1. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Chapter 13: Case Conceptualization

2. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Mapping the Territory (Step 1) Master the art of viewing. Necessary to develop a good map. Refers to knowing where to focus your attention while you are listening. A skill that is continually developed and refined throughout one’s career. Case conceptualization Technical term for the therapeutic art of viewing. Sometimes called assessment. Enables therapists to generate new perspectives, which enable them to be helpful to clients.

3. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Overview of Case Conceptualization Components of a systemic case conceptualization: Introduction to client Presenting concern Background information Client/family strengths and diversity Family structure Interactional pattern Intergenerational and attachment patterns Solution-based assessment Postmodern and cultural discourse conceptualization Client perspectives

4. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Introduction to Client Identifying who the client is. Individual Couple Family Identifying most salient demographic features that relate to treatment: Age Ethnicity Gender Sexual orientation/HIV status Current occupation (work status/grade in school)

5. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Presenting Concern How all parties involved are defining the problem. Collaborative therapy Each person involved has a different definition of the problem. Allows therapist to remain adaptable and creative. Honor each person’s perspective and refer to it throughout treatment. Should include: Reason each client states he/she is in counseling or why referred. Information from referring agent and their description of problem. A brief history of the problem and family. Descriptions of attempted solutions and outcomes. Any other relevant problem related information.

6. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Background Information Traditionally included is: History of trauma and abuse Substance use and abuse Precipitating events Related historical background Recommended that this information be written in a positive and hopeful light.

7. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Strengths and Diversity Resources Should be the first thing assessed. Can include strengths at several levels: Personal/individual strengths Relational/social strengths and resources Spiritual resources

8. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Personal or Individual Strengths Abilities Consider past, present, and future. Can increase client’s sense of hope and confidence to address the issue at hand. May provide creative problem solving ideas. Personal qualities What brings client’s to therapy is usually flip side of a strength. Ex. Someone who worries too much is likely a diligent and productive worker.

9. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Relational or Social Strengths and Resources Social support network that helps client in various ways. Physical Emotional Community Spiritual

10. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Diversity Resources and Limitations Common resources due to diversity: Strong support network Sense of community and connection, purpose and direction Resources for problem-solving Beliefs that provide comfort Access to social services Common limitations due to diversity: Experiences of harassment/discrimination Isolation/difficulty meeting others Difficulty finding opportunity and accessing services Difficulty communicating with institutions Lack of resources

11. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Family Structure Can be used with individuals, couples or families. Includes: Family life cycle stage Boundaries Triangles/coalitions Hierarchy between parents and children Satir’s communication stances Gottman’s divorce indicators

12. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Family Life Cycle Family life cycle stage Assessment of family structure often begins with this. The stages include: Leaving home — the single adult Committed relationship Families with young children Families with adolescent children Divorce Blended families Launching children Family in later life

13. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Boundaries Boundaries regulate closeness and distance. Most commonly associated with structural family therapy. The rules for negotiating interpersonal closeness and distance. Strongly influenced by culture. Can be clear, diffuse, or rigid.

14. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Boundaries Clear boundaries and cultural variance Negotiation of a healthy balance between closeness and separation. Collectivist cultures: More closeness. Individualistic cultures: Value greater independence. Diffuse boundaries and enmeshed relationships When couples or families overvalue togetherness at the expense of respecting each other’s individuality. Rigid boundaries When couples or families privilege independence over togetherness.

15. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Triangles and Coalitions Tension between two people is resolved by drawing in a third person to stabilize the original dyad. May include inanimate objects or processes as “third” Ex.: Drinking, drug use, work Assessed in several ways: Client overtly describes another as playing role in their tension. Description of a confidant. Finding an unmet need in a third party. When therapy is “stuck,” there is often a triangle at work.

16. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Hierarchy Between Child and Parent Is hierarchy developmentally and culturally appropriate? Assessing hierarchy tell therapists where and how to intervene. Excessive Insufficient Effective Inconsistent Can be helpful to consider the balance of roles within the parental subsystem. Business roles Personal roles

17. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Complementary Patterns Complementary patterns Each person takes on opposite or complementary ranging from functional to problematic. Ex.: Pursuer/distancer, emotional/logical Most couples readily identify complementary roles in their complaints about the relationship.

18. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Satir’s Communication Stances An approach for assessing communication. Based on five communication stances: Placating Blaming Superreasonable Irrelevant Congruent

19. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Satir’s Communication Stances Congruent Model for healthy communication. Other four are survival stances. Each stance recognizes different elements of self, other, and context.

20. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Satir’s Communication Stances I StyleRecognizesIgnores CongruentSelf, other, contextNone PlacatorOther, contextSelf BlamerSelf, contextOther SuperreasonableContextSelf, other IrrelevantNoneSelf, other, context

21. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Gottman’s Divorce Indicators John Gottman Over 30 years research on couples and communication. Can predict divorce with 97.5% accuracy by assessing 5 variables (Four Horsemen and repair attempts). The Four Horseman of the Apocalypse: Criticism Defensiveness Contempt Stonewalling

22. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Gottman’s Divorce Indicators Presence of “Four Horsemen” not only indicator; frequency of these differs in happy couples. 5:1 ratio Interactions to assess for frequency include: Failed repair attempts Rejection of influence Harsh start-up

23. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Problem Interaction Patterns One of hallmarks of family therapy. Therapist traces reciprocal relation patterns. Ex.: How person A responds to person B and vice versa. Three phases: Start of tension Conflict/symptom escalation Return to normal/homeostasis

24. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Systemic Hypothesis Developed after assessing family structure and interaction patterns. Working hypothesis about problem. Role symptom plays in maintaining homeostasis. Strategies for developing hypotheses: Client language and metaphors Positive connotation Love and power

25. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Intergenerational Patterns Easiest when using a genogram. Patterns often included in genograms: Family strengths and resources Substance and alcohol abuse and dependence Sexual, physical, and emotional abuse Personal qualities and/or family roles; complementary roles (e.g., black sheep, rebellious one, overachiever/underachiever, etc.) Physical and mental health issues (e.g., diabetes, cancer, depression, psychosis, etc.) Historical incidents of the presenting problem, either with the same people or how other generations and family members have managed this problem

26. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Attachment Patterns Often central in psychodynamic and EFT approaches. Sue Johnson indicates four categories of attachment: Secure Anxious and hyperactivated Avoidance Combination anxious and avoidant

27. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Solution-Based Assessment Address previous solutions that did not work. Address previous solutions that did work. Exceptions and unique outcomes. Difficult because most clients are unaware of when the problem was not a problem. Miracle question

28. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Narratives and Social Discourses Outline broader contexts in which client’s problems occur. Dominant discourses Identity narratives Local and preferred discourses

29. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Client Perspectives Therapists should reflect on areas of client agreement and disagreement with a case conceptualization. Particularly important when client differs from therapist in: Age Cultural background Socioeconomic status Gender Sexual orientation Often more difficult when client is very similar to therapist.

30. Mastering Competencies in Family Therapy (2 nd ed.) Diane R. Gehart ©2014. Brooks/Cole, Cengage Learning. All rights reserved. For classroom use only. Case Conceptualization, Diversity, & Sameness General problem with assessment and case conceptualization. No objective standards upon which a person can be measured. Role of culture.