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The CAS: Becoming Privy to the Process
The CAS offers an open reflection on the process itself. Many therapists treat the therapy conceptualization as "mystical," or a closely held commodity. In traditional forms of psychotherapy, such as group, individual, and family therapies, seldom is the patient directly privy to the therapeutic schema. As the findings may be retained by the therapist with only selective information being shared with the patient, there may be little opportunity too for the assembled to reflect on the evaluation process.
Some theories of therapist-client interaction do address greater sharing and openness of the therapist's conceptualization with the clients(s). Yalom ( 8), in his discussion of the "wrap-up" or in inpatient group therapy and his written summaries in outpatient group therapy, seeks to "demystify" the therapy (p.215). Revisiting Yalom's ideas, Beck and Bosman-Clark ( 9) utilized weekly written therapy summaries of the group behavior and dynamic in group psychotherapy. In "reflecting team" approaches, observers share their perceptions with the client(s) in the therapy, so that different perceptions of reality are heard and can be selected ( 10-12). Hoffman ( 13) echoes the belief that "reflecting teams" activate clients in therapy and turn them into full participants.
Especially in utilizing the written conceptualization, the process of therapeutic evaluation and dynamic understanding becomes the shared task as the couple and therapist evolve into a treatment team. The couple's response to the evaluation is to further assess realities, projections, and commitment in the relationship. Bischoff et al. ( 14) in their paper describing "therapist-conducted consultations" came closest to the CAS in describing a collaborative process of assessment and treatment. They assert that their model supports a "forum in which the therapist and client" communicate actively about the treatment process and its goal(s) (p.378).
The CAS: Its Structure
While a sampling of CASs would reveal a variety of presentation styles, all approach understanding the relationship system with a psychodynamic orientation. The CAS ultimately reads like a formulation with a developmental foundation and perspective and typically adheres to the following structure:
Part 1: A restatement of each partner's complaint(s) about the relationship conflict.
The CAS resembles the format of an abbrevieated biopsychosocial evaluation. In fact, the CAS is just that - a consumer-oriented summation of the couple's evaluation that supports a beginning or continuing dialogue between couples. The case below will illustrate an evolving assessment with a couple seen in a "successful outcome" treatment of approximately one year. "Success" is measured here in terms of the partners' decision to make specific personal changes within the context of a continuing, reduced conflict relationship.
The evaluation process culminated in a mutually agreed-upon perspective regarding the tasks to be faced by the partners. As has been noted previously, the CAS document will be shared with the couple at the end of the assessment process and will hopefully serve as a continuing guide for the treatment to follow. One couple and their CAS has been selected to illustrate the development of the summary and its application.
Emma, forty-seven, was the only child of a skilled blue-collar worker father and schoolteacher mother whose marital relationship was cool and distant. Her father died when Emma was thirteen and she was raised by her mother and grandmother in a constricted, emotionless household. Interestingly, she took up archery, a sport which placed her mostly in the company of men. It was a solo activity, and required quiet and an intense focus on the task at hand. She excelled, was admired from afar by the men with whom she competed, but had very few relationships prior to her marriage. In adolescence and young adulthood, her world was filled with activity and travels related to her sporting competition. The self-stated primary theme in her life was "abandonment" - her father's death, her mother's assigning another family member to the task of rearing her, and her husband's later retreat. Given little family support that she do so, she did not complete college. She went to work as a secretary, while maintaining her intense interest in her sport.
Don, age fifty-two, also an only child, was born to an executive father who died when Don was an adolescent. His mother was a homemaker and while present, was not significantly involved with her son's activities or interests. His was an affluent lifestyle, steeped in patrician tradition, and Don was sent to boarding school when in his early teens. This, he reported, was a mixed blessing for him, and, while lonely, it provided some relief as he "escaped" from his intrusive, critical mother. Don was a successful student, and completed an advanced professional degree from a prestigious university. Like his father, he excelled in his work, and with Emma's active involvement, became a millionaire in the process. He was contemplative, slow to respond in conversation, and seemingly remote. He repeatedly asserted that he was content with his life and his relationships, including his marriage. Don had few friends, yet many colleagues, and sought peaceful surroundings for his recreational interests. Necessarily socially adept for purposes of his career, he would shun purely social activities. Like his wife-to-be, Don gravitated to the sport that was primarily practiced by men, and one which required little or no personal interaction.
Don and Emma met while competing in their sport, bonded quickly, and ultimately married with compatible life, relationship, and business goals. Emma's later expressed expectations of emotional intimacy were not an obvious component of their initial "contract."
Don and Emma's only child, a son, graduated from college at the time they presented for couple's treatment. He was somewhat more interactive than his father, but not the emotion-seeking individual like his mother. His relationship with his parents was friendly but remote. Like his father he had been sent to boarding school. He chose a career as a skilled craftsman and businessman that provided a somewhat isolated existence. Each parent complained that he was seldom in touch and seemingly, secretive. The therapist, a devotee of Don and Emma's son's craft and sport, commented at one point as having seen an article about him in a national magazine. They were surprised, with Emma commenting, "We encouraged humility, but this is ridiculous."
Problems in the Relationship
Your sexual relationship has dramatically declined. Emma remembers that in the early years when they were becoming "cuddly and kissy," Don would retreat in frustration if he anticipated or learned that sex would not follow. Emma interpreted this as rejection of her attempts to be affectionate by reaching out to Don. You repeatedly cycled in and out of this pattern over the years, with diminishing sexual relations and decreased displays of affection.
Don, you were left floating as a child by your parents, and then learned to take care of yourself and later your business and Emma.. You were Emma's Henry Higgins, she your Eliza Doolittle. Emma, as you developed, and honed your social skills, you required more interaction and involvement from Don. He was more competent at leading than relating and the conflictual and relationship conflict began to emerge.
Emma, you ultimately entered intensive psychotherapy to deal with family conflicts. You began to identify early themes in your family that had a pronounced effect on your marital interaction. Don perceived you as retreating and less available, and questioned whether you had been having an affair, which you denied. Increasing conflict regarding early losses and your disappointment in Don's emotional unavailability resulted in his entering individual psychotherapy. To date, you are both doing an admirable job of identifying and working with your individual issues. Questions about intimacy and closeness are now surfacing as each of you are becoming clearer about yourselves as individuals.
To some extent, your relationship tasks are uncomplicated and clear. Intimacy has not been a strong suit in either of your families of origin. Emotional remoteness, limited dialogue, constricted relating, anxiety about impending closeness, and fear of abandonment are characteristics you share.
You have, though, capably begun to address these problems in a direct, comprehensive manner. As you each have extensive treatment experience, it is likely your personal growth will ready each of you for relationship growth.
This CAS reviews the historical antecedents to the partners dance of intimacy and distance. While Emma and Don were in individual psychotherapy, neither fully understood nor effectively addressed their struggle with one another. In briefly reviewing their individual histories, their CAS identified and tied together the formulation of their emerging conflictual relationship and simultaneously praised them for their efforts in self-understanding. The CAS additionally served as a tool for intervention as it supported the couple's effort to further understand the nature of their emotionally distant relationship and urged them to consider alternatives to getting and giving in the marriage. Finally, Emma and Don's CAS cemented their resolve to work together on building their communication skills.
This CAS reflects the imprint of therapist style, and the manner of the couple's interaction as it is blended or affected by the their behavior or individual characteristics. While the structure for the CAS is consistent document to document, the summary is thus "custom fitted" as to the partners' content and style to reflect their manner of presentation.
Reflection Exercise #1