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Chapter 13: Case Conceptualization

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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)

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Relational or Social Strengths and Resources

Social support network that helps client in various ways.

Physical

Emotional

Community

Spiritual

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Satir’s Communication Stances

An approach for assessing communication.

Based on five communication stances:

Placating

Blaming

Superreasonable

Irrelevant

Congruent

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Satir’s Communication Stances

Congruent

Model for healthy communication.

Other four are survival stances.

Each stance recognizes different elements of self, other, and context.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Satir’s Communication Stances

Style	Recognizes	Ignores
Congruent	Self, other, context	None
Placator	Other, context	Self
Blamer	Self, context	Other
Superreasonable	Context	Self, other
Irrelevant	None	Self, other, context

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Narratives and Social Discourses

Outline broader contexts in which client’s problems occur.

Dominant discourses

Identity narratives

Local and preferred discourses

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

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.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Case Conceptualization, Diversity, & Sameness

General problem with assessment and case conceptualization.

No objective standards upon which a person can be measured.

Role of culture.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart