My best example of the relationship between theory and practice comes from my own work as a clinical social worker doing psychotherapy. In this case I’ll illustrate the process of changing theories in the middle of working with a client.
I had been working with a group of colleagues to master Dr. Jeffrey Young’s Schema Therapy. After attending workshops and reading Dr. Young’s books, we decided that it made sense to pay for group case consultation with Dr. Young over the telephone. We would cluster around a speakerphone and take turns presenting cases. This allowed us not only to learn from all the cases presented, but also to share the expense. Over time our small group of social workers had found Schema Therapy to be extremely useful with many of our clients.
Schema therapy is an integrative therapy developed to work with people diagnosed with personality disorder, chronic depression, or other difficulties. According to Dr. Young’s website, it “integrates cognitive therapy, behavior therapy, object relations, and gestalt therapy” into a systematic approach. One of the core assumptions of schema therapy is that people develop maladaptive beliefs early in life based upon childhood experiences where needs are not met; these beliefs, combined with related styles of coping, are responsible for the behaviors, attitudes, and feelings that are associated with the current problems that people experience. Over time, Dr. Young modified schema therapy to incorporate the concept of self-parts in order to better explain the behavioral shift that you can see in people diagnosed with some of the more therapeutically challenging personality disorder diagnoses, specifically borderline personality disorder and narcissistic personality disorder. Dr. Young hypothesized that people developed parts of self that became organized modes of functioning (“Schema Modes“) such as Angry Child, Vulnerable Child, Punitive or Critical Parent, or Detached Protector.
On this particular occasion, Dr. Young had been working with me to apply the model with Madeline*, a young woman who had grown up with a great deal of physical and emotional abuse. Based on her psychosocial history, current situation and diagnoses (Borderline Personality Disorder and Avoidant Personality Disorder) Dr. Young and I felt she would be appropriate for Schema Therapy; Madeline had already responded well to Schema Therapy in some of our prior work. Madeline was now describing a very critical, self-punitive state (mode) that she would shift into that was quite painful and that could trigger self-harm. Dr. Young coached me on applying his model in working with Madeline on this mode—I employed various techniques to reject or expunge the punitive part, a strategy that had worked very well with other clients, all of whom were able to become less self-critical. However, as I started to apply schema therapy to this issue, something unexpected happened. Madeline began to dissociate more. This was evident because dissociation was one of a group of behaviors that Madeline and I were monitoring together. It became clear that the treatment model I was using with Madeline (that had been helpful for her up until this point) was now making her worse: Madeline reported experiencing loss of time—amnesia for significant periods of time (e.g., several hours)—a symptom that she had not reported before.
Madeline’s reaction didn’t fit what Schema Therapy had predicted. After reviewing the case with Dr. Young and my consultation group, it appeared as though I had implemented the approach correctly; it was just the Schema Therapy approach didn’t seem to be helpful for Madeline anymore. As a result, because dissociation was now emerging as a significant factor, I decided to bring Madeline’s situation to the attention of a consultant who was helping me to strengthen my skills in working with people with dissociative disorders. This new consultation proved fruitful: I began to conceptualize Madeline’s situation differently, utilizing a different theoretical approach, and began to achieve better outcomes.
So what does all of this illustrate about theories in social work practice?
I’ve outlined a process in the accompanying diagram that reflects how I see theory integrating with practice. As occurred with Madeline, I see this as an ongoing process as I work with client, not just a decision I make in the beginning of treatment. Each time I intervene I am making a prediction, and the result informs me about next steps. This particular diagram highlights the role of practice theory. However, to be fair, the green oval at the top also brings theory into play. For example, as I take a developmental history from my clients I am keeping various human development theories in mind as I listen to their lives. If a child undergoes significant medical procedures at age 2, it will affect her differently than if she goes through the same procedures at age 5.
The above example from Madeline’s treatment illustrates a few core principles:
- First and foremost, theories are tools. They are concepts, principles, and predictions. They are not TRUTH engraved in stone. They are living, breathing ideas that evolve over time in response to research and to clinical observation. Dr. Young, for his part, was fascinated by how this situation unfolded. We talked about how it seemed that his theoretical approach appeared to break down when there was a significant amount of dissociation. I don’t know what he’s done with that knowledge in his own theory development since the time I had the privilege to work with him. However he has, on occasion, sent people to consult with me when significant dissociation came up in their cases, so I know it’s something he’s monitoring. As I look back on what happened with Madeline, I have a great deal of respect for his curiosity and openness throughout the whole process.
- No theory fits every situation. Good theories help to guide our practice and point us in the direction of what is deemed to be important, as well as how to intervene in it. But the danger of theories is that they also can restrict our attention. Years ago, I recall watching a skilled master therapist present a case at a conference to demonstrate how she came to modify her own theory in order to better deal with a challenging case situation. While she ultimately came up with something new, it was painful to watch the tape of her persisting with the client over and over with her old approach when it clearly wasn’t working. I honestly think that her theory got in the way of her seeing what was happening far longer than was necessary. Listening and learning from our clients about who they are and what their lives are like is essential. We need to practice mindfully, that is, to see and hear with fresh eyes. While we may immediately hear how something they describe might fit with a theory, we must be careful that our theories don’t become blinders. It’s always good to ask what’s going on that doesn’t fit with my theory?
- Nothing substitutes for working closely with clients to systematically monitor (gather data about) their progress. Over the years I’ve found that when we did this together we were able to determine together what was working and what wasn’t working much sooner than if we had left it to a general perception about how they were doing. It also ensures that the client and I are using the same information to assess progress.
I have colleagues who will argue that we have little to no evidence that our theories of change work the way we our theories say they do. I’m very comfortable acknowledging that this might be true, although it also could be a consequence of our current limitations in conducting practice research. The reality is that a theoretical prediction (If we do X, the person will improve) might be accurate even though theoretical explanation (the mechanism by which the person got better) might not be upheld by research. To be more concrete about this, we can use aspirin to bring down a fever (and find that it does, indeed, do that), without ever knowing how it actually reduces the fever. If our theory about why and when to use aspirin guides us in making decisions that bring about the desired outcome, it may not matter much to the client that the mechanism of change isn’t what we hypothesize.
The real power of theories is that they help us organize our thinking regarding what to work on with a client and how to do it—in this way they can bring order to what could become a haphazard process, especially with a client who has many different concerns, presenting with a different crisis from session to session. But we need to hold onto our theories loosely and not treat them as rigid doctrine; a theory is only as good as its ability to help us help our clients. When it stops doing that it’s time to change.
*Not the client’s real name, but the name that she chose for me to use when I write or present about our work.
Dr. Nancy Smyth (@njsmyth) is Professor and Dean of School of Social Work at University at Buffalo and Associate Research Scientist at Research Institute on Addictions. She is also a member of @SWSCmedia Expert Panel.
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