Studia Psychologiczne. t. 53 (2015), z. 2, s. 19-28 PL ISSN 0081-685X DOI: 10.2478/V1067-010-0129-5 Anna Słysz Adam Mickiewicz University of Poznan, Institute of

ANALYSIS OF BARBARA INGRAM’S CORE CLINICAL HYPOTHESIS CONCEPT FOR SUITABILITY IN PSYCHOLOGICAL ASSESSMENT

The aim of this article is to present and analyze the core clinical hypothesis concept (Ingram, showing that the use of this concept can increase quality of the case conceptualization. The

Keywords: case conceptualization, psychological assessment, heuristic, cognitive error

INTRODUCTION of imposing a structure upon a diagnosis (including case conceptualization). The structured There are many studies on case conceptualiza- formulation of a case may lead to: 1) identifying tion within particular schools, including the - complex causes of behavioral issues of a client by Nancy McWilliams (2012) and Virues-Ortega, Haynes, 2005); 2) reducing bias (2013). I believe that focusing on a single theoreti- cal approach carries a certain risk. For instance, in Virues-Ortega, Haynes, 2005). I would like to a or psychotherapist may overlook hypothesis concept. Also, I will provide examples schemas if these components are missing from showing that relying on this kind of concepts in psychological diagnostic may contribute to reducing thus an opportunity to minimize this problem by heuristics and cognitive errors in clinical evalua- also drawing from additional transtheoretical con- tions. Therefore, the article aims not as much at cepts in the case conceptualization area. One such proposal is the concept of core clinical hypothesis strategy as for the diagnostic quality. In literature, the discussions of cognitive heu- proposes a structured formulation of a case. Bearing ristics and errors in diagnosis focus mainly on the in mind this characteristic, I shall take as the start- description of their types (e.g. Croskerry, 2003; ing point the advantages, described in literature,

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The hypotheses the author has compiled refer include above all directions on nosologic diagnosis to the potential causes (biological, situational, and (e.g., a recommendation to refer to the DSM or ICD environmental) of the client’s problems and models (behavioral, cognitive, existential, and psychody- functional or causal diagnosis are far less common namic), which explain the root of these problems. (Morrow, Deidan, 1992). The concept proposed group. Each hypothesis has been labeled with the same alphanumeric symbol as used by the author of the concept. of some symptoms in nosological diagnosis, using I. Biological hypotheses (B) a list of core clinical hypotheses allows us to avoid B1: The problem has a biological cause – the overlooking various causal factors in explaining. client needs medical intervention to protect life Moreover, such a list of hypotheses enables the and prevent deterioration or needs psychosocial assistance in coping with illness, disability, or other the sense of applying an external reference point biological limitations. and reducing the subjective factor in interpretation. B2: There are medical interventions that should be considered. B3: Mind-body connections lead to treatments PRESENTATION OF THE CONCEPT for psychological problems that focus on the body OF CORE CLINICAL HYPOTHESIS and treatments for physical problems that focus on the mind. The B2 hypothesis is of least importance for case a core hypothesis as a set of ideas which facilitate conceptualization because it leads to a decision to structuring the data received from the client and make a medical intervention (e.g., medication or lead to a better understanding of his/her problems, surgery). It may then be the role of a psychothera- reach sound decisions, and choose the appropriate pist to draw the medical roots of the problem into intervention method. attention and recommend a visit to a physician. - Conversely, the hypotheses B1 and B3 may be cally, during case conceptualization, which of the included in psychological explanation (the mecha- nism of disorder development). The client may need diagnostic data and which can be used to explain psychological assistance in coping with a disease, the particular client’s problem. The hypotheses disability, or other biological limitations. comprise the aspects lying in the heart of various theoretical approaches (behavioral, cognitive, psy- II. Crisis, stressful situations, and transitions (CS) chodynamic, and existential), also including cultural CS1: The client’s symptoms constitute an emer- and environmental factors. This concept seems to gency – immediate action is necessary. be all the more interesting and useful because it CS2: The client’s symptoms result from iden- allows a psychologist or psychotherapist to perceive even these aspects of the client’s problem which traumatic . are not recognized as key in the framework of the CS3: The client is at a developmental transition therapist’s theoretical approach yet may turn out and deals with issues related to moving to the next to be important to explaining this problem. stage of life.

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C2: Limiting and outdated elements in the faulty help during bereavement or for a loss-related prob- cognitive map (e.g., maladaptive schemas, assump- lem. tions, rules, beliefs, and narratives) are causing the problem or preventing solutions. C3: The client demonstrates faulty information session, given the serious consequences of ne- processing (e.g., overgeneralization, all-or-nothing glecting to take appropriate action. For instance, - this concerns cases where the patient should be ible cognitive style. hospitalized or was the victim of abuse or vio- C4: The problem is triggered and/or mainteined lence. When considering the CS2 hypothesis, it is by dysfunctional self-talk. important to assess whether the client’s symptoms states that psychotherapists should avoid setting Interventions based on the CS3 hypothesis may in contracts such goals like attaining a perfect, prevent the transformation of a crisis (e.g., in ado- problem-free life. The client may wish to com- lescence) into a long-term disorder. With respect to pletely eliminate unpleasant , which are an inevitable part of life. With respect to the C2 loss can be external (e.g., due to a death, divorce, hypothesis, the author suggests that assisting the or natural disaster) or internal (the loss of certain patients in modifying their way of thinking does opportunities due to disease or age). not result from some arbitrary standard of proper thinking but rather from the fact that faulty cog- III. Behavioral and learning hypotheses (BL) nitive maps may limit, e.g., meeting the needs, BL1: A behavioral analysis of both problem be- achieving goals, and satisfaction with life (Ingram, haviors and desired behaviors should yield informa- tion about antecedents (triggers) and consequences (reinforcers) that will be helpful in constructing an skills and the maladjustment of the cognitive style intervention. to the client’s goals and the context in which he BL2: A conditional emotional response (e.g., anxiety, fear, anger, and depression) is at the root of excessive emotion, avoidant behaviors, or mala- dysfunctional self-talk causes painful feelings and daptive mechanisms for avoiding painful . maladaptive behavior. lack of competence in applying skills, abilities, and V. Existential and spiritual hypotheses (ES) knowledge to achieve goals. ES1: The client is struggling with existential A full behavioral analysis allows to detect the issues, including the fundamental philosophical antecedents and consequences of a given person’s search for the purpose and of life. behavior. It is assessed if the desirable behaviors ES2: The client is avoiding the freedom and are in the client’s behavioral repertoire. Also, many autonomy that come with adulthood and/or does not problems recognized as pathological can be formu- accept responsibility for present and past choices. ES3: The core of the problem and/or the re- sources needed for resolving the problem are found IV. Cognitive hypotheses (C) in the spiritual dimension of life, which may (or may not) include religion. “miseries of everyday life” and has unrealistic As regards expanding the ES1 hypothesis, expectations of what life should be like. existential problems may include the purpose and

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meaning of life, morality, death-related issues, and The P2 hypothesis refers to the assumptions of various theories that early childhood points out that, while considering this hypothesis, psychotherapists should remember that everyone - - tions. A therapist should refrain from taking the role in her commentary to the ES2 hypothesis, Ingram that one can precisely determine the developmen- tal phase when the disturbance took place based take one of several forms: maintaining childhood illusions, blaming others, or becoming dependent Wheras in the discussion of the P4 hypothesis, the on other people. When clients are ready to engage authors indicates problems which may ensue the in responsible behavior, they may need assistance in making decisions (e.g., which educational path to reactions to traumatic events. choose, which job, etc.), as well as in making and VII. Social, cultural, and environmental fac- it is important to apply the ES3 hypothesis when tors (SCE) the client is struggling with problems of religious SCE1: The problem must be understood in the nature, including the subject of the client’s repre- context of the entire . sentation of relation with God. SCE2: Knowledge of the cultural context is necessary to understand the problem and/or to create VI. Psychodynamic hypotheses (P) a treatment plan that shows sensitivity to the norms, P1: The problem is explained in terms of parts rules, and values of the client’s cultural group. and that need to be heard, under- SCE3: The problem is either caused or main- stood, and coordinated. P2: The problem is a reenactment of early child- hood experiences: feelings and needs from early role performance contributes to the client’s distress childhood are reactivated and pattersn from the and dysfunction. family of origin are repeated. SCE5: A social problem (e.g., poverty, dis- crimination, or social oppression) is a cause of to progress beyond the immature sense of self the problem; social problems can also exacerbate and conception of others that is normal for very young children. - P4: The symptoms or problems are explained advantages or advantages to the social role of in terms of unconscious dynamics; defense mecha- mental patient. nisms keep thoughts and emotions out of . environmental factors: solutions can involve leav- points out that the client’s problems may result ing the environment, obtaining material resources, from, among other things, the lack of awareness of or accepting what can’t be changed. Compared to all other groups of hypotheses subpersonalities, suppression of various subperson- - alities, or domination of one of them. An increased est, containing seven hypotheses. Regarding the awareness of individual subpersonalities and their SCE1 hypothesis, the author points out situations dynamics may contribute to solving the problem. in which the symptoms of an individual contribute

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to the maintenance or stabilization of family ho- theoretical orientation. Some components, such as meostasis, and an improvement in the client may the hypotheses on potential causes of disorders, result in the symptoms appearing in another family are similar in various theoretical approaches. For member. Therefore, in some cases it is useful to ap- instance, cognitive-behavioral, existential, and ply an intervention to the whole family. The SCE2 narrative trends in present the cli- hypothesis takes into account the client’s cultural ent’s problems as resulting from his or her faulty - cognitive structures related to life experiences ture. In her commentary to the SCE3 hypothesis, - hypotheses, the author of the concept provides the tor playing an important role in preventing mental examples of theories which a psychotherapist may health problems. Social isolation may be both the employ (such as Ellis’ rational emotive behavior cause and result of problems. Most interestingly, therapy in the discussion of cognitive hypotheses), the author writes in regard to the SCE4 hypothesis but she does not consider them to be the only op- that role models and mentors may be more helpful tions. It is a clear indication of the open nature of in this area than psychotherapists. Whereas one this case conceptualization concept. Moreover, of the implications of teh SCE hypothesis is that it is noticeable that among the proposed theories social activism may be a more appropriate form suitable for the development of the P1 hypothesis (explaining the problem in terms of subperson- the author supposes that the client may simulate symptoms of a for material gain - tional Analysis but also Gestalt Therapy, whics is part of the humanist current in psychotherapy. This generally formulated. Thus, they may only guide group of hypotheses is thus not identical with the psychological explanations, and each of them could psychodynamic paradigm. Similarly, one should be supplemented by at least several detailed hypoth- not identify the respective groups of hypotheses - (behavioral, cognitive, and existential) with the sal list, however, since more detailed hypotheses respective theoretical paradigms: behavioral, cogni- tive, and existential. the examined person. Only lists of hypotheses re- - maining on a more general level can have practical tive vs. eclectic) is not totally clear. The author conceptualization concept belongs to integrative theories and is based on the metatheory of problem was to provide the clinicians with a tool to sup- port the multitheoretical diagnosis of the client all, by the focus on theory and not on therapeutic and integration conceptualization of a case. Even techniques, and by combining the components of though other authors (Lampropoulos, 2009; Stricker, two or more theories. It should be added, however, 2009) stress that Ingram’s (2009) concept is meant that the concept remains at a very general level. for therapists favoring the integration approach to Whereas the author presents the rules for and ex- psychotherapy, the author herself also points out the amples of combining selected components, they opportunities of applying her concept within a single do not combine into a comprehensive, integrated explanatory concept. It is rather fragmentary and core clinical hypotheses can be isolated within each leaves much freedom to the psychotherapist. Two

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general ways of using the core clinical hypothesis value to certain causal factors, depending on the concept can be distinguished: 1) application of theoretical trend in which they work, and to seek hypotheses matching a single theoretical approach those factors in their clients when other, overlooked and formulation of a case conceptualization based on this approach, and 2) formulation of a case conceptualization based on a chosen existing inte- and their possible causes requires diagnosticians grative concept or one’s own synthesis of elements to take into consideration all the psychological of various theories.1 In the case of the former, it categories it contains. Even though, in a way, the is not possible to make full use of the core clini- single theoretical approach contains all elements broad and allows a multiaspect approach to the comprised by these hypotheses. The latter way client’s problem. It is particularly important since enables taking a larger number of core hypotheses naming problems and determining their causes into consideration. The examples from her own enables setting a goal for intervention. To conclude the presentation of Ingram’s core she adopted this very approach. Using a list of core clinical hypotheses can of case conceptualization. Claudia is a married serve two main functions: it prevents a premature - closure of gathering information about the client dren, living with her husband and her 90-year-old and leads to posing appropriate clinical questions mother who requires support. It is known that the client described her loss of control of her emotions noticeable that clinicians tend to attach excessive and excessive severity towards her mother. Hy- potheses were made to explain the client’s problem 1 When a combination of elements from various theoretical in dealing with the sense of guilt, frustration, and approaches results in a coherent approach, this integration method can be called theoretical integration (Evans, Gilbert, 2005). Table 1. Case conceptualization (Claudia). Core hypotheses Hypotheses according to the analysed case When details were elicited, it became clear that there is no elder abuse or risk of abuse. The woman feels guilty over crying and raising her voice. She describes her mother as uncoopera- CS2 – Sitiational stressors external stress (situational), and most women in her situation would feel angry and frustrated. As Claudia’s mother condition deteriorates, client’s stress level rises. of a „good daughter”. The woman belives that any negative thought negates the assistance SCE2 – Cultural context she provides for her mother. She has internalised the following conviction: „a good daughter should be happy to help her mother” (the cultural message). She belives that it unacceptable in her culture to place her mother in an assisted-living facility, even though she and her siblings As long as the woman belives that she is a bad daughter if she show anger, she will lack the C2 – Faulty Cognitive Map ability to cope successfully with her normal emotional responses. The more the woman tries to suppress negative thoughts, the more likely is that they erupt in screaming. In this example of conceptualization, three (I. Crisis, stressful situations, and transitions; VI. core hypotheses were taken into account. Each of Social, cultural, and environmental hypotheses; III. Cognitive hypotheses). It may be said that this

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is a broad approach to the problem reported by the The complexity indicator of case conceptual- client and not limited to a single key aspect. I shall ization is the integration of several aspects of the refer to this example in the latter part of the article. problem or a person’s functioning. More complex conceptualizations integrate a number of aspects of the problem and the person’s functioning, whereas CONCEPT OF CORE CLINICAL low complexity means the discussion of just a single HYPOTHESES AND THE QUALITY OF CASE CONCEPTUALIZATION many examples of integration of several elements (aspects of a person’s functioning). It is, however, The core clinical hypothesis concept can be use- the conceptualization stage, which can be directed ful in diagnosis due to the opportunity to improve within the discussed concept of conceptualization the quality of case conceptualization by using it. only to some extent. Even when the conceptualiza- In my analysis of this question, I will make use tion of a certain case contains the same components of the following criteria of case conceptualization as another similar case, the relations between these quality: comprehensiveness, complexity, and co- ready guidelines on how to connect various ele- ments of case conceptualization with one another. The coherence of case conceptualization is the The comprehensiveness of interpretation is de- internal consistency of assertions about an individual. Similarly to the complexity of case conceptualization, in the formulation of a given case. For the quality using the core clinical hypothesis concept does not assessment of case conceptualization, it is not only directly translate into greater coherence. important if a certain category is present at all but also Out of the three above criteria of case concep- how thoroughly it has been developed. A good con- tualization quality, only the comprehensiveness to support the intervention (Sturmey, 2009). Using employing the core clinical hypothesis concept. It is related to how the cognitive processes function. contribute to improve the completeness of interpreta- For instance, the availability of the list of hypotheses tion. Even when /psychotherapists work and the diagnostic categories it contains enables within a single paradigm, using a list of hypotheses to increase the range of categories available in - memory and to avoid potential errors associated ries may allow them to see more of the latter. A few with using heuristics in diagnosis. examples of the categories which are components of individual core hypotheses include: developmental transition, social support, stress, cognitive schema, CONCEPT OF CORE CLINICAL autonomy, defensive mechanisms, family system, HYPOTHESIS AND THE social roles. These categories are derived from various APPLICATION OF HEURISTICS IN psychological perspectives, such as developmental DIAGNOSIS psychology, , , and others. Taking them into account may improve the Another criterion which can be recognized as comprehensiveness of interpretation. Still, it depends indicative of higher case conceptualization quality on the psychologist/therapist in how much detail each is the minimization of the application of classic category will be described. heuristics in the diagnostic process. When diagnosti-

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cians have much information available about their clients, they tend to use heuristics (Virues–Ortega, 2005). The application of this heuristic manifests Haynes, 2005). For one thing, they may accentu- itself in a situation where a physician estimates the likelihood of a disease by evaluating how much a given case is similar to a category or prototype or those similar to the information gathered from (Elstein, Schwarz, 2005). other clients (availability heuristic). I discuss be- It is a mistake to unthinkingly include a person in a given category (based on the characteristics concept for the minimization of classical heuristics they have in common) ignoring the fact that some in diagnosis. other characteristic may exclude the membership 1) Availability heuristic in that category or that there are other categories Thinking subordinated to the availability heu- with which the person shares common characteris- of category assignment as relevant may lead to developing evaluation criteria based on the cur- ignoring some of the information (Zdrahal–Ur- banek, 2004). A systematic analysis of possible memory. While it is easy to grasp the availability hypothesis concept may prevent one- or two-cause - explanations and encourage a diagnostician to take cult during a functional or causal diagnosis, when into consideration many causes of a problem or a psychologist refers to a similar case known to disorder. Even though the list of hypotheses is not him or her and to the circumstances conditioning enough to rule out careless inclusion of a person the given patient’s way of functioning. The same to a given category, it will make the diagnostician pertains to case conceptualization. consider other categories, with which the client Using an inventory of various possible causes shares common characteristics. Thus, the risk that may prevent one fr om stopping at a single cause, most available in one’s memory. Using a list of mistake is decreased. core clinical hypotheses, such as that proposed 3) Anchoring heuristic Anchoring heuristic is the tendency to regard the alternative hypotheses in working memory, and thus limits the application of availability heuristic in diagnosis. of further information; it may overlap with the 2) Representativeness heuristic In general terms, representativeness is the adequacy between the case and the category or aspects may serve as and “anchor”, with all modi- - nosis, representativeness heuristic involves the assessment of the extent to which, for an instance, a certain behavior corresponds to a personal- ity type or a certain symptom to a (physical or - mental) disorder entity. Similarity is both the ing a prop in the form of a set of possible causes, component of representativeness and the basis for categorization. Moreover, the coherence of prompt a diagnostician to research further and not information about the examined person increases

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CONCEPT OF CORE CLINICAL ate a treatment plan that shows sensitivity to the HYPOTHESIS AND COGNITIVE norms, rules, and values of the client’s cultural ERRORS IN DIAGNOSIS group) and SCE5 (Social problems, e.g., poverty, discrimination, or social oppression, are causes Apart from heuristics as rules which may lead to errors in thinking, the literature knows many the question of the acculturaton of an individual cognitive errors which may lead to making faulty and his or her family members is an important diagnostic decisions. They are by no means spe- element to be considered during diagnosis. Apart from isolating the core hypotheses SCE2 and errors may also increase the case conceptualiza- SCE5, the author points out yet another aspect tion quality. I discuss several examples of such of cultural context to be considered in diagnosis errors below. – psychotherapists should understand how their 1) Context minimization error own native culture shapes their therapeutic rela- The context minimization error involves not taking into consideration the external (environ- The sample analysis of the case of Claudia, ad- mental, cultural) factors when interpreting the duced in the former part of this article, shows that the list of core clinical hypotheses may facilitate of the fundamental attribution error (Stemplewska– avoiding the context minimization error. In the - may lead for example to evaluating and blaming potheses related to external factors: CS2 (situational patients for their mental disorders (disposition- stressors) and SCE3 (cultural context). Ingram’s al causes) and disregarding situational factors, which can also be responsible (Croskerry, 2003). conceptualization taking context into consideration, A special case of this error is the omission of the including cultural context. cultural context. the tendency among clinicians to make this error during case conceptualization, and thus to over- views or beliefs with a simultaneous tendency to ignore or dismiss the data which contradict The author states that the majority of the clients them (Holtz, 2009). It leads to looking for the who report to a psychotherapist have both dispo- data which support the diagnosis rather than the sitional and situational problems. The core clinical information which contradicts it and may dis- hypotheses which take into consideration a broad prove it, even though the latter are often more range of external factors include group VI. Social, cultural, and environmental factors (SCE) and the instance, a psychologist hypothesizes that the CS2 hypothesis (The client’s symptoms result from examined person has a schizoid personality dis- a past traumatic experience). the symptoms of this disorder while disregarding The core clinical hypotheses, which are the facts which might exclude this hypothesis. In basis for case conceptualization, also include the such a situation, even a faulty hypothesis can cultural context. Two of the hypotheses suggested SCE2 (Knowledge of the cultural context is nec- the hypotheses in the spotlight of the theoreti- essary to understand the problem and/or to cre- cal approach in which the psychologist/psycho-

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therapist works may, at least partially, prevent CONCLUSION As shown by the results of research (Eels et al., clinical hypothesis concept proposed by Ingram 2005), using more than one theoretical approach minimizes the fundamental attribution error in case models, psychodynamic, cognitive, behavioral, conceptualization. A diagnosis in the framework as well as existential. In her handbook, the author of a single theoretical approach with the use of herself indicates the tendency among therapists the core clinical hypothesis concept may have - prises the main thoughts of all theoretical currents (psychodynamic, cognitive–behavioral, humanistic, to believe that wa know more than we actually and psychology), the list is not exhaustive and can be developed further. a tendency to act based on incomplete information The merit-based analysis of the question makes or intuition alone. Often it is subjective opinions it possible to recognize the core clinical hypothesis rather than carefully gathered evidence which elicit tool for understanding the client in various perspec- the anchoring and availability heuristics. tives. What is still required, however, are empirical The prospect of plurality and diversity of hy- applicatio of the discussed concept on the quality of hypothesis concept may weaken the propensity for employed and to what extent it serves to minimize heuristics and cognitive errors in case conceptual- greater when one falls for such errors like hypothesis ization is largely dependent on the attitude of the psychologists and psychotherapists themselves. the narrow construal of a diagnostic problem (Smith, It is my opinion that this type of concepts is of Dumont, 2002), minimizing them — through bas- particular use for students and young practitioners, ing on an inventory of hypotheses — may in turn who do not have much professional experience and need a clear structrure of case conceptualization.

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