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 DataAssessing 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 FunctioningSubstance
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 DataAssessing 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
DataCase 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 inCase 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 inCase 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 FrameworksHowe, 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 MomentClient Lily Kim

• Immediate Suicidal risk
• Primary Depression
• Secondary Family Conflict

49
PlanningGoals 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 StageThemes 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 RolePreaffiliation
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 RolePreaffiliation
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 StageThemes 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 RolePower 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 StageThemes 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 StageThemes 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