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Multidimensional Biopsychosocial Assessment and Generalist Case Conceptualization: A Review

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Title: Multidimensional Biopsychosocial Assessment and Generalist Case Conceptualization: A Review


1
Multidimensional Biopsychosocial Assessment and
Generalist Case Conceptualization A Review
  • Lucinda A. Rasmussen, Ph.D., LCSW
  • San Diego State University
  • School of Social Work

2
Assessment Skills (Phase 2) Identifying and
Defining the Problems and Issues
3
Components of a Multidimensional
Assessment (Hepworth et al., 2006)
  • Defining the presenting problems
  • Identifying the underlying therapeutic issues
  • Assessing the clients biopsychosocial
    functioning
  • Identifying the clients strengths and resources
  • Evaluating the clients developmental needs and
    life transitions
  • Identifying the environmental systems affecting
    client concerns

4
Problem Identification Presenting
Problem (Hepworth et al., 2006)
  • Generally the client seeks services at a state of
    crisis or disequilibrium.
  • Initially the client will give a general account
    of the problem(s). This
  • Reflects the clients immediate perception of the
    problem.
  • Identifies systems that are constituent parts of
    the problems.
  • Is a focal point of clients motivation in
    seeking help.

5
Defining the Problems Presenting
Problem(s) (Hepworth, Rooney, Larsen, 2006)
  • What is the problem behavior?
  • Problem deficiency of something needed, or
    excess of something not desired
  • Precipitating event (antecedent) what brought
    client into treatment at this time
  • How does the client perceive the problem?
  • What key persons, groups, or organizations are
    participants in the clients difficulties?
  • What developmental needs and transitions are
    involved in the clients problem(s)?

6
Defining the Problems Presenting
Problem(s) (Hepworth et al., 2006)
  • Severity what level of care is needed?
  • Inpatient ? Day Treatment
  • Residential ? Outpatient
  • Meanings (attributions) what meaning does the
    client ascribe to the problem?
  • Pseudoscientific explanations
  • Psychological labeling
  • Skepticism about others ability to change
  • Belief that external factors cant be changed
  • Misconceptions about self
  • Sense of helplessness/powerlessness

7
Defining the Problems Presenting
Problem(s) (Hepworth et al., 2006)
  • Sites where does the problem occur? Where does
    it NOT occur?
  • Home?
  • School or work?
  • Onset and duration
  • Onset when did the problem start?
  • Duration - how long has the problem existed?
  • Context when does the problem occur?
  • (time of year, time of day, after certain events)

8
Defining the Problems Presenting
Problem(s) (Hepworth et al., 2006)
  • Frequency of the problem(s)
  • Consequences of the problem impact of the
    problem(s) on clients biopsychosocial
    functioning.
  • Identification of special issues
  • Substance abuse
  • Physical abuse, sexual abuse, child neglect
  • Domestic violence

9
Defining the Problems Presenting
Problem(s) (Hepworth et al., 2006)
  • Clients emotional reactions to the problems
  • Clients coping efforts and psychological
    defenses how has the client coped?
  • Needed Skills what skills are needed to resolve
    the problem? Examples
  • Parenting skills?
  • Anger management?
  • Communication skills?

10
Defining the Problems Presenting
Problem(s) (Hepworth et al., 2006)
  • Strengths what are the clients strengths and
    skills?
  • Cultural factors what aspects of diversity are
    present in this case? How do cultural factors
    affect the problem?
  • Support systems what support systems exist or
    need to be created for the client?
  • Resources what resources are needed by the
    client?

11
Assessment Skills (Phases 2 3) Gathering and
Interpreting Data Assessing Client Functioning
12
Assessing Client Functioning Domains of
Functioning (Hepworth et al., 2006)
  • Internal Factors
  • Physical/neurobiological functioning
  • Cognitive functioning
  • Emotional functioning
  • Behavioral/social functioning
  • Motivation
  • External Factors
  • Cultural factors
  • Environmental systems
  • Family dynamics

13
Physical/Neurobiological Functioning (Hepworth et
al., 2006 Lukas, 1993)
  • Physical characteristics/presentation
  • Physical health
  • If client has a physical symptom How long? How
    often? How much does it interfere with daily
    life? Has he/she seen a doctor?
  • If client is taking medication Was it
    prescribed? By whom? Why? What is it called? How
    much is client taking? How often? Is it helping?

14
Physical/Neurobiological Functioning Substance
Abuse (Hepworth et al., 2006 Lukas, 1993)
  • What substances?
  • How long?
  • How recently?
  • How much?
  • When does client use?
  • Why does client use?
  • What happens when client uses?
  • What impact does substance have on clients life?

15
Assessing Cognitive Functioning (Hepworth et al.,
2006)
  • Intellectual functioning
  • Judgment
  • Reality testing
  • Coherence
  • Cognitive flexibility
  • Values
  • Misconceptions
  • Self-concept

16
Assessing Emotional Functioning (Hepworth et al.,
2006)
  • Affect regulation
  • Range of emotions
  • Appropriateness of affect (role of culture)
  • Affective disorders
  • Bipolar Disorder
  • Depression/Anxiety
  • Suicidal risk

17
Assessing Behavioral Functioning (Hepworth et
al., 2006)
  • Power/Control
  • Nurturance/support
  • Responsibility
  • Social skills
  • Coping patterns
  • Personal habits
  • Communication
  • Accomplishment and independence
  • Affection/sexual

18
Assessing Motivation (Hepworth et al., 2006)
  • Direction of motivation What motivates the
    client?
  • Strength of motivation How strong is clients
    motivation?

19
Assessment Skills (Phases 2 3) Gathering and
Interpreting Data Assessing the Clients
Environment
20
Assessing Environmental Systems (Hepworth et al.,
2006)
  • Adequate nutrition
  • Predictable learning arrangements
  • Opportunities for education
  • Access to legal resources
  • Access to religious organizations
  • Employment opportunities

21
Assessing Environmental Systems (Hepworth et al.,
2006)
  • Social support systems
  • Access to health care
  • Access to day care
  • Access to recreation
  • Mobility to socialize
  • Adequate housing
  • Adequate fire/police protection
  • Safe and healthy working conditions
  • Financial resources

22
Assessing Family Functioning (Phases 2 3 of
Assessment)
23
Bowen Theory Assessing Intergenerational Themes
  • Mental illness (e.g., depression/suicide, bipolar
    disorder, schizophrenia)
  • Physical illness (e.g., diabetes, cancer)
  • Neurobiological problems (e.g., ADHD, learning
    disabilities)
  • Child abuse/neglect and domestic violence
  • Substance abuse / incarceration
  • Significant trauma or losses
  • Birth order of siblings

24
Assessing Family Dynamics with Minuchin and Bowen
Theories
  • Homeostasis (Both Minuchin Bowen)
  • Boundaries (Both)
  • Subsystems (Minuchin)
  • Hierarchy / decision making (Minuchin)
  • Alliances, coalitions, triangulation (Both)
  • Roles of family members (Both)
  • Birth order of children (Bowen)
  • Communication / family rules (Both)
  • Intergenerational themes (Bowen)

25
Phase 3 of Assessment - Interpreting
Data Case Conceptualization
26
Assessing Strengths Resources (Hepworth et al.,
2006)
  • Personal Family
  • Coping capacities
  • Skills
  • Values
  • Motivation
  • Community
  • Resources
  • Cultural support networks

27
Case Conceptualization
  • Pulls together and synthesizes relevant
    information gained in the initial interviews and
    collateral information from other professionals
    and agencies.
  • Identifies and analyzes the clients therapeutic
    issues.
  • Answers the question
  • How do you see the clients problems?

28
Case Conceptualization (continued)
  • Give hypotheses for the dynamics of the clients
    problems and therapeutic issues.
  • Highlights client strengths and identifies
    resource systems.
  • Identifies areas where further information is
    needed.
  • Can give a diagnostic impression (e.g., DSM-IV,
    defense mechanisms)
  • Applies theoretical knowledge to practice.

29
How to Complete a Case Conceptualization
  • Begin by assessing the client from the Generalist
    Practice Perspective. Assess transactions
    between the client and his or her environment.
  • Identify concerns and strengths from the micro,
    mezzo, and macro levels, and document these
    concerns/strengths from client self-report,
    collateral contacts, and/or clients responses to
    assessment tools.

30
How to Complete a Case Conceptualization
  • Analyze the data you have collected and identify
    the clients therapeutic issues.
  • Formulate hypotheses about the dynamics of the
    clients therapeutic issues.
  • The identified concerns/issues will guide your
    selection of theoretical orientation and will
    help you determine which level (micro, mezzo, or
    macro) would be the best way to approach the
    problem(s).

31
How to Complete a Case Conceptualization
  • Integrate additional practice theories and models
    that allow you to
  • examine the clients issues in depth.
  • understand who the client is and why the client
    thinks, feels, and behaves as he or she does.
  • The practice theories/models you choose will
    determine the questions you will ask, the goals
    you and the client will establish, and the
    interventions to apply.

32
Questions to Consider in Case Conceptualization
  • How do you see the clients problems and
    therapeutic issues?
  • What is your evaluation of the clients
    functioning in all domains (physical, cognitive,
    emotional, behavioral, cultural, environmental,
    and family dynamics?
  • What are the clients strengths and deficits at
    the micro, mezzo, and macro levels?

33
Questions to Consider in Case Conceptualization
  • How strong is the clients motivation for
    services? What are the clients expectations?
  • How supportive is the clients family?
  • Are there environmental factors that impact
    positively or negatively on the clients
    functioning?
  • What clinical practice issues are raised by this
    case?Are there any ethical/legal dilemmas?

34
Theoretical Perspective (Sheafor, Horejsi,
Horejsi, G. A., 1997)
  • Theory allows the worker to view human behavior
    through a lens composed of a coherent set of
  • concepts, beliefs, values, propositions,
    assumptions, hypotheses, and principles
  • It gives the worker an outline of ideas to
    understand how people function and how people
    change.

35
Types of Conceptual Frameworks Howe, 1987, p. 166
Conceptual Frameworks
Theoriesof Social Work
Theories for Social Work
Orienting Theories
Practice Frameworks
Practice Perspectives
Practice Theories
Practice Models
36
Important Definitions
  • Practice Perspective - a conceptual lens through
    which one views human behavior and social
    structures and which guides selection of
    intervention strategies (e.g., generalist,
    ecological, systems).
  • Practice Theory - Offers an explanation of
    certain behaviors and broad guidelines about how
    those behaviors can be changed.
  • Practice Model - A set of concepts or principles
    used to guide certain interventions not tied to
    any one explanation develops from actual
    clinical experience.

37
Phase Two of Assessment -Interpretation
Diagnosis/ Formulating Problem Statements
38
DSM-IV The Basics
  • Deals with mental disorders occurring in
    individuals, not families, groups, or
    communities.
  • Intentionally atheoretical
  • Based on objective, empirically verifiable
    evidence (signs and symptoms).
  • Tries to avoid theoretical speculation about the
    causes of psychiatric disorders.

39
DSM-IV Mental Disorder Defined
  • …a clinically significant behavioral or
    psychological syndrome or pattern that occurs in
    an individual and this is associated with present
    distress (e.g., a painful symptom) or disability
    (e.g., impairment in one or more important areas
    or functioning) or with a significantly increased
    risk of suffering death, pain, disability, or an
    important loss of freedom. (DSM-IV, p. xxi)

40
Diagnosing a Mental Disorder
  • Present distress - painful symptom
  • Disability - impairment in one or more areas of
    functioning
  • Emotional functioning
  • Cognitive functioning
  • Social functioning
  • Risk of death, pain, disability, or loss of
    freedom

41
Other Key Diagnostic Issues
  • Coexistence of more than one disorder in the same
    client. The complexities of clients physical,
    emotional, and interpersonal lives often lead to
    more than one diagnosis.
  • Lack of discrete division between disorders (or
    between mental disorder and normalcy). Current
    state of diagnostic art, and nature of clients
    themselves, precludes clear-cut borders between
    closely related disorders, and at times between
    normalcy and psychopatholgy.

42
Signs, Symptoms, and Syndromes (DSM-IV,
Appendix C)
  • SIGN - an objective manifestation of a
    pathological condition. Signs are observed by
    the examiner rather than reported by the affected
    individual.
  • SYMPTOM - A subjective manifestation of a
    pathological condition. Symptoms are reported by
    the affected individual rather than observed by
    the examiner.
  • SYNDROME - A grouping of signs and symptoms,
    based on their frequent co-occurrence, that may
    suggest a common underlying pathogenesis, course,
    familial pattern, or treatment selection.

43
DSM-IV Mental Disorder Defined
  • …a clinically significant behavioral or
    psychological syndrome or pattern that occurs in
    an individual and this is associated with present
    distress (e.g., a painful symptom) or disability
    (e.g., impairment in one or more important areas
    or functioning) or with a significantly increased
    risk of suffering death, pain, disability, or an
    important loss of freedom. (DSM-IV, p. xxi)

44
Problem Selection
  • During the assessment process, a number of
    problems may surface.
  • The client and practitioner must determine which
    problems are the most significant to focus on in
    the treatment process.
  • An effective treatment plan can only deal with a
    few selected problems (immediate, primary, and
    secondary).

45
Formulating Definable Problem Statements
  • Identify immediate, primary and secondary problem
    areas.
  • Describe problems in behavioral, descriptive
    terms
  • Signs and symptoms
  • May tie to criteria in DSM-IV
  • Describe how problems are significantly impairing
    the clients functioning.

46
Documenting Client Symptoms (Compare the
Following)
  • The client is having trouble coping with a recent
    divorce and death of a loved one.
  • The client is experiencing an adjustment disorder
    with depressed mood as evidenced by increased
    depression, withdrawal, and difficulties.
    Symptoms have occurred since the onset of two
    major stressors in the past three months,
    including death of his mother and his divorce.
    Affective impairment is noted as evidenced by
    feeling dysphoric most of the time and having
    difficulties feeling motivated to work, shop, or
    resume usual activities.

47
Documenting Client Symptoms (Compare the
Following)
  • The client is missing four days of work per week,
    has no friends, and has not phoned any family
    members for more than two months.
  • The client has felt depressed for the past 3
    weeks as evidenced by suicidal ideation, feeling
    hopeless and worthless, and excessive eating.
    There is resulting affective, cognitive,
    educational, and physical impairment as evidenced
    by constant fatigue, missing school 50 of the
    time from lack of sleep (average 3 hrs/night),
    decreased concentration (unable to comprehend
    after reading more than 3 to 4 minutes at a
    time), weight gain of 12 lbs.in the past 3 weeks,
    and increased negative self-statements noted by
    others.

48
? Practice Moment Client Lily Kim
  • Immediate Suicidal risk
  • Primary Depression
  • Secondary Family Conflict

49
Planning Goals Objectives
Individual
Group
Referral
Family
Work
Case
Self Help Program
50
Treatment Planning in the Generalist Intervention
Model (Kirst-Ashman Hull, 2001)
  • Translate problems into needs and establish
    treatment goals.
  • Identify alternative interventions.
  • Select appropriate courses of action
  • Contracting

51
Generalist Treatment Planning Step One Goal
Setting (Kirst-Ashman Hull, 2001)
  • Translate problems into needs and establish
    treatment goals
  • Immediate goals - address high risk factors and
    immediate needs.
  • Long-term goals - address underlying therapeutic
    issues.
  • Short-term goals/objectives - are the incremental
    steps of long-term goals.

52
Generalist Treatment Planning Step Two
Identifying Alternatives (Kirst-Ashman Hull,
2001)
  • What is the appropriate level of care?
    (outpatient, day treatment, inpatient, group
    home/foster home, residential, secure facility)
  • What are the best treatment modalities?
    (individual therapy, group treatment, couple
    therapy, family therapy, case management)
  • What practice theories, practice models,
    intervention strategies and techniques will best
    address clients problems and needs?

53
Step Three Selecting Practice Frameworks
(Sheafor, Horejsi, Horejsi, 1997)
  • What is the unit of intervention?
  • What type of change is expected?
  • Does the framework offer an explanation of how
    change occurs?
  • What is the role of the social worker?
  • What are the assumptions about the relationship
    between the social worker and the client?

54
Selecting Practice Frameworks (Sheafor, Horejsi,
Horejsi, 1997)
  • What power balance exists in the client-worker
    relationship?
  • What is the primary method of communication?
  • Appropriateness/inappropriateness?
  • Does the framework specify when its use is
    appropriate and effective, as well as when its
    use would be inappropriate?

55
Selecting Practice Frameworks (Sheafor, Horejsi,
Horejsi, 1997)
  • Does the framework identify clients for which use
    of the approach might be harmful?
  • Does the framework acknowledge the importance and
    impact of cultural and ethnic differences?
  • What is the setting/context required for
    effective application?

56
Selecting Practice Frameworks (Sheafor, Horejsi,
Horejsi, 1997)
  • Is the framework applicable for involuntary,
    court-ordered clients?
  • Does the framework explain how it is different
    from other frameworks?
  • What techniques are required?
  • Are certain clients excluded?
  • Is client allowed to stay with family and social
    networks?

57
Analysis of Practice Theory
  • Brief History, Major Contributors
  • Premises, Assumptions, Concepts
  • Role of the Therapist
  • Assessment
  • Treatment Planning
  • Cultural Sensitivity
  • Developmental Issues
  • Intervention - Strategies and Techniques
  • Strengths / Effectiveness
  • Limitations

58
Selecting Interventions
  • Practice Theories
  • Psychodynamic
  • Behavioral/Social Learning
  • Cognitive/Constructivism
  • Humanistic/Existential
  • Family Systems

59
Choosing Practice Models
  • Practice Models
  • Short-term Psychodynamic Therapy
  • Behavioral Therapy
  • Cognitive-behavioral Therapy
  • Solution-focused Therapy
  • Client-centered Therapy
  • Crisis Intervention

60
Generalist Treatment Planning Step Four
Contracting (Kirst-Ashman Hull, 2001 Hepworth
et al., 2006)
  • Specify goals to be accomplished.
  • Specify the means to accomplish the goals.
  • Clarify the roles of the participants.
  • Establish the conditions under which assistance
    is provided.

61
Formulating a Contract (Hepworth et al., 2006)
  • Goals to be accomplished (ranked)
  • Roles of the participants (client tasks, social
    worker tasks)
  • Interventions to be employed
  • Time frame, frequency length of sessions
  • Means of monitoring progress
  • Stipulations for renegotiation
  • Scheduling sessions, financial issues

62
Criteria for Evaluation of Treatment Goals
  • Evaluation Criteria must be
  • Descriptive
  • Objective
  • Measurable
  • Valid
  • Reliable

63
Group Practice
  • Formation of Groups
  • Group Dynamics and Process
  • Ethical and Legal Issues
  • Preparing for and Beginning
  • a Group
  • Group Development
  • Initial/preaffiliation stage
  • Power and control stage
  • Intimacy stage
  • Differentiation stage

64
Advantages of Groups (Corey Corey, 1997)
  • Groups provide mutual aid through peer support
    confrontation.
  • Groups can relieve symptoms, teach
    problem-solving strategies develop
    interpersonal skills.
  • Groups are a natural laboratory to work on
    problems of living.
  • Groups can be brief and cost-effective
    treatments.
  • Ask What are the advantages of group treatment?

65
Curative Conditions in Group (Yalom, 1995)
  • Instillation of hope
  • Universality
  • Imparting information
  • Altruism/mutual aid
  • Family recapitulation
  • Social skills/modeling
  • Existential factors
  • Interpersonal learning
  • Cohesiveness
  • Catharsis

66
Practical Considerations in Forming a Group
  • Open versus closed
  • Size of group
  • Frequency of meetings
  • Length of meetings
  • Location of meetings
  • Preparation of meeting room (e.g., seating
    arrangements, room temperature, rest rooms,
    refreshments)

67
Selection of Members Inclusion
  • Homogeneity versus heterogeneity
  • Motivation - is client motivated both to
    participate in the group and make changes?
  • Purpose - does the client understand the purpose
    of the group?
  • Needs - does the group meet the clients needs?
  • Goals - does the client have treatment goals that
    can be addressed by participation in the group?

68
Group Screening Exclusion
  • Hostile clients
  • Clients who monopolize
  • Extremely aggressive clients
  • Clients who act out behaviorally
  • Severely disordered clients
  • Suicidal, actively psychotic, sociopathic, highly
    paranoid, extremely self-centered, brain damaged,
    actively using substances

69
Pregroup/Initial Group Meeting (Corey Corey,
1997)
  • Explore members expectations.
  • Clarify goals/objectives of the group.
  • Discuss procedures (ground rules)
  • Guidelines confidentiality (rights, limitations)
    respect, participation
  • Policies attendance, smoking, eating, bringing
    friends, obtaining parental permission,
    socializing with members outside of group
  • Impart information about group process.
  • Establish commonality among members.

70
Group Process vs. Task
  • Process
  • A change to a particular result
  • Examine analyze progress
  • Dynamic interchange
  • Changes adaptation to an environment
  • Ways to think act to satisfy need, remove
    obstacles, achieve goals
  • Task
  • An assigned piece of work to be completed by a
    specified date
  • A focus of getting from A to B
  • Taking action
  • Systematic approach to goal accomplishment
  • Beginning, middle, end
  • Linear

71
Recognizing Group Process
  • Nonverbal behavior
  • Noticing what is said and what is not said
  • Identifying underlying tensions
  • Struggle for dominance
  • Support vs. Competition
  • Sharing vs. Autonomy
  • Attending to ones own feelings

72
Group Leaders Role
  • Create and maintain the group
  • Facilitate group to work towards the attainment
    of group individual goals
  • Build a therapeutic environment that encourages,
    supports facilitates change
  • Model positive adaptive behaviors
  • Gradually transfer responsibility for the group
    to the members

73
Initial/Preaffiliation Stage Themes of Trust
Security (Anderson, 1997 Corey Corey, 1997
Hepworth et al 2006 Yalom, 1995)
  • Developmental task Establish initial trust, a
    sense of belonging, a sense of meaning for the
    group.
  • Characteristics
  • Ambivalence about joining a group - How will the
    group benefit me?
  • Anxiety
  • Guarded interaction - hesitancy, resistance,
    silence, withdrawal

74
Preaffiliation Stage Typical Behaviors of
Individual Members (Anderson, 1997 Corey
Corey, 1997 Hepworth et al 2006 Yalom, 1995)
  • Approach-Avoidance behavior - a vacillating
    willingness to
  • assume responsibility
  • interact with others
  • support program activities events
  • Periods of silence awkwardness
  • Preoccupation with own problems/feelings
  • Apprehension to the response of others
  • Evaluating who to trust, what to disclose
  • Provocative actions

75
Preaffiliation Stage Typical Behaviors of the
Group (Anderson, 1997 Corey Corey, 1997
Hepworth et al 2006 Yalom, 1995)
  • Sizing each other up
  • Searching for similarities and common ground
  • Identifying each other by status roles
  • Searching for viable roles for themselves
  • Taking the focus off of themselves
  • Giving each other advice
  • Testing group limits
  • Testing competency of group leader
  • Directing communication in the group towards the
    leader

76
Tasks of the Initial Stage (Anderson, 1997 Corey
Corey, 1997 Hepworth et al., 2006 Yalom, 1995)
  • Groups Tasks
  • Overcome anxiety begin to participate
  • Establish commonality among members
  • Establish trust
  • Establish their own goals
  • Decrease member dependency on leader
  • Leaders Tasks
  • Explore fears invite participation
  • Point out similarities between members
  • Create safety
  • Clarify group purpose
  • Guide group in establishing ground rules and norms

77
Group Leaders Role Preaffiliation
Stage (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Goal Develop a climate of trust.
  • Pregroup Preparation
  • Define clarify purpose of the group.
  • Select/screen potential group members.
  • Prepare members for group experience.
  • Gather baseline data.
  • Define individual goals, and refine group goals.

78
Group Leaders Role Preaffiliation
Stage (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Early Group Meetings
  • State the group purpose.
  • Identify group goals.
  • Develop group guidelines and rules begin to set
    norms.
  • Intervene to address initial concerns.
  • Draw out feelings concerns of all members.
  • Model facilitative dimensions of therapeutic
    behavior.

79
Power Control Stage Themes of Control
Dominance (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Developmental Task Group shifts from
    preoccupation with acceptance, approval,
    involvement, and definitions of accepted behavior
    to a preoccupation with dominance, control, and
    power.
  • Characteristics
  • High anxiety and fears
  • Defensiveness and resistance
  • Conflict and struggle for control

80
Power Control Stage Typical Behaviors of
Individual Members (Anderson, 1997 Corey
Corey, 1997 Hepworth et al., 2006 Yalom, 1995)
  • Social pecking order - members rank
    relationships to others subgroups form.
  • Competition - members have increased conflicts
    power struggles.
  • Struggle for leadership - increased discussions
    re responsibility decisions.
  • Challenges to the group leader
  • Complaining - negative comments member
    criticism are more frequent.

81
Power Control Stage Typical Behaviors of the
Group (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Members find security in mutually formed
    positions, statuses, roles, and group norms.
  • The group establishes a frame of reference,
    patterns of communication, alliances,
    roles/social order.
  • The group moves from a non-intimate to an
    intimate system of relationships (time of
    transition).

82
Group Leaders Role Power Control
Stage (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Facilitate therapeutic group culture that enables
    functional, supportive, nonrigid structure and
    helps group members to.
  • recognize and express anxieties/fears
  • recognize defensive reactions and create climate
    to address resistances openly
  • recognize and openly deal with conflicts
  • encourage supportive confrontive feedback
  • Minimize changes in the group
  • Increase effective communication
  • Create therapeutic norms

83
Tasks of the Transition Stage (Anderson, 1997
Corey Corey, 1997 Hepworth et al., 2006
Yalom, 1995)
  • Leader Tasks
  • Teach coping skills.
  • Create an open climate
  • Model conflict resolution skills
  • Encourage responsibility.
  • Teach problem-solving decision-making.
  • Group Tasks
  • Deal with anxiety.
  • Express resistance openly.
  • Acknowledge and work through conflict.
  • Develop autonomy.
  • Develop problem-solving strategies.

84
Intimacy Stage Themes of Sharing, Closeness,
Commitment (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Developmental Task Choosing to commit to the
    group, achieving cohesiveness, using cohesiveness
    to develop authentic closeness and mutual aid.
  • Characteristics
  • Intensified personal involvement/commitment
  • Mutual trust - increased self-exploration
  • Cohesiveness group unity - sense of we-ness
  • Movement toward synergy---strengths of members
    group-as-a-whole combine to address member needs.

85
Intimacy Stage Typical Behaviors of Individual
Members (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Wishes for closeness (for honesty, authenticity,
    understanding) begin to motivate member
    behavior in group.
  • Risk taking spontaneous self-disclosure take
    place in the here and now.
  • Members learn to care about each other.
    Relationships move from control to contact from
    the power of positions, statuses, roles to the
    power of care concern.

86
Intimacy Stage Typical Behaviors of the
Group (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Norms are clear and are respected.
  • Leadership is provided by the group members
    rather than the group leader.
  • Status is allocated to members who are honest and
    open in self-disclosure and feedback.
  • Group members work productively toward personal
    and group goals.
  • Group unity is protected negative
    feelings/conflict may be suppressed.

87
Group Leaders Role Intimacy Stage (Anderson,
1997 Corey Corey, 1997 Hepworth et al., 2006
Yalom, 1995)
  • Enable self-disclosure and feedback that
    contributes to closeness between members mutual
    aid.
  • Model self-disclosure and feedback.
  • Encourage communication between members.
  • Clarify group purpose renegotiate the contract.
  • Detect obstacles to work.
  • Relate outside concerns to the here and now of
    group process.

88
Tasks of the Intimacy Stage (Anderson, 1997
Corey Corey, 1997 Hepworth et al., 2006
Yalom, 1995)
  • Group Tasks
  • Develop cohesiveness.
  • Focus on deeper issues (disclosure, honesty,
    spontaneity, acceptance, responsibility)
  • Relate disclosures to here and now.
  • Confront/support.
  • Develop insight.
  • Commit to change
  • Leader Tasks
  • Promote cohesiveness.
  • Model appropriate behavior (empathy, confronting
    with caring and honesty).
  • Encourage risk taking and feedback).
  • Challenge obstacles.
  • Interpret positively.
  • Clarify purpose/goals

89
Differentiation Stage Themes of Mutual Aid
Interdependence (Anderson, 1997 Corey Corey,
1997 Hepworth et al., 2006 Yalom, 1995)
  • Developmental Task to access group resources
    and move from the mutual trust of closeness to
    the mutual aid of interdependence.
  • Characteristics
  • Tight group cohesion, with group culture (e.g.,
    customs, rituals, name)
  • Dynamic balance of individual/group needs
  • Open discussion of conflict

90
Differentiation Stage Typical Behaviors of
Individual Members (Anderson, 1997 Corey
Corey, 1997 Hepworth et al., 2006 Yalom, 1995)
  • Accepting valuing member differences.
  • Experiencing own needs and trying to meet those
    needs through the resources provided in the
    group.
  • Freely participating and feeling genuinely
    accepted by other members.
  • Valuing the group due to security in their roles
    and relationships in the group.
  • Spontaneously assuming leadership roles.

91
Differentiation Stage Typical Behaviors of the
Group (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Group creates its own organizational structure.
  • Customs traditional ways of operating emerge.
  • Group energy is directed toward carrying out
    purposes tasks which are clearly understood
    accepted.
  • Roles are functional and flexible.
  • Conflicts are brought into the open obstacles
    are discussed.
  • Group considers all opinions strives to reach
    decisions by consensus.

92
Group Leaders Role Differentiation
Stage (Anderson, 1997 Corey Corey, 1997
Hepworth et al., 2006 Yalom, 1995)
  • Enable the group to use its mutual aid resources.
  • Stay out of the groups way and serve as a
    consultant to the group when it recognizes needs
    and seeks assistance.
  • Offer experiential activities, exercises,
    techniques to enhance the groups therapeutic
    work.

93
Tasks of Differentiation (Anderson, 1997 Corey
Corey, 1997 Hepworth et al., 2006 Yalom, 1995)
  • Group Tasks
  • Recognize each members uniqueness.
  • Use differences as resources.
  • Intensive focus on achieving group and individual
    goals.
  • Help each other achieve goals through mutual aid.
  • Leader Tasks
  • Model acceptance of each members uniqueness
  • Stimulate/advance differences.
  • Confirm goals and promote efforts to work on
    them.
  • Help members achieve mutual aid.
  • Be a consultant.

94
Monitoring and Evaluating Practice
  • Barriers to Treatment
  • Addressing Client Resistance
  • Managing Transference, Countertransference, and
  • Vicarious Traumatization
  • Termination and Evaluation
  • Evaluating Progress/Measuring Outcomes
  • Strategies for Termination
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