Assessment and Developing Case Conceptualisation

BeeLeaf Contemporary Psychotherapy in Practice

© Copyright Pamela Gawler-Wright and BeeLeaf 1997-2021

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Chapter 3

Assessment and Developing

Case Conceptualisation

Introducing the SCORE Model

Exploring “Cause” as Current Contexts and Triggers

Exploring “Cause” as Historic, Meaning-Making,

Learning and Belief-Formation

Dancing Trances and Conversational

Transformations

More on Context and Case Conceptualisation in

beComing

Identifying possible new ways to Operate in

becOming

From BECOMING to BECOME



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A Potted History of Psychotherapy A Quest Lead by Questions

Gawler-Wright 2018

Psychic Theory

of Mental Condition

Mesmer, Braid, Pinel, Charcot, Breuer, Janet

Physical Theory of Mental Condition

Hippocrates, Burton, Brighte, James

“The First Force”

Psychoanalysis

Freud, Adler, Jung

Klein, Fromm, Rank, Bion

Ferenczi, Alexander, Sullivan

“The Second Force”

Behaviourist Psychology

Pavlov, Watson, Skinner, Eysenck

“The Third Force”

Humanistic Psychology Kempler, Maslow, May,

Rogers, Perls, Moustakas, Berne, Yalom

“The Fourth Force”

Family and Systemic Transpersonal

Bowlby, Gottman

Whitaker, Bradshaw

Bowen, Satir, Assagioli

WHY? WHAT HAPPENED? WHAT? HOW?

WHO? WHAT FOR? WHO ELSE? HOW COME?

“The Fifth Force” Theoretical Integration, Eclectic Practice

Constructive Functional Psyche, Contemporary Psychotherapy Transtheoretical, Pluralistic

M. H. Erickson, Bateson, Rossi, Zeig, Lazarus, Mahoney, Gilligan, Goolishian, Hoffman, Johnson, White, Damasio, Yapko, Zeig, Gilligan, Fenner, Kabat-Zinn, Conner, Piranian

Minuchin, Linehan, Hayes, Hubble, Duncan, Miller, Cooper, McLeod

Of all of these - WHICH? WHICH WORKS BEST FOR WHICH PERSON AT WHICH TIME?

WHAT CAN BE EVIDENCED BASED?



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Understanding Psychotherapeutic Theories as Constructs Serving Different Times and Perspectives

What we believe will be shaped by what we experience. What we experience will be shaped by where we direct our attention. Where we direct our attention will be shaped by what questions we ask. What questions we ask will be shaped by what we can notice, name, recognise and are able to measure. What we notice, name, recognise and are able to measure can depend on what we value, believe and are most in need of

…..at a specific time



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Constructing Theory, Practice and Reality

As Psychotherapy Theory is To the Process of Psychotherapy,

Religion is to Spirituality

What Education is to Learning, Procedure, Protocol and Modality

Are to the Practice of Psychotherapy

As Ritual, Observance and Denomination are to Being a Seeker

Sensed Experience “Process”

Linguistic Construct “Theory”

Application New Information

Reflection Adjustment

Evolution “Practice”

Relationship



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The S.C.O.R.E Model As I observe you working together, I often notice you using S.C.O.R.E. in an unconsciously excellent way, especially when we have explored our own experiences of successful changes that we have made in the past, and also when aligning to the outcomes that motivate us towards growth and change. The SCORE model was originally created as an engineering tool! The S.C.O.R.E. is regarded as the minimum amount of information needed to assist any effective, sustainable and ecological change. The purpose of the S.C.O.R.E is to help draw a conceptual plan for remedy of measurable and practical problems – blueprint-and-prototype and map-and-territory metaphors align beautifully with this. Even though apparently serving a very mechanistic discipline, as with inventive engineering, the model in fact serves to utilise the very systemic nature of real-time challenges and potentials. The SCORE model can serve to sort, clarify and simplify information gleaned from asking specific questions of a problematic event or situation. It is both tool and task for the conceptual mind, so that we can appropriately apply decisions, actions and resources and then monitor our process and progress, without distorting or inhibiting the somatic process that revels in the complexity of fluid events and experience. We can use SCORE as a checklist of questions we have explored in our assessment of a situation, or as a way of anchoring information into a workable linear continuum. The effect of taking a client through a SCORE will not only give you information but will stimulate your client to redefine the challenge they have come to work on and to begin to develop new possibilities and motivations in an outcome oriented way. There are many ways to use SCORE in a procedure with a client and it can be adapted into conversational, creative and relationship building processes. We will be adapting the use of the SCORE as a tool for assessment and conceptualization of the psychotherapeutic case. Guided by inter-disciplinary psychological paradigms of Gregory Bateson, SCORE was transferred from the arena of the physical sciences into the context of psychology and personal growth and further developed by Robert Dilts and the late Todd Epstein (1987). From Dilts and Epstein’s tradition of Systemic NLP, the psychotherapeutic use of SCORE comes with a presupposition that we humans work as an ecological system, (as opposed to merely a mechanistically constructed string of associations as some Behavioural models might sometimes suggest). However, the SCORE is often effective because it does enable a purposefully constructed chain of associations, practical actions and meaning-full applications. If used creatively and in alignment with building a person’s flexible present-relational-presence, the mere perception of a problem can become a trigger for a chain of newly conditioned steps towards new outcome-oriented options and possibilities.

SYMPTOMS Indications and evidence that the problem exists, the sensory experience of it, its frequency, duration, intensity, context. Also, relevant or “driver” internal representations we have when



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experiencing the problem. Often the name given to the issue will change through exploring the issue more precisely or acquire a new “handle” like a metaphor or key sensation.

CAUSES This can refer to both derivative causes, that is, past experiences that created beliefs, decisions and patterns, but very importantly, to what we are doing now to continue to have the problem, such as trigger reactions, behaviours, beliefs, context-sensitive states or parts, internal representations and other even mildly contributing factors.

OUTCOME It is an important principle in outcome oriented psychotherapy that we focus energy on what we do want, moving energy away from what we don’t want. What separates this from superficial or avoidant types of “positive thinking” is that in psychotherapy we are facilitating the person to express what they want from an associated position to the experience of the problem, rather than their current mapping of what is “good” or “right”. From that deeper relationship with this more vulnerable or less-formed self, we are drawing on this more somatic guidance, wisdom and yearning that is being expressed as a “symptom”. Outcomes need to be well-formed, that is, under own control and responsibility (not about changing other people or rescuing them), realistic and with sufficient specificity to guide next steps, experiments and questions as we have explored in previous work.

RESOURCES A corner stone of clinically optimistic psychotherapy is the recognition and utilisation of resources, strengths and creativity towards the creation of new options, learning and possibilities. It can be helpful to remind our client of how they have overcome problems in the past, how these existing strategies can be adapted or incorporated, or assessed for what is preventing them in “solving” the issue, what resources they identify confidently and resources they wish to strengthen or develop.

ECOLOGY Here we are exploring the wider effects of making this change. How will life be different when we have solved this problem? Will it effect our relationships, identity, timetable? Are our strategies for change ecological with our values? Is this a one-off action or, more commonly, will change require a journey of exploration and habituation of new behaving, thinking, responding through repetition of new links and meaning-making.



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Information Gathering Processes as The S.C.O.R.E. Model

N.B. All processes are information-gathering processes, especially those that yield unexpected results

S Signals and Symptoms

C

Causes

O Outcomes

R

Resources

E Ecology and Effects

Meta Modelling Retrieve sensory details, examples, scope and context. Back-pacing Into a memory of experience, towards reassociation with the “problem” experience (as if here-and-now). Modalities and Patterns What is the sensory experience of the state/problem? What is the pattern (“syntax”)? Does this pattern occur in other contexts? Meta Modelling Trigger moments, connected events and contexts Discover beliefs, presuppositions, of cause and attribution (what “makes” this happen? Back-pacing Any earlier experiences that are connected to present experience. Earlier Decisions, Beliefs and constructions of Meaning Strategies How do you make the state/problem exist/occur for you? Chunking Up Values, motivations and effects Future-Pacing Sensory experience of what is wanted Well-Formedness – Under own Control, Realistic, Sensory Exploration, New Names for “Not This” Experiments, Options, Decisions, Goals and Planning Timeframes and Opportunities for Change

State management, ‘Affect Regulation’, PRP, Self-Compassion A Positive Counter Example Conversational Perceptual Positions Back and Future-Pacing Strategies Internal Reps and Behaviour of Past Successes Modelling Tracking another’s successful procedures, beliefs and values Reframing Anything you observe in the client can be reframed as a resource, especially “resistance” Future-Pacing Exploring effects Perceptual Positions Effects on others Cartesian co-ordinates Alternatives and Reframes of Outcome Physiological Congruence



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The Dancing Score Developed by Judith DeLozier 1993

Using spatial anchors for unconscious processing using somatic intelligence, chaining anchors

and own gestured anchors, and breaking old anchors to the problem

1. Create a spatial timeline on the floor, going from past to future. Create a meta position to the side of this line with the resources you want to have here, such as peace, insight, humour.

2. Place in the present a space that marks SYMPTOM. From the meta position reflect upon

the symptoms of the problem that you experience in the present. 3. Now step in and associate to the SYMPTOM. Exaggerate the physiology of this position,

create a physical gesture that expresses what your body feels and knows about this space.

4. Allow the feelings in your body to draw you back into the CAUSE of the problem. As you

do this allow your body to draw backwards into the past, creating a space of CAUSE on the timeline. Let your physical and emotional knowledge of this lead you into a physical gesture that expresses what is in this space.

5. Step out into meta position, allowing yourself to shake off the old state entirely. Now

look to the future area of the timeline and step into a space on this line that represents the outcome that you would like to experience. Step into that space and associate to it. Let your physical and emotional knowledge of this place lead you into expressing it with a physical gesture.

6. Let your awareness spread forward and outwards, drawing you physically into a space

further in the future, a physical move into a new space on the timeline that expresses EFFECTS. Explore the knowledge in your feelings and physiology regarding the ecology and effects of achieving this outcome. Let your body express this knowledge through a gesture.

7. Step into meta position and shake off the last state. Now walk through the line from past

to present, making each gesture CAUSE, SYMPTOM, OUTCOME, EFFECT, taking note of the way your body links up the move from SYMPTOM to OUTCOME. Repeat the sequence META, CAUSE, SYMPTOM, OUTCOME, EFFECT, several times, speeding up until you have one smooth movement (dance) from CAUSE to EFECT.

Continued……. development from SYMPTOM to OUTCOME. In the meta position associate to these resources and allow your physiology and emotions to lead you into a gesture that expresses these resources. 8. Now re-run the steps of CAUSE, SYMPTOM, OUTCOME, EFFECT, but develop each step to

incorporate the gesture of RESOURCES. 9. Re-run the steps of CAUSE/RESOURCES, SYMPTOM/RESOURCES, OUTCOME/RESOURCES,

EFFECT/RESOURCES, META. Re-run until a smooth dance develops.

10. If this is being done with a Guide, it is important that the Guide is willing to be lead in the dance and to match the gestures/steps of the Explorer.



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The Dancing SCORE continued

8. Go to meta and become aware of the resources that link the development from SYMPTOM to OUTCOME. In the meta position associate to these resources and allow your physiology and emotions to lead you into a gesture that expresses these resources.

9. Now re-run the steps of CAUSE, SYMPTOM, OUTCOME, EFFECT, but develop each step

to incorporate the gesture of RESOURCES.

10. Re-run the steps of CAUSE/RESOURCES, SYMPTOM/RESOURCES, OUTCOME/RESOURCES, EFFECT/RESOURCES, META. Re-run until a smooth dance develops.

If this is being done with a Guide, it is important that the Guide is willing to be lead in the dance and to match the gestures/steps of the Explorer.



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Exercise: The Dancing S.C.O.R.E.

In Pairs. Use the steps in the previous red box and the diagram below to guide each other through The Dancing Score

META

C S O E

PAST → PRESENT → FUTURE

META

C S O E

META

R

C/R S/R O/R E/R



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CP Pattern - SCOREing with your Client Or – Early Assessment as a Holding Structure for Integration

Developed by Pamela Gawler-Wright, 1996 From SCORE Model, Robert Dilts and Todd Epstein

Presupposition 1 - Skillful Information Gathering

is already a Therapeutic Intervention Presupposition 2 - You cannot not anchor,

so you may as well anchor intentionally 1. As you meet a person and begin to gather information, be aware that you are setting up

anchors and giving signals all the time. Be comfortable in being a precise communicator and turn your full attention to the communication you are having with this person.

2. Ask specific questions that elicit specific sensory information to align with the person’s SCORE.

3. As you do this, attend to your rapport with your client by breathing with them and

repeating their words. 4. Concentrate on repeating back words that are to do with the problem state and causes

while making a specific repeated gesture, to anchor the problem state and context. 5. When repeating back words to do with Resources, Outcomes and Values, accompany

them with a different gesture. Use these words on the client's outbreath. 6. When you have gathered the information sufficiently to perceive your client's SCORE,

distract for a moment by talking about something else. This is an ideal time to tell a story or to draw your client's attention to something new that you have noticed or an idea coming to your mind, such as a metaphor for appropriate change or resources or something psycho-educational.

7. Then ask your client: “So (Client's name), when you think about this that you have come

to work on (fire Problem anchor), how do you feel/are you thinking/what comes to mind now?”(fire the Outcome anchor in time with the client's outbreath).

8. The answer your client gives will be highly informative and you now have two distinctly

useful anchors to use whenever you are working with this person.



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EXERCISE: Anchoring the S.C.O.R.E. (Or Anchoring a Positive Encounter using Gestures and pacing client's

language and breath) 1. Decide who is to be Guide and Explorer. Guide is going to do information gathering from

Explorer using the S.C.O.R.E. model. 2. Guide paces Explorer, especially their breathing. Guide asks questions, using their rapport skills,

along the lines of:

SYMPTOMS What is the problem issue that we are working on? When did it start? How long does an experience of this problem last? When do you notice the problem? What is a specific recent experience of this? What are the signs that it is a problem? What specific sensory experiences let you know you are experiencing the problem? (key driver indicators) CAUSES – Current and Historic What triggers this experience of the problem? What happened just before a recent experience of this? What specific events or contexts cause the problem to happen in your life now? What behaviour, internal processes, internal representations and internal dialogue result in you experiencing the problem? What do you believe are the causes of the problem? Does this experience remind you of earlier situations or experiences like this? OUTCOME What do you want instead of this problem? What outcome do you seek? How would you know you had solved the problem? If you were one day to know this issue is behind you, how would you know that, what would be the signs for you? RESOURCES How have you solved problems in the past or in other contexts? What resources do you already have that you can use to address this problem? What resources have you already brought to this issue? When you are in the experience of this problem, what do you most yearn for, seek, need that would make a difference? Is this resource, or the lack of it of significance to you? Do you know anyone else who has these resources or has overcome a similar challenge? ECOLOGY What will be affected by your solving this problem? Who else will it affect when you have your outcome? What else will be possible? How will you manage the changes?



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Exercise: SCOREing with your Client (on the First Date!) From Assessment to Case Formulation/Conceptualisation In Pairs. 1. Explorer chooses an appropriate area to work on - something that they would like to change. 2. Using the SCORE model and the notes overleaf, information gather. 3. Work to Elicit and Identify:

A Calibration of the Problem State (First Test in “TOTE”) An Outcome, In the Positive (not “not”), Sensorily Specific, within the Client's control, Ecological Effects, The Process and Deeper Structure (Internal Sensory Specific Components) of the Problem

4. Back track with your partner to confirm whether the problem is in any of the following problem processes:

Unresourceful or Uncomfortable State Difficult Communication with Another Residual Emotion to Past Event Unwanted Behaviour Need for Motivation and Planning S - R (Negative Anchor) Conflict of Parts Unsuccessful Strategy – Conditioned pattern of thinking and acting Limiting Belief Need for More or Different Resources

5. Identify with your partner what might be the most obvious process of the problem to work with first. What new Operation needs to be developed?



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Cycles of Stablising and Unstablising – Activating Growth Patterns within the Verges

Merge Guiding Principles and Beliefs apply here

and work well – life follows expectations as

truths are “always so”

Challenges fall within scope of conscious

and unconscious competence – can be difficult but confidently addressed

Names of things are easily articulated Feelings about them are tolerably owned

Dirge Familiar feared, avoided or resented

context where Self, Others or World do not conform to

dearly held principles. Expectations are

“never” met

Challenges activate awareness or fear of incompetence, deficiency or pain

Difficulty in trying to explain to self or others – contradiction, inconsistency, opposition or paradox

Feelings, deficits or pain are denied, ‘contained’ or trivialised to keep them at a

level of just tolerable

Decisions and options avoided or disowned

Splurge Unfamiliar or new context or threshold that

overthrows principles or conditions that held things in the familiar patterns

Beliefs challenged even to an existential

level, living in an impossible truth

Challenges reveal deficit, missing

competence or the function of the specific

pain - choice to deny them is gone

Control gone. An enforced change of

environment/context, in environment/context or change of way of

being in environment/context

Decisions and choices can no longer be

avoided or have become out-sourced.

Options may have become narrowed

Urge Revelation and articulation, new-naming of

principles, contexts, outcomes

Seeking new environments, change in

environment or change of way of being in environment

Approaching challenges as experimental and learning opportunities – no “absolutes” or certainty but new options are possible

New questions, words, concepts, behaviours

SC

OU

RG

E

FOR

GE

EMERGE SUBMERGE

1. Identify the context/environment/issue being explored. Somatically run the sequence of

the experience, moving through the Continuous Becoming cycle. 2. Repeat the cycle, giving extra attention to the “Verges”. Let cognitive mind be curiously

lead by somatic experience to uncover new information and descriptions.

3. What are points of loss/finding, holding/letting go, being with/taking action, moving

towards/away from? 4. What new ideas, competencies, principles, information, feelings are being forged and

added to the merge (positive stable) with each cycle.

5. What new “how-to” or “when-to” can be identified as emerging, or yet to be discovered, that can help you navigate the verges of this challenging context?

Documents

Assessment and Developing Case Conceptualisation