Home
Previous Chapter
Hypothesis Part I Overview
Next: Part III Clinical Matrix
In This Section:
Spilling out the puzzle pieces and looking for an explanation
Developing a Hypothesis II-- A Practical Guide
Key Pieces of Information
The first step in building a hypothesis is to assemble a rich collection of data. It will help you form a tentative understanding of what is wrong, where the patient should be, and what has been preventing the patient from getting there. The patient's overt, conscious ideas must be heard and respected, but are not necessarily the only or even the most important ones. There will very likely be a parallel, unconscious agenda which must be understood to untangle the knot of entrenched dysfunctional patterns of reaction. Remember that you are looking for one overarching, organizing issue to tie everything into a cohesive picture. If you don't find a full hypothesis, then try partial explanations. Here is a list of helpful data points:
1. Chief Complaint: What the patient considers to be the trouble, and how he or she would like things to be better. Note that it is critical to obtain a crystal clear picture from the patient. If he or she was unclear, there is resistance that needs to be cleared up.
2. The Patient's Goal: The energy to drive the therapy will come from the differential between where the patient starts and the desired goal, so the bigger the difference, the greater motivation and drive there will be. The patient's expressed goal is filtered by his or her ideas of what is acceptable and proper, and may only express the deeper agenda in some indirect way.
3. Resistance: What does the patient think he or she is working against? Why hasn't the goal been reached already? (This may or may not be the same as what you identify as unconscious resistance to the therapeutic process.)
4. Clues: In addition to the basic outline, patients reveal a great deal between the lines. Here are some questions to ask yourself:
At what points has the patient said things that surprised you?
Were there any things skirted, avoided or left out?
In what other ways does the patient's personality, behavior or functioning seem to deviate from what you might expect?
When did you see the strongest expressions of emotion from the patient?
What were the strongest impressions the patient made on you?
5. The Patient's Theory: At some point it is very useful to ask the patient for his or her private theory as to why things are the way they are. The answer you get will often be quite spontaneous and will almost always be telling you something important.
6. Life Story: What are the broad outlines and curious highlights of the patient's life? How might these facts point to patterns repeated in the patient's contemporary life?
First Organize the Data
Your right hemisphere will be more useful in organizing the data and extracting meaning from it. Listening to subterranean data is more like understanding poetry than prose. When two things feel related, they probably are. When the patient tells you something, the question is not whether, but how it is true.
In organizing the data, I personally picture a Christmas tree with ornaments strung from the top down the sides. At the top are the earliest, prototypical experiences or feelings. Each string is made up of things that seem to belong together. For example, a trauma patient was repeatedly cornered by her abuser at age 5. As an adult, when she took a job, she felt terribly confined by the work rules and had strong impulses to escape. Pointing out a connection between her contemporary reaction and her early experience was very helpful to her gaining awareness of a lifetime of trying to escape outside control. The original confinement was physical, but metaphorically the job constraints felt the same. This organization is very loose, and connections may not hold up to the test of time. On the other hand, these metaphorical links exactly parallel the associative processes that are native to the brain.
Reverse Engineering
Now it is time for the creative process of trying to imagine the one main issue that could explain all that you have learned. Write all the data on a blackboard or paper and ask, "What were the stresses or problems that resulted in the solution that you see in front of you." Take each piece of information and ask, "Why?" If you don't have a full hypothesis, or even the beginning of one, you will at least have many new questions and hopefully some partial ideas that explain some of the puzzle. The questions will help develop the partial answers you have, and may lead closer to a unified hypothesis that explains the whole picture.
Sometimes a hypothesis comes together easily. Other times, it takes many months for all the pieces to make sense. And in yet other instances, there are important elements that only appear as the work becomes far advanced. Part of the job is keeping questions open, tolerating your ignorance and working with a partial or provisional hypothesis. In all cases, your desire to find the truth will push you to formulate new questions. Maintain a list, mental or written, of unanswered questions. It is surprising how reliably the answers eventually come.
Obviously this is a very challenging task, and one that is never perfected. Experience helps more than anything, and supervision, reading and collaboration with other colleagues are all very helpful.
Part III: A Clinical Matrix