PART Ill -

Clinical Case
Documentation
495
 CHAPTER
11
Case Conceptualization
LearningObjectives
After reading this chapter and a few hours of focused studying, you
should be able to:
• Describe the purpose of case conceptualization.
• Complete a cross-theoretical systemic case conceptualization using
the form provided.
Step 1: Mappingthe Territory
There are few moments as exciting or neurosis-inducing in a therapist's training as "the
first session": seeing your first client and losing your therapeutic "virginity," so to speak.
We know the questions that follow: "Was it good for you?" "Did I get it right?" "Was I
okay?" Before the session, there are other predictable questions: "What do I say?" "What
do I do?" "What if I can't remember X?" Although logical, these questions can cause a
new therapist to quickly become lost and off course. That is why the first step in therapy
is to map the territory. To develop a good map, therapists need to master the art of view­
ing, which in a talking profession like therapy refers to knowing where to focus your
attention while listening.
The heart of therapy-the seeming brilliance of a great therapist-has always been in
the viewing. The most useful question for new therapists to ask their supervisors is: What
should I be noticing and listening for when I talk with this client? Thankfully, this is
much easier than trying to memorize what to say. The apparent magic that distinguishes
master therapists from average therapists and average therapists from the average person
lies in what someone attends to when another is speaking. Essentially, the better you get
at knowing how to focus your viewing, the better therapist you will be. I believe it is a
skill that great therapists continually develop and refine over the course of their careers­
so don't plan on mastering it anytime soon.
497
 Overview of Cross-Theoretical Case Conceptualization 499
4. Client/Family Strengths and Social Location
5. Family Structure
6. Interactional Patterns
7. Intergenerational and Attachment Patterns
8. Solution-Based Assessment
9. Postmodern: Social Location and Dominant Discourses
10. Client Perspectives
~ The complete form for case conceptualization is available on MindTap® (see Cengagebrain
.com) or you can download the form at masteringcompetencies.com. The rest of this chap­
ter describes how to complete the form. An example of completed form is at the end of the
chapter based on the case study in Chapter 4.
Introductionto Clientand SignificantOthers
Case conceptualization starts by identifying: (a) who the client is (individual, couple, or
family) and (b) the most salient demographic features that relate to treatment.
Common demographic information includes the following:
• Gender: Female, Male, Trans-female, Trans-male, Other
• Age
• Race and Ethnicity: Try to be as specific as possible for ethnicity; instead of white,
Caucasian, Hispanic, or Latino, try to specify ethnicity.
• Sexual orientation
• Current occupation/work status or grade in school
• Any other useful identifier, such extracurricular activities for children.
I use a combination of abbreviations that make it easy to track family members using
confidential notation:
AF = Adult female
AM = Adult male
CF = Child female
CM = Child male
To distinguish members in large families and same-sex couples, I add the age after each
abbreviation (AF36, CM8). This can also be particularly helpful to a supervisor or in­
structor to follow your notes.
PresentingConcerns
The presenting concern is a description of how all parties involved are defining the prob­
lem: client, family, friends, school, workplace, legal system, and society. Often new-and
even some experienced therapists-assume that this description is a straightforward and
clear-cut matter. It can be, but it is usually surprisingly complex. Collaborative therapists
(Anderson, 1997; Anderson & Gehart, 2006) developed a unique means of conceptual­
izing the presenting problem in their collaborative language systems approach, also re­
ferred to as collaborative therapy (see Chapter 10). This postmodern approach maintains
that each person who is talking about the problem is part of the problem-generating sys­
tem, the set of relationships that produced the perspective or idea that there is a problem.
Each person involved has a different definition of the problem; sometimes the difference
is slight and sometimes it is stark . For example, when parents bring a child to therapy, the
mother, father, siblings, grandparents, teachers, school counselors, doctors, and friends
have different ideas of what the problem actually is. The mother may think it is a medical
problem, such as attention-deficit/hyperactivity disorder (ADHD); the father may believe
it is related to his wife's permissiveness; the teacher may say it is poor parenting; and the
child may think there really is no problem.
 Overview of Cross-Theoretical Case Conceptualization 501
BACKGROUND INFORMATION
Trauma/Abuse History (recent and past): _______ ______ _
Substance Use/Abuse (current and past; self, family of origin, significant
others): _______________ _________ _
Precipitating Events (recent life changes, first symptoms, stressors,etc.): __ _
Related Historical Background (family history, related issues, previous coun-
seling, medical/mental health history, etc.): __ _________ _
Often, this background information is considered the "facts" of the case. However, as
family therapists have historically cautioned, how we describe the facts makes all the differ­
ence (Anderson, 1997; O'Hanlon & Weiner-Davis, 1989; Watzlawick, Weakland, & Fisch,
1974). For example, saying that the client "recently won a state-level academic decathlon"
and saying that "her mother recently divorced her alcoholic father" paints two very differ­
ent pictures of the same client for you as therapist and for anyone else who reads the as­
sessment. Therefore, although this may seem like the "factual" part of the report in which
you as a professional are not imposing any bias, in fact, therapists impose bias by their sub­
tle choice of words, their ordering of information, and their emphasis on particular details.
Based on research about the importance of the therapeutic relationship and of hope
(Lambert & Ogles, 2004; Miller, Duncan, & Hubble, 1997), I recommend that thera­
pists write the background section so that they and anyone reading the report, poten­
tially including the client, will have a positive impression of the client and hope for the
client's recovery; these two factors affect the outcome of treatment.
Client/FamilyStrengthsand SocialLocation
Client strengths and resources should be the first thing assessed. This is a lesson I learned
the hard way. When I began teaching systemic assessment, I put the client strength sec­
tion at the end because it is more clearly associated with solution-based and postmodern
approaches (see Chapters 9 and 10; Anderson, 1997; de Shazer, 1988; White & Epston,
1990), which were historically developed later. What I discovered is that after reading
about the presenting problem, history, and problematic family dynamics, I was often feel­
ing quite hopeless about the case. However, often upon reading the strengths section at
the end, I would immediately perk up and find myself having hope, deep respect, and
even excitement about the clients and their future. I have since decided to start by assess­
ing strengths; I believe it puts the therapist in a more resourceful mind-set, whether work­
ing from either a systemic or postmodern perspective.
Emerging research supports the importance of identifying client strengths and re­
sources. Researchers who developed the common factors model (discussed in Chapter 2;
Lambert & Ogles, 2004; Miller et al., 1997) estimate that 40% of outcomes can be at­
tributed to client factors, such as severity of symptoms, access to resources, and support
system; the remaining factors include the therapeutic relationship (30%), therapist inter­
ventions (15 % ), and the client's sense of hope (15 % ). Assessing for resources leverages
client factors (40%), strengthens the therapeutic relationship (30%), and instills hope
(15%), thus drawing on three of the four common factors. Thus, the benefit of assessing
strengths is hard to overestimate.
 Overview of Cross-Theoretical Case Conceptualization 503
e-
-
PROBLEMS AND RELATED STRENGTHS
PROBLEM POSSIBLE ASSOCIATED STRENGTH
Depression • Is aware of what others think and feel
• Is connected to others and/or desires connection
• Has dreams and hopes
• Has had the courage to take action to realize dreams
• Has a realistic assessmentof self/others (according to recent research;
Seligman, 2004)
Anxiety • Paysattention to details
• Desires to perform well
• Is careful and thoughtful about actions
• Is able to plan for the future and anticipate potential obstacles
Arguing • Stands up for self and/or beliefs
• Fights injustice
• Wants the relationship to work
• Has hope for better things for others/self
Anger • Is in touch with feelings and thoughts
• Stands up against injustice
• Believes in fairness
• Is able to sense his/her boundaries and when they are crossed
Overwhelmed • Is concerned about others' needs
• Is thoughtful
• Is able to see the big picture
• Sets goals and pursues them
TryIt Yourself
Witha partneror on yourown,identifya personalqualitythat isa problemin one
area of your life. Next, identifyanothercontextin whichthat samequality is a
form of strength.
Identifying strengths relies heavily on the therapist's viewing skills. A skilled therapist
is able to see the strengths that are the flip side of the presenting problem while still re­
maining aware of the problem.
Relational or Social Strengths and Resources
Family, friends, professionals, teachers, coworkers, bosses, neighbors, church members,
salespeople, and numerous others in a person's life can be part of a social support net­
work that helps the client in physical, emotional, and spiritual ways:
• Physical support includes people who may help with running errands, picking up the
children, or doing tasks around the house.
• Emotional support may take the form of listening to or helping to resolve relational
problems.
• Community support includes friendships and acceptance provided by any community
and is almost always there in some form for a person who may be feeling marginal­
ized because of culture, sexual orientation, language, religion, or similar factors. These
communities are critical for coping with the stress of marginalization.
 Overview of Cross-Theoretical Case Conceptualization 505
Social Location: Resources and Limitations
In addition to client and family strengths, all clients bring with them certain resources
and limitations from their experiences of diversity, including race, ethnicity, age, gender,
sexual orientation, gender orientation, socioeconomic status, educational level, abilities,
religion, language, etc. Thus, therapists can assess for these too.
Common resources due to diversity include:
• Strong support network of people who understand client's situation
• Sense of community and connection
• Sense of purpose and direction
• Resources for solving problems
• Beliefs that provide comfort
• Connections with persons outside of immediate network
• Access to social services
Common limitations include:
• Isolation, difficulty meeting others
• Experiences of harassment and discrimination
• Difficulty finding opportunities
• Difficulty communicating with institutions
• Difficulty accessing social services
• Lack of sufficient financial resources, housing, legal representation, etc.
FamilyStructure
This assessment can be used with individuals, couples, or families. The approach pre­
sented here draws from the major theories in family therapy. Consistent with both sys­
temic (earlier forms of family therapy) and postmodern (later forms of family therapy)
practices, it uses multiple descriptors to generate a complete, "both/and" perspective
(Keeney, 1983) and a rich, multivoiced depiction of the problem (Anderson, 1997).
FAMILY STRUCTURE
Family life-Cycle Stage (Check all that apply)
D Single adult D Committed Couple D Family with Young Children D Family
with Adolescent Children D Divorce D Blended Family D Launching Children
D Later Life
Describe struggles with mastering developmental tasks in one or more of
these stages: -- ---- --- ----- --- --- ----- -
Typical style for regulating closenessand distance in couple/family: _ __ _
Boundaries with/between
Primary couple (A_!A_J:D Enmeshed D Clear D Disengaged DNA Description/
example: -- --- ----- --- ---- --- ---- ----
Parent A_ & Children: D Enmeshed D Clear D Disengaged D NA Description/
example: -- ---- --- --- ----- --- ---- ----
 Overview of Cross-Theoretical Case Conceptualization 507
• Committed relationship: Committing to a new system; realigning boundaries with
family and friends
• Families with young children: Adjusting marriage to make space for children; joining
in child-rearing tasks; realigning boundaries with parents and grandparents
• Families with adolescent children: Adjusting parental boundaries to increase freedom
and responsibility for adolescents; refocusing on marriage and career life
• Divorce: Interruption to the family life cycle, typically requiring most members to
increase their sense of independence, with parents also developing a new form of in­
terdependence (i.e., coparenting without being a couple).
• Blended families: Typically involves a complex balance of independence and interde­
pendence that requires two or more family systems to be entwined, often at different
stages of the family life cycle. Explicit discussion of needs for interdependence and in­
terdependence is helpful to navigate this challenging transition, which typically takes
several years (Visher & Visher, 1979).
• Launching children: Renegotiating the marital subsystem; developing adult-to-adult
relationships with children; coping with aging parents
• Family in later life: Accepting the shift of generational roles; coping with loss of
abilities; middle generation takes more central role; creating space for wisdom of the
elderly
Boundaries: Regulating Closeness and Distance
Most commonly associated with structural family therapy (see Chapter 5), bound­
aries are the rules for negotiating interpersonal closeness and distance (Minuchin,
197 4). Boundaries exist internally within the family and externally with those outside
the nuclear family. These rules are generally unspoken and unfold as two people in­
teract over time, each defining when, where, and how he or she prefers to relate to
the other. With couples, these rules are often highly complex and difficult to track.
Boundaries can be clear, diffuse, or rigid; all boundaries are strongly influenced by
culture.
• Clear boundaries and cultural variance: Clear boundaries refer to a range of possible
ways that couples and families can negotiate a healthy balance between closeness (we­
ness) and separation (individuality). Cultural factors shape how much closeness or
separation is preferred. Collectivist cultures tend toward greater degrees of closeness,
whereas individualistic cultures tend to value greater independence. The best way to
determine whether boundaries are clear is to determine whether symptoms have de­
veloped in the individual, couple, or family. If symptoms have developed, boundaries
are probably too diffuse or too rigid. Most people who come in for therapy have
reached a point at which boundaries that may have worked in one context are no
longer working, often because of shifting needs in the family life cycle. For relation­
ships to weather the test of time, couples and families must constantly renegotiate
their boundaries (rules for relating) to adjust to each person's evolving needs. The
more flexible couples are in negotiating these rules, the more successful they will be in
adjusting to life's transitions and setbacks .
• Diffuse boundaries and enmeshed relationships: When couples or families begin to
overvalue togetherness at the expense of respecting each other's individuality, their
boundaries become diffuse and the relationship becomes enmeshed. (Note: Techni­
cally, boundaries are not enmeshed; they are diffuse.) In these relationships, one or
more parties may feel that they are being suffocated, that they lack freedom, or that
they are not cared for enough. Often people in these relationships feel threatened
whenever the other disagrees or does not affirm them, resulting in an intense tug­
of-war to convince the other to agree with them. Couples with diffuse boundar­
ies may also have diffuse boundaries with their children, families of origin, and/
or friends, with the result that these outside others become overly involved in one
 Overview of Cross-Theoretical Case Conceptualization 509
Therapists assess for triangles and problematic subsystems in several ways:
• Clients overtly describe another party as playing a role in their tension; in these cases,
the clients are aware of the process at some level.
• When clients describe the problem or conflict situation, another person plays the role
of confidant or takes the side of one of the partners (e.g., one person has a friend or
another family member who takes his or her side against the other).
• After being unable to have a need met in the primary dyad, a person finds what he or
she is not getting in another person (e.g., a mother seeks emotional closeness from a
child rather than from a husband).
• When therapy is inexplicably "stuck," there is often a triangle at work that distracts
one or both parties from resolving critical issues (e.g., an affair, substance abuse, a
friend who undermines agreements made in therapy, etc.).
Identifying triangles early in the assessment process enables therapists to intervene more
successfully and quickly in a complex set of family dynamics.
Hierarchy between Child and Parents
A key area in assessing parent and child relationships is hierarchy, a structural family con­
cept (see Chapter 5). When assessing parental hierarchy, therapists must ask themselves:
Is the parent-child hierarchy developmentally and culturally appropriate? If the hierarchy
is appropriate, the child usually has few behavioral problems. If the child is exhibiting
symptoms or there are problems in the parent-child relationship, there is usually some
problem in the hierarchical structure: either an excessive (authoritarian) or insufficient
(permissive) parental hierarchy given the family's current sociocultural context(s). Immi­
grant families, because they usually have two different sets of cultural norms for parental
hierarchy (the traditional and the current cultural context), have difficulty finding a bal­
ance between authoritarian and permissive hierarchies.
Assessing hierarchy is critical because it tells the therapist where and how to inter­
vene. If therapists assess only the symptoms, they may make inappropriate interventions.
For example, though children diagnosed with ADHD have similar symptoms-hyper­
activity, defiance, failing to follow through on parents' requests-these same symptoms
can occur in two dramatically different family structures: either too much or too lit­
tle parental hierarchy. When the parental hierarchy is too rigid, the therapist works
with the parents to develop a stronger personal relationship with the child and to set
developmentally and culturally appropriate expectations. If there is not enough pa­
rental hierarchy, the therapist helps parents to be more consistent with consequences
and to set limits and rules. Thus, the same set of symptoms can require very different
interventions.
When conceptualizing parental hierarchy, it can also be helpful to consider the
balance of roles within the parental system. Raser (1999) describes the parenting re­
lationship as comprising business roles (setting rules, socializing) and personal roles
(warmth, fun, caring, play); the former correlates most often with an effective hierar­
chy and the latter with secure attachment (see "Attachment Patterns," below). Typically,
a parent is better at one than the other, which often leads to problematic polarization
between the parents. Ideally, both parents are able to balance within themselves the
business and personal sides of parenting, and both parents can then set an effective hi­
erarchy as well as maintain a close emotional bond. Assessing just this single dimension
can provide therapists with a razor-sharp focus for treatment, often resulting in rapid
improvements.
Complementary Patterns
Complementary patterns characterize most relationships to a certain degree, especially
long-term committed relationships. Complementary in this case refers to each person
 Overview of Cross-Theoretical Case Conceptualization 511
addresses the fact that the behavior is always embedded within larger systems and that
the symptoms help maintain the system's homeostasis or sense of normalcy (even if the
behavior is not considered normal by the members of the system). I find it most helpful
to think of tracing the problem interaction through three basic phases, which can vary
significantly from problem to problem.
THREE PHASES OF PROBLEM INTERACTION PATTERN
• Start of tension: What are the behaviors that signal a rise in tension or
the start of the problem? How do things unfold from here? How does
each person respond and react to the rise in tension?
• Conflict/symptom escalation: What happens when the problem fully
emerges (it may be a conflict for a family or a depressive episode for an
individual)? The focus here is on the behavioral actions and responses
of each person involved, even in cases of "individual" problems, such
as anxiety, depression, or psychosis.
• Return to "normal"/homeostasis: Often the most enlightening part,
the interaction cycle is finally traced back to "normal" or homeostasis.
What does each person do to get back to the sense of "normal"?
A therapist can assess these patterns using a series of questions, first by identifying the
emergence of the problem and then by tracing each person's emotional and/or behavioral
responses to others until "normalcy" or homeostasis is achieved again. The process looks
something like this.
ASSESSING INTERACTION PATTERNS
Client describes how the problem begins:
Example: Mother gets a call from the school saying her son is failing a class.
The therapist inquires about the mother's next actions and the son's response:
Example: Mother lectures son and sets an extensive punishment; the child
argues and saysshe is being unfair. Mother says, "Wait until I tell your dad."
The therapist continues to trace this exchange in terms of how each re­
sponded to the other until they return to normal:
Example: Mother responds to son's accusations of her being unfair by add­
ing more consequences and punishments.
The therapist also inquires about how significant others in the family system
respond to the problem situation:
Example: How did the father participate? What does the younger sister do
while this is going on? What effects does this have in the marital relationship?
The therapist continues assessingthe interaction pattern until it is clear that
the entire family has returned to a sense of "normalcy."
 Overview of Cross-Theoretical Case Conceptualization 513
GENOG ·
Male Marriage
□ Note: Husband on Left Q_9
Female
0
Identified Separation
Patient [DJ u
Pregnancy
D Divorce
Death
Q,S
~
Remarriage
Psychological Note: New Spouse to Side
Disorder I] 9 9#9y
Alcohol/Substance Living Together
Abuse/Dependence y____
___
_y
- Children
0
Biological Foster Adopted Identical
Child Child Child Pregnancy Twins
Twins
Symbols for lnteractional Patterns
11
rtvC? Q y
Conflicted Cut Off Close Enmeshed
~ ~
Distant Sexual Abuse Physical Abuse Conflictually Enmeshed
Commonly Used Genogram Symbols
I
INTERGENERATIONAL AND ATTACHMENT PATTERNS
Construct a family genogram and include all relevant information including :
• Ages, birth/death dates
• Names
• Relational patterns
• Occupations
• Medical history
(continued)
 Overview of Cross-Theoretical Case Conceptualization 515
Solution-Based
Assessment
SOLUTION-BASED ASSESSMENT
Attempted Solutions that DIDN'T work:
1. -------- --------- ---------- -
2. ------------- ------ ---------
3. --------- ------------ -------
Exceptions and Unique Outcomes (Solutions that DID work): Times, places,
relationships, contexts, etc. when problem is less of a problem; behaviors that
seem to make things even slightly better:
1. ----- ----- ------------- -----
2. ----- ------------ --------- --
3. ---------- ----------- -------
Answer to the Miracle Question: If the problem were to be resolved over­
night, what would client be doing differently the next day? (Describe in
terms of doing X rather than not doing Y).
1. ---------- -------- ----------
2. -------- -------------- ----- -
3. ------ ------- ------------ ---
Previous Solutions That Did Not Work
When assessing solutions, therapists need to assess two kinds: those that have worked
and those that have not. The MRI group (Watzlawick et al., 1974) and cognitive-behav ­
ioral therapists (Baucom & Epstein, 1990) are best known for assessing what has not
worked, although they use these in different ways when they intervene. With most clients,
it is generally easy to assess failed previous solutions.
QUESTIONS FOR ASSESSING SOLUTIONS THAT DID NOT WORK
The therapist may begin by asking a straightforward question:
What have you tried to solve this problem?
Most clients respond with a list of things that have not worked. If they need
more prompting therapists may ask:
I am guessing you have tried to solve this problem (address this issue) on
your own and that some things were not as successful as you had hoped.
What have you tried that did not work?
Exceptions and Unique Outcomes: Previous Solutions That Did Work
Solution-focused therapists (de Shazer, 1988; O'Hanlon & Weiner-Davis, 1989) assess for
previous solutions that did work, a process that is similar to identifying unique outcomes
 Overview of Cross-Theoretical Case Conceptualization 517
POSTMODERN: SOCIAL LOCATION AND DOMINANT DISCOURSES
Dominant discourses informing definition of problem:
Cultural, ethnic, socioeconomic status, religious etc.: How do key cultural dis­
courses inform what is perceived as a problem and the possible solutions?
Gender, sexual orientation, etc.: How do the gender/sexual discourses inform
what is perceived as a problem and the possible solutions? ___ ____ _
Contextual, family, community, school, and other social discourses: How do
other important discoursesinform what is perceived as a problem and the pos-
sible solutions? ________ ______ ________ ___ _
Identity/self-narratives: How has the problem shaped each family member's
identity?: ____ ________ ____ _________ _ _
Local or preferred discourses: What is the client's preferred identity narrative
and/or narrative about the problem? Are there local (alternative) discourses
about the problem that are preferred?: ___ ____ ______ _
Dominant Discourses
Assessing the dominant social discourses in which a client's problems are embedded often
creates a new and broader perspective on a client's situation (Freedman & Combs, 1996;
White & Epston, 1990). I find that this broader perspective frequently helps me feel more
freedom and possibility, increasing my emotional attunement to clients and allowing me
to be more creative in my work. For example, when I view a client's reported "anxiety" as
part of a larger discourse in which the client feel powerless, such as being gay or lesbian, I
begin to see the anxiety as part of this larger social dance. I also see how it is possible for
this person to give less "faith," weight, or credence to the dominant discourse and gener­
ate new stories about what is "normal" sexual behavior and what is not. By discussing
the difficulty in concretely defining what is normal sexual behavior and what is not, the
client and I can begin to explore the truths that this person has experienced. We join in an
exploratory process that offers new ways for the client to understand the anxiety as well
as his/her identity.
Common dominant discourses or broader narratives that inform clients' lives include
the following:
• Culture, race, ethnicity, class, immigration, religion
• Gender identity and sexual orientation
• Community, school, and professional cultures
• Wealth, poverty, power, fame
• Small-town, urban, regional discourses
• Health, illness, body image, etc.
 Case Conceptualization, Diversity, and Sameness 519
CaseConceptualization,
Diversity,and Sameness
Just in case you were beginning to feel that you finally understood something about case
conceptualization, let me throw a wrench or two into the mix: diversity and sameness. The
problem with case conceptualization and assessments in general is that, unfortunately,
there are no objective standards against which a person can be measured for "clear bound­
aries," "healthy hierarchies," or "clear communication." Healthy, emotionally engaged
boundaries look quite different in a Mexican American family and an Asian American
family. In fact, problematic boundaries in a Mexican American family (e.g., cool, dis­
engaged) may look more like healthy boundaries (e.g., quietly respectful) than problem
boundaries (e.g., overly involved) in Asian American families. Thus, therapists cannot rely
simply on objective descriptions of behavior in assessment. They must also consider the
broader culture norms, which may include more than one set of ethnic norms as well
as local neighborhood cultures, school contexts, sexual orientation subcultures, religious
communities, and so forth. Although you will undoubtedly take a course on cultural is­
sues and will read that professional codes of ethics require respecting diversity, it takes
working with a diverse range of families and a willingness to learn from them to cultivate
a meaningful sense of cultural sensitivity. I believe this to be a lifelong journey.
Ironically, I have found that new therapists in training today sometimes have the most
difficulty accepting diversity in clients from within their same culture of origin. The more
similar clients are to us, the more we expect them to share our values and behavioral
norms and the lower our tolerance of difference. For example, middle-class Caucasian
therapists often expect middle-class Caucasian clients to have particular values regarding
emotional expression, marital arrangements, extended family, and parent-child relation­
ships and may be quick to encourage particular systems of values-namely, their own.
Thus, whether working with someone very similar to or very different from yourself,
you need to slowly assess and evaluate, always considering clients' broader sociocultural
context and norms. Therapists who excel in conceptualization and assessment approach
these tasks with profound humility and a continual willingness to learn.
ONLINERESOURCES
Genoware, Inc.: Genogram Maker practice quizzes, apps, and more-all in
www.genogram.org one place. If your instructor didn't assign
MindTap, you can find out more informa­
Go to MindTap® for an eBook, videos of tion at CengageBrain.com.
client sessions, activities, digital forms,
REFERENCES
Anderson, H. (1997). Conversations, lan­ Bertolino, B., & O'Hanlon, B. (2002). Col­
guage, and possibilities. New York: laborative, competency-based counseling
Basic. and therapy. New York: Allyn & Bacon.
Anderson, H., & Gehart, D.R. (Eds.). (2006). Carter, B., & McGoldrick, M. (1999). The
Collaborative therapy: Relationships and expanded family life cycle: Individu­
conversations that make a difference. als, families, and social perspectives
New York: Brunner-Routledge. (3rd ed.). New York: Allyn & Bacon.
Bateson, G. (1972). Steps to an ecology of de Shazer, S. (1985). Keys to solution in
mind. New York: Ballantine. brief therapy. New York: Norton.
Bateson, G. (1979/2002). Mind and na­ de Shazer, S. (1988). Clues: Investigating
ture: A necessary unity. Cresskill, NJ: solutions in brief therapy. New York:
Hampton. Norton.
Baucom, D. H., & Epstein, N. (1990). Freedman, J., & Combs, G. (1996). Narra­
Cognitive-behavioral marital therapy. tive therapy: The social construction of
New York: Brunner/Mazel. preferred realities. New York: Norton.
 Case Conceptualization, Diversity, and Sameness 521
For use with individual, couple, or family clients.
Date: 6/19/16 Clinician: Maria Sanchez, MFT Trainee Client/Case#: 4001
Introductionto Client & SignificantOthers -----
Identify significant persons in client's relational/family life who will be mentioned in case
conceptualization:
Adults/Parents: Select identifier/abbreviation for use in rest of case conceptualization
AF1: Female Age: 36 Hispanic/Latino Married heterosexual Occupation: Department store clerk
Other: Catholic
AM1: Male Age: 34 Hispanic/Latino Married heterosexual Occupation: Insurance Agent Other:
Son of Immigrants from Mexico, Catholic
Children/ Adult Children: Select identifier/abbreviation for use in rest of case conceptualization
CF1: Female Age: _!§_ Hispanic/Latino Grade: 10 School: Green Field Highschool Other identifier:
Active in multiple school activites, including music and soccer
CM1: Male Age: 14 Hispanic/Latino Grade: 8 School: Valley Middle School Other identifier: Honor
- --
Student
Others: Identify all:__ ___ __ ____ __ ____ _ ____ __ ___ _
PresentingConcerns
Describe each significant person's description of the problem, focusing on OBSERVABLE behaviors:
AF1: Couple separated six months ago due to AM34's affair; AF36's family is very disapproving but
AF36 re fuses to stay together; primary concern is CF16's recent alcohol/drug use.
AM1: Fell in love with another woman; feels bad about effects on family bu t is not sure what else to
do; primary concern is the children and CF16's drug use .
CF1: Angry about parent's likely divorce; feels father abandoned family; sees "partying" as normal
and feels that she is entitled because of the stress her parents caused her.
CM1: Sees father as weak for affair and frustrated with mother's anxiety over religious issues. Disap­
pointed in parents but copes by staying focused on school.
Broader System: Description of problem from extended family, referring party, school, legal system, etc.:
Extended Family: AF Family of Origin : Views divorce from religious perspective and believes couples
should work things out. AM Family of Origin: Understanding of divorce given the distant marriage that
AM34 parents had.
Mrs.Gomez: School Counselor: Concerned that CF16 is starting down dangerous path in reaction to
parents' separation.
Name:
---- --- --- --- ---- --- ---- --- -- ---- -- -
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 Case Conceptualization, Diversity, and Sameness 523
Based on the client's social location-age, gender race, ethnicity, sexual orientation, gender
identity, social class, religion, geographic region, language, family configuration, abilities, etc.­
identify potential resources and challenges:
Unique Resources: AF has strong familial support even though they do not agree with her actions
entirely; AF has strong religious faith and community that she finds very helpful; parents have overall
been successful in handling cross-generational differences in terms of acculturation.
Potential Limitations: When AF contemplates divorce, she must consider religious, cultural, and family
values and balance them with asserting her personal needs. Heavy drinking is part of family's culture,
making it harder for CF 16to reflect on her use.
FamilyStructure
□ Single Adult
D Committed Couple
D Family with Young Children
[g] Family with Adolescent Children
[g] Divorce
□ Blended Family
D Launching Children
D Later Life
Describe struggles with mastering developmental tasks in one or more of these stages: Couple has
had difficulty maintaining couple connection since having children. AF36 feels as though she has had
primary responsibility for raising the children, AM34 feeling disconnected from family life.
Boundaries with/between:
Primary couple [g] Enmeshed D Clear D Disengaged D NA Example: Historically en-
meshed, the couple's boundary definition has only gotten more confusing with the separation, each hav­
ing a more difficult time allowing the other to have unique opinions and feelings, especially about the
children. Most every interaction is charged with over-personalization
AF & Children ~ Enmeshed D Clear D Disengaged DNA Example: AF36 can be highly
reactive when kids do not follow rules and has taken CF16's drug use very personally.
AM & Children D Enmeshed D Clear [g] Disengaged D NA Example: AM34 has always
been a more detached father figure, which is even more exaggerated since the separation.
Siblings D Enmeshed [g] Clear D Disengaged D NA Example: _____ _ _
Extended Family ~ Enmeshed O Clear D Disengaged D NA Example: Extended family very
involved in separation.
Friends/Peers/Others [g] Enmeshed O Clear D Disengaged DNA Example: AM has left family for
lover; he does not balance time with her and children.
{continued)
, Ph.D
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 Case Conceptualization, Diversity, and Sameness 525
Genogram should be attached to report. Summarize key findings below:
Substance/Alcohol Abuse: DNA l8l History: AM34's father and brother
abuse alcohol : CF has p oten­
tial to develo o same p roblem
Sexual/Physical/Emotional Abuse: l8l NA D History: __ _ _____ __ _
Parent/Child Relations: D NA l8l History: __ __ ___ _ __ _
Physical/Mental Disorders: D NA l8l History: __ _ _____ _ _ _
History Related to Presenting Problem: D NA l8l History: ___ _ ___ _ __ _
Describe family strengths, such as the capacity to self-regulate and to effectively manage stress:
AF36 has strong religious tradition, which helps to stabilize her and the family.
Describe typical attachment behavior when person does not feel secure in relationships.
AF: l8l Anxious D Avoidant D Anxious/Avoidant. Frequency: Select Describe: Pursue husband,
and often tried to use verbal attack to reengage him; she also pursues children when they distance
themselves.
AF: D Anxious l8l Avoidant D Anxious/Avoidant. Frequency: Select Describe: Distancer in mar­
riage; using affair to "solve" marital problems.
CF: l8lAnxious D Avoidant D Anxious/Avoidant. Frequency: Select Describe: When feels unsafe,
generally pursues connection, often through conflict or approval from friends.
CM:D Anxious l8l Avoidant D Anxious/Avoidant. Frequency: Select Describe: Generally avoids
conflict; tries to be perfect to avoid criticism.
Additional: - - -- ------ -- -- - ---- - -- - ----- - ---
So]ution-Based Assessment
Attempted Solutions that DIDN'T work:
1. Parents lecturing CF 16 has not reduced her drinking and drug use.
2. AF36 setting harsh but unenforced consequences not working; stalling on moving forward with the
divorce may not be as effective as hoped.
Exceptions and Unique Outcomes (Solutions that DID work): Times, places, relationships, contexts,
etc., when problem is less of a problem; behaviors that seem to make things even slightly better:
1. CF16 reports choosing to not continue using harder drugs because she is afraid of them; although her
grades have dropped, she is still passing; she has retained some friends who support healthier choices.
2. CF16 reports using less the weekend the family went out of town.
Miracle Question/Answer: If the problem were to be resolved overnight, what would client be
doing differently the next day? (Describe in terms of doing X rather than not doing Y):
1. AF and AM would wake up in the same house, happy to be together (AF and kids).
2. CF would have new group of friends; more freedom if able to prove making good decisions re:
substances (parents; CF somewhat agree).
3. CF and CM would both be getting good grades, involved in school activities, and the family would
have more fun family adventures.
(continued)
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