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THE INFLUENCE OF REFLECTIVE PRACTICE ON THE CASE

CONCEPTUALIZATION COMPETENCE OF COUNSELOR TRAINEES

Vassilia Binensztok

A Dissertation Submitted to the Faculty of

The College of Education

in Partial Fulfillment of the Requirements for the Degree of

Doctor of Philosophy

Florida Atlantic University

Boca Raton, Florida

ii THE INFLUENCE OF REFLECTIVE PRACTICE ON THE CASE

CONCEPTUALIZATION COMPETENCE OF COUNSELOR TRAINEES

V assilia Binensztok

This dissertation was prepared under the direction of the candidate's dissertation advisor, Dr. Len Sperry, Department of Counselor Education, and has been approved by all members of the supervisory committee. It was submitted to the faculty of the College of Education and was accepted in partial fulfillment of the requirements for the degree of Doctor of Philosophy.

SUPERVISORY COMMITTEE:

Len S~M~(/(;r;?<

P~ul Peluso, Ph.D. ~Ad'#M £~ Carman Gill, Ph.D.

Paul Peluso, Ph.D. Chair, Department of Counselor Education

Apci \ ~. lotq Khaled Sobhan, Ph.D. Date Interim Dean, Graduate College

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ACKNOWLEDGEMENTS

I would like to take this opportunity to thank everyone that has helped me on my journey through the doctoral program and seeing this dissertation to its end. First and foremost, I would like to express my appreciation to my advisor and committee chair, Dr.

Len Sperry. I feel honored that you chose me to work on important projects with you.

During these projects, I have learned not only how to be a scholar but also learned many lessons about myself. The assignments you gave me pushed me to explore the limits of what I could do and showed me I am capable of much more than I once thought I was.

You have helped me gain the confidence to set out on my own ventures and attempt things I had not dreamed of before. I will be forever grateful not only for the academic opportunities you have afforded me but also for the opportunity to grow as a person and a thinker.

I would like to thank my committee members Dr. Paul Peluso and Dr. Carman

Gill. Dr. Peluso, thank you for taking the time to work with me and help me through my dissertation process. You bring a great presence to the Department and help the students feel supported through the program. Dr. Gill, you have inspired me in many ways, and I see you as a role model as both a scholar and a woman. I feel fortunate to have had the opportunity to learn from you and to have participated in so many meaningful class discussions with you. I would like to thank Dr. Jon Sperry for accommodating me in my research and for going to great lengths to help me collect my data.

I want to acknowledge my family and friends, without whom nothing I have achieved would be possible. Thank you to my grandparents, Nina and David, may they rest in peace, who survived many hardships and eventually lived the American Dream and instilled this value in me. My grandfather, David, gave me his resilience, perseverance, and idealism. Thank you to my cousin, Sara, for always holding it down for me. I am doing my best not to live under the family spell, for all of us. Thank you to my great, great grandmother for watching over me, and thank you to my ancestors for the blessings. Thank you to my cousin, Joe, and my aunt and uncle Aviva and Leon, for supporting me and finally taking my side. Also, I would like to acknowledge my parents, who were right about some things, wrong about a lot of things, but, for better or worse, helped make me who I am.

Thank you to my friends Lexie, Allison, and George. You are my fans, my support, and my confidantes. I love you, and I don’t know where I would be if it weren’t for you. I can’t wait to get out and finally see more of you now that I’m done with all this work! Thank you to the most amazing Ph.D. friends anyone could ask for —The

Outliers Ali and Tiffany. You have helped me navigate one of the most turbulent times, and I hope that I have done the same for you. I will be forever grateful to you and the thread. The further I got into this dissertation, the more I realized how fitting norepinephrine was.

Finally, last but not least, I would like to thank and dedicate my dissertation to all the students I taught at Palm Beach State College from 2012 through 2018. My students changed my life. You believed in me so much that I started believing in myself. You

liked me so much I started liking myself. I might never have pursued this dream of earning a doctorate if it weren’t for you all.

ABSTRACT

Author: Vassilia Binensztok, M.S.

Title: The Influence of Reflective Practice on the Case Conceptualization Competence of Counselor Trainees

Institution: Florida Atlantic University

Dissertation Advisor: Dr. Len T. Sperry

Degree: Doctor of Philosophy

Year: 2019

The purpose of this quasi-experimental, longitudinal study was to measure the

effects of reflective practice coaching on 35 participants, as compared to participants who

did not receive coaching. Data was collected over a period of eight weeks. A secondary

purpose was to examine the effects of a standardized case conceptualization training

lecture on 84 participants. A third purpose was to examine the relationships between

counselor trainee demographic variables, their attitudes towards evidence-based practice, disposition towards reflective reasoning, and competence in writing case conceptualizations. This was the first study to contribute to the reflection in counseling literature. A convenience sample of N = 84 participants participated in two standardized case conceptualization training lectures. An intervention group (N = 35) received an additional three one-on-one reflection coaching sessions. The comparison group (N = 49)

received the training lectures and no coaching. Participants from both groups attended

two 3-hour training lectures, which taught the integrative case conceptualization model

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developed by Sperry (2010). Intervention group participants took part in three additional one-on-one reflection coaching sessions. Pre- and post-training lecture case conceptualization skills were assessed using the Case Conceptualization Evaluation Form

(CCEF) 2.0. Levels of reflective thinking were measured with pre-, post-, and post-post- administrations of The Reflection in Learning Scale (Sobral, 2005).

Variance in case conceptualization competence was analyzed using a MANOVA.

Intervention group participants’ mean CCEF 2.0 scores were significantly higher than those of the comparison group (M = 72.64 and M = 46.81, respectively). Reflective thinking was determined not to be a mediating or moderating variable. Mean CCEF 2.0 scores from the first training lecture increased from the pre-test to the post-test (M =

11.20 and M = 24.10, respectively) for all participants. Mean case CCEF 2.0 scores also increased from the pre-test to the post-test in the second training lecture (M = 21.33 and

M = 52.29, respectively) for all participants. Additionally, a paired sample t-test showed improvement on the Reflection in Learning Scale (Sobral, 2005) between the post-test and post-post test for the intervention group. Results were significant (|t| = 1.91, df 34, p

< .001, one-tailed).

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THE INFLUENCE OF REFLECTIVE PRACTICE ON THE CASE

CONCEPTUALIZATION COMPETENCE OF COUNSELOR TRAINEES

List of Tables ...... xiii

List of Figures ...... xiv

I. Introduction ...... 1

Statement of the Problem ...... 5

Need for standardized training of case conceptualization skills...... 10

Purpose of the Study ...... 11

Research Questions and Hypotheses ...... 11

Definitions of Key Terms ...... 13

Study Design ...... 16

Organization of the Dissertation ...... 17

Summary ...... 17

II. Literature Review ...... 19

Case Conceptualization ...... 19

Significance of Case Conceptualization ...... 21

Practitioner Expertise ...... 23

Case Conceptualization Training ...... 25

Types of Case Conceptualization Models ...... 27

Context and organizational models...... 27

Research models...... 27 ix

Non-Integrative Models ...... 28

Cognitive-behavioral models...... 28

Behavioral models...... 28

Biopsychosocial models...... 29

Adlerian models...... 29

Dynamic models...... 29

Integrative Models ...... 30

Evaluation of Integrative Case Conceptualizations ...... 32

Reflective Practice ...... 33

History of Reflective Practice ...... 36

Significance of Reflective Practice ...... 41

Reflective Practice and Counseling Expertise ...... 43

Teaching Reflective Practice ...... 45

Socratic questioning...... 45

Reflective Practice Research...... 47

III. Method ...... 48

Research Questions and Hypotheses ...... 48

Variables ...... 50

Dependent variables...... 50

Independent variables...... 50

Mediating variable...... 51

Study Design ...... 51

Case conceptualization training lectures...... 51

Reflective practice coaching...... 53

Coaching Protocol ...... 53

Participants ...... 54

Instruments ...... 54

Case Conceptualization Evaluation Form (CCEF) 2.0...... 55

Views about Case Conceptualization questionnaire (VACC)...... 56

Evidence-Based Practice Attitude Scale (EBPAS)...... 57

Demographic questionnaire...... 59

Reflection in Learning Scale (RLS)...... 59

Procedure and Data Collection ...... 60

Lecture facilitators...... 60

Case conceptualization raters...... 61

Case Conceptualization and Instrument Collection ...... 63

Data Analysis ...... 64

IV. Results...... 66

Sample Population Characteristics ...... 66

Hypothesis Testing...... 70

Summary ...... 80

V. Discussion ...... 81

Significance of the Results...... 81

Contributions of the Study ...... 84

Implications for Theory, Practice, and Research ...... 85

Theoretical implications...... 85

Practice implications...... 87

Research implications...... 89

Study Limitations ...... 91

Conclusion ...... 92

Appendices ...... 94

Appendix A: Adult Consent Form ...... 95

Appendix B: Case Conceptualization Training Lecture Questionnaire ...... 97

Appendix C: Case Conceptualization Training Demographic Questionnaire ...... 98

Appendix D: Institutional Review Board Documentation ...... 99

References ...... 100

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LIST OF TABLES

Table 1. Rater Descriptive Statistics ...... 61

Table 2. Participant Case Conceptualizations Incorporated in the Study ...... 63

Table 3. Documents and Instruments Collected Per Training Session ...... 63

Table 4. Participant Demographic Information ...... 67

Table 5. Study Participant Credits Completed ...... 68

Table 6. Study Participant Grade Point Averages ...... 69

Table 7. Study Participant Years Experience Counseling ...... 69

Table 8. Results of the Paired Samples Test for Null Hypothesis 2 ...... 74

Table 9. Results of Paired Samples Test for Null Hypothesis 4 ...... 76

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LIST OF FIGURES

Figure 1. Mean case conceptualization scores for intervention and comparison

groups for all case conceptualizations CC1 through CC8...... 72

Figure 2. Effects of mediation...... 73

Figure 3. Effects of moderation...... 73

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I. INTRODUCTION

The Council for Accreditation of Counseling and Related Educational Programs

(CACREP) outlines a set of standards to which counseling students’ adherence will aid in

developing their skill sets, forming professional counseling identities, and growing, both personally and professionally (CACREP, 2016). Furthermore, practicing accountability in a mental health practice requires counselors to effectively plan treatments (Seligman &

Reichenberg, 2014). For these reasons, CACREP standards now require students to be taught the use of evidence-based practices. By connecting assessment and treatment with outcomes, case conceptualization can act as a "bridge" between theory and practice

(Sperry & Sperry, 2012) and so has been referred to as the "heart of evidence-based practice” (Bieling & Kuyken, 2003, p. 53). It is considered a “core clinical skill” (Fleming & Patterson, 1993, p. 345), and the American Psychological Association

Presidential Task Force on Evidence-Based Practice (2006) recommends that all practitioners be capable of formulating logical case conceptualizations.

While researchers focus on different elements of a case conceptualization, sometimes also referred to as a case formulation, there is consensus with respect to the

main elements. Case conceptualization can be defined as "a method and clinical strategy

for obtaining and organizing information about a client, understanding and explaining the

client's situation and maladaptive patterns, guiding and focusing treatment, anticipating

challenges and roadblocks, and preparing for successful termination" (Sperry, 2010b, p.

110).

Clinicians must be able to organize and make sense of numerous items of client

data. Clients may have a range of complex issues that span the course of a lifetime and that may obscure the presenting problem. For example, a client might present to

counseling with complaints about stress from school but may also have relational

problems, exhibit symptoms of an anxiety disorder, or have a history that includes

domestic violence, a spiritual crisis, substance abuse, or medical issues. Moreover, the

client’s ingrained patterns may exacerbate the current problem. To select proper

treatment interventions, the clinician must be able to not only assess all of these areas but

also sort through all these data and understand how they fit together. Case

conceptualization is a tool for organizing client data in a comprehensive way and so can

be viewed as a “road map,” “blueprint,” or “compass” to do so (Sperry & Sperry, 2012).

A case conceptualization helps counselors make “explanatory inferences” that guide treatment through termination (Kuyken, Fothergill, Musa, & Chadwick, 2005, p. 1188).

Moreover, case conceptualizations answer two critical questions—“Why did it happen?”

(Sperry, 2005a, p. 72) and “How do you know what to do in psychotherapy?” (Eells,

2015, p. 13).

The need for case conceptualization is more evident than ever before, largely

because of managed care and the drive towards accountability (Falvey, 2001; Sperry,

2005b). Clinicians are expected to plan focused and brief treatments and to demonstrate

not only the rationale for these treatments but also their expected outcomes. Treatment is

tailored to a client’s needs and expectations (Sperry, 2005b). Because it provides a

comprehensive, individualized plan that is client-centered, case conceptualization can improve treatment focus and efficiency as well as outcomes. Case conceptualization

allows the clinician to assess client change and guide and alter treatment as necessary. It goes beyond the symptom-focused approach of the Diagnostic and Statistical Manual of

Mental Disorders (American Psychiatric Association, 2013) by providing explanations for symptoms and problems and information about their treatment (Sperry & Sperry,

2012). Diagnosis alone does not reveal the underlying causes of a presenting problem.

However, case conceptualization can fill the space between diagnosis and treatment (Sim,

Gwee, & Bateman, 2005) and even improve the accuracy of diagnosis by eliciting and organizing more complex client data (Sperry, 2005b).

Positive correlations were found between a practitioner's case conceptualization skill level and improved client outcomes (Silberschatz, Fretter, & Curtis, 1986), improved therapeutic alliance (Crits-Cristoph, Barber, & Kurcias, 1993), enhanced practitioner empathy (Eells, 2015), improved treatment with complex and challenging cases (Persons, 1992), and maintenance of treatment gains after discontinuing treatment (Jacobson, et al., 1989). Practitioners who can conceptualize their cases have showed improved performance (Morran, 1986) and better accuracy in analyzing client problems (Crits-Christoph, Cooper, & Luborsky, 1988) and have been better able to perceive the need to alter treatment (Malatesta, 1995a). These clinicians were also more confident in their abilities (Ladd, 2015) and were perceived as more effective by their clients (Morran, Kurpius, Brack, & Rozecki, 1994).

Just as case conceptualization helps integrate theory with practice, reflective practice is cited as being crucial to integration of knowledge in a multitude of academic disciplines, especially counselor education (Lundgren & Poell, 2016). Bennett-Levy

(2006) identified reflective practice as a “key task” for counselor trainees. Reflective

practice assumes that learning results not from experiencing an event per se but from a

reflective analysis of the event after it has occurred (Bennett-Levy, 2006). Reflection can be defined as “a metacognitive skill, which encompasses the observation, interpretation and evaluation of one’s own thoughts, emotions and actions, and their outcomes” and can be viewed as a process in which individuals “explore their experiences in order to lead to new understandings and appreciations” (Boud, Keogh, & Walker, 1985, p. 19). Thus, this process encompasses more than just thinking or gaining insight. Instead, reflection improves awareness and leads to changes in understanding that can have long-term effects on one’s abilities (Neufeldt, Karno, & Nelson, 1996).

Bennett-Levy (2006) addressed the need for a reflective system in counselor education as it helps integrate declarative knowledge (theories, formulas, etc.) with procedural knowledge (tacit knowledge), thus forming the basis for development of expertise. Expert counselors have more complex schemas than novices, allowing them to make more advanced interpretations and generate more alternatives (Sparks-Langer,

Simmons, Pasch, Colton, & Starko, 1990).

Moreover, research has indicated the significant degree to which a clinician’s level of expertise is tied to counseling outcomes (Crits-Christoph et al., 1991; Luborsky et al., 1986). Novice counselors are less skilled at identifying meaningful patterns in client data and think more superficially about cases (Eells, Lombart, Kendjelic, Turner, &

Lucas, 2005) whereas expert practitioners can identify meaningful patterns (Chase &

Simon, 1973), evaluate problems in depth, be aware of their own mistakes (Glaser & Chi,

1988), and use their skills with judgment and flexibility (Betan & Binder, 2010).

Expertise, however, is not a byproduct of experience (Chi, Glaser, & Farr,

1988). Rather, a reflective practice is the key to turning experience into

expertise (Neufeldt et al., 1996; Skovholt & Jennings, 2005). As novices, counseling

students often experience difficulty applying research, theory, and experience to practice,

but reflection has been found to facilitate this process (Hart, 1993), thus rendering

reflective practice integral to their professional development.

Statement of the Problem

Counselors must be able to organize and integrate complex client data, including

patterns and precipitating and perpetuating factors, in order to properly understand clients and plan their treatment (Kendjelic, 1998). This can be an impossible task for counselors who do not receive training in case conceptualization, and research has shown that

counselors typically do not receive adequate training in this area (Eells, 2007), leaving

many counselors confused about the purpose and process of case conceptualization and

able to formulate only narrow case summaries instead (Kendjelic & Eells, 2007). Many

researchers in this field agree that counselor trainees’ case conceptualization skills are

typically lacking (Binder, 1993; Fleming & Patterson, 1993; Sperry, Gudeman,

Blackwell, & Faulkner, 1992; Toews, 1993).

An analysis of nominal case conceptualizations written by clinicians at an

outpatient psychiatric facility revealed that the clinicians had primarily written case

summaries instead of actual case conceptualizations that integrated client data,

precipitants, and perpetuants (Eells, Kendjelic, & Lucas, 1998). In another

study, a review of the quality of resident psychiatrists’ written case conceptualizations

revealed these to be less competently formulated, suggesting that this competency to do

so was not prevalent amongst this group of clinicians (McClain, O'Sullivan, & Clardy,

2004). An analysis of 150 assessment letters for referrals to a psychiatric clinic found

that 94% of those letters included no case conceptualizations (Abbas, Premkumar,

Goodarzi, & Walton, 2013). Kuyken, Fothergill, Musa, and Chadwick (2005) found that

only 44% of case conceptualizations written by 115 clinicians could be considered “at

least good enough.” Researchers also indicated that training in case conceptualization

for counselor trainees is lacking. In a study of 57 psychiatry training supervisors in the

United States, Canada, United Kingdom, and Ireland, 60% of respondents stated that they

did not receive adequate training in this area (Ben-Aron & McCormick, 1980). Another

study indicated that 69% of psychiatry residents surveyed believed they did not receive

adequate case conceptualization skills and guidelines in training (Fleming & Patterson,

1993).

Case conceptualization skills can and must be taught (Ben-Aron & Mc.Cormick,

1980; Sperry, 2005a). Sperry and Sperry (2012) state, “Learning and mastering competency in case conceptualization does not occur by chance, instead it requires having an intentional plan and strategy for increasing this essential competency” (p.

12). On the other hand, “if training programs fail to provide opportunities for learning to conceptualize cases, and if faculty do not teach and model effective case conceptualization, trainees are less likely to develop effective treatment plans and interventions” (Sperry, 2005a, p. 73). Training of counselors can be complex (Johnson &

Heppner, 1989), and researchers have questioned the effectiveness of some counselor training methods (Johnson & Heppner, 1989; Roffers, Cooper, & Sultanoff, 1988). Sim,

Gwee, and Batemen (2005) stress that this “key clinical skill ... is still largely undertaught

and underlearned” (p. 289).

Additionally, a number of myths about case conceptualization identified by

Sperry and Sperry (2012) contribute to infrequent and improper use of this

competency. First, some counselors believe a summary of client data is a case

conceptualization. However, while data concerning the client’s presenting problem,

social and biological histories, and other information are important, these data do not

explain the reasons for or potential treatments of the client’s problem. Case conceptualization requires inferential thinking that goes beyond a simple case summary (Sperry & Sperry, 2012). Second, although case conceptualizations are linked to improved outcomes, some clinicians believe they are not clinically useful and so do not improve treatment. Third, although mastering the foundations of this competency can

be completed in just a few hours through a training lecture, some counselors view case

conceptualizations as too difficult to learn and too time consuming to write.

Fourth, some clinicians believe that there is only one kind of case

conceptualization and that it is suitable for all clients. Sperry and Sperry (2012),

however, specify three types of case conceptualizations: provisional, written after intake

evaluation and updated as needed; brief, which includes a few elements and is better suited for higher functioning clients with particular presenting problems; and full-scale, which includes most or all of case conceptualization elements and is better suited for low-

functioning clients exhibiting relatively complex problems. Finally, clinicians may

believe that all case conceptualizations are the same, whereas, in fact, there are three

methods for developing case conceptualizations: structured case conceptualization

methods, non-standardized methods, and the integrative method. Sperry’s (2010b) integrative method was employed in this study.

As with case conceptualization, many counseling students do not receive adequate

training in reflection because of traditional modernist approaches to teaching (Guiffrida,

2005). The lack of self-reflection in counselor training constitutes a roadblock to students’ understanding of themselves and their preconceived notions and so is a major obstacle in their ability to integrate theory and practice (Guiffrida, 2005). Thus, failure to properly train counseling students negatively affects the scope of the field, from research to practice (Bennett-Levy, 2006). Additionally, research shows that, once counselors complete their education, many do not read counseling research or place much value on theory (Guiffrida, 2005). Schon (1995) attributed this gap between theory and practice to modernist pedagogy's lack of influence on self-reflection, and critical self-reflection was identified as the most important distinguishing factor between counselors who continue their professional development and those who burn out and allow themselves to stagnate

(Skovholt & Ronnestad, 1992).

Some counselor educators erroneously believe that simply teaching counseling theory will foster understanding and reflection (Guiffrida, 2005). Critical self-reflection, however, is a competence that must be taught. McAuliffe and Eriksen (2000) estimate that up to 50% of mental health clinicians are unreflective when selecting intervention strategies and conducting treatment planning and define this lack of reflection as

“adherence to a single technique, and/or maintenance of the status quo when more inclusive and socially critical interventions are needed” (McAuliffe & Eriksen, 2000, p.

199).

Reflective practice is critical to building expertise, as it serves as the bridge

between declarative and procedural knowledge (Bennett-Levy, 2006; Binder, 1999;

Nelson & Neufeldt, 1998). Counselors with expertise create relatively more

sophisticated case conceptualizations because they “use theoretical knowledge and think

about patients with greater understanding, flexibility, creativity, and innovation than do

novice therapists” (Betan & Binder, 2010, p. 144). Defining metabolization of theory as

“the process of bringing ideas and concepts to live inside one's mind and psyche so they

become part of the self and identity” (Betan & Binder, 2010, p. 144), these authors state

that counselors must “metabolize” theory in order to develop expertise. In this way,

theory becomes part of a clinician’s “deep structure,” allowing the clinician to

automatically organize client data through a theoretical framework. Betan and Binder

(2010) stress that reflective practice is the key to metabolizing theory. Glaser and Chi

(1988) also stress that the key to expertise building is the ability to monitor oneself. For

these reasons, numerous researchers stress the importance of teaching reflection in order

to help students integrate theory with practice and build expertise (Bennett-Levy, 2006;

Niemi & Tiuraniemi, 2010; Skovholt, Ronnestad, & Jennings, 1997), and some believe

that current teaching methods do not adequately instruct students in reflective practice

(Guiffrida, 2005).

The evidence base for self-reflection is still sparse and mostly comprised of qualitative research (Thwaites, Bennett-Levy, Davis, & Chaddock, 2014). Additionally, few studies exist and the ones that do are largely more than ten years old. Thus, there is a need for new research, and quantitative research on reflective practice, including study of the longer-term effects of reflection (Thwaites et al., 2014). Reflective thinking has also

proven difficult to measure, particularly as it relates to learning (Lee & Birdsong

Sabatino, 1998). Complications in measuring reflection have confounded many studies, leading researchers to question the extent to which their findings are attributable to the reflective process or some other construct (Lee & Birdsong Sabatino, 1998). For this reason, there is still a dearth of evidence on the utility of reflection in learning (Lee &

Birdsong Sabatino, 1998). Bennett-Levy terms the lack of quantitative research on self- reflection a "major oversight in the development of psychological theories of learning"

(Bennett-Levy, 2006, p. 60). Additional studies are needed to measure the value of reflective practice on counselor education, as there is a lack of literature on strategies counselor educators can use to foster reflective practice (Guiffrida, 2005).

Need for standardized training of case conceptualization skills. According to previous studies, case conceptualization skills improve with practice, allowing expert clinicians to produce relatively more complex and comprehensive case conceptualizations (Betan & Binder, 2010; Eells et al., 2005; Eells et al., 2011). Other researchers, however, contend that case conceptualization can be learned through standardized training and independently of a clinician’s experience level (Abbas, Walton,

Johnston, & Chikoore, 2012; Kelsey, 2014; Kendjelic & Eells, 2007; Ladd, 2015;

Stoupas, 2016). Standardized training can help even novice clinicians make significant improvements in case conceptualization and can dispel myths about this competency, helping trainees become more open to learning the skill (Kelsey, 2014; Ladd, 2015;

Stoupas, 2016).

Previous studies on case conceptualization training included small sample sizes

(Abbas et al., 2012; Kendjelic & Eells, 2007), included non-clinicians or clinicians with

varying degrees of experience (Kendjelic & Eells, 2007), failed to include pre-

intervention assessment of case conceptualization abilities (Abbas et al., 2012; Kendjelic

& Eells, 2007), and inadequately assessed post-intervention abilities (Kendjelic & Eells,

2007). Additionally, no previous studies have examined the effect of reflective practice on case conceptualization skills in conjunction with standardized training. Finally, no study with counselor trainees has examined the effects of case conceptualization training over time.

Purpose of the Study

The primary purpose of this study was to measure the effects of reflective practice coaching on counselor competence in writing case conceptualizations. A secondary purpose was to examine the effects of a case conceptualization training lecture on counselor trainees’ competence in writing case conceptualizations. A third purpose was to examine, on the one hand, the relationships between counselor trainee demographic variables, attitudes towards evidence-based practice, and disposition towards reflective reasoning and, on the other, the competence of these trainees in writing case conceptualizations.

Research Questions and Hypotheses

The study sought to answer the following research questions:

Research Question 1: What is the effect of reflective practice coaching on coaching recipients’ competence in writing case conceptualizations?

Null Hypothesis 1 (H01): Reflective practice coaching has no effect on coaching

recipients’ competence in writing case conceptualizations.

Research Question 2: What is the effect of reflective practice coaching on counselor trainee reflective thinking?

Null Hypothesis 2 (H02): Reflective practice coaching has no effect on counselor trainee reflective thinking.

Research Question 3: Does a three-hour initial training lecture increase counselor trainee competence in developing a case conceptualization?

Null Hypothesis 3 (H03): A three-hour initial training lecture has no effect on counselor trainee competence in developing a case conceptualization.

Research Question 4: Does a three-hour initial training lecture reduce counselor trainee myths about case conceptualizations?

Null Hypothesis 4 (H04): A three-hour initial training lecture does not reduce counselor trainee myths about case conceptualizations.

Research Question 5: Does a follow-up training lecture increase counselor trainee competence?

Null Hypothesis 5 (H05): A follow-up training lecture does not increase counselor trainee competence.

Research Question 6: What variables (age, gender, race/ethnicity, grade point average, graduate school training, counseling experience, attitudes toward evidence- based practice, disposition toward reflective thinking) influence reflective thinking?

Null Hypothesis 6 (H06): None of the variables listed above influence counselor trainees’ reflective thinking.

Research Question 7: What variables (age, gender, race/ethnicity, grade point average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking) are related to case

conceptualization competence prior to training?

Null Hypothesis 7 (H07): None of the variables listed above are related to case

conceptualization competence prior to training.

Research Question 8: What variables (age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking) influence response to an initial

case conceptualization training lecture?

Null Hypothesis 8 (H08): None of the variables listed above influence the

response to an initial case conceptualization training lecture.

Research Question 9: What variables (age, gender, race/ethnicity, grade point average, graduate school training, counseling experience, attitudes toward evidence- based practice, disposition toward reflective thinking) influence response to a follow-up

training lecture?

Null Hypothesis 9 (H09): None of the variables listed above influence the

response to a follow-up training lecture.

Research Question 10: What variables (age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking) influence the persistence of case

conceptualization training effects over time?

Null Hypothesis 10 (H010): None of the variables listed above influence the

persistence of case conceptualization training effects over time.

Definitions of Key Terms

Case Conceptualization is a “method or clinical strategy for obtaining and

organizing information about a client, understanding and explaining the client’s situation

and maladaptive patterns, guiding and focusing treatment, anticipating challenges and

roadblocks, and preparing for successful termination”(Sperry, 2010a, p. 110).

Clinical Formulation refers to the explanation of a client’s symptoms, concerns,

level of functioning, and maladaptive relational problem (Sperry, 2010a).

Competencies are the consistent and prudent use of knowledge, skills, clinical

reasoning, emotions, values, and reflection in clinical practice (Sperry,

2010b). Competence refers to an individual’s capacity to assess and revise decisions through reflective practice (Kaslow, 2004).

Competency refers to the integration of knowledge, skills, and attitudes (Sperry,

2010b).

Counselor Competence is the consistent and judicious use of knowledge, skills,

clinical reasoning, emotions, values, and reflection in clinical practice by counseling

personnel (Sperry, 2010b).

Counselor Trainees are individuals enrolled in a master’s level graduate

counseling program for the purpose of becoming professional counselors.

Cultural Formulation refers to the systematic assessment of cultural factors and

dynamics (Sperry & Sperry, 2012)

Diagnostic Formulation refers to the descriptive appraisal of a client’s

presentation and precipitants and reflects that client’s pattern (Sperry & Sperry, 2012).

Explanatory Power provides an explanation for a client’s presenting problem in

a case conceptualization (Sperry & Sperry, 2012).

Evidence-Based Practice is the integration of research-based evidence, client context, values and preferences, and clinical expertise (American Psychological

Association Presidential Task Force on Evidence-Based Practice, 2006).

Pattern (Adaptive) refers to a style of thinking, feeling, and behaving that is flexible, appropriate, and effective (Sperry & Sperry, 2012).

Pattern (Maladaptive) refers to a style of thinking, feeling, and behaving that is inflexible, inappropriate, and ineffective (Sperry & Sperry, 2012).

Perpetuants are triggers that maintain an individual’s pattern, resulting in the presenting problem. A perpetuant is also called a maintaining factor (Sperry & Sperry,

2012).

Precipitant is a trigger that sets off the pattern resulting in the presenting problem (Sperry & Sperry, 2012).

Predictive Power provides an anticipation of obstacles and facilitators to treatment success in a case conceptualization (Sperry & Sperry, 2012).

Predisposing Factors are the factors that foster adaptive and maladaptive functioning (Sperry & Sperry, 2012).

Presentation refers to the presenting problem and characteristic responses to the precipitants (Sperry & Sperry, 2012).

Reflective Practice refers to "a metacognitive skill, which encompasses the observation, interpretation and evaluation of one's own thoughts, emotions and actions, and their outcomes," and to a process in which individuals "explore their experiences in order to lead to new understandings and appreciations" (Boud et al., 1985, p. 19).

Reflective Practice Coaching is a standardized intervention designed to facilitate reflective thinking and analysis.

Tailored Treatment Interventions are interventions which meet the need of the client, given that client’s unique circumstances.

Treatment Formulation is an explicit blueprint for intervention planning (Sperry

& Sperry, 2012).

Study Design

The purpose of the study was to determine the effect of training sessions on participant counselor trainees’ case conceptualization competence, views about case conceptualization, trainees’ attitudes towards evidence-based practice, and reflective thinking. Study participants consisted of a non-random, convenience sample of counselor trainees located in the South Florida area. They were divided into two groups, an intervention group (N = 35) and a comparison group (N = 49), for a total of (N = 84).

Participants in both groups took part in two separate interventions, both of which were presented as clinical training lectures. These standardized trainings were based on the integrative case conceptualization model developed by Dr. Len Sperry (1989) and expanded upon in Sperry (2010b) and Sperry and Sperry (2012). These training lectures taught participants about case conceptualizations and how to write them and included such elements as presentation, precipitant, predisposing factors, and perpetuating factors.

Participants in the intervention group also participated in three one-on-one reflection coaching sessions employing a reflective practice coaching protocol.

The following instruments were employed in this study to obtain study data:

Views about Case Conceptualization questionnaire (VACC) (Sperry, 2012) to measure

participant views on case conceptualization; Case Conceptualization Evaluation Form 2.0

(CCEF) developed by Sperry and Sperry (2012) and used to measure participant case

conceptualization competence; Evidence-Based Practice Attitude Scale (EBPAS) created

by Aarons (2004) and used to measure participant attitudes toward evidence-based practice; and Reflection in Learning Scale (RLS) created by Sobral (2005) and used to measure participant reflective thinking. These instruments will be discussed in detail in

Chapter III. All have been employed in past studies and so possess proven validity. The quantitative methods MANOVA, ANOVA, and correlation, and paired samples t-test were then employed to analyze the study data.

Organization of the Dissertation

This dissertation is formatted as follows: Chapter I introduces case conceptualization and reflective practice, existing problems related to case conceptualization, limitations of previous research studies on case conceptualization, and the purpose of this study. Chapter II provides a review of the literature pertinent to this study, including research on case conceptualizations and reflective practice. Chapter III

details the study methods, procedures, instruments, and data analysis employed in the

conduct of this study. Chapter IV presents the study results, which are then discussed in

Chapter V. The dissertation conclusion, Chapter VI, provides a summary of the study’s findings and their implications; discusses the study’s contributions, both practical and academic; details its limitations; and presents areas for future research.

Summary

Counselors must be able to assess, understand, and integrate complex client data in a logical way in order to provide their clients adequate and effective

treatment. Clinicians must be able to tailor treatment to unique client needs and

dynamics, justify their choice of treatment, and plan for challenges encountered during

treatment and termination. Although research has shown that these skills can be taught to

counselors, many counselors do not use this competency, and training in this area is lacking in most counselor education programs. This study adds to the existing literature by examining the effects of standardized case conceptualization training on counselor trainees and exploring the effects of reflective practice as learned through a coaching intervention.

II. LITERATURE REVIEW

The following chapter consists of a review of the literature relevant to the

study. First reviewed is case conceptualization research, including different case

conceptualization models, relationships of such conceptualizations to counseling

outcomes, previous training studies, and the connection between case conceptualizations

and reflective practice through expertise. Lastly, this review discusses reflective practice,

including its definition, history, role in education, and role in development of expertise.

Case Conceptualization

In the era of managed care and accountability, more emphasis is being placed on

using evidence-based practice in counseling. Clinical expertise is an invaluable skill necessary for providing effective treatment and applying empirically supported techniques (Betan & Binder, 2010). Additionally, CACREP standards now require

counseling students to be taught to use evidence-based practices (CACREP, 2016). Case

conceptualizations are now recognized as being an integral part of evidence-based

practice and a “primary skill that may be the linchpin of practice” (Betan & Binder, 2010,

p. 141). For instance, case conceptualization has been called the “heart of evidence-based

practice” (Bieling & Kuyken, 2003, p. 53) and the key to evidence-based practice for the

scientist-practitioner (Kuyken et al., 2005). Case conceptualization is considered a “core

clinical skill” (Fleming & Patterson, 1993, p. 345) that is essential to client care and that

leads to improved treatment outcomes (Kendjelic & Eells, 2007). Case conceptualization

has been attributed with “fill[ing] the gap between diagnosis and treatment” (Sim et al.,

2005, p. 289) and helping a counselor to better understand and explain a client’s

presenting problem, precipitating factors, and treatment options (Sim et al.,

2005). Consequently, the American Psychological Association Presidential Task Force on Evidence-Based Practice (2006) now recommends that all expert practitioners be able to formulate theoretically logical case conceptualizations.

A case conceptualization helps integrate theory with practice (Sperry, 2005a)

and allows the making of “explanatory inferences” (Kuyken et al., 2005, p. 1188) that

guide the course of treatment from assessment to termination. Case conceptualizations

answer two critically important questions: “Why did it happen?” (Sperry, 2005a, p. 72)

and “How do you know what to do in psychotherapy?” (Eells, 2015, p. 13). In addition, a

case conceptualization can be seen as a process through which client data are organized

and integrated to formulate a treatment plan (Toews, 1993) and allows the counselor to

develop an individualized, empirical approach to each client (Persons, 2006) that leads to

a more holistic understanding (Eells, 2007). Eells et al. (2005) define a case

conceptualization as a working hypothesis about the causes, predisposing factors, and

maintaining factors of a client’s presenting problem, and Sperry et al. (1992) state that it

includes a proposed treatment plan arising from this hypothesis. Betan and Binder (2010)

recognize a case conceptualization as the “framework for implementing other skills and

activities in clinical practice, including assessment and diagnostic judgment, meaning

making and interpretation, clinical decision making and intervention, and interpersonal as

well as multicultural sensitivity” (p. 143). While these definitions touch on many of the

elements of a complete, coherent case conceptualization, a more thorough definition is

given by Sperry (2010b):

Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for a successful termination (p. 110).

A comprehensive case conceptualization provides the counselor with a ‘map’ of the client’s behavioral patterns that will serve as a guide for continued assessment, treatment, and termination (Sperry, 2005b). It can be seen as a “clinician’s ‘theory’ of a particular case” (Sperry, 2005b, p. 354).

Significance of Case Conceptualization

The managed care industry is now seen as the “gatekeeper” of mental health care, requiring practitioners to justify their treatment decisions in terms of client outcomes

(Falvey, 2001). These regulations have impacted the entire scope of the field, creating the need for a way for clinicians to effectively incorporate client data into treatment planning (Sperry, 2005b). In this era of accountability, clinicians must know not only how to make sound treatment decisions, but also how to ethically and legally justify those decisions (O'Donohue, Fisher, Plaud, & Curtis, 1990). This push has affected how training programs and credentialing bodies identify the primary skills needed for effective treatment (Falvey, 2001). This shift is apparent in California’s requirement that a clinician be able to develop a theory-based treatment plan for that clinician’s licensure; this requirement is rooted in the belief that linking theory and practice improves client outcomes and protects consumers (Sperry, 2005a).

Sackett and Rosenberg (1995) write, “The ascendancy of the randomized trial heralded a fundamental shift in the way that we establish the clinical bases for diagnosis, prognosis, and therapeutics” (Sackett & Rosenberg, 1995, p. 620). This shift towards

assessing and integrating evidence into practice has become the new standard for client

care (Sackett & Rosenberg, 1995). The push towards evidence-based practice by managed care requires clinicians to employ an empirical approach for each client

(Persons, 2006). Still, clinicians vary in their level of success in this area (Luborsky et al., 1986). Betan and Binder (2010) assert that a clinician’s relational skills are not sufficient for successful treatment outcomes. Although interpersonal factors are important, little empirical evidence supports any one specific quality as contributing to successful therapy (Baldwin & Imel, 2013). The client, however, is the ultimate agent of change (Bohart & Tallman, 2010), and failure to elicit client factors sets clinicians up for treatment failure (Duncan, 2014). For this reason, case conceptualization has become the core skill in evidence-based practice (Betan & Binder, 2010).

Case conceptualization bridges the gap between assessment and treatment (Toews, 1993) and can be noted as lying “at the intersection of etiology and description, theory and practice and science and art” (Sim et al., 2005, p. 289). Diagnosis as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition

(American Psychiatric Association, 2013) does not award sufficient attention to the precipitants, patterns, and perpetuates that lead to and maintain a client’s problems and are, thus, integral to an individualized treatment plan (Sim et al., 2005). Client data are not self-explanatory. Case conceptualization helps clinicians look beyond symptom presentation to a more critical analysis of other factors that should guide treatment (Falvey, 2001). The case conceptualization approach to mental health care grants flexibility needed for individualized treatment, particularly in complex cases, because it allows for continued client assessment and theory-driven decision-making

(Persons, 2006). Case conceptualization uses these hypotheses to inform treatment rather

than symptom-based treatment approaches that are often inadequate to foster positive

client outcomes (Persons, 1992). Crits-Christoph et al. (1988) found that practitioner

interventions formulated through case conceptualization were more accurate. Moreover,

other studies have also identified improved treatment outcomes resulting from case

conceptualization-driven therapy (Silberschatz et al., 1986) and improved accuracy of therapeutic interpretations (Crits-Christoph et al., 1988). Additionally, case conceptualization has been found to improve treatment in complex cases (Malatesta,

1990; Persons, 1992), improve treatment for comorbid depression (Persons, Bostrom, &

Bertagnolli, 1995), and contribute to maintaining treatment gains at six months (Jacobson et al., 1989). Case conceptualization has also been found to help clinicians determine when to alter a treatment protocol (Malatesta, 1995a; Malatesta, 1995b). Morran et al.

(1994) postulated that clinicians who could comprehensively conceptualize their clients

“should also be able to construct better cognitive models to guide their counseling

efforts” (p. 656). Clinicians who use case conceptualization also tend to express greater

feelings of confidence (Hill, 2005), and the way counselors understand and make

decisions about their clients affects the treatment process and therapy outcomes (Eells &

Lombart, 2003).

Practitioner Expertise

Practitioner expertise can profoundly affect therapy outcomes (Beutler, Machado,

& Neufeldt, 1994; Wampold, 2001). A meta-analysis of 201 studies revealed that the

therapeutic alliance accounted for just 7.5% of the variance in counseling

outcomes (Horvath, Del Re, Fluckiger, & Symonds, 2011). Studies have indicated that a

practitioner’s level of expertise is significantly tied to counseling processes employed and

outcomes (Crits-Christoph et al., 1991; Luborsky et al., 1986). Novice practitioners’

level of therapeutic performance is less effective than that of experts (Sperry, 2010b).

Novices are less adept at identifying meaningful patterns in client data and tend to think

superficially about cases (Eells et al., 2005). Some research has pointed to the role of

time in the gaining of expertise, notably observing that a minimum of 10 years of practice is necessary for development of such expertise (Hayes, 1985). Subsequent research, however, has indicated that practice itself is not sufficient for development of expertise (Eells et al., 2005), that is, that practitioners with years of experience do not necessarily possess such expertise (Chi et al., 1988). Betan and Binder (2010) state,

“Twenty years of experience is not the same as one year of experience repeated twenty times” (p. 142). Research indicates that expert practitioners may process information differently (Chi, 1988) and are able to identify meaningful patterns (Chase & Simon,

1973) and use theory and understanding to approach problem-solving (Glaser & Chi,

1988). Expert practitioners cannot only identify systemic patterns but also evaluate problems in depth and identify their mistakes (Glaser & Chi, 1988). They can use their skills with adequate judgment and flexibility, integrate clinical skills, self-reflect, and adjust their actions appropriately (Betan & Binder, 2010). Specifically, Betan and Binder

(2010) write, “Expertise requires not only a strong knowledge base, but also the ability to apply and adapt one's knowledge in a way that is meaningful and ultimately helpful” (p.

142). Thus, experts can understand clients’ complex presentations, correctly identify therapeutic interventions, evaluate treatment progress, and adjust treatment as indicated,

making them highly effective (Sperry, 2010b). However, building expertise requires the

ability to integrate theory with practice.

With respect to case conceptualizations, experts are better able to use deductive and inductive reasoning in their formulation than are novice practitioners (Sperry &

Sperry, 2012). Deductive reasoning is reasoning from general ideas to specific ones, and arriving at a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis requires deductive reasoning. The clinician moves from general diagnostic criteria to specific symptoms in order to match symptoms to disorder and so formulate a diagnosis.

Use of deductive reasoning is valuable when completing a diagnostic assessment and formulation. Inductive reasoning, on the other hand, is reasoning from specific ideas to general ones and requires the integration of many items of data that may initially seem unrelated. Data about client functioning, symptoms, and detailed history must be integrated in a meaningful way to explain the causes, precipitants, and maintaining factors for the client's presenting problem. Identifying themes and patterns in these data and integrating them in a meaningful way requires inductive reasoning, and, thus, it is key to developing a case conceptualization’s clinical, cultural, and treatment formulations

(Sperry, 2010b).

Case Conceptualization Training

Various studies have examined the effects of training on case conceptualization skills, with varying rates of success. Kendjelic and Eells (2007) developed and delivered a two-hour case generic conceptualization training to 20 participants. They evaluated the quality of the participants’ case conceptualizations and compared them to those of a control group (N=23), whose members did not receive the training. They found the case

conceptualizations of the group whose members received the training to be more

comprehensive, detailed, complex, and exact than those of the control group’s

members. The training participants were also more likely to include complex points

about precipitants, predisposing factors, and explanations of presenting problems in their

case conceptualizations. The participants in the control group, however, either failed to

make interpretations about symptoms and problems or included only rudimentary

interpretations that were not tied to other factors. The mean effect size was 1.12,

indicating that the participants who received the training wrote better case

conceptualizations than 86% of the control group’s participants.

Abbas, Walton, Johnston, and Chikoore (2012) examined the effects of an integrated case conceptualization training on an experimental group (N = 12) as

compared to a control group (N = 12) in a randomized, controlled trial. The results of this

study indicated that participants in the experimental group improved their written case

conceptualizations so that they scored 8.5 points higher than those in the control group.

Kelsey (2014) investigated the effects of a standardized two-hour integrative case

conceptualization training developed by Sperry and Sperry (2012). Eighty-five

counseling graduate students received the training and showed improvement in case

conceptualization competence. Utilizing the same standardized two-hour integrative case

conceptualization training in a study with 145 graduate counseling students, Ladd (2015)

obtained similar, positive results. In an unpublished dissertation, Stoupas (2016)

examined the effects of a six-hour, two-part integrative case conceptualization training

developed by Sperry and Sperry on mental health practitioners and found that participants

not only improved the quality of their case conceptualizations but also that these gains

were maintained over time.

Types of Case Conceptualization Models

Various types of case conceptualization models exist and can be categorized as either content and organization models or research models (Kendjelic, 1998). These encompass models from different theoretical orientations, including biopsychosocial, behavioral, cognitive-behavioral, psychodynamic, Adlerian, and integrative models

(Abbas et al., 2013; Eells et al., 2005; Kendjelic & Eells, 2007; Sperry, 1989; Sperry &

Sperry, 2012).

Context and organizational models. Both content and organizational models focus on gathering and organizing client data in a descriptive summary (Kendjelic &

Eells, 2007) drawn from the biopsychosocial approach (Ben-Aron & Mc.Cormick,

1980). Because these models are typically more generic (Abbas et al., 2013) and focus on data collection rather than interpretation and meaning making, they were outside this study’s focus and so were excluded.

Research models. Development of research models, which are typically used in research studies, has centered on a theoretical orientation. Research models typically have more structure than do content and organization models, make interpretations about behavior, and “emphasize identifying central relationship conflicts or maladaptive concepts of the self or the world” (Kendjelic & Eells, 2007, p. 67). These models seek to make interpretations about the behavioral patterns underlying maladaptive behavior and presenting problems (Eells, 2007; Kendjelic, 1998). In contrast to context and organizational models, research models are “more explanatory, longitudinal, and attempt

to offer a rationale for the development and maintenance of symptoms and dysfunctional life patterns” (Sperry, 1989, p. 502). Research models are either integrative or non-

integrative, and descriptions of these primary types of research models follow.

Non-Integrative Models

There are five types of non-integrative research models: cognitive-behavioral,

behavioral, biopsychosocial, Adlerian, and dynamic models. These are described below.

Cognitive-behavioral models. Cognitive-behavioral case conceptualizations are

based on the tenets of Cognitive-Behavioral Therapy (CBT), which is a blend of the

cognitive therapy and the behavioral therapy perspectives (Wright, Basco, & Thase,

2006). The cognitive behavioral model focuses on how the client’s “central

dysfunctional attitudes interact with stressful life events to cause symptoms” (Persons,

1992, p. 472). The primary focus of cognitive-behavioral therapies and case conceptualizations is maladaptive cognition, including automatic thoughts, intermediate

beliefs, and schemas. The cognitive-behavioral case conceptualization also includes

clinical, cultural, and treatment formulation components that help explain presenting

problems and patterns of maladaptive beliefs and behaviors (Sperry & Sperry, 2012).

Behavioral models. Although behavioral case conceptualizations share many

features with cognitive-behavioral conceptualizations, their emphasis is on maladaptive

behaviors and the factors that precipitate and maintain them rather than on cognitions. A

behavioral case conceptualization starts with a comprehensive assessment of the client’s

problems, including their development, their environment and the circumstances in which

they occur, and predisposing factors (Wolpe & Turkat, 1985). This information is used

to formulate a hypothesis about the precipitants and consequences for specific behaviors,

which, in turn, yields a plan for the modification of these behaviors.

Biopsychosocial models. Developed to give medical doctors and mental health

professionals a more holistic and detailed way to view clients, the biopsychosocial model

differs from the others in that it is atheoretical (Sperry & Sperry, 2012). Sometimes

called the clinical method (Sperry et al., 1992), the biopsychosocial model is more

broadly based and includes the biological, psychological, and sociocultural

domains. This model type views a client’s problems in terms of his individual

vulnerabilities and their interaction with his stressors and resources (Sperry & Sperry,

2012).

Adlerian models. Based on Alfred Adler’s psychological theories, the Adlerian

model emphasizes strengths and health (Sperry & Sperry, 2012). Adlerian theory

assumes that individuals are driven by a need for belonging and development as a social

interest (Carlson, Watts, & Maniacci, 2006), which the Adlerian model views as affected

by family dynamics, birth order, and where the person finds a sense of belonging and

worth. For this reason, Adlerian assessment focuses on acquiring information on early

childhood development, early recollections, and family dynamics. Special attention is

given to cultural dynamics and their interplay with the client’s personality (Sperry &

Sperry, 2012). Thus, the client is seen in terms of his “situational and longitudinal patterns” (Sperry & Sperry, 2012, p. 196).

Dynamic models. The dynamic model is rooted in psychodynamic theory,

originating from psychoanalysis. This approach operates on the premise that individuals

develop maladaptive patterns, relating to the self and others, early in life and that these

patterns then become cyclical and are maintained by present relationships (circular

causality) (Levenson, 2010). The dynamic model views psychopathology as a

manifestation of these poor relational patterns and so stems from relationships with early

caregivers. Current problems and symptoms then reflect this psychopathology (Sperry &

Sperry, 2012) as cyclical maladaptive patterns represent an individual’s rigid, self-

defeating and self-perpetuating behaviors and expectations, along with negative appraisals of the self that lead to maladaptive interactions (Butler, Strupp, & Binder,

1993). The dynamic case conceptualization includes diagnostic and clinical formulations based on the client’s cyclical maladaptive patterns and a cultural formulation that assesses influence of cultural dynamics and their interplay with personality dynamics

(Sperry & Sperry, 2012).

Integrative Models

Although no consensus exists on which type of case conceptualization model is superior, those having the greatest clinical utility integrate a client’s context, strengths, resources, and needs into their diagnostic, clinical, and treatment formulations (Sperry,

2005b). Eells (2015) credits Sperry (1992) with the creation of the integrative model, that credited with having the most clinical utility, and an integrated case conceptualization is defined as one that “meaningfully combines relevant data about an individual’s current pattern of functioning and psychopathology in terms of its origins, triggering and reinforcing mechanisms, as well as predicted response to treatment”

(Sperry, 1989, p. 502). Sperry and Sperry (2012) describe the integrative model with comprehensive guidelines for conceptualizing client problems. Not only can this model type be used with different theoretical orientations but it is the most comprehensive

(Faulkner, Kinzie, Angell, U'Ren, & Shore, 1985) and provides a basis for treatment

planning with a prognosis for treatment (Sperry, 1988). The integrative case

conceptualization model developed by Sperry and Sperry (2012) includes four

key components with 17 different elements that allow clinicians to understand client

problems, effectively select treatment interventions, and plan for termination.

The four key components are their diagnostic, clinical, cultural, and treatment

formulations. The diagnostic formulation describes the client’s presenting problem;

personality pattern, or DSM 5 diagnosis; and any precipitating and perpetuating factors.

The clinical formulation explains the causes underlying the client’s maladaptive pattern,

and these can include biological, psychological, and social factors. The cultural formulation analyzes the role of culture in the client case conceptualization. Finally, the treatment formulation lays out an intervention plan that addresses factors in the preceding formulations and outlines specific interventions, treatment goals, and treatment obstacles.

The 17 key elements include the presenting problem, the precipitant and perpetuants, and the client’s maladaptive pattern. Also included are predisposition factors that underlie the presenting problem and the maladaptive pattern. Cultural identity explains the client’s identification with a particular cultural group, and acculturation refers to the client’s level of cultural blending, where applicable, and levels of stress attributable to

this blending. The treatment focus element specifies a plan for shifting the client to a

more adaptive pattern. Cultural explanation is the client’s body of beliefs about the cause

of the presenting problem, whereas culture vs. personality specifies whether the client’s

cultural or personality dynamics are operative to a greater or lesser extent. Treatment

pattern specifies the target adaptive pattern, and treatment goals outline both the short-

term and long-term goals of treatment. The interventions element details specific

interventions targeted towards meeting the treatment goals. Finally, treatment obstacles

are presented as well as culturally indicated interventions, and a treatment prognosis is

given.

Evaluation of Integrative Case Conceptualizations

In both research and education, being able to assess the quality and utility of case

conceptualizations is crucial in order to promote learning and develop effective

instructional methods. To assess the complexity, precision of language, overall

coherence, a priori structure, goodness of fit of the formulation and treatment plan, and

elaboration of the treatment plan, Eells, Kendjelic, and Lucas (1998) developed the Case

Formulation Content Coding Method (CFCCM), a 94-item, Likert-type scale. This

instrument was designed after evaluation of case conceptualization research identified the

four major aspects of most case conceptualizations: symptoms and problems,

precipitating events and stressors, predisposing events and stressors, and a mechanism

that links those three categories while explaining their influence on the client’s presenting

problems (Eells et al., 1998). In addition, Sperry (2012) developed the Case

Conceptualization Evaluation Form (CCEF), a streamlined instrument for evaluating case

conceptualizations, a seven-item Likert-type scale that evaluates their presentation,

precipitants, maladaptive pattern, predisposing factors, treatment goals and interventions,

explanatory power, completeness, and coherence. The CCEF is easy to administer and

boasts robust psychometric properties, as will be discussed further in Chapter III. An

updated version of the CCEF, the CCEF 2.0 was employed in this study.

Reflective Practice

The use of reflective practice to facilitate learning and integrate theory into

practice has been noted across a multitude of academic disciplines, particularly in

counselor education (Lundgren & Poell, 2016). In fact, Bennett-Levy (2006) identified facilitating reflection in counselor trainees as a “key task.” Reflective practice in

education is rooted in the understanding that learning does not occur from experience by

itself but rather from a process of cognitive analysis of the mental representation of an

experience (Bennett-Levy, 2006). Reflection can be defined as "a metacognitive skill,

which encompasses the observation, interpretation and evaluation of one's own thoughts,

emotions and actions, and their outcomes," and a process in which individuals "explore

their experiences in order to lead to new understandings and appreciations" (Boud et al.,

1985, p. 19). Since therapists use this skill to analyze their own clients, it could be a

beneficial process in mastering the competence of case conceptualizations. Schon (1983)

postulated that reflection is key to the development of clinical expertise because it assists

counselors in discerning "in what context, under what conditions, and with what people,

particular strategies may be useful" (Bennett-Levy, 2006, p. 60). Reflective practice is

defined as a process that includes asking why, searching for alternatives, studying others'

practices, and challenging assumptions that underlie behavior (Lee & Birdsong Sabatino,

1998). This process also hinges on questions that lead to analysis and, eventually, the

formulation of a theory and a plan (Lee & Birdsong Sabatino, 1998).

Bennett-Levy (2006) identified the need for a reflective system in counselor

education. Such a system facilitates a link between declarative and procedural memory,

an essential element in the integration of theory with practice, by analyzing past, present,

and future experiences and then comparing the results of that analysis with already stored

information so as to identify a method for approaching a task (Bennett-Levy, 2006).

Dewey’s (1933) early definition of reflection outlined a process that “involves active,

persistent, and careful consideration of any belief or supposed form of knowledge in light

of the grounds that support it and the further consequences to which it leads” (p. 9).

Griffith and Frieden (2000) define reflective thinking as “the active, ongoing examination

of the theories, beliefs, and assumptions that contribute to counselor’s understanding of

client issues and guide their choices for clinical interventions” (p. 82). Reflective

thinking requires the ability to identify the concepts, formulas, theories, and facts

necessary for analyzing complicated and vague problems (King & Kitchener, 1994).

Thus, in counselor education, reflection is the operation through which counselors

continuously analyze therapeutic processes leading to deeper levels of understanding

(Griffith & Frieden, 2000). Reflection aids counselors in approaching solutions through

an effort to understand a problem in different ways and projecting possible consequences

to a course of action (Hart, 1993). The reflective process encompasses the following factors: association of new information with previously learned information, integration by identifying relationships between data, validating one’s own ideas and feelings, and appropriation of knowledge into one’s schema (Hart, 1993).

As seen in the psychoanalytic tradition, reflection requires the ability to "mentally represent past, current or future experience ... and evaluate it against the contents of procedural or declarative memory” (Bennett-Levy, 2006, p. 67). This representational system, which was termed autonoetic consciousness by Wheeler, Stuss, and Tulving

(1997), requires advanced thinking and processes in the prefrontal cortex. Autonoetic

consciousness allows humans to mentally represent and attend to their experiences over time and is integral in undertaking cognitively complex tasks. Because it allows one to focus on subjective experiences suspended in time and perceive them on the continuum between past and future through this awareness, Wheeler et al. (1997) term this “the most highly evolved form of consciousness” (p. 335). The cognitive operations required to understand and evaluate autonoetic consciousness include self-questioning and Socratic questioning (Bennett-Levy, 2006). Autonoetic consciousness theorists state that humans learn not from an experience itself but from reflective cognitive operations involving a mental representation of the experience that foster a deeper understanding (Bennett-Levy,

2006). Reflective thinking surpasses understanding by facilitating the integration of personal meaning (Leung & Kember, 2003).

A qualitative study by Neufeldt, Karno, & Nelson (1996) identified the unique attributes of reflective practice as conceptualized by five leading researchers in this domain: Donald Schon, Thomas Skovholt, Michael Ronnestad, Willis Copeland, and

Elizabeth Holloway. In this study, Holloway describes reflection as “the movement back and forth between the awareness of an event that triggers something that results in a process in which we reflect on ... our own understanding of [therapy], both from the theoretical and personal point of view” (Neufeldt et al., 1996, p. 5). Schon touched on what the authors refer to as the ‘locus of attention’ by stating “reflection is a process of turning the mind towards something” (Neufeldt et al., 1996, p. 7).

Neufeldt et al. (1996) identified four dimensions that are the hallmark of a reflective perspective: intention, active inquiry, openness, and vulnerability. Intention can be characterized by comments by Holloway (“Someone becomes reflective about

their work so that they know how to understand what they do in a deliberate way”) and

by Copeland (“You have to examine your action in the light of its purposes”) (Neufeldt et

al., 1996, p. 7). Active inquiry is a journey of searching through meaningful questions,

and openness, according to a comment by Skovholt, is “a process of allowing themselves

to be surprised and puzzled by their clinical experiences” (Neufeldt et al., 1996, p. 7).

Finally, the vulnerability dimension is characterized by the reflective practitioner's

willingness to explore the unknown and try new approaches (Neufeldt et al., 1996).

Thus, the reflective process is more than just thinking or gaining insight. Reflection

improves awareness and leads to changes in understanding and behavior that have long-

term consequences on one’s professional abilities (Neufeldt et al., 1996).

History of Reflective Practice

Reflection is a concept originating in the Confucian tradition, as seen in this quote

of Confucius, "While there is anything that he has not reflected on, or anything which he

has reflected on which he does not apprehend, he will not intermit his labour" (Leung &

Kember, 2003, p. 62). Self-awareness in learning can be traced back to spiritual educators

and philosophers such as Jiddu Krishnamurti and Joseph Campbell (Guiffrida, 2005).

Krishnamurti (1953) wrote, "Understanding comes only through self-knowledge, which is awareness of one's total psychological process. Thus education, in the true sense, is the understanding of oneself" (p.17).

These views were held by early learning theorists such as Dewey, Lewin, and

Piaget, who believed reflection was a necessary process in learning (Lee & Birdsong

Sabatino, 1998). Dewey (1933) defined reflective thinking as "active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the

grounds that support it and the further conclusion to which it tends" (p. 9). He wrote of

the value of critical reflection in learning and challenging established beliefs and

theorized that the reflective process begins with a sense of doubt and confusion that only

a process of searching and inquiry can attenuate (Dewey, 1933).

Based on early learning theories, constructivists like von Glaserfeld postulate that learning is best fostered not in a direct line from educators to pupils but when students are engaged in a process of self-discovery and critical evaluation (Guiffrida, 2005). von

Glaserfeld (1989) discusses the origins and philosophies of constructivism, starting with philosopher Giambattista Vico’s epistemological treatise stating that we can know only that which we have put together (von Glaserfeld, 1989). For constructivists, knowledge consists of conceptual structures considered reasonable to epistemic bodies (von

Glaserfeld, 1989). Constructivism can be understood through von Foerester’s (1970) metaphor—all senses (visual, auditory, etc.) send electrochemical signals to the cortex that can only be distinguished by the brain’s relation to the body, not by the environment’s output itself (von Foerster, 1981).

Constructivists base their approaches to learning on Vygotsky's zone of proximal development and Wood, Bruner, and Ross' (1976) scaffolding, concepts which view learning as occurring in the context where experts and novices meet (Ronnestad &

Skovholt, 2003). Jean Piaget, a theorist von Glaserfeld (1989) refers to as “the most prolific constructivist in our century” (p.125), viewed knowledge not as a representation of the physical environment but as an amalgamation of concepts incorporated into an individual’s body of experience and understanding (von Glaserfeld, 1989). Piaget’s learning theory specifies that experience occurs at the sensory-motor level, but creation

of new schemes and conceptual networks occurs through ‘reflective abstraction’ (von

Glaserfeld, 1989). In this tradition, von Glaserfeld's (1984) radical constructivism engenders self-reflection and integration of theory through practice (Guiffrida, 2005).

Reflective practice gained popularity in professional disciplines with Schon's publication of The Reflective Practitioner (1983) and Mezirow's (1997) Transformative

Model of Learning. Shon (1992), whose work has become the foundation of reflective practice in education (Neufeldt et al., 1996), describes Dewey’s influence on his radical constructivism theory, “[Dewey] believed that the meaning of logic could be discovered only by turning inquiry back on itself, that is, by inquiry into inquiry” (Schon, 1992, p.

122). Dewey viewed the learner as an active participant in knowledge as opposed to an outside observer and valued the integration of theory into practice and a constructivist approach to problem solving (Dewey, 1938). Dewey conceptualized reflective practice as a process of generating possible solutions to a problem, evaluating these solutions, and then experimenting with them (Neufeldt et al., 1996). Outlining the processes professionals employ when they reflect on their work, Schon echoes the ideas of early constructivists: “Practitioners do not reflect on their knowing-in-practice .... They think back on a project they have undertaken, a situation they have lived through, and they explore the understandings they have brought to the handling of the case ... in a deliberate effort to prepare themselves for future cases” (Schon, 1983, p. 61). Schon identifies different forms of reflection: reflection-in-action (reflecting during performance) and reflection-on-action (reflection after performance) and distinguishes them from the act of knowing-in-action (knowledge revealed in performance) (Schon,

1983). Yip (2006) likens this process to peeling the layers of an onion, stating that

reflection can continue to deepen from awareness of one’s actions to a critical assessment

of the beliefs underlying one’s thinking (Yip, 2006).

In his Transformative Model of Learning, Mezirow (1997) states that students

acquire information according to their existing notions and beliefs and that self-reflection is necessary to foster awareness of existing frames of reference and integrate new experiences. Fong (1998) describes this as a collaborative learning process in which knowledge is constructed through group discussion and then applied to generalized settings.

Mezirow’s model addressed the notion that adult learners are prone to incorporating only those ideas that fit their existing understanding of a problem. Mezirow (1997) states that learners should be cognizant of their existing frames of reference and then be guided “toward a frame of reference that is more inclusive, discriminating, self-reflective, and integrative of experience” (Mezirow, 1997,

p. 5). Mezirow describes a hierarchy of reflection beginning with critical

consciousness (Lundgren & Poell, 2016) of which the highest level is theoretical

reflectivity or “becoming critically aware of how ... we see ourselves and our

relationships ... and acting upon these new understandings” (Mezirow, 1981, p. 6).

Next, Mezirow distinguishes between non-reflective action and reflective action

and raises the idea of critical reflection—reflection on premises. Mezirow includes

content reflection (reflection on the description of a problem) and process reflection

(problem-solving strategies) (Lundgren & Poell, 2016). In doing so, he builds on

Dewey’s ideas, writing “reflection is the process of critically assessing the content,

process, or premise(s) of our efforts to interpret and give meaning to an experience”

(Mezirow, 1991, p. 109). Ultimately, Mezirow sees critical reflection of assumptions as

the highest level of reflective practice, based on King and Kitchener’s (1994) model of

reflective judgment.

Critical reflection of assumptions encompasses pondering not only assumptions

but also the process leading to assumptions (Lundgren & Poell, 2016). King and

Kitchener’s (1994) Reflective Judgment Model outlines the development of critical

thinking from childhood through adulthood and, when applied to counseling, helps

counselors “identify, understand, and evaluate the basis for clinical judgments” (Griffith

& Frieden, 2000, p. 83). King and Kitchener (1994) identify seven stages of critical

thinking development grouped into three levels: pre-reflective thinking, quasi-reflective thinking, and reflective thinking. Pre-reflective thinking assumes knowledge is certain and concrete and can be ascertained from observation or authority figures. Quasi- reflective thinking acknowledges that some knowledge is uncertain and yet equates knowledge and opinion. Reflective thinking views knowledge in context and values certain sources of knowledge over others (King & Kitchener, 1994).

Mezirow cites King and Kitchener’s definition of ‘epistemic cognition’ as the link to his theory of critical reflection of assumptions (Mezirow, 1998). Reflective judgment for King and Kitchener (1994) “includes a person’s knowledge about the limits of knowing, the certainty of knowing and the criteria for knowing.” (p. 12). Like Mezirow and Schon’s models, King and Kitchener (1994) view reflective judgment as a

“discursive rationality arriving at agreement on meaning through discourse by giving and assessing reasons, critically assessing arguments and assumptions, examining evidence and seeking to validate beliefs and interpretations consensually” (Mezirow, 1998, p. 189).

Significance of Reflective Practice

Reflection has long been seen as integral to professional development and as a factor that helps counselors develop their clinical practice and professional judgment

(Griffith & Frieden, 2000; Neufeldt et al., 1996). Emphasis on reflective practice in

learning is based on the notion that thinking critically increases knowledge and strengthens abilities (Lee & Birdsong Sabatino, 1998), and Bennett-Levy (2006) considers reflection a ‘key task’ in counselor education and development (p. 68). Self-

reflection encourages students to foster awareness and responsibility for their own

development and integrate theories into their practice in a more creative and empathic

way (Thwaites et al., 2014). "It links the experiential with the conceptual, the

interpersonal and the technical, the 'therapist self' and the 'personal self'" (Thwaites et al.,

2014, p. 251). Counseling students often find it challenging to apply research, theory, and

experience to practice but reflective practice can facilitate this process (Hart,

1993). Reflection helps counselors link knowledge to outcomes and increasingly

complex and creative ideas (Hart, 1993). Hayes and Paisely (2002) stress that, in today’s

rapidly changing professional landscape, “multicultural society demands that we prepare

out students to be self-reflective, life-long learners” (p.169). Learning reflective skills and

practicing self-reflection are considered “crucial for the accommodation of prior

knowledge, for setting new goals for learning and, subsequently, for continuous

professional development” (Niemi & Tiuraniemi, 2010, p. 266). For this reason, Niemi

and Tiuraniemi (2010) stress the importance of learning reflective skills and view it as a

‘meta-goal’ for counselors in training.

Drawn from a cross-sectional and longitudinal qualitative study of the training

and development of 100 counselors, Ronnestad and Skovholt (2003) declare that

“continuous reflection is a prerequisite for optimal learning and professional development

at all levels of experience” (p. 29). Leung and Kember (2003) demonstrated a significant

positive relationship between learning and reflective thinking. In a study incorporating

self-practice and self-reflection (SP/SR) in training of cognitive-behavioral therapy

(CBT) skills, participants experienced improvement in skills, self-confidence, and belief in the theory (Bennett-Levy & Lee, 2014). Counselors can also benefit personally through increased self-awareness, and many participants in the study reported experiencing a "deeper sense of knowing" (Bennett-Levy & Lee, 2014, p. 55). Reflection may be especially helpful for counselors working with clients with complex problems, particularly personality disorders (Bennett-Levy & Lee, 2014). In Cognitive Therapy of

Personality Disorders (1990), Aaron Beck remarked on the importance of reflection and therapist self-awareness in managing the therapeutic relationship and countertransference. Reflection helps counseling students link course work with experience and make meaning out of what they learn, thus leading to an increased understanding and improved performance that is likely to persist long-term if reflective

practice is continued (Lee & Birdsong Sabatino, 1998). Gipe and Richards (1992) found

that student teachers’ improvement was strongly and positively linked to the number of

reflections they produced, and other studies found students who reflected showed

statistically significant changes in their thought processes, problem-solving abilities, and ability to apply content knowledge to hypothetical scenarios (Hart, 1993; Short &

Rinehart, 1993).

Reflective Practice and Counseling Expertise

Several studies have shown that continuous reflection differentiates average

therapists from novice therapists (Bennett-Levy, 2006). Skovhold and Ronnestad (1992) concluded that self-reflection was the most important distinguishing factor between counselors who continued their professional development and those who became idle and faced burnout. Traditional clinical training strategies have not been linked to therapeutic effectiveness in empirical studies, leading researchers to stress the need to prepare reflective practitioners (Griffith & Frieden, 2000). Sparks-Langer, Simmons, Pasch,

Colton, & Starko (1990) stress that the schemas of experts are more complex than those of novices, allowing them to make more advanced interpretations and generate more alternatives (1990). Skovholt et al. (1997) contend that cognitive complexity is only one dimension of expertise, arguing that expertise occurs only when the practitioner has integrated information after thousands of hours of practice over an average of 15 years. They propose that professional reflection, similar to deliberate practice, is instrumental to the process of internalizing theory and developing expertise (Skovholt et al., 1997). Acquiring expertise takes time, but experience itself is not sufficient (Beutler,

1997; Skovholt & Jennings, 2005). Skovholt and Jennings emphasize that “experience has to be used to grow in an environment that encourages exploration” (2005, p. 15).

Moreover, reflective practice is the key to turning experience into expertise (Neufeldt et al., 1996; Skovholt & Jennings, 2005). Skovholt and Ronnestad (1992) describe this process as individuation—an integration of the professional and personal selves, and they state that the development of expertise “includes a movement from an unarticulated, preconceptual, and ideological way of functioning to a mode of functioning that is

founded on the individual’s own integrated, experience-based generalizations” (Skovholt

& Ronnestad, 1992, p. 507).

Expertise is acquired when declarative knowledge is integrated into procedural

knowledge (Bennett-Levy, 2006; Binder, 1999; Nelson & Neufeldt, 1998). Bennett-Levy

(2006) outlines this process in his DPR conceptual model, in which counselor

competence includes declarative knowledge, procedural knowledge, and self-reflective skills. Declarative knowledge includes interpersonal, conceptual, and technical knowledge and is learned through didactic coursework and supervision but does not

“provide guidance about when and how to implement theories, concepts, principles, and rules” (Binder, 1999, p. 711). However, without knowledge of how to apply it in real-

world settings, declarative knowledge remains ‘inert’ (Whitehead, 1929). Procedural

knowledge is a manifestation of declarative knowledge in practice (Bennett-Levy, 2006).

Practitioners with expertise are able to apply declarative knowledge in context without necessarily being cognizant of this process. This is a manifestation of procedural knowledge or what Schon terms knowing-in-action (Binder, 1999; Schon, 1983).

Building procedural knowledge requires more than practice of skills; it requires reflection-on-action (Bennett-Levy, 2006; Binder, 1999; Niemi & Tiuraniemi, 2010;

Skovholt & Ronnestad, 1992, p. 510). Researchers believe that reflection can enhance and hasten the movement from declarative to procedural knowledge, from novice to expert, by helping practitioners link knowledge and experience (Lee & Birdsong

Sabatino, 1998).

Teaching Reflective Practice

Teaching reflective practice has marked a shift in pedagogy to constructivism (Nelson & Neufeldt, 1998). Schon (1983) stressed the importance of educating reflective practitioners who can are able to employ information in complex thought processes and decision making. Although some educators erroneously view critical reflection as a natural result of the didactic instruction of theory, reflection itself is a skill that must and can be taught (Guiffrida, 2005; Niemi & Tiuraniemi, 2010).

Therefore, students should be taught to think critically about the assumptions underlying their practice and be given feedback on their processes (Brookfield, 1987; King &

Kitchener, 1994; Mezirow & Associates, 1990). Procedural knowledge, the hallmark of expertise, is best facilitated by instructional methods that actively involve the learner

(Binder, 1999), including Socratic questioning, journaling, and reflecting teams (Bennett-

Levy, 2006; Griffith & Frieden, 2000; Lee & Birdsong Sabatino, 1998). Questions may be the most important part of the process. Lee and Birdsong Sabatino (1998) quote

Daudelin in defining questions as “one of the most basic and powerful elements of the reflection experience” (p. 163). Questions help learners “open up possibilities, to clarify meaning” (Lee & Birdsong Sabatino, 1998, p. 163).

Socratic questioning. The Socratic method is a way of teaching thinking and content knowledge through the process of questioning. It originated with the Greek philosopher Socrates, who taught his students by asking questions in conversations that have come to be known as Socratic dialogs (Turkcapar, Kahraman, & Sargin, 2015), in which the learner is encouraged to remember previously acquired knowledge to find new meanings and understandings and to construct new knowledge (Turkcapar et al., 2015).

The instructor asks open-ended questions that foster reflection and yield knowledge that was once outside of the learner’s awareness (Neenan, 2009). This is a collaborative process (Turkcapar et al., 2015) in which the Socratic teacher does not lecture but rather guides students to “realize the answers lie within themselves” (Overholser, 1991, p. 68).

The Socratic method allows educators to help students understand the thinking and values that drive their decision-making through a series of questionings (Griffith &

Frieden, 2000). In particular, the teacher asks students exploratory questions that foster reflection and then can ask follow-up questions that press them to understand the meanings behind their responses (Griffith & Frieden, 2000). This process is one of “self- initiated discovery” (Overholser, 1991, p. 68), and Overholser (1991) argues that didactic instruction can be counterproductive and that greater insight can be gained when learners

“discover a relationship on their own than when it is explained to them” (p. 68). The

Socratic method includes systematic questioning, inductive reasoning, and universal definitions. Systematic questioning refers to a “progressive series of questions designed to stimulate the supervisee’s creative and critical thought process” (Overholser, 1991, p.

69). These questions supersede information-gathering questions by guiding learners to become aware of their knowledge and apply it to complex situations. Inductive reasoning helps the learner draw conclusions about events using his or her knowledge and experience (Overholser, 1991). This process ultimately allows the learner to develop deeper understandings and discover universal definitions that help integrate concepts with experience (Overholser, 1991).

Reflective Practice Research

A study of 46 counseling trainees and practitioners found engaging in reflective practice improved participants’ understanding of therapy practices, enhanced their skills, and boosted their confidence and awareness (Bennett-Levy & Lee, 2014). Another study of year three medical students (n = 163) found that students equipped with critical reflection guidelines and feedback on reflective ability increased their competence in writing reflective essays to a significantly greater extent than students who did not receive such guidelines and feedback (Aronson, Nichaus, Hill-Sakurai, Lai, &

O’Sullivan, 2012). Evaluating written feedback on reflective essays from 43 educators,

Dekker, Schonrock-Adema, Snoek, van der Molen, & Cohen- Schontanus (2013) found feedback that was most conducive to improving reflection included questions written in a positive tone.

III. METHOD

Chapter I outlined case conceptualization and reflective practice, and Chapter II presented a review of the literature related to this study, including articles about case conceptualizations, reflective practice, and related research. This chapter describes the study in detail, including its research questions and hypotheses, variables, study design, participants, instruments, procedure, data collection, and data analysis.

Research Questions and Hypotheses

This study sought to examine the following research questions:

Research Question 1: What is the effect of reflective practice coaching on coaching recipients’ competence in writing case conceptualizations?

Null Hypothesis 1 (H01): Reflective practice coaching has no effect on coaching

recipients’ competence in writing case conceptualizations.

Research Question 2: What is the effect of reflective practice coaching on

counselor trainee reflective thinking?

Null Hypothesis 2 (H02): Reflective practice coaching has no effect on counselor

trainee reflective thinking.

Research Question 3: Does a three-hour initial training lecture increase counselor

trainee competence in developing a case conceptualization?

Null Hypothesis 3 (H03): A three-hour initial training lecture has no effect on

counselor trainee competence in developing a case conceptualization.

Research Question 4: Does a three-hour initial training lecture reduce counselor

trainee myths about case conceptualizations?

Null Hypothesis 4 (H04): A three-hour initial training lecture does not reduce

counselor trainee myths about case conceptualizations.

Research Question 5: Does a follow-up training lecture increase counselor trainee

competence?

Null Hypothesis 5 (H05): A follow-up training lecture does not increase counselor

trainee competence.

Research Question 6: What variables (age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking) influence reflective thinking?

Null Hypothesis 6 (H06): None of the variables listed above influence counselor

trainees’ reflective thinking.

Research Question 7: What variables (age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking) are related to case

conceptualization competence prior to training?

Null Hypothesis 7 (H07): None of the variables listed above are related to case conceptualization competence prior to training.

Research Question 8: What variables (age, gender, race/ethnicity, grade point average, graduate school training, counseling experience, attitudes toward evidence- based practice, disposition toward reflective thinking) influence response to an initial case conceptualization training lecture?

Null Hypothesis 8 (H08): None of the variables listed above influence the

response to an initial case conceptualization training lecture.

training lecture?

Null Hypothesis 9 (H09): None of the variables listed above influence the

response to a follow-up training lecture.

Research Question 10: What variables (age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence- based practice, disposition toward reflective thinking) influence the persistence of case conceptualization training effects over time?

Null Hypothesis 10 (H010): None of the variables listed above influence the

persistence of case conceptualization training effects over time.

Variables

The study included the following variables:

Dependent variables. Counselor trainees’ case conceptualization competence as

measured by the CCEF 2.0

• Counselor trainees’ views about case conceptualization, as measured by the

VACC

• Counselor trainees’ reflective thinking as measured by the RLS

Independent variables. A three-hour standardized basic case conceptualization

training program

• A three-hour standardized advanced training program focused on culturally-

sensitive treatment, strengths, challenges, and prediction

Mediating variable. A reflective practice coaching, as measured by scores on

the Reflection in Learning Scale

Study Design

Participants took part in two separate interventions, both of which were presented

as clinical training lectures. These standardized trainings were based on the integrative

case conceptualization model developed by Dr. Len Sperry (1989) and expanded upon in

Sperry (2010b) and Sperry and Sperry and Sperry (2012). The purpose of these training

lectures is to teach participants about case conceptualizations and how to write them,

including elements such as presentation, precipitants, predisposing factors, and

perpetuating factors.

During the first training lecture, participants reviewed and signed consent forms outlining confidentiality, benefits and risks of the study, and other related information. Participants were given a case vignette developed specifically for this training and used in three previous studies (Kelsey, 2014; Ladd, 2015; Stoupas, 2016).

Participants were then given 15 minutes to write a case conceptualization based on this vignette. Participants completed the Views about Case Conceptualization instrument pre- test (Sperry, 2012), the Evidence-Based Practice Attitude Scale pre-test (Aarons, 2004), and The Reflection In Learning Scale (Sobral, 2005) pre-test.

Case conceptualization training lectures. The first training lecture consisted of a 90-minute pre-recorded presentation by Dr. Jonathan Sperry, co-author of Case

Conceptualization: Mastering this Competency with Ease and Confidence (Sperry &

Sperry, 2012). Participants were given booklets outlining the information presented in

the training, which they were allowed to keep. The first training reviewed case

conceptualization, myths associated with it, the relationship of case conceptualizations to

evidence-based practice, and the specific elements of brief case conceptualizations. The

training lecture included a video of a portion of a counseling session and a written case

conceptualization for the client in this video that demonstrated high explanatory and

predictive power. A second counseling session video was used for a 10-minute

interactive segment in which participants generated answers for specific case

conceptualization elements. Following this part of the training, participants were given

another 15 minutes to complete a second case conceptualization using the same case

vignette as in the pre-test. Participants then completed the Views about Case

Conceptualization post-test. Both pre- and post-case conceptualizations were evaluated

using the Case Conceptualization Evaluation Form 2.0 (CCEF) developed by Sperry and

Sperry (2012).

The second training lecture consisted of a new 90-minute pre-recorded training video. The presenter for this session was Dr. Len Sperry, co-author of the book Case

Conceptualization: Mastering this Competency with Ease and Confidence (Sperry &

Sperry, 2012). The second training lecture built upon the initial training and included new elements pertaining to a full case conceptualization, including culture, strengths, treatment obstacles, and explanatory power. Participants were given another booklet containing information presented in this training lecture, which also included a new counseling session video clip and a related sample case conceptualization. This doctoral student then facilitated a 10-minute interactive portion. Following this training,

participants were asked to write another case conceptualization using the same case

vignette as used in the pre-test, which was scored using the CCEF 2.0. Participants then

completed the Evidence-Based Practice Attitude Scale post-test (Aarons, 2004), and The

Reflection In Learning Scale (Sobral, 2005) post-test.

The vignettes used for the initial and follow-up training lectures were designed specifically for these trainings. The first vignette was used in three prior studies (Kelsey,

2014; Ladd, 2015; Stoupas, 2016). The vignettes provide a summary of client data pertinent to the case conceptualization elements reviewed in the training lectures and the client’s DSM-5 diagnosis.

Reflective practice coaching. Participants in the intervention group also participated in three one-on-one reflection coaching sessions. The first coaching

occurred between the first and second case conceptualization training workshops. The

second two coaching sessions occurred after the second training lecture.

Coaching sessions were 15-minutes long each and were timed to adhere to the

standardized timeline. Participants were asked to complete the Reflection in Learning

Scale prior to participating in the reflective practice coaching, as part of the initial

training lecture pre-test that all participants received. Coaching participants also completed a Reflection In Learning Scale (Sobral, 2005) post-post test at the end of their third individual coaching session. The protocol for the coaching sessions was as follows:

Coaching Protocol

1. Initial assessment – Review scores on reflection instruments and CCEF 2.0 pre-

test, and use this information to guide the focus for the reflective practice

intervention.

2. Collaborative assessment – Review case conceptualization assignment(s) with the

student and identify specific elements that need improvement.

3. Expert feedback – Give the student specific feedback on the case

conceptualization element(s) in question.

4. Questioning/Discussion – Engage in a series of questions to encourage the

student’s reflective thinking.

a. What do you find challenging about this case conceptualization element?

b. Questions will continue based on identified CC element – i.e.,

pattern/movement and purpose – How do you think this client behaves in

relation to others? What purpose could the client’s movement possibly

serve? What might be a more effective strategy for the client to serve her

needs in a more adaptive way?

5. Support – Commend the student on progress made and encourage the student to

continue to be mindful of our conversation until the next meeting.

Participants

This study employed a non-random, convenience sample of masters-level counseling students from two South Florida universities, one a public university with a

CACREP-accredited graduate counseling program and the other a private university with

a non-CACREP accredited graduate counseling program. The number of participants in

the intervention group was 35, and the number in the control group was 49 for a total of

84 participants.

Instruments

The following instruments were employed to collect the study’s data. All have

been employed in previous studies and have proven validity.

Case Conceptualization Evaluation Form (CCEF) 2.0. Participants’ case

conceptualizations were evaluated using the Case Conceptualization Evaluation Form

(CCEF) 2.0. This 10-item instrument is a revision of the seven-item instrument designed by Sperry and Sperry (2012) to evaluate the quality of case conceptualizations according to the integrative model. The 10 items correspond to the 10 key components found in this model, and the instrument can be used to evaluate case conceptualizations from many different theoretical perspectives.

The content elements in the CCEF 2.0 are as follows: presentation, precipitants, maladaptive pattern, predisposing factors, treatment goals and interventions, explanatory power, completeness, coherence, cultural sensitivity, tailoring power, and predictive power. Each item rates the case conceptualization on a 0-10 Likert-type scale, where 0 represents failure to identify the item and 10 represents full and accurate articulation of the item. For example, in Item 1 on the CCEF 2.0, 0 = fails to identify presentation and/or precipitant and/or link between both whereas 10 = fully and accurately identifies presentation and precipitant and link between both. To calculate the overall score, the average of each of the 10 items is taken, and, therefore, the range of possible CCEF 2.0 scores are 0 to 10. The gain score range is 0 to 100.

While the first training lecture in this study did not address some of the elements found on the CCEF 2.0, such as cultural issues, this instrument was used to rate participants’ pre- and post-training case conceptualizations for both training lectures so as to obtain scoring consistency and comparability of results. Changes in participant CCEF

2.0 scores between training lectures were attributed to participant performance rather than changing of instrumentation.

Comparing the CCEF to the Case Formulation Content Coding Method (CFCCM) designed by Eells et al. (1998), Kelsey (2014) found that it more effectively discriminated between items and concluded that it was overall a more useful instrument. Her reliability analysis for the CCEF resulted in a Cronbach’s alpha of .709 for the pre-test and .815 for the post-test, in contrast to the CFCCM’s alphas of .708 for the pre-test and .703 on the post-test. Kelsey also found that the CCEF had good construct and face validity, as CCEF scores were related to CFCCM scores and the instrument represents all of the elements found in a case conceptualization. In addition, the 10-item CCEF 2.0 takes approximately 15 minutes to score, whereas the 94-item

CFCCM takes between 45-60 minutes to score. Ladd (2015), who used the CCEF in a study evaluating the case conceptualizations of graduate counseling students, also found it to be a reliable and easy-to-use instrument. Ladd’s reliability analysis resulted in an overall alpha of .969. Using the CCEF 2.0 in a pre/post design with a basic and an advanced training, Stoupas (2016) obtained an overall alpha of .87 on the reliability analysis. The developer of this instrument granted permission for it to be used in this study.

Views about Case Conceptualization questionnaire (VACC). This six-item instrument was developed by Dr. Len Sperry to evaluate participants’ views about case conceptualization (Sperry & Sperry, 2012). Items 1-5 employ a 1-7 Likert-type scale, where 1 = completely agree and 7 = completely disagree. The VACC items are as follows: (1) Case conceptualizations are not clinically useful; (2) There are other clinical

skills that are more important than case conceptualizations; (3) Formulating and writing

case conceptualizations is too time consuming; (4) Learning how to write case

conceptualizations is too difficult; and (5) A case conceptualization is basically a case

summary. The score range for the first five questions is 5-35, and the overall score is

obtained by adding each item. The sixth question requires participants to circle either a,

b, c, d, or e, which represent selections to complete the sentence “My knowledge and

experience with formulating and writing case conceptualizations is”: (a) no knowledge

and no experience; (b) some knowledge and no experience; (c) some knowledge and

some experience; (d) considerable knowledge and some experience; and (e) considerable

knowledge and considerable experience.

Participants completed this instrument twice, once before the first training lecture and again afterward to measure differences in their views following the training (pre- post). The VACC was not used again in the second training lecture because the importance of case conceptualization was addressed in the first training lecture. Ladd’s

(2015) sample of 139 graduate counseling students had a pre-test mean of 25.82 (SD =

3.88) and a post-test mean of 33.76 (SD = 4.18). Kelsey (2014), Ladd (2015), and

Stoupas (2016) used this instrument and reported good face validity and internal consistency on items. Kelsey (2014) reported a Cronbach’s alpha of .863 on the pre-test and .707 on the post-test, and Ladd (2015) reported .512 for the overall instrument. The developer of this instrument (Sperry, 2012) granted permission for it to be used in this study.

Evidence-Based Practice Attitude Scale (EBPAS). Aarons (2004) created the

EBPAS to assess mental health service provider attitudes towards evidence-based

practice. This instrument consists of 15 items constituting four subscales: Appeal

(the appeal of learning new practices), Requirement (the likelihood of adopting EBPs if

required to do so by a supervisor, organization, institution, or state), Openness (general

acceptance of new practices), and Divergence (perceived difference between current clinical practice and research-based interventions). The Requirement subscale has three

items, while the remaining subscales each have four items each. Respondents are asked to

rate their “feelings about using new types of therapy, interventions, or treatment” on a

five-point Likert-type scale ranging from 0 (“Not at all”) to 4 (“To a very great extent”)

in response to the statements representing the 15 items.

Items 1-8 ask respondents to rate their level of agreement with a statement regarding evidence-based practice. Examples of these statements include “I like to use new types of therapy/interventions to help my clients” (Openness) and “I know better

than academic researchers how to care for my clients” (Divergence). Items 9-15 ask respondents to rate their likelihood of adopting a new kind of therapy or intervention in various circumstances. These include statements like “if it was required by your supervisor” and “if it was being used by colleagues who were happy about it.” Subscale scores are obtained by calculating the mean score for the items on each subscale, and the

total EBPAS score is the average of each subscale. EBPAS subscale scores can be

calculated individually by computing the mean score for items in that subscale. The

EBPAS total score is obtained by first reverse scoring items from the Divergence

subscale and then averaging the subscale scores. Scores for both the total EBAS and

subscales range from 0 to 4.

In Aarons’ (2004) original sample of 322 clinicians, the mean score for the total

instrument was 2.30 (SD = 0.45) with the following reported subscale means:

Requirements, 2.47 (SD = 0.88); Appeal, .2.90 (SD = 0.67); Openness, 2.49 (SD = 0.75); and Divergence, 1.34 (SD = 0.67). In the original study, the EBPAS showed good internal consistency, with a Cronbach’s alpha of .77 for the total instrument and subscale alphas as follows: Requirements, .90; Appeal, .80; Openness, .78; and Divergence, .59.

Aarons concluded that removing items would not have improved the lower score

of the Divergence subscale. A subsequent study established means with a group of 1,089

mental health service providers from a national sample (Aarons, Cafri, Lugo, &

Sawitzky, 2012). In this study, the Divergence subscale alpha increased to .67. The

national norms established here were: Total EBPAS 2.33 (SD = 0.45); Requirement, 2.41

(SD = 0.99); Appeal, 2.91 (SD = 0.68); Openness, 2.76 (SD = 0.75); and Divergence, 1.25

(SD = 0.70).

Demographic questionnaire. Participants completed a questionnaire about

demographic information, including participant age, race/ethnicity, grade point average, graduate school training, counseling experience, religious and spiritual beliefs.

Reflection in Learning Scale (RLS). The Reflection in Learning Scale was created by Sobral (2005) to measure levels of reflective thinking in medical students.

The RLS is a 14-item paper-and-pencil measure with a seven-point Likert-type scale, where 1 represents “never” and 7 represents “always.” Questions include “To what extent have I integrated all topics in a course with each other” and “To what extent have I pondered over the meaning of the things I was studying and learning in relation to my personal experience.” Because this instrument was originally created for medical

students, it was adapted to fit counseling graduate students. In a study of medical students

(N = 275), the RLS yielded an alpha of .88 (Sobral, 2005). Permission to use the RLS

was obtained from Blackwell-Wiley.

Procedure and Data Collection

Prior to collecting any data, permission was sought through the Institutional

Review Boards (IRB) for both universities participating in the study. Both boards

granted the study exempt status. This doctoral student, as well as another doctoral student

conducting a similar study, facilitated the training lectures. The other doctoral student

received Exempt status through IRB as well. All reflective practice coaching sessions

were conducted by this doctoral student. To protect participant confidentiality, all forms

were referred to by numbers. Participant documents are only available to the principal

investigator, this doctoral student, and trained raters.

Lecture facilitators. Both standardized training lectures were presented in pre-

recorded video format, and the lectures were accompanied by printed booklets containing

all the lecture slides, which participants were allowed to keep. The facilitator of the first

training lecture has an assistant professorship in counseling at a private university in

South Florida and holds a Ph.D. in counseling from a CACREP-accredited institution.

The facilitator of the second training lecture was a professor of counseling at a public,

CACREP-accredited South Florida University This facilitator also holds several degrees,

including a Ph.D. and an M.D. Both facilitators are the co-authors of the book informing

the training lectures—Case Conceptualization: Mastering this Competence with Ease

and Confidence (Sperry & Sperry, 2012).

Case conceptualization raters. This doctoral student scored paper and pencil measures, including the Views About Case Conceptualization instrument, Evidence-

Based Practice Attitudes Scale, Reflection in Learning Scale, the demographic questionnaire, and the lecture questionnaire. Case conceptualizations, including those collected in the lecture trainings and as homework assignments, were scored using instrument CCEF 2.0 by six independent raters, two male and four female, all of whom were doctoral students in counselor education. Raters were compensated for their time and scored all case conceptualizations anonymously. Raters were trained in scoring case conceptualizations by this doctoral student, and training consisted of reviewing and scoring several case conceptualizations as a group. Raters were assigned numbers and their identifiers and scores were entered into SPSS for analysis. A Cronbach’s alpha was calculated several times until the raters reached an > .7 (Lance, Butts, & Michels,

2006). The final interrater reliability Cronbach’s alpha𝛼𝛼 was .894. Table 1 below shows

the descriptive statistics for the six raters involved in the study.

Raters were then paired, and each case conceptualization was rated by one pair of raters. Scores for both raters were entered into SPSS, yielding three scores—Rater A score, Rater B score, and an average of both scores. Raters were not affiliated with the study any other way.

Table 1.

Rater Descriptive Statistics Rater ID N Mean Std. Dev. r1 3 33.67 17.10 r2 3 33.67 35.84 r3 3 39.33 12.90 r4 3 25.67 22.48 r5 3 27.67 17.04

r6 3 39.33 13.20 r1 = Rater 1, r2 = Rater 2, etc.

Case Conceptualization and Instrument Collection

All data, both from lecture trainings and homework assignments, was collected over a period of eight weeks. Eight case conceptualizations were collected from all participants. Two were completed as pre/post measures at the first case conceptualization training lecture and two were completed as pre/post measures at the second case conceptualization training lecture. Four additional case conceptualizations were collected over the course of a semester as homework assignments. For the purposes of this study and statistical analyses, case conceptualizations are ordered, and will be referred to, in the order they were completed by participants (see Table 2 below).

Table 2.

Participant Case Conceptualizations Incorporated in the Study

Designation Source CC1 Training lecture 1 Pre-test CC2 Training lecture 1 Post-test CC3* Homework 1 CC4 Homework 2 CC5 Training lecture 2 Pre-test CC6* Training lecture 2 Post-test CC7* Homework 3 CC8 Homework 4 * Reflection Coaching sessions took place for intervention group participants after collection of this CC.

Table 3 below lists the documents and completed instruments collected during each of the two training sessions comprising the study.

Table 3.

Documents and Instruments Collected Per Training Session Training Session Documents/Instruments Completed & Collected Lecture Training 1 Case Conceptualization Pre-test I Views About Case Conceptualization Pre-test Reflection in Learning Scale Pre-test Evidence-Based Practice Attitudes Scale Pre-test

Demographic Questionnaire Case Conceptualization Post-test I Views About Case Conceptualization Post-test Evidence-Based Practice Attitudes Scale Post-test Lecture Questionnaire Lecture Training 2 Case Conceptualization Pre-test II Case Conceptualization Post-test II Reflection in Learning Scale Post-test

Data Analysis

Research Question 1 (What is the effect of reflective practice coaching on

coaching recipients’ competence in writing case conceptualizations?); Research Question

3 (Does a three-hour initial training lecture increase counselor trainee competence in

developing a case conceptualization?); and Research Question 5 (Does a follow-up

training lecture increase counselor trainee competence?) were all analyzed using a

MANOVA. Results were confirmed with a t-test. Pre-post case conceptualization scores

from both training lectures were used to analyze the effects of the training lectures, while

scores from the four case conceptualization assignments were used to analyze the effects

of reflective practice coaching. Case conceptualizations were rated using the CCEF 2.0.

Research Question 2 (What is the effect of reflective practice coaching on

counselor trainee reflective thinking?) was analyzed using paired-samples t-test. Research

Question 4 (Does a three-hour initial training lecture reduce counselor trainee myths

about case conceptualizations?) was analyzed using an ANOVA.

Research Question 6 (What variables [age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking] influence reflective thinking?);

Research Question 7 (What variables [age, gender, race/ethnicity, grade point average,

graduate school training, counseling experience, attitudes toward evidence-based

practice, disposition toward reflective thinking] are related to case conceptualization competence prior to training?); Research Question 8 (What variables [age, gender, race/ethnicity, grade point average, graduate school training, counseling experience, attitudes toward evidence-based practice, disposition toward reflective thinking] influence response to an initial case conceptualization training lecture?); Research

Question 9 (What variables [age, gender, race/ethnicity, grade point average, graduate school training, counseling experience, attitudes toward evidence-based practice,

disposition toward reflective thinking] influence response to a follow-up training

lecture?); and Research Question 10 (What variables [age, gender, race/ethnicity, grade point average, graduate school training, counseling experience, attitudes toward evidence-based practice, disposition toward reflective thinking] influence whether the effects of case conceptualization training persist over time?) were analyzed using

ANOVA and correlation analysis. All statistical analyses were performed on SPSS

Version 25.

IV. RESULTS

This study examined the effect of a two-part standardized case conceptualization training lecture and the effects of reflection coaching on counseling students’ case conceptualization competence. This chapter outlines the results of this study.

Descriptive statistics of the population sample are provided, and ten hypotheses are explored and the study findings summarized.

Sample Population Characteristics

A total of 84 participants (N = 84) from graduate counseling programs participated in the study. A G-power analysis indicated the sample size should be 50.

Statistical power is affected by number of participants and Cohen (1988) suggests achieving a power of no less than 0.8.

Participants were masters-level counseling students from two South Florida universities. One university is a public university with a CACREP-accredited graduate counseling program. The second is a private university with a non-CACREP accredited graduate counseling program. Participants varied in terms of level of counseling experience and demographic characteristics. Participants were distributed into two groups — an intervention group (N = 35) and a comparison group (N = 49). Participants

were not randomly assigned to either group. Both groups participated in two three-hour case conceptualization training lectures. In addition, the intervention group participated in three 15-minute one-on-one reflective practice coaching sessions in addition to the

case conceptualization training lectures. Table 4 below describes the sample’s

demographic characteristics.

Table 4.

Participant Demographic Information

Frequency Percent Cumulative Gender Male 15 17.9% 17.9% Female 69 82.1% 100.0% Total 84 100.0% Age 18-27 56 66.7% 66.7% 28-37 10 11.9% 78.6% 38-47 11 13.1% 91.7% 48-57 6 7.1% 98.8% 58-67 1 1.2% 100.0% Total 84 100.0% Race Asian 1 1.2% 1.2% Black 14 16.7% 17.9% Hispanic 23 27.4% 45.2% White 44 52.4% 97.6% Other 2 2.4% 100.0% Total 84 100.0% Religious/Spiritual Yes 46 54.8% 54.8% No 38 45.2% 100.0% Total 84 100.0% Paranormal Beliefs Yes 29 34.5% 34.5% No 55 65.5% 100.0% Total 84 100.0%

Of the 84 participants, 17.9% (N = 15) were male and 82.1% (N = 69) were

female. Participants varied in age (18-27, 28-37, 38-47, 48-57, 58-67) but the highest number of participants, 66.7% (N = 56), represented the 18-27 age group. The participant 67

sample was diverse, with 1.2% Asian, 16.7% Black, 27.4% Hispanic, 52.4% White, and

2.4% identifying as other.

As shown in Table 5, participants had completed varying levels of graduate

course credits, with most having completed 28 graduate credits, 33% (N = 28). The second most frequent number of credits completed was none, 15.5% (N = 13). Of the 84 participants, six did not provide a response to this question.

Table 5.

Study Participant Credits Completed

Credits Completed Frequency Percent Cumulative Percentage 0.00 13 15.5% 15.5% 6.00 3 3.6% 19.0% 9.00 4 4.8% 23.8% 12.00 6 7.1% 31.0% 15.00 2 2.4% 33.3% 18.00 28 33.3% 66.7% 21.00 2 2.4% 69.0% 24.00 6 7.1% 76.2% 25.00 1 1.2% 77.4% 27.00 2 2.4% 79.8% 32.00 1 1.2% 81.0% 33.00 1 1.2% 82.1% 36.00 4 4.8% 86.9% 38.00 1 1.2% 88.1% 40.00 2 2.4% 90.5% 50.00 1 1.2% 91.7% 54.00 1 1.2% 92.9% Missing 6 7.1% 100.0% Total 84 100.0%

As shown in Table 6, the most frequent graduate school GPA reported was 3.6-4.0, with

82% (N = 69) participants selecting this option. The majority of participants had no

counseling experience, with 77.4% (N = 65) reporting zero years of counseling experience.

Table 6.

Study Participant Grade Point Averages

GPA Frequency Percent Cumulative Percentage 2.6-3.0 3 3.6% 3.6% 3.1-3.5 12 14.3% 17.9% 3.6-4.0 69 82.1% 100.0% Total 84 100.0%

Table 7.

Study Participant Years Experience Counseling

Years Frequency Percent Cumulative Percentage .00 65 77.4% 77.4% .16 1 1.2% 78.6% .33 1 1.2% 79.8% .42 1 1.2% 81.0% .50 1 1.2% 82.1% .58 1 1.2% 83.3% .67 1 1.2% 84.5% .75 1 1.2% 85.7% 1.00 2 2.4% 88.1% 1.50 2 2.4% 90.5% 2.00 2 2.4% 92.9% 3.17 1 1.2% 94.0% 4.00 1 1.2% 95.2% 4.90 1 1.2% 96.4% 5.58 1 1.2% 97.6% 6.00 1 1.2% 98.8% 10.50 1 1.2% 100.0% Total 84 100.0%

Participants were asked two additional questions on the demographic form (see

Table 4) regarding spiritual and religious beliefs. Both questions, “Do you consider 69

yourself religious and/or spiritual?” and “Do you have paranormal beliefs? (e.g., ESP,

ghosts, psychic abilities, etc.)” required yes or no responses. Regarding the

religious/spiritual question, 54.8% responded “yes” and 45.2% responded “no.”

Regarding the paranormal beliefs question, 34.5% responded “yes” and 65.5% responded

“no.”

Hypothesis Testing

Research Questions 1 and 3 pertain to the influence of reflective practice on both

counselor competence and reflective thinking skills. These questions were analyzed

using MANOVA, ANOVA, and multiple regression. Research Questions 3, 4, and 5

concern the effects of a case conceptualization training lecture on counselor competence

in writing case conceptualizations. These data pertinent to these questions were analyzed

using MANOVA. Finally, Questions 6, 7, 8, 9, and 10 pertain to the relationships

between demographic variables, levels of reflective thinking, etc., and counselor

competence and reflective thinking. The findings related to each research question and its association null hypothesis are presented below.

Research Question 1: What is the effect of reflective practice coaching on coaching

recipients’ competence in writing case conceptualizations?

Null Hypothesis 1 (H01), based on Research Question 1, states that reflective

practice coaching has no effect on coaching recipients’ competence in writing case

conceptualizations. To measure competence level, scores for the four case

conceptualization course assignments (CC3, CC4, CC7, and CC8) were analyzed by

group, intervention – N = 35, and comparison group – N = 49. A MANOVA was then

used to analyze case conceptualization scores for the intervention and comparison groups.

Mauchley’s test for sphericity was significant (W = .000), a common issue indicating probable inflation of Type I error. Therefore, scores were converted into standardized Z- scores, but neither the results nor the level of sphericity were significantly different.

Therefore, results calculated from raw scores are being reported.

In cases such as this where Mauchley’s test for sphericity was significant,

Haverkamp and Beauducel (2017) recommend reporting the Huynh-Feldt correction.

Employing it yielded F(4.77) = 71.767, p < .001. Results of the one-way between- subjects multivariate analysis of variance showed that participants who participated in reflection coaching demonstrated increased competence in case conceptualizations; the

F-statistic F(7, 76) = 56.9 with p <.001.

In the following discussions, see Figure 1 for a visual comparison of the mean case conceptualization scores M for each group for each case conceptualization completed throughout the study. Final case conceptualization scores for CC8 differed significantly for intervention and comparison groups (M = 72.64 and M = 46.81, respectively). Intervention group participants also outperformed comparison group participants on CC4 (M = 46.97 and M = 24.13, respectively) and CC7 (M = 58.21 and M

= 48.38, respectively). An independent t-test showed that the difference between intervention and comparison groups was significant , and the effect size was large (t =

22.82 df = 82, p = .000, one-tailed, d = 5.06). Therefore, Null Hypothesis 1 (H01), which

states that reflective practice coaching has no effect on coached participants’ competence

in writing case conceptualizations, was rejected.

Figure 1. Mean case conceptualization scores for intervention and comparison groups for all case conceptualizations CC1 through CC8. Reflective practice training was also examined for its possible role as either a mediating or moderating variable between the case conceptualization training lecture and case conceptualization competence.

Mediation occurs when one variable affects an outcome by having an influence on the independent variable, which then affects the dependent variable (Baron & Kenny,

1986). For example, experiencing childhood abuse (independent variable) can lead to perpetrating abuse (dependent). This relationship is not always guaranteed, and negative self-other schemas that develop as a result of abuse, can mediate the effects of the independent variable. Mediation can be either partial or total. See Figure 2 below:

Figure 2. Effects of mediation. Moderation occurs when one variable affects the relationship between the

independent and dependent variables but has no causal effect of its own. For example,

number of hours spent studying (independent variable) affects the score received on an

exam (dependent variable). Intelligence can moderate this relationship. See Figure 3

below:

Figure 3. Effects of moderation. There are various ways to measure the effects of mediation and moderation. For the purpose of this study, the Andrew F. Hayes PROCESS tool was used in SPSS. The

Hayes tool was used because variables sometimes act as mediating moderators or

moderating mediators and the PROCESS tool tests for all these variations simultaneously

(Hayes & Rockwood, 2017). Results showed that reflective practice coaching had no

mediating or moderating effects.

Research Question 2: What is the effect of reflective practice coaching on counselor

trainee reflective thinking?

Null Hypothesis 2 (H02) states that reflective practice coaching has no effect on counselor trainee reflective thinking, and the Reflection in Learning Scale was used to measure this. Intervention group participants completed the RLS before the initial training lecture (pre-test), after the second training lecture (post-test), and after the final reflection coaching session (post-post test). The comparison group participants completed the RLS before the initial training lecture (pre-test) and after the second training lecture (post-test). Results of one-way analysis of variance (N=84) were not significant for either group. A paired sample t-test showed that the only improvement was between the post-test and post-post test for the intervention group. Results were significant (|t| = 1.91, df 34, p < .001, one-tailed). (See Table 8 below.) Therefore, Null

Hypothesis 2 (H02), which states reflective practice coaching has no effect on counselor

trainee reflective thinking, was only partially rejected.

Table 8.

Results of the Paired Samples Test for Null Hypothesis 2

95% CI of Std. Std. Err. Difference Sig. Level Mean Deviation Mean Lower Upper t df (2-tailed) 1. RLS Pre - RLS Post 0.59 7.61 0.84 -1.07 2.25 0.71 82 0.48 2. RLS Post - RLS Post Post -3.43 10.63 1.80 -7.08 0.22 -1.91 34 0.07 3. RLS Pre - RLS Post Post -2.94 10.80 1.83 -6.65 0.77 -1.61 34 0.17

Research Question 3: Does a three-hour initial training lecture increase counselor

trainee competence in developing a case conceptualization?

Null Hypothesis 3 (H03) states that a three-hour initial training lecture has no effect on counselor trainee competence in developing a case conceptualization. To

measure competence level, scores for the pre/post case conceptualizations in Training

lecture 1 (CC1 and CC2) were analyzed by group (N=84). A MANOVA was then used to

analyze case conceptualization scores for the intervention and comparison groups.

Mauchley’s test for sphericity was statistically significant (W = .000), and the Huynh-

Feldt correction yielded F(4.77) = 71.767, p < .001. Average case conceptualization

scores increased from the pre-test to the post-test (M = 11.20 and M = 24.10, respectively) for all participants. Therefore, Null Hypothesis 3 (H03), which states that a three-hour initial training lecture has no effect on counselor trainee competence in developing a case conceptualization, was rejected.

Research Question 4: Does a three-hour initial training lecture reduce counselor trainee myths about case conceptualizations?

Null Hypothesis 4 (H04) states that a three-hour initial training lecture does not reduce counselor trainee myths about case conceptualizations. Such myths were measured using the Views About Case Conceptualization (VACC) instrument, a six-item

instrument developed by Dr. Len Sperry to evaluate participants’ views about case

conceptualization (Sperry & Sperry, 2012). Items 1-5 use a 1-7 Likert-type scale, where 1

= completely agree and 7 = completely disagree. The VACC was given pre- and post- in

the first case conceptualization training lecture, and a t-test showed a significant

difference in views on case conceptualization myths (N = 84) before and after the training

lecture (|t| = 8.14, df 83, p < .001, one-tailed). See Table 9 for this SPSS output.

A sixth question on the VACC asked participants to rate their level of experience

with case conceptualizations. In the pre-test, 31(36.9%) participants indicated that they

had no knowledge and no experience; 28 (33.3%) participants indicated they had some

knowledge and no experience; 22 (26.2%) participants indicated that they had some

knowledge and some experience; and 3 (3.6%) participants indicated that they had

considerable knowledge and experience.

After the training lecture, in the post-test, 2 (2.4%) participants indicated that they had no knowledge and no experience; 13 (15.5%) participants indicated that they had some knowledge and no experience; 39 (46.4%) participants indicate that they had some knowledge and some experience; and 26 (31%) participants indicated that they had considerable knowledge and experience. Therefore, Null Hypothesis 4 (H04), which

states that a three-hour initial training lecture does not reduce counselor trainee myths

about case conceptualizations, was rejected.

Table 9.

Results of Paired Samples Test for Null Hypothesis 4

95% CI of Std. Std. Error Difference Sig. Level Mean Deviation Mean Lower Upper t df (2-tailed) VACC Pre - VACC Post -4.07 4.58 0.50 -5.07 -3.08 -8.14 83 0.000

Research Question 5: Does a follow-up training lecture increase counselor trainee

competence?

Null Hypothesis 5 (H05) states that follow-up training lecture will not increase counselor trainee competence. To measure competence level, scores for the pre/post case conceptualizations in Training lecture 2 (CC5 and CC6) were analyzed by group (N=84).

A MANOVA was then used to analyze case conceptualization scores for both the intervention and comparison groups. Mauchley’s test for sphericity was significant (W =

.000). Huynh-Feldt-correction yielded F(4.77) = 71.767, p < .001. Average case conceptualization scores increased from the pre-test to the post-test (M = 21.33 and M =

52.29, respectively) for all participants. Therefore, Null Hypothesis 5 (H05), which states that a follow-up training lecture does not increase counselor trainee competence, was rejected.

Null Hypothesis 6 (H06) states that none of these participant characteristics exert

any influence on counselor trainees’ reflective thinking. Reflective thinking was

measured using the Reflection in Learning Scale pre-test scores. A univariate analysis

(N=84) was used to analyze variables including age, gender, race/ethnicity, grade point

average, attitudes toward evidence-based practice, and disposition toward reflective

thinking. A correlation analysis was used to analyze the variables graduate school

training, and counseling experience. No variables were found to be significantly related

to reflective thinking. Therefore, Null Hypothesis 6 (H06), which states none of these

variables influence counselor trainees’ reflective thinking, could not be rejected.

Research Question 7: What variables (age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking) are related to case

conceptualization competence prior to training?

Null Hypothesis 7 (H08) states that none of these variables are related to case

conceptualization competence prior to training. This question was employed to establish

baseline CCEF 2.0 differences amongst participants as well as to identify which variables

are associated with pre-training competence, which was measured using the CCEF 2.0

scores from CC1. A univariate analysis (N=84) was used to analyze variables including age, gender, race/ethnicity, grade point average, attitudes toward evidence-based practice, and disposition toward reflective thinking. In addition, correlations were calculated to analyze the variables graduate school training and counseling experience. No variables were found to be significantly related to case conceptualization competence prior to training. Therefore, Null Hypothesis 7 (H07), which states these variables are not related to case conceptualization competence prior to training, could not be rejected.

Null Hypothesis 8 (H08) states that these variables have no influence on response to an initial case conceptualization training lecture. This was measured with the gain score for the pre/post case conceptualizations from the first training lecture (CC1 and

CC2). A univariate analysis (N=84) was used to analyze variables including age, gender, race/ethnicity, grade point average, attitudes toward evidence-based practice, and disposition toward reflective thinking. A correlation analysis was used to analyze the variables graduate school training and counseling experience. No variables were found to be significantly related to the response to the initial case conceptualization training lecture. Therefore, Null Hypothesis 8 (H08), which states that these variables have no influence on response to an initial case conceptualization training lecture, cannot be rejected.

Research Question 9: What variables (age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking) influence response to a

follow-up training lecture?

Null Hypothesis 9 (H09) states that these variables have no influence on response

to a follow-up training lecture. This was measured with the gain score for the pre/post

case conceptualizations from the second training lecture (CC5 and CC6). A univariate analysis (N=84) was used to analyze variables including age, gender, race/ethnicity, grade point average, attitudes toward evidence-based practice, and disposition toward reflective thinking. A correlation analysis was used to analyze the variables graduate school training, and counseling experience. No variables were found to be significantly related to the response to the initial case conceptualization training lecture. Therefore, Null

Hypothesis 9 (H09), which states these variables have no influence on response to a

follow-up training lecture, could not be rejected.

Research Question 10: What variables (age, gender, race/ethnicity, grade point

average, graduate school training, counseling experience, attitudes toward evidence-

based practice, disposition toward reflective thinking) influence whether the effects

of case conceptualization training persist over time?

Null Hypothesis 10 (H010) states that these variables will have no influence on

whether the effects of case conceptualization training persist over time. This was

measured with the gain score for the pre/post case conceptualizations from the first

training lecture and final homework (CC1 and CC8). A univariate analysis (N=84) was

used to analyze variables including age, gender, race/ethnicity, grade point average,

attitudes toward evidence-based practice, and disposition toward reflective thinking. A

correlation analysis was used to analyze the variables graduate school training and

counseling experience. No variables were found to be significantly related to the

response to the initial case conceptualization training lecture. Therefore, Null Hypothesis

10 (H010), which states that these variables have no influence on whether the effects of case conceptualization training persist over time, cannot not be rejected.

Summary

This chapter presented the results of statistical analyses designed to test the ten

study hypotheses. Sample demographics were also presented. A MANOVA was used to

assess counselor trainees’ case conceptualization competence (measured by the CCEF

2.0), the trainees’ views on case conceptualizations (measured by the VACC), the

trainees’ attitudes toward evidence-based practice (measured by the EBPAS), and

trainees’ reflective thinking skills (measured by the RLS). The Huynh-Feldt correction was employed in response to sphericity. Overall, four of the 10 null hypotheses (H01,

H03, H04, H05) were rejected completely, and one (H02) was rejected partially. The next

chapter will discuss the implications of these results.

V. DISCUSSION

This study was the first to add a reflective practice coaching component to a standardized case conceptualization training developed by Sperry (2010b). Previous studies (Kelsey, 2014; Ladd, 2015; Stoupas, 2016) investigated the effects of the case conceptualization training with no added coaching. Additionally, these studies did not include comparison groups whereas the present study did. The present study found an initial case conceptualization training increases counselor competence in writing case conceptualizations, and that a second training further increases competence. The present study also found that participants coached in reflective practice demonstrated significantly higher rates of improvement in case conceptualization competence than those who did not receive coaching. Finally, the present study found that case conceptualization training reduces myths about case conceptualization.

This chapter will discuss the significance of the results of the present study and the study’s theoretical, practice, and research implications. Recommendations for future research as well as the limitations of the present study will be addressed.

Significance of the Results

Counselors must be able to organize and integrate important client details,

including patterns, and precipitating and perpetuating factors in order to properly plan

treatment (Kendjelic, 1998). Unfortunately, this task can be challenging, if not

impossible, for counselors who do not receive training in case conceptualization, and studies indicate that counselors do not receive adequate training in this area (Eells,

2007). This lack of training leaves many counselors confused about the purpose and

process of case conceptualization, and able to formulate only narrow case summaries

(Kendjelic & Eells, 2007).

Crits-Christoph, Cooper, & Luborsky (1988) found that practitioner interventions

formulated through case conceptualization had greater accuracy. Other studies have

also found improved treatment outcomes for case conceptualization driven therapy

(Silberschatz et al., 1986) and increased accuracy of therapeutic interpretations (Crits-

Christoph et al., 1988). Additionally, Case conceptualization was found to improve treatment in complex cases (Persons, 1992; Malatesta, 1990), improve treatment for comorbid depression (Persons et al., 1995), and contribute to maintaining treatment gains at six months (Jacobson et al., 1989). Case conceptualization was also found to help clinicians determine when to alter a treatment protocol (Malatesta, 1995a; Malatesta,

1995b).

Incorporating case conceptualization into practice requires not only formal case conceptualization training, but also a method that facilitates learning and the development of expertise. Betan and Binder (2010) write, “expertise requires not only a strong knowledge base, but also the ability to apply and adapt one's knowledge in a way that is meaningful and ultimately helpful” (p. 142). Experts are better equipped to conceptualize clients’ complex presentations, correctly identify therapeutic interventions, evaluate treatment progress, and adjust treatment as indicated, making them highly effective

(Sperry, 2010b). Building expertise requires the ability to integrate theory with practice.

Reflection has long been seen as integral to professional development and as a factor that helps counselors develop their clinical practice and professional judgment,

facilitating learning and the development of expertise (Neufeldt, Karno, & Nelson, 1996;

Griffith & Frieden, 2000). Theories behind reflective practice in learning are based on the idea that thinking critically will increase knowledge and strengthen abilities (Lee &

Birdsong Sabatino, 1998). Bennett-Levy (2006) considers reflection a ‘key task’ in counselor education and development (p. 68). Self-reflection encourages students to foster an awareness and responsibility for their own development and integrate theories into their practice in a more creative and empathic way (Thwaites et al., 2014). "It links the experiential with the conceptual, the interpersonal and the technical, the 'therapist self' and the 'personal self.'" (Thwaites et al., 2014, p. 251). Counseling students often find it challenging to apply research, theory, and experience to practice but this process can be facilitated by reflective practice (Hart, 1993).

Several studies have shown continuous reflection delineates average and novice therapists (Bennett-Levy, 2006). Skovhold and Ronnestad (1992) concluded that self- reflection was the most important distinguishing factor between counselors who continued their professional development and those who became idle and faced burnout.

Reflective practice is the key to turning experience into expertise (Neufeldt et al., 1996;

Skovholt & Jennings, 2005). Skovholt and Ronnestad (1992) describe this process as individuation - an integration of the professional and personal selves. They state the development of expertise “includes a movement from an unarticulated, preconceptual, and ideological way of functioning to a mode of functioning that is founded on the individual’s own integrated, experience-based generalizations” (p. 507). Expertise builds when declarative knowledge is integrated into procedural knowledge (Nelson &

Neufeldt, 1998; Bennett-Levy, 2006; Binder, 1999). Without knowing how to apply it in

real world settings, declarative knowledge remains ‘inert’ (Whitehead, 1929). Thus, integrating a reflective practice into the learning of case conceptualization can help facilitate this skill and build expertise.

Previous studies on case conceptualization training included small sample sizes

(Abbas et al., 2007), included nonclinicians or clinicians with varying degrees of experience (Kendjelic & Eells, 2007), failed to include pre-intervention assessment of case conceptualization abilities (Abbas et al., 2012; Kendjelic & Eells, 2007), and inadequately assessed post-intervention abilities (Kendjelic & Eells, 2007).

This study is significant because it examined the effects of a standardized case conceptualization training with the added component of reflective practice coaching.

Additionally, this study is the first to utilize a comparison group. Finally, this is the first study to examine the effects of case conceptualization training over time with counseling students.

Contributions of the Study

The present study made several contributions to the literature on both reflection and learning, and case conceptualization. This study added to past research using the

Sperry (2010b) integrative case conceptualization model training lectures (Kelsey, 2014;

Ladd, 2015; Stoupas, 2016). This was the first study to include both intervention and comparison groups. Additionally, this was the first study to use the two-part training lecture with graduate counseling students. Kelsey (2014) and Ladd (2015) used one-part training lectures, while Stoupas (2016) used the two-part training lecture with practicing clinicians, rather than students.

Second, the present study contributed to the literature on reflective practice and its

role in learning. To date, research on reflection is sparse most studies on reflection have

been qualitative (Thwaites et al., 2014). The present study provides quantitative analyses of the influence of direct reflective practice coaching on counselor competence.

Reflective thinking, and its relation to learning, has also proven challenging to measure

(Lee & Birdsong Sabatino, 1998). Therefore, there is still a lack of evidence on the

utility of reflection in learning (Lee & Birdsong Sabatino, 1998). The present study

contributes to the literature by measuring the value of reflective practice on counselor education.

Implications for Theory, Practice, and Research

This study demonstrated that (a) case conceptualization is a skill that can be

taught to counselors in training through standardized training lectures, (b) participants

who receive reflective practice coaching demonstrate greater competence in writing case

conceptualizations, (c) myths about case conceptualization can be dispelled through

standardized training lectures, (d) reflective practice coaching has some influence on

reflective thinking. The following sections explore the study results’ theoretical, practice,

and research implications. Recommendations for future research are made.

Theoretical implications. The present study has several theoretical implications.

The case conceptualization construct in this study is based in Sperry’s (2010b) pattern-

focused therapy. This theory posits that effective therapy aims to ameliorate clients’

maladaptive patterns. Pattern, here, is defined as a persistent, reflexive, self-perpetuating

way of thinking, feeling, and behaving (Sperry, 1989). Counselors who are able to

recognize and understand client patterns are more likely to facilitate better therapeutic

alliances and produce effective treatment plans. Learning to write case

conceptualizations helps counselors synthesize client data, recognize patterns, and use

this information for effective treatment. The present study supports this theoretical

framework. After a standardized case conceptualization training lecture, participants

demonstrated increased ability to identify patterns correctly, as well as synthesize this

information to select accurate treatment recommendations and accurately predict

treatment prognosis and obstacles, as evidenced by increased scores on the CCEF 2.0.

This study indicates that case conceptualization skills can be learned, building on similar

results from previous research (Kelsey, 2014; Ladd, 2015; Stoupas, 2016).

Further, the present study’s results have implications related to Bennett-Levy’s

(2006) DPR conceptual model. The DPR model includes declarative knowledge (D),

procedural knowledge (P), and self-reflective skills (R). Declarative knowledge refers to

technical and conceptual knowledge acquired through coursework and didactic learning.

Procedural knowledge is a manifestation of declarative knowledge in practice.

Declarative knowledge must be converted to procedural knowledge to be effectively

applied. This process represents the development of expertise. Practice of skills is

insufficient in this process, as Bennett-Levy (2006) posits that reflection is the key component in the integration of declarative knowledge into procedural knowledge. The present study supports this theoretical framework. Participants who received reflection coaching demonstrated significantly higher competence participants who received no coaching, as indicated by scores on the CCEF 2.0. While participants who received no coaching outperformed coaching participants on the second training lecture post-test,

coaching participants demonstrated greater increased competence overall.

Finally, as reflective practice is rooted in constructivist theory. Constructivists base their approaches to learning on Vygotsky's zone of proximal development and

Wood, Bruner, and Ross' scaffolding, concepts which state that learning occurs in the context in which experts and novices meet (Ronnestad & Skovholt, 2003). Vygotsky stated that students learn skills and concepts when they are supported while in the Zone of Proximal Development (ZPD), meaning the state in which the student is most receptive to, or nearing, learning. In the ZPD, a student is most likely to learn through support from an expert. This process is called scaffolding (Smagorinsky, 2012). The present study supports the theoretical framework of Vygotsky’s theories of zone of proximal development and scaffolding. Participants who received one-on-one reflection coaching demonstrated increased competence in writing case conceptualizations than those who received no coaching. Essentially, these participants received scaffolding from someone with more expertise, between training lectures, which can be considered the zone of proximal development. Additionally, support was part of the standardized reflection coaching protocol, further scaffolding the coaching participants.

Practice implications. The present study has several implications for clinical practice. The first is that case conceptualization competence can be taught. Standardized training lectures using Sperry’s (2010b) integrative model improved participants competence in writing case conceptualizations using standardized cases. Results of the one-way between-subjects multivariate analysis of variance showed that participants who participated in the initial standardized training lecture demonstrated increased competence in case conceptualizations; the F-statistic F(7, 76) = 56.9 with p <.001.

Average case conceptualization scores increased from the pre-test to the post-test (M =

11.20 and M = 24.10, respectively) for all participants. Furthermore, myths about case

conceptualization were greatly reduced. A t-test showed a significant difference in views on case conceptualization myths (N = 84) before and after the training lecture (|t| = 8.14,

df 83, p < .001, one-tailed).

Additionally, participants’ competence was further improved by the second

training lecture, which contains instruction on completing a cultural formulation. This

skill is a particularly significant and timely one for counselors. Though cultural

competence is crucial for counselors, Manis (2012) writes, “Much is left to discover

about how to most effectively deliver multicultural education and ensure that counselors

are able to engage in ethical and competent counseling and advocacy with diverse

populations,” (p.48). The present study indicates the standardized case conceptualization

training model is effective for teaching cultural competence. Results of the one-way

between-subjects multivariate analysis of variance showed that participants who

participated in the second standardized training lecture demonstrated increased

competence in case conceptualizations; the F-statistic F(7, 76) = 56.9 with p <.001.

Average case conceptualization scores from the second training lecture increased from

the pre-test to the post-test (M = 21.33 and M = 52.29, respectively) for all participants.

Another implication of this study is that reflective practice increases counselor

competence. Reflection is a skill that can be incorporated into graduate counseling

curriculums and can be further cultivated in an individual practice. This serves as a

useful method for incorporating new knowledge into practice, facilitating the

development of expertise. Results of the one-way between-subjects multivariate analysis

of variance showed that participants who participated in reflection coaching demonstrated

increased competence in case conceptualizations; the F-statistic F(7, 76) = 56.9 with p

<.001. Final case conceptualization scores for CC8 differed significantly for intervention and comparison groups (M = 72.64 and M = 46.81, respectively). Intervention group participants also outperformed comparison group participants on CC4 (M = 46.97 and M

= 24.13, respectively) and CC7 (M = 58.21 and M = 48.38, respectively).

Finally, the present study indicates that reflection can be taught through individual coaching using Socratic questioning. While results of one-way analysis of variance in scores on the Reflection in Learning Scale were not significant for either group, a paired sample t-test showed that there was significant improvement between the post-test and post-post test for the intervention group. Results were significant (|t| = 1.91, df 34, p <

.001, one-tailed). Although overall gains were not statistically significant, results from the intervention group’s post-post test indicate that additional coaching sessions may be needed. Overall increases in reflective thinking, as measured by the Reflection in

Learning Scale may have been significant had participants received at least one more reflection coaching session.

Research implications. The present study presented some implications for future research. First, because the intervention group demonstrated significant improvement on their scores on the Reflection in Learning Scale between the post-test and post-post-test, but not between the pre-test and post-test or post-post-test, future research should explore the influence of reflection coaching on reflective thinking by employing a greater number of coaching sessions. This could possibly include more data points to measure variations in reflective thinking over time.

The present study incorporated reflective practice through direct coaching. Future

research may explore additional methods of reflection in addition to coaching, like

instructing students to keep a reflection journal in which they respond to standardized

prompts. A personal reflective practice may strengthen the effect of reflection coaching.

Qualitative results from such a study would also be useful for understanding how

counselors incorporate case conceptualization knowledge into their practice.

Another implication for future research concerns the reflection instrument, the

Reflection in Learning Scale. Few instruments exist to measure levels of reflective

thinking. This has led to the majority of studies on reflective thinking to be qualitative.

In order to continue to contribute to the quantitative literature on reflective practice,

future research should continue to use the RLS in future studies.

With a total score of 98, it is also possible that ceiling effects were present (Meier,

2015). Descriptive statistics show that the highest score on the RLS pre-test (for both

groups) was 94, and the average score was 74.65. Because the RLS is the most user-

friendly reflection instrument with the most robust psychometrics, future research may

attempt to create a new reflection instrument, specifically one for counselors or those in

the helping professions. The RLS was created for medical students and had to be adapted

to fit graduate counseling students.

Finally, future research can focus on the integration of case conceptualization

with the Sperry (2010b) model and multicultural competence. Multicultural

competencies and interventions are necessary not only for effective client care, but also

for counselors to stay on the forefront of evidence-based practice as not only multicultural competence, but also social justice advocacy, are now considered necessary

by the American Counseling Association (Mannis, 2012). The cultural formulation component of the Sperry (2010b) integrative case conceptualization model has been demonstrated to be an effective way of teaching counselors to write culturally-sound case conceptualizations. Future research can focus on this method as a strategy for teaching greater multicultural competencies.

Study Limitations

This study posed several limitations, as follows:

• This study used a convenience sample of graduate counseling students who

volunteered to participate in the training lectures, coaching sessions, and this

study. Participants may have been motivated by factors such as professors’ and

department expectations, though participants were assured their participation, or

lack of participation, would not affect their grades or status in the graduate

counseling program. Thus, the representativeness of this sample is limited,

making the results less generalizable to graduate counseling students, or to

counselors as a larger group.

• This study did not assess certain participant variations like intelligence, prior

training, or personal learning and practice. It is possible that these variables

contributed to some of the effects.

• There were more participants in the comparison group (N = 49) than in the

intervention group (N = 35). It is possible that this discrepancy effected the

results.

• Another doctoral student conducted a similar study on case conceptualization

simultaneously. All participants, from both studies, participated in training

lectures together and the comparison group was shared. Students in the

intervention groups were randomly assigned to participate in this study and

receive reflective practice coaching, while the others received different coaching.

It was revealed that students in both groups discussed their grades and

interventions with one another and there was some dissent as to who was

receiving the “superior” intervention. It is possible that this decreased participant

morale and affected how participants performed.

• All coaching sessions were conducted by this doctoral student. It is possible

results would be different if another person were conducting the coaching

sessions.

Conclusion

The present study contributed to the literature on reflection and case

conceptualization, adding to past studies using the Sperry (2010b) integrative case

conceptualization model (Kelsey, 2014; Ladd, 2015; Stoupas, 2016). This was the first

study to include both intervention and comparison groups and the first study to use the

two-part training lecture with graduate counseling students.

This study demonstrated that case conceptualization can be taught through a

standardized training lecture and that greater gains are indicated after a second training

lecture. It also demonstrated that participants who receive reflective practice coaching

improve their written case conceptualizations more than participants who do not receive

coaching. Effects of standardized training lectures on case conceptualization myths were reported as well as effects of coaching on reflective thinking. This chapter discussed

these results and their theoretical, practice, and research implications. Recommendations for future research were made, and study limitations discussed.

APPENDICES

APPENDIX A:

ADULT CONSENT FORM

APPENDIX B:

CASE CONCEPTUALIZATION TRAINING LECTURE QUESTIONNAIRE

APPENDIX C:

CASE CONCEPTUALIZATION TRAINING

DEMOGRAPHIC QUESTIONNAIRE

APPENDIX D:

INSTITUTIONAL REVIEW BOARD DOCUMENTATION

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