Assessing, hypothesizing and diagnosing, domain 2

Before meeting a family, a Milan team reviews the referral and proposes that the daughter's refusal to eat may keep her older brother from leaving home. The team plans questions to test this idea and expects to revise it after the session. This activity is BEST described as:

1. Circularity
   Circularity is the interviewing method of asking about relationships and differences; the questions the team plans serve the hypothesis but are a separate principle.
2. Hypothesizing
   Forming a provisional systemic explanation before the session, testing it with questions and revising it afterward is the Milan practice of hypothesizing.
3. Neutrality
   Neutrality is the therapist's balanced stance toward all members, not the act of forming a working explanation.
4. Positive connotation
   Positive connotation is a message that gives every member's behavior a benevolent purpose; here the team is still building and testing an explanation, not delivering a message.

During a family argument about the son's grades, the father calmly lists statistics about college admissions, speaks in a detached, lecturing tone, and denies feeling upset. According to Satir, which communication stance is the father using?

1. Placating
   A placater gives up their own needs to please and appease others; the father lectures rather than appeases.
2. Blaming
   A blamer attacks and finds fault to protect the self; the father stays calm and impersonal rather than accusing anyone.
3. Super-reasonable
   Relying on facts and logic while denying any feeling of his own or attention to others' feelings is Satir's super-reasonable stance.
4. Distracting (irrelevant)
   The distracting (irrelevant) stance changes the subject; the father stays on the topic of grades, just without emotion.

A teacher found a note in which a 16-year-old wrote that everyone would be better off without her. At intake, with both parents present, she says, "I'm fine, it was nothing," and looks at the floor. What should the therapist do FIRST?

1. Interview her alone about suicidal thoughts
   A note saying others would be better off without her is a suicide warning sign, and teens often deny in front of parents, so the first step is to ask her directly about suicidal thoughts in private.
2. Give her a depression screen with parents present
   A depression screen completed with parents watching faces the same barrier as the intake: she is unlikely to answer honestly in front of them.
3. Ask the parents to describe her recent mood
   The parents' account of her mood is collateral information; asking them first, with her in the room, sidesteps the direct private question about suicide that the warning sign demands.
4. Accept her denial and schedule a follow-up
   Accepting a flat denial after a written warning sign leaves possible suicide risk unassessed until a later visit.

Six weeks after a 15-year-old's school refusal improved in family therapy, her 11-year-old brother began having stomachaches and refusing to go to school. The parents' marital tension has not changed. Which systemic hypothesis BEST fits?

1. The brother has an unrelated anxiety disorder
   Calling it an unrelated anxiety disorder treats the timing as coincidence and ignores the unchanged family pattern.
2. The brother is imitating his sister's past behavior
   Imitation explains why the symptoms look alike, but not why they appeared just as the sister improved while the parents' tension stayed the same.
3. The family's problem has shifted to the younger child
   The sister improves, the brother develops a similar symptom and the marital tension is unchanged: a systemic view reads this as the family's problem moving to another member.
4. The improvement in the daughter is not lasting
   The stem says the daughter's improvement has held; nothing points to a relapse in her.

A 26-year-old newlywed reports that for eight months attempts at intercourse have caused sharp pain, and she tenses and fears penetration. She has not raised the problem with a physician. Her husband is supportive. What should the therapist do FIRST?

1. Refer her for a gynecological evaluation
   Pain with penetration can have medical causes such as infection, dermatologic conditions or endometriosis, so a gynecological evaluation comes before any sex-therapy plan.
2. Explore her religious beliefs about sex
   Her beliefs about sex may matter later, but exploring them first skips the medical evaluation that pain symptoms require.
3. Begin sensate focus exercises with the couple
   Starting sensate focus before any medical exam treats penetration pain as purely relational and can miss a physical cause.
4. Diagnose vaginismus and begin dilator work
   Vaginismus is an outdated label; DSM-5-TR uses genito-pelvic pain/penetration disorder, and no diagnosis or dilator work should come before a medical exam.

A Black couple reports rising conflict at home. The husband, the only Black manager at his firm, describes being passed over and hearing repeated "jokes" about his hair, and he comes home tense and withdrawn. Which factor should the therapist MOST directly assess?

1. His family-of-origin conflict style
   Turning to his family-of-origin conflict style skips the current workplace stressor he is describing and locates the problem in his history.
2. A communication-skills deficit in the couple
   A skills frame puts the problem in the marriage and skips the workplace racism he describes.
3. His possible adjustment disorder
   Moving to an individual diagnosis pathologizes a reaction to discrimination before the stressor itself has been assessed.
4. Race-based stress from his experiences at work
   Repeated racial 'jokes' and being passed over are race-based stressors that spill over into the marriage; naming and assessing them is part of culturally responsive assessment.

A couple's questionnaires say they "communicate well," but the therapist has not yet watched them work through a conflict. A structural therapist who wants to assess their actual interaction would MOST likely

1. ask them to discuss a current disagreement in session
   A structural therapist sets up an enactment: the couple discusses a real disagreement in the room, so the therapist can observe their actual interaction.
2. ask each partner to rate their communication from 0 to 10
   A 0-10 rating is a solution-focused scaling question; it measures perception, not observed interaction.
3. have each partner describe a typical argument at home
   A description of a typical argument is still self-report, filtered through each partner's view, and does not show the interaction itself.
4. give them a communication-skills inventory to complete
   A skills inventory is another questionnaire, the kind of self-report that already said they communicate well.

In a separate screening interview, a wife says her husband has never hit her, but he took her paychecks, runs all the accounts, gives her a small weekly allowance, and forbids her to work overtime. She says she "can't afford to leave." How is this pattern BEST understood?

1. A cultural difference in the couple's money roles
   Calling it a cultural difference in money roles ignores that she has no access to money and feels unable to leave, which points to control, not a shared arrangement.
2. Economic abuse within coercive control
   Taking her paychecks, controlling all accounts and forbidding overtime is economic abuse, a common form of coercive control that traps partners without physical violence.
3. A money conflict for couple work
   Treating it as an ordinary money conflict for couple work misses the power imbalance and could put her at risk in conjoint sessions.
4. Situational couple violence
   Situational couple violence (Johnson) describes conflicts that occasionally escalate to physical aggression without a pattern of control; this is the reverse: control without physical violence.

During the assessment of an 8-year-old recently diagnosed with ADHD, the therapist notices that his father interrupts often, loses track of appointments, and says, "I was just like him as a kid." Chaotic routines at home make the boy's symptoms worse. What is the MOST useful assessment step?

1. Advise the father to get stricter at home
   Telling the father to be stricter is advice, not assessment, and ignores why he struggles to keep routines.
2. Focus only on the child's diagnosed ADHD
   Focusing only on the child's diagnosis treats him as the identified patient and misses a family factor that keeps the chaos going.
3. Ask the mother to take over all the routines
   Shifting every routine to the mother overloads one parent before the father's difficulties have been understood.
4. Explore whether the father has ADHD too
   ADHD is highly heritable, and a parent's own untreated ADHD can undermine the structure the child needs, so assessing the father can change the treatment plan.

While drawing a genogram with a family, the therapist connects two siblings with a zigzag line. This symbol indicates

1. an emotional cutoff
   An emotional cutoff is drawn as a broken line between the two people.
2. a conflictual relationship
   In standard genogram notation (McGoldrick, Gerson and Petry), a zigzag line between two people marks a conflictual relationship.
3. a divorce between them
   Divorce is marked by a double slash across a marriage line; siblings are never joined by a marriage line.
4. a fused, overly close relationship
   A fused, overly close relationship is drawn with three parallel lines, not a zigzag.

A 6-year-old speaks freely at home but has not spoken at school all year. Her parents answer for her whenever teachers or relatives speak to her. Which hypothesis is MOST consistent with systemic thinking?

1. She has an expressive language disorder
   Speaking freely at home argues against a language disorder; her speech fails only in certain settings.
2. Her silence is deliberate defiance of teachers
   Reading the silence as defiance misreads anxiety-driven avoidance as willful behavior.
3. Her parents' anxiety is the cause of her mutism
   Naming the parents' anxiety as 'the cause' is linear blame; the systemic view describes a loop that keeps the symptom going.
4. Adults' accommodation maintains her silence
   Answering for her relieves her anxiety in the moment but keeps her from speaking, a circular pattern in which the adults' accommodation maintains the silence.

Four months into a remarriage, the husband's 12-year-old son and the wife's 13-year-old daughter fight constantly over bathroom time, bedrooms and "whose house it is." From a structural perspective, the MOST important assessment area is

1. how boundaries and rules about space are negotiated
   Fights over bathrooms, bedrooms and 'whose house it is' are boundary questions the new stepfamily has not settled, which is the structural focus.
2. each child's feelings about the divorces
   Feelings about the divorces matter, but they do not explain fights over space and ownership as directly as the unsettled rules do.
3. each child's individual temperament
   Individual temperament turns a stepfamily boundary problem into a trait of each child.
4. the couple's emotional and sexual satisfaction
   The couple's emotional and sexual satisfaction matters for the parental subsystem, but it is not where these territory disputes come from.

A genogram shows alcohol problems in the maternal grandfather, two uncles and now the 19-year-old son. The mother says, "It's in our blood; nothing can be done." What is the therapist's MOST useful assessment focus?

1. Which relative first introduced alcohol to the son
   Searching for who first gave him alcohol invites blame instead of revealing the pattern.
2. The mother's own drinking history in isolation
   Looking at the mother's drinking in isolation narrows a multigenerational pattern to one person.
3. The family's shared beliefs and patterns around drinking
   The mother's fatalism and the family's rules and roles around drinking are what therapy can change, and they shape whether the son seeks help.
4. The son's genetic risk for alcohol use disorder
   Stressing genetic risk feeds the 'it's in our blood' belief and offers nothing the family can act on.

A couple reports that the wife rarely wants sex. The husband keeps initiating and she turns away, and both describe growing resentment. A medical evaluation found no physical cause. Which hypothesis is MOST useful?

1. The husband has an unusually high sex drive
   Calling the husband's drive unusually high takes sides and turns a difference between partners into his defect.
2. A pursue-avoid cycle is shaping their sex life
   Pursuit lowers desire and lower desire increases pursuit; a pursue-avoid cycle explains both partners' resentment and is something the couple can change.
3. The wife has female sexual interest/arousal disorder
   DSM-5-TR does not diagnose female sexual interest/arousal disorder when the problem is better explained by relationship distress, and a diagnosis puts the whole problem in her.
4. Her avoidance stems from unresolved childhood trauma
   Childhood trauma is a speculative cause with no support in the stem; it skips the pattern the couple describes.

A 30-year-old woman repeatedly undermines her own chances of promotion. She mentions that her mother gave up a promising career to raise her. A contextual therapist would MOST likely hypothesize

1. a detouring triad with her parents
   A detouring triad involves a child drawn into the parents' conflict; no parental conflict is described.
2. a destructive entitlement she holds
   Destructive entitlement is seeking repayment from innocent others for one's own past injuries; she is sabotaging herself, not claiming repayment.
3. an invisible loyalty to her mother
   Not surpassing a mother who gave up her career is an unconscious obligation to her: Boszormenyi-Nagy's invisible loyalty.
4. an emotional cutoff from her mother
   An emotional cutoff means managing fusion through distance; nothing suggests she has distanced herself from her mother.

A 10-year-old boy's teacher reports that for the last three months he daydreams in class, loses materials, and does not finish assignments. His mother says these problems began after she and his father separated, and that his earlier report cards praised his focus. What is the MOST appropriate next step?

1. Diagnose ADHD, predominantly inattentive presentation
   ADHD needs a persistent pattern with several inattentive symptoms present before age 12. His earlier report cards praised his focus, which contradicts that history, so a diagnosis now skips the assessment.
2. Assess how the recent family change is affecting him
   The problems began three months ago, right after the separation, and earlier report cards praised his focus. A recent change that follows a family transition points first to his reaction to that change, so the family context is assessed before any diagnosis.
3. Refer him for a stimulant medication evaluation
   A medication referral treats a presumed ADHD diagnosis before the family situation that most likely explains the change has been assessed.
4. Recommend a classroom behavior management plan
   A classroom plan may help later, but it manages the symptoms without first finding out how the separation is affecting him.