Paradigms of Counseling and Psychotherapy

PARADIGMS OF COUNSELING

AND PSYCHOTHERAPY

By

Robert Rocco Cottone

PARADIGMS OF COUNSELING

AND PSYCHOTHERAPY

By Robert Rocco Cottone

Published by Robert Rocco Cottone at Smashwords. Robert Rocco Cottone, Publisher, P. O. Box 282, Cottleville, Missouri (MO) 63338-0282.

Copyright © 2012 Robert Rocco Cottone. All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system without written permission from the author, except for the inclusion of brief quotations in a review or through Smashwords and its contracted distribution affiliates.

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Cover Image by Mike Bougher, entitled Spirit, and downloaded from: http://mikebougher.com

DEDICATION: This book is dedicated to my students, whose interest in my ideas has been both humbling and flattering.

Table of Contents

PREFACE

Chapter 1: Defining Paradigms of Counseling and Psychotherapy

Theories, Therapies, and Paradigms

Counseling Paradigms

Therapies as Paradigm Subcategories

Paradigms and Inter-professional Skirmishes

Counseling versus Psychotherapy

A Word about Postmodernism and the Bias of this Book

Chapter One Conclusion

Chapter 2: Criteria for Defining Paradigms of counseling and psychotherapy

Criteria for a Counseling Paradigm

Criterion I: Paradigm as a Scientific Theory

Criterion II: The Presence of Competition

Criterion III: Epistemological and/or Ontological Significance

Criterion IV: Distinct Cause-and-Effect Perspective

Criterion V: Professional Adherents

Criterion VI: Therapies as Subcategories

Comparing Scientific and Counseling Paradigms

Chapter Two Conclusion

Chapter 3: The Organic-Medical Paradigm

Historical Overview: General Discussion of the Medical Model

The Emergence of Psychiatry as a Medical Specialty

Propositions

Tenets of Practice

Epistemological and Ontological Considerations

Cause-and-Effect

Professional Adherents

Therapies as Subcategories

Psychiatric Case Management: A Paradigm-Specific Therapy

The Diagnostic Process

Case Management

Chapter Three Conclusion

Chapter 4: The Psychological Paradigm

Historical Overview

A Critique of Organic-Medical Propositions

The Psychological Solution

Propositions

Tenets of Practice

Epistemological and Ontological Considerations

Cause-and-Effect

Professional Adherents

Therapies as Subcategories

Freud’s Psycho-analysis: A Trans-Paradigm Therapy

Rogers’ Person Centered Therapy: A Paradigm-Specific Therapy

Behavior Therapy: A Paradigm Specific Therapy

Within Paradigm Variations

Chapter Four Conclusion

Chapter 5: The Systemic-relational Paradigm

Historical Overview

Definition of Common Systemic Terms

Propositions

Tenets of Practice

Epistemological and Ontological Considerations

Defining Systems as Things

Cause-and-Effect

Professional Adherents

Therapies as Subcategories

Satir’s Conjoint Family Therapy: A Trans-Paradigm Therapy

Haley’s Strategic Problem Solving Therapy: A Paradigm-Specific Therapy

Minuchin’s Structural Family Therapy: A Paradigm-Specific Therapy

Chapter Five Conclusion

Chapter 6: The Social Constructivism Paradigm: An Emerging Paradigm

Historical Overview

The Feminist Critique of Social Systems Theory: An Example of Anomaly

The Social Constructivism Solution

Propositions

Tenets of Practice

Epistemological and Ontological Considerations

Cause-and-Effect

Professional Adherents

Therapies as Subcategories

Milan-Systemic Family Therapy: A Trans-Paradigm Approach

Solution-Focused Therapy: A Paradigm-Specific Therapy

Narrative Therapy: A Paradigm-Specific Therapy

Chapter Six Conclusion

Chapter 7: TRANSPARADIGM, Cross-Paradigm, AND WITHIN PARADIGM VARIATIONS

Carol Anderson’s Psychoeducational Approach: A Cross-Paradigm Model

Chapter Seven Conclusion

Chapter 8: Experimental Issues and Conclusion

Paradigm Research and Social Constructivism

Paradigm Research in Context

Questions and Answers on Paradigm Research

Does the Paradigm Framework Interface with the Common Factors Movement?

Chapter Eight and Book Conclusion

REFERENCES

ABOUT THE AUTHOR

OTHER BOOKS BY ROBERT ROCCO COTTONE

PREFACE

This book, in many ways, is a culmination of years of study and analysis of mental health treatment approaches. It presents my theory about theories of counseling and psychotherapy. This book defines paradigms of counseling and psychotherapy--large therapy encompassing frameworks of mental health treatment. Four paradigms are defined: the organic medical paradigm, the psychological paradigm, the systemic-relational paradigm, and the social constructivism paradigm. Paradigms present the big picture of mental health service delivery.

As an undergraduate psychology major, I remember my dismay at having a professor assign Thomas Kuhn’s book The Structure of Scientific Revolutions, a book that defined scientific paradigms. Kuhn’s book was a difficult read, and I spent many evenings trying to discern the significance of paradigms to psychology. It is ironic that such an advanced assignment in an undergraduate course could so significantly influence my career and ways of viewing my work as a psychotherapist. Kuhn’s book turned out to be inspiring, and it later motivated me to analyze counseling and psychotherapy at a higher theoretical level. So, I am thankful that I was challenged at an early stage of my professional development.

This book is designed also to challenge readers. It requires high level theoretical analysis, the kind of analysis that should be expected of students in professional mental health disciplines. It is written as a secondary text for courses on theories of counseling and psychotherapy, including general theories courses and specialized courses on psychological or relational treatment approaches. It can also be used as a primary text for doctoral level theories courses or seminars. The intent of the book is to present the big picture—to raise the level of discourse on the topic of counseling and psychotherapy to an advanced level. It is meant to challenge readers to question the philosophical and professional foundations of their intended practices. It is designed to open the reader’s mind to multiple treatment frameworks that stand above the theories and therapies of everyday practice. It also provides an historical framework for the development of theories of counseling and psychotherapy.

I hope that you find this book engaging, educational, and thought-provoking. Also, I hope you agree that the mental health field has achieved the status of a paradigm science. It is my wish that the paradigm framework will be able to enhance the practice and research of counseling and psychotherapy.

Thank you.

Robert Rocco Cottone

St. Louis, Missouri

Acknowledgement: A special thank you goes to Jessica Taylor, my graduate assistant, whose work on this project was invaluable. She assisted at every stage of this book’s development.

Back to Table of Contents

Chapter One: Defining Paradigms of Counseling and Psychotherapy

This book is about paradigms of counseling and psychotherapy. Paradigms are large, theory encompassing frameworks that not only have unique philosophical foundations, but they also have significant alignment across mental health professions (e.g., counseling, psychology, psychiatry, and marital/family therapy). A number of widely accepted theories are referenced in this text, so that readers will get a good understanding of how theories align with the defined paradigms. So it is assumed that readers have some acquaintance with psychotherapeutic approaches, even if only a beginning or cursory acquaintance. But this book does not focus on theories of counseling and psychotherapy. Rather, this book attempts to outline the underlying professional, theoretical, political, and philosophical foundations of traditional and current theories of counseling and psychotherapy. In effect it is about a theory of theories, or a metatheory of counseling and psychotherapy. The term metatheory is used here to imply a larger framework--a super-ordinate theoretical structure distinguishable by operational criteria. A metatheoretical perspective provides a means for classifying theories along professional, political, and philosophical grounds. In the supermarket of theories of counseling and psychotherapy, a metatheoretical framework is the equivalent of offering an organizational framework, so that all the types of meat and all the types of potatoes, all the breads and the butters, are placed alongside of each other in an orderly fashion. The metatheoretical framework used in this book is that of paradigms of counseling and psychotherapy. The word paradigm, although viewed as trendy by many and viewed as confusing by others, is simply a way of saying a large, theory-encompassing model. The word paradigm is borrowed from Kuhn's (1970) classic work describing scientific paradigms, The Structure of Scientific Revolutions, and it is modified in this text to apply to mental health services (see Cottone, 1989a, 1992, 2007). Paradigms of counseling and psychotherapy (also called counseling paradigms) are models that, to a large degree, are mutually exclusive and based on different professional, political, and philosophical positions related to the nature of the psychotherapeutic enterprise. Because paradigms in the mental health services account for professional and political issues, as well as practical-theoretical issues, the discussion of theories according to paradigm-relevant issues makes this text unique. Paradigms are larger than theories in counseling and psychotherapy.

Four paradigms will be presented in this text, and each paradigm will have several theories under its wing. The four paradigms are: (a) the organic-medical paradigm; (b) the psychological paradigm; (c) the systemic-relational paradigm; and (d) the social constructivism paradigm. Each paradigm is defined according to criteria which are outlined and described in Chapter 2. The premise of this text is that paradigms are operationally real in the mental health field and, at a high level, they organize professional activities for serving mental health clients. For example, the paradigm operating at a hospital-based treatment center for the severely psychiatrically disabled (probably the organic-medical paradigm), may be quite different from the paradigm operating at a college counseling center (probably the psychological paradigm). Moreover, the paradigm operating at the college counseling center may be quite different from the paradigm operating at a marital or family services agency (probably the systemic-relational paradigm). In each of these settings, paradigms to some degree define and constrain the activities of the mental health professionals working in those settings. In this sense, beyond being organizational, paradigms are operational frameworks.

Paradigms of counseling or psychotherapy offer new insights into why human service professionals operate as they do. Paradigms, therefore, are frameworks for understanding and frameworks for actions. Each paradigm defines a separate professional reality--each real in its own right and within its community--but distinct and bounded when viewed from the perspective of a competitive paradigm. Understanding paradigms in counseling or psychotherapy is a unique way to understand the mental health professions.

The reason a discussion of paradigms to this point has been linked to a discussion of professional roles and responsibilities of the mental health professions is that paradigms, as defined in this book, are directly linked to the politics of mental health professions.

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BOX 1-1

Comparative Definitions

Theories of Counseling and Psychotherapy--specialized therapeutic approaches.

A Metatheory--a scientific, primarily deductive, theoretical framework that provides a big picture. A metatheory is a theory about theories. The metatheory presented in this book is that of counseling paradigms.

A Paradigm of Counseling and Psychotherapy (also called a counseling paradigm)--a means for demonstrating the big picture in counseling and psychotherapy. Counseling paradigms are metatheoretical hypothetical operational frameworks that provide a means for classifying and understanding theories of counseling and psychotherapy. What makes the study of counseling paradigms unique is the emphasis on the philosophical, political, and professional (disciplinary) issues underlying paradigms of counseling and psychotherapy.

END BOX 1-1

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In fact, one of the six criteria for a paradigm (listed in Chapter 2 of this book) is the existence of a group of professionals that adheres to the unique philosophical position underlying the paradigm. It will be argued that in the United States, paradigms are often associated with distinct professional groups competing in a political, ethical, and economic context for a limited pool of clients, patients, or funding for treatment. Each group will have a philosophy that is absolutely distinct among the mental health professions. Yet all groups share the basic philosophy that emotional and behavioral concerns are amenable to intervention by trained professionals. In this way, the study of paradigms should interest people intrigued by the study of professions as well as those with a penchant for the theoretical and philosophical.

This book is organized into three parts. Part one (Chapters One and Two) defines the historical, philosophical, and professional discipline-related issues that act as a rationale for delineating theories according to paradigms of counseling and psychotherapy. Specific criteria are defined for delimiting counseling paradigms. In part two (Chapters Three through Six), the four counseling paradigms are defined in detail: the Organic-Medical, Psychological, Systemic-Relational, and Social Constructivism paradigms. Each paradigm is described according to the criteria defined in Chapter Two, and specific theories of counseling and psychotherapy that demonstrate the assumptions and consequential directives of the larger paradigm frame of reference are identified and discussed. Part three (Chapters Seven and Eight) addresses cross-paradigm and related issues and provides a detailed discussion about how theories may be categorized within and across the paradigm framework. Part three also concentrates on the experimental consequences of paradigmatic thinking, and the issue of common factors among theories as predictors of successful outcome is addressed. Overall, a postmodern paradigm-comparative research agenda is proposed.

Theories, Therapies, and Paradigms

There are a number of counseling textbooks that use the word theory in their titles. In fact, the terms theory and therapy are used almost interchangeably in the counseling literature. For example, Ellis's (1962; 1994) Rational Emotive Therapy (RET, more recently called Rational Emotive Behavior Therapy, REBT) is presented as a foundation for understanding and predicting behavior, which is exactly what theory is supposed to do. And behavioral therapies derive primarily from the application of theoretical learning principles to the therapeutic situation. Yet the term theory deserves closer scrutiny. It is a term that implies a scientific ideal--a rational construction representative of some reality. It is both limited by, and limiting of, language. In fact, any good theory should build upon what has come before, while providing a new vocabulary to build upon. Theories, therefore, should provide a language of possibility--a means to predict the future in some unique way. Theories, at their very best, not only should aid in understanding but should give a new perspective for viewing the body of knowledge of a field. At the very least, theories should provide a new path for experimentation.

There is a relative consensus among scientists, emerging from a philosophy called logical positivism, that scientific theories, if they are to be valued, must be able to be disproved (Popper, 1959). According to positivistic ideals (logical positivism), a good scientific theory allows for operational hypotheses amenable to empirical investigation. In other words, it is important to be able to frame specific questions from a scientific theory and, additionally, there must be a means to answer specific questions. This presupposes the objectification of that which is to be studied. The objectification issue, however, is a difficult one in the study of theories of counseling and psychotherapy, since objectification of the subjective distress of clients is not an easy task.

Related to theories of counseling and psychotherapy, it may not be valid to presuppose the objectification of what is studied across all theoretical lines. Counseling often is related to the subjective distress of clients. Otherwise, a client is usually referred for counseling at the request of a third party who perceives a difficulty. Whether clients are distressed and self-referred or viewed as disturbed and referred by others for professional services, a decision about the success of treatment is as much a professional-political issue as a personal issue. Accordingly, attempts to assess the effectiveness of one therapeutic approach against another often reduce to: (a) an assessment of the subjective self-assessments of clients; or (b) observations of the behaviors of clients from the perspective of an observer (using instruments or criteria that may reflect primarily the values of the investigator-observer as opposed to a true assessment of what the client values). Because personal and political issues are predominant in defining the nature of what is to be objectified in the study of theories of counseling and psychotherapy, measures of outcome may not be taken for granted. Outcome measures must be viewed as reflecting the priorities of the theoretical framework as much as they are viewed as a reflection of an absolute criterion of mental health. (There is more discussion about outcome measures in psychotherapy research in the final chapter of this book.) Consequently, it is questionable whether therapies are (or should be treated as) theories in the scientific sense, even though the terms theory and therapy are used almost synonymously by practitioners, theorists, and textbook authors in the mental health field.

To clarify the confusion about theories in counseling and psychotherapy, in this book the term theory will be used in two easily distinguishable ways. First, the term theory will mean a therapy-specific framework delimited by the constructs and precepts defined by proponents of a therapeutic approach. When used in this way, it will be referred to as a theory, a theory of counseling or psychotherapy, a counseling theory, or a psychotherapy. Second, the term theory will be used to refer to a scientific ideal, as described earlier in this section. Whenever the theory is meant to represent a scientific ideal, the term scientific theory will be used. In this way, the two meanings of theory will be easily discernible. Unless the term scientific precedes the word theory, it can be assumed to mean a counseling theory.

It will be argued in this book that paradigms of counseling and psychotherapy are amenable to scientific inquiry, and, in fact, are more closely aligned to what is traditionally called scientific theory in the physical sciences or in the more scientific social sciences, such as experimental psychology. For example, Deese (1972), in Psychology as Science and Art, defined scientific theory as follows:

A scientific theory is a set of propositions or statements, some of which are axioms and some of which are assumptions. It is distinguished from pure mathematics or logic by the fact that some propositions can be coordinated with empirical data to produce facts….Theorems are statements that can be regarded as logical consequences of assumptions and axioms….If the empirical facts and theorems agree, the theory is said to be a good one. (p. 29)

Therefore, scientific theories are sets of propositions based on consensually recognized assumptions about the nature of reality. More concretely, scientific theories are hierarchical, with theoretical principles of an abstract or general nature at higher levels and more concrete or specific hypotheses at lower levels (Henderson, Goodman, Tenenbaum & Woodward, 2010, p. 172). These principles and hypotheses are tested in an empirical arena where data from the real world is used to test the scientific theoretical propositions. From an extreme positivistic standpoint, when there is a coordination of data and scientific theoretical propositions, absolute truth (what is unquestionably real) is defined. However, as the philosophy of science has developed, the idea of studying nature to find absolute truth has been replaced by a philosophy that can be described as postpositivistic. The postpositivistic revolution in science (influenced significantly by Kuhn, 1970) attempts to assess scientific theories as measures of relative truth, rather than measures of absolute truth. Accordingly, the truest test of a scientific theory is a critical test of the scientific theory against a competitive scientific theory. This means that experiments must be devised that compare one scientific theory to another in tests of strength at predicting outcomes. Mindful that there is almost nothing that remains an eternal verity (Deese, 1972, p. 31), the strongest test of a scientific theory is only a comparative one (Deese, 1972, p. 32). Unfortunately, when discussing counseling theories or psychotherapies, comparative tests have generally found that no one therapeutic approach dominates. For instance, Lambert, Shapiro, and Bergin (1986), after reviewing the literature comparing specific therapeutic approaches, concluded:

The meta-analytic summary data and the relatively high-quality individual studies reviewed here, in sum, tend toward the conclusion that psychosocial therapies are relatively equal in efficacy. (p. 170)

And more recently, Joyce, Wolfaardt, Sribney, and Aylwin (2006) concluded:

The metaanalytic literature supports two main conclusions. First, psychotherapy is indisputably superior to the absence of treatment. Across all reviews, patients treated with psychotherapy exhibit greater improvement than untreated patients. Second, the reviews consistently indicate that different approaches to psychotherapy yield equivalent effects. (p. 801)

So related to outcome, counseling theories appear to be fairly equal. And counseling, in and of itself, is better than no counseling at all (Joyce et al., 2006; Lambert et al., 1986). It is nice to know that psychotherapy works; the fact that psychotherapy is helpful is encouraging. But the idea that no one approach holds special status is perturbing, given the effort placed upon training of specialized approaches and techniques. As a result, research has begun to