Clinical Case Formulations Matching the Integrative Treatment Plan to the Client BARBARA LICHNER INGRAM @WILEY JOHN WILEY & SONS, INC. This book is printed on acid-free paper. @ Copyright © 2006 by John Wiley & Sons, Inc. All rights reserved. Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1 976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. 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[DNLM: 1. Psychotherapy-methods. 2. Mental Disorders-therapy. 3. Models, Psychological. 4. Psychological Theory. WM 420 154c 2006] RC459. I54 2006 6 1 6. 89'14-dc22 Printed in the United States of America. 10 9 8 7 6 5 4 2005029941 REVIZE 2010 To the memory of my parents, Rose and Sydney Lichner, to Tony, Sami, and Paul, and to all my students, past and future. Contents Tables Preface Case Formulation Skills Can Be Systematically Taught Treatment Quality Is Enhanced by Integrating Different Approaches Empirical Validation Can Come from Clinical, Single-Case Methodology Not Just from Random Clinical Trials We Need to Address the Needs of Culturally and Religiously Diverse Clients We Need a System to Communicate More Effectively with Case Managers in Managed Care and Insurance Companies Acknowledgments Part I Getting Started 1 A Framework for Case Formulations How Am I Going to Know What to Do? Core Clinical Hypotheses The Problem-Oriented Method Tasks and Processes of Case Formulation The Learning Process Suggested Readings 2 Gathering Data Data-Gathering Tasks Intake Processes Exploration of the Cognitive Domain The Clinician as Objective Observer Client History xv xix XXI xxii XXll xxiii xxiii xxv 1 3 4 5 10 13 23 25 26 26 32 45 48 50 vii viii Contents Activities for Data Gathering Homework Assignments as a Source of Data Suggested Readings Part II Twenty-Eight Core Clinical Hypotheses How to Approach the Hypotheses 3 Biological Hypotheses Key Ideas for B 1 Biological Cause When Is B 1 a Good Match for Your Client? Treatment Planning for B 1 Biological Cause Integration of Hypotheses with B 1 Biological Cause Key Ideas for B2 Medical Interventions When Is B2 a Good Match for Your Client? Treatment Planning for B2 Medical Interventions Integration of Hypotheses with B2 Medical Interventions Key Ideas for B3 Mind-Body Connections When Is B3 a Good Match for your Client? Treatment Planning for B3 Mind-Body Connections Integration of Hypotheses with B3 Mind-Body Connections Suggested Readings 4 Crisis, Stressful Situations, and Transitions Key Ideas for CS 1 Emergency When Is CS 1 a Good Match for Your Client? Treatment Planning for CS 1 Emergency Integration of Hypotheses with CS 1 Emergency Key Ideas for CS2 Situational Stressors When Is CS2 a Good Match for Your Client? Treatment Planning for CS2 Situational Stressors Integration of Hypotheses with CS2 Situational Stressors Key Ideas for CS3 Developmental Transition When Is CS3 a Good Match for Your Client? Treatment Planning for CS3 Developmental Transition Integration of Hypotheses with CS3 Developmental Transition Key Ideas for CS4 Loss and Bereavement When Is CS4 a Good Match for Your Client? Treatment Planning for CS4 Loss and Bereavement 55 57 59 61 62 65 67 69 72 75 77 80 83 87 88 90 94 99 100 103 104 105 107 1 10 1 1 1 1 17 1 19 1 26 1 28 1 34 1 36 137 138 146 147 Contents ix Integration of Hypotheses with CS4 Loss and Bereavement 152 Suggested Readings 1 54 5 Behavioral and Learning Models 157 Key Ideas for BL1 Antecedents and Consequences 160 When Is BL1 a Good Match for Your Client? 166 Treatment Planning for BL1 Antecedents and Consequences 167 Integration of Hypotheses with BL1 Antecedents and Consequences 170 Key Ideas for BL2 Conditioned Emotional Response 172 When Is BL2 a Good Match for Your Client? 173 Treatment Planning for BL2 Conditioned Emotional Response 175 Integration of Hypotheses with BL2 Conditioned Emotional Response 178 Key Ideas for BL3 Skill Deficits or Lack of Competence 179 When Is BL3 a Good Match for Your Client? 1 8 1 Treatment Planning for BL3 Skill Deficits or Lack of Competence 1 8 1 Integration of Hypotheses with BL3 Skill Deficits or Lack of Competence 1 87 Suggested Readings 1 88 6 Cognitive Models 191 Key Ideas for C 1 Utopian Expectations 1 92 When Is CIa Good Match for Your Client? 1 93 Treatment Planning for C1 Utopian Expectations 193 Integration of Hypotheses with C 1 Utopian Expectations 194 Key Ideas for C2 Faulty Cognitive Map 1 95 When Is C2 a Good Match for Your Client? 203 Treatment Planning for C2 Faulty Cognitive Map 204 Integration of Hypotheses with C2 Faulty Cognitive Map 2 1 1 Key Ideas for C3 Faulty Information Processing 213 When Is C3 a Good Match for Your Client? 217 Treatment Planning for C3 Faulty Information Processing 2 1 8 Integration of Hypotheses with C 3 Faulty Information Processing 220 Key Ideas for C4 Dysfunctional Self-Talk 222 When Is C4 a Good Match for Your Client? 222 Treatment Planning for C4 Dysfunctional Self-Talk 222 Integration of Hypotheses with C4 Dysfunctional Self-Talk 226 Suggested Readings 226 x Contents 7 Existential and Spiritual Models Key Ideas for ESIExistential Issues When Is ES 1 a Good Match for Your Client? Treatment Planning for ES 1 Existential Issues Integration of Hypotheses with ES 1 Existential Issues Key Ideas for ES2 Avoiding Freedom and Responsibility When Is ES2 a Good Match for Your Client? Treatment Planning for ES2 Avoiding Freedom and Responsibility Integration of Hypotheses with ES2 Avoiding Freedom and Responsibility Key Ideas for ES3 Spiritual Dimension When Is ES3 a Good Match for Your Client? Treatment Planning for ES3 Spiritual Dimension Integration of Hypotheses with ES3 Spiritual Dimension Suggested Readings 8 Psychodynamic Models Key Ideas for PIInternal Parts and Subpersonalities When Is PIa Good Match for Your Client? Treatment Planning for PIInternal Parts and Subpersonalities Integration of Hypotheses with PIInternal Parts and Subpersonalities Key Ideas for P2 Reenactment of Early Childhood Experiences When Is P2 a Good Match for Your Client? Treatment Planning for P2 Reenactment of Early Childhood Experiences Integration of Hypotheses with P2 Reenactment of Early Childhood Experiences Key Ideas for P3 Immature Sense of Self and Conception of Others When Is P3 a Good Match for Your Client? Treatment Planning for P3 Immature Sense of Self and Conception of Others Integration of Hypotheses with P3 Immature Sense of Self and Conception of Others Key Ideas for P4 Unconscious Dynamics When Is P4 a Good Match for Your Client? Treatment Planning for P4 Unconscious Dynamics Integration of Hypotheses with P4 Unconscious Dynamics Suggested Readings 229 230 235 237 241 243 253 254 265 269 276 278 283 284 287 287 293 295 300 301 308 308 3 14 3 1 7 322 324 327 329 332 334 336 337 Contents xi 9 Social, Cultural, and Environmental Factors 340 Key Ideas for SCE1 Family System 340 When Is SCE1 a Good Match for Your Client? 348 Treatment Planning for SCE1 Family System 350 Integration of Hypotheses with SCE1 Family System 353 Key Ideas for SCE2 Cultural Context 356 When Is SCE2 a Good Match for Your Client? 362 Treatment Planning for SCE2 Cultural Context 363 Integration of Hypotheses with SCE2 Cultural Context 367 Key Ideas for SCE3 Social Support 368 When Is SCE3 a Good Match for Your Client? 370 Treatment Planning and Integration of Hypotheses with SCE3 Social Support 370 Key Ideas for SCE4 Social Role Performance 372 When Is SCE4 a Good Match for Your Client? 373 Treatment Planning for SCE4 Social Role Performance 373 Integration of Hypotheses with SCE4 Social Role Performance 373 Key Ideas for SCE5 Social Problem Is a Cause 375 When Is SCE5 a Good Match for Your Client? 376 Treatment Planning for SCE5 Social Problem Is a Cause 377 Integration of Hypotheses with SCE5 Social Problem Is a Cause 378 Key Ideas for SCE6 Social Role of Mental Patient 379 When Is SCE6 a Good Match for Your Client? 381 Treatment Planning for SCE6 Social Role of Mental Patient 383 Integration of Hypotheses with SCE6 Social Role of Mental Patient 384 Key Ideas for SCE7 Environmental Factors 384 When Is SCE7 a Good Match for Your Client? 387 Treatment Planning and Integration of Hypotheses with SCE7 Environmental Factors 387 Suggested Readings 388 10 Using Clinical Hypotheses 393 Brainstorming 393 Applying and Testing Hypotheses 396 Selecting and Combining Best-Fit Hypotheses 397 Integrating Hypothesis Testing into the Clinical Interview 403 Integrating Psychodynamic Hypotheses 404 xii Contents Part III Steps to a Complete Case Formulation 11 Problem Identification and Definition Problem Identification Problem Definition Standards for Problem Definition 12 Setting Outcome Goals Benefits of Clearly Defined Future Goals Helping Clients Define "Smart Outcomes" Outcome Goals for Case Formulations Standards for Outcome Goals 13 Presentation of the Database Standards for Database 14 A Coherent Integrative Assessment Standards for Assessment 15 The Treatment Plan Standards for Plans Appendixes Appendix I: Forms for Clinical Case Formulations Form LA Form I.B Form I.C Form LD Form I.E Form LF SOAPing a Problem Using the BASIC SID Life History Timeline American History Timeline Worksheet for Preparing Formulation Twenty-Eight Clinical Hypotheses to Use with Your Own Cases Appendix II: Useful Charts Chart ILA Chart n.B Chart lLC Chart lLD Chart n.E Chart n.F Twenty-Eight Core Clinical Hypotheses Thirty-Three Standards for Evaluating Case Formulations Mental Status Exam Client History Patient Impairment Lexicon Problem Categories from Treatment Planning Manual 409 411 41 1 417 419 436 438 439 443 444 451 45 1 469 470 486 486 513 515 5 1 6 5 1 8 520 523 526 527 529 530 532 534 536 538 539 Contents xiii Chart II.G Domains of Functioning 540 Chart II.H Bar-On' s Emotional Intelligence: Fifteen Competencies 542 Chart 11.1 Inventory of Needs 543 Chart II. J Outline for Multiproblem Case Formulation Report 545 Appendix III: Skill-Building Activities 547 Activity 1 . 1: Writing Your Baseline Case Formulation Report 548 Activity 2. 1 : Practice with the BASIC SID 549 Activity 2.2: Metamodel Practice 549 Activity 10. 1 : Brainstorm Hypotheses 55 1 Activity 10.2: Apply and Test Hypotheses with Case Vignettes 552 Activity 10.3: Provide Commentary for a Transcript 559 Activity 1 1 . 1 : Using the BASIC SID for Preliminary Problem List 561 A Case for Practice: Maria 562 Activity 1 1.2: Is It a Problem Title or an Assessment Idea? 565 Activity 1 1 .3: Problem Definition from Your Preliminary List 566 Activity 1 2. 1 : Developing "Smart Outcomes" 566 Activity 1 2.2: Is It a Process Goal or an Outcome Goal? 566 Activity 1 2.3: Practice Writing Outcome Goals 567 Activity 1 3 . 1 : Is It Subjective Data or Objective Data? 567 Activity 1 3.2: Find the Assessment in the Subjective Section 567 Activity 1 3.3: Is It Objective Data or Assessment? 568 Activity 14. 1 : Using a Three-Column Worksheet 568 Activity 14.2: Writing Your Assessment Discussion 569 Activity 1 5. 1 : Components of the Plan 569 Activity 1 5.2: Evaluation of a Complete Report 570 Appendix IV: Examples 579 Sample SOAP for Activity 1 . 1 : Writing Your Baseline Case Formulation Report 580 Student' s Case Formulation Report for His Own Problem (Data Changed to Protect Anonymity) 580 Sample Answers for Activity 10.2: Apply and Test Hypotheses with Case Vignettes 583 Maria: A Sample Case Formulation Report 589 References 599 Author Index 617 Subject Index 623 Tables 1 . 1 Two Features of Case Formulations 5 1 .2 Twenty-Eight Core Clinical Hypotheses 8 1 .3 How to SOAP a Problem 1 2 1 .4 Components of the Database 16 1 .5 Thirty-Three Standards for Evaluating Case Formulations 22 2. 1 Examples of Trial Interventions for Data-Gathering Purposes 30 2.2 Three Phases of First Interviews 33 2.3 Four Frames for Exploring a Specific Problem 35 2.4 The BASIC SID: An Adaptation of Lazarus's BASIC ID 36 2.5 Data Gathering, Using the BASIC SID, for Difficulty Completing Project 39 2.6 Representational Systems (V-A-K) and Data Gathering 41 2.7 Metamodel Questions 43 2.8 Exploring Cognitive Classification Systems 49 2.9 Subjective Units of Discomfort Scale Self-Monitoring Chart 58 3. 1 Biological Hypotheses 66 3.2 Useful Problem Titles for Biologically Based Issues 73 3.3 Indications for a Referral to a Psychiatrist for Medication Evaluation 8 1 3.4 Optional Surgeries to Improve Psychological Functioning 84 3.5 Common Medication Issues 86 3.6 Abilities and Capacities for Optimal Body Functioning 9 1 3.7 Techniques of Relaxation Training 97 4. 1 Crisis, Stressful Situations, and Transitions 103 4.2 Managing a Violent Client 105 4.3 Assessment of Suicide Potential 106 4.4 Crisis Intervention Framework 1 14 4.5 Items from the Holmes and Rahe Life Change Index Scale 1 17 4.6 Signs of Trauma-Related Stress 1 19 xv xvi Tables 4.7 Steps in Crisis Intervention 121 4.8 Treatment Interventions for Posttraumatic Stress Disorder 1 23 4.9 Helping Clients Cope with HIV Diagnosis 125 4. 10 Stages of Development 1 3 1 4. 1 1 Developmental Stages of Intimate Relationships 1 34 4. 12 Six Stages of Parenthood 1 35 4. 1 3 Stages of Grieving 141 4. 14 Guidance for Coping during Bereavement 150 5. 1 Major Learning Paradigms 158 5.2 Behavioral and Learning Models 158 5.3 Suggestions for Applying Behavioral and Learning Hypotheses 1 60 5.4 Uses of BL1 Antecedents and Consequences Hypothesis 1 66 5.5 Principles and Tactics of Behavior Change 1 68 5.6 Skills-Training Domains 1 82 5 .7 Behavioral Rehearsal 1 87 6. 1 Cognitive Models 1 9 1 6.2 Cognitive Concepts from Diverse Theorists 1 92 6.3 Adler' s Basic Mistakes 198 6.4 Albert Ellis's Core Irrational Ideas 199 6.5 Cognitive Bases for Extreme Emotional States 200 6.6 Jeffrey Young's Early Maladaptive Schemas 201 6.7 Applying the C2 Faulty Cognitive Map Hypothesis 204 6.8 Errors in Thinking 215 6.9 Faulty Information Processing in Psychological Disorders 217 6. 10 Applying the C4 Dysfunctional Self-Talk Hypothesis 223 6. 1 1 Modification of Self-Talk 224 6. 12 Self-Talk Monitoring Chart 226 7. 1 Existential and Spiritual Hypotheses 229 7.2 Applying the ES2 Avoiding Freedom and Responsibility Hypothesis 255 7.3 Concepts of Spirituality 270 8. 1 Psychodynamic Models 287 8.2 Criteria for Healthy Internal Dynamics 289 8.3 Problems Explained by the P1 Internal Parts and Subpersonalities Hypothesis 294 8.4 Voice Dialogue Instructions 298 8.5 Reenactment Patterns in Marriage 307 8.6 Problems Explained by the P2 Reenactment of Early Childhood Experiences Hypothesis 309 8.7 Strategies for Helping Couples 3 14 Tables xvii 8.8 Examples of Capacities of a Healthy Self 3 17 8.9 Mature Object Relations 3 1 8 8.10 Model of Developmental Diagnosis 321 8. 1 1 Problems Explained by P3 Immature Sense of Self and Conception of Others Hypothesis 322 8. 1 2 Demonstration of Point-of-View Exercise 325 8. 1 3 Using the Selfobject Transference 326 9. 1 Social, Cultural, and Environmental Factors 340 9.2 Family Systems Concepts 346 9.3 Dysfunctional Communication Patterns 348 9.4 Using Family System Concepts in Individual Therapy 352 9.5 Working with Couples 353 9.6 Issues of Lesbian, Gay, and Bisexual Clients 361 10. 1 Skills for Using Hypotheses 394 10.2 Problem: Excessive Alcohol Use 405 10.3 Problem: Concerns over Living apart from Parents 406 1 1 . 1 Using the BASIC SID for Problem Identification 414 1 1 .2 Examples of Faulty Problem Definition 420 1 1 .3 Guidelines for Lumping and Splitting 432 1 1 .4 Examples of Umbrella Titles with Subproblems 433 1 1 .5 Problem Definition for Borderline Personality Disorder 434 1 2. 1 Criteria for a "Smart Outcome" 441 1 2.2 Sample Goal Statements 444 1 2.3 Differentiating Outcome Goals and Process Goals 448 1 3. 1 Suggested Data Topics for Specific Problems and Hypotheses 453 13.2 Distinction between Subjective and Objective Data 456 13.3 Organizing the Subjective Section 465 14. 1 Using a Worksheet for Preparing the Formulation 470 14.2 Transitional Phrases to Enhance Analytical Writing 483 14.3 Sample of a Well-Organized Assessment Discussion 484 15. 1 Components of Treatment Plans 487 15.2 Treatment Ideas for Twenty-Eight Core Clinical Hypotheses 489 1 5.3 Planning for Different Orders of Change 493 15.4 Preparing Plan from Completed Assessment Discussion 494 15.5 Identifying the Conceptual Foundation for Chosen Plan 495 15.6 Procedures for Meeting Intermediate Objectives 499 1 5.7 Sequencing of Interventions 501 1 5.8 Stages of Therapy in the Plan 502 Preface This book' s creation began over 25 years ago, continuing throughout my career as professor of psychology in Pepperdine University' s graduate clinical psychology program. My challenge as a teacher and practicum supervisor was to have my students achieve very specific objectives: mastery of the skills of case formulation as well as feelings of competence and confidence as a beginning therapist. Each class contained between 10 and 1 8 students (a small enough size for me to become familiar with each person' s learning process and to find ways to make my methods clearer). From review of case formulation reports and suggestions from students, I was able to improve this book by reorganizing the sequence, breaking skills into smaller components, and providing more examples and opportunities for practice. Feedback from former students has assured me that this book meets its intended goals: • To bridge the gap between graduate school and clinical placement. • To provide tools for the development of effective treatment plans that match the client's needs. • To teach a method for integrating ideas and techniques from different theories in a coherent way. • To enhance the quality of clinical conceptualizations, promoting the integration of textbook knowledge with creativity. • To serve as a reference book for clinical hypotheses from biological, cognitive-behavioral, psychodynamic, humanistic-existential, family systems, and sociocultural frameworks. I shared drafts of this book with professionals and found that it met their needs as clinicians. Although a majority of therapists call themselves eclectic or integrative (Lambert, 2004), they lack a clear conceptual framework for drawing on the wisdom of all approaches. Therapists who may want to learn how to create integrative case formulations may lack a methodology. This book will help. Regardless of their years of clinical practice, experienced therapists have probably never received systematic training in how to create an integrative xix xx Preface clinical case formulation. My interest in case formulation skills stemmed from my own frustration as a trainee and new therapist. My supervisors did not teach me how to think critically and creatively about cases but either expected me to follow a set of rules by rote or threw me into sessions with clients, expecting me to figure it out by trial and error. When I expressed my anguish, supervisors assured me that most beginners had similar feelings and that I was doing fine. My humanistic supervisor said that developing a good relationship with clients was enough. My psychodynamic supervisor said that I should explore the countertransference issues surrounding my need for structure and control, and my intolerance for ambiguity. When I worked in a behavioral clinical setting, I found structure, but I knew I would never be satisfied unless I could integrate ideas from all the theories I had studied. Although eclectic was a disreputable idea (as it still is in a few professional circles), I had already formed in my mind the principle that is the core of the method in this book: You must create a formulation that fits the client rather than try to squeeze the client into your preferred formulation. I made a promise to myself when I began teaching graduate psychology students: I will spare them the misery I went through and help them learn a framework for combining ideas, coherently, from different models. Only people who have gone through psychotherapy training can understand the levels of anxiety and self-doubt felt by a beginning therapist. The more compassionate and responsible you are, the more you worry about doing harm. The more you worry, the harder it is for you to draw from your academic knowledge and feel calm and confident as you face clients. The transition from classroom to therapy room is a momentous change in the life of a future psychotherapist. Many students experience a sharp disconnect between what they learn in the classroom and what is expected in their face-to-face contacts with clients. I open Chapter 1 with a question that is at the back of all beginners' minds: How will I know what to do when Iface a client? The answer to that question is that you need a specific set of skills that are not taught in most graduate programs or clinical training sites. Case formulation skills refer to the ability to conceptualize your client's needs in a way that leads to effective treatment plans. With the use of these skills, which this book presents, you will be able to think intelligently, critically, and creatively. You will draw from your personal understanding of clients as well as your academic knowledge base, to develop a treatment plan that is tailor-made for each client. In trying to determine why there is this void in the formal education of future counselors and psychotherapists, I concluded that several elements of training programs give the illusion that students are being adequately taught to conceptualize their client's problems and needs when, in fact, they are not: • The emphasis on learning to use the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; American Psy- Preface xxi chiatric Association, 2002) leads to the faulty assumption that psychiatric diagnosis, a labeling, categorization process with a specific set of inclusion criteria, is equivalent to a case formulation, which is the creation of an individualized conceptual framework for a single, unique client. • The message to "choose an orientation" from well-established theoretical approaches results in the adoption of a ready-made formulation that is chosen before the therapist lays eyes on a new client. Despite the evidence that most therapists combine ideas from different approaches and that no single model is comprehensive enough to incorporate biological, psychological, interpersonal, and social factors in human functioning, faculty and supervisors often discourage an integrative approach. • The complicated, time-consuming paperwork in clinical settings focuses on meeting legal and administrative requirements without developing the trainee's conceptualization skills. Busy clinicians are not going to be able to find time for such intensive focus on individual clients. CASE FORMULATION SKILLS CAN BE SYSTEMATICALLY TAUGHT Teachers, supervisors, and program administrators are not aware that it is possible to teach case formulation skills in a systematic, structured way because they learned their skills in a haphazard way in the apprenticeship model of clinical training, through mentorship relationships with supervisors and their own trial-anderror learning. They believe that a beginner's self-doubt and frustration is a normal developmental stage in the learning process and that the ability to conceptualize develops naturally, over time, and with clinical experience. Even those professionals who themselves integrate ideas from different theoretical models in their sessionto-session decision making urge their students to stick to one orientation. Many kind-hearted practitioners advise trainees that your first session is a success if you just get through it, maintain your composure, and instill enough hope in the client so that he or she will come back. The idea that you should leave your first session with a set of relevant clinical hypotheses in your mind would seem overly ambitious to them. An assumption underlying this book is that conceptualization skills can be systematically taught. This may be the first book in this field that teaches these skills in a structured, systematic manner. Therapists are rarely taught how to think and conceptualize: These abilities are assumed to flow naturally from native intelligence, experience, and unstructured conversations with supervisors. Although the personality and innate qualities of a therapist are important, it is a mistake to allow therapists to face clients relying solely on their intuitions and hunches. They need skills-both interpersonal and conceptual skills. This book presents an alternative to "choosing an orientation"-a coherent model for integrating ideas from a comprehensive range of theoretical frameworks and mental health models. xxii Preface TREATMENT QUALITY IS ENHANCED BY INTEGRATING DIFFERENT APPROACHES This book teaches how to conceptualize clinical cases by integrating ideas, skills, and techniques from a variety of theoretical perspectives to design treatment plans that are the best match for the needs of a client. Although some approaches to integration lead to the development of a new integrative theory (called a transtheoretical approach), this book keeps theories separate, extracting their core ideas, and then allowing the creative clinician to cOlnbine or choose those ideas that lead to the best treatment plans. A list of 28 core clinical hypotheses offers a metatheoretical framework that embraces all theories, orientations, and mental health intervention models. Combining and recombining these hypotheses leads to new discoveries about effective treatment, without contributing to the proliferation of new theories. Because the description of each hypothesis is free of technical jargon, this framework has the potential to break down barriers among orientations and professional guilds and to unify the knowledge base of all of the professions that provide psychotherapy and other mental health services. With 28 different clinical hypotheses available, the clinician has more "ingredients" to make individualized "recipes" of treatment plans. For each hypothesis, I have provided a summary of what I consider to be key ideas, some examples and guidelines for when this hypothesis is a good match, and a set of treatment suggestions. I know that I will not please everybody: Experts will complain that I have oversimplified, whereas novices will complain that some sections are overly complicated. I hope that the references and suggested readings will serve the important function of steering readers toward sources with more complete and comprehensive presentations of the different models. This book encourages readers to consult the research literature, use empirically supported treatments when appropriate, and to individualize treatment to the client' s needs. Lambert, Garfield, and Bergin (2004), in a massive review of empirical literature in psychotherapy over the past 10 years, offered an opinion that supports the use of core hypotheses instead of abstract theories: We do not foresee any major new theoretical developments along the line of global, comprehensive theories that attempt to explain all aspects of personality, psychopathology, and psychotherapy, as we have in the past. It is more likely that the trend toward minitheories centered on specific problem domains and empirical evaluations will continue. (p. 8 1 9) EMPIRICAL VALIDATION CAN COME FROM CLINICAL, SINGLE-CASE METHODOLOGY NOT JUST FROM RANDOM CLINICAL TRIALS The current emphasis on empirically validated treatments (EVTs) gives disproportional power to academic researchers, who randomly assign large groups of Preface xxiii patients to different, manualized treatment methods, and devalues the knowledge and wisdom of experienced practitioners who work in clinical settings. Clinicians need to convince the researchers-and managed care companiesthat the effectiveness of a treatment plan can be validated by monitoring progress in an individual case, not just by traditional quantitative research studies. It is sound scientific practice to evaluate the effectiveness of a treatment plan by implementing it with a client and monitoring, by data collection, the changes in the client' s functioning. To assure rigor in the use of the case formulation method, I provide a list of 33 standards for evaluating case formulations. When you read the rules, you will see familiar guidelines for the use of the scientific method: Keep data separate from speculation, test the validity of hypotheses with data, and treat interventions as experiments. The method in this book guides therapists not only to evaluate the effect of therapeutic interventions right from the beginning but also to have the flexibility to modify their conceptualization and plans if they discover that what they are doing is not working. WE NEED TO ADDRESS THE NEEDS OF CULTURALLY AND RELIGIOUSLY DIVERSE CLIENTS Within the list of 28 hypotheses, several address cultural factors and the religious/spiritual dimension. More important, this book teaches that each person exists in a specific cultural/social/historical context, and that therapists must understand the client's multiple identities, including gender, race, ethnic group, sexual orientation, religion, and age "cohort, to create the best treatment plan. WE NEED A SYSTEM TO COMMUNICATE MORE EFFECTIVELY WITH CASE MANAGERS IN MANAGED CARE AND INSURANCE COMPANIES Currently, most books on treatment planning emphasize meeting the needs of the case manager. This book helps therapists focus on the client's needs, while using a language that will have the clarity and specificity that insurance and managed care companies require. The problem-oriented method taught in this book is already widely practiced, using the SOAP (i.e., subjective data, objective data, assessment, and plan) format for organizing a case formulation. This simple structure provides a framework for integrating hypotheses. The method in this book is not just window dressing to pacify case managers. This system promotes a commitment to accountability that will satisfy our own professional, ethical desire to provide the highest quality services to our clients. The case formulation skills taught in this book require a foundation ofprofessional study and good intellectual abilities. This book is clearly not a cookbook xxiv Preface for nonprofessionals. There are no shortcuts to becoming a competent psychotherapist: Case formulation skills are just part of the package of abilities, knowledge, and judgment that is necessary for professional practice. No single book can possibly substitute for the quantity ofreading and the variety of supervised clinical experiences that contribute to clinical competence. BARBARA LICHNER INGRAM Acknowledgments I am grateful to the competent and creative students who served as my assistants over the years: Andi Cupp, Nicole Crouch, Natalie Feinblatt, Amy Jones, Michal Mayo-Dvir, Michelle Logvinsky, Laura Paulson, and David Schafer. The following students gave valuable feedback and suggestions: Ardell Broadbent, Arlene Cruz, Gunilla David, Cori Day, Charles Dvorak, Nicola Flinn, Michelle Friedman, Matt Keener, Tamara Kline, Merry Lambert, Tom Rankin, Alice Richardson, Bruce Singer, Greg Spano, Alvin Sandjaja, Marilyce Srugies, Chantelle Thomas, Gail Wilburn, Renee Wilkinson, Wendi Williams, and Amanda Wood (I apologize for inadvertent omissions). I also thank anonymous students and trainees who provided material for case examples. Many teachers, colleagues, and professionals contributed to my knowledge, reviewed portions of this book, or gave me encouragement: Kathi Borden, Ros Byrne, Kathy Castle, Richard Chung, Anat Cohen, Leslie Eichenbaum, Steven Frankel, Barbara Fritz, Nick Ingram, David Levy, Francie Neely, Michelle Pearce, Mary Jane Rotheram-Borus, Daryl Rowe, and Jerome Singer. The name of George Saslow appears several times in the text; if he hadn't chosen to take a confused psychology intern into his education program for psychiatric residents, I would not have become the passionate proponent of coherent case formulations that I am today. My appreciation goes to all the people at John Wiley & Sons who contributed to the creation of this book with special thanks to Tracey Belmont, who acquired it and improved it with the help of well-selected reviewers; to Christy Croll, copyeditor, who made many helpful suggestions; and to Pam Blackmon and the staff at Publications Development Company. My special thanks go to Heather Turgeon for her editing skills and her sound advice. Finally, I thank three friends who gave me inspiration and emotional support-Anita Bavarsky, Ruth Blaug, and Nao Hauser-and my husband, Paul, a very special, one-of-a-kind person, who brought humor, insights, and love into my life while I was working on this book. BLI xxv PART I GETTING STARTED The first chapter is an overview of the case formulation method, including definitions of key concepts (e.g., case formulation, integrative, core clinical hypothesis, and the problem-oriented method), descriptions of the steps in creating a case formulation, and two important lists that are repeated in Appendix II (Charts I 1 .A and I l .B): 1. Twenty-Eight Core Clinical Hypotheses. 2. Thirty-Three Standards for Evaluating Clinical Formulations. These two charts become reference tools to help write case formulation reports by combining the core hypotheses when they fit the data. (Part II will take you through each of the 28 hypotheses.) The framework of the problem-oriented method (POM) organizes the case formulation report into sections: problem title, outcome goal, two kinds of data, an explanatory assessment essay, and detailed treatment plans. As you write the report, you can check each step by referring to the standards. (Part III will take you through each of the 33 standards.) At the end of Chapter 1, you are introduced to the first activity: An invitation to write a "baseline" formulation, using the ideas from Chapter 1 . To build case formulation skills, you are encouraged to stop and do the activities in Appendix III if a box announcing an activity appears in the text. An alternate approach is to first complete the book, and then use the activities as a method of review. Chapter 2 addresses the topic of data gathering. The quality of a case formulation and your ability to be integrative both depend on gathering a comprehensive, unbiased database. Many different charts and tools are presented in Chapter 2 to assure that you gather and organize data in a way that will make it easy to apply the clinical hypotheses and develop good treatment plans. When you have completed Part I, you have two choices: (1) You can proceed to Part II where each chapter addresses one of the seven categories in which the core hypotheses are organized. (2) You can go directly to Part III (Chapters 1 1 through 15) to learn the details of the case formulation method. 1 Chapter 1 AFRAMEWORKFOR CASE FORMULATIONS As a beginning therapist, facing your first clients, you probably ask yourself: How am I going to know what to do? When your training begins, you may wonder: What should I do with this specific client? With more experience, you will grasp a more important need: When Iface any new client, how do I create a treatmentplan that is the best matchfor that client? Even experienced therapists face this challenge. Thus, you need skills to create case formulations-the focus of this book. A clinical case formulation is "a conceptual scheme that organizes, explains, or makes clinical sense out of large amounts of data and influences the treatment decisions" (Lazare, 1 976). A formal clinical case formulation is an oral or written presentation that communicates the treatment plan along with the conceptual rationale and justification for that plan. Jerome Frank (Frank & Frank, 1991) defined two components of a case formulation: (1) A plausible explanation for the patient'S symptoms, in the form of a conceptual scheme or even a myth, which provides a rationale for (2) the prescription of a ritual or other type of procedure for resolving them. Based on this definition, a case formulation includes the following elements: • Symptoms or problems that need to be changed. • A large amount of information that needs to be organized. • A conceptual scheme that provides an explanation. • Treatment decisions that lead to specific procedures. A clearly articulated case formulation is essential for communicating with supervisors and treatment team members, as well as with case managers representing the companies who pay for treatment. Other benefits for learning how to create clinical case formulations include: 3 4 Getting Started • Increased confidence and reduced anxiety at the thought of facing new clients. • Tools and skills for evaluating the needs of clients and understanding clients from multiple perspectives. • A coherent strategy for applying what you have learned in the classroom to your work with clients. • A framework for developing appropriate treatment plans. • A structure for bringing your creativity and academic education to the rewarding process of helping people. HOW AM I GOING TO KNOW WHAT TO DO? To create a formulation, you can either choose an orientation and follow its rules or develop a unique, integrative formulation for each client. Choose an Orientation By choosing an orientation, you develop case formulations using the theories of your preferred theoretical model. This may be an attractive approach because it offers structure, guarantees you consistency and coherence among your ideas, and wins you approval from members of the profession who have followed this path. Furthermore, if you choose an orientation, it removes ambiguity and stress from clinical decision making, helps you feel prepared for job interviews, and gives you access to professional organizations and training programs with like-minded professionals. If your orientation is the best match to the needs of a specific client, it serves you well; however, there is a tendency to squeeze clients into your preferred model even when other clinical hypotheses might lead to more effective treatment. Develop Unique, Integrative Formulations In an alternative process, the therapist integrates ideas, skills, and techniques from different theoretical approaches to create a unique formulation that is tailormade for each client's problems, personality, and sociocultural context. This approach recognizes that every theory has something of value to offer but is not sufficient as a sole guide for therapy. This book supports the second approach and teaches an integrative method for creating case formulations. Table 1 . 1 describes the two key features ofthe method. Though many therapists shy away from using the word eclectic, studies have shown that a majority of therapists integrate ideas from different models (Lambert & Ogles, 2004). An integrative treatment plan combines Goncep�s, �nd.t�chn.iqlie�;frg!jl' �liffer0nt therapy approaches, in a.systematic; co1):eren( way,:tel' ll;l��!;the )l�eds 9f (\.uniq�e. client. . , . . ' '" " . . .. . ' : . .. .., " ' ,' . ' ' . ' : .. .• . " '. Table 1.1 Two Features of Case Formulations A Framework for Case Formulations 5 The integration of ideas from the 28 core clinical hypotheses. The list of hypotheses is in Appendix II, Chart II.A. The chapters in Part II present each hypothesis in turn. These hypotheses: • Extract the essential explanatory ideas from all theories and approaches to therapy; • Permit combination and integration of components of different theories; and • Lead logically to treatment plans. A structured framework called the problem-oriented method. A list of 33 standards for evaluating the application of this method is in Appendix II, Chart II.B. The chapters in Part III explain each of these standards. The problem-oriented method (POM) requires: • Identification of the problem, which is the target for treatment; • Specifications of the outcome goal, the desired change in the client's functioning; • Well-organized summaries of the collected information about the client (the database); • A coherent explanation of each problem, integrating clinical hypotheses (assessment); • Recommended treatment plan, consistent with the explanation, and focused directly on achieving the outcome goal. In applying the POM, you will learn to SOAP each problem that you identify for a client. SOAP stands for Subjective Data, Objective Data, Assessment, and Plan. The system in this book differs from other approaches to integrating theories-samples of which are listed in the Suggested Reading section at the end of this chapter. You learn to select and combine core clinical hypotheses based on how you believe they explain a clearly defined problem. Using a problem-oriented method (POM) and integrating multiple hypotheses helps you think intelligently, critically, and creatively to develop a treatment plan that is tailor-lnade for each client. You may still have normal anxieties as a beginning therapist, but, with these case formulation skills, you are more likely to feel challenged and focused rather than confused, overwhelmed, and inadequate. If you are an experienced therapist, you will find that, using this framework, you integrate new ideas into your customary approach and have tools for troubleshooting when interventions fail to produce the expected benefits. CORE CLINICAL HYPOTHESES Lazare (1976) provided a clear definition: A core clinical hypothesis is a single explanatory idea that helps to structure data about a given client in a way that leads to better understanding, decision making, and treatment choice. 6 Getting Started Every theoretical orientation can be broken down into core hypotheses. When we examine these hypotheses, it is apparent that different theorists use the same ideas, but package them with different jargon. For instance, cognitive-behavioral, existential, and narrative therapists all explain problems as faulty cognitive constructions of life experiences. Chemistry provides an analogy: A theoretical orientation is like a complex chemical compound and a single hypothesis functions like a pure chemical element. The same element (hypothesis) can appear in many different formulas (orientations), and a compound (single orientation) can be broken down into component elements (hypotheses). Lazare ( 1976) recommended using a list of hypotheses to help the clinician make efficient use of limited time, guard him from coming to premature closure in the collection of data, and provide a stimulus for the exploration of relevant but neglected clinical questions. . . . In the process of bringing these partial formulations to the interview for consideration, they become hypotheses to be tested. The clinician, by thinking in terms of hypotheses, keeps himself from being bombarded or overloaded with large amounts of unstructured data. Each new observation can now be considered in terms of its relevance to a limited number of hypotheses under consideration instead of being one out of thousands of possible facts. (pp. 96-97) If you use these hypotheses with a scientific attitude, you understand that a formulation is tentative and you do not need to stick to it if it does not lead to beneficial change in the client's functioning. If you only have one hypothesis, you are wedded, dogmatically, to a single orientation. If you choose one orientation, but want to avoid the mistake of imposing an inappropriate treatment plan on your new client, you need two hypotheses: 1 . My approach is a good fit for this client, so I can proceed with my preferred type of therapy. 2. My approach does not fit this client, and therefore I should refer the client to another therapist. I have been developing and reshaping a list of core clinical hypothese.s ever since my first exposure to Lazare' s suggestion. The essential ideas from different theoretical approaches and mental health intervention models are extracted and freed from theoretical jargon; given names, codes, and brief descriptions; and organized into seven categories: I. Biological Hypotheses (B) II. Crisis, Stressful Situations, and Transitions (CS) III. Behavioral and Learning Models (BL) IV. Cognitive Models (C) V. Existential and Spiritual Models (ES) VI. Psychodynamic Models (P) A Framework for Case Formulations 7 VII. Social, Cultural, and Environmental Factors (SCE) Although 28 seems like an excessive number of hypotheses to learn, with familiarity, the list becomes a helpful tool for examining the data of a new case. In addition, the list is useful when you are exposed to what appears to be a new approach to psychotherapy: See if you can deconstruct the new model down to three or four core hypotheses from my list; if a new idea doesn't fit, you should expand the list to contain 29 hypotheses. Table 1 .2 contains 28 hypotheses, which are explained in detail in Chapters 3 through 9. When you shift from espousing theoretical orientations to using clinical hypotheses, you discover that (a) all theories comprise multiple hypotheses and (b) there are multiple treatment possibilities for all problems and diagnoses. The following examples illustrate both those points: Gestalt Therapy's Core Ideas Represent Multiple Hypotheses • B3 Mind-Body Connections: Gestalt therapists recognize mind-body connections when they comment on the message in the movement of a leg or have the client pay attention to breathing. • PI Internal Parts and Subpersonalities: Gestalt therapists identify poIm"ities-inner parts in conflict, such as "top dog" and "underdog"-and encourage their dialogue. • P2 Reenactment of Early Childhood Experiences: Gestalt therapists help clients deal with unfinished business from the past so that they don't remain stuck, like a broken record, reenacting the same dysfunctional pattern. • ES2 Avoiding Freedom and Responsibility: Gestalt therapists help clients to confront their freedom instead of using childhood manipulations to get other people to provide support. Treatment for Posttraumatic Stress Disorder Is Consistent with Multiple Hypothesis • B2 Medical Interventions: Medication is available for symptoms and there is research in progress to create a medication that will prevent PTSD. • B3 Mind-Body Connections: The symptoms of both reexperiencing (flashbacks) and avoidance have underpinnings in brain function and how memories are encoded; a method like Eye Movement Desensitization Reprocessing (EMDR; F. Shapiro, 1996) attempts to integrate neural pathways. • BL2 Conditioned Emotional Response: Emotional deconditioning methods are used-either a desensitization or flooding model of treatment-or in vivo exposure, if possible. Table 1.2 Twenty-Eight Core Clinical Hypotheses I. Biological Hypotheses (B) Bl Biological Cause The problem has a Biological Cause: The client needs medical intervention to protect life and prevent deterioration, or needs psychosocial assistance in coping with illness, disability, or other biological limitations. B2 Medical Interventions There are Medical Interventions (e.g., medication, surgery, or prosthetics) that should be considered. B3 Mind-Body Connections A holistic understanding of Mind-Body Connections leads to treatment for psychological problems that focus on the body and treatment for physical problems that focus on the mind. II. Crisis, Stressful Situations, and Transitions (CS) CSI Emergency CS2 Situational Stressors CS3 Developmental Transition CS4 Loss and Bereavement The client' s symptoms constitute an Emergency: Immediate action is necessary. The client's symptoms result from identifiable recent Situational Stressors or from a past traumatic experience. The client is at a Developmental Transition, dealing with issues related to moving to the next stage of life. The client has suffered a Loss and needs help during Bereavement or for a loss-related problem. III. Behavioral and Learning Models (BL) BLI Antecedents and Consequences A behavioral analysis of both problem behaviors and desired behaviors should yield information about Antecedents (triggers) and Consequences (reinforcers) that will be helpful in constructing an intervention. BL2 Conditioned Emotional A Conditioned Emotional Response (e.g., anxiety, fear, Response anger, or depression) is at the root of excessive emotion, avoidant behaviors, or maladaptive mechanisms for avoiding painful emotions. BL3 Skill Deficits or Lack The problem stems from Skill Deficits-the absence of of Competence needed skills-or the Lack of Competence in applying skills, abilities, and knowledge to achieve goals. Cl Utopian Expectations C2 Faulty Cognitive Map C3 Faulty Information Processing C4 Dysfunctional Self-Talk 8 IV. Cognitive Models (C) The client is suffering from the ordinary "miseries of everyday life" and has unrealistic Utopian Expectations of what life should be like. Limiting and outdated elements in the Faulty Cognitive Map (e.g., maladaptive schemas, assumptions, rules, beliefs, and narratives) are causing the problem or preventing solutions. The client demonstrates Faulty Information Processing (e.g., overgeneralization, all-or-nothing thinking, and mind reading) or is limited by an inflexible cognitive style. The problem is triggered and/or maintained by Dysfunctional Self-Talk and internal dialogue. Table 1.2 (Continued) V. Existential and Spiritual Models (ES) ESI Existential Issues ES2 Avoiding Freedom and Responsibility ES3 Spiritual Dimension PI Internal Parts and Subpersonalities P2 Reenactment of Early Childhood Experiences P3 Immature Sense of Self and Conception of Others P4 Unconscious Dynamics The client is struggling with Existential Issues, including the fundamental philosophical search for the purpose and meaning of life. The client is Avoiding the Freedom and autonomy that come with adulthood and/or does not accept Responsibility for present and past choices. The core of the problem and/or the resources needed for resolving the problem are found in the Spiritual Dimension of life, which may or may not include religion. VI. Psychodynamic Models (P) The problem is explained in terms of Internal Parts and Subpersonalities that need to be heard, understood, and coordinated. The problem is a Reenactment of Early Childhood Experiences: Feelings and needs from early childhood are reactivated and patterns from the family of origin are repeated. Difficulties stem from the client' s failure to progress beyond the Immature Sense of Self and Conception of Others that is normal for very young children. The symptom or problem is explained in terms of Unconscious Dynamics. Defense mechanisms keep thoughts and emotions out of awareness. VII. Social, Cultural, and Environmental Factors (SCE) SCEI Family System SCE2 Cultural Context SCE3 Social Support SCE4 Social Role Performance SCES Social Problem is a Cause SCE6 Social Role of Mental Patient SCE7 Environmental Factors The problem must be understood in the context of the entire Family System. Knowledge of the Cultural Context is necessary to understand the problem and/or to create a treatment plan that shows sensitivity to the norms, rules, and values of the client's cultural group. The problem is either caused or maintained by deficiencies in Social Support. Difficulty meeting demands for Social Role Performance contributes to the client' s distress and dysfunction. A Social Problem (e.g., poverty, discrimination, or social oppression) is a Cause of the problem. Social problems can also exacerbate difficulties stemming from other causes. You must avoid blaming the victim. The problem is causally related to disadvantages or advantages to the Social Role of Mental Patient. The problem is explained in terms of Environmental Factors. Solutions can involve modifying the environment, leaving the environment, obtaining material resources, or accepting what can't be changed. 9 10 Getting Started • C3 Faulty Information Processing: Cognitive distortions need to be corrected. • P4 Unconscious Dynamics: The dissociative symptoms represent unconscious processes-the lack of memory for events that were experienced. Random, intrusive flashbacks can be eliminated if memories are encoded verbally and brought under conscious control. • SCE3 Social Support: The social support of others who have gone through the same trauma can be helpful. For instance, groups of veterans can share stories of what happened and relive painful memories. THE PROBLEM-ORIENTED METHOD This book uses a problem-oriented framework for integrating clinical hypotheses into a coherent conceptualization that leads to effective treatment. The problemoriented method (POM; Weed, 197 1) requires a set of skills, which includes defining problems, setting goals, and designing plans focused on the achievement of those goals. Fowler and Longabaugh (1975) describe the benefits of this method: • Problems are clearly defined and delimited at the level ofdata, not diagnosis. • Problem lists require clinicians to be accountable for all problems. • The problem title provides the target for treatment plans. • Progress notes document that plans are being followed. • By separating data from assessment, the clinician can document the processes of clinical judgment. • The method clarifies and simplifies peer and utilization review functions. The term problem refers to difficulties� dysJUnctions, c'omplaihts: and impair� ments that are identified by the client,'by others with' whom the client interacts (e.g., family members, courts, or school �ystem�) ' ,. or' by the 'prefessionals who evaluate the client's functioning. ' We are in the business of helping people resolve problems and become better problem-solvers on their own. Mental health clinics and psychiatric hospitals invariably use Presenting Problem as one of the required sections of an intake report. Managed care and insurance companies ask providers to specify the problelll that is the target of treatment. Once you master this method, it seems like common sense because you have a foundation in problem-solving skills from your everyday life. When you take your car to a mechanic, you expect to see a demonstration of problem-solving skills. Mechanics identify the problem (e.g., car will not start; funny noise when brakes are applied), seek out explanations (e.g., fuel pump is broken; brake pads are worn down), and implement a plan to resolve the problem (e.g., replace bad parts with new parts). The quality of their work is evaluated not by the elegance of their theory or by research findings from studies of other cars but by the at- A Framework for Case Formulations 11 tainment of the desired outcome with this particular car: It starts when you turn the key, and it stops when you step on the brakes. The POM framework embraces all possible theories and organizes the clinician' s thinking, setting no limitation on the choice of explanatory hypotheses or treatment methods. The terms problem-oriented or problem-solving have been associated with directive, short-term approaches such as cognitive-behavioral therapy (CBT) and strategic family therapy. Therefore, you may mistakenly assume that using the POM means you must use these problem-focused therapies. On the contrary, the POM also supports the application of psychodynamic and humanistic-existential models, providing an effective format for communicating treatment recommendations. The treatment strategy could be a directive, problem-solving approach, such as the cognitive therapy of Aaron Beck; a nondirective client-centered approach, such as that used by Carl Rogers; or a creative integration of both. A quick glimpse at the four major orientations will show how the POM will be a useful tool for integrating theories. 1 . Behavioral and Cognitive-Behavioral: Therapists who work in behavioral and cognitive-behavioral orientations already use a problem-oriented approach. The POM will give them a framework for integrating ideas from psychoanalytic and existential theories (e.g., explanations for why "maladaptive schemas" are resistant to change). 2. Family Systems: Practitioners from family systems orientations feel comfortable with the idea of a problem-oriented approach. Therapists who describe their therapy as "solution-focused" will appreciate that the POM requires clear specification of the desired future goals. 2. Psychodynamic: Students who are attracted to psychodynamic theories will find that both cognitive and family systems frameworks can shed light on the early family dynamics that are usually the focus of this kind of therapy. 3. Humanistic and Existential: Many therapists from these orientations have already developed integrative approaches (Cain & Seeman, 2001 ; Gendlin, 1996; Greenberg, Watson, & Lietaer, 1 998). Although words like case and data may seem dehumanizing, these terms do not imply a way of treating the client, but rather they refer to the clinician's formulating process. The POM framework permits the treatment plans to include a focus on an authentic human relationship. SOAPing Each Problem One of the distinguishing features of the POM is the way you organize data and your formulation. You do not write an overall discussion of the whole client but, rather, first give titles to his or her problems and then provide material, organized into four categories, under each problem title. Table 1 .3 presents a description of Table 1.3 How to SOAP a Problem Problem title: A statement of the difficulties, dysfunctions, complaints, and impairments for which the client seeks help. The problem title must be clear, specific, and free of theoretical jargon. Outcome goal: A statement of the desired state at the end of therapy. The outcome goal is directly related to the problem title and contains no description of how the goal will be attained. THE DATABASE S Subjective Data This section contains data that the client reports to you (the word story is another word beginning with s to remind you what belongs in this section). Factual information that is learned from the client goes in this section (e.g., age, number of years in school, number of children). Information from family members also goes in this section. It is helpful to selectively provide direct quotations from the client. This section must be complete for purposes of the formulation because no additional data can be introduced in the A and P sections. Subjective data is organized by topics, without reference to when and how you got the information. You must be careful that conceptualizations and theoretical constructs do not appear in this section. o Objective Data The primary source of data in this section is the therapist' s observations (another word beginning with 0 to remind you what belongs in this section). The therapist uses technical terminology to describe the client's mental status and the nature of the interpersonal process between client and therapist. Other examples of objective data are test results, reports from professionals, and written records. A Assessment THE FORMULATION This section contains the clinician' s conceptual scheme for understanding the problem based on clinical hypotheses. Assessment encompasses much more than a diagnostic label or a summary of data. This section contains a well-organized essay, which thoroughly discusses your analysis of the problem, including explanations, hypotheses, conceptualizations, and theoretical speculation. The ideas in this section must be consistent with the data and should lead to plans that will resolve the problem. New data may not be introduced in this section. However, data that were previously presented may be repeated to make a specific point. Revise your final written product several times to improve the quality of your case conceptualization. P Plan This section describes a treatment strategy that follows logically from the previous conceptualization. The plan describes how the therapist will work with the client to achieve the goals of treatment and resolve the problem. Process goals and intervention strategies are discussed. Every recommendation must have a foundation in the assessment section. A plan addresses the goals for different stages of therapy and recommends techniques and creation of a productive therapist-client relationship. The plan may address how to evaluate progress toward goals, as well as considerations about an appropriate time to terminate treatment. 12 A Framework for Case Formulations 13 these four categories, which make up the acronym SOAP (subjective data, objective data, assessment, and plan): The database has two categories (subjective and objective data) and the formulation has two components-an explanatory discussion (which fits under assessment) and treatment recommendations (plan). The SOAP format organizes all your data about a specific client and provides a structure for presenting a formulation in which the database is separate from the formulation. Therefore, you can present a clean database when you are communicating with supervisors and team members. The assessment (conceptualization) is separate from the plan (prescribed treatment) so that you can design different interventions based on the same conceptualization. The term assessment has many meanings in clinical practice, including the administration and interpretation of psychological tests. I use the term assessment because the SOAP acronym is easy to remember and is in wide clinical use. The word formulation, strictly speaking, refers to the conceptualization, but you must include an "assessment-plan" combination if asked, "What is your formulation of the client's problem?" TASKS AND PROCESSES OF CASE FORMULATION Formulating, as a verb, refers to the creative cognitive processes of developing an official formulation. You are formulating when you sit face-to-face with the client and generate hunches about the causes of problems or structure questions to test a specific hypothesis. You are formulating when you spend time between sessions thinking about the client. Formulating is different from writing progress notes in a chart. The notes that you write in charts-which are legal documents open to scrutiny in many different contexts-emphatically do not contain the creative speculation that is part of a good formulation. Unlike the final product (a report in a linear format), the tasks and processes of creating a formulation can occur simultaneously; you can go back and forth between steps. Figure 1 . 1 is a diagram of the six tasks of formulating: 1 . Gather Data. 2. Define Problems. 3. Specify Outcome Goals. 4. Apply Hypotheses. 5. Plan Treatment. 6. Monitor Effects of Interventions. Gather Data The term database (S-0 in the SOAP) refers to theentirebody ofinformation availablefor a specific client. Subjective data refers to what the client tells you and objective data refers to what you see and hear during the session. Chapter 2 presents 14 Getting Started Gather Data Presenting Complaints Desired Future State History of Presenting Problems Clinical Observations Resources and Assets Life History (Timeline) Genogram Exploring Hypotheses Tests and Charts Consultation Data That Show the Effects of Interventions Apply Hypotheses Biological Crisis Developmental Cognitive Behavioral Psychodynamic Existential Spiritual Social Family Systems Environmental Plans Follow Logically Plans and Goals Must Be Consistent Process Goals Strategies Techniques Therapist-Client Relationship Priorities Community Resources Ethical and Legal Issues Referral Monitor Effects of Interventions Figure 1.1 Overview of case formulation skills and processes. techniques and suggestions for gathering a comprehensive, unbiased database, and Chapter 13 presents guidelines for presenting a well-organized database. The tenn data is sometimes associated with scientific models (e.g., the medical-psychiatric model and the research-based cognitive-behavioral model) and might sound cold or businesslike. However, the terms data and database are theory free and refer to the information you gather about the client. The contents of the database must be uncontaminated by theoretical assumptions, inference, and interpretation: Different professionals would agree about the content of the database, regardless of their orientation. Data gathering starts before the therapist sets eyes on the client, often with a phone call. Although the first session (often called the intake) is a major source of information about the client, the data-gathering process occurs in every session. I I� A Framework for Case Formulations 15 In the beginning, your focus is on identifying and exploring problems. Later in therapy, data gathering is the tool for evaluating whether the plan is effective in helping the client make progress toward outcome goals. The therapist may gather data not only through interviewing but also by reading charts, communicating with faInily members, consulting with other professionals, administering and interpreting tests, and giving homework assignments. The process of testing hypotheses to see which ones fit the data is a task that requires thorough knowledge of the 28 core clinical hypotheses, plus the ability to gather data in an open and unbiased way. The first session can be overwhelming if the therapist believes that all important data must be gathered immediately. This attitude can be disastrous for developing rapport with the client, and it can distort the data. View the first session as a chance to rule out two important hypotheses: biological causes (Bl) and emergency issues (CSl) that require immediate action, such as hospitalization, warning intended victims, or instituting crisis intervention strategies. Once you are convinced that there is no pressure to act immediately, you can continue the intake process into the second and third sessions. Three sessions is a reasonable period to gather sufficient data for a preliminary, tentative case formulation. Because the clinical interview is the main tool of data gathering, the clinician must be a competent interviewer or the validity of the database is comprOlnised. Therapists need to become aware of their personal values, biases, and possible countertransference issues that could contaminate data. In actual training, the building of case formulation skills should be integrated with the development of interviewing skills, including the following: attentive nonverbal behaviors, accurate observation of the client's nonverbal behavior, reflection of feelings, accurate paraphrasing and summarizing, effective open-ended questions, and focused questions that achieve specific data-gathering and hypothesis-testing goals. Table 1 .4 presents the major components of the database. Define Problems We all have a tendency to rush to explanations and solutions, instead of spending time identifying the problem or problems. The ability to create good problem titles might be the most important skill taught in this book. The definition of the problem helps to focus the discussion in the assessment section and keeps it from becoming an abstract discussion of the client's personality or the therapist' s pet theory. A "good" title means that the therapist and the client have agreed on a target for change that leads to achievable, realistic, and desirable outcome goals. Chapter 1 1 explains the problem identification process, and how to write specific problem titles, teaching you to make the following distinctions: • Specific problem title: Lack ofcontrol ofanger while disciplining children. • Vague problem title: Anger problems. • Faulty problem title that contains formulation ideas: Unresolved issues with abusive father. Table 1.4 Components of the Database Presenting Complaints The therapist must note and explore the reasons why the client came to therapy, described in the client' s own words. In addition, the therapist might be able to identify additional problems or reframe the presenting problems into a more solvable form. History of Presenting Problems A detailed timeline of recent history is essential for understanding the onset and development of the presenting complaints. Therapists seek the answer to questions (e.g., Was there an identifiable onset of the problem ? and Why is the client seeking help now, instead ofsooner or later?), along with information about past efforts to resolve problems. Clinical Observations The therapist attends to the client's appearance, speech and behavior, and uses a specialized vocabulary to describe the client (e.g., see Chart II.C, Mental Status Exam, in Appendix II). The "here and now" of the session provides samples of the client's style of relating. Desired Future State Therapists probe to discover what the client wants in the future, assuring that it is a reasonable, attainable goal that will not cause damage. Life History with Timeline Organizing information about the client's personal history shows the stages and transitions of a unique life. By using a visual timeline, therapists recognize gaps in their information and how seemingly unconnected events coincide in time. It is also very useful to match the individual' s life history timeline with a timeline of historical events to grasp some of the social, economic, and cultural factors in a person' s history. Resources and Assets Therapists need information about success, support networks, strengths, and talents. It is important to assess competence as well as weakness. Genogram This is a diagram of the family tree going back at least to the grandparent generation. A visualization of this information, along with details about culture, relationships, and family dynamics, can be enormously helpful. Tests and Charts Data may be available in preexisting medical records. The therapist can seek additional data through testing or structured data-gathering homework assignments. Consultation Information is sometimes obtained by consulting with people who have had contact with the client. Effects of Interventions When a plan is implemented, it is essential to gather data to see if it is working as predicted. Trial interventions are useful, before a formal case formulation is developed, to evaluate their effectiveness. 16 A Framework for Case Formulations 17 The starting point in the case formulation process is the development of a comprehensive list of problems. Give each problem a clear, specific, and understandable title, worded without theoretical jargon. A preliminary list of problems is derived from the client' s initial complaints, as well as from your focused questions and clinical observations. Occasionally, problems are identified through complaints from people who know the client. In defining problems, you will make many judgments and decisions. Certain complaints need to be "normalized," instead of targeted for treatment. As new data are gathered, problem definitions may change. People frequently define problems in ways that cannot be solved; for example, "I want my boyfriend to change." The therapist must avoid that trap. Every problem title must lead to an outcome that is possible and you need to be sure that the problem is defined so that the focus is on what the client has control over. Be careful not to impose your values and try to change the client in ways that the client does not want. After years of academic training in psychology, it is hard to resist jumping to clinical explanations before clearly defining the problem. To avoid letting your conceptualization creep into the problem title, you must keep reminding yourself to word problem titles in simple, ordinary language that is free of theoretical concepts. Problem titles must be agreeable to practitioners of all orientations, so it is incorrect to include theoretical terms that are specific to one orientation. Save the explanations for the assessment (the A in the SOAP). Specify Outcome Goals Chapter 12 discusses how to specify outcomes-the desired state at the end of therapy. Outcome goals refer to the client's behavior outside of the therapy session-in real life-and are described in language that is free oftheoreticaljargon. The method taught in this book is both problem and goal oriented-defining a problem leads to specification of goals and sometimes goal setting comes first and helps you define a problem. Outcome goals must be defined in a way to allow outside evaluators to verify whether they were attained or not. Outcome goals do not contain any clues about the "how" of therapy or the techniques used in the process. Therapists from different orientations will agree on what a successful outcome is, even as they prepare to use different treatment strategies to attain it. Outcome goal statements must be clear, realistic, and free of theory. For instance, "to make the unconscious conscious" or "to become a fully actualized person" are faulty outcome goals: They (a) contain theoretical constructs and (b) are too idealistic and utopian to be achieved. The wording of these goal statements must be changed so that the goal is specific and attainable. By specifying outcome goals, we determine how we know that we have achieved problem resolution and that it is appropriate to terminate therapy. Reference to outcome goals in the plan helps to focus your intervention strategy. 18 Getting Started If you only use a problem focus, you are stuck exploring "what' s wrong." Therapists sometimes refer to outcome goals with other terms, such as the preferred scenario and the future vision. The definition of problems and the specification of outcomes are bidirectional processes. As the vision of the desired future becomes clearer, the wording of the problem may be modified. There is a logical relationship between a problem title and a goal. When you write a clear problem title, the outcome goal often seems self-evident, as in this example: Problem: Lack offriends Outcome: Initiate and maintain a friendship However, the identification of the desired outcome can shape the wording of the problem title. The following examples illustrate how you can start with the outcome goal and work backward to the problem title. Outcome: Develop a support network Problem: Social isolation or Lack offriends Outcome: Decide on career goal Problem: Indecision and ambivalence about career goals Often, going back and forth between problem title and outcome statement helps you clarify both. During therapy, you will continually reassess the goals of treatment. As goals are met, you can cross problems off the problem list. As new problems are defined and new data are gathered, outcome goals can be specified and changed. Certain goals may be recognized as too costly in time and effort. In creating goals for clients, distinguish between outcome goals and process goals. Outcome goals refer to desired client functioning at the termination of therapy such as "develop social skills." Like problem titles, outcome goals must be completely free of theory in their wording. Process goals (described later) refer to desired in-session experiences and are based on the therapist' s conceptualization. Process goals will reveal the theory of the therapist (e.g., ventilation of feelings, demonstration of insight, free association, or building a hierarchy of feared situations). If the goal refers to the therapist' s actions and intentions (e.g., to help, to facilitate, to support, or to challenge), it is a process goal. In the section of the case report called Outcome Goals, eliminate all process goals and focus on the client' s functioning at the end of therapy, without reference to how this will be achieved. This rule allows therapists of all theoretical persuasions to agree on outcome goals. To assure that something is a good statement of an outcome goal, ask: A Framework for Case Formulations 19 • Will achievement ofthis goal produce positive out-of-therapy changes? • Will I be able to verify that this goal has been achieved? • Ifthe client achieves this goal, will that be sufficient to resolve the problem? Apply Hypotheses The application of relevant hypotheses involves multiple tasks and competencies. First, learn the hypotheses by reading Chapters 3 through 9. Then, practice applying them through the activities in Chapter 10. Of all the skills taught in this book, applying hypotheses is the most complex. It involves the following: • A searchfor the "best-fit" hypotheses: The clinician sorts through the available clinical hypotheses that are compatible with the data about this specific client. • "Testing " the fit of a specific hypothesis: The focus of the interview becomes gathering data to rule "in" or "out" that hypothesis. If you commit to a specific hypothesis too quickly, the search for information will be biased by your expectations. • Selecting and combining hypotheses: You will not include every possible hypothesis that fits but instead seek a combination that will lead to a good plan. This process includes examination of cost-effectiveness: Given hypotheses of equal merit, determine which ones lead to a plan that is more economical in time, money, and effort. Once you have selected hypotheses, you need to develop the integrative, explanatory discussion that goes in the A section of the SOAP (see Chapter 14). Every idea in the assessment must be consistent with and justified by the data. You cannot ignore significant data nor can you apply hypotheses that are not supported by data. There is no reason to retain a hypothesis that does not direct you to a treatment strategy. Plan Treatment The end product of a formulation and the reason that you are bothering to develop these skills is the creation of a treatment plan, designed for a specific individual, which describes a strategy for attaining the desired outcome goals (Chapter 15). The plan cannot be created by a computer program or by a nonprofessional, just based on a problem title. The plan must be tailor-made for each client. Even if you choose to use a treatment package that involves systematic instructions, it is still necessary that you administer this treatment with empathy, flexibility, and sensitivity to cultural and relationship factors. 20 Getting Started The prescribed interventions in the plan follow logically from the ideas in the assessment. The bridge between the assessment and the plan consists ofprocess goals. W H AT A R E P RO C E S S G OA L S ? Process goals describe events and conditions that occur in the therapy sessions. They answer two questions: 1 . How will I achieve the outcome goal (i.e., by empathizing, challenging cognitions, teaching skills, restructuring the family system, or creating a trusting relationship)? These goals may reveal the therapist's theory. 2. What interventions follow logically from the chosen hypotheses? Skill deficit Build new skills Dysfunctional self-talk Modify self-talk Unconscious dynamics Make the unconscious conscious Process goals may contain language that belongs to a specific theory and refer to constructs that cannot be observed or verified (e.g., utilize the transference, integrate disowned parts of the personality, and resolve unfinished business with parents). Every important idea in the assessment section must be followed by process goals and a specific strategy in the plan section. Eliminate ideas in the assessment section that do not merit a plan. If you write ideas in the plan that were not addressed in the assessment essay, go back to that section and insert the rationale for the plan. To reach many outcome goals, it is necessary to set intermediate objectivesshort-term goals that are steps toward achieving outcome goals. Process goals and intermediate objectives can overlap. For instance, if the outcome goal is for the client to be appropriately assertive with his boss and coworkers, an intermediate objective might be for the client to role-play an assertive encounter in the session. This is a process goal, because it refers to activity in the session, and it is also an intermediate objective, because the client is demonstrating attainment of new skills that would transfer outside of therapy and contribute to achievement of his outcome goal. There can be many different strategies for achieving a process goal, and your choices will depend on multiple factors, including your own training and level of competence, the abilities and preferences of the client, and the institutional context. The written plan is a guide, but, as therapy progresses, new choices will be made. Although the clinical case formulation is organized in a linear structure, the implementation of plans is fluid, flexible, and creative. There is room for intuition, trial and error, and snap decisions that bubble up from our unconscious, which-as explained by Gladwell (2005) in Blink,-stem from both expert knowledge and the ability to process information faster than we code our thoughts into words. Monitor Effects of Interventions A Framework for Case Formulations 21 The effectiveness of therapy is judged by a comparison of pretherapy (problem) and posttherapy (outcome) functioning, with three possible outcomes: ( 1 ) improvement (successful therapy), (2) deterioration ( harmful therapy), and (3) no change (ineffective therapy). The POM helps therapists be accountable for the effectiveness of their treatments by forcing them to specify the goals that they are working toward and monitor their success in reaching those goals. The quality of a formulation is evaluated by examining the impact treatment has on the client's real-life, outside-of-therapy functioning. The interventions in the treatment plan can be viewed as an experiment: "If my hypothesis is correct, this strategy should resolve the problem and achieve the desired outcome." Does it work? Does it help? Does it lead to the desired outcome? You gather data about the change in the client's functioning and if he achieves the desired goals, then you confirm the formulation's merit. If not, then you must cycle back through the formulation tasks. You should watch for signs that the interventions are making problems worse or creating new problems. What you may label as "resistance" must be viewed as a source of useful data and a powerful clue that you need to improve the formulation. Two important criteria for evaluating the quality of formulations are effectiveness and cost-effectiveness: 1 . Effectiveness: A formulation is effective when its prescribed interventions lead to desired change in the client's functioning and achievement of the client's goals. 2. Cost-effectiveness: A formulation is cost-effective when, compared to alternative effective approaches, it achieves the desired outcome with less time and effort and in a more economical manner. This criterion is especially important when resources are scarce or when third parties such as insurance or managed care companies are providing payment. When you understand how to monitor the effects of treatment, you will worry less that you might inflict harm on clients because of inexperience. This scientific attitude means that you are as concerned about empirical validation for treatment as are researchers in large institutions who are conducting random clinical trials. Report Writing The case formulation method in this book is a tool to help you to think creatively and develop good treatment plans. It is not a method of keeping chart notes or writing official reports. However, to develop skills, it helps if you make a commitment to write reports that take considerable time and effort (see Chart ILl in Appendix II for the outline that I recommend). You will have achieved competence when your report meets the 33 standards listed in Table 1 .5. Table 1.5 Thirty-Three Standards for Evaluating Case Formulations Problem Definition 1 . Problems are defined so that they are solvable targets of treatment. 2. Titles refer to the client' s current, real-world functioning. 3. Titles are descriptive, designed for a specific client, and are justified by the data. 4. Problem titles do not contain theoretical, explanatory concepts. 5. The therapist is not imposing cultural or personal values in problem definitions. 6. Lumping and splitting decisions are justified in that they lead to good treatment planning. 7. The problem list is complete and comprehensive. Outcome Goals 8. Outcome goals are directly related to the problem title and are consistent with the client's values. 9. Outcome goals refer to real-world functioning and do not contain formulation ideas. 10. Outcome goals are realistic and are not utopian. 1 1 . Outcome goals do not contain the " how" of the treatment plan. Presentation of Database (S and 0) 1 2. The database is thorough, comprehensive, and complete: There are sufficient data so that multiple hypotheses can be applied. 1 3 . Subjective and objective data are appropriately distinguished. 14. Good quotations from the client are included in the subjective data section. 15. The subjective section does not include formulation concepts (unless they are quotations from the client). 16. There is no reference to how and when the information was gathered in the subjective data section; this information, if relevant, goes in the objective section. 17. The subjective section is well organized and appropriately concise: There is selection, summarization, and condensation of details. 18. The objective section does not contain theoretical concepts, biased opinions, or formulation discussion. Assessment (A) 19. The assessment integrates hypotheses that are consistent with the prior database. 20. The assessment does not introduce new data. 2 1 . The focus of the assessment is on the specific problem of the specific client: This is not an abstract essay about a theory. 22. The writer is not including all possible hypotheses, just the ones that are useful in developing intervention plans. 23. If theoretical jargon is used, it enhances rather than detracts from understanding and does not contribute to tautological explanations. 24. The writer is integrating material from the highest level of education thus far attained. Commonsense ideas are appropriate but are not sufficient for explaining the problem. 25. The writer demonstrates professional-level thinking and writing skills to provide a coherent conceptualization. 22 Table 1.5 (Continued) Plan (P) A Framework for Case Formulations 23 26. The plan is focused on resolving the identified problem and achieving outcome goals. 27. The plan follows logically from the assessment discussion and does not introduce new data or hypotheses. 28. There is clarity regarding process goals, intermediate objectives, strategies, specific techniques, relationship issues, and sequencing of interventions. 29. The plan is tailor-made for the specific client: Such factors as gender, ethnicity, and personal values are considered. 30. The plan is appropriate for the treatment setting, contractual agreements, and financial constraints. 3 1 . When there is more than one problem, the therapist addresses issues of priorities, sequencing, and integration of plans. 32. The therapist considers community resources and referrals, if appropriate. 33. Legal and ethical issues are addressed appropriately, if relevant. THE LEARNING PROCESS Learning case formulation skills can be fun, interesting, creative, and rewarding. The biggest obstacle to this being a pleasurable learning experience is that most students, by the time they get to graduate school, want to earn grades of A on their first try. It is hard to adjust to a learning-by-doing process. Although detailed instructions are necessary and useful, the way to learn is by submitting samples of your work and getting detailed feedback. Here is a piece of advice that former students asked me to pass on: "Do not put pressure on yourself to get it right the first time you try." The long list of standards can make the method seem overly complicated and difficult. However, the method is actually familiar to most professionals: We have all had extensive prior experience with the scientific method and with the development of problem-solving skills. You are not starting with a blank slate but instead are building on abilities and attitudes that you probably already have, including: • The ability to distinguish between data and theory and between evidence and conclusions. This skill can also be described as the ability to differentiate between sensory experience (what you saw and heard) and conceptualization (what you think). • The ability to generate hypotheses consistent with available data and to identify data needed to test hypotheses. • An attitude of relativism rather than dogmatism, which allows you to realize that there is more than one way to work with a client. Sometimes prior professional training has created habits that interfere with initial success with this method. For instance, attorneys integrate their reasoning and evidence, whereas the method in this book requires the evidence (data) to be 24 Getting Started presented first, without any reasoning (assessment). Mental health workers who write concise chart notes and protect the client's privacy by not providing too much specific content find it difficult to expand at length on both the client' s content (data) and their own thought processes (assessment). The learning process is much smoother when we accept that, as with most skills (as discussed under BL3 Skill Deficits or Lack of Competence), competence comes with experience, practice, and feedback. The development of case formulation skills is an ongoing, continual process, and improvement will occur in stages, as you gain more clinical experience and learn more about the clinical hypotheses. Chapters 3 through 9, on the clinical hypotheses, serve as an introduction or a review; they are not sufficient for learning a theory that you have never studied. Reading about ideas for treatment is not the same as learning how to implement those plans in therapy. Nevertheless, as a trainee, you will benefit from practicing conceptualization skills even when you are not yet skilled in all of the treatment approaches you will want to recommend. One thing that this book does not teach is how to convince your supervisors to endorse an integrative approach if they do not already lean in that direction. Many training programs will limit your ability to implement an integrative treatment plan. Luckily, the method in this book, while intended to promote integration of hypotheses, also serves well as a format for organizing your thoughts and plans in a single theoretical orientation. An anonymous student shared his thoughts about mastering case formulation skills: The improvement of my case formulation skills cannot be measured because I had none when this course began. To this point, I had not had any professor ask me to structure an analysis of a client in the way we did in this class. The method is reminiscent of my experience learning how to compose music. Without knowing how, l one day found myself writing music skillfully. I look back and realize that I learned to believe in myself. I feel the same way now about my case formulation skills. Developing an integrative case formulation is a task that requires a comprehensive knowledge base, strong analytic skills, and creativity. This creative process must occur anew with each client-that is what this book is going to teach. ACT I V I TY 1 . 1 W r i t i n g Yo u r B a se l i n e C a s e Fo r m u l at i o n R e p o rt Appendix I I I contains i nstructions for you to select a personal problem and write your first case formulation report, using the SOAP format on Form LA in Appendix I. This will give you a chance to apply the ideas in this chapter and evaluate your baseline performance before studying the 28 hypotheses in Part I I and the skills and standards in the chapters of Part I I I . r SUGGESTED READINGS A Framework for Case Formulations 25 American Psychiatric Association. (2002). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Arlington, VA: American Psychiatric Association. Lambert, M. J. (Ed.). (2004). Bergin and Garfield's handbook ofpsychotherapy and behavior change (5th ed.). Hoboken, NJ: Wiley. Theories of Psychotherapy Corsini, R. J. (2005). Current psychotherapies (7th ed.). Itasca, IL: F E. Peacock. Gurman, A. S., & Messer, S. B. (2003). Essential psychotherapies: Contemporary theory and practice (2nd ed.). New York: Guilford Press. Prochaska, J. 0., & Norcross, 1. C. (2002). Systems ofpsychotherapy: A transtheoretical analysis (5th ed.). Belmont, CA: Wadsworth. Sue, D. W., & Sue, D. (2002). Counseling the culturally diverse: Theory and practice (4th ed.). Hoboken, NJ: Wiley. Integrative Approaches Beitman, B. D. ( 1987). The structure of individual psychotherapy. New York: Guilford Press. Beutler, L. E., & Harwood, T. M. (2000). Prescriptive psychotherapy: A practical guide to systematic treatment selection. New York: Oxford University Press. Frances, A. J., Clarkin, J. F, & Perry, S. ( 1 984). Differential therapeutics in psychiatry: The art and science of treatment selection. New York: Brunner/Routledge. Frank, J., & Frank, 1. ( 1 99 1 ). Persuasion and healing: A comparative study ofpsychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press. Gendlin, E. ( 1 996). Focusing-oriented psychotherapy: A manual of the experiential method. New York: Guilford Press. Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). ( 1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association. Lazarus, A. ( 1 976) . Multimodal behavior therapy. New York: Springer. Norcross, 1. C. (Ed.). ( 1 987). Casebook of eclectic psychotherapy. New York: Brunner Maze!' Norcross, 1. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patient needs. New York: Oxford University Press. Norcross, J. c., & Goldfried, M. R. (2005). Handbook ofpsychotherapy integration (2nd ed.). New York: Oxford University Press. Stricker, G., & Gold, 1. R. ( 1 993). Comprehensive handbook ofpsychotherapy integration. New York: Plenum Press. Guides for Reports and Treatment Planning Johnson, S. L. (2003). Therapist's guide to clinical intervention: The J-2-3 's of treatment planning (2nd ed.). San Diego, CA: Academic Press. Jongsma, A. E., & Peterson, L. M. (2003). The complete adult psychotherapy treatmentplanner (3rd ed.). Hoboken, NJ: Wiley. Kennedy, 1. A. (2003). Fundamentals ofpsychiatric treatment planning (2nd ed.). Washington, DC: American Psychiatric Association. Maruish, M. E. (2002). Essentials of treatment planning. Hoboken, NJ: Wiley. Zuckerman, E. L. (2000). Clinician's thesaurus: The guidebook for writing psychological reports (5th ed.). New York: Guilford Press. Chapter 2 GATHERING DATA The quality of the entire case formulation rests on the therapist' s ability to gather a complete, unbiased database. This chapter addresses the clinical interview, which is the primary source for building a client database in outpatient settings. This chapter also provides helpful frameworks and tools for gathering and organizing data. DATA-GATHERING TASKS In an interview with a client, the tasks of gathering data, testing hypotheses, and providing helpful interventions are intertwined. This fluid and often circular process contrasts with the linear organization of data, explanations, and interventions in the formal case formulation report. Because the client undergoes change from the very first contact with the therapist, it is impossible to construct a pure database of how things were before the therapist entered the scene. For instance, the instillation of hope that occurs from making a phone call and setting an appointment with a therapist alters slightly the emotions and beliefs that are part of the client's presenting problem (the data). Furthermore, the very nature of the relationship, the personality of the therapist, and the context and setting of the interview all influence the data. In the context of seeking help from a culturally designated expert, the client will take the most neutral message from the therapist-a head nod, silence, or "uh-huh"-as an opinion, instruction, or advice. Even Carl Rogers selectively reinforced certain material and responded with less enthusiasm to other material; not surprisingly, the reinforced content increased in frequency and the other types of content decreased. The idea that the therapist can be a "blank screen" has largely been abandoned because it is widely recognized that a therapist' s distant, removed manner is far from neutral. Instead, clients experience this as cold and hostile. Part of your training should include feedback to develop an awareness of how other people perceive and respond to you. You also need to be aware of your values, emotional reactions, cognitive filters, defensive tendencies, and cultural factors (which may differ from those of the client) to prevent contaminating and biasing the data. Through supervision and consultation with more experienced 26 Gathering Data 27 therapists, as well as peers in a training program, you will learn how to interpret data from the unique interpersonal dynamics of your relationship with a specific client. Data Gathering from a "Not-Knowing" Position In many clinical settings, trainees are taught to conduct an intake from a predetermined outline, often with a questionnaire in hand. Even if not following a written outline, many interviewers structure questions according to the categories of the report they know they are going to have to write. These approaches not only restrict and shape the client' s content but also neglect the importance of the client's process: The "how" of the client's storytelling is a significant part of the database. It is important to gather data about how the client relates to a stranger, how she organizes her story, her approach to the help-seeking role, her degree of initiative or passivity, and so on. Freedman and Combs (1996) wrote: When we meet people for the first time, we want to understand the meaning of their stories for them. This means turning our backs on "expert" filters: not listening for chief complaints; not "gathering" the pertinent-to-us-as-experts bits of diagnostic information interspersed in their stories; not hearing their anecdotes as matrices within which resources are embedded; not listening for surface hints about what the core problem "really" is; and not comparing the selves they portray in their stories to normative standards. Instead, we try to put ourselves in the shoes of the people we work with and understand, from their perspective, in their languages, what has led them to seek our assistance. (p. 44) Expert filters and problem identification tasks are necessary, but they must be postponed until you grasp what it is like to be inside the client's reality. Empathic Relationship Research has consistently found that therapeutic success is facilitated by therapists who show warmth, understanding, and acceptance (Beutler, Machado, & Neufeldt, 1994; Lambert & Ogles, 2004). Empathic listening not only is a tool for effective data gathering but also a potent therapeutic factor. Lambert and Ogles (2004) even noted in their comprehensive review of the literature that relationship factors (e.g., trust, warmth, understanding, acceptance, kindness, and human wisdom) may have a greater effect on therapeutic change than do specific techniques (p. 1 8 1). People feel better when they have a chance to ventilate and to talk at length, without being rushed, while having the full attention of an empathic, patient listener who is calm, interested, respectful, concerned, and focused. If clients begin to trust that you are a caring human being, they are more likely to reveal parts of themselves that are usually hidden from others. However, when a therapist is working with a client from a different culture, the challenge 28 Getting Started to achieve and demonstrate understanding is greater and requires not only the knowledge found in texts on cultural diversity (e.g., T. B. Smith, 2004; D. W. Sue & Sue, 2002) but also the willingness to do research after your first encounter with a new client. Although the words gather data and interview probably evoke thoughts of asking questions, and questions are necessary for data gathering, they are not sufficient; questions must be balanced by statements-paraphrases, summaries, and reflections-that show your understanding of what the client is expressing. Such empathic reflection is powerful and effective because it accomplishes the following goals: • It develops rapport and helps the client feel understood, respected, and valued. • It gathers data with statements and serves the same function as an open question, getting the client to elaborate on a topic. • It makes clear to clients that they are the sole source of data regarding their internal world of feelings and thoughts. Avoid Premature "Fixing" Therapists' techniques fall into two broad categories: 1 . Exploring: You are receptive and curious, gathering data without trying to produce change. Your no-change agenda is to discover what is and to remind yourself of the explorer role with the saying, "take only photos and leave only footprints." 2. Intervening: You are consciously trying to intervene and help the client achieve goals. You have a change agenda. Restrain yourself from intervening until you have a formulation to guide you. In my experience, the biggest challenge for beginning therapists is to resist the impulse tofix the client. In my practice sessions, trainees are asked to go 1 5 minutes in pure exploratory mode and to end with a summary. The vast majority of trainees find it difficult to abstain from a change agenda and will sneak some advice and suggestions into their final sentences. Rushing to action violates the principles of good problem solving: gather data, identify problems, decide on goals, test hypotheses, and then move toward solutions. Intervening too quickly will cut short your data gathering, distort the data that you do gather, and, if your attempted solutions fail, undermine the client' s confidence in your abilities. Premature fixing may even send a disrespectful message to the client-as if the problem is so easy and he is so incompetentthat you can solve in 1 hour what he has possibly struggled with for months. You must start with data gathering and hypothesis testing as your primary tasks, and know that the interventions you plan will benefit from your patience. Gathering Data 29 Exploratory Questions Produce Change When you engage in competent data gathering, staying in a receptive, exploring mode, you are already engaged in a helpful process that will result in beneficial change. There is a paradox about exploring: The very act of patiently engaging in exploration is actually already an action. The metamessage is: Yourproblem can be understood and ifwe think together, we willfind solutions. From the client's point of view, the data-gathering process can be the beginning of new insights and ideas for constructive action. A skilled therapist blends listening and questioning in a way that causes important information to become explicit, exposing the complexity of a situation while also achieving clarity. Certain techniques of data gathering are challenging enough to produce beneficial change in the client because they get the client thinking in new ways. For instance, questions about past behavior, Didyou ask him aboutyourfeelings? carry the metamessage, Ifyou do that, things will be better. Basic questions like When did youfirstfeel that way? followed by What was happening in your life at that time ? make the client curious about causation. Furthermore, in the process of gathering information, you are teaching problem-solving skills-that before you can come up with plans, you need to gather information and then think about it. You are even modeling impulse control when you resist your client's demands to tell her, immediately, what to do. Use of Clinical Hypotheses There is no such thing as a complete database, and it takes experience to know what is "good enough." Beginners normally err in two directions: ( 1 ) jumping to a formulation with insufficient information or (2) postponing action while they pursue details that are not necessary for creating a good formulation. The use of clinical hypotheses helps you judge what data are necessary to evaluate the utility of various hypotheses and gives you a sound basis to decide that you have enough data to support a specific formulation. At the beginning of the first session, the client speaks freely and you begin to recognize that certain hypotheses seem to fit. As more information is revealed, some hypotheses are ruled out, while others are supported. As you explore these hypotheses, you focus the clinical interview on specific topics. If you recognize that several hypotheses fit the data, you begin to make judgments about which hypotheses will lead to the best treatment plans. To help in making these judgments, you need to gather even more data. New data appear in every session, providing information about the effectiveness of the treatment strategy, changes in the client's life situation, and new problems or goals that should be a focus of therapy. Trial Interventions Trial interventions allow the therapist to walk the line between data gathering and a change agenda. Such interventions are based on a specific hypothesis and are intended to gather data and test the validity of that hypothesis. Table 2. 1 30 Getting Started Table 2.1 Examples of Trial Interventions for Data-Gathering Purposes What would your husband say �f he were here ? Data desired: Does the client know the husband' s point of view or has she been mind reading (C2)? Does the client understand that two people have different points of view and that her view is not the "truth" (P3)? Possible benefits: The client could develop empathy for the husband. Possibilities for compromise and problem solving may become apparent. How would you feel about role-playing this situation ? I'll pretend to be your coworker and you can express whatever you think would be an effective approach to solving this problem. Then we can switch roles and you can show me how you think she will respond. Data desired: What is the quality of the client's communication skills (BL3)? How much anxiety does the client have about confrontation (BL2)? The activity can give data about what the other person' s behavior is like, which is useful for checking the validity of the client's interpretations (C3). Possible benefit: The client could become less anxious and more confident, recognize that she is exaggerating the level of her coworker' s hostility, and change some beliefs about how scary it is to confront a coworker. I wonder ifthere is a similarity between thefeelings you have with the group you are working with andfeelings you had with your brother and sisters when you were little. Data desired: The therapist is exploring whether there is a reenactment of the dynamics in the family of origin (P2). If there is a similarity, there is a likelihood of a self-fulfilling prophecy (C2). Possible benefit: The client could recognize that his response is part of a lifetime pattern. gives examples, with hypotheses indicated by their codes (refer to Chart II.A in Appendix II for the list of hypotheses with codes). Cultural Issues and Data Gathering Appendix I of the Diagnostic and Statistical Manual ofMental Disorders, fourth edition, text revision (DSM-IV-TR) provides guidelines for developing a cultural formulation, requiring that data be gathered in four categories: 1 . Cultural identity: Ethnic orcultural reference groups, degree ofinvolvement with both host and original culture, and language abilities and preferences. 2. Cultural explanations of illness: Idioms of distress, the meaning and perceived severity of symptoms, perceived causes and explanations; and preferences and experiences with types of care. 3. Culturalfactors related to psychosocial environment and levels offunctioning: Social stressors, supports, and role of religion and kin networks. 4. Cultural elements of the relationship between the individual and the clinician: Differences in culture and social status and possible difficulties these differences may cause in diagnosis and treatment. Gathering Data 31 Part of cultural competence is learning the importance of overcoming your unconscious biases and prejudices. You must treat each client as a unique individual and not make assumptions or impose stereotypes. When you gather data, you learn from the client' s own words how he describes his cultural identification, and you gather data to establish the level of acculturation of the client and his family members. You can learn about the specific cultural messages that have been internalized as well as those that have not been. You cannot generalize from the textbook summary of a culture to an understanding of the specific client in front of you. During the first session, you must not only gather important cultural data but also create good rapport and establish your credibility in a manner that is sensitive to the client's culture. After the first session with the client, it is impm'tant to start doing research on the cultural factors relevant to your client. For instance, if the client is a Japanese American who was born in this country in the past 65 years, you need to be aware of the impact of internment camps during World War II, not only on the people who endured the experience but also on their descendents. If the client comes from another country, you need to be eager to learn about that country' s history and culture (the topic of cultural competence is also addressed under hypothesis SCE2 in Chapter 9). Self-Report Questionnaires An inventory of depression or anxiety, such as Beck's Depression Inventory, provides a baseline of distress and can be readministered at various intervals to monitor progress and at the end of therapy to measure outcome and document improvement. The use of such scales is common with managed care companies seeking to increase accountability and researchers wanting to find empirical support for treatments. Other examples of questionnaires include a reinforcement survey, which allows the client to identify potential pleasurable experiences and rewards for behavioral interventions (BLl), and Adler's Lifestyle Questionnaire, which elicits information about the early family constellation (P2). Note Taking When therapists take continual notes throughout the intake, they interfere with the empathic, genuine human connection that facilitates the optimal flow of the client's story. A few notes are fine and shared note-taking activities are often productive. Some clients appreciate note-taking because it shows that an expert is listening and taking them seriously. However, a therapist who sits with a pad in hand, frantically trying to get down every word, is damaging the database, as well as the therapeutic rapport. In training settings, the ability to tape-record your therapy sessions reduces anxiety about, and usually builds trust in, the quality of your memory. 32 Getting Started INTAKE PROCESSES The term intake is commonly used for the initial session. In some mental health clinics, a staff member conducts a single intake interview, writes up an intake report, and presents the case at a staff meeting, where the client is assigned to a therapist. This separate intake process is necessary for screening for emergencies and for selecting an appropriate therapist, especially when there are trainees of differing levels of experience or when there are staff therapists with varying specializations. If this is the setup at your clinic, then from the client' s point of view, the first meeting with you represents a second intake session, and he may feel frustrated at having to start over again. Although the database already in the chart is useful, it would be a mistake for you to rely on it. Gather your own database, regardless of how much information you receive in a chart or staff meeting. Begin the first contact with a client by asking for the whole story to be told from the beginning. You should view your first two or three sessions as the intake: Inform the client that these sessions are an assessmentphase, after which you will offer recommendations for treatment. At that point, the client can accept, reject, negotiate, and learn about alternatives. With the "informed consent" ofthe client, a verbal contract exists for a certain type of therapy, and therapy begins. Realizing that there are a few sessions to arrive at a formulation takes the pressure off the first session; however, you still must use the first session to test the emergency hypotheses (Bl in Chapter 3 and CSI in Chapter 4). You need to rule out the need for crisis intervention, medical referral, hospitalization, mandated reporting, and other types of required action on your part. Once hypotheses of this nature are eliminated, you can view the data-gathering and hypothesis-generating process in a more leisurely and creative fashion. There are several sessions to get to know the person and to test relevant hypotheses, so you can create a pace that is "in tune" with the individual client. Otherwise, you are so preoccupied with the data-gathering task that it is easy to turn into an interrogator. Structuring Time A good initial session generally has three phases, providing a balance between structure and ambiguity. In the beginning, you should be as nondirective as possible, encouraging the client to tell the story, responding with empathy and interest. Then you can shift into focused exploration, gathering data while continuing to be empathic. Table 2.2 describes the phases in more detail. Interviewing Skills Because the clinical interview is the chief tool of data gathering, the quality of the data is dependent on the quality of the interviewer's skills. Therapists must have the capacity for empathy and the ability to make the client feel understood and valued. They must have the ability to describe the client' s process and understand the relationship, to gauge the credibility of the client as a source of in- Table 2.2 Three Phases of First Interviews Phase 1: Nondirective Data Gathering Gathering Data 33 Open-ended questions help the client begin his story without direction or structure. If a prompt is needed, invite the client to tell you what is troubling him or why he is seeking help at this time. You want the client's story to flow, unobstructed, in his own words and style. To see if the client feels understood, check with him by paraphrasing periodically. If you ask a direct question, it must be vague enough to let the client choose the direction. In the first phase of the first interview, try to let go of expert filters and to keep an open mind so that you gather data without influencing it. Good rapport is your first priority. Phase 2: Focused Exploration Your goal is to begin to identify problems and outcomes and get relevant information for the timelines of recent and past history. When you choose to probe a specific area, it is important to create a bridge to what the client has been saying, rather than to switch into an interrogator mode. The therapist processes the client' s information through the filters of hypotheses. When a specific hypothesis seems to fit, the therapist focuses the interview to gather specific data to test that hypothesis. Phase 3: Closing The therapist keeps track of time without being rude or distracting (it helps to have a table or wall clock that you can see while facing the client.) Near the end of the session, if an important topic, such as substance abuse, has been overlooked, you can ask direct questions. You might give a summary of what you've learned about the client, allowing the client to react to it and correct it, if necessary. Part of what you say may include elements of the case formulation: You can clarify problem titles and outcome goals and offer your own formulation hunches. At the end of the session, address certain business issues such as scheduling the next appointment, information about clinic policies and procedures, and fees. formation, and also to glean data from the client's behavior. They also need skills to ask focused questions, without biasing the answers, to explore hypotheses. As a therapist, you need to be competent in two styles and to be aware of the process in which you are engaged: 1 . Tracking: You follow what the client says, with minimal intervention on your part, allowing the client to tell the story freely, in his or her own style, without interference. Your verbal responses follow directly from what the client just said; you do not make a leap to a different topic. You make efforts to match the client's tempo, choice of language, and body posture. 2. Leading: You direct the client toward a focus of your choosing so that you can gather specific data, test hypotheses, make necessary evaluations, and develop your formulation. You have the ability to use both open and closed questions, as well as statements, to direct the flow of the interview. Although those styles may mingle in your exploration, each response you make should be clearly one or the other, or the client will pick up mixed messages. In addition, you need to be able to tolerate silence-not only permitting several beats after the client stops talking but also allowing a period of a 34 Getting Started minute or more, for the client to reflect on what is said and have a pause, which allows her to take the initiative. When you feel it appropriate to break a silence, your prompt should invite the client to share what was going on inside rather than introduce a change of topic. Exploring a Specific Problem When you are ready to sit down and start working on your case formulation, your first two tasks will be problem identification and specification of outcome goals, so the most important topics during the intake process are what brings the client to therapy right now and what he or she hopes to gain. Table 2.3 shows four "frames" (Linden, 1998) for exploring a specific problem: (1) the problem, (2) the outcome, (3) the obstacles, and (4) the resources. The most commonly used frame in clinical practice is the problem frame, focusing on "what's wrong" and the etiology of the problem-events in the past that help explain causation. Often neglected is the outcome frame-the picture of the desired future. Clarifying realistic, achievable goals helps define the problem, provides specific goals for treatment, and instills hope in clients. Once a problem is explored and a desirable future state is identified, some clients will realize they already have the resources to attain their goals. However, when there is a gap between the present problem state and the desired future, it is useful to focus on obstacles and resources. What barriers, both internal and external, exist? What would it take for the client to achieve the desired outcome? One of the most useful tools for organizing data about the presenting problem and its development is the use of a recent history timeline-a horizontal line with the right end representing the present moment in time and the left end a designated amount of time prior to now. In inpatient settings, using the acronym PTA (prior to admission) is convenient shorthand for reporting time sequences. The following is a sample for a client referred for problems with handling stress. -8 -7 -6 -5 Using the BASIC SID -4 Months -3 -2 -1 Arnold Lazarus (1981) created the acronym, BASIC ID, which stands for seven modalities: Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal, and Drug/Biology (the letter D instead of B was chosen for the last letter as a humorous reference to the id of Freudian theory). A growing awareness of the spiritual and religious issues that come up in therapy (Richards & Bergin, 2000; Shafranske, 1996; Sperry, 2001) supports the addition of the Spiritual domain to the BASIC ID, making the acronym BASIC SID. Table 2.4 explains the eight do- Table 2.3 Four Frames for Exploring a Specific Problem Problem What' s wrong? Since when? Why now? Outcome What do you want? Obstacles Barriers to getting what you want. Resources What would help you get what you want? Description of the problem: What are the complaints, symptoms, signs of distress? What is the "operational definition" of the problem behavior? When and how was the onset? Are there specific precipitating events? External stressors? Positive changes that tax an individual' s coping abilities? What was time and cause of onset ( if acute)? A specific event that triggered the presenting problem? A turning point when the problems began? What has been the course of development of the problem? If the problem seems to be chronic, look for the point in time when things started becoming worse. Specific details of progressive deterioration: Look for evidence of downward spirals. Do poor efforts to solve problems create new problems? Does increased stress lead to greater cognitive distortions followed by increased disorganization of behavior? What is the history? Are there prior episodes and early relevant experiences? When has the problem not occurred? Are there examples of successful coping? What has the client already done to try to solve this? What has been helpful? What has made things worse? Are there examples of independent use of resources? How would things be different if the problem were resolved? What do you desire for the future? What is your vision of how it would be if the problem were solved? What are the outcome goals? If you woke up tomorrow morning and the problem was gone, how would your life be different? Describe what the day would be like. What prevents the achievement of your desired goals? What stops you? How do you stop yourself ? Are there internal barriers in the form of thoughts or feelings? Are there external, environmental obstacles and barriers? Are there family members who are creating obstacles? Are there social or cultural barriers? What coping skills do you already have that can be applied to solving the problem and achieving the desired outcome? What strengths and assets have you demonstrated in the past that will help you with this problem? Have you been successful before in a similar situation? What social supports are available? Are there environmental changes or material tools that would help? What knowledge do you need? What community resources could help? What new skills are needed? 35 Table 2.4 The BASIC SID: An Adaptation of Lazarus's BASIC ID B A s I c 36 Category Behavior What the person is doing and not doing; what others can observe; the quality of skills. Affect Internal experience and overt verbal and nonverbal expression of feelings. Sensation Awareness of the body; use of senses; sensory data with minimal filtering through cognition. Imagery Mental imagery, about past, present, or future; fantasies and dreams. Cognitive Constructed meaning; self-talk; beliefs and schemas; information-processing skills and other mental abilities. Examples of Data Specific description of observable behavior. Excessive behaviors-occur too intensely or frequently. Skills that are present or absent. Activities that are engaged in or avoided. The term affect in the Mental Status Exam refers to observed manifestations of feelings; here it has a broader meaning. Mood (the subjective state) and congruence or incongruence with outward expressions. Level of awareness of own feelings. Level of expression of feelings to others. The labels for feelings that are experienced. Functioning of sensory organs. Presence of hallucinations or perceptual illusions. Presence of pain or muscular tension. Excessive sensitivity to environmental stimuli. What the person heard (use quotations) and saw (concrete experiential data). Obsessive mental images. Disturbing nightmares. Distorted body image. Flashbacks of past trauma. Responses to guided imagery activity. Content of thought (e.g., ideas expressed; self-talk). Process of thought (e.g., tangential or circumstantial). Style of thinking (e.g., rigid or flexible). Errors of logic and reason (e.g., overgen­ eralization). Quality of cognitive skills (e.g., problem solving). Cognitive symptoms (e.g., obsessions about contamination). Description of beliefs, standards, assumptions, expectations, and rules. Table 2.4 (Continued) s I D Category Spiritual Spirit or soul; religion as well as nonreligious aspects of spirituality; creativity; moral issues; and the lack of spirituality. Interpersonal Relationships with others; family; membership in social groups; cultural factors; and issues of social injustice. Drug and Biological Physiology, biology, genetics, medical issues; use of legal and illegal drugs, including alcohol. Gathering Data 37 Examples of Data Beliefs regarding Supreme Being. Identification with religious group. Spiritual and religious practices, private and communal. Spiritual resources and activities (e.g., meditation, nature, and creativity). Conscience, moral code, guilt, forgiveness. Degree of social isolation and social support. Quality of relationships: family, friendship, and work. Presence of socially unacceptable behavior. Cultural/ethnic/racial identity. Level of acculturation. Experiences with racism and social oppression. Level of interpersonal skills. Use of alcohol and illegal substances. Use of prescription medications. Degree of compliance with medical instructions. Symptoms of delirium or dementia. State of health, presence of illness. Problems with weight, eating, or biological effects of stress. mains, providing examples of data. Form I.B in Appendix I is a blank chart for you to copy and use with your clients. Having an acronym assures that you are being thorough and comprehensive in your data gathering. We all have a tendency to view client problems through a preferred lens, and by using eight different lenses, you are less likely to overlook important information. Use the BASIC SID between sessions to review the data you have gathered and to set goals for future exploration. It can also operate as a template in your mind as you face the client. When you are ready to focus the exploration, you mentally review the acronym: Which modalities has the client already described? What other modalities would I like to learn about? Remember that it is less important to identify the "right" category for a specific bit of information than it is to be thorough. For instance, descriptions of social behavior fit under Behavior as well as Interpersonal; hallucinations are a disturbance of sensory processing (Sensation) as well as the creation of mental images (Imagery). 38 Getting Started Table 2.5 gives an example of the BASIC SID as a data-gathering guide for a client whose main complaint was "procrastination"-defined with the problem title: Difficulty completing an important project. ACT I V I T Y 2 . 1 Pract i c e w i t h t h e B A S I C S I D This activity i n Appendix I I I asks you to use the BASIC SID o n yourself and then with a partner. Internal Processing It is important to have tools to understand the client's internal processinghow the client links thoughts, feelings, images, and sensations. The founders of Neurolinguistic Programming (NLP; Bandler & Grinder, 1 990; CameronBandler, 1985) were interested in how people encode and program their experience, through words, pictures, sounds, emotions, movements, and sensations. They use the term representational systems (rep system for short) for the different modalities for storing and processing experiences. A small proportion of experience is represented through taste and smell; the majority of our sensing occurs through sight (visual), hearing (auditory), and awareness of emotions and the body ( kinesthetic). For therapists to communicate and organize these types of data, it is convenient to use the letters V, A, K as shorthand. • Visual (V): What we see in the external environment and our internal visual imagery. • Auditory (A): External and internal sounds, including the voices of our internal speech. • Kinesthetic (K): Experiences in our bodies, including emotions, bodily sensations, movement, and the sense of touch. Laborde ( 1987) provides a metaphor that explains how rep systems work: It is as if each of us were an elaborate television set with five recording devices tuned to pick up five different stations. One station transmits only sound, another only pictures. One sends feelings, and the last two stations send tastes and smells. We have only one screen for our conscious mind. We switch from station to station, favoring one at a time over the others. All the information from the other four channels is being recorded, but not tended to consciously. (p. 52) To continue this metaphor, consider the possibility that people tend to trust one station more than the others. They pay attention to data, retrieve memories, and communicate with words from their preferred modality. Table 2.5 Data Gathering, Using the BASIC SID, for Difficulty Completing Project Behavior What specifically does she do to avoid working on the project? What exactly are her behaviors when she enters her office and faces the computer? What writing skills might she be lacking? Does she know how to use practical skills of time and project management? Can she break the task into " baby steps" and set reasonable goals for a specific time period? Identify specific excess behaviors: what are antecedents (triggers) and consequences (reinforcers)? Identify deficient or absent (desired) behaviors: Are they in the client' s behavioral repertoire? Affect Insert feeling words to fit in this frame: You feel ______ because of your difficulties completing your project. Are there symptoms of depression or anxiety interfering with her work? Is her productivity related to specific mood states? Does she have control over the ability to access a confident, productive emotional state? What are sources of her fears? In what ways does anger, towards self and towards others, contribute to her difficulties? Sensation What form does the anxiety take? Where in her body does she experience tension? Is there physical discomfort associated with sitting at the computer? What visual input from the environment affects the problem? What auditory input from the environment affects the problem? Has she gathered sensory data about her assumptions? What specifically has she been told would happen if she doesn' t complete it by a certain date? Imagery Are there visual images that either impede or facilitate the process? Can she visualize herself actually holding the completed document in her hand? What images come to mind when she thinks of earlier experiences in her life working on a major project? Has she had any dreams lately? Cognitive What kind of self-talk does she have when she sits down to work on the project? What does completing this project mean to her? Does she value other activities more than completing the project? What kinds of underlying schemas does she have about success, achievement, and perfectionism? What is her explanation for her difficulties? What ideas does she have about the problem and a possible solution? What shoulds and can'ts are involved? (continued) 39 40 Getting Started Table 2.5 (Continued) Spiritual Is she forcing herself to work every day, or is she allowing herself a guilt-free Sabbath day of rest? Does she believe in a higher power and can that belief serve as a resource in dealing with this problem? What spiritual needs are being neglected during this period of hard work and stress? Is it possible that there is a moral dilemma that is keeping her "stuck"? Interpersonal What rewards and punishments do people in her social world offer her, related to working or not working on her project? What do other people actually say to her about her work, her problem, her topic? In terms of her culture, what does completion mean? Will her social role change when she completes the project? Does "finishing" and "not finishing" have an impact on her family system? How does her relationship with boss and/or coworkers affect completion of this project? Drug and Biology Are there health issues that might be interfering? How is her sleep and appetite? Is she using alcohol or drugs? Could she benefit from some kind of pharmacological agent? Beginner therapists commonly ask, How do you feel? This practice taps into the client's kinesthetic modality. Instead, it is preferable to ask neutral questions such as What are you experiencing? so that you do not unintentionally direct the client into a particular sensory modality. Therapists should learn about their own preferred rep system, develop skills in identifying the preferred rep system of a client, and have the flexibility to create verbal responses from all rep systems. Table 2.6 presents five important applications of V-A-K awareness for the data-gathering process. More about internal processing is discussed in Chapter 5 under BLI Antecedents and Consequences: In conducting a behavioral analysis, consider not only the client's self-talk and other cognitive mediation but also how her internal processing of sensory information affects both problem and desired behaviors. Metamodel Questions The developers of NLP made a huge contribution when they explained how people create faulty mental maps of reality, failing to test their linguistic/cognitive models against the experience of their senses. Neurolinguistic Programming practitioners use the term metaperspective to describe the understanding that a representation of reality is not the same as reality-"the map is not the territory" and "the menu is not the meal." Table 2.6 Representational Systems (V-A-K) and Data Gathering Identifying the Client's Leading Representational System Some clients will tell their story using all possible modalities. Others will rely primarily on one, which can be called the "primary" or leading representational (rep) system. As clients tell stories, without direction or interruption, you can identify the leading system and recognize which modalities are neglected. Developing Good Rapport Good rapport is developed by matching the rep system that the client is using. For instance, when a therapist wants to communicate understanding, there are different ways to word the message: V: I see what you mean or I can picture that clearly. A: I hear you or That sounds right. K: I grasp what you mean or That feels right. People who rely on the visual modality are forming pictures in their minds. It is possible that if you lock eyes with such a client in an attempt to make good eye contact, you will be interfering with her internal processing. Exploring Underused Representational Systems At an appropriate time, you can lead the client with a specific question into the underused system. For instance, you can ask a person who leads with the auditory system, What pictures come to mind? What are you feeling right now? A person who is very emotional and describes events in colorful visual impressions could be asked auditory questions: What were you hearing during the argument? What were you saying to yourself ? You can also give homework assignments that force a person to attend to a neglected modality. By leading the person into a different modality, you gather data and at the same time, expand awareness. The underused rep system often carries the very resources that the person needs to solve a problem. Responding after a Period of Silence If the client is barraged with your questions and quick verbal responses, there is no time for internal processing during the session. Explain to the client that you will not always have a response and that it is okay to take time to process (a neutral word) what is being experienced. If you break the silence with an invitation, you can word it neutrally, yet show your interest in understanding the internal experience: I wonder what you're experiencing now? Would you be willing to share what's going on inside? Eye Movement as Clues to Internal Processing NLP practitioners suggest eye movements provide clues to the type of internal data that is being accessed. Upward eye movements reflect visual processing, and lowered eyes occur when the person is either experiencing feelings or accessing internal speech. By attending to the client's eye movements as they correspond to the different types of content in the session, you can determine if there are reliable eye movement clues for this particular individual' s internal processing. When the client i s silent, i t i s useful t o attend t o eye movement for two reasons: ( 1 ) It convinces you that "something is going on in there." Many beginning therapists get anxious during silence because they think "nothing is happening," and then think "it's my responsibility to make something happen." (2) It gives you clues on how to break a silence and show empathic attunement. For instance, if you know your client' s eyes go up when she is visualizing, and you see that movement during silence, you can gently ask, Are you picturing something you ' d care to share with me? 41 42 Getting Started Bandler and Grinder ( 1990) explain that because we use words to store, file, and retrieve our experiences, there is a natural tendency to delete (eliminate information), generalize (ignore differences), and distort (classify information arbitrarily or erroneously). Furthermore, because we code in words, we can only code those events for which we have words. There is an inevitable gap between a person' s model of the world (recognized through the use of language) and his or her real-world experiences. To reduce this gap, the therapist needs a set oftools for recognizing, exploring, and challenging the information presented by the client. To meet this goal, Bandler and Grinder created a set of linguistic information-gathering tools that they called the Metamodel. They defined a set of nine categories of deletion, overgeneralization, and distortion, which together can be called "metamodel violations" (the word "violation" means that there is an insufficiency in the verbalized cognitive map). The therapist's task is to search for specific data about concrete experience, moving the client from the cognitive level to sensory information. For instance, when a client says that she is ending a friendship with her best girlfriend because she betrayed me, the therapist asks How specifically did she betray you ? Here are examples of two different types of answers: 1 . Cognitive answer (no sensory data): She was very disloyal. She showed me that she is completely untrustworthy. 2. Sensory-specific answer: She told me that she is dating my ex-boyfriend. You want the client's answer to be "fully specified," containing enough concrete sensory data to be a clear statement about reality. Some clients reveal very little concrete information, seeming to be accessing stored language and meaning systems rather than sensory data. These clients are storing sensory experience but they will need direction to access it. Metamodel questions, presented in Table 2.7, provide tools for achieving this direction. They gather data and challenge the client to recognize her own faulty thinking, often leading to new discoveries. Consider the following response to the question above: Insightful answer: Iguess I'm wrong to say that she betrayed me. Ibroke up with him 10 years ago, and I never told her I still have anyfeelingsfor him. For each category of "violation," there is a specific type of question. Table 2.7 presents the Metamodel with sample questions and answers for each category. You will realize that the client's words can be classified in more than one category and could be responded to with different questions. Furthermore, the answers could be followed up with additional questions to get more specific sensory-specific data. Table 2.7 Metamodel Questions Metamodel Violation Examples Deletion Some details are missing. Use brief information gathering questions like where, when, of what, by whom. Lack of Referential Index Vague pronoun, vague plural or abstract noun. Ask for identification of the specific people or things that are being referred to. Unspecified Verb Vague about the observable actions and behaviors. Ask how to elicit specific actions and behaviors. Client's Words Metamodel Question Sensory-Specific Answer Client's Words Metamodel Question Sensory-Specific Answer Client's Words Metamodel Question Sensory-Specific Answer Nominalization Client's Words An ongoing process that is Metamodel Question turned into a static thing by using an abstract noun. Avoid repeating the noun and Sensory-Specific Answer ask the unspecified verb question. Universal Quantifier Client's Words Overgeneralization; all- Metamodel Question or-nothing thinking. Exaggerate the word or ask for an exception. In the Sensory-Specific Answer answer, the client either recognizes it is as an overgeneralization or provides information to prove that it is valid representation of experience. Modal Operator Imposed limits; shoulds and can'ts. I. For can'ts-Search for obstacle. II. For shoulds-Examine imagined consequences of not obeying "should." Client's Words Metamodel Question Sensory-Specific Answer I am afraid. Of what, specifically? That he will say something mean to me. Men can't be trusted. Which man, specifically, can't you trust? I can't trust Joe, I caught him in several lies. He bullies other kids. How specifically does he bully them? He threatens to hit them if they don't give him some of their lunch. Our relationship is dull. How specifically are you relating? We spend the evenings and weekends in separate rooms watching different TVs. I'm never included. Never? Have you ever been included? Example 1: I can remember two times when they invited me. Example 2: No, and once when I asked if I could come, they said, "No, we don't want your company." I. I can't tell him how I feel. II. I have to spend every Sunday with my mother. I. What stops you? II. What would happen if you didn't? I. I have a fear of discovering that I care more than he does. II. My mother will complain about what a bad son I am. (continued) 43 44 Getting Started Table 2.7 (Continued) Metamodel Violation Mind Reading Making assumptions about another person's feelings, thoughts, or intentions. Search for sensory data which support the assumption; this can challenge the client to stop mind reading. Cause-Effect Errors There is a faulty assumption that A causes B, or that A prevents B. A common example is "another person makes me feel something" or "I would do it but ____ Challenge the causal link and search for disconfirming data; you may need to ask several questions to get the client to recognize that there is no proof of causation. Lost Performative Imposed values; an unexamined platitude. Inquire about source of belief. You want the client to challenge the truth of the statement or take responsibility for choosing it as a personal value or preference. Examples Client's Words Metamodel Question Sensory-Specific Answer Client's Words Metamodel Question Sensory-Specific Answer Client's Words Metamodel Question Sensory-Specific Answer He wants me to fail. How specifically do you know? Example 1: I guess I don't really know, I never asked him how he feels about it. Example 2: He told me that he hopes I don't pass the test. She makes me feel guilty. How are your guilty feelings caused by her? (Have you ever not felt guilty when she said that? Could you imagine feeling differently?) I guess I let her get to me, I suppose I could just feel sorry for her. Vacations are a waste of money. According to whom? Example 1: My parents always said that, but they were very poor, and I have lots of money and can decide to spend it the way I want. Example 2: According to me. I prefer to spend money on remodeling my home. It takes several hours of drill for metamodel skills to become automatic. You listen to a sentence and then practice asking the right kind of question remembering that each sentence probably can be challenged in different ways. An answer invites another question, until the answer is sufficiently concrete and specific or the client recognizes the gap between belief and evidence. You would not bombard a client with question after question, but in a practice drill, the goal is to learn the metamodel rather than to develop sensitive counseling skills. The reward for this effort is that you can never again not take the metaperspective. At that point, you discover that there are many ways, besides metamodel questions, to move away from cognitive labeling and descriptions to the real experiences: Gathering Data 45 • Tell me the whole story ofthe argumentyou had, startingfrom the beginning. • IfI were watching you on TV, what would I be seeing? • What is your definition of that word? • Could you give me some examples? • What specific actions and behaviors were you observing? ACT I V I TY 2 . 2 Meta m o d e l P r a c t i c e This activity in Appendix I I I asks you to practice t h e skills from Table 2 . 7 o n a list of client statements. EXPLORATION OF THE COGNITIVE DOMAIN You may have noticed that the question "why" is not one of the metamodel questions. That is because " why" asks for the client's reasons and explanations, which are elements of the cognitive rather than the sensory domain. There are other tactics for exploring the extremely broad and complex domain of thinking. There are many types of cognitive contents (e.g., belief, delusion, or superstition) and cognitive processes (e.g., deciding, blaming, or judging) that therapists can help clients identify and explore. The following list, although no means complete, shows the wide variety of cognitive concepts: Abstractions Dogmas Perceptions Appraisal Expectations Philosophy Aspirations Evaluations Prediction Assumptions Formulation Premises Attributions Hypotheses Presuppositions Beliefs Ideas Principles Categorize Ideology Processing of information Classify Inferences Realizations Comprehension Insight Reasoning Conceptualize Interpretations Rules Conclusion Judgments Stereotypes Constructs Knowledge Superstition Convictions Logic Theories Decision Meaning Thoughts Deductions Obsession Understanding Delusions Opinions Values Notice how in the following questions the insertion of a cognitive word makes it clear to the client that you are interested in his unique belief system and thought processes. 46 Getting Started • What are the rules you have regardingfirst dates? • What are your values about spending money? • What inferences (or conclusions) did you drawfrom his behavior? • What meaning do you give Valentine 's Day cards? • What kind ofreasoning led you to conclude that he intended to marry you? • What kind ofphilosophy do you have regarding child rearing? • How do you interpret that? • Tell me about how youformed thesejudgments ofhim? • On what do you base that opinion? • What insights did you gainfrom your prior therapy? These questions strengthen the awareness of the client that she is the one who is constructing her reality; they are very effective with people who let emotions dominate reason. Cognitive Empathy In learning the skill of empathic reflection, trainees recognize the importance of understanding the emotional domain and using feeling words. To help clarify the cognitive domain, the response should have a cognitive word preceding the summary of the client's core meaning. Instead of saying So you feel very hurt because he rejected you, you insert a word that emphasizes the client's thinking, and say So youfeel very hurt because you interpreted his behavior to be rejection. If the client says "If he cared, he would have visited me in the hospital," you can respond: Your assumption is that if a person cares, he would just want to come visit, or One ofyour rulesforfriendship is that "ifyou care about a person, when they 're sick, you have to pay a visit. " Personal Meaning Another task in exploring the cognitive domain is to become familiar with your client's unique "dictionary." Be cautious about making assumptions that you understand what a person means just because you understand a word: The same word often means different things to different people. Ask for a definition or for examples when you wish to clarify a word's meaning. For instance, if the client says she wants to become more "independent," you could offer any of these responses: • Explain what you mean by independent. • What are some things you would be doing ifyou were more independent? • What's an example ofa time when you didfeel independent? Gathering Data 47 Take the attitude that you want to learn and understand and be alert to the possibility that your client might construe your question as a criticism-as if he chose the wrong word. Often it helps to explain ahead of time the concept of "personal definitions" and the importance of not making assumptions but rather understanding exactly what the client means. George Kelly ( 1 955), one of the earliest modern theorists to explore the importance of the cognitive model of the world, used the term personal construct. His premise was that if you can make the client aware of how he has constructed his own meaning in life, you can give him the tools to choose alternate ways of viewing his existence. A construct is a bipolar dimension, or dichotomy, such as "good-bad," "strong-weak," and "active-passive." The constructs that a person uses have significance for what he views as possible and desirable. Kelly advises us: To understand what your client means by a certain word, ask what the polar opposite would be. Be sure that you understand which pole is good and which is bad. As a demonstration of this idea, cover the words on the right with your hand. Then examine the adjectives on the left and write down a word that represents the opposite of each, for you. Don't just quickly respond with an automatic antonym but rather think about the meaning for your life experience. Aggressive Humorous Lazy Compulsive Passive, supportive, polite Serious, boring, solemn Ambitious, driven, productive Spontaneous, disorganized, flexible Note whether your choice of opposite was listed. Kelly ( 1955) believed that the most important constructs were developed with our families of origin and could be discovered by examining all the important people in your childhood in groups of three, asking "How are two of them alike and different from the third?" By writing down the word that describes the similar pair and the word that describes the third person, you arrive at a list of the bipolar constructs through which you filter experience. Cognitive Classification Systems To fully explore an individual's unique cognitive map, you need to know his or her classification systems. Any word or concept is part of a "cognitive family tree": The word has a "parent" category (a broader, more abstract concept of which it is an example); it has "siblings" (other members of that category, which are analogous or parallel); and it has "children" (component attributes or concrete examples). 48 Getting Started That means there are three directions you need to explore-up, across, and down-which in information-processing terms is chunking. Here is an example of the chunking process for the word dog. • Chunking down: Getting more specific, giving concrete attributes or examples: a brown dog, a tame dog, or a pug. • Chunking up: Finding superordinate categories into which the concept fits. The dog can be viewed as a canine, a domestic animal, a pet, a belovedfamily member, an object offear, an annoying responsibility that keep me from traveling, or a nuisance that makes noise and keeps me awake. When you are given two examples of an event or behavior, and you ask "How are those two similar?" you are instructing the client to "chunk up." • Chunking across: Seeking other examples in the same category: Dog and cat (pets), Dog and airplanes (things I'm afraid of), Dog and wolf(canines). It is unlikely that the therapist and client have the same classification system for a word-this is especially true when the client comes from a different culture. Table 2.8 shows the kinds of questions you would ask to explore the cognitive space surrounding a specific concept. Asking chunking-type questions balance exploring and intervening. You are looking for data from the client's classification system, but usually the answer isn't readily available for retrieval. Instead, the client is pushed to think in new ways. Your questions are modeling an analytic approach and will move the conversation toward effective abstract thinking. The technique of reframing, explained in Chapter 6, is based on the process of chunking. When you ask the client Can you think ofany way that this is a good thing, not a problem? or What is the positive intention underlying this negative behavior? you are asking him to chunk up, but to move from the current frame (bad things) to a different one (good things). THE CLINICIAN AS OBJECTIVE OBSERVER One of the most important rules for the first interview is to start by letting clients tell their stories in their own way. By asking an open question about the client' s reasons for seeking therapy, you provide some ambiguity. You can then observe how the client responds to the lack of structure: how coherent the story is, whether the thought associations are tight or loose, and whether the connections between ideas are tangential, circumstantial, or appropriate. Your task is to describe the mental status of the client and to evaluate the type of relationship the client forms with you, a stranger and a helping professional. The Mental Status Exam (MSE; see Appendix II, Chart ILC) provides the clinician with a specific vocabulary and set categories of information to describe a client. This information is not raw data, but rather data that an experienced clinician has processed and evaluated. You take the client's story, as well as your own observations, and form certain conclusions, applying a technical vocabulary. For in- Gathering Data 49 Table 2.8 Exploring Cognitive Classification Systems THE CLIENT'S CONCEPT: "MY HUSBAND'S ANGER PROBLEM." Cbunking Down (Getting More Concrete) Can you give me a specific example? (He punches his hand in the door and there is a hole there now.) How, specifically, does he show anger? (He yells and hits property, but doesn't hit people.) In what specific contexts does it occur: where, when, with whom? (At home with family, never at work.) What is the entire sequence of events from the minute he walks in the door to the moment of the anger outburst? (Client describes events, including her own behavior, and may recognize how she provokes him.) Cbunking Up (Getting More Abstract) How would you categorize that behavior? (It is abusive, infantile, or a risk factor for a heart attack.) What is the significance of this problem to you? ( Makes me want a divorce; leads me to avoid sex.) Do you view this as something that can be changed? (No, it is an unchangeable personality trait; yes, if he chooses to exercise self control.) You say he has this anger problem and earlier you said that he thinks you nag him too much. Can there be any relation between these two things? (Both are things we do that push the other away, both are ways that we resemble our parents, both are things that we want to change about the other.) What does his anger stem from? (He has trouble putting his feelings into words. He can't handle any frustration. He had an abusive father.) What need does it meet or what purpose does it serve? (He gets to blow off steam in a safe environment. It lets him put the blame on others and avoid responsibility. It allows him to feel powerful instead of weak. He really wants to divorce me but wants me to be the one who takes the first step.) Chunking Across Referring to higher category that has been mentioned: Are there other examples besides angry outbursts? (No, otherwise he' s a kind and considerate husband; yes, he jeopardizes his health by unhealthy eating and lack of exercise.) Looking for opposites and exceptions: Can you think of situations when he didn't get angry when you expected him to? (When he was drinking water instead of alcohol, when I cook him a special meal.) Looking for metaphors and analogies: If you were to describe his style of anger as a particular animal, what would it be? (A shark, a Chihuahua.) When you feel the same way he does, how do you express it? (The same way that he does, the "silent treatment.") stance, the term mood refers to the client's description of his feeling state, whereas the term affect refers to the reactions and expressions observed by the clinician. Inappropriate affect is a judgment that involves comparing the affect with the content of the client's story. Zuckerman (2000) wrote a guide to reportwriting that provides numerous examples of terminology for putting clinical observations into words. 50 Getting Started The MSE is often described as assessment. However, this does not Inean that it belongs in the assessment (A) section of the SOAP. Relnember that the assessment section contains explanations of the problem, leading to a plan. The MSE contains descriptive terms applied by a professional expert (you) without conceptualizing or diagnosing. It therefore belongs in the objective (0) section of the SOAP (subjective data, objective data, assessment, and plan). Each clinical setting will have its own preferred outline for the MSE. Appendix II, Chart II.C presents 15 categories with examples. Because the MSE is usually taught for use with patients with severe pathology, it is generally more difficult to describe a "normal" client than to describe one with pathology. To build objective observation skills, it is helpful to practice perceiving and describing people outside of clinical situations-something you can do when you're at a social gathering or a staff meeting at work. Objective data is only as good as the awareness and competence of the clinician. Therapists need training and experience to be able to describe their clients with accuracy. The objectivity of the therapist can be compromised for many reasons: The client may remind the therapist of someone else, the client's issue may be similar to the therapist's unresolved conflicts, or strong needs or fears of the therapist may be aroused in the session. The term countertransference is a useful label for the variety of reasons why experienced and well-trained therapists might distort, misperceive, and bias the database. Although this term originates with psychodynamic theorists, it has become a widely used label for personal reactions of therapists. Countertransference is not necessarily an obstacle to professional competence. If the therapist has insight and self-control, these reactions can be a valuable source of data about the client. When therapists tune into their feelings and impulses with a client, they can access important information: • Clues to how other people may respond to the client. • Clues to the role in which the client tends to put others. • Clues tofeelings that the client may not be acknowledging in himself After a session, and preferably in front of a video recording of it, you can explore what you were truly thinking and feeling at various points of the interview. The skills of recognizing and understanding such countertransference must be built into every training program. Trainees can watch videos of clients expressing especially difficult emotions (e.g., hostility, rage, dependency, helplessness, or seductiveness) and compare the accuracy of their perception and their emotional reactions with other members of the training group. CLIENT HISTORY In the typical intake or case history report, the client's history is organized into categories such as those appearing in Appendix II, Chart II.D: Identifying information, Gathering Data 51 presenting problem (and reason for referral), current situation, prior psychological treatment, family history, educational and occupational history, social and sexual history, and other topics, when relevant, such as military history. When using the problem-oriented method (POM), data that apply to a specific problem title should be placed in the S section under that title. As discussed in the previous Intake Processes section, you are encouraged to allow the interview to flow in a way that keeps the focus on the client and allows information to be revealed as part of the spontaneous storytelling. Although you may worry that information needed on paperwork may be missed if you don't follow an outline of topics, even more information will elnerge if you focus on rapport and creating a safe environment. Rapport-building questions, which also elicit data about the client' s history, include open-ended questions (Tell me about yourfamily), probing questions that flow naturally from what the client has been saying (Does this experience remind you ofanything when you were young ?), or focused questions that are a coherent part of hypothesistesting (Could there be a pattern here that was developed in yourfamily?). At the end of the session, if you feel that there are gaps in the history, you can pose your structured questions. Life History Timeline By far the most useful tool for noting life history data is a timeline. Whereas the recent history timeline, described previously, covers the immediate period of time prior to the client's seeking help, the life history timeline covers the entire life. Once you know the client' s current age or year of birth, you can draw a horizontal line slightly longer than the client's life span. Indicate the year of birth near the left end, allowing space prior to birth for genealogical information, data about pregnancy, and the parents' situation prior to birth. Then plug in all the important information, anchored by the age of the client. Form I.C in Appendix I can be copied for use in preparing timelines. Creating a timeline immediately after a session, when your head is flooded with information, will give you confidence that you have a good memory and do not need to take notes during the session or follow a structured outline. With a timeline, you have a visual aid to understanding the stages, transitions, and key events in the client's life. Constructing a detailed timeline helps you organize information and engages your creativity in developing good formulations and recognizing important gaps in the database. When writing the formal report, the narrative of the database is already outlined, and you can organize the flow of the story, using the client' s age (see Standard 17 in Chapter 1 3). In addition, a timeline helps you organize data that clients, when permitted to tell their story freely, will often present haphazardly. The following example of information from an intake performed in 2004 for a 37-year-old woman shows how to figure out the client's age when it is not explicitly stated. 52 Getting Started • The date: We moved to California in August of 1991-13 years ago, subtract that from 37 and she was 24. • The amount of time prior to the present day: My divorce was final 2 years ago- when she was 35. • Reference to other events and contexts: -When my younger brother was 3-You pinpoint the clients age at 7 because you know there is a 4-year difference. -My daughter is 10 years old-The client was 27 when she had this child. -When / finished high school-You estimate 18. -/ stayed in that job for 3 years and then / quit. I've been unemployed for 4 years.-She held the job from ages 30 to 33, when her daughter was 3 to 6. Once that information is put on a timeline, the life history is easier to grasp; additional facts can be added as the therapist learns them. Brother High school Move to Had Start Quit born graduate California child job job Now I I I I I I I I I I I I I 7 18 24 27 30 33 37 Years The events that you put on a timeline will depend on the client's life story. You definitely want to get information about past psychological problems, psychiatric treatment, medications, and so forth (remember that the recent history timeline has data about the onset and development of current symptoms). Here are some ideas about significant life history events: • Childhood and adolescence: Births of siblings, deaths of grandparents, separations from parents, transitions in schooling, relocation to new neighborhoods, changes in school, changes in family composition from divorces and remarriages, special achievements, hobbies, activities, significant friendships, onset of puberty, first romantic relationship, driver's license, childcare responsibilities, beginning of sexual activity, first job. • Adulthood: Move out of family home, post-high school education, employment milestones (e.g., change of jobs, promotion, periods of unemployment, retirement), marriage, separation, divorce, changes in family composition (e.g., birth of first child, birth of other children, last child leaves home), death of parents, special achievements, hobbies, activities, creative pursuits, geographic relocation, health problems, accidents, operations, chronic illnesses. During case conferences and supervision groups, each person can draw a timeline and jot down notes as the speaker presents information. I regularly do this and find interesting connections or important gaps. Using a timeline side by Gathering Data 53 side with the client during a session allows the client to discover important connections: My mother must have been depressed at the time because my grandmother-her mother-hadjust died. A very effective way to develop a timeline is to instruct the client to create a list of "stepping stones" (Progoff, 1 992). Here is how you might word your request: "Make a list of 10 to 12 turning points in your life: These should be events that were significant because they were the start of a new phase for you. They could be traditional milestones, like starting high school, but there should also be events that have personal meaning for you." A person' s life history needs to be understood in two different frameworks: 1 . Psychological stages of development. 2. The historical and cultural context of a specific cohort. Psychological Stages of Development Form I.C in Appendix I contains notes to remind you of developmental stages, discussed later in Chapter 4, under C3 Developmental Transitions (review Tables 4. 10 and 4. 1 2). It is important to know what stage the person is currently grappling with as well as the relative success with which the tasks of prior developmental stages were accomplished. It helps to understand that normal development involves a disruption of the established personal equilibrium every 7 to 10 years for adults. This transition, sometimes a "developmental crisis," brings losses, challenges, and opportunities. In childhood and adolescence, the developmental tasks follow a predicted course, depending on age, but during adulthood in twenty-first century American culture, there is great variation in the sequence of developmental tasks. For certain cultural subgroups and cultures in other countries, there are very strict norms about the developmental stages of adulthood. People commonly evaluate where they are in life through comparisons with others and a yardstick of the age norms they have accepted. The Client's Cohort and Culture You need to contextualize your client's story in a broader social/cultural/historical context. If your client is the same age as you, and from the same culture, you can make assumptions that you are familiar with the historical and cultural events in this person's past history. Otherwise, it is important to have tools that help you understand the wider context of the life experience. Cohort refers to a group of people born at the same time. When you know a person's age, you also know the year of birth, and this gives you information about the person's life history in a specific historical context. An example of a cohort difference is age norms for marriage: In the 1950s, a woman who got married at 23 was older than expected-practically an "old maid," whereas in the present decade, 23 is considered fairly young to be a bride in many cultural groups. 54 Getting Started Different cohorts can be given nicknames. The term baby boomers is applied to the cohort of people born after World War II who are now approaching 60. Sheehy (1996) called the cohort born between 1 946 and 1955 the Vietnam Generation and those born from 1956 to 1965 the Me Generation. When you know the cohort, you know the social, political, and economic factors that influenced life experience, including wars, the Depression, cultural movements (e.g., feminism or the civil rights movement), and so on. Different cohorts encounter different developmental challenges as they leave adolescence. You can speculate about the significance of entering the job market during the era of the Depression and the impact of feminism on women entering early adulthood during the late 1960s. Increased longevity and economic factors have radically changed the nature of development after the age of 50, as compared to what it was like for our parents. Years ago, age 70 was viewed as close to the end of life, whereas now it is often the beginning of a phase of at least 15 years, which can involve new friends and interests. Part of your inquiry into the client' s life history can be asking about key events: Were there significant events in the world at that time that had an impact on you? Members of one cohort will say the assassination of President Kennedy, whereas a younger cohort will say the explosion of the Challenger. Clinicians in future decades will need to be aware of the impact of September 1 1 and Hurricane Katrina, especially if their clients come from New York or New Orleans. To facilitate an appreciation of how historical events and cultural changes impact each individual's life history, Form I.D in Appendix I provides an "American History Timeline" covering key events in history, entertainment, and technology from 1 900 to 2005. In reviewing my choice of events, I recognize how my own life experience biased my judgments about what is important. The decade of the 1 960s is extremely rich in detail because that was the period in my life when I experienced the most significant events for me (ages 14 to 24). I included the earthquake in LA, where I live, but not Hurricane Andrew on the East Coast. To understand the relevance of cohort differences, imagine three different clients coming to you in the year 2000: ( 1 ) a 25-year-old woman, raised with a single mother; (2) a 55-year-old Black man (that's the term he prefers over African American); and (3) a 75-year-old upper middle-class widow. How do the events on the American History Timeline help a therapist understand their lives? 1 . The 25-year-old woman was born in 1 975. Her mother was probably influenced by the feminist movement. Divorce no longer carried a stigma. She may have grown up with expectations that, as a woman, she could make her own choices and function in life without depending on a husband. 2. The 55-year-old man was born in 1945 and was eligible for the draft during the Vietnam War. He might very well be a war veteran; he definitely Gathering Data 55 had friends who went to war and probably knew someone who was killed. The assassination of Martin Luther King when he was 23 probably was of enormous significance. 3. The 75-year-old woman who was born in 1 925 was 35 in 1960. She could be the type of woman for whom Betty Friedan wrote her book, The Feminine Mystique. This woman has been raising children and keeping house, and did not experience other choices. Her husband might have wanted her to stay home and would have been embarrassed if she worked-people might think he wasn't an adequate breadwinner. If the client is from a different country or culture, you will need to do research on significant sociocultural-historical events. For instance, if someone from Iran talks about geographic relocation in the late 1 970s, you should know that there was a revolution at that time. When working with Jewish clients, the Holocaust may be a significant factor in their personal histories and identities, even if they were born after World War II. Armenian clients will appreciate your understanding that they were victims of genocide. ACTIVITIES FOR DATA GATHERING There are several ways of gathering data other than face-to-face conversation. The following examples are also explained under the designated hypothesis. These activities have many benefits: They bypass storytelling and access new sources of information; they allow for systematic exploring of hypotheses; and they engage the client' s sense of play and tap into resources such as creativity, imagination, and humor. Role-Play (BL3, P2) You can ask the client to role-play himself in a designated situation so that you can gather data about the client's current level of skill. It is common to then ask the client to switch roles with you, and play the role of the other person in the interaction. In this way, you gather data either on how the other person really behaves, or on the client's imagined version. You can gather data about a past situation-Pretend I'm your boss and show me exactly what you said and how you said it-or a hypothetical situation-What would you like to say? Imagine she 's sitting in that chair. You can have the client roleplay herself at different ages, or role-play significant others from the family of origin. An advantage of this approach to data gathering is that you are moving away from the recitation of narratives that the client may have repeated many times, and tapping into new sources of information. 56 Getting Started Expression of Different Inner Parts (PI) In the course of the interview, when the client and therapist have identified and discussed different parts or voices, it can be a very natural next step to invite the client to let each part speak for itself. For instance, you might say, You mentioned that you have a very critical inner voice. How about talking directly with the voice ofthat inner critic. Request a Different Point of View (P3) After the client has described an interpersonal situation (her own point of view; POV), you can ask her to take two different POVs-that of an impartial observer and that of the other person. Imagine you are Susan. Okay, now Susan, how do you feel about the argument? Pretend that you are watching the argument between (client's name) and Susan on a videotape. How would you describe it? Table 8. 12 gives a demonstration of an exercise that can be used as a data-gathering activity. Genogram (SCEI) A genogram (Bowen, 1 994; McGoldrick, Gerson, & Shellenberger, 1999) is a family tree that maps at least three generations of a family. You ask the client to provide information, sitting side by side, so the client can watch as you draw symbols. Starting with the family of origin, use circles for females and squares for men and draw symbols for the siblings, beginning with the oldest at the left. Write in dates of birth, death, marriage, divorce, and marital separation. Go back at least to the grandparent generation and get facts about culture and immigration. These diagrams can get quite complicated if there are remarriages of parents, with step- and half-siblings. The most interesting part COlnes when the client describes relationships and interaction patterns. If there is a coalition, you would put a circle around the people, and you can indicate close bonds or estrangement with appropriate symbols. For instance, you can indicate the quality of relationships by connecting two people with lines: three parallel lines for a very close relationship, a dotted line for a distant relationship, a zigzag line for a conflicted relationship, and a gap in the middle of a straight line for estrangement. With clients from cultures who have close ties to extended family and other community members, you can be innovative and create additional lines and symbols. Couple and Family Enactments (SCEI) When you are doing conjoint therapy-seeing more than one member of a relationship or family-you have the opportunity to instruct the clients to engage in a specific task together while you watch. For instance, you can ask a family with children of different ages to plan a vacation together. In this way, the interaction patterns are demonstrated rather than described. Gathering Data 57 HOMEWORK ASSIGNMENTS AS A SOURCE OF DATA The use of homework contributes to a collaborative relationship by putting responsibility on the client to actively participate. The client' s response to the assignment is a valuable piece of objective data. Is the client compliant or defiant? Dutiful or irresponsible? Careless, competent, or perfectionistic? Here are some examples of how hOlnework assignments can be used to gather data. Charting a Specific Behavior An essential part of a behavioral analysis (BLI) is keeping a daily record of specific behavior to discover the frequency as well as the antecedents and consequences. For instance, if the goal is to stop smoking, the client would be asked to make an entry on a chart every time he smokes a cigarette, including the context (where? with whom?), the trigger (what precipitated the decision to light up?), and feelings before and after. The data-gathering goal is to get a baseline; however, the homework assignment contains a paradox. The instruction to write down your behavior but don't change anything contains contradictory messages: Be the same and Be different by being very conscious and honest about what you do. It is very likely that the client will smoke less that week, an example of how data gathering overlaps with intervention. See Table 6. 12 for an example of a chart that focuses on self-talk. Learning to Use the Subjective Units of Discomfort Scale There are two main reasons why you will want to teach clients how to monitor their emotions with a quantitative scale. First, quantitative data about a presenting problem-excessive anxiety, depression, or anger-allows you to measure progress and evaluate the effectiveness of interventions. Second, by quantifying and monitoring her emotional state, the client increases self-awareness, takes responsibility for achieving control over emotional states, and has a powerful tool for developing skills of emotional regulation. Behavior therapists came up with a name for an interval scale that can measure any type of problematic emotion and called it the SUDS, using an acronym for Subjective Units of Discomfort Scale. A scale of 1 to 10 is usually sufficient for most purposes although some therapists prefer a 100-point scale. When used for anger problems, the numerical scale is often called an "emotional thermometer." The most common use of the SUDS is for anxiety: People need to learn relaxation for health reasons (B3), coping with stress and crises (CS2), deconditioning anxiety (BL2), or applying difficult interpersonal skills (BL3). The scale is used as a continuum from total relaxation ( 1 ), almost to the point of sleep, to an extreme amount of anxiety (10), as in a panic attack. The midpoint (5) is calibrated as a state of functional alertness-neither too tense nor too relaxed. A range of 4 to 6 represents good concentration, the ability to focus, alert 58 Getting Started attention, and a capacity to carry out complex thinking and behaviors-the desirable level for taking a test, negotiating a contract, and dealing with a conflict. When the scale value rises above 6, the emotional arousal is entering the dysfunctional zone. Although therapists can give suggestions for experiences that correspond to numbers on the scale, it is important that the client develop the scale for herself and key the different scale values to familiar experiences. Before using the scale for a specific problem, the client should randomly sample experiences during the week, and practice assigning a SUDS number, as well as describing sensations, feelings, and thoughts that occurred at the time. Identifying Thoughts Homework charts are essential in teaching clients to identify their self-talk (C4) and implicit assumptions (C2). In this way, clients discover for themselves that their feelings are not caused by the situation but rather by how they think about it. Table 2.9 gives an example of a SUDS self-monitoring chart for a graduate student with Generalized Anxiety Disorder. Instructions to Interact The therapist can ask the client to talk to specific people (e.g., partners, parents, grandparents, or coworkers). The purpose could be to use these people as informants to gather specific data, for example, to assess the SUDS level and selftalk while interacting with that person, or to gather data to test the validity of an assumption about how the person would respond. Table 2.9 Subjective Units of Discomfort Scale Self-Monitoring Chart Body Situation Sensations (e.g., where, (e.g., heart, Day and what, or with muscles, or Feeling SUDS Time whom) breathing) Thinking Words (1-10) Tuesday First day of Chest feels I'm going to Anxious, self- 8 3 P.M. class, open tight, sweaty sound stupid. conscious. square arrange- palms. Everyone is ment of tables, looking at me. called on by teacher. Thursday Having dinner Warm hands, He' s fun. He Comfortable, 5 8 P.M. with Charlie, full stomach, likes me. happy, amused. talking about smooth movie. breathing. Sunday Lying in bed, Slow breathing, Not aware of Sleepy, loving. 2 9 A.M. petting my dog. warm, relaxed. anything. Gathering Data 59 Use of a Journal Journal writing has many useful functions; one of them is data gathering. The client can be asked to either write freely or address specific topics. It can be beneficial, with some clients, to give them the assignment to write their thoughts and feelings on a daily basis. Another approach might be autobiographical, life history writing. Here is a writing assignment from a book on "self-discovery" (Snow, 1 992) that would be useful for a client who is examining a current or recently terminated relationship. J O U R N A L A C T I V I T Y You will need a half hour to an hour ofuninterrupted time. A. Tell the story of how you fell in love. Include where you met, what attracted you, and what there was about the other person that resonated with some deep wish or need of yours. B. Tell a little about the early stages of your relationship, your first date, your first brief interlude together. Write about the feelings you had at the time, and include your expectations. What did you expect would eventually occur in the relationship (don't think about what occurred, but go back to the original time and the original feelings and expectations)? C. At the beginning of a relationship, there is a little clue that registers (and is subsequently disregarded) that something will go wrong eventually or that the relationship isn't going to last forever. Write about this clue offailure. SUGGESTED READINGS Bandler, R., & Grinder, 1. ( 1 990). The structure ofmagic: A book about language and therapy. Palo Alto, CA: Science and Behavior Books. Egan, G. (2002). The skilled helper (7th ed.). Belmont, CA: Brooks/Cole. Groth-Marnat, G. (2003). The assessment interview. In Handbook ofpsychological assessment (pp. 69-101). Hoboken, Nl: Wiley. Ivey, A. E., & Ivey, M. B. (2003). IntentionaL interviewing and counseling: Facilitating client development in a multicultural society (5th ed.). Belmont, CA: Wadsworth. McGoldrick, M., Gerson, R., & Shellenberger, S. ( 1 999). Genograms: Assessment and intervention (2nd ed.). New York: W. W. Norton. Rigazio-DiGilio, S . A., Ivey, A. E., Kunkler-Peck, K. P., & Grady, L. T. (2005). Community genograms: Using individual, family, and cultural narratives with clients. New York: Teachers College Press. Zuckerman, E. L. (2000). Clinician's thesaurus: The guidebookfor writing psychological reports (5th ed.). New York: Guilford Press. PART II TWENTy-EIGHT CORE CLINICAL HYPOTHESES The following chapters address seven categories of hypotheses: Chapter 3: Biological Hypotheses (B) Chapter 4: Crisis, Stressful Situations, and Transitions (CS) Chapter 5: Behavioral and Learning Models (BL) Chapter 6: Cognitive Models (C) Chapter 7: Existential and Spiritual Models (ES) Chapter 8: Psychodynamic Models (P) Chapter 9: Social, Cultural, and Environmental Factors (SCE) The complete list of hypotheses was presented in Table 1 .2 in Chapter 1 and is available in a one-page chart in Appendix II, Chart II.A. The capital letters in parenthesis are abbreviated codes to identify each hypothesis. These codes will make absolutely no sense to anyone who has not read this book; however, for people who are using this method, the codes will facilitate communication. Each hypothesis is discussed, using the following outline. • Introductory chart with title, description, and three clinical vignettes: Once you are familiar with the hypothesis, this chart will serve as a reminder of when to use the hypothesis. The first row of the chart contains a code (e.g., Bl�the combination of letters for the model and a number for the hypothesis), followed by the official title of the hypothesis (e.g., Biological Cause). The title is followed by a formal definition of the hypothesis. The second row in the chart provides explanations that are central to understanding and using the hypothesis. In the third row, three clinical vignettes show when the hypothesis is an appropriate match. 61 r 62 Twenty-Eight Core Clinical Hypotheses • Key Ideas: I have chosen ideas that I think are central to understanding the hypothesis, realizing how much more could be said. The selection process was guided by the audience for whom I am writing: practitioners who want to use these ideas with their clients. The size of this section varies, depending on the breadth and complexity of the hypothesis. • When Is This Hypothesis a Good Match? This section presents suggestions for recognizing the relevance of the hypothesis, including specific client data, problem titles, and DSM-IV-TR diagnoses, when appropriate. • Treatment Planning: This section provides a selection of ideas for treatment. It is not all-inclusive: There will be effective treatment ideas that are overlooked, and that does not mean that they are of lesser value than those that have been included. Some approaches that are mentioned have strong support by respected groups of clinicians; others are controversial or are so recent that they are not widely known. This section is not intended to instruct you about what to put in your treatment plan but rather to provide a range of possibilities. The plans that you create will be based on the facts of a specific case, your professional judgment, the research literature that applies, your client' s preferences, and your competence. • Integration of Hypotheses: To see samples of how hypotheses are integrated, go to Chapter 10. Otherwise, the title of this section might not make sense: It contains a list of those hypotheses that will often be combined with the hypothesis in question. At first reading, it may not be very helpful because you may not have reached the chapter that discusses the hypothesis in depth. However, when you are using this book as a reference in preparing a case formulation, this section should be useful. Each chapter concludes with a Suggested Reading section, which contains a selection of books that will expose you to the diversity of contributors to that single hypothesis. HOW TO APPROACH THE HYPOTHESES You need to understand each hypothesis before you can use it appropriately. It may seem overwhelming to face 28 hypotheses, but you probably will recognize most of them. There are three phases of learning the hypotheses: first, skim through the material quickly to get the key ideas; second, read more slowly and identify your own strengths and interests; finally, when you have client data to work with, go back and study the relevant hypotheses more closely, with attention to treatment plan ideas. When you sit down with a new client, there are only a few clinical hypotheses that must be addressed in the first session: You need to recognize issues that require immediate attention to prevent irreversible negative consequences. If you want to jump immediately to the hypotheses that are essential for intakes, they Twenty-Eight Core Clinical Hypotheses 63 are BI Biological Cause and CSI Emergency Issues. You need to rule out (or rule in) medical problems and substance abuse, emergency and trauma issues, obligations for legal reporting, and diagnoses of severe mental disorders. When you see the same problem mentioned under different hypotheses, you can conclude that those hypotheses can be effectively integrated. For instance, chronic pain is addressed under B2 Medical Interventions because it can be treated by medication and also under B3 Mind-Body Connections because it responds to stress-management techniques and body-focused interventions such as biofeedback training. Broad problems like "depression" and "difficulty establishing intimate relationships" will be mentioned under many hypotheses. Confusion might result from seeing the name of a theorist listed under several hypotheses. We usually think of therapeutic approaches as a bundle of ideas belonging under the name of the founder of a theory, so it may be surprising to see the contributions of a single person unpackaged and placed in different bins. For instance, Jung's contributions are mentioned under three hypotheses: PI Internal Parts or Subpersonalities because his model of the self included subselves, such as the Ego and Persona, which are in conscious awareness; P4 Unconscious Dynamics because his theory includes both the personal unconscious and the collective unconscious; and ES3 Spiritual Dimension because his theory has a strong spiritual emphasis. Chapter 10 provides examples of how the different hypotheses can be applied and integrated. If you are a person who likes to dig right in, go to Activity 10. 1 , and see how well you can apply hypotheses to clinical vignettes and propose strategies to gather relevant data for hypothesis-testing. Chapter 3 BIOLOGICAL HYPOTHESES The field of medicine is gradually acknowledging the advantages of the biopsychosocial model over the traditional biomedical model, whereas the field of psychology is increasing its interest in neuroscience and the functioning of the body. The mind and body are inseparable. Every emotion, thought, and behavioral impulse has underpinnings in the activities of the brain, making it impossible to view psychological symptoms as distinct from biology. We understand that there are bidirectional influences between the physical and mental domains, but we currently have very limited ability to make assertions about causality because of the fact that physiological and psychological processes are simultaneous rather than sequential. For instance, we know that low levels of serotonin correspond with depression, but we can't say which comes first-the depressed mood or the inadequate amount of neurotransmitter at the synapse. Sometimes causation is relatively clear. Biological causation is demonstrated when brain trauma, disease, and ingestion of toxic substances are followed by mental symptoms such as memory impairment, anxiety, depression, confusion, and personality change. There is also strong support for the proposition that psychological states affect the chemistry of the brain and can both boost and lower immune system function. For instance, the placebo effect shows that positive expectations in the absence of an active chemical in the pill can produce physical benefits; psychological stress, such as academic pressure, divorce, and unemployment, can increase the probability of becoming ill; and group therapy can result in reduced recurrence and mortality rates in cancer patients. Recently, research demonstrated that the activities of psychotherapy-putting experiences into words, emotional attunement, and helping clients confront their fears-is effective in building neural networks and changing the chemical activity of the brain: The "talking cure" changes the brain (Cozolino, 2002). Decisions about treatment plans must be based on knowledge of both physiological and psychosocial factors, with attention to the complex connections of the mind and body. The three biological hypotheses offer different templates for examining client problems (see Table 3. 1). Only the Biological Cause hypothesis (Bl) is based on clear biological causation. The Medical Interventions (B2) and the Mind-Body Connections (B3) hypotheses assume that mind-body connections are complicated, but that attention to the physical and somatic realm is 65 66 Twenty-Eight Core Clinical Hypotheses Table 3.1 Biological Hypotheses Bl Biological Cause The problem has a Biological Cause: The client needs medical intervention to protect life and prevent deterioration, or needs psychosocial assistance in coping with illness, disability, or other biological limitations. B2 Medical Interventions There are Medical Interventions (e.g., medication, surgery, or prosthetics) that should be considered. B3 Mind-Body Connections A holistic understanding of Mind-Body Connections leads to treatments for psychological problems that focus on the body and treatments for physical problems that focus on the mind. necessary for treatment planning. In some cases, more than one of these hypotheses will fit, and can be combined in the formulation. If you find yourself struggling to decide which of the two seems more appropriate, the odds are that both should be included. The treatment of anxiety can illustrate the differences among the three biological hypotheses. BI: After a medical examination and a complete blood panel, the client is diagnosed with a thyroid condition. After taking thyroid medication to bring her hormone levels back to normal, she no longer complains of anxiety. B2: A medical examination did not reveal any abnormalities. The client had gone to many therapists but has not been able to successfully reduce the anxiety. A referral to a psychiatrist for medication evaluation leads to a prescription for antianxiety medication. B3: A medical examination did not reveal any abnormalities. The client is constantly on the go, handling work and family responsibilities without any time taken for relaxation. After scheduling an hour every weekend for a massage, half an hour every day for relaxation practice, and a five-minute pause every hour for a deep breathing and positive imagery exercise, the client is no longer bothered by anxiety. The following example shows a client for whom all three hypotheses are integrated: A 66-year-old retired man suffered a spinal cord injury as a teenager that left him a partial paraplegic. As he ages, his physical disabilities have become more severe, and he uses an electric scooter to get around (81 ). Recently, he has become increasingly depressed because of his declining mobility, as well as the death of his best friend and the termination of a close relationship, and has been staying home and avoiding the few activities that bring pleasure and social interaction. His therapist recommended a trial of antidepressants (82), and he had begun to respond positively when he suffered a leg injury. He is now dealing with daily pain, but doesn't want to take a recommended medication because a possible side effect is loss of balance. His therapist taught him a method of selfhypnosis that helps reduce the pain (83). Biological Hypotheses 67 Bl BIOLOGICAL CAUSE Definition The problem has a Biological Cause: The client needs medical intervention to protect life and prevent deterioration or psychosocial assistance in coping with illness, disability, or other biological limitations. Explanation This hypothesis applies to a wide range of physical problems that produce psychological symptoms and impairments, including strokes, brain tumors, spinal cord injuries, Alzheimer's syndrome, transient toxic states, drug and alcohol intoxication, AIDS, vitamin deficiency, and endocrine disorders. It should also be used when the client needs help coping with a medical condition or physical disability or dealing with limitations from biological sources such as genetics or aging. Pamela, a psychology graduate student, was experiencing fatigue and difficulty concentrating, symptoms that she attributed to "stress" and "depression." Despite her loss of appetite, she was gaining weight and her waistband was getting tighter and tighter. A thorough medical examination and testing revealed a huge malignant tumor growing in her abdomen. Examples George was diagnosed with Schizophrenia 2 years ago, but never responded to medication. In a "psychotic episode," he murdered his girlfriend and then committed suicide. The autopsy revealed that he had a huge brain tumor. If the tumor had been diagnosed 2 years ago, surgery would have eliminated his mental symptoms and prevented two unnecessary deaths. KEY IDEAS FOR Bl BIOLOGICAL CAUSE Teresa and Pedro came to therapy because of Teresa's hurt over her husband's emotional withdrawal and avoidance of sex for a year. Pedro was very embarrassed about discussing the problem, saying that he was overloaded with work and always exhausted. A referral to a physician led to a diagnosis of diabetes and the discovery that his lack of erection was physiologically-based. The status of medical research at a specific point in history will determine whether the Bl hypothesis is used correctly. Sometimes what clinicians believe to be a biological cause of illness is later proven to be false. In some cases, the cause is not biological at all; in others, the cause is biological but not what was initially hypothesized. Faulty Diagnoses from Lack of Scientific Knowledge The Madness ofKing George, produced in 1996, is a movie that illustrates the faulty diagnosis of the mental illness of George III of England, the monarch at the time of the American Revolution. The clinical case formulations of the experts of the time are demonstrated as the drama unfolds: Bl Hypothesis in the Eighteenth Century The physicians believe that the body contains "humors" and that mental problems result from an excess of humors in the brain. Based on this hypothesis, the 68 Twenty-Eight Core Clinical Hypotheses treatment is to dip glass jars into a flame and then place their round edges on the King' s back and legs to create blisters that should draw humors away from the brain. Nonbiological, Psychosocial Hypothesis When the painful blistering method doesn't work, a more "modern" expert is found. This doctor, previously a clergyman, believes that the King' s madness developed from getting his way all the time and therefore developing a "weak character." His hypothesis is that the madness will be cured when the character is "curbed, stood up to, and thwarted." The treatment for misbehavior is strapping the King in a chair and keeping him in restraints until he becomes docile. Bl Hypothesis in the Twentieth Century At the end of the movie, after the credits, two sentences on the screen reveal the hypothesis based on modern medical science: "The color of the King's urine suggests that he was suffering from porphyria, a physical illness that affects the nervous system. The disease is periodic, unpredictable, and hereditary." As viewers read these words, we remember that a servant brought the doctors a basin of the King's urine, exclaiming over the fact that it was blue. This information supports the diagnosis of porphyria, but it was meaningless to the physicians of the late eighteenth century. Medically Unexplained Symptoms Sometimes clients are referred to therapists when physicians cannot find a diagnosis for symptoms. The assumption will usually be that the person is a "somatizer," converting psychological distress to physical sYlnptoms, which therefore do not have biological causation. However, we need to leave room for the possibility that the symptoms have a medical cause that has not yet been discovered by medical science. Chronic Fatigue Syndrome used to be called "neurasthenia" and was viewed as a form of neurosis, whereas it is now accepted as a physical illness for which there is no definable cause. In the future, research might find that the cause is a virus, environmental toxins, or neuroendocrine malfunction. The term medically unexplained symptoms (MUS) is useful because it does not assume psychiatric disorder as does the term somatization. The Importance of Diagnostic Skills "Differential diagnosis" is a systematic approach for inclusion or exclusion of diagnoses, based on preliminary examination of the data. The diagnoses on the list of possibilities must then be subjected to tests to rule out diagnoses for which there are no confirmatory data. One of the biggest errors that a therapist can make is failing to detect symptoms of a possibly fatal or disabling medical disorder, thus failing to include the medical problem in the differential diagnosis. If you are not a physician, you are not expected to be a diagnostician of medical problems, but as a licensed psychotherapist you are required to be competent in recognizing the DSM-/V-TR criteria for biologically-based disorders and to Biological Hypotheses 69 knoW when referral to a physician is necessary. You need to be aware that psychological symptoms (e.g., anxiety, depression, memory impairments, and changes in personality) can be caused by both biological and psychosocial disorders. Procedures for confirming a medical diagnosis include analyses of blood and urine, X-rays, and brain scans. Clinical psychologists with competence in neuropsychological assessment can pinpoint locations in the brain that are associated with specific functional deficits caused by stroke, brain trauma, or degenerative brain diseases. Biological Causation with Co-Occurring Disorders Medical problems may coexist with other types of psychiatric disorders. To complicate matters, the same symptoms may stem from both biological and psychosocial causes. The most common example of this is the coexistence of depression and medical illness. Depression can be a symptom of the illness and a consequence of difficulty coping with the illness-and the same person can have depression stemming from both causes. One third of medical patients have at least moderate mood symptoms. Depression in elderly clients is very common because of their multiple physical impairments, social isolation, and grief from many losses, and therefore often coexists with dementia, complicating the diagnostic process. Anxiety disorders and substance abuse also can accompany biologically-based disorders. WHEN IS THIS HYPOTHESIS A GOOD MATCH? DSM-/V-TR lists various mental disorders such as Delirium, Dementia, and Amnesia that stem from such medical conditions as vascular disease (stroke); intracranial injury (head trauma); HIV disease; and a variety of diseases named after their discoverers-Alzheimer, Parkinson, Huntington, Pick, and Creutzfeldt-lakob. There are also disorders in the DSM, such as ObsessiveCompulsive Disorder (OCD) and Attention-Deficit/Hyperactivity Disorder (ADHD), for which recent brain scan research finds evidence of correspondence between activation of parts of the brain and manifestation of behavioral symptoms. Until research firmly establishes causation, these disorders are best addressed under B2. Although the primary importance of this hypothesis is in recognizing biologically-based disorders that might be misdiagnosed and untreated, it also fits when the client needs help in coping with a medical condition or dealing with impairments in functioning that stem from physiological causes. Another application of this hypothesis is to help your client identify those biological "givens," such as temperament, talents, physical disability, or body type, which limit choices or determine the type of environmental niche that would be most beneficial. The need for medical referral is recognized by such data as impaired memory, concentration, and consciousness; the use of alcohol, drugs, and medications; 70 Twenty-Eight Core Clinical Hypotheses changes in appetite, weight, sleep patterns, mood, and personality traits; events such as head injury, illnesses, and accidents; and family members' reports of poor grooming, neglect of home and health, and loss of competence at work. Substance-Related Disorders Problems with drugs and alcohol are extremely common and should be considered with every client. The ingestion of alcohol and drugs can result in a transient, reversible syndrome called intoxication. The term dependence refers to a physiological condition where the body needs the drug and without it will develop a group of symptoms called withdrawal. Clinicians need to probe for specific details of frequency and quantity of consumption. Recognition of substance use is especially important with pregnant women and clients who need intact impulse control, such as potentially suicidal clients. The consequences of prolonged alcohol abuse are illustrated in this case example: A 40-year-old man, a successful writer, denied that alcohol was a problem in his life. Even after he broke his leg in an alcohol-related accident, he claimed that it was an exceptional circumstance. Finally, he was arrested for d riving under the influence, and was forced to attend AA meetings. He successfu l ly terminated alcohol use and attended AA until completion of his probation. Six months later he was found dead by his neighbor, holding a bottle of vodka. The autopsy report showed severe liver damage and extreme cardiomyopathy-"his heart looked like that of a man twice his age," the pathologist explained. Medical Conditions that Masquerade as Mental Disorders Medical disorders can cause any of the following symptoms: anxiety, depression, mania, psychosis, delirium, dementia, uncontrollable rage, and personality changes. If a client presents with dementia or psychotic symptoms, clinicians are usually alert to the fit of the Bl hypothesis. However, more commonplace symptoms, such as anxiety or depression, may be treated as purely psychological when, in fact, they might be caused by medical conditions such as thyroid disorders, renal failure, an autoimmune disease like lupus, or electrolyte imbalance. Client Needs Help Coping with Medical Condition or Physical Disability Biologically-based conditions involve emotional, behavioral, and cognitive dimensions including subjective level of pain, intensity of emotional distress, the need to develop new skills, alterations in cognitive maps, demands to make difficult decisions, social isolation, and disruption to the functioning of the family. Often just receiving a serious diagnosis can overwhelm a person's ability to cope. Conditions that therapists might encounter include aphasia following a stroke, amputation following war service, paraplegia from an accident, and partial or complete loss of functioning in one of the sense organs. The aging process involves physical changes that interfere with mobility and can cause chronic pain. Biological Hypotheses 71 Opportunities for Prevention Often clients describe behaviors or lifestyle choices-smoking, overeating, excessive drinking, unprotected sex, and reckless driving-that put them at risk for developing medical problems. For instance, a lifestyle of high stress, workaholism, overeating, and no exercise can contribute to heart conditions. Excessive smoking can result in serious, irreversible damage to the lungs. Anorexia Nervosa and the accompanying weight loss and condition of starvation affects metabolism, heart rate and pulse, blood pressure, skin and hair, and bone density. For bulimics, the effects of purging include electrolyte imbalance, which can cause heart attack and brain damage. Therapists can formulate problems in ways that promote prevention and early interventions. For instance, if your client is a postmenopausal woman who works 14 hours a day at a high-pressure job, neglecting nutrition and exercise, you can explain the connection between lifestyle and health, bring the risk of osteoporosis to her awareness, encourage proper diagnostic tests (e.g., bone-density test), and support her making a commitment to better self-care. Coping with Genetic "Givens" Without minimizing the role of nurture and the freedom of people to make choices, we must recognize that genetic factors do set limits on freedom and influence psychological and behavioral functioning. Clients benefit from recognizing that varied factors are hardwired into their makeup, the makeup of a child, or that of a significant other. Examples include character traits like introversion/extraversion, aptitudes and talents for things like mathematics or music, sexual orientation and gender identity, and aspects of physical appearance such as height and body type. Although you might think telling a client to accept genetic limits is discouraging, many clients experience an increase in selfacceptance when they realize that they are not at fault for difficulties that they have been unable to resolve. This hypothesis is very useful when counseling parents who want their violinist son to be an athlete or their athletic daughter to be a bookworm. When parents are able to acknowledge their child's core, unchangeable characteristics, their frustration is reduced and the psychological well":being of the child is enhanced. Parents who have trouble accepting the sexual orientation of their gay, lesbian, or bisexual child need to understand that same-sex attraction is an innate part of a person' s makeup to stop blaming their child or themselves. As genetic research progresses, there will be greater understanding of inherited characteristics and discoveries of gene therapies that will overcome genetic limitations. An interesting new issue for therapists will be counseling clients who need to make choices about genetic testing. For instance, if a Jewish woman of Eastern European background with family history of breast cancer discusses her indecision about whether to get tested to see if she carries the gene associated with breast cancer, the therapist will need to explore the pros and cons and how she would cope if the news were bad. 72 Twenty-Eight Core Clinical Hypotheses Many aspects of sexual functioning are part of our biological hardwiring. Some of these factors, although evolutionarily adaptive, can result in considerable emotional pain. It makes sense (in terms of preserving the species) that a middle-aged man should have a stronger sexual attraction for an attractive woman of childbearing years than for his postmenopausal wife, but this does not provide consolation for the wife and family if the husband acts on these biologically-based impulses. For women, sexual intercourse creates the same bond to the sexual partner as that which occurs with their newborn infant, thus securing protection for mother and baby; however, this bond is unfortunate for a woman who finds it difficult to sever an unsatisfactory relationship. In both those examples, the head says "this is not good for me," but the body and emotions have a different agenda. TREATMENT PLANNING When biologically-based issues are involved, one of the problem titles should be the name of the disease, disorder, or disability that will be treated by medical professionals. The other problems that you define might be consequences of the medical problem, concurrent psychological problems, or lifestyle problems that increase health risk. Table 3.2 lists some examples of useful problem titles. Referrals You need to have the flexibility to leave the traditional role of psychotherapist and take on roles of social worker, case manager, advocate, and supportive cheerleader. In your initial intake, when you recognize signs of a biologicallybased condition such as impaired memory, confusion, or personality changes, you need to arrange for the client to get a medical evaluation. Depending on the level of impairment, you should involve family members or call an ambulance. If the client does not already have a primary care physician, you can help the client find someone who is suitable, considering constraints of geography, financial means, and health insurance guidelines. It is helpful to establish good professional relationships with physicians in the community. Use of Community Resources It is essential to have access to printed or online directories of resources and services. Fortunately, psychosocial treatment programs are often available in hospitals or in the community to help patients and their families deal with specific disorders such as breast cancer, strokes, spinal cord injuries, prostate cancer, heart disease, Alzheimer's disease, and HIV/AIDS. Substance abusers usually need multiple resources-residential programs, Twelve Step groups, and religious or social organizations that allow them to build new substance-free social networks. Biological Hypotheses 73 Table 3.2 Useful Problem Titles for Biologically-Based Issues Problems Associated with Brain Damage Inadequate self-care Risk of violence or injury Frustration over inability to communicate needs Difficulties Coping with Medical Disorders Refusal to modify work schedule despite debilitating weakness fr01n chemotherapy Noncompliance with doctor's instructions Difficulty asserting needs with medical personnel Problems of Caretakers Needfor respite from caregiver responsibilities Engaging in elder abuse Difficulty coping with spouse 's loss ofmemory Problems Associated with Terminal Illness Indecision about entering hospice program Refusal toface grief over impending death (for patient as well as family) Difficulty coping with family members ' refusal to talk about death Problems Associated with Drug Addiction Drug-seeking, criminal behavior Inability tofulfill occupational obligations Inability to sustain healthy relationships Legalproblems stemming from sale ofillegal substances Problems That the Addict Had before Use of Drug Difficulty maintaining intimate relationships Difficulty coping with painful emotional states Difficulty committing to future goals that require work, persistence, andfrustration tolerance Becoming Informed Unless you are a medical doctor, you will frequently be confronted with your ignorance about your client's condition. To provide your client the highest level of care, you will need to gather information and educate yourself. Thanks to Internet search engines, such as Google, it is easy to find medical information and support groups for sufferers of a specific disease. The following electronic databases provide access to medical research and critical reports of the research: Cochrane Library, Medline, Healthstar, and EMBASE. Allow your client to educate you about the medical disorder and consult with physicians and health psychologists to broaden your knowledge base and understanding of the client's particular situation. Because mos-t medical patients get very limited time with physicians and nurses, a well-informed psychotherapist can provide a 74 Twenty-Eight Core Clinical Hypotheses valuable service by helping the client understand the medical condition-however, be sure to uphold professional ethics and make it clear that you are not a medical authority. Working in Interdisciplinary Teams The coordination of care is of huge benefit to the client. If you are working in a health setting, you need to be familiar with different professional roles: What does each team member do, and what can they provide the client? Collaboration with a team of rehabilitation specialists is an important part of treatment of people with irreversible impairments such as loss of speech in stroke victim and loss of mobility for quadriplegics. Being an effective advocate for quality care for terminally ill individuals and their families involves working as part of multidisciplinary teams to ensure that individual needs and quality of life issues are understood and addressed, such as the need for increased pain control. Family Involvement It is important to involve family members in treatment discussions, especially if the client has serious impairments that are expected to worsen. Caregiver stress is a common problem that can lead to mistreatment ofthe client and the development of emotional and health problems in the caregiver. When a child has a seri- 0us illness and is getting the majority of the parents' attention, siblings can develop conduct problems or mood symptoms as a result of neglect. The treatment plan needs to attend to the needs of the whole family to help prevent these consequences. Referral to family therapy may be advisable when the therapist notices new problems developing in the already stressed family unit, as illustrated by the following example: A 45-year-old woman insisted on having her mother, a brain trauma victim with lack of speech and severe paralysis, move into the small house she shared with her husband and 1 3-year-old daughter. Four years later, the patient showed little improvement, despite many different kinds of rehabilitation programs. Her daughter refused to let go of the fantasy that her mother wou ld eventual ly show miraculous i mprovement and neglected her obligations to her husband and chi ld; the husband suffered from many stress-related complaints that seemed to be related to anger; and the patient's granddaughter had two car accidents within 3 months of getting her driver's license. Working with Terminally III Clients The web site for the American Psychological Association (www.apa.org) offers guidelines for end-of-life counseling. Here are a few key points: • When working with people who are dying, it is essential to assess the overall quality of care they are receiving, to identify sources of suffering and Biological Hypotheses 75 ways of alleviating them, and to determine what decisions need to be made and who needs to be involved in making and implementing them. • You can help dying persons raise and resolve issues of meaning in their individual lives through values clarification and life review. Religious and spiritual issues often arise and need to be discussed. There may be issues of unresolved grief from prior losses, such as the deaths of parents. • Themes that frequently arise in counseling dying persons are loss of autonomy, control, dignity, and meaning as well as fears of dependency and being a burden to others emotionally, physically, or economically. Those factors often contribute to requests for assisted suicide and euthanasia, even more than pain and depression. • Some patients and families may turn to you for help with decision making regarding death-related issues such as advance care directives, designating a guardian or health-care proxy, and details of the desired funeral or memorial service. Ethical and Legal Issues You always need to be aware of legal and ethical issues that affect your practice; with clients who have medical problems, it is especially important to have a good resource for understanding your responsibilities and risks (e.g., Sales, Miller, & Hall, 2005). Zuckerman (2003) provides useful forms for professional practice, such as release forms that clients must sign so that you can share information and coordinate treatment plans with other health professionals. The ethical principle "limits of competence" is especially important when working with populations for whom specialized training is necessary. If you are treating an elderly person in an assisted living setting, you must be screening for any signs of abuse that will need to be reported. INTEGRATION OF HYPOTHESES One or more of the following hypotheses are often combined with the one just reviewed to create an integrative formulation for a specific problem. The decision about whether a specific hypothesis )Should be integrated is based on your professional judgment. ) CS4 Loss and Bereavement This hypothesis is useful when people deal with the emotional pain of losing abilities and functions. Therapists can help patients express and explore the roots of their anger, which can otherwise be manifested as hostility toward medical professionals. When people have terminal illnesses, clinical work may focus 76 Twenty-Eight Core Clinical Hypotheses on grief, mourning, loss, and feelings about dying and death. The patient and family members need help coping with sorrow, depression, anger, guilt, and anxiety. Unresolved grief over the earlier deaths of loved ones is likely to arise as some dying people relive past losses in preparation for losing everything. BLl Antecedents and Consequences A thorough behavioral analysis is necessary for health-related behaviors, such as poor medication compliance. For example, a client can identify triggers to appropriate use of medication, such as counting pills once a week and using a plastic container with compartments. Be aware that clients experience negative side effects as punishment for taking pills and need help in focusing on the rewarding consequences. A behavioral intervention designed to increase "activity level" in small increments from a baseline, using contingency contracting, is an appropriate treatment for Chronic Fatigue Syndrome (Demitrack & Abbey, 1999). BL2 Conditioned Emotional Response Medical patients with fears of hospitals or certain procedures may benefit from a desensitization paradigm to reduce their fears, preferably through in vivo contact with the hospital, staff, and equipment. BL3 Skill Deficits or Lack of Competence Social skills training may be helpful for learning how to elicit social support and deal with medical professionals. The field of rehabilitation overlaps with psychotherapy: People with brain damage from strokes or tumors need to develop cognitive and independent living skills. C2 Faulty Cognitive Map The client needs to have accurate information about the disease and may require help in making rational decisions. Cognitive distortions need to be identified, as when the client is catastrophizing ("If I can't walk, I'll never be happy again") and overgeneralizing ("Cancer is always a terminal disease"). Attitudes toward taking medication and adhering to other treatment recorrunendations need to be addressed. C4 Dysfunctional Self-Talk Dysfunctional self-talk is an important target of treatment, especially because there is evidence that positive thinking enhances health outcomes. ESl Existential Issues Patients are often dealing with loss of meaning in life and are questioning " why me?" Discussing the question of suicide is often relevant, either because Biological Hypotheses 77 of concurrent depression or because the quality of life is so greatly diminished and the prognosis so poor that patients want to make decisions about dying with dignity. ES3 Spiritual Dimension Spiritual activities, such as prayer or meditation, may have a positive effect on the course of the illness. With dying patients, spiritual and religious issues are very important. Collaborative relations with members of the clergy can be very helpful at that time. SCE3 Social Support One of the most important functions of a therapist will be assuring that there is a support network for the person who is experiencing a medical crisis or adjusting to physical disability. A common problem with cancer and AIDS is that even well-intentioned friends withdraw from the patient, finding it too painful to see physical changes and feeling that what they have to offer is inadequate. Support groups are extremely useful for both patients and caregivers. Patients may initially resist the idea of listening to other people suffering from the same disease, but if they can agree to try a group for a few sessions, they often will report surprising benefits from the therapeutic factors that Yalom (1995) describes, including practical advice, instillation of hope from people who are coping successfully, and the chance to be altruistic and offer help to others. SCE7 Environmental Factors When clients are faced with irreversible disabilities or the givens from their genetic makeup, they need to recognize that their happiness can be enhanced by choosing a satisfying environmental niche and obtaining needed environmental resources. For instance, people can choose to move to dry and warm states like Arizona if they have difficulty breathing in other climates. Electric scooters and elevators in homes can vastly improve the lives �f people who are unable to walk. Relapse prevention for addicts involves avoiding places where drugs are available. The client's need to obtain financial resources and to utilize legal assistance is something that you should be ready to address. KEY IDEAS FOR B2 MEDICAL INTERVENTIONS Two movies, both starring Jack Nicholson, show the appropriate and inappropriate application of this hypothesis: As Good as It Gets The main character suffers from OeD, as well as from misanthropic attitudes and terrible social skills. He becomes deeply attached to a waitress and demonstrates r- ' 78 Twenty-Eight Core Clinical Hypotheses B2 MEDICAL INTERVENTIONS Definition There are Medical Interventions (e.g., medication, surgery, and prosthetics) that should be considered. Explanation The primary application of this hypothesis will be when the use of psychotropic medication is indicated for a psychiatric disorder. Other medical interventions (e.g., surgery, or the use of appliances and prostheses) and interventions from alternative medicine can also be used to alleviate psychological symptoms. Gerald is a chronic pain patient, suffering from a cycle of pain, anxiety, and tension. He is in a treatment program with a multidisciplinary treatment team. One professional is teaching him biofeedback for the tension but, at the same time, he has been prescribed pain medication and tranquilizers. Examples Tipper Gore, wife of the candidate for president in 2000, went through a very difficult time when her young son was severely injured in a car accident. Seeking help, she received the diagnosis of clinical depression and was prescribed medication for her condition. Marian, an obese woman who had struggled with weight problems since childhood, opted for gastric bypass surgery. The surgeon required a psychological evaluation to assure that she had realistic expectations and would be able to handle lifestyle changes after the surgery. his caring by helping her son get appropriate treatment for an illness. Nevertheless, his annoying behaviors and severe anxieties appear to be insurmountable obstacles to a successful romantic relationship. The happy ending of the film corresponds to his admission that he has resumed taking antianxiety medications. One Flew Over the Cuckoo's Nest The main character is a malingerer who feigns mental illness in order to be sent to a mental hospital rather than prison. His behavior is disruptive to the smooth management of the ward, but we see it as a healthy response to the repressive, dehumanizing behavior of the head nurse, as well as therapeutic for the other patients on the ward. At the end of the movie, a surgical procedure on his brain renders him docile and takes away his essence as a human being. Medical Research The acceptability of medical treatment for psychological complaints depends on the status of medical research at a particular point in history. Today, Schizophrenia is a disorder for which medication is widely accepted as a necessary component of treatment. A few decades ago, however, it was respectable to claim that Schizophrenia could be caused by double-binding, schizophrenogenic mothers. Today, the treatment of ADHD is controversial, with many parents and practitioners strongly opposed to the use of medication despite the fact there is much Biological Hypotheses 79 research evidence of the benefits of medication and that, furthermore, brain scans show differences in the brains of children with this diagnosis when compared to controls. With further research in neuroscience, the use of medication may become more widely accepted. As brain physiology research progresses, the B2 hypothesis will be more widely used, and the scope of the BI hypothesis will likely expand. Biases about Medical Interventions All practitioners have the following obligations: (a) Understand your prejudices and values about medical interventions, some of which are absorbed, without reflection, from teachers and supervisors; (b) stay abreast of the research literature (e.g., Thase & Jindal, 2004); and (c) maintain a biopsychosocial, integrative perspective rather than exercise either-or thinking. Nonphysician therapists often view medication as a last resort when psychotherapy has failed to produce expected progress, or as a useful adjunct to psychotherapy, but not something that alone could be sufficient. In contrast, physicians, as well as cost-conscious managed care companies, find treatment with medication, without concurrent psychotherapy, to be satisfactory, and neglect the benefits that come from empirically supported psychotherapy interventions. In addition to medication, surgical and medical interventions elicit strong personal biases. In our culture, we value self-reliance, admire demonstrations of what we call "willpower," and scorn the idea of "relying on crutches." Therefore, an operation like gastric bypass surgery or the use of a methadone maintenance treatment for drug addiction may be disapproved of, even by professionals. There are also strong personal values regarding the desirability of "aging naturally," versus taking advantages of aesthetic surgery to look younger. Training in Psychopharmacology Psychopharmacology training is important for all psychotherapists; it is critical that you understand when medication might be appropriate and that you are able to communicate intelligently with the psychiatrist involved in the case. Some of the competencies that need to be developed are (a) the ability to recognize symptoms and syndromes that justify referral to a psychiatrist for a medication evaluation, (b) an understanding of the therapeutic effects and side effects from the most common types of psychotropic medications, and (c) the ability to discuss medication with clients with an understanding of factors that promote and impede medication compliance. Because new medications are continually being developed, have the most recent edition of a concise psychopharmacology guide (e.g., 1. Johnson & Preston, 2004) and the current Physician's Desk Reference (PDR; Medical Economics, 2005) available to keep abreast of current research developlnents in psychopharmacology. Psychologists who take advanced training in psychopharmacology may not yet have prescription privileges, but they are considered experts for purposes of consultation. 80 Twenty-Eight Core Clinical Hypotheses The Split-Treatment Model Gitlin (1996) used the term split-treatment model for the common practice of having one professional, typically a nonphysician therapist, provide psychotherapy while another (e.g., a psychiatrist, internist, or family practice physician) prescribes medication. The nonprescribing psychotherapist needs to be a knowledgeable participant in the pharmacological treatment. This includes talking to clients about medication and also communicating directly with the prescribing professional. Every nonprescribing therapist should create a good professional relationship with a psychiatrist for referral purposes: someone who is highly competent, shares your values, and respects your strengths. Effective collaboration provides the client with the strongest combination of skills and resources. The split-treatment model is not ideal, but exists for two reasons: ( 1 ) an insufficient number of psychiatrists to perform therapy with all clients who need medication and (2) the lack of prescription privileges for psychotherapists in other professions. Wiggins (2004) summarizes the research evidence in support of psychologists' attainment of statutory authorization to write prescriptions, as they now have in the military. WHEN IS THIS HYPOTHESIS A GOOD MATCH? We need to be aware that for severe disorders, such as Schizophrenia and Mania, psychopharmacological treatment is not considered optional, but is rather a part of the "standards of care" for physicians (see Agency for Healthcare Research and Quality at www.ahrq.gov and American Psychiatric Association at www.psych .org) and that "to knowingly withhold pharmacotherapy from patients with these disorders thus could amount to malpractice" (Thase & Jindal, 2004, p. 756). Thase and Jindal (2004) cite strong research support for combining medication and psychotherapy for Schizophrenia, Major Depressive Disorder, OeD, and Bipolar Affective Disorder. Other disorders for which medication is effective include panic attacks, other anxiety disorders, eating disorders, Attention Deficit Disorder (ADD), and substance abuse disorders. Target Symptoms That Respond to Psychotropic Medication It is through a competent differential diagnosis process that you will recognize when to recommend referral for medication. In the intake interview, you will be screening for target symptoms that are criteria for the disorders listed above: • Signs of thought disorder (e.g., loose associations or incoherent speech); psychosis (e.g., hallucinations or delusions). • Depression (e.g., negative self-appraisal, suicidal ideation, and vegetative symptoms such as sleep disturbance, appetite disturbance, weight gain or Biological Hypotheses 81 loss, fatigue, decreased sex drive, agitation, psychomotor retardation, diurnal variation in mood, and anhedonia). • Mania (e.g., flight of ideas or grandiose delusions). • Anxiety (e.g., restlessness or impaired concentration). Medication evaluation is also indicated when the client reports panic attacks or meets diagnostic criteria for ADHD and OeD. Sometimes presenting symptoms that suggest Anxiety or Attention Deficit Disorder stem from either caffeine consumption or withdrawal or are effects of taking medications. Table 3.3 provides indications that strongly support referral for medication evaluation. Addictions Medical intervention can be very helpful in the initial stage of detoxification and withdrawal and for assistance during the recovery stages. Therapists should be knowledgeable about the existence of medical interventions: nicotine patches for smoking cessation; methadone programs for heroin addiction; Antabuse (disulfiram), which produces nausea when combined with a1coho�, and a newer Table 3.3 Indications for a Referral to a Psychiatrist for Medication Evaluation The Client Is Actively Suicidal or Has Severe Functional Impairments The client' s symptoms are interfering with basic functioning-the ability to get out of bed in the morning, go to work, feed herself, and bathe-or the therapist considers the client to be a suicide risk or a risk to othc: rs if symptoms are not aggressively treated. The Symptoms Have Persisted despite Psychotherapeutic Interventions The client has been in therapy with the current therapist or another therapist for a significant period of time and symptoms have not been alleviated. The Client Is Self-Medicating When the client reports the use of alcohol, prescription pain medication, street drugs, herbal remedies, or over-the-counter medicine, it is important to find out specifically what benefits are derived from the chemical. For instance, diet pills can improve concentration and productivity for school assignments, and alcohol can help overcome shyness or reduce sexual inhibitions. This information will tell the therapist that the client may have an underlying condition that could be addressed with medication. Psychotropic Medication Worked for the Client in the Past The client has a psychiatric history and medications have worked to alleviate symptoms in the past. Prior success with a medication is one of the strongest reasons for using it with the CUfrent symptoms. Psychotropic Medication Has Worked for Family Members with Similar Symptoms A family history of similar psychiatric symptoms should be taken as strong evidence that the client might respond to medication, especially if family members have been successfully treated with medication. 82 Twenty-Eight Core Clinical Hypotheses drug, Acamprosate, which helps to maintain abstinence from alcohol by reducing cravings. Nonphysician psychotherapists must be careful not to recommend the treatments but rather to recommend a referral to a qualified physician for further evaluation. When clients have received advice from physicians to use a prescribed substance to overCOlne dependency on another substance, they may be obstinately opposed, as was demonstrated in the movie Ray, which dramatized Ray Charles's decision to go through heroin withdrawal cold turkey. Medication for Physiological Conditions Conditions related to eating, sleeping, and sexual functioning respond to medication. For example, Viagra can correct erectile dysfunction and sleep medication can treat insomnia. For people who are struggling to lose weight, there are Inedications to suppress appetite and stimulate metabolism, which can help jumpstart a weight loss program, but which will not lead to long-term success unless the person learns to change eating habits and maintain those changes after the medication is terminated. Other Medical Interventions Therapists need to be knowledgeable about the array of interventions on the physical level that can produce mental health benefits. When you discuss these options with clients, note the following caveat for nonphysicians: Be careful not to exceed the scope of your practice by doing anything that could be construed as medical advice. Acupuncture Acupuncture was formerly considered a fringe treatment, yet now it is commonly integrated into group medical practices and receives reimbursement from health care companies. A common application is in an integrated pain management treatment program for such problems as headaches, back pain, and arthritis. It also has been effective with addictions, weight problems, and depression. Invasive Treatment of the Brain It may come as a surprise that psychosurgery is still used, though infrequently: Eskander, Cosgrove, and Rauch (2001) estimate fewer than 25 operations annually in the United States and Great Britain. Rodgers ( 1 992) describes the successful treatment of uncontrollable violent rage episodes: Fortunately, the methods are more advanced than the lobotomy method of the 1 940s-an icepick in the orbit of the eye. Modern methods of psychosurgery, including deep brain stimulation and irreversible lesioning, have been used successfully with refractory OCD (Husted & Shapiro, 2004). Electroconvulsive therapy (ECT) is Biological Hypotheses 83 still practiced on patients with severe mood disorders or subtypes of Schizophrenia that have not responded to medication. Electroconvulsive therapy is considered when there is an imminent risk of suicide, because it has more immediate results than antidepressant medication. The name of this treatment still evokes horror, so the patient needs to understand that the seizure activity is carefully monitored and controlled, while patient comfort is assured with medication during the procedure. Optional Surgery When surgery offers benefits to the client's mood, functioning, or life satisfaction, the therapist can help the client make a decision and cope with the adjustments that follow. Surgeons frequently require psychological evaluation before deciding whether to provide the requested surgery. Table 3.4 lis\ts several examples of optional surgeries that can improve psychological functionIng: Appliances and Prostheses Clients may need to consider devices to reduce symptoms or help compensate for loss of functioning. Many clients refuse to consider devices that could improve their quality of life; for example, a person who misses half of conversations, but will not get a hearing aid, or an elderly person who cannot walk without pain but refuses to use a wheel chair because she does not want the negative attention of people who would view her as "crippled." Sometimes the issue is the need for information and access, other times there is a need to explore opposition to use of an appliance that is based on beliefs and assumptions. TREATMENT PLANNING An effective approach to case formulation would be to define one problem, for instance, acute depressive episode, so that the medical intervention is the main feature of the plan. Then assign other problem titles for issues that do not require a medical intervention. For instance, for a depressed client, other problems could be excessive discouragement in response to beingpassed overforpromotion; difficulty accepting supportfrom friends andfamily; difficulty coping with loss and separation. How to Handle a Medication Referral When the need for a medication referral is recognized, the therapist must take steps to ensure that it will be a productive experience. Presenting the Suggestion Describe specific target symptoms when explaining the rationale for suggesting a referral for a medication evaluation; assume that the client is wondering why now? When you describe the potential value of medication, you must be rr o o 84 Twenty-Eight Core Clinical Hypotheses Table 3.4 Optional Surgeries to Improve Psychological Functioning Physical Treatments for Erectile Dysfunction Erectile dysfunction can have physical and psychological causes. In an otherwise healthy man, this condition may be due to the following: (a) neurological or hormonal abnormalities prevent the initiation of an erection, (b) blockage of arteries prevents the erection chambers from filling with blood, or (c) scarring of the erection chambers prevents them from storing blood. Well-known medications for erectile dysfunction (Viagra, Levitra, and Cialis) are appropriate for the first cause but will be ineffective for the other two. Therapists, even if not specializing in sex therapy, should be knowledgeable about the options available: (a) a vacuum constriction device, (b) insertion of a medicated pellet into the urethra, (c) self-injection therapy, (d) penile prosthesis insertion (penile implant) and, rarer than the other choices, (e) the option of penile revascularization (bypass) surgery. Evaluation of the need for this surgery should involve a team approach, including an urologist and a sex therapist. Gastric Bypass Surgery Surgeons generally require prospective patients to undergo a psychological evaluation prior to gastric bypass surgery to rule out psychological issues that might negatively affect the results of the surgery, such as depression, substance abuse, or eating disorders. The evaluation assesses whether the patient has realistic expectations, understands the seriousness of the procedure, and is capable of the lifestyle changes that are necessary after surgery. Sex Reassignment Surgery Transsexualism, a problem of gender identity, needs to be distinguished from homosexuality (sexual attraction to the same gender) and fetishistic cross-dressing (achieving sexual arousal while wearing the clothes of the other gender, without desiring to actually be that gender). A client who is considering surgical reassignment needs to be referred to a responsible expert who would require psychological evaluation as well as an extended time period living in the role of the desired gender. Generally, the drastic intervention of a sex change operation would not be considered unless the following criteria are met: (a) conviction since childhood of having been born into the wrong sex, (b) repugnance towards one's sexual characteristics, and (c) a wish to be accepted in the community as belonging to the opposite sex. Cosmetic (Aesthetic) Surgery When reconstructive surgery is medically necessary (e.g., after burns, mastectomies, trauma, or severe acne scarring), it belongs under B1. Cosmetic surgery is not covered by health insurance and is chosen for the benefits of physical enhancement, as with these problem titles: Excessive embarrassment and discomfort in social situations or Extreme dissatisfaction with physical appearance. Therapists can help evaluate the client's reasons for the surgery and help challenge unrealistic expectations and misconceptions about how plastic surgery will improve the client's life. Utopian expectations (CI) can be identified if the client thinks that a straight nose will bring happiness and instant success with dating. Deeper issues of selfloathing, social anxiety, or inability to accept aging gracefully may be uncovered in therapy. Alternatively, opposition to the idea can come from a set of schemas (C2) that oppose vanity: The thought that " you should accept the body that God gave you," or "there are better ways to spend your money." careful not to state or imply that medication is necessary. You are not telling the client that she needs medication, just that you think it is a good idea to have an evaluation from someone with the expertise to make that decision. You should discuss client fears and beliefs, and help shape realistic, positive expectations. Biological Hypotheses 85 Exploring the Client's Reaction Exploring a client' s reaction should be a two-way dialogue. What meaning does the client attach to the suggestion? Is the therapist admitting defeat? Is this a rejection? The client might ask: Does this mean that I'm crazy? Many clients are very resistant to the idea of taking medication because they fear the stigma, as if medication officially stamps them as having "mental illness," or they have personal rules that prohibit relying on external substances for emotional well-being. If the client is worried about the cost of medication, the therapist should explain that psychiatrists have free samples and that many drug manufacturers have programs for free or reduced cost medication. Explaining the Roles of the Two Professionals Make clear to the client that you will continue to provide psychotherapy, while the prescribing psychiatrist will monitor the effect of medication on target symptoms. Two copies of a two-way release of information form should be signed and the client should understand that the two professionals will communicate to best coordinate care. The Referral The therapist provides the psychiatrist with a short history and reasons for requesting the evaluation prior to the appointment and expects to receive a followup report and phone conversation following the appointment. Debriefing the Evaluation with the Client The therapist invites the client to talk about reactions after the evaluation. The roles of the two professionals are again clarified, and boundaries are explained. When the Client Is on Medication Whether the client was already on medication when entering therapy or has just begun medication following a referral, you need to be prepared to deal with the following: (a) issues specific to medication, such as experiencing side effects as well as other reasons for desiring to be noncompliant, ( b) issues that arise from seeing two different professionals, and (c) new problems that emerge after symptom reduction is obtained. You should encourage the client to discuss questions and concerns with the prescribing professional. Although you will reinforce and explain what the other professional has communicated, you must be careful not to overstep the bounds of your competence. Sometimes, you may have to explain that you will no longer be able to see the client, because of the limits on the scope of your practice, if the client's severe symptoms are not controlled by medication. Table 3.5 lists some common medication issues. 86 Twenty-Eight Core Clinical Hypotheses Table 3.5 Common Medication Issues Onset of Clinical Action Clients need to understand that it will sometimes take several weeks before they are expected to experience improvement and they should not quit taking the drug because they are not noticing any positive effects. Dealing with Side Effects A major cause of discontinuation is distress over side effects. Urge the client to talk to the prescribing psychiatrist if he or she experiences side effects from the medication. Giving the medication a little more time might be recommended by the physician, with specific predictions of normal side effects. If troublesome side effects persist, they are usually managed by adjusting dosage or switching to another medication. Understanding and Following Instructions Clients need to understand that they must not discontinue taking medication because they feel better, but instead should do so under the guidance of the psychiatrist. Sudden discontinuation can produce withdrawal symptoms. Clients should understand and follow rules for avoiding light, getting required blood tests, discussing intention to become pregnant, and not combining prescribed medication with alcohol, drugs, or herbal remedies. Relapse Prevention There are many conditions that require long-term maintenance on medication to prevent recurrence of symptoms. Therapists can help clients to do a cost-benefit analysis of maintenance versus discontinuation, comparing the negative effects of medication with the consequences of a recurrence of the disorder. Clients may have been taught that medication is only a temporary measure. However, it is common practice now, when the client has a third recurrence of the disorder that responded to medication, to consider continuous rather than intermittent use. Direct Communication between Professionals Effective coordination of care requires ongoing communication. Therapists need to be aware of the possibility of the client telling different stories in the two settings. In one case, a client told the therapist that she was drinking and taking street drugs but denied this to the psychiatrist. The two professionals, after comparing notes, decided that the psychiatrist would order drug testing. "Splitting " This is a psychodynamic term for the interpersonal dynamic where the client sees people as all good or all bad. This can occur when the client is seeing two professionals: One becomes idealized and the other devalued. The therapist needs to be aware of the potential for this dynamic, and make it a focus of therapy if it occurs. The professional who is being idealized must recognize this process and not collude with the client's efforts to denigrate the other professional. To deal effectively with splitting, the two professionals must already have a good working relationship. Emergence ofNew Problems These may be problems that were ignored because of the severity of the symptoms, or new ones that emerge as symptoms subside. Corrullon problems include: Biological Hypotheses 87 • Suicidal risk: Clients with severe depression do not have the energy to mobilize resources to kill themselves. When antidepressants begin to work, the risk of suicide may increase. • Deficits in life skills: Although the clients' symptoms were extreme, she was relieved of responsibilities for life tasks or excused for impairments in functioning. Now that the symptoms are clearing up, it becomes clear that there are deficits that need to be addressed, for instance, poor job skills. • Problems in interpersonal relationships: When a client is stabilized on medication, many interpersonal problems may be identified (e.g., lack of a good friendship network, poor communication skills, or difficulty coping with conflict). INTEGRATION OF HYPOTHESES You should always consider the following hypotheses when clients are evaluated for psychotropic medication. C2 Faulty Cognitive Map The client's attitudes and schemas about medication are important factors. Some clients want a quick fix when a better approach would involve developing new skills or working patiently on long-standing emotional issues; other clients reject the idea of medication because of the meaning they attribute to taking it (I'm weak, crazy, mentally ill) or faulty beliefs (My boss willfind out). If taking medication means that the illness is physical rather than mental (I'mjust correcting a neurotransmitter imbalance, it's like a person with diabetes taking insulin), it can be very comforting, removing the stigma of being severely mentally ill. SCE2 Cultural Context Cultures and subgroups differ in their values and prejudices about medication and psychotherapy. Psychotherapists may believe that medication carries more stigma than psychotherapy, whereas many clients may believe the opposite. SCE6 Social Role of Mental Patient Knowledge that a person is taking psychotropic medication can put the person into the social role of mental patient, which can influence the reaction and judgments of others, as well as the client's self-appraisal. 88 Twenty-Eight Core Clinical Hypotheses B3 MIND-BODY CONNECTIONS Definition A holistic understanding of Mind-Body Connections leads to treatment for psychological problems that focus on the body and treatment for physical problems that focus on the mind. Explanation This hypothesis is a good fit for clients classified as somatizers, for many types of stress and tension complaints, and for sexual disorders. Clients often need to increase their awareness of and control over their bodies and to develop a somatic awareness of feelings. Many bodycentered therapies have utility for psychological problems. Psychological states can affect the brain, autonomic nervous system, and immune system. Health problems, such as cancer and AIDS, are benefited by positive mental states. Paul had difficulty expressing emotions and was incapable of spontaneity. Even though he had read unfavorable things about it, he chose Reichian therapy. The therapist worked directly on his body's musculature. While experiencing physical pain, Paul recovered memories from childhood that he had repressed. Following treatment, his capacity to express feelings and feel close to his fiancee was greatly improved. Examples Nick's gastrointestinal pain began when his wife began neglecting him, to pay attention to her newly divorced sister's children. The physician ruled out a medical cause for the pain. In psychotherapy, he discovered that the somatic symptoms were caused by emotional tensions. Nick was feeling angry and abandoned, but never communicated these feelings. When he learned to express his needs, the symptoms disappeared. Barbara described herself as "living entirely in her mind." She didn't know what she felt or what she truly wanted, and she operated solely on "shoulds" and automatic submission to the demands of other people. She went to a therapist who integrated Eugene Gendlin's focusing method into therapy. She learned the skill of focusing on her bodily experience and waiting for a "felt sense" to occur. This method helped her resolve a major dilemma. KEY IDEAS FOR B3 MIND-BODY CONNECTIONS The bidirectional connections of mind and body have been documented in numerous ways (e.g., brain scans of people with symptoms of ADD or OeD, health outcomes of cancer patients in support groups, the effective use of imagery in pain management, and the reduction of blood pressure from biofeedback techniques). The professional specializations of health psychology, behavioral medicine and liaison psychiatry are based on the application of the B3 hypothesis. Stress The term stress has multiple meanings. Sometimes it means "external environmental stressors," as when I say "There's a lot of stress in my life now, " referring to academic pressure, divorce, or unemployment. It also refers to the physiological responses involved in "fight-flight" reactions: activation of the sympathetic nervous system, biochemical changes in the brain and glands, and avoidant responses. Stress can manifest in somatic symptoms such as stomach aches, muscle tension, Biological Hypotheses 89 headaches, fatigue, nausea, dizziness, and skin rashes. The mind-body relationships are bidirectional: Psychological factors influence muscle tension and autonomic responses, while the arousal level of the body leads to the subjective experience of anxiety, anger, or panic. Psychological Trauma When Freud developed his theory of neurotic mechanisms, he included conversion reactions, where unconscious defenses repress emotional pain while producing a symptom in the body, such as paralysis or blindness, often symbolic of the underlying psychic conflict. Wilhelm Reich (1980) focused on the way the child's body developed rigidity as a defense against emotional pain, using the term character armor for these enduring self-protective mechanisms. Levine (1997) describes how "survival energy" from the fight-flight reaction, which was not appropriately discharged at the time of the trauma, remains "stuck" in the body and the nervous system; the various symptoms of trauma result from the body's attempt to manage and contain this unused energy. Neuroscientists describe Posttraumatic Stress Disorder (PTSD) in terms of dysregulation of the central nervous system involving chronic hyperarousal, the intrusions of sensory, somatic, and emotional memories into current consciousness as if they were happening in the present (flashbacks), dissociation and amnesia in extreme situations, and inhibition of language centers. Psychoneuroimmunology Psychoneuroimmunology (PNI) is the field that studies the interactions among the neural, immune, and endocrine systems; most commonly, PNI refers to the link between someone's state of mind and her health, with special attention to the evidence that mental activities can promote healing. The well-known placebo effect, referring to improvement in members of the control group of a drug study who have been given an inert substance instead of medication, demonstrates that positive expectancies have measurable physiological benefits. Norman Cousins (1979) popularized the view that positive emotions, particularly humor, can produce dramatic benefits to physical health. The Simonton Cancer Center in California reports evidence that guided imagery and meditative techniques produce positive changes in cancer patients. Participation in support groups has been associated with better life expectancies for cancer patients as compared to patients who did not participate. When patients have a sense of control over the management of their illness, they are likely to have a more positive outlook. Negative psychological experiences can depress the immune system. A wide range of stressful events have been associated with lowered immune system function, including school examinations, divorce, and bereavement. Research has confirmed the commonsense belief that we are more susceptible to the common cold when we are experiencing higher levels of stress. It follows that people who use good coping strategies and have social support when faced with stressful events will have better-functioning immune systems. There is even research 90 Twenty-Eight Core Clinical Hypotheses showing that people can learn to suppress overreactive immune responses, which cause such diseases as lUpus. Although it is important to understand the progress made in this new field, be aware of two risks: ( 1 ) fueling unrealistic faith in the power of positive mental states, possibly leading to the rejection of medical care; and (2) triggering guilt in medical patients who may blame themselves (e.g., for poor stress management or excessive anger) for causing their disease. Physiological States Physiological conditions, such as sexual arousal, hormonal changes, and fatigue, can greatly influence mental states. For instance, adolescent, menopausal, premenstrual, and postpartum hormonal states can be extremely disruptive to emotional, cognitive, and behavioral functioning. The very common experience of jet lag occurs from disruption of sleep and waking cycles. The release of endorphins produces a pleasurable effect, which serves as positive reinforcement for the behavior that elicited this biological response. This reinforcing effect can be beneficial when it helps people develop healthy habits of regular exercise. However, the release of endorphins also reinforces harmful behavior, such as self-mutilation. Abilities and Capacities for Optimal Body Functioning Individuals possess a variety of abilities and capacities that contribute to good physical and Inental health. Table 3.6 presents a list of abilities and capacities for optimal body functioning. By understanding the components of positive health, therapists can identify problems and set outcome goals. WHEN IS THIS HYPOTHESIS A GOOD MATCH? From the previous topics, we can develop problem titles for impairments and dysfunctions: A few examples are Inability to relax and enjoy leisure time; difficultyfocusing on body sensations during sexual intercourse; or difficulty accessing and labeling emotions. The following categories provide a wide range of common applications. Stress, Anxiety, and Tension Clients need help with stress reactions whether they are coping with difficulties from a current, temporary situational stressor, dealing with chronic stress conditions that put health at risk, or coping with the aftereffects of severe trauma. The client needs to learn how to enter a physiologically relaxed state, putting the body ' s arousal level under voluntary control. This goal fits a variety of problems including anxiety symptoms and disorders, anger management issues, stress-related physical disorders, difficulty falling asleep, and overeating because of emotional factors. Difficulty relaxing and enjoying breaks from work is a common complaint of workaholics and perfectionists. Table 3.6 Abilities and Capacities for Optimal Body Functioning The Ability to Take Care of the Needs of Your Body Eating, sleeping, bathing, providing for shelter, enhancing immunity from disease, social contact, and sexual fulfillment are all essential processes in maintenance of physical health and well-being. We also need behaviors that improve health: good nutrition, exercise, medical check-ups, and relaxing leisure. Caring for the body can also include luxuries like massages, facials, and aromatherapy. Coordination of the Body Ideally, the movement of the body is smooth and fluid, the muscles are loose and free of tension, and the posture is upright with the head balanced loosely on the spine. These qualities are especially important for people engaged in performance arts or sports as their occupations or hobbies. The body bears the imprint of early experiences with stress and trauma in the form of tightness, rigidity, and loss of spontaneity. Sensory Awareness of Cues from the Body It is important to be able to assess one' s level of arousal, distinguish between physical hunger and emotional cravings for food, and recognize the difference between emotional and physical pain. Attention to the body should be under voluntary control. During sex, it is desirable to be able to attend fully to specific sensations in the body and tune out external stimuli. However, you want to be able to ignore signals from the body, such as pain, if you are facing an external threat. The Capacity to Regulate Arousal When the fight-flight reaction is triggered, it is essential to be able to distinguish real danger from conditioned or symbolic threat. In the latter case, you need the ability to lower your arousal. The ability to induce in yourself a state of relaxation, at will, is probably one of the most important coping skills you can develop. It also may be necessary to voluntarily increase your arousal, as when you need higher levels of concentration to complete a project or higher levels of sexual arousal when you so choose. The Ability to Put Your Emotional and Somatic Experiences into Words This behavior is associated, on a neural level, with integration between cognitive and emotional processing networks and communication between both hemispheres of the brain. Lack of this ability, which means lack of neural integration, results in problems such as poor affect regulation and dissociative states. When emotional experiences are not verbalized, the risk of somatization-replacing awareness of feelings with somatic symptoms-is increased. The Capacity to Register What You Want and Feel, versus What You "Should" Want and Feel What a person thinks she feels and wants can be completely at odds with a deeper body sense that carries a more valid expression of true desires. The technique offocusing (Gendlin, 1 982) teaches how to access a "felt sense" in the body. The Ability to Experience Pleasure and Contentment at Moderate to Low Levels of Arousal There are people who associate high levels of stimulation with pleasure and feel bored or anxious at lower levels. This is problematic in a committed relationship: New lovers are exciting, but will no longer be appreciated when a sense of familiarity and comfort develops. Some people find that if they stay busy and stressed, they maintain a good mood, but when they get more relaxed, they feel terrible. For instance, " workaholics" can't enjoy vacations and "stimulus junkies" get depressed when operating at normal levels of stimulation. (continued) 91 92 Twenty-Eight Core Clinical Hypotheses Table 3.6 (Continued) The Ability to Tolerate Unpleasant Emotions Anxiety can cause an increased heart rate and sweaty palms, anger reddens the face and blurs vision, and grief overwhelms the body with lethargy and aches. It is not easy to sit with these feelings and simply endure them; people find strategies for either eliminating awareness of these feelings or immediately acting out on them to make them go away. These tactics can lead to countless problems: distortions of reality through projection and displacement, obsessions and compulsions, agoraphobia, kleptomania, aggressive acting out behavior, addictions to substances as well as to unsatisfying relationships, and suicide. The Awareness of and Ability to Control Nonverbal Messages Our bodies send messages through facial expressions, posture, gestures, and movements that are interpreted by the viewer to have social meaning. Often, these messages are incongruent with our internal thoughts and feelings, creating an unintended impact. If a client wishes to be warm and friendly to strangers but unintentionally sends uninviting messages, he may need help in changing nonverbal messages. The Ability to Appraise and Evaluate the Appearance of Your Body Realistically There are many ways that people hold distorted body images: A person of average weight sees a "fat person" in the mirror; an anorectic person views her emaciated body as normal, and an obese person describes himself as "somewhat overweight." Chronic Pain Pain is usually a temporary state that either goes away naturally or is a signal of a medical disorder that can be treated. When the pain is continual or recurring and interferes with daily functioning, and the person has to learn to live with it rather than hope for a medical cure, the term chronic pain is used. Chronic pain is both physical and psychological. Psychotherapists can be part of an interdisciplinary treatment team or receive referrals when pain medication is not appropriate or sufficient for dealing with chronic pain. A theoretical model of pain, like that of stress, involves interactions of physiological changes, cognitive appraisal, and muscular tension. Sufferers of chronic pain are at risk for substance abuse and often experience depression. Medical Complaints without Medical Cause Therapists may receive referrals from physicians of patients who insist that there is something physically wrong with them, even after multiple tests produce normal findings. The term hypochondriasis applies when the patient overreacts to bodily sensations, convinced that there is a serious disease. The term somatization is used when patients fit the following profile: Their health problems began at an early age, covering a variety of organ systems, and they pursue surgeries even when clinical findings are in the normal range. These people are not consciously malingering; the mechanism for substituting physical and somatic symptoms for psychological issues is outside of their awareness and not under conscious control. The symptoms give the person an entrance ticket to attention, Biological Hypotheses 93 care, and nurturing from the health professionals and provide a means of indirectly controlling other family members. The clinician must refrain from suggesting "it's all in your head," an attitude that destroys the therapeutic alliance, but instead validate that the suffering is real. Because real medical problems can coexist with somatization complaints, the therapist cannot eliminate the need for medical evaluations. Problems with Eating, Sleep, and Sexual Functioning Problems with eating can include severe disorders, such as Anorexia Nervosa and Bulimia, as well as common frustrations of failure to attain a desired weight and lack of control over one's eating or drinking behaviors. These clients need to learn to monitor body sensations of hunger and fullness, as well as to identify bodily sensations that are signs of emotions other than hunger. Sleep disturbances include the occasional by-product of worry and stress, symptoms of depression and anxiety disorders, and more complicated conditions requiring referral to sleep disorder clinics, such as sleep apnea, the intermittent cessation of breathing during sleep. Problems in sexual functioning involve complex interactions between mind and body. Therapists need to be able to talk comfortably about sex with clients: Many trainees feel embarrassed to probe in this area, and clients might not feel comfortable talking about it without encouragement. Therapists should be ready to refer clients to competent sex therapists. Dissatisfaction with Body The client may directly express dissatisfaction with some aspect of the body and its functioning. Body Dysmorphia is a DSM diagnosis for people who have a distorted view of the size of their own body. Athletes, singers, musicians, and dancers may need psychological interventions because of problems with their performance. For instance, a tennis player may need tools for focusing concentration and a concert pianist may suddenly have debilitating attacks of stage fright. In addition, medical patients may need psychological help adjusting to the impact of the disease on their body. For instance, ostomy patients adjusting to the use of an external bag have difficulties in coping with the loss of dignity and fear of public humiliation. Difficulties with Awareness and Expression of Emotions Excessive emotional arousal, with lack of awareness of sources of emotions or tools for appropriate management and expression, is an extremely common problem in therapy. Patients diagnosed with Borderline Personality Disorder show extreme emotional instability and need help with emotional regulation. People with lack of control over expressions of anger may end up in therapy through a court referral. 94 Twenty-Eight Core Clinical Hypotheses At the other extrelue, there are people who are out of tune with how they feel and have no idea about how to access internal states for information about their own feelings and desires. A person may talk in a monotone and verbalize feelings with a lack of congruence in the bodily signs of that emotion. Excessive rigidity in the body and shallow breathing can cut off the experience of feeling. Mental States and Behaviors That Put Health at Risk When the client has already been diagnosed with a luedical illness, he or she may need help in bolstering the immune system through positive, health-enhancing attitudes. The choices that a person makes regarding environment, social contacts, and occupation, as well as decisions about smoking, alcohol, diet, exercise, protected sex, and leisure affect the level of risk for physical problems such as accidents, infectious disease, stroke, heart attack, HIV/AIDS, and cancer. Conditions That Respond to Reputable Body Therapies Descriptions of therapies that focus on the body give ideas about when to consider referral for one of those treatments. For instance, neurofeedback has been found to be effective with ADHD and Eye Movement Desensitization Reprocessing (EMDR) is widely used for PTSD. TREATMENT PLANNING Many body-focused treatment strategies require advanced training, supervision, and even certification. You must decide whether you are qualified to implement a desired plan or whether you need to offer the client a referral. Strategies to Increase Awareness of the Body For some clients, especially those with eating disorders, lack of sexual arousal, and tendencies to intellectualize, a primary element of the treatment plan is to increase awareness of their bodies. This awareness can be developed a number of ways, including through journaling, feedback, and focusing. Diary A compulsive overeater needs to learn to identify the difference between eating from physical hunger (stomach hunger) and eating to fulfill an emotional need (mouth hunger) a daily monitoring chart (see Table 2.9) could be designed where the client can keep track of the time of day, the situation, the exact amount of food consumed, thoughts and feelings, and also have a column to indicate whether the eating was triggered by "stomach hunger" or "mouth hunger." Discussion in therapy of these diaries can help clients identify the functions of their eating and assist them in finding alternate ways of dealing with their emotions. Biological Hypotheses 9S Feedback about Messagesfrom the Body The client' s movements, gestures, tics, posture, and facial expression all carry messages. The therapist pays attention to the body and comments on body movements, even asking the person to exaggerate them, to understand their meaning. The painful, tense, and tight areas of a client' s body may carry psychological messages. For instance, a stiff neck may mean that he thinks someone is a "pain in the neck" while curved, tense shoulders may show how burdened the client feels. Focusing Thefocusing method, developed by Eugene Gendlin, involves specific guided instructions to help people move from their mental definitions of problems to a physically felt body sense. Therapists can use this method in sessions and clients can learn focusing skills independently or with peers. Treatments for Stress Management A number of strategies can be integrated in teaching clients to control emotional responses that contribute to physiological stress. Psychoeducation Therapists teach the client about stress, explaining how psychological factors influence muscle tension and autonomic responses and how the arousal level of the body leads to the experience of anxiety, anger, or panic. There are many useful books that clients can read about stress, for example, Benson's book, The Relaxation Response. The client learns that by directing the mind toward relaxation instead of tension, he or she can directly affect the brain, hormonal activity, blood pressure, and other physical processes and simultaneously alter the subjective sense of anxiety, stress, or panic. Physical Movement Any form of physical activity can help to reduce stress. In addition, exercise can allow a client to take a break from stressful activities and gain some perspective on his situation. T' ai chi-one of the martial arts from Asia that is performed in very slow motion-is a technique that reduces stress and produces a sense of confidence and self-mastery. The practice of yoga includes meditation, a focus on breathing, and gentle stretching and simulation of every part of the body, including internal organs. Use ofthe Subjective Units ofDiscomfort Scale The use of the SUDS was described in Chapter 2. The most common use of this scale is for intense emotional arousal, either from anxiety or anger. Through use of diaries as homework, the client learns to use SUDS numbers for various events during the week and to discriminate different bodily states and emotional reactions. The client then is taught tools to lower discomfort levels during stressful situations, such as taking a "time out" or engaging in deep breathing. 96 Twenty-Eight Core Clinical Hypotheses Relaxation Training As part of your assessment you must determine whether the client can voluntarily lower the SUDS level with simple advice. If not, you should directly teach skills of relaxation. Table 3.7 offers examples of diverse ways of teaching clients how to get control over their level of physiological arousal. Biofeedback Learning to lower stress and induce a state of relaxation can be enhanced by the use of physiological monitoring devices. Sensors are attached to the client to measure blood pressure, skin temperature, heart rate, muscle tension, or perspiration. Then the client concentrates on a relaxation technique, paying attention to the feedback from the monitoring equipment to learn if he is successful in changing the body' s processes. For instance, learning how to raise the temperature in one's fingers can be beneficial for vascular (migraine) headaches and learning how to reduce the muscle tension in the frontalis muscle is helpful for reducing tension headaches. Alteration of Brain Functioning Progress in the field of neuroscience will lead to innovative ways to modify the brain to get changes in thinking, feeling, and behaving. Neural integration or new neural pathways are outcomes in the brain of effective psychotherapy and other learning experiences. Four methods illustrate ways of directly modifying the brain and states of consciousness to achieve positive clinical results. Neurofeedback Like biofeedback, neurofeedback is a technique that uses physiological monitors. However, instead of getting feedback on blood pressure, galvanic skin response (GSR), or body temperature, the feedback is from an electroencephalogram (EEG), which gives information on brain wave activity. Through use of a video display and audio signals, the client learns to match the video display to a desirable frequency band of brain activity. This technique has been used with many types of problems, including sleep problems, addiction, chronic pain, and mood disorders. Hypnosis During hypnosis, the practitioner uses verbal suggestions to induce the client to enter and deepen a trance state, which involves intense absorption in the object of concentration, lack of awareness of other experiences, and suggestibility to the instructions and guidance from the person who induced the trance. With practice, the client learns to enter the trance quickly and to use self-hypnosis for therapeutic aims. Hypnosis can help pain sufferers by reducing the perceived level of pain as well as help people lose weight and give up smoking. For hypnosis to work, the client has to meet a threshold of suggestibility and be motivated for the type of change being sought. Table 3.7 Techniques of Relaxation Training Progressive Relaxation Training (PRT) The client is instructed to focus attention on specific muscle groups (e.g., hand or forehead) and to first tighten and then release (relax) them. When those muscles are "completely relaxed," attention is directed to the next group. She repeats this with each muscle group, moving systematically throughout the body, until every muscle group is covered. At the end of the process, the entire body is relaxed. With practice, the client can produce a relaxed state by recall or by counting. It is helpful to have the client make an audio recording of the relaxation instructions for home practice until the method becomes automatic. Autogenic Training and Self-Hypnosis The use of suggestion, first from the therapist and then by the client, can induce a relaxed state. Autogenic training is a method of passive concentration on bodily sensations, such as heaviness, warmth, coolness, or breathing, without tensing muscles. Another method (not to be used for elevator phobics) is: Imagine that you are going down an elevator in a tall building, and as you go to each lowerfloor, you become more and more relaxed, until, when you get to the bottomfloor, you are completely relaxed. Meditation Techniques derived from Asian religions are used for producing physiological relaxation and a peaceful mental state. The client learns to discipline the mind to focus on the present moment and to create a sense of stillness, free of the usual chatter that occurs in the mind. The term mindfulness refers to awareness, without judgment, of ongoing internal and external experience. In Transcendental Meditation, the person repeats a mantra-a silent word or phrase-to quiet the stream of internal dialogue. However, any type of quiet focused attention on sensory and bodily experience can be considered a form of meditation. People who enjoy knitting describe the pleasurable meditative state they achieve through the rhythmic, repetitious clicking of needles and the visual and tactile pleasure from attending to the yarn. Breathing Focus Often a part of other methods, this can be used alone: As the breath is released, it carries tension from the body. By simply focusing on breathing, and increasing the depth of breathing, and hence the intake of oxygen, the client calms mental processes, which achieves a bodily state of relaxation. Learning to breathe from the stomach (diaphragm) rather than from the upper chest helps people reduce anxiety. Here is an example of a simple set of instructions to induce relaxation and to teach the client how to self-relax: Close your eyes and get comfortable. . . . Take a deep breath in through your nose. . . . Put your hand on your stomach and feel it expand as you inhale again, breathing into the diaphragm rather than into the chest. . . . Exhale through your mouth andfeel the diaphragm lower. . . . Focus on the breath and continue a few more times. Imagery The therapist asks the client to remember a place where total relaxation was experienced. The therapist can offer suggestions-the beach with the sound of the ocean, a cool mountain forest, or a hammock under a tree-but the client has to choose something that works for him. The client closes his eyes and imagines himself in that place. The therapist provides verbal suggestions that direct the client' s attention to visual, auditory, tactile or olfactory sensations, until total relaxation is achieved. A tape can be made so that the client uses this technique as a self-management tool. 97 98 Twenty-Eight Core Clinical Hypotheses Eye Movement Desensitization Reprocessing Developed by Francine Shapiro (1996) in 1987, and now called Reprocessing Therapy, this approach teaches clients to stay out of "bad trances" that they experience as symptoms and uncomfortable psychological states. The therapist creates alternating stimulation to the two sides of the brain, while the client brings to mind a past negative incident and links it with a desired future outlook. In treating PTSD, past traumatic events are recalled and processed with a protocol that involves focus of attention on cognitive, emotional, and sensory domains, combined with the therapist stimulating alternate sides of the body, either by hand movements or touch. Alternative activation may enhance neural connectivity and integration of traumatic memories into normal, explicit memory processes. Phototherapy (Light Therapy) for Depression There is substantial medical research (e.g., Lundberg, 1998; Terman & Terman, 2005) documenting the benefits of a machine emitting the amount of light that is equivalent to standing outdoors on a clear spring day, for the treatment of Seasonal Affective Disorder, a pattern of major depressive episodes that occur and remit with changes in seasons. Light is registered by the eyes through the retina, which then transfers impulses to the hypothalamus in the brain to normalize the circadian rhythm. There is research supporting the use of light therapy with other conditions, such as nonseasonal depression, premenstrual syndrome, Bulimia Nervosa, difficulties adjusting to night-shift work, and circadian rhythm sleep disorder. A light machine does not require a prescription and can be bought on the Internet. Body-Centered Therapies These approaches are rarely covered in the graduate curriculum, but students can find information in the web sites of associations for body psychotherapies in Europe (www.eabp.org) and the United States (www.usabp.org). Some therapies focus on the body through verbal techniques and others involve physical touching. Because they attempt to bypass the defenses and coping strategies of the conscious mind, they carry risks for negative effects, especially when the client has been a victim of severe trauma, and they should only by used by people with extensive specialized training. For practitioners who implement techniques that involve touching the client andlor having the client remove clothing, there is risk of violating laws and ethics, or of being maliciously accused of doing so. Releasing Old Traumas Reichian Therapy and Rolfing are two approaches (derived from Wilhelm Reich and Ida Rolf, respectively) that involve touching the body of the patient, often in very painful ways, to release emotional pain, sometimes triggering recall of forgotten experiences. Levine (1997) describes a method of "somatic experiencing": The client develops an inventory of resources and then is helped by the therapist to shift back and forth between the high activation of traumatic material and the calming effect of resources. Biological Hypotheses 99 Alexander Technique This method is popular in England as a treatment for physical and emotional problems, but is much less known in the United States. An Alexander teacher is not a psychotherapist but someone who has been trained to teach clients to restructure their posture to recover the spontaneity and coordination that was lost in childhood. The student lies or sits fully dressed while the teacher gently aligns the body into its natural, correct posture, repeating brief verbal instructions. The student learns the verbal instructions and experiences what correct posture feels like, and then is expected to practice the technique between sessions. Energy Approaches Many approaches attribute psychological benefits to changes in the flow of energy in the body. In Bioenergetics the client assumes postures that lead to trembling and shaking, attributed to the flow of energy. Acupuncture and acupressure are treatments that have been found to have psychological as well as somatic benefits. Treatment of Chronic Pain Treatment for chronic pain integrates many of the techniques described earlier, as well as clinical techniques drawn from cognitive therapy and behavior therapy. A multidisciplinary approach in an inpatient treatment program lasting 2 to 4 weeks at Johns Hopkins Pain Treatment Program includes the following components in addition to medications and physical therapy: Psychoeducation Includes lectures about chronic pain, mind-body relationships, and treatment modalities. Psychotherapy Individual, group, and family therapy to explore how pain affects feelings and feelings affect pain, to deal with the grief and loss from chronic pain, and to increase coping skills and interpersonal relationships. Therapeutic Group Activities Involvement in recreational and vocational activities that decrease social isolation and give positive experiences. INTEGRATION OF HYPOTHESES One or more of the following hypotheses are often combined with the one jlJst reviewed to create an integrative formulation for a specific problem. The decision about whether a specific hypothesis should be integrated is based on your professional judgment. 100 Twenty-Eight Core Clinical Hypotheses CS2 Situational Stressors Whereas B3 deals with the bodily state of stress, CS2 focuses on the stressors from the environment that impinge on the person and create demands to cope adaptively. The concept of trauma links an external cause and an internal, often physiological, response. BL3 Skill Deficits or Lack of Competence Many adults lack competence in differentiating messages that signal exhaustion, hunger, and thirst. A person who overeats in response to all bodily sensations of discomfort needs to learn to recognize hunger. Many types of skills help people reduce body tension: relaxation skills, time management skills, even skills for reducing clutter in their living space. PI Internal Parts and Subpersonalities Consider that the body needs a spokesperson to articulate its needs. A goal oftherapy could be strengthening a self-nurturing part that takes good care ofthe body. SCE2 Cultural Context Eastern religions provide a completely different mind-body perspective from Western culture. In Chinese medicine, organs in the body represent specific mental or emotional conditions. Cultural conditioning affects attitudes toward our bodies, including comfort with nudity, sexuality, and aging. Many cultures use dance, touching, and rituals involving the body to enhance mental health and reduce suffering. Cultures differ in their encouragement of open expression of feelings. Somatization is more common in cultures where emotional expression of stress and anxiety is discouraged. SCE3 Social Support Social support brings emotional comfort, and it can reduce stress and boost the immune system. ES3 Spiritual Dimension Prayer and other spiritual activities have been found to have positive effects on health and are beneficial resources when coping with stress, chronic pain, and trauma. SUGGESTED READINGS Heilman, K., & Valenstein, E. (Eds.). (2003). Clinical neuropsychology (4th ed.). New York: Oxford University Press. Kalat, 1. W. (2003). Biological psychology (8th ed.). Belmont, CA: Wadsworth. Pinel, 1. P. 1. (2005). Biopsychology (5th ed.). Boston, MA: Allyn & Bacon. Biological Hypotheses 101 BI Biological Cause Morrison, 1. ( 1997). Psychological problems mask medical disorders: A guide for psychotherapists. New York: Guilford Press. Taylor, R. L. (1 990). Distinguishing psychological from organic disorders: Screening for psychological masquerade. New York: Springer. Zarit, S. H., & Zarit, 1. M. ( 1 998). Mental disorders in older adults: Fundamentals of assessment and treatment. New York: Guilford Press. Neuropsychological Assessment Groth-Marnat, G. (Ed.). (2000). Neuropsychological assessment in clinical practice. New York: Wiley. Lezak, M. D. (2004). Neuropsychological assessment (4th ed.). New York: Oxford University Press. Health Psychology American Psychiatric Association. (2001). Practice guideline for the treatment of patients with HIVIAIDS (American Psychiatric Association Practice Guidelines). Arlington, VA: Author. Baum, A., & Andersen, B. L. (Eds.). (2001). Psychosocial interventions for cancer. Washington, DC: American Psychological Association. Derogatis, L. R., & Wise, T. N. (1989). Anxiety and depressive disorders in the medical patient. Washington, DC: American Psychiatric Press. Gatchel, R. 1., & Oordt, M. S. (2003). Clinical health psychology and primary care: Practical advice and clinical guidance for successful collaboration. Washington, DC: American Psychological Association. Holland, 1., & Lewis, S. (200 1 ). The human side of cancer: Living with hope, coping with uncertainty. New York: Quill. Langer, K. G., Laatsch, L., & Lewis, L. (Eds.). (1 999). Psychotherapeutic interventions for adults with brain injury or stroke: A clinician's treatment resource. Madison, CT: Psychosocial Press. Nezu, A. M., Nezu, C. M., Friedman, S. H., Faddis, S., & Houts, P. S. (1998). Helping cancer patients cope: A problem-solving approach. Washington, DC: American Psychological Association. Spiegel, D., & Classen, C. (1 999). Group therapy for cancer patients: A research-based handbook ofpsychosocial care. New York: Basic Books. B2 Medical Interventions Bezchlibnyk-Butler, K. Z., & Jeffries, 1. (Eds.). (2002). Clinical handbook of psychotropic drugs ( 1 2th ed.). Cambridge, MA: Hogrefe & Huber. Johnson, 1., & Preston, 1. D. (2004). Clinical psychopharmacology made ridiculously simple (5th ed.). Miami, FL: Medmaster. Medical Economics. (Ed.). (2005). Physicians ' desk reference (59th ed.). Montvale, NJ: Thomson Healthcare. Thase, M. E., & Jindal, R. D. (2004). Combining psychotherapy and psychopharmacology for treatment of mental disorders. In M. J. Lambert (Ed.), Bergin and Gmjield's handbook of psychotherapy and behavior change (5th ed., pp. 743-766). Hoboken, NJ: Wiley. 102 Twenty-Eight Core Clinical Hypotheses B3 Mind-Body Connections Benson, H., & Klipper, M. Z. (2000). The relaxation response (Reissue ed.). New York: HarperTorch. Bernstein, D. A., Borkovec, T. D., & Hazlett-Stevens, H. (2000). New directions in progressive relaxation training: A guidebookfor helping professionals. Westport, CT: Praeger. Cozolino, L. (2002). The neuroscience of psychotherapy: Building and rebuilding the human brain. New York: W. W. Norton. De Alcantara, P. (1999). The Alexander Technique: A skillfor life. Wiltshire, England: Crowood Press. Erickson, M. H., & Rossi, E. L. (1 989). The February man: Evolving consciousness and identity in hypnotherapy. Philadelphia: Brunner-Routledge. Evans, J. R., & Abarbanel, A. (Eds.). (1999). Introduction to quantitative EEG and neurofeedback. San Diego: Academic Press. Lowen, A. (1994). Bioenergetics (Reissue ed.). New York: Penguin. Rossi, E. L. (1993). The psychobiology ofmind-body healing: New concepts of therapeutic hypnosis. New York: W. W. Norton. Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New York: Norton. Schore, A. (2003). Affect regulation and the repair of the self New York: W. W. Norton. Schwartz, M. S., & Adrasik, F. (1998). Biofeedback (2nd ed.). New York: Guilford Press. Selye, H. ( 1 978). The stress of life (2nd ed.). New York: McGraw Hill. Shapiro, F. (1996). Eye movement desensitization and reprocessing (EMDR): Basic principles, protocols and procedures. New York: Guilford Press. Siegel, D. J. (2001). The developing mind: How relationships and the brain interact to shape who we are. New York: Guilford Press. Smith, E. W. L. (2000). The body in psychotherapy. Jefferson, NC: McFarland. Totton, N. (2003). Body psychotherapy: An introduction. Berkshire, England: Open University Press. Chapter 4 CRISIS, STRESSFUL SITUATIONS, AND TRANSITIONS A CrISIS often pushes people to seek therapy, and, at their first session, they face the therapist with urgency, intense emotions, and doubts about their ability to cope. The therapist needs to remain calm, respond empathically to emotional stories, and use assessment skills to determine: Is this someone who needs an immediate, active intervention, or is this a client who can safely wait a week for a second session ? There are two errors that must be avoided: (1) Failing to prevent serious consequences, including death, destructive actions, and long-term pathology by not promptly responding in crisis mode, and (2) pathologizing a condition that, while painful and debilitating, is best understood as a normal, expectable response to the stressors, traumas, and transitions of living. The four hypotheses listed in Table 4. 1 are useful in preventing these errors. Although each of these hypotheses can be used alone, there will be many opportunities to integrate them. For instance, the death of a spouse involves Situational Stressors (C2), triggers the psychological experience of Loss and Bereavement (CS4), and initiates the Developmental Transition (CS3) to widowhood. If the grieving spouse becomes suicidal, Emergency interventions (CSl), such as breaking confidentiality and hospitalization, are needed. Table 4.1 Crisis, Stressful Situations, and Transitions CSt Emergency The client' s symptoms constitute an Emergency: Immediate action is necessary. CS2 Situational Stressors The client's symptoms result from identifiable recent Situational Stressors or from a past traumatic experience. CS3 Developmental Transition The client is at a Developmental Transition, dealing with issues related to moving to the next stage of life. CS4 Loss and Bereavement The client has suffered a Loss and needs help during Bereavement or for a loss-related problem. 103 104 Twenty-Eight Core Clinical Hypotheses CSt EMERGENCY Definition The client's symptoms constitute an Emergency: Immediate action is necessary. Explanation This hypothesis must always be considered in the first session because of the severe negative consequences for not taking action. It applies to situations where patients must be hospitalized, and where there are legal requirements for reporting abuse or intended violence. It also fits when the client is about to take an irrevocable action. Charles recently lost his family in an acrimonious divorce and states to his therapist, in an agitated voice, "I don't want to go on living." He has a gun at home and has given away his prized baseball card collection. You judge him to be a danger to himself and take immediate steps to get him hospitalized. Examples Angela is about to take an impulsive, irreversible action-quit her job in a fit of anger over someone else getting a promotion she desired. You switch to a directive and active style of intervention because you want to assure that she takes her time in making such a major decision. KEY IDEAS FOR CSt EMERGENCY Tom is in therapy for help with "anger management" because of his poor selfcontrol at work. As you ask him how he vents his frustration outside of work, he reveals that he often beats his 6-year-old child. You explain to him that you must report child abuse to the proper authorities. The Emergency hypothesis leads you to take immediate action and to use crisis models instead of leisurely approaches to therapy. Your first task is to stabilize the client's condition. You then need to develop a problem list for issues that caused the emergency and for problems that will continue once the emergency is over: For example, difficulty coping with loss of significant other for a person who made a suicide attempt; poorparenting skills and lack ofcontrol over anger for a perpetrator of child abuse, which you had to report; and poor medication compliance and needfor supervised living situation for someone having a psychotic episode. Knowledge of Community It is not enough to know about hospitalization and day treatment as abstract topics; you need to be prepared with a clear flowchart of necessary actions, starting with the hospital you will use, the phone number you will dial, the consultants you can count on, and, if possible, the hospital staff member who will work with you if you do not have staff privileges. Legal and Ethical Issues Licensed practitioners are required to know the laws and judicial decisions that affect psychotherapy in their state, such as the laws requiring a prompt report of Crisis, Stressful Situations, and Transitions 105 Table 4.2 Managing a Violent Client Maintain a demeanor of calm and confidence; take your time-do not hurry the situation. If the client has a weapon, insist that it be removed from the scene. Frame your role: I want to help you get control over these feelings; I want to help you find a better means of handling the situation. Do not block the client's access to the door. Have support people available-leave the door open, have someone else present, or have an alarm system. Lower the client' s emotionality: Talk in simple direct language, help put words to feelings, and ask factual questions. Provide structure and limits: Make it clear that violence will not be tolerated. Give praise for signs that the client is keeping his temper under control. Call police or psychiatric emergency team, if needed. Do not hesitate to do what you need to feel safe, even if you think it will offend the client. child abuse, the criteria for involuntary hospitalization, and legal decisions that mandate notification of intended victims. Ethical issues that are particularly relevant in emergencies are the limits on confidentiality and the requirement to work within the limits of your competence. Sales et al. (2005) provide a useful text on laws affecting clinical practice. Managing Violent Clients It is important to have the knowledge and skills to deal with a client who enters your clinic or office in a violent state. Ideally, in your training program, you had the opportunity to role-play these scenarios and will work in a setting with buzzer systems for safety and a staff that is trained to deal with this type of emergency. Table 4.2 gives guidelines from Hipple and Hipple ( 1 983) for this situation. WHEN IS THIS HYPOTHESIS A GOOD MATCH? To recognize emergency situations, screen for three conditions: ( 1 ) danger to self, (2) danger to others, and (3) inability to take care of basic needs. You need to assess whether emergency action is needed, as well as manage the interview in a constructive way when you are going to take actions that the client may object to, such as breaking confidentiality to notify family members or report child abuse. Assessing suicide risk is automatically part of initial sessions and is always performed when there are signs of depression. Be assured that it is a myth that talking about suicide puts the idea in someone's head: Avoiding the topic is riskier than approaching it. Trainees should role-play the assessment of suicide potential, as described in Table 4.3. 106 Twenty-Eight Core Clinical Hypotheses Table 4.3 Assessment of Suicide Potential Be direct in a discussion of suicide, showing comfort in dealing with the topic: Have you had thoughts about taking your life ? Ask about specific suicidal thoughts, asking follow-up questions to assess the duration and intensity: How often do you think about shooting yourself? Inquire about the presence of a plan: Have you thought about how you would kill yourself? What steps have you already taken ? Assess lethality of the chosen method: The more specific the plan, the higher the rating of lethality. Does the client have the means? Is there a possibility of rescue? Explore suicidal behavior as communication. What message is the person communicating? What response is hoped for? Is there a specific person from whom a response is desired? Has the person severed communication and lost hope of any help? Gather details of past attempts: Have you ever tried to take your life ? Tell me about that. Assess social support resources: How isolated is the client? Who can be turned to for help? Is the significant other a helpful resource or a part of the problem? Assess the level of current substance abuse-a factor that diminishes impulse control. Assess the level of depression and the possibility of psychosis-factors that increase risk. Explore precipitating factors. Is there an acute stressor in the life of a stable person or is there a pattern of chronic suicidal behavior? Evaluate the level of ambivalence: How strong is the "death" side versus the "stay alive" side? Has anyone else in the family attempted or completed suicide? Have there been final preparations for death, such as making a will, giving away valuables, or making arrangements for pets? Risk of Violence against Others In assessing the client's potential for violence use these criteria: past history of violent behaviors, specificity of plan, possession of weapon, diagnoses of psychosis, current state of intoxication, demonstration of agitation, presence of threatening behaviors, and capacity to control anger in your presence. Recognition of Child, Spousal, and Elder Abuse The American Medical Association has guidelines for detecting and responding to various kinds of abuse-child abuse, child sexual abuse, elder abuse, domestic violence, and sexual assault-at http://www.ama-assn.org/ama/pub Icategory/3548.html. A frustration for professionals is that victims lie to protect their abusers. Children internalize messages that they deserved what they got, or they may be silenced by threats from the perpetrator. When the abuser is a parent, children also fear the loss of that relationship. In elder abuse by a family member, the victim has many reasons to deny a problem-the biggest being the fear that being put in an institution is worse than the suffering caused by the abusive spouse or child. Walker ( 1984) was one of the first to de- Crisis, Stressful Situations, and Transitions 107 ribe "battered woman syndrome," suggesting that women do not report s �use because of (a) the "honeymoon" phase after an episode of violence when �he man is repentant, ( b) the fear of danger to self or children for reporting the abuser, and (c) the belief that the violence was her fault. Judgments about abuse can be made from clues dropped by the client, even if the victim of abuse is not present. For instance, while discussing how she is trying to meet eligible men� a divorc�d moth�r may say that she left her young child at home without a babYSItter, lockIng her In the bedroom so that she wouldn't get into trouble. A caretaker of his mother, a stroke victim, may reveal how he has cut off her telephone access to her daughter, who lives in a distant state, "because it gets her upset," without realizing that he is denying her a basic right. Small Emergencies There is no dispute about taking immediate directive actions for "big" emergencies. However, many therapists are willing to ignore the client's real-life crises so that they can proceed calmly and patiently with their theory of choice. For instance, a student in a practicum class reported that her supervisor wanted her to help a client develop insight into early childhood dynamics. Meanwhile, the client was involved in a custody dispute and was about to lose her children. Every member of the practicum group agreed that the first priority should be a focus on real-world actions that the client could take, such as immediately getting a lawyer. TREATMENT PLANNING In managing emergencies, unlicensed trainees must remain in close contact with supervisors; even experienced licensed professionals should seek consultation for both expert guidance and emotional support. Be sure to document assessment and actions in charts and memos. The "right thing to do" is not always clear, despite numerous laws, rules, and guidelines. There will be complicated grey areas, and you will need to weigh costs and benefits. For instance, hospitalization might mean you'll sleep easier at night, but perhaps the patient can get through the crisis in a less restrictive environment as long as he knows he can call you at any time during the night. The "best interests of the client" may conflict with your own need to do what is easiest and most comfortable for you. The Decision to Hospitalize You need to determine whether the client and his support system can manage the client's emotional state and protect the client and others from harm. After a period of emotional ventilation, empathic and soothing responses, and structured, 108 Twenty-Eight Core Clinical Hypotheses crisis management problem-solving efforts, the risk level may be much lower than it seemed at first. The guiding principle is to try to keep the client in the least restrictive environment. If hospitalization is judged to be necessary, you can encourage voluntary admission, before seeking an involuntary hold. Hipple and Hipple (1983) recommend the following steps: • Explain to the client and family why you believe hospitalization is the best choice at this time. • Provide information, including a description of the admissions process, ward activities, and treatments that will be offered. • Offer reassurance and help create realistic expectations. • For voluntary hospitalization, call ahead and let staff know when the client will be arriving; provide the intake staff with your written notes. • If involuntary hospitalization is necessary and client will be transported by police, help him understand what procedures to expect, such as the mandatory use of handcuffs. Maintaining the Therapeutic Alliance When your legal duties involve breaking confidentiality, the therapeutic alliance is jeopardized; informing the client in the first session of the limits of confidentiality does not protect you from the client's sense of betrayal. You need to be able to tolerate anger and work to restore trust. Suicidal Clients Therapists need skills and sensitivity for working with suicidal clients. Therapists must consider their own needs for support and back-up. Countertransference is an inevitable part of working with these clients, and, if unexamined, might lead to inadvertently sending the message that you wish the client would disappear, which would increase the client's suicidal potential. Jongsma and Peterson (2003) list a variety of therapeutic interventions for suicidal ideation, including the following: • Notify family and significant others of the suicidal ideation. Ask them to form a 24-hour suicide watch until the crisis subsides. • Assist the client in developing an awareness of his or her cognitive messages that reinforce hopelessness and helplessness. • Draw up a contract with the client identifying what he or she will do when experiencing suicidal thoughts or impulses. • Assist the client in finding positive, hopeful things in his or her life at the present time. Crisis, Stressful Situations, and Transitions 109 • Assist the client in developing coping strategies for suicidal ideation (e.g., more physical exercise, less internal focus, increased social involvement, and more expression of feelings). • When suicidal ideation is connected with survivor guilt, implement a "penitence ritual." • Assist the client in becoming aware of life factors that were significant precursors to the beginning of his or her suicidal ideation. Reporting Abuse and Intended Violence Mental health professionals are mandated reporters of child and elder abuse and need to know the laws and procedures of their states. For instance, in California, Section 1 1 166 of the Penal code requires a mandated reporter who has knowledge of, or observes, a child in his or her professional capacity or within the scope of his or her employment whom he or she knows or reasonably suspects has been the victim of child abuse to report the known or suspected instance of child abuse to a child protective agency immediately, or as soon as practically possible, by telephone and to prepare and send a written report thereof within 36 hours of receiving the information concerning the incident. Similarly, knowledge or reasonable suspicion of elder abuse requires you to make a report. When you are aware that a client intends violence against an identifiable person, you have a duty to contact the intended victim as well as the police, a duty established by the Tarasoff decision in California (Tarasoff v. Regents ofthe University ofCalifornia, 17 Cal. 3d 425, 1976). A recent court ruling in California extended the duty to include knowledge that comes from family members of the client. These responsibilities and duties can be very anxiety-provoking for therapists and the wisest thing to do is to consult with experts. Fortunately, the major professional organizations have consultation available. For instance, members of the American Association of Marriage and Family therapists can arrange for telephone consultation with a legal expert through their web site, http://www.aamft.org. Ensuring Safety for Battered Women It is not a simple task to persuade a battered woman to leave her home and seek shelter for herself and her children. One strategy is to have a woman from a shelter come talk to the client because of the credibility of someone who has gone through the same experience. You can guide the client through steps to get a protective order from the court. A useful intervention is to help the victim draw up a formal written safety plan, which she can consult at a time of future need. The Alaska Network on Domestic Violence and Sexual Assault provides a very clear 110 Twenty-Eight Core Clinical Hypotheses and thorough template at http://www.andvsa.org/safety.htm. The opening stateInent affirms positive action: This is my plan for increasing my safety and preparing in advance for the possibility of further violence. Although I do not have control over my partner' s violence, I do have a choice about how to respond to him and how to best get myself and my children to safety. The document includes phone numbers of emergency hotlines and shelters, advice for handling an assault, steps for leaving home safely, a list of items to take, and suggestions for including neighbors as resources. INTEGRATION OF HYPOTHESES All of the following hypotheses are relevant for assessing and managing emergencies. BI Biological Cause Psychiatric symptoms with abiological basis, such as signs ofa stroke,mayrequire emergency action. A client with Anorexia may require immediate hospitalization. B2 Medical Interventions Evaluation for psychotropic medication is often necessary, especially when an emergency situation is being managed outside of a hospital. SCE3 Social Support Family members and other members of the client' s support network need to be contacted and involved in the planning of emergency actions. SCE6 Social Role of Mental Patient One reason for choosing an environment that is less restrictive than a psychiatric hospital is to reduce the stigma involved in putting someone in a mental patient role when they are experiencing a temporary psychological emergency. ES3 Spiritual Dimension Spiritual emergency is a term for psychological difficulties stemming from spiritual practices and spontaneous spiritual experiences. An example would be a psychotic episode following intense immersion in spiritual practice (yoga and meditation). Additionally, spiritual resources such as prayer and support from clergypersons and congregations can help individuals and families cope with emergencies. � Fi Crisis, Stressful Situations, and Transitions 111 CS2 SITUATIONAL STRESSORS Definition The client's symptoms result from identifiable recent Situational Stressors, or from a past traumatic experience. J �� . , Explanation n ' is :important to evaluate whether the client's symptoms and impairments are proportional to the level of stress. You need to specify the external stressors, which may range from life-threatening traumas to the accumulation of daily hassles of living, and have an objective way of measuring their severity. Crisis intervention techniques can prevent crisis reactions from developing into long-term disorders. Adult survivors of early abuse and trauma and people with PTSD need specialized treatment modalities. Rachel was visiting her family and friends in Israel, , where she grew up. She was sitting at a beachfront cafe when a suicide bomber exploded in front of the restaurant. She and her . friends were unharmed, but she was sprayed with blood and body parts. She took a flight home the next day and refused to talk about the experience in order not to upset her husband. She is troubled by intense anxiety symptoms and nightmares, Examples At first, Grant's depression seemed to stem from being passed over for a promotion a year ago. However, the symptoms didn't develop until 2 months ago, after his wife called his father and discussed his condition behind his back. You realize that "situational stress" is not an adequate hypothesis; the wife's "betrayal" is a symbolic stressor, which taps into vulnerabilities from his early relationship with his father. Lisa came to a sex therapist with her husband because she was unable to have sexual intercourse. She enjoyed hugging and kissing, but as soon as he touched her genitals, she froze, had severe anxiety symptoms, and started crying. The therapist arranged to meet separately with each partner. Lisa admitted that she had been a victim of incest as a child. She had never told anyone and was afraid to tell her husband. KEY IDEAS FOR CS2 SITUATIONAL STRESSORS Stressors are a normal part of life; when they are in manageable limits they are viewed as stimulation and challenges. However, when stressors increase in intensity, they can overwhelm an individual' s ability to cope and disrupt her psychological equilibrium. During the intake process, you need to ask questions about situational stressors that might have served as precipitating factors in the development of the presenting problems. Severity of Stressors It is useful to have an objective rating of the severity of stressors to recognize whether the reaction of an individual is a typical, appropriate response to the situational stressor, or if it is excessive compared to others (real or hypothetical) in the same situation. Is the stressor objectively dangerous (a lion escapes his cage and approaches you) or harmless, but appraised as dangerous (a cat howling outside your window)? Losing a job entails serious financial and emotional costs but having a boss who frowns all the time does not result in objective harm. ,-- ' 112 Twenty-Eight Core Clinical Hypotheses Vulnerability and Resilience Situational stressors alone cannot explain the response of individuals; there is wide variation in how people deal with the same precipitating factors. The concept of predisposing factors refers to individual difference variables influenced by biological endowment and prior history-vulnerabilities and weaknesses on one hand and hardiness and resilience on the other. Internal sources of resilience include easy temperament, social competence, ability to problemsolve, optimism, self-directedness, sense of humor, intelligence, and emotional and behavioral adaptability (Katz & Pandya, 2004). In children, important protective factors are an inner capacity for emotional regulation, an effective use of social systems for support, and the protective influence of caring and competent adults ( Koplewicz, Cloitre, Reyes, & Kessler, 2004). According to Myers ( 1 989), factors that make individuals vulnerable to extreme reactions to a disaster include the following: • Lack of verbal ability to describe experiences. • Disabilities that limit ability to get needed resources. • Preexisting stresses. • Previous traumatic life events that were not successfully resolved. • Lack of adequate social support. • Poor coping skills. • Separation from family. Crisis Theory People usually find their coping and defensive processes effective in resolving problems of living and thus sufficient to maintain their psychological equilibrium. However, when the difficulty of a problem exceeds the available repertoire of coping resources, a crisis may be precipitated. The immediate precipitant could be a severe personal trauma such as rape or a diagnosis of cancer; a negative life event such as divorce or unemployment; the accumulation of stress from hassles of daily living; or a major disaster that affects an entire community. Caplan (1964) described the development of a crisis in four phases: 1 . Rise in tension: In response to stressful stimuli, there is an initial rise in tension and discomfort. 2. Unsuccessful coping efforts: When there is a lack of success in coping, the stressful stimuli and discomfort increase. 3. Mobilization of emergency resources: A further increase in tension mobilizes internal and external resources and emergency problem-solving mechanisms are tried. 4. Disorganization: If the problem continues and can be neither solved nor avoided, tension increases and a major disorganization occurs. Crisis, Stressful Situations, and Transitions 113 Crisis theorists find it useful to refer to the Chinese character for crisis, which combines danger and opportunity. The danger is the risk of a temporary crisis developing into a long-term psychological disorder; the opportunity comes from increased flexibility and openness to new learning during a state of disequilibrium, which can result in a higher level of functioning than the precrisis condition. Caplan believed that prompt and effective interventions during a crisis would achieve goals of primary and secondary prevention of mental disorders: 1. Primary prevention: lowering the rate of new cases of mental disorder among people at risk. 2. Secondary prevention: prevention of long-term consequences in individuals who are experiencing early symptoms and dysfunctions. Crisis Intervention Crisis intervention is a method of therapeutic treatment that focuses on resolving an immediate crisis, which has overwhelmed a person's abilities to cope, with the goals of relieving symptoms and returning the person to the precrisis level of functioning. The goals of crisis intervention usually include the following: reduce harmful pressures on the individual or family, help to strengthen coping skills, and muster environmental and social support. Wilkinson and Vera ( 1989) summarize five concepts of crisis intervention: 1 . The coping skills of the client are temporarily overwhelmed. 2. Rapid and specific help from others can restore the person to the precrisis level of functioning. 3. Only those functions that the person cannot handle should be handled by others. 4. The help offered must be congruent with the usual coping style of the person. 5. Help should be discontinued as soon as possible. Aguilera ( 1 998) describes two approaches to crisis intervention: 1. Generic approach: Focuses on the characteristic course of the particular kind of crisis rather than on the unique characteristics of each individual in crisis. It can be carried out by nonmental health professionals. 2. Individual approach: Emphasizes assessment by a mental health professional of the interpersonal and intrapsychic processes of the person in crisis. It differs from brief psychotherapy in that the focus is exclusively on the immediate causes for disturbed equilibrium. The therapist takes an active and directive role in the intervention. 114 Twenty-Eight Core Clinical Hypotheses Balancing Factors Aguilera ( 1 998) frames cnSlS intervention as problem solving and identifies three balancing factors between the stressful situation and resolution of the problem, as shown in Table 4.4. In each category, strengths will lead to resolution of crisis, and weaknesses may exacerbate the crisis and create new problems. Disasters Disasters are traumatic events that happen to groups of people and disrupt the functioning of a community as well as the individuals directly involved. They Table 4.4 Crisis Intervention Framework PERCEPTION OF THE EVENT Perceptions that facilitate crisis resolution: The perception of the stressful event is realistic. The person understands the relationship between the event and emotional responses. The person has a sense of self-efficacy (Bandura, 1989), judging herself competent for the situation. An expectation of a successful outcome, leading to confidence, optimism, and persistence in the face of obstacles. Perceptions that increase stress: The event has a meaning that threatens an important life goal or value. The environmental demands are perceived as exceeding coping abilities and endangering well-being (Lazarus & Folkman, 1984). The stressor threatens self-esteem or a sense of control, disrupts attachments and commitments, and contains uncertainties and unpredictable elements (Houston, 1987). SITUATIONAL SUPPORTS Social isolation increases vulnerability. House (1981) developed a framework for social support that included four components: 1. Social support: esteem, affection, trust, concern, and listening 2. Appraisal support: affirmation, feedback, and social comparison 3. Informational support: advice, suggestion, directives, and information 4. Instrumental support: supplies, tools, and money COPING MECHANISMS People use different methods to reduce anxiety and tension and maintain psychological integrity when their normal equilibrium is disrupted: • Attack: attempting to remove or overcome obstacles, • Flight: removing the threat or removing oneself from the situation, and • Compromises: accepting substitute goals or changing values and standards. People also have tension-reducing defense mechanisms such as rationalization, regression, or denial. Adapted from Crisis Intervention: Theory and Methodology, 8th ed., by D. C. Aguilera, 1 998, St. Louis, MO: Mosby. Crisis, Stressful Situations, and Transitions 115 are divided into natural disasters (e.g., hurricanes, tsunamis, and tornados) and man-made ones (e.g., airplane crashes, terrorist attacks, and nuclear power plant accide�ts). Factors in a disa�ter that incr�ase the severity of survivors' difficulties mclude lack of warnIng, the belIef that the event could have been prevented, the presence of human error, fear of recurrence, scope and intensity of the event, degree of personal loss, traumatic stimuli such as dead bodies, lack of opportunity for effective action, and the deprivations and frustrations of the postdisaster environment (Myers, 1989). Disaster victims with severe emotional reactions and functional impairments should receive psychological interventions to prevent the development of disorders in the future, such as Posttraumatic Stress Disorder (PTSD), phobias, or generalized anxiety disorders. Educational material about coping with disasters is available from the Red Cross, Federal Emergency Management Agency (FEMA), the American Psychological Association (APA), and from county mental health agencies. Victims of Crime Violent crime is one of the most traumatic situational stressors imaginable. Victims include not only the person who was criminally attacked but also, in cases of homicide and kidnapping, family members, friends, and classmates. Even crimes that affect property rather than persons, like having a car stolen or a house burglarized, are traumatic personal violations. M. A. Young ( 1989) notes that victims experience "second assaults" by the criminal justice system, the media, helping agencies, and insurance companies, and lists the intangible losses following a violent crime: loss of sense of control over one's life, loss of trust in people, loss of sense ofjustice, and for some, loss of identity or sense of future. Furthermore, family and friends may withdraw from the victim, whose emotional pain is unbearable, or blame the victim for not having avoided the crime, as in rape, kidnapping of children, or "battered wife syndrome." The terrorist attacks on September 1 1 , 2001, combined the worst elements of both disasters and violent crime, adding the loss of both the sense of security within the national borders and the fantasy of America's invulnerability. Survivors of Trauma Since the Vietnam War, there has been increased understanding of the longterm effects of exposure to trauma; in 1980, the American Psychiatric Association added PTSD to the DSM-III. The syndrome of PTSD has received extensive study: A web site for veterans (www.ncptsd.va.gov) provides a thorough review of epidemiology, diagnosis, and treatment. The traumatic events most often associated with PTSD for men are rape, combat exposure, childhood neglect, and childhood physical abuse. The most traumatic events for women are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse. About 30% of the men and women who have spent 116 Twenty-Eight Core Clinical Hypotheses time in war zones experience PTSD. There are four major risk factors for development of PTSD: 1 . Severity of stressor: magnitude and intensity, unpredictability, uncontrollability, sexual (as opposed to nonsexual) victimization, real or perceived responsibility, and betrayal. 2. Prior vulnerability factors: genetics, early age of onset and longer-lasting childhood trauma, and concurrent stressful life events. 3. Subjective threat level: greater perceived threat or danger, suffering, terror, and horror or fear. 4. Lack of social support: lack of functional social support or a social environment that produces shame, guilt, stigmatization, or self-hatred. Adult Survivors of Child Abuse Adult survivors of childhood abuse, especially survivors of incest, are a population with a high incidence of PTSD symptoms, as well as disorders such as depression, borderline personality, substance abuse, and eating disorders. They frequently have problems trusting and permitting closeness in relationships and engage in self-destructive behaviors. All forms of child abuse inflict two levels of trauma on the child: ( 1 ) the trauma of the abuse and (2) the effects of blaming themselves, protecting the perpetrator, and experiencing the betrayal of other adults who fail to help them. Incest by a parent is considered the worst type of child abuse because of the loss of innocence and betrayal of trust by someone who is responsible for the safety of the child. Holocaust Survivors and Second- and Third-Generation Members Children who survived the Holocaust are now in their 60s and 70s and therapists who work with them are well aware of their unique history of trauma. However, therapists also need to recognize that children and grandchildren of Holocaust survivors carry scars that would not be understood without putting it in the context of their family' s history. Such transgenerational transmission ofHolocaust trauma has been studied, leading to a body of literature and a network of support groups. Issues presented by the second and third generation include depression, anxiety, symptoms of PTSD, separation anxiety, and guilt. This framework provides a valuable template for making sense of a client's suffering. Job-Related Burnout It is important to understand burnout not only for the sake of the clients you will be helping but also to protect yourself from its effects. Helping professionals (including psychotherapists, nurses, teachers, and hospice workers) have the unique job demand of attending to the emotional needs of others, many of whom are emotionally traumatized, in a nonreciprocal relationship where their own Crisis, Stressful Situations, and Transitions 117 needs must be put aside. Maslach (2003) developed an inventory in 198 1 to measure a burnout syndrome in human service professionals that included feelings of emotional exhaustion, diminished interest, apathy, physical complaints, and symptoms of depression. This burnout syndrome also includes the development of a dehumanizing attitude toward clients, replacing the original compassion, dedication, and idealism with callousness, dislike, and detachment. There is often a reduced sense of personal accomplishment and resentment over the futility of and lack of appreciation for one's efforts. Burnout can lead to substance abuse, suicide, and incompetent and negligent professional behaviors, which in turn can lead to legal problems, ethical sanctions, and loss of license. Currently, the term burnout is used for all types of jobs (Leiter & Maslach, 2005). Personal factors that contribute to burnout include lack of interests, hobbies, and friendships that are unrelated to work; overwork and lack of self-care activities; and disengagement from family. Risk factors in the work environment include lack of opportunities to share problems and get support from work colleagues, understaffing, and bureaucratic rules and procedures that undermine effective service delivery. WHEN IS THIS HYPOTHESIS A GOOD MATCH? Holmes and Rahe ( 1 967) developed a scale of stressful events and gave them numerical scores to indicate their intensity. Positive and desired events as well as negative ones are included because both kinds of events tax the individual' s capacity to adjust to change. By adding up the scores for every life change in the prior year, the therapist and client can discover that there is ample justification for the symptoms and impairments in functioning. Table 4.5 gives samples of the scores for selected items. The term hassles was used by R. Lazarus and Folkman ( 1984), referring to daily negative interactions with the environment. An accumulation of these Table 4.5 Items from the Holmes and Rahe Life Change Index Scale Event Death of spouse Divorce Detention in jail or other institution Marriage Retirement from work Gaining a new family member Foreclosure on a mortgage or loan Outstanding personal achievement Troubles with the boss Changing to a new school Christmas Points 100 73 63 50 45 39 30 28 23 20 1 2 Adapted from "The Social Readjustment Rating Scale," by T. H. Holmes and R. H. Rahe, 1 967, Journal of Psychosomatic Research, 11, pp. 2 1 3-2 1 8 . 118 Twenty-Eight Core Clinical Hypotheses mundane, minor events can result in disruptions in functioning. For instance, a student had a mini-breakdown during finals week when her car broke down and her dishwasher flooded the kitchen on the same day. DSM-IV-TR Diagnoses These diagnoses incorporate situational stressors: • Adjustment Disorders (309): Clinically significant symptoms develop within 3 months after the onset of the stressor and are resolved within 6 months; more time is allowed if the stressor is chronic, as in a serious illness, or has enduring consequences, as with divorce or loss of a job. • Acute Stress Disorder (308.3): The client has been exposed to a traumatic event, which involved actual or threatened death or serious injury, and responded with fear, helplessness, or horror. Symptoms include dissociation, avoidance, anxiety, and reexperiencing the event, lasting between 2 days and 4 weeks. If the duration is longer, the diagnosis is changed to PTSD. • Posttraumatic Stress Disorder (PTSD; 309.81): The traumatic event may be recent or in the past; the symptoms are the same as Acute Stress Disorder, but have lasted for more than 1 month. • Brief Psychotic Episode with Marked Stressors (298.8): This disorder was called BriefReactive Psychosis inDSM-///-R. The symptoms do notlastmore than 1 month, and the person returns to a premorbid level offunctioning. Variety of Reactions to Stress Reactions to stress fall into three categories: 1 . Somatic: fatigue, nausea, insomnia, bruxism (grinding of teeth), loss or increase of appetite, migraine, muscle tremors, twitches, rapid heart rate, difficulty breathing, thirst, visual difficulties, vomiting, weakness, dizziness, profuse sweating, or chills. 2. Cognitive and emotional: anxiety, depression, guilt, fear, intense anger, suspiciousness, irritability, nightmares, confusion, poor attention, poor decisions, heightened or lowered alertness, poor concentration, memory problems, or poor problem solving and abstract thinking. 3 . Behavioral: Changes in activity, social withdrawal, emotional outbursts, or substance abuse. Table 4.6 presents a list of trauma-related stress symptoms published by the Arizona Department of Health Services (www.azdhs.gov/bhs/traumal.pdf). Children show different symptoms from adults. A review of the child trauma literature by Lubit, Rovine, Defrancisci, and Eth (2003) found that preschoolers tend to express fear through avoidance of new activities, middle school children avoid school and become preoccupied with danger and reminders, and adolescents engage in new or increased aggression and substance abuse. Crisis, Stressful Situations, and Transitions 119 Table 4.6 Signs of Trauma-Related Stress �urring thoughts or nightmares about the event Having trouble sleeping or changes in appetite Experiencing anxiety and fear, especially when exposed to events or situations reminiscent of the trauma Being on edge; being easily startled or becoming overly alert Feeling depressed, sad, and having low energy Experiencing memory problems including difficulty in remembering aspects of the trauma Feeling "scattered" and unable to focus on work or daily activities Having difficulty making decisions Feeling irritable, easily agitated, or angry and resentful Feeling emotionally numb, withdrawn, disconnected, or different from others Spontaneously crying, feeling a sense of despair and hopelessness Feeling extremely protective of, or fearful for, the safety of loved ones Not being able to face certain aspects of the trauma, and avoiding activities, places, or even people that remind you of the event Greenstone and Leviton ( 1 993) describe the profile of a person whose inability to cope with stressful situations has pushed him to the crisis point: • Confusion: I can't think clearly. • Impasse: Ifeel stuck; nothing I do helps. • Desperation: I've got to do something. • Apathy: Nothing can help me. • Helplessness: I can't take care ofmyself • Urgency: I need help now!!!!!!!! • Discomfort: Ifeel miserable, restless, and unsettled. (p. 6) TREATMENT PLANNING Stress management has two components: ( 1 ) active problem solving and (2) coping with negative emotions. Therapists help clients, on an individual basis, to discover strategies for reducing painful emotions and finding respite from the stress of coping with problems. When active coping is not possible, "passive coping" requires serenity and patience. The tools that people use for making themselves feel better are varied and include the following: relaxation techniques such as deep breathing and meditation, exercise, yoga, enjoying a hobby or sport, watching TV, talking with friends, music, reading, hot baths, massage, aromatherapy, changing one's attitude, humor, prayer, ventilating feelings by screaming or having a "good cry," and seeking pleasurable activities. A creative imagery technique is to visualize the stress, portraying it as a monster, and then r---- 120 Twenty-Eight Core Clinical Hypotheses express feelings to this imaginary character. The use of food and drink for relaxation can be very appropriate, as long as the client is not creating new problems such as substance abuse and undesired weight gain. Crisis Intervention Table 4.7 presents steps in crisis intervention, incorporating ideas from Hipple and Hipple ( 1 983), Aguilera ( 1 998), and Greenstone and Leviton ( 1 993). Posttrauma Debriefing One popular intervention after a disaster is the Critical Incident Stress Debriefing (CISD; J. T. Mitchell & Everly, 2001). A form of crisis intervention, it aims to reduce initial distress and to prevent the development of later psychological problems. A typical debriefing session is a single group meeting lasting about 2 hours that takes place 2 to 3 days after the trauma. It has two parts: 1 . Ventilation and normalization: Clients are encouraged to give a detailed narrative account of the trauma, including facts, cognitions, and feelings. During the CISD, the facilitator asks each participant to describe the trauma "to make the whole incident come to life again in the CISD room." Emotional reactions are addressed in some detail with an emphasis on normalization-assuring them that they are responding normally to an abnormal event. 2. Preparationfor possiblefuture experiences: Clients are taught how to deal with their reactions and where to find further support, if necessary. There is controversy over CISD, because it lacks empirical validation (Bisson & Deahl, 1 994; McNally, Bryant, & Ehlers, 2003) and carries the risk of possibly retraumatizing the client through intense imaginal exposure to the traumatic event. For rape victims, reexposure to the event may increase their sense of shame. Another concern is that when a counselor describes possible future symptoms to the trauma victim, the intervention might create a self-fulfilling prophecy for people who might not otherwise have had those problems. Mandatory debriefing can lead to passive participation and resentment in victims. According to Brom, Kleber, and Hofman ( 1 993), victims needs general information about psychological reactions following a serious traumatic event, a safe and quiet environment so they can realize the traumatic event is over, the opportunity to go over the experience again and again to reconstruct the event and to regain their sense of control, and proper referrals, if necessary. Ideally, there should be several sessions, the last of which should be at least 2 to 3 months after the event. Table 4.7 Steps in Crisis Intervention - Goal ;;'-ove emotional state Set direction Assessment of the crisis Screen for emergency Help client to understand the crisis Facilitate emotional expression Use cognitive restructuring Therapist Actions Instill hope, and give reassurance to the client. Show that you are calm and confident and that you believe that there will be a positive outcome. Use nonverbal and verbal messages to lower the level of emotionality. Normalize the experience to counteract the fear that symptoms mean weakness or "going crazy." Be in charge of the interview, provide structure, and present yourself as a problem-solving expert. Include family members or other members of the social network, if available. Help the client begin to reorder the chaos and confusion in his mind. Use active focusing techniques to obtain an accurate assessment of the precipitating event. Assess for the balancing factors described in Table 4.4, such as perception of the event, the social supports, and the coping mechanisms that have been used and, if not used, are available. Inquire about past successful coping experiences to identify resources. Assess both realistic and symbolic meanings of the crisis event. Discover how much the crisis has disrupted the client's life and the effects of this disruption on others. Evaluate whether the client is a danger to self or others and rule out the need for hospitalization. If person has suicidal ideation, use a no-suicide contract and increase the frequency of the sessions. Explain the connection between stressors or trauma and the intensity of the emotional reactions. Provide education about possible phases in emotional reactions following a trauma. Explain the theory of crisis, using concepts of equilibrium and disequilibrium. Help the client realize that the crisis state is temporary. Encourage the client to express feelings. Show understanding of emotional reactions, using feeling words in your responses to help the client label emotions (e.g., shock, confusion, anger, overwhelmed, or guilt). Help the client access feelings that may be suppressed, such as anger towards loved ones-an emotional catharsis with a caring listener can help reduce tension. The opportunity to repeatedly put experiences in words may help in preventing the avoidance that characterizes PTSD. Cognitive restructuring techniques can change appraisals of the stressors as well as the client's capacity to cope. Clients may have faulty assumptions that certain traumatic events could have been predicted and prevented if they had acted differently, and therefore may be inappropriately blaming themselves. (continued) 121 122 Twenty-Eight Core Clinical Hypotheses Table 4.7 (Continued) Goal Develop action plan Shore up social supports Monitor progress Anticipatory planning Terminate Therapist Actions Model problem-solving skills. List alternatives and help the client to evaluate pros and cons: Assure that the plan is consistent with the client' s personal and cultural values. Break the plan into steps that are simple, concrete, realistic, and appropriate for the client's functional level. Intermediate objectives should be set in terms of hours and days. If other agencies are involved, make sure that there is proper coordination. Social support can come from the individual' s social network, other sufferers going through the same crisis, and community organizations. If possible, include family members in the treatment process. Intervene if there are signs of family crisis developing from the personal crisis. Encourage participation in group activities that provide support and channel energy towards appropriate goals. As positive changes occur, summarize the progress and help the client understand which coping strategies have been most effective. Provide reinforcement and encouragement. Use problem-solving skills to handle unforeseen obstacles. After the current crisis is managed, help the client develop insights and skills to prevent future crisis situations and to cope better with them if they do occur. Terminate crisis intervention when the client is restored to prior equilibrium and is handling problems effectively. If further help is needed, make the appropriate referral or discuss a psychotherapy contract for identified problems. Treatment for Posttraumatic Stress Disorder Table 4.8 provides an overview of the major treatment Inethods for PTSD (Foa, Keane, & Friedman, 2000), which draws from several different hypotheses. Treatment of Adult Survivors of Childhood Abuse Several organizations provide information, support, and access to self-help groups for these victims, such as Adult Survivors of Child Abuse (ASCA; www.ascasupport.org); Survivors of Incest Anonymous (www.siawso.org); and Voices in Action, Inc. (www.voices-action.org). There is consensus that one of the most important components of treatment is the quality of the therapist-survivor relationship (e.g., Courtois, 1 996). Therapists need to create a warm and safe environment and show great sensitivity to the survivor's fear of closeness and difficulty with trust. Incest survivors bear the extra burden of secrecy and shame, so it is especially important to help clients express the emotional truth of the experience and correct the distorted perception that they were in any way responsible. If the survivor is in a stable relationship, the partner can be included in treatment (Graber, 1 99 1 ), although this Table 4.8 Treatment Interventions for Posttraumatic Stress Disorder Education The therapist educates the trauma survivor and his family that PTSD is a disorder that occurs in normal individuals exposed to extremely stressful conditions, and that probably all people would develop PTSD if they were involved in a severe enough trauma. This message normalizes the symptoms and counteracts the belief that PTSD symptoms are a sign of weakness. The therapist explains facts about PTSD and gives the rationale for the different treatment approaches. Exposure (BL2) The client engages in careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context to face and gain control of the fear and distress that was overwhelming during the trauma. After learning relaxation techniques, the client progresses gradually up a hierarchy of trauma-related stimuli (systematic desensitization). In some cases, trauma memories or reminders can be confronted all at once (flooding). Cognitive-Behavioral Therapy Methods (C2, C3, C4) The therapist gives the rationale that PTSD is, in part, caused by the way we think. Cognitivebehavioral therapy (CBT) can help change the way we think (cognitive restructuring) by exploring alternative explanations and assessing the accuracy of our thoughts. Even if we are not able to change the situation, we can change the way we think about a situation. CBT for trauma includes strategies for processing thoughts about the event and challenging negative or unhelpful thinking patterns Eye Movement Desensitization and Reprocessing (B3) Eye Movement Desensitization and Reprocessing (EMDR), a method developed by Shapiro (1996), combines elements of exposure therapy and CBT. The client follows instructions to focus thought and move his or her eyes, while the therapist creates an alternation of attention back and forth across both brain hemispheres. Although this is a newer treatment, favorable research support is accumulating. Group Therapy PTSD patients can discuss traumatic memories, PTSD symptoms, and other problems with people who have had similar experiences. As survivors discuss and share how they cope with trauma-related shame, guilt, rage, fear, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. The group leader's task is not to interact therapeutically with each group member but to create a safe and supportive environment in which members interact therapeutically with one another. Medication (B2) Medication can reduce anxiety, depression, and insomnia and can help survivors participate in therapy. Researchers are searching for effective medications to prevent PTSD. Coping Skills (BL3) Skills are taught for coping with anxiety (e.g., breathing retraining or biofeedback), managing anger, preparing for stress reactions (i.e, stress inoculation), handling future trauma symptoms, resisting urges to use alcohol or drugs when trauma symptoms occur, and communicating and relating effectively with people (i.e., social skills or marital therapy). Clients are encouraged to increase recreational, artistic, or work activities that help distract a person from memories and reactions, without using this tactic as a substitute for therapy. 123 124 Twenty-Eight Core Clinical Hypotheses should be determined on a case-by-case basis, depending on the nature of the abuse and the sensitivity and shame of the victim. Courtois ( 1 996) described three stages in the treatment process: Stage I: Alliance-building, safety, and stabilization. Stage II: Deconditioning, mourning, and resolution of the trauma. Stage III: Reconnection; self and relational development. The ASCA also recommends a three-part recovery framework in its literature and groups: Stage 1: Remembering The survivor acknowledges the truth of the physical, sexual, or emotional abuse, makes a commitment to recovery, agrees to reexperience memories as they surface, and accepts "that I was powerless over my abusers' actions which holds them responsible." Stage 2: Mourning The survivor identifies problem areas, faces feelings of shame and anger, identifies faulty beliefs and distorted perceptions, recognizes self-sabotage, accepts the right to make free choices about how to live, and affirms "I am able to grieve my childhood and mourn the loss of those who failed me." Stage 3: Healing The survivor commits to strengthening self-esteem, improving behavior and relationships, resolving issues with the offenders "to the extent that is acceptable to me," and transforming the self-image from survivor to "thriver." The group modality offers the benefit of sharing stories with people who have endured similar traumas, thus relieving the shame and feelings of aloneness and providing the inspiration of people who are further along on the path toward healing. Therapists can also recommend helpful books (e.g., Bass & Davis, 1988; Bass & Thornton, 1983). Coping with HIV/AIDS Receiving the diagnosis of a serious illness is always stressful; however, testing positive for HIV brings an array of problems and stressors that easily outpace an individual' s capacity to cope. Despite advances in treatment, there is still no cure for AIDS, so news of positive HIV status is often interpreted as a death sentence. Although AIDS sufferers are now protected against discrimination and covered by the Americans with Disability Act (ADA; www.usdg.gov!crt lada/adahom1 .htm), there is both a stigma attached to the disease and a risk of Crisis, Stressful Situations, and Transitions 125 Table 4.9 Helping Clients Cope with HIV Diagnosis Msure the client that confidentiality will be protected, and abstain from judging, blaming, interrogating, or making decisions for the client. Provide empathy and support, allowing the client to express the emotional impact of the diagnosis (possibly disbelief, anger, fear, or betrayal). Recognize that intense emotional reactions may prevent the client . fr�m understanding the information received about the diagnosis and the need to prevent transmISSIOn. Impart needed information and clarify misconceptions. The therapist should be knowledgeable about transmission and prevention, natural history of HIV, and prevention and support services. Address the need to notify others and how to do this. The therapist can help the client assess if there is physical danger in sharing results. Otherwise, you might help the client role-play how to share the information. Help the client access medical and other support services. It is important to know about appropriate resources in the community. Help the client create a plan for mobilizing social support, including finding a support group at a local AIDS resource center. Make sure the client understands the need for ongoing support and counseling. Emphasize the importance of preventing transmission of the disease and ensure that the client has specific behavioral goals for protecting others. Explain that she needs to protect not only others from infection but herself from being exposed to a different strain of HIY. Help the client to maintain hope and realize he can live well. This goal is facilitated by contacts with people who are living full and satisfying lives with HIV/AIDS. losing social connections when there is the greatest need for social support. Counselors who work with AIDS patients face unusually demanding challenges and need support for themselves, including a forum for sharing experiences with colleagues. Although most HIV/AIDS counseling will occur in settings where the testing is performed or in clinics that specialize in that population, all practitioners need guidelines for helping people cope with this disease. Table 4.9 offers suggestions for helping a client cope with news of HIV positive status, based on guidelines from the Centers for Disease Control and Prevention (2001 ) and The Synergy Project (2005). Community Resources It is essential to know how to access resources in your community. For instance, in California, the Resource Directory Group, Inc. (www.resourcedirectory.com) publishes the Social Service Rainbow Resource Directory for major counties, in printed volumes and electronic versions. As you gain experience dealing with crises, keep a Rolodex or electronic file of people in the community with whom you can consult, for specific types of crises, and of services to which you can refer clients in crisis. �-- 126 Twenty-Eight Core Clinical Hypotheses Making a Referral When making a referral, take into consideration that the crisis state has overwhelmed normal adult coping abilities. If necessary, place the call and make the appointment for the client. Write instructions down and check to see if there are any anticipated obstacles to keeping the appointment. Be sure to follow up with the client to see how the contact with the referral agency went. INTEGRATION OF HYPOTHESES Sometimes you can help the client cope with stress and trauma solely through empathic listening, clarification, and psychoeducation. Otherwise, the integration of other hypotheses is necessary. Many of the following hypotheses have already been integrated in the previous tables and discussions. B2 Medical Interventions People coping with trauma can benefit from an evaluation for the use of prescription medication. B3 Mind-Body Connections Psychological trauma affects mind and body. Early prolonged trauma causes many brain and hormonal changes that affect memory, learning, and regulating impulses and emotions. Posttraumatic Stress Disorder has many biological correlates, including abnormal levels of cortisol, epinephrine, and norepinephrine. The fight-flight reaction of stress results in physiological arousal, which, if prolonged, can negatively impact health. Stress management tools such as relaxation training and meditation are presented under B3. BL2 Conditioned Emotional Response Reactions to current stressors can be excessive because of past conditioning. Furthermore, the current trauma creates new maladaptive conditioning. Following a traumatic event, anxiety responses are generalized to new stimuli, leading to excessive fear and avoidance, and possible development of an anxiety disorder. Counter-conditioning techniques such as desensitization and flooding are very useful interventions. BL3 Skill Deficits or Lack of Competence It is important to evaluate the coping skills of the client. These skills include cognitive skills (e.g., planning, problem solving, or decision making), life skills (e.g., job search, financial management, project management, or time management), communication skills (e.g., the ability to say "no" when new tasks and commitments are offered), and stress management skills. Therapists assess Crisis, Stressful Situations, and Transitions 127 whether the client already has skills in her repertoire for dealing with this particular stressor; if not, treatment plans include strategies for acquiring new and better skills. C3 Faulty Information Processing The way the client appraises the stressor is an important predictor of whether a stressful situation turns into a crisis. Paraphrasing the prayer that is used in Twelve Step programs (e.g., Alcoholics Anonymous) Is this a situation that requires courage to take action to change something, or serenity to accept something that can't be changed? ES3 Spiritual Dimension Traumatic experiences can result in anger toward God and a loss of Ineaning. At the same time, spiritual resources can be of tremendous benefit in coping. Beveridge and Cheung (2004) describe a spiritual framework for treatment of incest survivors, using a definition of forgiveness as "no longer wanting revenge on the perpetrator" (p. 1 13), and countering the belief of being defective with spiritual responses: "God offers unconditional love for all." P2 Reenactment of Early Childhood Experiences Clients are helped when they can distinguish between emotional reactions that are appropriate to the stressor and those that carry baggage from early experiences. The reactions to current stressors can be affected by stress and abuse that occurred in childhood. Past experiences with parents can explain why, for one person, an unpleasant boss is a trigger for so much anger that his job performance deteriorates, while for another, the boss's behavior is a minor nuisance. P4 Unconscious Dynamics Dissociation, considered an unconscious mechanism, is a major component in the development of PTSD. The controversy over recovered "repressed memories" of childhood sexual abuse should be understood through available research (e.g., Pope & Brown, 1996). SeE! Family System A family can be a source of either support or additional stress. Furthermore, the crisis or trauma in one member has repercussions for the entire family. For instance, in families of soldiers returning from combat experience, children Inay develop school problems and spouses may engage in verbal or physical violence. Therapists need to educate families on how to cope with crisis and to intervene in ways that serve both treatment and prevention goals. 128 Twenty-Eight Core Clinical Hypotheses SCE2 Cultural Context The meaning of stressors will be dependent on the cultural context. For instance, the accidental "outing" of a gay person would be extremely traumatic when the ethnic or religious group ostracizes gays but could be a relief in a very liberal, supportive context. There are cultural differences in how support should be provided following a disaster or trauma: Ventilation (talking through the trauma) may not be useful outside of Westernized groups. For example, talk therapy approaches were ineffective among some Taiwanese natural disaster victims but traditional religious practices were beneficial (Marsalla & Christopher, 2004). Interventions with victims should use their language and communication patterns. SCE3 Social Support As discussed previously, social support is a major buffer against crisis and is an important ingredient in action plans. The presence of a confidante, and the feeling that one is not all alone in the struggle, can prevent a normal reaction to stress from turning into more serious mental and emotional problems. In addition to the support of the existing social network, victims of trauma often benefit from support from people who have had similar experiences, and they can derive hope from people who have healed. SCES Social Problem Is a Cause Stressors that affect an entire cOlmnunity may stem from a social problem. For instance, when the economy is in a recession and unemployment is at a high level, difficulties of the job search process are very much greater than when the economy is doing well. When there are social causes, the most effective plans may be those that benefit the entire group, such as joining in a lawsuit or creating a neighborhood-watch group. The suffering of victims of Hurricane Katrina was compounded by inequities in our socioeconomic system and malfunction of our governmental entities. SCE7 Environmental Factors Action plans for coping with stress and crisis can include changing or leaving the environment. KEY IDEAS FOR CS3 DEVELOPMENTAL TRANSITION Healthy maturation involves change, tension, stress, and a disruption of harmonious living, followed by periods of consolidation and stability. Erik Erikson Crisis, Stressful Situations, and Transitions 129 t, .. .�. CS3 DEVELOPMENTAL TRANSITION �\" . Definition \ ·.ihe' client is at a Developmental Transition, dealing with issues related to moving to the �. 'heJ(t :�tage of life. t�r .., .�" . Explanation r 'H ' �