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Section 15
Couple Assessment Summary: A Bridge from Assessment to Treatment

Question 15 | Test | Table of Contents

The CAS: Becoming Privy to the Process
The Couple Assessment Summary (CAS) is presented in the fourth session and a written conceptualization is shared with both partners. Included is a detailed narrative or outline that summarizes the therapist's ideas about the relationship conflict and its etiology. The CAS includes: a brief review of the presenting complaints, a summation of individual history and family history, a review of relationship history and its evolution, an abbreviated formulation/conceptualization of the relationship problems, and recommendations for treatment. The document is given to each partner for review and discussion. Both partners are encouraged to share their thoughts about the CAS, clarify any misinformation, and respond to the given interpretations.
The rationale for utilizing the CAS is:

  1. It assists the therapist in stepping back from the chaos and maintaining a "big picture," meta/analytical role.
  2. It provides a structured tool for the therapist to conceptualize underlying dynamics.
  3. It offers the couple a sense that they are in capable, safe hands while some order is being made out of chaos.
  4. It provides a sharpening of focus for the therapy in defining major themes that can then be addressed throughout the process.
  5. It gives the couple and therapist some respite from the chaotic interchanges in the here-and-now as the document is examined, reflected upon, and discussed.

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
It has been found that this written presentation is best made in a conversational, nontechnical manner so as to reach the couple affectively as well as intellectually. As a therapist attempts to use the unique language of the patient to connect, so too is the CAS written in a tone and language that will reach the partners.

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.
Part 2: A summation of family, individual, and relationship history.
Part 3: A review and restatement of the relationship problems as the therapist(s) understands it. This statement offers the therapist(s) and partners an opportunity to revisit their perspectives on the problems and offers an additional opportunity to move toward a "consensus opinion" as to the nature of the conflicts.
Part 4: The conceptualization, the core of the CAS, offers a therapist-generated overview of the presenting problems and his or her understanding of their nature and maintenance.
Part 5: The treatment plan, the final section, draws treatment effort conclusions for the couple and therapist. Treatment tasks are made problem specific and potential outcomes are considered.

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.

Case Study
Emma and Don, married for twenty-five years and the parents of one child, presented for couple treatment upon the referral of both Emma's analyst and Don's individual therapist. Despite a productive business partnership over many years of marriage, the successful raising of a competent, seemingly content only child, the couple acknowledged a high degree of emotional distance.

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."

History
You are two individuals who were somewhat "developmentally delayed." There is some shyness, some self-esteem problems, and interpersonal inexperience that continued through adolescence. Both of you became intensively competitive athletes and were quite successful at your sport. You had a short courtship and limited experience in communicating feelings or engaging openly on an intimate level with one another. Both of you came from emotionally remote families of origin and each of you was an only child and lonely.

Problems in the Relationship
You are each extremely cautious with the other (seemingly the issue is not caution with me); measure your words; are tentative in your interaction and report having your most intense interaction when loosened up by a few drinks. You have differing perceptions and memories of significant early events.

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.

Formulation
You were each late bloomers, yet each of you developed athletic skills that helped you define yourselves among peers and with each other. Each of you was from a family in which there was disappointment, constrictedness, and relatively little support for venturing out socially. Each of you had little experience in expressing emotions or negotiating emotionally, i.e., years of unexpressed feelings about the waning physical relationship. The relationship has thus carried the burden of unfinished business in each of your family of origin - Emma, isolated in your earlier years, experienced your first gratifying interpersonal successes in your sport - despite its being relatively noninteractive. Emma, you chose Don for your shared interests, his solidity, and seeming social/interactional abilities, yet you ultimately found him to be a more dependent yet controlling mate. He did provide an appropriate "escape" from your constricted family.

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.

Recommendations
Ongoing couples therapy focusing on:

  1. Increasing communication regarding a new "marital contract."
  2. Increasing communication regarding earlier contract.
  3. Increasing comfort with affection.
  4. Looking at sexual attitudes, needs, and feelings and improving the sexual relationship.

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.

Emma and Don's summary describes their relationship and highlights their already developing understanding of themselves. Don had been previously in twice-weekly individual treatment at the time he began couple treatment. Emma had moved from individual treatment to four-times weekly analysis. The partners carefully studied the document presented to them. Don commented on the fact that he had been provided something concrete and comprehensible. Emma suggested that she and Don take some time to study the document. It appeared that these two business partners were further engaged by the therapist's efforts to "open the file" for purposes of establishing a treatment contract. While the couple would likely have warmed to a problem-solving checklist, this was not provided. Yet, the therapist attempted to remain focused on the previously established goals. It is thus partner and therapist's responsiblity to maintain a mutually agreed-upon flexible path.

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.

- Beck, R. L. (Winter 2000) The Couple Assessment Summary: A Bridge from Assessment to Treatment. American Journal of Psychotherapy, 54(1).
Reviewed 2023

Update
Couple therapy in the 2020s: Current status and emerging developments

Lebow, J., & Snyder, D. K. (2022). Couple therapy in the 2020s: Current status and emerging developments. Family process, 61(4), 1359–1385. https://doi.org/10.1111/famp.12824

Peer-Reviewed Journal Article References:
Brock, R. L., Ramsdell, E. L., Franz, M. R., Stasik-O'Brien, S. M., Gervais, S. J., & Calkins, F. C. (2023). Free to be me with you: Development of the Individuality in Couples Questionnaire. Psychological Assessment, 35(7), 602–617. https://doi.org/10.1037/pas0001238

Cook, J. M., Simiola, V., McCarthy, E., Ellis, A., & Stirman, S. W. (Sep 2018). Use of reflective journaling to understand decision making regarding two evidence-based psychotherapies for PTSD: Practice implications. Practice Innovations, 3(3), 153-167.

Feuerman, M. L. (2018). Therapeutic presence in emotionally focused couples therapy. Journal of Experiential Psychotherapy, 21(3), 22-32.

Mohd Hasim, M. J., Hashim, N. H., & Mustafa, H. (2023). Married life: Measuring adult romantic attachment and satisfaction. Couple and Family Psychology: Research and Practice, 12(3), 119–131. https://doi.org/10.1037/cfp0000188

O'Malley, R., Glenny, R., Poppleton, S., & Timulak, L. (2023). A qualitative meta-analysis exploring client-reported outcomes of couple therapy. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000513

Riekkola, J., Rutberg, S., Lilja, M., & Isaksson, G. (2019). Strategies of older couples to sustain togetherness. Journal of Aging Studies, 48, 60–66.

QUESTION 15
What is one of the therapist rationales for utilizing the Couples Assessment Summary? To select and enter your answer go to Test.

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