cases of partner relational

problems (Lundblad & Hansson, 2005), the counselor’s bio-psycho-social-spiritual model

can be ethically and effectively applied to better understand this disorder.

The Biological Level:

At the biological level, the counselor will gain information from a medical

physician’s examinations of both partners to determine the presence/absence of any

medical related problem(s) (Maxmen et al., 2009) that might be influencing the couple

relationship problem. The counselor will also employ psychopharmacology to determine

if either partner in the relationship is on medication and observe/determine the

helpful/harmful effects of using/possibly using psychotropic medication, as well as each

partner’s cultural attitude regarding the use of medication (Archer & McCarthy, 2007;

Hays, 2008). Developmental psychotherapy will provide the counselor with information

on each partner’s ego development deficits, in relation to regulatory processes:

hypersensitivity, underreactivity, and stimulus-seeking-impulsive-aggressive behaviors;

and possible deficits in their capacity to engage, relate, and maintain intimate

relationships. It will also provide information of each partner’s possible maladaptive

interpretations of self in relation to intentional boundary-defining gestures, behaviors, and

affects, as well as more complex patterns of communication between self (each partner)

and others. Developmental psychotherapy will inform the counselor of each partner’s

possibly underdeveloped representational capacity and differentiation (Greenspan, 1997).

Underdevelopment of the ego in either partner will provide the counselor with insight

into problematic way(s) each partner is interacting in the couple’s relationship.


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The Psychological Level:

Along the psychological domain, cognitive-behavioral therapy, will aid the

counselor in assessing each partner’s information processing system. It will determine the

presence of cognitive distortions and unrealistic expectations (APA, 2000) in the couple’s

relationship based on each partner’s dysfunctional schemas/modes of thinking (Archer &

McCarthy, 2007), and defense mechanisms (Lundblad & Hansson, 2005). It will also aid

in identifying the presence/absence of abnormal/erratic, including violent (Siegel, 2006)

and withdrawal (APA, 2000) behaviors relating to the self and other that can be attributed

to behavioral dysfunction (Martell, 2007) in each/either partner.

The Social Level:

The social domain is addressed using person-centered and family systems

theories. The counselor will develop a genuine, caring, and empathic relationship

(Gilliland & James, 1998) with the couple to determine the extent to which criticisms

(APA, 2000) made by each partner towards the other displays a lack of self-

differentiation. While actively examining the couples relationship for information relating

to the presence of triangulation, family projection, multigenerational cultural

transmission, and cut off, and negative societal factors will identify the couple’s

psychopathology at the social level, using Bowen’s family systems theory (Murdock,

2007). Bowen’s family systems theory will also allow the counselor to address the degree

of anxiety present in each partner within his/her family, as well as each partner’s family

relationships, social supports and socioeconomic status (Hatala, 2013).

The Spiritual Level:


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The spiritual domain will provide the counselor with information relating to each

partner’s relationship/lack of relationship with God, and this/her conscience- apart from

cognitive values (Hodge, 2005). Attachment theory will provide the counselor with

information of each partner’s representation(s) of God; the presence of God-image

representations as negative, distant, and/or controlling (Noffke & Hall, 2008), will be

attributed to insecure: ambivalent, avoidant, and/or disorganized attachment from each

partner’s relational representations based on his/her primary caregiver(s) responses

during infancy (Johnson, 2004; Johnson & Woolley, 2009). All the information collected

from the bio-psycho-social-spiritual model will guide the counselor in selecting the best

empirically-based treatment that will aid in addressing the couple’s problem(s).

This section provided a discussion of the bio-psycho-social-spiritual model in

relation to the diagnosis: partner relational problem. The next section will provide

descriptions of three empirically based treatment recommendations for this condition.

Section C: Empirically-Based Treatment Recommendations

Section B introduced partner relational problem using the bio-psycho-social-

spiritual model. This section examines three empirically-based treatment interventions for

the condition: behavioral marital therapy, insight-oriented marital therapy, and

emotionally-focused couples therapy (American Psychological Association [APA], n.d.).

Behavioral Marital Therapy:

One of the most researched forms of marital therapy and an empirically supported

therapy (Shadish & Baldwin, 2005), Behavioral Marital Therapy is a didactic process in

which the therapist working with the couple employs interventions focused on helping

them learn interpersonal skills through “instruction, modeling, rehearsal, and feedback”


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(Wills, Faitler, & Snyder, 1987, p. 665). The treatment modality also addresses “problem-

solving skills, relationship enactments, and contingency contracting” (Snyder, Wills, &

Grady-Fletcher, 1991, p. 139). Today, the most commonly used variation of this model is

termed Integrative Behavioral Couples Therapy (IBCT) (Gurman, 2013). IBCT

incorporates acceptance and change techniques and strategies with behavioral

interventions in treatment. The counselor working with a couple adopts a functional-

contextual orientation that is non-judgmental, facilitating empathy and individuality. Any

event that unfolds in therapy is viewed as relevant in helping the couple and counselor

understand why problematic behaviors exist in their present circumstances. Functional

analysis is used to assess the couple’s behavior pattern to identify and correct conditions

and consequences of the behavior’s occurrence (Gurman, 2013).

Insight-Oriented Marital Therapy:

Insight-Oriented Marital Therapy (IOMT) focuses on resolving a couple’s

conflictual emotional processes that are present within either and/or both partners

separately, interactively, and/or systemically (within the family) (Snyder & Wills, 1989).

IOMT employs probing techniques, reflecting processes, and affective reconstruction so

that each partner and the couple can examine the emotional dimensions of their

relationship, identify underlying affect states, and give meaning to the underlying

dynamics resulting in the couples present problematic state (Wills et al., 1987). The

counselor also uses probes, clarification, and interpretation to assist the couple in

understanding “developmental issues, collusive interactions, incongruent expectations,

and maladaptive relationship rules…contributing to the current observable marital

difficulties” (Snyder et al., 1991, p. 139).


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Emotionally-Focused Couples Therapy:

Emotionally-Focused Couples Therapy (EFCT) is “an empirically validated, brief,

systemic approach to changing distressed couples’ rigid interaction patterns and

emotional responses and promoting the development of a secure bond between partners”

(Johnson & Woolley, 2009; p. 554). The EFCT therapist combines both experiential and

integrative approaches, focusing on each partner’s intrapersonal, as well as, their

interpersonal levels so that the couple can reorganize their emotional experience which

shifts their interactional positions allowing them to engage in a secure bonding

relationship (Johnson, 2004). In EFCT the client is the relationship between the couple,

not the couple themselves, and the therapist is a process consultant who assists the couple

in reprocessing the emotional experiences in their relationship (Johnson & Greenman,

2006). Attachment theory provides the EFCT counselor with a map to understanding

adult intimacy; particularly love (Johnson, 2004). The nine steps of EFCT are divided

into three categories/stages that dictate the progression of therapy. Stage one involves the

de-escalation of negative cycles of interaction between the couple by slowly expanding

and clarifying the role each partner plays in the relationship. Stage two involves

restructuring the interactional positions of the couple by first attending to the

withdrawn/submissive partner so they come to acknowledge and own their emotions,

then attending to the dominant/pursuing partner so they can express vulnerability

(Crawley & Grant, 2005). Finally, stage three involves consolidation and the integration

of all that transpired over the course of therapy so that the couple can enjoy secure

emotional attachment in their relationship (Johnson & Woolley, 2009). There are three

tasks for the counselor using EFCT (Johnson, 2004): 1) creating and maintaining a


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therapeutic alliance with the couple from the onset; 2) actively accessing and

reformulating the couple’s emotion(s); and 3) assisting the couple in restructuring key

interactions. The counselor is able to accomplish these tasks by employing EFCT

techniques, which include: reflecting present emotional experience; validation; evocative

responding; heightening; empathic conjecture or interpretation; tracking, reflecting, and

replaying interactions; reframing in the context of the cycle and attachment process; and

restructuring and reshaping interactions (Johnson 2004; Johnson et al., 2005; Johnson &

Greenman, 2006; Johnson, 2007; Johnson & Woolley, 2009).

This section provided three empirically-based treatments for addressing partner

relational problems, the following section will provide a closer examination of

emotionally-focused couples therapy (EFCT) applied to a case study, found on the

Appendix, for the same condition.

Section D: Case Study of Partner Relational Problem

The previous section focused on empirically-based treatments for addressing

Partner Relational Problems. This section will expand on Emotionally-Focused Couples

Therapy (EFCT) by providing a session-by-session protocol to address Partner Relational

Problem based on the case study information presented in the Appendix of this paper.

EFCT was chosen as the best treatment modality for the current condition based on

research findings by Wood, Crane, Schaalje, and Law (2005) indicating its effectiveness

over behavioral marital therapy in the treatment of moderate marital distress, which is the

distress level of the couple in the present case study based on assessment results.

The information presented in the treatment protocol for Mr. and Mrs. Potter in

relation to partner relational problem at Johnson’s (2004) three stages of EFCT (de-


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escalation, restructuring, and consolidation) comes from Johnson (2004); Johnson et al.

(2005); Johnson and Greenman, (2006); Johnson (2007); Johnson and Woolley (2009);

and Crawley and Grant (2005).

Sessions 1- 4: Assessment:

The assessment of Mr. and Ms. Potter will span the first four sessions of therapy.

In the first two therapy sessions, the counselor will employ the assessment instruments

listed in the Appendix, in addition to conducting mental status exams. Detailed intake

reports of each partner: jointly and separately, and of the couple’s relationship will also

be made to provide a detailed bio-psycho-social-spiritual profile of the couple’s

relationship and identified relationship problem(s). Using EFCT, the counselor will begin

stage 1: de-escalation, by establishing a safe and accepting working alliance with both

partners, while assessing the nature of their relationship problem; each partner’s goals for

therapy; and creating a therapeutic agreement; step 1 of EFCT. The counselor will also

seek to identify the couple’s negative interactional cycle that is contributing to their

current distress; step 2 of EFCT. The third and fourth sessions will be one-on-one

sessions with each partner and the counselor. The individual session will focus on

obtaining uncensored perceptions each partner has of the other in relation to their

relationship problem, while refining impressions made of each partner’s underlying

feelings and insecure attachment style that’s contributing to the couple’s negative

interactional (pursue-withdraw) cycle. The counselor will use: reflection; validation;

evocative reflections and questions; tracking and reflecting interactions; and reframing

techniques during these sessions.

Sessions 5-6: De-escalation:


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During session 5, the counselor will seek the access the primary emotions that

appear outside each partner’s awareness but to some “hidden” extent present in the

couple’s interactions (e.g. criticisms, unrealistic expectations); step 3 of EFCT. In session

6, the counselor will also seek to incorporate each partner’s primary emotional responses

and their accompanying attachment needs with the aim of magnifying the context of Mr.

and Ms. Potter’s relational problem (deteriorating communication); step 4 of EFCT. The

counselor will use: validation; evocative reflections and questions; heightening; empathic

conjecture; tracking and reflecting patterns and cycles of interaction; and reframing of the

problem in terms of context and cycles as techniques during these sessions.

Sessions 7-11: Restructuring:

During sessions 7 and 8, the counselor will work with Mr. and Ms. Potter by

helping each partner identify their individual attachment needs and aspects of the self that

they have neglected, and have each partner integrate these needs and parts of self into

their relationship and relationship problem; step 5 of EFCT. This experiential change

process assists each partner to become more of who he/she is. In session 9, the counselor

will focus on helping each partner accept, integrate and respond to this new view of

his/her other partner’s experience/behavior in their relationship; step 6 of EFCT. The

counselor in sessions 10 and 11 will act to facilitate the expression of Mr. and Ms.

Potter’s needs and wants and provide the space for emotional engagement to occur. This

will lead both partners to experience change in their interactional positions, where Ms.

Potter, the withdrawer in the relationship, reengages; and Mr. Potter, the pursuer, softens

and becomes vulnerable. The counselor will use: evocative responding: reflections and

questions; heightening; empathic conjecture; tracking and reflecting the cycle; reframing;


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and restructuring interactions, as techniques during these sessions to deepen Mr. and Ms.

Potter’s emotional engagement with each other.

Sessions 12-13: Consolidation:

During session 12, the counselor works with Mr. and Ms. Potter to re-define their

relationship problem; the couple learn to face problems together-as a unit, instead of

alone-isolated individuals. As such, the counselor facilitates the development of new

solutions by the couple that addresses old problems in their relationship; step 8 of EFCT.

In session 13, the counselor will help Mr. and Ms. Potter to consolidate their new

responsive positions in relation to their now positive cycle of interaction, while

integrating the changes made in therapy into their relationship; step 9 of EFCT. In

addition, the counselor will seek to encourage Mr. and Ms. Potter to maintain a secure

base in their relationship; decreasing their anger and anxiety while increasing open and

positive communication bridges, allowing each partner to remain attuned to the other.

The counselor will use: reflection and validation of new patterns and responses; evocative

responding; reframing; and restructuring interactions, as techniques during these sessions

to consolidate a secure base in Mr. and Ms. Potter’s relationship.

Depending on the level of distress in the couple’s relationship and the progress of

each individual partner, the counselor will pace therapy sessions to facilitate growth in

each partner and the couple, which might involve adding/subtracting sessions at any stage

of the therapeutic process.

Session 14: Termination and Aftercare:

During the final session of therapy, the counselor will seek to address fears and

concerns present in Mr. and Ms. Potter. If either partner experiences heightened anxiety,


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the counselor will use evocative responding to explore the partner’s fears, allowing

him/her to share their fears with the other partner, who becomes a source of help and

security. The counselor will explore the feelings of sadness/grief regarding termination

and offer the couple an invitation to keep in contact by providing follow-up sessions at 1,

3, 6, and 12 months after termination. If there is need for more individual therapy for

either partner to address deeply rooted intrapersonal issues, the counselor will provide

referrals and/or offer counseling services to the partner(s) in need, in keeping with ethical

practice.

This session provided an expanded session-by-sessions account of EFCT in

relation to partner relational problem.

Conclusion

This paper examined a bio-psycho-social-spiritual model that can be used

throughout therapy, in assessment, case conceptualization, treatment planning, and

treatment and aftercare. The bio-psycho-social-spiritual model discussed the DSM-IV-

TR diagnosis: partner relational problem. Behavioral marital therapy, insight-oriented

marital therapy, and emotionally-focused couples therapy were identified as

empirically-based treatment recommendations for partner relational problem. A

session-by-session protocol of emotionally-focused couples therapy was provided

using a case study, found in the Appendix, addressing partner relational problem.

Couple/marriage therapy can be difficult but very rewarding work because the process

of change, unlike individual therapy, usually takes place within the therapy room. For

the counselor working with couples from an integrative bio-psycho-social-spiritual

model, there are many ethical, effective and empirically-based resources to draw from.


22

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28

Appendix

Assessment

In order to have a comprehensive assessment of Mr. and Ms. Potter’s problem, the

counselor used the following tests: WHODAS 2.0, the PROMIS Emotional Distress-

Anger-Short Form, and the PROMIS Emotional Distress-Anxiety-Short Form (American

Psychiatric Association, 2012), ENRICH marital inventory (Olson, Fournier, &

Druckman, 1983), the Marital Satisfaction Inventory (Snyder, 1979), the Beck

Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Clinical

Anger Scale (Snell, Gum, Shuck, Mosley, & Hite, 1995), and the Beck Anxiety Inventory

(Beck, Epstein, Brown, & Steer, 1988). In addition, a detailed intake report was

conducted, that included mental status exams, the construction of life maps, genograms,

and significant-other lists.

The next section provides information from the couple’s psychological

evaluation.

Written Psychological Evaluation NAME: William Potter DOB: 04/05/1968 AGE: 45 SSN: 234-56-7890 SEX: Male NAME: Mary Potter DOB: 05/17/1970 AGE: 43 SSN: 123-45-6789 SEX: Female DATE OF INTAKE: 10/05/2013 DATE OF REPORT: 10/21/2013 INTERVIEWER: John Harrichand

Identifying Information and Reason for Referral

William Potter, a 45-year-old male, and Mary Potter, a 43-year-old female, have

been married for eight years. They are both of European descent, and willingly presented

themselves for marital assessment after being referred by their Pastor, Mr. Weasley. The

couple’s presenting complaint focuses on the deterioration of their relationship,


29

particularly in regards to communication, which they describe as being: non-existent,

negative, and/or distorted, at times.

Behavioral Observations (with Mental Status Exam)

Mr. Potter appeared to be a little unkempt, a bit overweight but nourished, and

somewhat distressed. Ms. Potter appeared to be well groomed, of slender build and well

nourished, and in no apparent distress. They were both adequately dressed for their

assessment, appearing congruent with their stated ages. They both maintained appropriate

eye contact, Mr. Potter less so than Ms. Potter; and both clients were a little nervous

based on their tense postures.

Both clients spoke clearly and were articulate. They were mostly cooperative, but

Ms. Potter was somewhat resistant when she was asked to provide some intimate details

of her marital relationship. Both clients were goal directed, although Ms. Potter seemed

less oriented than Mr. Potter. Neither client evidenced signs of distractibility and/or

disturbances in their logic. They both evidenced high levels of cognitive functioning,

which was congruent with their educational and professional backgrounds.

History of the Present Problem (or Illness)

Both Mr. and Ms. Potter agreed that there was a noticeable breakdown in their

communication patterns, which started four months ago, and has become significantly

worse over the past three weeks. Mr. Potter reported that he has observed that every time

he tries to communicate with Ms. Potter, she “shuts him out” and this has resulted in him

experiencing angry outburst. Ms. Potter reported that it has become increasingly difficult

to “care for her husband” which has increased her anxiety. They both have observed that

their communicational problems have been negatively influencing their family dynamics


30

with their children: seven-year-old Harry and five-year-old Hermione. Both clients

indicated that they have been frequently engaging in fights at the dinner table, in front of

their children. Their most recent argument took place outside the home, at church, in the

presence of Pastor Weasley, who recommended they enter into marital counseling. In

addition, they both reported frustrations in their professional life, as a result of their

communication problems. Mr. Potter, an architect, indicated that he isn’t able to focus

and generate any “workable architectural designs at work”; while Ms. Potter, a crossword

puzzle compiler, indicated that she is finding it difficult to complete her work

assignments on time. They both denied having feelings or thoughts of self-harm, and they

both admit that in keeping with their Christian faith, they are against physically

hurting/harming others. They both denied having feelings of sadness or depression, and

both clients indicated that there was no disturbance in their sleep and appetite.

Both clients indicated feeling anxious, and evidenced physical signs (Ms. Potter’s

non-verbal facial expression, and Mr. Potter’s non-verbal body movements) during

assessment. Both clients also indicated they had feelings of anger, that was evidenced in

the heated arguments they share with each other, and that manifested psychosomatically,

Mr. Potter’s described his “head is on fire and about to explode” when he is angry, and

Ms. Potter’s described her anger as “her chest and abdomen feeling hot”. Both clients

stated that they came from happy families, both being the only child in their respective

families, and they stated that their family history had no bearing on their present

situation. However, when assessing their individual family history it was identified that

the way in which their parents addressed conflict in their respective families was

different; Mr. Potter’s parents addressed conflict by engaging in huge arguments where


31

each parent criticized the other, while Ms. Potter’s parents always withdrew from each

other during times of conflict. Mr. Potter’s work environment for the past few months

was identified as a stressor in Ms. Potter’s life, because of Mr. Potter’s co-worker: Ms.

Rita Skeeter, who Ms. Potter identified as the “other woman in Mr. Potter’s life”.

Past Treatment (Psychiatric) History and Family Treatment (Psychiatric)

History

Neither Mr. Potter nor Ms. Potter identified being engaged in previous treatment,

or having any previous clinical problems individually, as a couple, or as a family.

Relevant Medical History

Mr. Potter indicated that he has no history of being hospitalized. While Ms. Potter

indicated that she was hospitalized twice, during the births of her two children, Harry and

Hermione. They both described that they are in “good physical health” as determined

recently by their Family Physician, Dr. Snape, during their annual check-up. Their

doctor’s visit indicated that there was no sign of diabetes, thyroid issues, high blood

pressure, or any other health concern at this time. Neither client is taking any prescription

and/or nonprescription medication. Dr. Snape can be reached at 434-534-6789.

Development History

Both clients reported no knowledge of any difficulties pertaining to their mothers’

pregnancies or their births. They both indicated that they met all of the appropriate

social, behavioral, and cognitive milestones. They were both successful in school from

kindergarten to college. As teenagers, they were both active in physical activities, Mr.

Potter was a member of his college’s football team, and Ms. Potter was a member of her


32

college’s swim teams. They both denied being abused within the home; they described

their relationships with their parents as mostly positive and supportive.

Social and Family History

Mr. and Ms. Potter have been married for eight years now and are the proud

parents of two children, Harry and Hermione. They both came from families where they

were the only-child. They described their family relationships and their family

environments as positive for the most part, except when it came to addressing family

conflicts. They both stated that their parents’ Christian faith factored heavily into family

life. They met each other while in college, and became romantically interested after

completing college, and have been together since. They both completed their college

education, and they both entered into the workforce and found good, stable jobs in their

fields before entering into marriage. During Ms. Potter’s pregnancies, ages 35 and 38, she

was still able to work from home, as a crossword puzzle compiler, and after the birth of

Hermione, she remained at home for two years before returning to her office, where she

presently works. Mr. Potter, works at a huge architectural firm, and within the past year

he was promoted to the role of Architectural Supervisor, where he oversees 25 other

employees. In terms of their sexual history, Mr. Potter stated that after the birth of his

daughter, Hermione, five years age, their sex life declined, and over the past four months,

no sexual relations between him and Ms. Potter has occurred; she was somewhat

reluctant to share on this matter. There is no history of aggression/violence and no history

of drug/alcohol use by either client. They both still keep in close contact with a few

friends from college, engage in golfing for recreation, and they are both active in their

local church, Mr. Potter being the pianist, and Ms. Potter being a member of the choir.


33

Current Situation and Functioning

Both Mr. and Ms. Potter work full time outside the home, Mr. Potter in an

architectural firm, as an architectural supervisor, and Ms. Potter in a newspaper agency,

as a crossword puzzle compiler. Their two children are in school during the day and after

school, they stay at a nanny’s house before being picked up by either parent on their way

home. They have noticed that they each have been quick to react to the other on simple

matters, and their disagreements have spilled over into family time (meals), where they

argue in front of their children. They have also observed that their anger towards each

other has been affecting their professional lives, and has also resulted in heightened levels

of anxiety in both clients. They are both aware that their communication system is

deteriorating and negatively impacting their marriage and family relationships. Mr. Potter

perceives his strength lies in his ability to construct plans and his musical talent. Ms.

Potter perceives her strength lies in her ability to be focused and structured, and her vocal

talent. Neither client was able to identify he/her self-perceived weakness. Both clients

know that their communication troubles are widening the distance between them, and

they are fearful of what the future would be if they cannot find a way to improve their

communication with each other. Overall, they both appear functional, and able to

complete most of their activities of daily living, however, they are both plagued by

increased anger and anxiety as a result of their deteriorating communication system.

Diagnostic Impressions

Both Mr. Potter and Ms. Potter endorsed anger and anxiety. According to the

WHODAS 2.0 (American Psychiatric Association [APA], 2012), both clients were rated

as having moderate levels of disability. The PROMIS Emotional Distress-Anger-Short


34

Form, and the PROMIS Emotional Distress-Anxiety-Short Form (American Psychiatric

Association, 2012) confirmed their moderate levels of anger and anxiety, respectively. It

appears from their life map, their communication problems began approximately four

months ago, with Ms. Potter accusing Mr. Potter of infidelity. Their lack of intimate

relations after the birth of their last child, Hermione, is also contributing to their present

difficulties. Their responsibilities at home, work, and church are keeping each from

confronting their growing problem, which further compounds their lack of healthy

communication. Their increase in anger and anxiety has resulted in more frequent

arguments both inside and outside the home. Although, their communication problem

started four months ago, and has persisted, it has intensified in frequency and duration,

over the past three weeks. They both deny having thoughts of self-harm, and

hallucinations of any type. Therefore, the (tentative) multi-axial diagnostic impressions

(American Psychiatric Association, 2000) for each client: Mr. and Ms. Potter are:

(Tentative) multi-axial diagnosis for Mr. Potter:

Axis I: V61.10 Partner Relational Problem; V62.81 Relational Problem Not

Otherwise Specified.

Axis II: V71.09 No Diagnosis on Axis II

Axis III: Overall good physical health.

Axis IV: Angry outbursts and anxiety stem from marital distress with Ms. Potter,

problematic literary agent, and him being unsure of his relationship with Ms. Potter.

Axis V: GAF score = ~60; Mr. Potter has moderate symptoms present, including

moderate difficulty in his social and occupational functioning.

(Tentative) multi-axial diagnosis for Ms. Potter:


35

Axis I: V61.10 Partner Relational Problem; V62.81 Relational Problem Not

Otherwise Specified.

Axis II: V71.09 No Diagnosis on Axis II

Axis III: Overall good physical health.

Axis IV: Anger and anxiety resulting from marital distress, being a working

mother, and being unsure of her relationship with Mr. Potter.

Axis V: GAF score = ~55; Ms. Potter has moderate symptoms, particularly

related to social functioning, she tries to control life but she is finding it difficult

to maintain control.

This section focused on the diagnostic impressions of the clients, the next session

provides a bio-psycho-social-spiritual case conceptualization of Mr. and Ms. Potter.

Case Formulation

Employing a bio-psycho-social-spiritual model, that utilizes Emotionally-Focused

Couples Therapy (EFCT); it appears that Mr. Potter has been the pursuer for most of his

marriage with Ms. Potter, while she took the role of being the withdrawer. Neither client

evidences any serious medical condition. Psychologically, both clients are experiencing

moderate levels of distress due to communication problems in their marriage. Socially,

both clients are engaging in arguments with each other, that is compounded by feelings of

anger and anxiety. Spiritually, both clients are devoted Christians, but their present

relationship difficulties have made them neglect their relationship with God, and this has

led them to feel more angry and anxious, believing that God is punishing them in some

way or judging them for not being able to fix their marital problems.


36

Mr. Potter appears to be the more vulnerable partner in the marriage; he is willing

to do what it takes to make their marriage/relationship work. He is also more abstract in

his thinking and more exaggerated, which might influence him being an architect and

being over dramatic. He holds the view that possibly came from his family of origin,

which stated that no matter how difficult a relationship got once each partner’s feet

connected under the blankets, it would indicate that they had entered the demilitarized

zone and things were going to be alright; they were still an “us”. But this does not seem

to be happening in his marriage, leading him to more distress. Mr. Potter seems to have

ambivalent/resistant attachment; his anger towards Ms. Potter stems from the fact that she

is too structured, she views him as being a child (her third kid) and can’t seem to give

him the attention he needs, especially when he appears to have a greater need for love

and affection from her. This is leading him to feel hurt in the form of anger because he

has been vulnerable towards her and he feels that she is not reciprocating his response(s).

He fears that his unmet needs are creating more distance in his relationship with Ms.

Potter, and he can’t seem to build the bridge to keep them together.

Ms. Potter appears to be one who bottles up her emotions, letting them out only

when she argues/criticizes Mr. Potter. She is very structured in her life, and appears to

have an avoidant attachment style. She creates crossword puzzles, a job in addition to

being a mother. She views crosswords comforting because they provide answers to little

questions, which leads her to have closure when she completes a puzzle. She holds the

view that sharing anything truly intimate with another person, even talking, is an affair,

affecting the person/partner who the “cheater” is supposed to be most intimate with. She

believes Mr. Potter had an affair with his employee, Rita Skeeter; an accusation that Mr.


37

Potter denies, and she is not able to forgive him for it. She thinks that love is something

that people are allowed to fall in and out of. She also thinks that Mr. Potter is too

childlike, always trying to build/design things. Ms. Potter thinks Mr. Potter just tries to do

things to satisfy himself, while she is left to do things keeping everyone else in mind-

disregarding her needs at times. Ms. Potter has adopted the view from her family of

origin that once something is broken it cannot be fixed. This is how she is beginning to

view her marriage with Mr. Potter, leading her to feel hopeless that things can get any

better. As such, she is angry at Mr. Potter for allowing her/them to move from being

deeply in love at the beginning of their marriage to being out of love and possibly

contemplating divorce. She feels shame because she is not able to save her marriage, and

have her needs for love and attention met; she has been trying to meet the needs of others.

This section provided a case conceptualization of Mr. and Ms. Potter using a bio-

psycho-social-spiritual model. The next section provides a treatment plan chart and

treatment protocol chart using Emotionally-Focused Couples Therapy (EFCT).

Treatment Plan

Both Mr. and Ms. Potter have the awareness that their deteriorating

communication pattern is resulting in their present couple relational problem. They both

report that their goals in therapy are: to decrease their levels of anger and anxiety, which

would lead to less criticizing between them; be more attuned to each other’s needs and

responses, which would decrease each partner’s unrealistic expectations of each other;

and increase positive communication interactions. They believe that they are ready and

motivated to work on these problems, as evidenced by their commitment (strength) to be


38

in therapy. Both partners believe that they would have resolved their couple’s relational

problem by achieving their joint goals.

Drawing on the work of Johnson (2004) and Johnson et al. (2005), the counselor

working with Mr. and Ms. Potter will address their Partner Relational Problem using

Emotionally-Focused Couples Therapy (EFCT) in three stages. First in stage one, de-

escalation, the therapist will seek to observe the negative interactional cycle between Mr.

and Ms. Potter, by expanding and clarifying the role that each partner is playing: Mr.

Potter the pursuer, and Ms. Potter the withdrawer, in their relationship. During the second

stage, restructuring, the therapist will focus on redesigning the couple’s interactional

cycle, by first attending to Ms. Potter-the withdrawer, so that she can become aware and

acknowledge her emotions. Then the therapist will attend to Mr. Potter-the pursuer, so

that he can safely express his vulnerability in front of Ms. Potter. Finally, in the third

stage, consolidation, the therapist will seek to work with the couple on integrating what

the have learned/discovered during the therapeutic process, so that they can continue

practicing and enjoying secure emotional attachment in their marriage.

Treatment Plan Chart

Problem or Concern

Measurable Treatment Goal

Treatment Intervention

Expected Number of

Session Devoted to Reaching This Goal

Means of Evaluating and Monitoring

Progress Toward Goal

Aftercare Plan/

Follow-Up

Criticizing Move Mr. and Ms. Potter from moderate to mild levels of anger

and anxiety

Identify and challenge maladaptive cognitions:

throughout therapy

Behavioral activation: exercise 45 minutes., 3

times/week

~6 sessions the PROMIS emotional distress –

anger-short form

the PROMIS emotional distress – anxiety-short form

Follow-up treatment to

monitor progress at

1.3.6.12 month

intervals


39

Progressive relaxation training:

10-20 minutes, 5 times/week

Arguments due to Unrealistic Expectations

Move Mr. and Ms. Potter from

having 10 arguments /week

to having 3 arguments/week

Automatic thought list: create list when there is an urge to engage in an

argument

Situational analysis: when negative automatic thoughts arise that might trigger the need to argue


anger-short form


Self-repost: clients,

family


monitor progress at

1.3.6.12 month

intervals

Lack of Positive Communication

Increase Mr. and Ms. Potter’s

positive communications from 2 times/day

to 8/day

Downward arrow technique: when negative feelings towards partner

arise

Examine the evidence and generate alternatives:

when the feel the need to engage in negative

communication

Paradoxical technique: when either partner engages in negative

communication styles


anger-short form


Self-repost: clients,

family


monitor progress at

1.3.6.12 month

intervals

Treatment Protocol Chart

Stage of Treatment

Session Number Treatment Focus

Techniques Used

De-escalation 1 Establish a safe and accepting work alliance with couple.

Assess the nature of couple’s relationship problem; each partner’s

goals for therapy; and create a therapeutic agreement.

Reflection

Validation

Evocative reflections and questions


40

2 Identify couple’s negative interactional cycle contributing to current distress

Tracking and reflecting interactions

Reframing 3 (one-on-one sessions)

Obtain uncensored perceptions each partner has of the other in relation to

their relationship problem.

Refine impressions of each partner’s underlying feelings and insecure

attachment style contributing to the couple’s negative interactional (pursue-

withdraw) cycle.

4

5 Access primary emotions outside each partner’s awareness but present in

couple’s interactions (e.g. criticisms, and unrealistic expectations).

Validation

Evocative reflections and questions

Heightening

Empathic conjecture

Tracking and

reflecting patterns and cycles of interaction

Reframing of the

problem in terms of context and cycles

6 Incorporate each partner’s primary emotional responses and their

accompanying attachment to magnifying the context of couple’s relational

problem (deteriorating communication).

Restructuring 7 and 8 Help each partner identify their individual attachment needs and aspects

of the self that they have neglected.

Have each partner integrate their needs and parts of self into their relationship

and relationship problem.

Reflections and questions

Heightening

Empathic conjecture

Tracking and

reflecting the cycle

Reframing

Restructuring interactions

9 Help each partner accept, integrate and respond to the new view of his/her other

partner’s experience/behavior in the relationship.

10 and 11 Facilitate the expression of Mr. and Ms. Potter’s needs and wants.


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Provide the space for emotional

engagement to occur.

Lead both partners to experience change in their interactional positions, where Ms. Potter, reengages; and Mr. Potter,

softens and becomes vulnerable.

Consolidation 12 Re-define the couple’s relationship problem.

Facilitate the development of new

solutions by the couple that addresses old problems in their relationship.

Reflection and validation of new

patterns and responses

Evocative responding

Reframing

Restructuring interactions

13 Help Mr. and Ms. Potter consolidate their new responsive positions in relation to their now positive cycle of interaction.

Teach the couple to integrate the

changes made in therapy into their relationship; maintain a secure base while being attuned to each other.

Termination & Aftercare

14 Address fears and concerns raised by the couple.

Address heightened anxiety by either

partner.

Assess treatment goals and explore feelings of sadness/grief regarding

termination.

Invite couple to engage in follow-up sessions at 1, 3, 6, and 12 months after

termination.

Provide referrals/individual therapy, if there is need for individual therapy for either partner to address deeply rooted

intrapersonal issues.

Reflection and validation of new

patterns and responses

Evocative responding

Documents

Theoretical Integration: A bio-psycho-social-spiritual ... · Liberty University . ... A simulated psychological evaluation and treatment plan accompany ... Case conceptualization