Richard is a 47-year-old male accountant who has been referred for therapy by his physician, Dr. Abrams. Dr. Abrams has been seeing Richard regularly over the years for a variety of physical complaints including joint pain, weakness in his fingers, dizziness, constipation, and headaches. Richard does have a medical diagnosis for ulcers and has also been diagnosed with anemia in the past, but Dr. Abrams has found no evidence of any illness or condition that would account for the other symptoms. Richard does not drink or use substances, and he is not currently taking any medications.

Richard also worries that he may have a disease like hepatitis-C or possibly fibromyalgia, and every time he feels sick he seeks information via an internet search engine. Dr. Abrams has repeatedly reassured him that he does not have these diseases, but Richard is certain something is amiss and demands more tests be performed. Richard is anxious and distressed, and sometimes explodes in anger when his friends are skeptical or simply do not believe what he says about his symptoms. He was fired from two firms because of absences related to illness and medical appointments. His wife Carlotta agrees with Dr. Abrams suggestion that he seek therapy, as he talks more about his symptoms than anything else, and she feels exhausted. Richard has not been able to find steady work. He spends most of his days on the internet researching medical conditions or in chat rooms with others who have similar somatic complaints and symptoms.

Waving and pointing to a folder full of medical documents and test results, Richard tells Carlotta, "This is not all in my head!", says he feels alone and misunderstood, and silently cries. Upon Carlotta's gentle urging, Richard finally agrees to go for couples therapy with her.

• What was most and least helpful about using the decision tree?
• What additional information would be relevant to understanding Richard from systemic and cultural perspectives?