AN INTRODUCTION TO
FAMILY THERAPY
Tags: Family Therapy - Practical Guide – Manual – Theory – Summary - Course – counselling – counsellor
Compiled by Dean Amory
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Title: An Introduction to Family Therapy Compiled by: Dean Amory
[email protected] Publisher: Edgard Adriaens, Belgium
[email protected] ISBN: 978-1-291-38975-3 PUBLIC DOMAIN PUBLICATION © Copyright 2013 Edgard Adriaens, Belgium, - All Rights Reserved.
This book has been compiled based on information that is freely accessible in the public domain on the internet. Whenever you cite such information or reproduce it in any form, please credit the source or check with author or editor. If you are aware of a copyright ownership that I have not identified or credited, please contact me at:
[email protected]
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Cover Illustration: Zirta - Ilustrador, Diseñador, Historietista
Beatriz Torres, 1981, Tampico, México. He dibujado historias toda mi vida. Estudié la carrera de Diseño Gráfico, pero mi verdadera pasión son los cómics. En 2001, mi amiga Shiaya y yo creamos HED: Hilando el Destino. En 2006 propuse Oseano como tira cómica al diario La Razón de Tampico, donde lo publiqué diariamente hasta 2011. Actualmente me desempeño como ilustradora freelance, y estoy trabajando en mi primera novela gráfica. Contacto:
[email protected]
Zirta - Illustrator, designer, cartoonist
I've drawn stories all my life. I studied Graphic Design, but my real passion is comics. In 2001, my friend Shiaya and I created HED: Spinning Destiny. In 2006 I proposed the comic strip Oseano to the newspaper “La Razón de Tampico”, and published daily until 2011. Currently I am working as a freelance illustrator and I am working on my first graphic novel.
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Preface All information in this manual was collected for personal use from freely accessible sites on the internet, a lot of it was found in the free encyclopaedia Wikipedia. The same applies to all pictures used, which I downloaded from public domain sites, with exception for the cover picture “la familia Dupont”, which was kindly made available to this purpose by its creator, Zirta (Beatriz Torres, Mexico). Since I feel many people will benefit and appreciate being allowed to get easy access to this kind of information ordered in short, easily accessible chapters, I decided to make this compilation work available for free to everybody as a download file. A printed copy of the manual can be purchased at http://www.lulu.com (http://www.lulu.com/shop/various-authors/practical-manual-of-family-therapy/paperback/product15478201.html) Should any of the authors of the borrowed texts feel that the present manual is not compatible with the way in which they planned to make their work available to the public, then I hereby invite them to contact me at
[email protected] and let me know which part of the manual should be adapted or replaced by information from other sources.
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Family Therapy – Contents Cover Illustration:...................................................................................................................................5 Zirta - Ilustrador, Diseñador, Historietista ........................................................................................5 Preface ......................................................................................................................................................7 Family Therapy – Contents....................................................................................................................8 Family Therapy – Background Information ......................................................................................23 History of Marital Therapy .................................................................................................................24 Phase I - 1930 to 1963 - Atheoretical...........................................................................................24 Phase II - 1931 to 1966 - Psychoanalytic Experimentation ..........................................................24 Phase III - 1963 to 1985 - Family Therapy Incorporates .............................................................24 Phase IV - 1986 to now - Refining and Integrating .....................................................................24 History and theoretical frameworks ....................................................................................................25 Techniques ..........................................................................................................................................27 Publications .........................................................................................................................................28 Licensing and degrees .........................................................................................................................28 Values and ethics in family therapy ....................................................................................................28 Founders and key influences ...............................................................................................................29 Principal Leaders in the Field: ............................................................................................................29 Salvador Minuchin ..........................................................................................................................30 Jay Haley.........................................................................................................................................30 Murray Bowen ................................................................................................................................31 Nathan Ackerman............................................................................................................................31 Virginia Satir ...................................................................................................................................32 Ivan Boszmormenyi-Nagy ..............................................................................................................32 John Elderkin Bell...........................................................................................................................33 Philip Guerin ...................................................................................................................................33 Don Jackson ....................................................................................................................................33 Carl Whitaker ..................................................................................................................................34 Betty Carter .....................................................................................................................................34 Michael White .................................................................................................................................35 Models and Schools ............................................................................................................................36 Some contemporary family therapies: ............................................................................................36 Structural Family Therapy (Minuchin, 1974, Colapinto, 1991) .....................................................36 Conjoint Family Therapy (Satir, 1967) ...........................................................................................36 Contextual Therapy (Boszormenyi-Nagy, 1991) ............................................................................36 Strategic Therapy (Madanes, 1981) ................................................................................................36 Brief Therapy ..................................................................................................................................37 Milan Systemic Therapy (Boscolo et al, 1987)...............................................................................37 Narrative Therapy (Freedman, Combs, 1996) ................................................................................37 Academic resources ............................................................................................................................37 Professional Organizations..................................................................................................................37 Useful Internet links ............................................................................................................................38 Wikipedia links ...............................................................................................................................38 8
External links ..................................................................................................................................38 Brief Strategic Family Therapy ...........................................................................................................39 Description ..........................................................................................................................................39 Program background ...........................................................................................................................39 Indicated..............................................................................................................................................39 Content focus ......................................................................................................................................39 Intervention by domain .......................................................................................................................40 Parents as a primary target population: ...........................................................................................40 Individual: .......................................................................................................................................40 Family : ...........................................................................................................................................40 Peer :................................................................................................................................................40 Key program approaches.....................................................................................................................40 Parent-child interaction: ..................................................................................................................40 Parent training: ................................................................................................................................40 Skill development: ..........................................................................................................................40 Techniques used ..............................................................................................................................40 Therapy ...............................................................................................................................................40 How it works ...................................................................................................................................40 There are four important BSFT steps:.............................................................................................41 Barriers and problems .....................................................................................................................41 Brief Strategic Family Therapy for Adolescent Drug Abuse............................................................42 Foreword .............................................................................................................................................42 Chapter 1 - Brief Strategic Family Therapy: An Overview ................................................................43 BSFT is based on three basic principles. ........................................................................................43 Why Brief Strategic Family Therapy? ............................................................................................44 What Are the Goals of Brief Strategic Family Therapy?................................................................44 What Are the Most Common Problems Facing the Family of a Drug-Abusing Adolescent? ........44 The Family Profile of a Drug-Abusing Adolescent ........................................................................45 The Behavioral Profile of a Drug-Abusing Adolescent ..................................................................45 Negativity in the Family..................................................................................................................45 What Is Not the Focus of Brief Strategic Family Therapy?............................................................46 This Manual ....................................................................................................................................46 Chapter 2 - Basic Concepts of Brief Strategic Family Therapy..........................................................47 Context ............................................................................................................................................47 Family as Context ...........................................................................................................................47 Peers as Context ..............................................................................................................................47 Neighborhood as Context................................................................................................................47 Culture as Context...........................................................................................................................48 Counseling as Context.....................................................................................................................48 Systems ...........................................................................................................................................48 A Whole Organism .........................................................................................................................48 Family Systemic Influences ............................................................................................................48 The Principle of Complementarity..................................................................................................49 Structure: Patterns of Family Interaction ........................................................................................49 9
Strategy: The Three Ps of Effective Strategy..................................................................................50 Content Versus Process: A Critical Distinction ..............................................................................51 Chapter 3 - Diagnosing Family System Problems ..............................................................................52 Leadership .......................................................................................................................................52 Subsystem Organization..................................................................................................................52 Subsystem Membership ..................................................................................................................52 Triangulation ...................................................................................................................................53 Communication Flow......................................................................................................................53 Resonance .......................................................................................................................................53 Enmeshment and Disengagement ...................................................................................................53 Resonance and Culture....................................................................................................................54 Enmeshment (high resonance) and Disengagement (low resonance).............................................54 Developmental Stages .....................................................................................................................54 Assessing Appropriate Developmental Functioning.......................................................................55 Common Problems in Assessing Appropriateness of Developmental Stage..................................55 Life Context ....................................................................................................................................56 Antisocial Peers...............................................................................................................................56 Parent Support Systems and Social Resources ...............................................................................56 Juvenile Justice System...................................................................................................................56 Identified Patient .............................................................................................................................56 Conflict Resolution .........................................................................................................................57 A Caveat..........................................................................................................................................58 Chapter 4 - Orchestrating Change.......................................................................................................59 Establishing a Therapeutic Relationship .........................................................................................59 Joining .............................................................................................................................................59 A Cautionary Note: Family Secrets ................................................................................................60 Tracking ..........................................................................................................................................61 Encouraging the Family to Interact.................................................................................................61 Tracking Content and Process.........................................................................................................61 Mimesis ...........................................................................................................................................61 Building a Treatment Plan ..............................................................................................................62 Enactment: Identifying Maladaptive Interactions ...........................................................................62 Family Crises as Enactments ..........................................................................................................62 A Cautionary Note: Adolescents Attending Therapy Sessions on Drugs.......................................63 From Diagnosis to Planning............................................................................................................63 Producing Change ...........................................................................................................................63 Seven Frequently Used Restructuring Techniques .........................................................................64 1. Working in the present ................................................................................................................64 2. Reframing: Systemic Cognitive Restructuring ...........................................................................64 Affect: Creating Opportunities for New Ways of Behaving...........................................................65 3. Reversals .....................................................................................................................................66 4. Working With Boundaries and Alliances ...................................................................................66 Behavioral Contracting as a Strategy for Setting Limits for Both Parent and Adolescent .............67 Boundaries Between the Family and the Outside World ................................................................67 5. Detriangulation............................................................................................................................68 Attempts by the Family to Triangulate the Counselor ....................................................................68 6. Opening Up Closed Systems.......................................................................................................69 7. Tasks ...........................................................................................................................................69 Central Role ....................................................................................................................................69 General Rule....................................................................................................................................69 Hope for the Best; Be Prepared for the Worst ................................................................................69 10
Chapter 5 - Engaging the Family Into Treatment ...............................................................................70 The Problem ....................................................................................................................................70 Dealing With Resistance to Engagement ........................................................................................71 The Task of Coming to Treatment ..................................................................................................72 Joining .............................................................................................................................................72 Establishing a Therapeutic Alliance................................................................................................73 Diagnosing the Interactions That Keep the Family From Coming Into Treatment ........................73 Restructuring the Resistance ...........................................................................................................74 Types of Resistant Families ............................................................................................................74 Powerful Identified Patient .............................................................................................................74 Contact Person Protecting Structure ...............................................................................................75 Disengaged Parent...........................................................................................................................76 Families With Secrets .....................................................................................................................76 Chapter 6 - Clinical Research Supporting Brief Stategic Family Therapy .........................................77 Outpatient Brief Strategic Family Therapy Versus Outpatient Group Counseling ........................77 Conduct Disorder. ...........................................................................................................................78 Association With Antisocial Peers..................................................................................................78 One Person Brief Strategic Family Therapy ...................................................................................79 Brief Strategic Family Therapy Engagement..................................................................................79 The six levels of engagement effort ................................................................................................80 Efficacy of methods of engagement...............................................................................................80 References .......................................................................................................................................81 Solution focused brief therapy .............................................................................................................86 Contents...............................................................................................................................................86 Basic Principles:..................................................................................................................................86 Questions.............................................................................................................................................87 The miracle question .......................................................................................................................87 Scaling Questions............................................................................................................................88 Exception Seeking Questions..........................................................................................................88 Coping questions.............................................................................................................................88 Problem-free talk.............................................................................................................................89 Resources ............................................................................................................................................89 History of Solution Focused Brief Therapy ........................................................................................89 Solution-Focused counselling .............................................................................................................90 Solution-Focused consulting ...............................................................................................................90 References ...........................................................................................................................................90 Brief (psycho-) therapy .........................................................................................................................91 Founding proponents of Brief Therapy...............................................................................................91 An Overview of Brief Therapy ...........................................................................................................93 The brief therapy solution-focused approach can be summed up in three stages, ..........................93 Strategic Family Therapy.....................................................................................................................94 Haley Model........................................................................................................................................95 Behavior Problems ..............................................................................................................................95 Family Interaction ...............................................................................................................................95 Therapy ...............................................................................................................................................95 Who Does it Help? ..............................................................................................................................97 11
Bowen’s Strategic Family Therapy .....................................................................................................98 Contents...............................................................................................................................................98 Introduction .........................................................................................................................................98 The family system ...............................................................................................................................98 There are eight interlocking concepts in Dr. Bowen's theory: ........................................................99 1) Differentiation of self:.............................................................................................................99 2) Triangles:.................................................................................................................................99 3) Nuclear family emotional system: ..........................................................................................99 4) Family projection process: ......................................................................................................99 5) Multigenerational transmission process:.................................................................................99 6) Emotional cut-off: ...................................................................................................................99 7) Sibling position: ......................................................................................................................99 8) Societal emotional process:.....................................................................................................99 1. Differentiation of Self ...............................................................................................100 2. Triangles....................................................................................................................103 3. The Nuclear Family Emotional Processes ................................................................105 4. The Family Projection Process..................................................................................108 5. The Multigenerational Transmission Process ...........................................................112 6. Sibling Position .........................................................................................................114 7. Emotional Cut-off .....................................................................................................116 8. Societal Emotional Processes....................................................................................118 Areas of assessment ..........................................................................................................................120 1) Spousal relationships.................................................................................................................120 2) De – Triangulation ....................................................................................................................121 3) Differentiation Of The Self and Emotional Cutoff. ..................................................................122 4) Understanding family emotional systems.................................................................................123 Normal Family Development............................................................................................................126 Family Disorders...............................................................................................................................126 Family Therapy with One Person .....................................................................................................126 Goals of Therapy...............................................................................................................................127 The practice of Bowen family therapy is governed by the following two goals: .........................127 Treatment entails ...........................................................................................................................127 More specifically, the therapist .....................................................................................................127 Techniques ....................................................................................................................................128 Other concepts:..............................................................................................................................128 More about Triangles ........................................................................................................................129 1. Cross-generational coalitions ....................................................................................................129 2. The authors reviewed three family triangles:............................................................................129 3. The Emotionally Disturbed Child as the Family Scapegoat. ....................................................130 4. Marks, S. (1989). Towards a systems theory of marital quality. ..............................................131 seven different manifestations of the dual triangle construct........................................................131 Criticisms on the triangle theory ...................................................................................................132 Salvador Minuchin’s Structural Family Therapy ...........................................................................133 Contents.............................................................................................................................................133 Family Rules .....................................................................................................................................133 12
The family – homeostasis & change .............................................................................................135 The presenting problem.................................................................................................................136 The Process of Therapeutic Change..................................................................................................137 Therapeutic Goals and Techniques ...................................................................................................138 See also..............................................................................................................................................138 References .........................................................................................................................................138 Definitions.........................................................................................................................................139 Structure, subsystems and boundaries...........................................................................................139 Examples demonstrating boundaries and subsystems...................................................................139 Reaction to change: .......................................................................................................................140 As with boundaries, hierarchies can be either be too rigid or too weak .......................................140 Salvador Minuchin’s Style ............................................................................................................140 Family member behaviour can be understood only in the family context. ...................................141 Counselors must differentiate between first-order and second-order changes. ............................141 Key concepts: ................................................................................................................................141 Three reasons that make clients move: .........................................................................................142 Conditions for behaviour change ..................................................................................................142 Four sources of family stress: .......................................................................................................142 Sets: ...............................................................................................................................................142 Goals: ............................................................................................................................................142 How therapy addresses boundaries ...............................................................................................143 Interventions:.................................................................................................................................144 Assessment of therapy...................................................................................................................144 Four steps identified by Minuchin and his colleagues. .................................................................144 Therapy techniques : The seven steps of family therapy ..............................................................144 Step 1: joining and accommodating ..............................................................................................144 Step 2: Enactment .........................................................................................................................145 Step 3: structural mapping ............................................................................................................145 Step 4: highlighting and modifying interactions ...........................................................................145 Step 5: boundary making ..............................................................................................................145 Step 6: unbalancing .......................................................................................................................145 Step 7: challenging unproductive assumptions .............................................................................146 Conclusion.....................................................................................................................................146 Virginia Satir’s Humanistic Family Therapy...................................................................................147 Key concepts: ....................................................................................................................................147 Turn roles into relationships, rules into guidelines. ..................................................................147 Interventions:.....................................................................................................................................147 Criteria for termination: ....................................................................................................................148 Behavioural & Conjoint Family Therapy.......................................................................................149 Matching intent and impact of communication. ...............................................................................149 The four components in a family situation that are subject to change are ........................................149 The three keys to Satir’s system are..................................................................................................149 Communication and Response Patterns ............................................................................................150 The counseling method of conjoint family therapy involves............................................................150 Games................................................................................................................................................150 The Counsellor’s Role.......................................................................................................................151 Key Concepts ....................................................................................................................................151 13
Milan Systemic Family Therapy or “Long Brief Therapy”..........................................................152 Key Concepts: ...................................................................................................................................152 Therapy: ............................................................................................................................................152 Interventions:.....................................................................................................................................152 Assessment....................................................................................................................................153 Family Development through a systemic lens ..............................................................................154 The process of change...................................................................................................................155 Roadblocks to family developmental change ...............................................................................157 Interventions that create a context for developmental change. .....................................................157 Conclusion.....................................................................................................................................158 Response-based Family Therapy .......................................................................................................159 Therapeutic Methods.........................................................................................................................159 References .........................................................................................................................................160 Related Reading ................................................................................................................................160 Contextual Family Therapy Approach .............................................................................................161 The core of Contextual Approach rests on two postulates................................................................161 Four-Dimensional Interventions .......................................................................................................162 Facts ..............................................................................................................................................162 Individual Psychology...................................................................................................................162 Transactions ..................................................................................................................................163 Critics ................................................................................................................................................163 Entitlement ........................................................................................................................................164 References and Bibliography ............................................................................................................165 Narrative Family Therapy .................................................................................................................166 Contents.............................................................................................................................................166 Overview ...........................................................................................................................................166 Narrative therapy topics ....................................................................................................................167 Concept .........................................................................................................................................167 Narrative approaches.....................................................................................................................167 Common elements.........................................................................................................................168 Method ..........................................................................................................................................168 Outsider Witnesses........................................................................................................................168 Definitions.........................................................................................................................................170 The identified patient ....................................................................................................................170 Homeostasis (Balance)..................................................................................................................170 The extended family field. ............................................................................................................170 Differentiation ...............................................................................................................................170 Triangular relationships ................................................................................................................170 Multisystemic Therapy..................................................................................................................170 Calibration:....................................................................................................................................170 Family Life Cycle: ........................................................................................................................171 Centrifugal/centripetal: .................................................................................................................171 Circular (mutual, reciprocal) causality:.........................................................................................171 Open/Closed systems: ...................................................................................................................171 14
Cybernetics:...................................................................................................................................171 Double bind...................................................................................................................................171 Equifinality / Equipotentiality:......................................................................................................171 First-order / Second-order change:................................................................................................171 Pseudo mutuality:..........................................................................................................................171 Punctuation:...................................................................................................................................172 Rules:.............................................................................................................................................172 Criticisms of Narrative Therapy........................................................................................................172 See also..............................................................................................................................................172 Theoretical foundations.................................................................................................................172 Related types of therapy................................................................................................................172 Other related concepts...................................................................................................................172 References .........................................................................................................................................172 We do not tell stories only: we are stories. .......................................................................................173 Basic Techniques in Family Therapy ................................................................................................174 OBSERVATION...............................................................................................................................174 IDENTIFICATION...........................................................................................................................174 I/ INFORMATION-GATHERING TECHNIQUES.........................................................................175 GETTING INFORMATION THROUGH USING OPEN-ENDED QUESTIONS. ....................175 THE GENOGRAM.......................................................................................................................175 THE FAMILY FLOORPLAN ......................................................................................................176 FAMILY PHOTOS.......................................................................................................................176 II/ JOINING ......................................................................................................................................177 1) TRACKING:.............................................................................................................................177 2) MIMESIS:.................................................................................................................................177 3) CONFIRMATION OF A FAMILY MEMBER: ......................................................................177 4) ACCOMMODATION:.............................................................................................................177 III/ DIAGNOSING...........................................................................................................................177 IV/ FAMILY SYSTEM STRATEGIES ..........................................................................................178 ASKING PROCESS QUESTIONS. .............................................................................................178 FAMILY SCULPTING ................................................................................................................178 FAMILY CHOREOGRAPHY......................................................................................................178 V/ INTERVENTION TECHNIQUES ..............................................................................................179 RELATIONSHIP EXPERIMENTS..............................................................................................179 COACHING..................................................................................................................................179 I-POSITIONS................................................................................................................................179 DISPLACEMENT STORIES. ......................................................................................................179 TAKING SIDE & MEDIATING..................................................................................................180 THE EMPTY CHAIR ...................................................................................................................180 FAMILY COUNCIL MEETINGS ...............................................................................................180 STRATEGIC ALLIANCES..........................................................................................................180 PRESCRIBING INDECISION .....................................................................................................180 PUTTING THE CLIENT IN CONTROL OF THE SYMPTOM .................................................180 SPECIAL DAYS, MINI-VACATIONS, SPECIAL OUTINGS ..................................................181 PROBLEM SOLVING .................................................................................................................181 15
FAMILY CONTRACTS...............................................................................................................181 REFRAMING ...............................................................................................................................181 PUNCTUATION ..........................................................................................................................182 UNBALANCING .........................................................................................................................183 RESTRUCTURING......................................................................................................................183 ENACTMENT ..............................................................................................................................183 BOUNDARY FORMATION .......................................................................................................183 WORKING WITH SPONTANEOUS INTERACTION ..............................................................183 INTENSITY..................................................................................................................................183 SHAPING COMPETENCE..........................................................................................................183 ADDING COGNITIVE CONSTRUCTIONS ..............................................................................183 VI/ COMMUNICATION SKILL BUILDING TECHNIQUES.......................................................184 REFLECTING ..............................................................................................................................184 REPEATING.................................................................................................................................184 FAIR FIGHTING..........................................................................................................................184 TAKING TURNS EXPRESSING FEELINGS ............................................................................184 NONJUDGMENTAL BRAINSTORMING .................................................................................184 EFFECTIVE COMMUNICATION..............................................................................................185 Problem - Centered Systems Family Therapy..................................................................................186 Stages and Steps of Therapy .............................................................................................................186 Assessment....................................................................................................................................186 Contracting....................................................................................................................................186 Treatment ......................................................................................................................................186 Closure ..........................................................................................................................................186 A Guideline for Family Assessment .................................................................................................186 1. Orientation.................................................................................................................................186 2. Data Gathering ..........................................................................................................................186 3. Problem List ..............................................................................................................................186 4. Problem Clarification ................................................................................................................186 Summary of Dimension Concepts ....................................................................................................187 Problem-solving ............................................................................................................................187 Seven stages to the process ...........................................................................................................187 Communication .............................................................................................................................187 Roles..............................................................................................................................................187 Other family functions: .................................................................................................................187 Affective Responsiveness .............................................................................................................187 Affective Involvement ..................................................................................................................187 Behavior Control ...........................................................................................................................187 Structure of a Family Therapy Session .............................................................................................188 Instructions........................................................................................................................................188 1. Research and Background.........................................................................................................188 2. Family Session ..........................................................................................................................188 Structure of Family Therapy .............................................................................................................189 A. Assumptions .................................................................................................................................190 B. Salvador Minuchin .......................................................................................................................190 C. Theoretical formulations - three essential constructs ...................................................................190 16
D. Normal family development.........................................................................................................191 E. The development of behaviour disorders .....................................................................................191 F. Goals of therapy............................................................................................................................191 G. Techniques — join, map, transform structure..............................................................................191 1. Joining and accommodating, then taking a position of leadership ...........................................191 2. Enactment for understanding and change .................................................................................191 3. Working with interaction and mapping the underlying structure .............................................191 4. Diagnosing ................................................................................................................................191 5. Highlighting and modifying interpersonal interactions is essential ..........................................191 6. Boundary making and boundary strengthening ........................................................................192 7. Unbalancing may be necessary .................................................................................................192 8. Challenging the family’s assumptions may be necessary .........................................................192 9. Therapists must create techniques to fit each unique family ....................................................192
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Systemic Family Therapy Manual.....................................................................................................197 1. Introduction ...................................................................................................................................197 1.1 Origins of the Manual .............................................................................................................197 1.2 Aims and applicability of the manual .....................................................................................197 1.3 Notes on use of manual ...........................................................................................................197 1.4 Ethical & Culturally Sensitive Practice..................................................................................198 1.5 Clinical Examples ............................................................................................................198 2. Guiding Principles.........................................................................................................................199 2.1 Systems Focus.........................................................................................................................199 2.2 Circularity ...............................................................................................................................199 2.3 Connections and Patterns ........................................................................................................199 2.4 Narratives and Language.........................................................................................................199 2.5 Constructivism ........................................................................................................................199 2.6 Social Constructionism ...........................................................................................................199 2.7 Cultural Context ......................................................................................................................199 2.8 Power.......................................................................................................................................200 2.9 Co-constructed therapy ...........................................................................................................200 2.10 Self-Reflexivity .....................................................................................................................200 2.11 Strengths and Solutions.........................................................................................................200 3. Outline of Therapeutic Change .....................................................................................................201 3.1 Models of Therapeutic Change ...............................................................................................201 3.2 Overview of Specific Goals ....................................................................................................202 4. Outline of Therapist Interventions ................................................................................................203 4.1 Linear Questioning..................................................................................................................203 4.2 Circular Questions...................................................................................................................203 4.3 Statements ...............................................................................................................................204 4.4 Reflecting Teams ....................................................................................................................204 4.5 Child Centred Interventions ....................................................................................................206 5. Therapeutic Setting .......................................................................................................................207 5.1 Convening Sessions ................................................................................................................207 5.2 Team........................................................................................................................................207 5.3 Video .......................................................................................................................................207 5.4 Pre-therapy preparation ...........................................................................................................207 5.5 Pre & Post Session Preparation...............................................................................................208 5.6 Correspondence.......................................................................................................................209 5.7 Case notes................................................................................................................................209 5.8 Session notes ...........................................................................................................................209 6. Initial sessions ...............................................................................................................................210 Goals during initial session ...........................................................................................................210 6.1. Outline Therapy Boundaries & Structure ..............................................................................210 6.2 Engage and Involve all family members.................................................................................211 6.3 Gather and Clarify Information...............................................................................................211 6.4 Establish Goals and Objectives of Therapy ............................................................................211 Initial Session Checklist for Therapists.........................................................................................212 7. Middle Sessions ............................................................................................................................213 Goals during middle sessions........................................................................................................213 18
7.1 Develop engagement ...............................................................................................................213 7.2 Gather Information & Focus Discussion.................................................................................213 7.3 Identify & Explore Beliefs ......................................................................................................213 7.4 Work towards change at the level of beliefs and behaviours..................................................215 7.5 Return to Objectives and Goals of Therapy ............................................................................220 Middle Sessions Checklist for Therapists .....................................................................................220 8. End Sessions.................................................................................................................................222 Goals during ending sessions ........................................................................................................222 8.1 Gather Information & Focus Discussion.................................................................................222 8.2 Continue to work towards change at the level of behaviours and beliefs ..............................222 8.3 Develop family understanding about behaviours and beliefs ...........................................223 8.4 Collaborative ending decision..........................................................................................223 8.5 Review the process of therapy ................................................................................................224 End Sessions Checklist for Therapists ..........................................................................................224 9. Indirect Work ................................................................................................................................225 9.1 Child Protection ......................................................................................................................225 9.2 Clarifying therapy with referrer present..................................................................................225 9.3 Identifying the network and clarifying relationships ..............................................................226 9.4 Assessing risk..........................................................................................................................226 10. Proscribed Practices ....................................................................................................................227 10.1 Advice ...............................................................................................................................227 10.2 Interpretation .........................................................................................................................227 10.3 Un-transparent/Closed Practice.............................................................................................227 10.4 Therapist monologues ...........................................................................................................227 10.5 Consistently siding with one person .....................................................................................227 10.6 Working in the transference ..................................................................................................227 10.7 Inattention to use of language ...............................................................................................227 10.8 Reflections.............................................................................................................................227 10.9 Polarised position ..................................................................................................................227 10.11 Sticking in one time frame ............................................................................................228 10.12 Agreeing / not challenging ideas...................................................................................228 10.13 Ignoring information that contradicts hypothesis ...............................................................228 10.14 Dismissing ideas..................................................................................................................228 10.15 Inappropriate affect .............................................................................................................228 10.16 Ignoring family affect .........................................................................................................228 10.17 Ignoring difference..............................................................................................................228 APPENDIXES......................................................................................................................................229 Appendix 1: Sample Appointment Letter ...........................................................................................229 Appendix II: Sample Video Consent Form.........................................................................................230 Appendix III: Sample Referrer letter ..................................................................................................231 Appendix IV: Post-assessment letter ................................................................................................232 Appendix V: Closing letter to referrer ..............................................................................................233 Appendix VI : Session Notes Record Form......................................................................................234 Appendix VII – Diagonistic Interview Outline.................................................................................236
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BASIC FAMILY THERAPY TECHNIQUES .................................................................................239
ACCOMMODATION ..............................................................................................................239 ADVICE & INFORMATION...................................................................................................239 AFFECTIVE CONFRONTATION ..........................................................................................239 ASKING PERMISSION...........................................................................................................240 BEGINNER’S MIND ...............................................................................................................240 BOUNDARY FORMATION ...................................................................................................240 ADDING COGNITIVE CONSTRUCTIONS ..........................................................................241 1.Advice & Information ............................................................................................................241 2. Pragmatic fictions..................................................................................................................241 3. Paradox..................................................................................................................................241 COMMUNICATION TECHNIQUES......................................................................................241 1. MATCHING THE CLIENT’S LANGUAGE ......................................................................241 2. MATCHING SENSORY MODALITIES.............................................................................241 3. CHANNELING THE CLIENT’S LANGUAGE..................................................................241 4. USE OF VERB FORMS.......................................................................................................241 5. GIVE CLOSE EXAMINATION TO THEIR LANGUAGE AND YOURS........................241 COMMUNICATION SKILL-BUILDING TECHNIQUES.....................................................242 1. REFLECTING ......................................................................................................................242 2. REPEATING.........................................................................................................................242 3. FAIR FIGHTING TECHNIQUES........................................................................................242 CONCLUSION .........................................................................................................................242 CONFIRMATION OF A FAMILY MEMBER: ......................................................................242 DEFRAMING ...........................................................................................................................242 DETRIANGULATION.............................................................................................................244 DIAGNOSING..........................................................................................................................244 DIFFERENTIATION OF SELF ...............................................................................................244 DISEQUILIBRIUM TECHNIQUES........................................................................................244 1. REFRAMING: ......................................................................................................................244 3. BOUNDARY MAKING.......................................................................................................246 4. PUNCTUATION: .................................................................................................................247 4. UNBALANCING: ................................................................................................................247 LESSONS IN EFFECTIVE COMMUNICATION ..................................................................248 EMOTIONAL CUT-OFF .........................................................................................................249 THE EMPTY CHAIR ...............................................................................................................250 ENACTMENT ..........................................................................................................................250 FAMILY CHOREOGRAPHY..................................................................................................250 FAMILY CONTRACT.............................................................................................................250 FAMILY COUNCIL MEETINGS ...........................................................................................250 FAMILY FLOOR PLAN..........................................................................................................251 FAMILY LIFE CYCLE ............................................................................................................251 FAMILY PHOTOS...................................................................................................................251 FAMILY SCULPTING ............................................................................................................251 FAMILY SYSTEM STRATEGIES..........................................................................................252 THE GENOGRAM...................................................................................................................252 GOAL SETTING ......................................................................................................................252 ICEBREAKER COMPLIMENT OR POSITIVE STATEMENT ............................................252 IDENTIFICATION...................................................................................................................253 INFORMATION-GATHERING TECHNIQUES ....................................................................253 1. The Genogram.......................................................................................................................253 20
2. Family Photos........................................................................................................................253 3. Family Floorplan...................................................................................................................253 INTENSITY..............................................................................................................................253 INTERVENTION TECHNIQUES ...........................................................................................253 INVOLUNTARY CLIENT SHEMA .......................................................................................253 JOINING ...................................................................................................................................255 1. Tracking: ...........................................................................................................................255 2. Mimesis:............................................................................................................................255 3. Confirmation of a family member: ...................................................................................255 4. Accommodation: ...............................................................................................................255 5. Maintenance ......................................................................................................................256 NORMALIZATION .................................................................................................................256 OBSERVATION.......................................................................................................................258 POSITIVE CONNOTATION ...................................................................................................258 PARADOXICAL INJUNCTIONS ...........................................................................................259 PRAGMATIC FICTIONS ........................................................................................................259 PRESCRIBING INDECISION .................................................................................................259 PROBLEM TRACKING ..........................................................................................................260 PROBLEM SOLVING TECHNIQUES ...................................................................................260 PROBLEM DISSOLUTION ....................................................................................................260 PUNCTUATION ......................................................................................................................260 PUTTING CLIENT IN CONTROL OF THE SYMPTOM......................................................260 QUESTIONS.............................................................................................................................261 1. THE MIRACLE QUESTION:.............................................................................................261 2. FAST-FORWARDING QUESTIONS .................................................................................261 3. THE EXCEPTION QUESTION:.........................................................................................261 4. STRATEGIC BASIC QUESTIONS:....................................................................................261 5. PROVOCATIVE QUESTIONS: ..........................................................................................261 6. SCALING QUESTIONS AND PERCENTAGE QUESTIONS ..........................................261 7. EXCEPTION SEEKING QUESTIONS ...............................................................................262 8. COPING QUESTIONS.........................................................................................................262 9. OPEN QUESTIONS .............................................................................................................263 10. PROCESS QUESTIONS. ..................................................................................................264 11. LINEAR QUESTIONS......................................................................................................264 12. CIRCULAR QUESTIONS .................................................................................................264 15. PROBLEM TRACKING QUESTIONS .............................................................................268 16. CONVERSATIONAL QUESTIONS ................................................................................270 17. FRAMING QUESTIONS ...................................................................................................272 18. DEFRAMING QUESTIONS..............................................................................................272 REFRAMING ...........................................................................................................................272 REFRAMING PROBLEM DEFINITIONS .............................................................................272 RESTRUCTURING..................................................................................................................273 SHAPING COMPETENCE......................................................................................................273 USE OF SILENCE....................................................................................................................273 SPECIAL DAYS, MINI-VACATIONS, SPECIAL OUTINGS ..............................................274 WORKING WITH SPONTANEOUS INTERACTION ..........................................................274 STRATEGIC ALLIANCES......................................................................................................274 TRACKING ..............................................................................................................................274 UNBALANCING .....................................................................................................................275 INTRODUCING UNCERTAINTY..........................................................................................275 UTILIZATION STRATEGY....................................................................................................275 21
Summary of Family Therapy Theories & Techniques ....................................................................282 Family Therapy Survey ......................................................................................................................282 I. The Foundations of Family Therapy - Outline by David Peers.....................................................282 A. The myth of the hero ................................................................................................................282 B. Psychotherapeutic sanctuary ....................................................................................................282 C. Family vs. Individual therapy...................................................................................................282 D. Psychology and social context .................................................................................................282 E. The power of family therapy ....................................................................................................283 F. Contemporary cultural influences.............................................................................................283 G. Thinking in lines vs. Thinking in circles..................................................................................283 II. The Evolution Of Family Therapy - Outline by Lori Rice...........................................................284 A. The undeclared war ..................................................................................................................284 B. Small group dynamics ..............................................................................................................284 C. Child guidance movement ........................................................................................................284 D. The influence of social work ....................................................................................................284 E. Research on family dynamics and the etiology of schizophrenia.............................................284 III. Early Models And Basic Techniques - Outline by Sarah Sifers: ................................................285 A. Family therapy has a history of being condescending .............................................................285 B. Sketches of leading figures.......................................................................................................285 C. Theoretical formulations - group..............................................................................................285 D. Theoretical formulations - communications ............................................................................285 E. Normal family development .....................................................................................................286 F. Development of behavior disorders ..........................................................................................286 G. Goals of therapy .......................................................................................................................286 H. Conditions for behavior change ...............................................................................................286 I. Techniques of group family therapy ..........................................................................................286 J. Techniques of communications family therapy.........................................................................286 K. Lessons from early models.......................................................................................................287 L. System’s anxiety .......................................................................................................................287 M. Stages of family therapy ..........................................................................................................287 N. Family assessment....................................................................................................................287 O. Working with managed care - it’s necessary, so cooperate .....................................................287 IV. The Fundamental Concepts Of Family Therapy - Outline by Anabella Pavon .........................288 A. Conceptual influences on the evolution of family therapy ......................................................288 B. Enduring concepts and methods...............................................................................................289 V. Bowen Family Systems Therapy - Outline by Jared Warren......................................................290 A. Sketches of leading figures ......................................................................................................290 B. Theoretical formulations ..........................................................................................................290 C. Normal family development.....................................................................................................290 D. Development of behaviour disorders .......................................................................................291 E. Goals of therapy........................................................................................................................291 F. Conditions for behavior change ................................................................................................291 G. Techniques ...............................................................................................................................291 H. Evaluating therapy theory and results ......................................................................................291 I. Summary - Seven prominent techniques ...................................................................................291
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VI. Experiential Family Therapy Outline by Sarah Sifers ................................................................292 A. Leading figures and background ..............................................................................................292 B. Theoretical formulations ..........................................................................................................292 C. Normal family development.....................................................................................................292 D. Development of behavior disorders .........................................................................................292 E. Goals of therapy........................................................................................................................293 F. Conditions for behavior change ................................................................................................293 G. techniques.................................................................................................................................293 H. Evaluation.................................................................................................................................293 VII. Psychoanalytic Family Therapy Outline by Anabella Pavon ....................................................294 A. Introduction ..............................................................................................................................294 B. Sketches of leading figures.......................................................................................................294 C. Theoretical formulations ..........................................................................................................294 D. Normal family development.....................................................................................................294 E. Development of behavior disorders..........................................................................................295 F. Goals of therapy........................................................................................................................295 G. Conditions for behavior change ...............................................................................................295 H. Techniques ...............................................................................................................................295 VIII. Structure Family Therapy — Outline by Patty Salehpur .........................................................296 A. Assumptions .............................................................................................................................296 B. Salvador Minuchin ...................................................................................................................296 C. Theoretical formulations - three essential constructs ...............................................................296 D. Normal family development.....................................................................................................296 E. The development of behavior disorders ...................................................................................296 F. Goals of therapy........................................................................................................................297 G. Techniques — join, map, transform structure..........................................................................297
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Family Therapy – Background Information From Wikipedia, the Free Encyclopedia Family therapy, also referred to as couple and family therapy and family systems therapy, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of interaction between family members. It emphasizes family relationships as an important factor in psychological health. What the different schools of family therapy have in common is a belief that, regardless of the origin of the problem, and regardless of whether the clients consider it an "individual" or "family" issue, involving families in solutions is often beneficial. This involvement of families is commonly accomplished by their direct participation in the therapy session. The skills of the family therapist thus include the ability to influence conversations in a way that catalyzes the strengths, wisdom, and support of the wider system. In the field's early years, many clinicians defined the family in a narrow, traditional manner usually including parents and children. As the field has evolved, the concept of the family is more commonly defined in terms of strongly supportive, long-term roles and relationships between people who may or may not be related by blood or marriage. Family therapy has been used effectively in the full range of human dilemmas; there is no category of relationship or psychological problem that has not been addressed with this approach. The conceptual frameworks developed by family therapists, especially those of family systems theorists, have been applied to a wide range of human behaviour, including organizational dynamics and the study of greatness.
Contents
1 History and theoretical frameworks 2 Techniques 3 Publications 4 Licensing and degrees o 4.1 Values and ethics in family therapy 5 Founders and key influences 6 Summary of Family Therapy Theories & Techniques 7 Academic resources 8 Professional Organizations 9 See also 10 References 11 External links
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History of Marital Therapy Guman &Fränkel point out that couples therapy (formerly marital therapy) has been largely neglected, even though family therapists do 1.5-2 times as much couple work as multigenerational family work. They also note this is not such a bad ratio, as 40% of people coming to therapy attribute their problems to relationship issues. (Gurman, A. S. & Fraenkel, P. (2002). The history of couple therapy: A millennial review. Family Process, 41, 199-260.) G&F define Four Phases in the History of Couples Therapy: Phase I - 1930 to 1963 - Atheoretical
1929 to 1932 - Three marital clinics opened; they were service and education oriented, and saw mostly individuals The closest thing to theory was what was borrowed from psychoanalytic - interlocking neurosis 1931 the first marital therapy paper was published Theory was marginalized due to a lack of brilliant theorists, and a lack of distinction from individual analysis
Phase II - 1931 to 1966 - Psychoanalytic Experimentation
Therapists are seen as telling truth from distortion, rather than creating a truth Mostly individual sessions, but some conjoint; still treated like seeing two individual clients in the same room though Some started to downplay the role of the therapist Family was outshining couples work, and the couple techniques weren't innovative or particularly effective
Phase III - 1963 to 1985 - Family Therapy Incorporates
Family therapy overpowers couples, even though a number of big name people really mostly saw couples o o
o
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Jackson Coined concepts like quid pro quo, homeostasis, and double bind for conjoint therapy Satir Coined naming roles members played, fostered self-esteem and actualization, and saw the therapist as a nurturing teacher Bowen Multigenerational theory approach, with differentiation, triangulation, and projection processes, with the therapist as an anxiety-lowering coach - societal projection process was the forerunner of our modern awareness of cultural differences. Haley Power and control (or love and connection) were key. Avoided insight, emotional catharsis, conscious power plays. Saw system as more, and more important, than the sum of the parts
Phase IV - 1986 to now - Refining and Integrating
1986 was the publication of G&K book New Theories were tried and refined, like Behavioural Marital Therapy, Emotionally Focused Marital Therapy, and Insight-Oriented Marital Therapy. All four have received good empirical support. Couples therapy was used to treat depression, anxiety, and alcoholism. Efforts were focused on preventing couples problems with programs like PREP Feminism, Multiculturalism, and Post-Modernism impacted the field Eclectic integration, brief therapy, and sex therapy ideas were incorporated into our work. http://www.psychpage.com/family/library/history_of_couples_therapy.html
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History and theoretical frameworks Formal interventions with families to help individuals and families experiencing various kinds of problems have been a part of many cultures, probably throughout history. These interventions have sometimes involved formal procedures or rituals, and often included the extended family as well as non-kin members of the community (see for example Ho'oponopono). Following the emergence of specialization in various societies, these interventions were often conducted by particular members of a community – for example, a chief, priest, physician, and so on - usually as an ancillary function. Family therapy as a distinct professional practice within Western cultures can be argued to have had its origins in the social work movements of the 19th century in England and the United States. As a branch of psychotherapy, its roots can be traced somewhat later to the early 20th century with the emergence of the child guidance movement and marriage counselling. The formal development of family therapy dates to the 1940s and early 1950s with the founding in 1942 of the American Association of Marriage Counsellors (the precursor of the AAMFT), and through the work of various independent clinicians and groups - in England (John Bowlby at the Tavistock Clinic), the US (John Bell, Nathan Ackerman, Christian Midelfort, Theodore Lidz, Lyman Wynne, Murray Bowen, Carl Whitaker, Virginia Satir), and Hungary (D.L.P. Liebermann) - who began seeing family members together for observation or therapy sessions. There was initially a strong influence from psychoanalysis (most of the early founders of the field had psychoanalytic backgrounds) and social psychiatry, and later from learning theory and behaviour therapy - and significantly, these clinicians began to articulate various theories about the nature and functioning of the family as an entity that was more than a mere aggregation of individuals. The movement received an important boost in the mid-1950s through the work of anthropologist Gregory Bateson and colleagues – Jay Haley, Donald D. Jackson, John Weakland, William Fry, and later, Virginia Satir, Paul Watzlawick and others – at Palo Alto in the US, who introduced ideas from cybernetics and general systems theory into social psychology and psychotherapy, focusing in particular on the role of communication (see Bateson Project). This approach eschewed the traditional focus on individual psychology and historical factors – that involve so-called linear causation and content – and emphasized instead feedback and homeostatic mechanisms and “rules” in here-and-now interactions – so-called circular causation and process – that were thought to maintain or exacerbate problems, whatever the original cause(s). (See also systems psychology and systemic therapy.) This group was also influenced significantly by the work of US psychiatrist, hypnotherapist, and brief therapist, Milton H. Erickson - especially his innovative use of strategies for change, such as paradoxical directives (see also Reverse psychology). The members of the Bateson Project (like the founders of a number of other schools of family therapy, including Carl Whitaker, Murray Bowen, and Ivan BöszörményiNagy) had a particular interest in the possible psychosocial causes and treatment of schizophrenia, especially in terms of the putative "meaning" and "function" of signs and symptoms within the family system. The research of psychiatrists and psychoanalysts Lyman Wynne and Theodore Lidz on communication deviance and roles (e.g., pseudo-mutuality, pseudo-hostility, schism and skew) in families of schizophrenics also became influential with systems-communications-oriented theorists and therapists.A related theme, applying to dysfunction and psychopathology more generally, was that of the "identified patient" or "presenting problem" as a manifestation of or surrogate for the family's, or even society's, problems. (See also double bind; family nexus.) By the mid-1960s a number of distinct schools of family therapy had emerged. From those groups that were most strongly influenced by cybernetics and systems theory, there came MRI Brief Therapy, and slightly later, strategic therapy, Salvador Minuchin's Structural Family Therapy and the Milan systems model. Partly in reaction to some aspects of these systemic models, came the experiential approaches of Virginia Satir and Carl Whitaker, which downplayed theoretical constructs, and emphasized subjective experience and unexpressed feelings (including the subconscious), authentic communication, spontaneity, creativity, total therapist engagement, and often included the extended family. Concurrently and somewhat independently, there emerged the various intergenerational therapies of Murray Bowen, Ivan Böszörményi-Nagy, James Framo, and Norman Paul, which present different theories about the intergenerational transmission of health and dysfunction, but which all deal usually with at least three generations of a family (in person or conceptually), either directly in therapy sessions, or via "homework", "journeys home", etc. Psychodynamic family therapy - which, more than any other school of family therapy, deals directly with individual psychology and the unconscious in the context of current relationships - continued to develop through a number of groups that were influenced by the ideas and methods of Nathan Ackerman, and also by the British School of Object Relations and John Bowlby’s work on attachment. Multiple-family group therapy, a precursor of psycho educational family intervention, emerged, in
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part, as a pragmatic alternative form of intervention - especially as an adjunct to the treatment of serious mental disorders with a significant biological basis, such as schizophrenia - and represented something of a conceptual challenge to some of the "systemic" (and thus potentially "family-blaming") paradigms of pathogenesis that were implicit in many of the dominant models of family therapy. The late-1960s and early-1970s saw the development of network therapy (which bears some resemblance to traditional practices such as Ho'oponopono) by Ross Speck and Carolyn Attneave, and the emergence of behavioural marital therapy (renamed behavioural couples therapy in the 1990s; see also relationship counselling) and behavioural family therapy as models in their own right. By the late-1970s the weight of clinical experience - especially in relation to the treatment of serious mental disorders - had led to some revision of a number of the original models and a moderation of some of the earlier stridency and theoretical purism. There were the beginnings of a general softening of the strict demarcations between schools, with moves toward rapprochement, integration, and eclecticism – although there was, nevertheless, some hardening of positions within some schools. These trends were reflected in and influenced by lively debates within the field and critiques from various sources, including feminism and post-modernism, that reflected in part the cultural and political tenor of the times, and which foreshadowed the emergence (in the 1980s and 1990s) of the various "post-systems" constructivist and social constructionist approaches. While there was still debate within the field about whether, or to what degree, the systemic-constructivist and medicalbiological paradigms were necessarily antithetical to each other (see also Anti-psychiatry; Bio psychosocial model), there was a growing willingness and tendency on the part of family therapists to work in multi-modal clinical partnerships with other members of the helping and medical professions. From the mid-1980s to the present the field has been marked by a diversity of approaches that partly reflect the original schools, but which also draw on other theories and methods from individual psychotherapy and elsewhere – these approaches and sources include: brief therapy, structural therapy, constructivist approaches (e.g., Milan systems, post-Milan/collaborative/conversational, reflective), solution-focused therapy, narrative therapy, a range of cognitive and behavioural approaches, psychodynamic and object relations approaches, attachment and Emotionally Focused Therapy, intergenerational approaches, network therapy, and multi systemic therapy (MST). Multicultural, intercultural, and integrative approaches are being developed. Many practitioners claim to be "eclectic," using techniques from several areas, depending upon their own inclinations and/or the needs of the client(s), and there is a growing movement toward a single “generic” family therapy that seeks to incorporate the best of the accumulated knowledge in the field and which can be adapted to many different contexts; however, there are still a significant number of therapists who adhere more or less strictly to a particular, or limited number of, approach(es). Ideas and methods from family therapy have been influential in psychotherapy generally: a survey of over 2,500 US therapists in 2006 revealed that of the ten most influential therapists of the previous quarter-century, three were prominent family therapists, and the marital and family systems model was the second most utilized model after cognitive behavioural therapy. As we move through the 21st century, the internet is fostering the growth of online programs that make courses and programs in family therapy more widely accessible. Using mass media techniques to increase public understanding of issues in family therapy has added a new frontier for amplification in the future.
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Techniques Family therapy uses a range of counselling and other techniques including:
communication theory media and communications psychology psychoeducation psychotherapy relationship education systemic coaching systems theory reality therapy
The number of sessions depends on the situation, but the average is 5-20 sessions. A family therapist usually meets several members of the family at the same time. This has the advantage of making differences between the ways family members perceive mutual relations as well as interaction patterns in the session apparent both for the therapist and the family. These patterns frequently mirror habitual interaction patterns at home, even though the therapist is now incorporated into the family system. Therapy interventions usually focus on relationship patterns rather than on analyzing impulses of the unconscious mind or early childhood trauma of individuals as a Freudian therapist would do - although some schools of family therapy, for example psychodynamic and intergenerational, do consider such individual and historical factors (thus embracing both linear and circular causation) and they may use instruments such as the genogram to help to elucidate the patterns of relationship across generations. The distinctive feature of family therapy is its perspective and analytical framework rather than the number of people present at a therapy session. Specifically, family therapists are relational therapists: They are generally more interested in what goes on between individuals rather than within one or more individuals, although some family therapists—in particular those who identify as psychodynamic, object relations, intergenerational, EFT, or experiential family therapists—tend to be as interested in individuals as in the systems those individuals and their relationships constitute. Depending on the conflicts at issue and the progress of therapy to date, a therapist may focus on analyzing specific previous instances of conflict, as by reviewing a past incident and suggesting alternative ways family members might have responded to one another during it, or instead proceed directly to addressing the sources of conflict at a more abstract level, as by pointing out patterns of interaction that the family might have not noticed. Family therapists tend to be more interested in the maintenance and/or solving of problems rather than in trying to identify a single cause. Some families may perceive cause-effect analyses as attempts to allocate blame to one or more individuals, with the effect that for many families a focus on causation is of little or no clinical utility.
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Publications Family therapy journals include: Journal of Marital and Family Therapy, Family Process, Journal of Family Therapy, Journal of Systemic Therapies, The Australian & New Zealand Journal of Family Therapy, The Psychotherapy Networker, The Journal of Sex and Marital Therapy, The Australian Journal of Family Therapy, The International Journal of Narrative Therapy and Community Work, Journal for the Study of Human Interaction and Family Therapy,
Licensing and degrees Family therapy practitioners come from a range of professional backgrounds, and some are specifically qualified or licensed/registered in family therapy (licensing is not required in some jurisdictions and requirements vary from place to place). In the United Kingdom, family therapists are usually psychologists, nurses, psychotherapists, social workers, or counsellors who have done further training in family therapy, either a diploma or an M.Sc.. However, in the United States there is a specific degree and license as a Marriage and Family therapist. Prior to 1999 in California, counsellors who specialized in this area were called Marriage, Family and Child Counsellors. Today, they are known as Marriage and Family Therapists (MFT), and work variously in private practice, in clinical settings such as hospitals, institutions, or counselling organizations. A master's degree is required to work as an MFT in some American states. Most commonly, MFTs will first earn a M.S. or M.A. degree in marriage and family therapy, psychology, family studies, or social work. After graduation, prospective MFTs work as interns under the supervision of a licensed professional and are referred to as an MFTi. Marriage and family therapists in the United States and Canada often seek degrees from accredited Masters or Doctoral programs recognized by the Commission on Accreditation for Marriage and Family Therapy Education(COAMFTE), a division of the American Association of Marriage and Family Therapy. Requirements vary, but in most states about 3000 hours of supervised work as an intern are needed to sit for a licensing exam. MFTs must be licensed by the state to practice. Only after completing their education and internship and passing the state licensing exam can a person call themselves a Marital and Family Therapist and work unsupervised. License restrictions can vary considerably from state to state. Contact information about licensing boards in the United States are provided by the Association of Marital and Family Regulatory Boards. There have been concerns raised within the profession about the fact that specialist training in couples therapy – as distinct from family therapy in general - is not required to gain a license as an MFT or membership of the main professional body, the AAMFT.
Values and ethics in family therapy Since issues of interpersonal conflict, power, control, values, and ethics are often more pronounced in relationship therapy than in individual therapy, there has been debate within the profession about the different values that are implicit in the various theoretical models of therapy and the role of the therapist’s own values in the therapeutic process, and how prospective clients should best go about finding a therapist whose values and objectives are most consistent with their own. Specific issues that have emerged have included an increasing questioning of the longstanding notion of therapeutic neutrality, a concern with questions of justice and selfdetermination, connectedness and independence, "functioning" versus "authenticity", and questions about the degree of the therapist’s "pro-marriage/family" versus "pro-individual" commitment.
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Founders and key influences Some key developers of family therapy are:
Alfred Adler (phenomenology) Nathan Ackerman (psychoanalytic) Tom Andersen (Reflecting practices and dialogues about dialogues) Harlene Anderson (Postmodern Collaborative Therapy and Collaborative Language Systems) Harry J Aponte (Person-of-the-Therapist) Gregory Bateson (1904–1980) (cybernetics, systems theory) Ivan Böszörményi-Nagy (Contextual therapy, intergenerational, relational ethics) Murray Bowen (Systems theory, intergenerational) Steve de Shazer (solution focused therapy) James Dobson (Christian psychologist) Focus on the Family Milton H. Erickson (hypnotherapy, strategic therapy, brief therapy) Richard Fisch (brief therapy, strategic therapy) James Framo (object relations theory, intergenerational) Edwin Friedman (Family process in religious congregations) Harry Goolishian (Postmodern Collaborative Therapy and Collaborative Language Systems) John Gottman (marriage) Robert-Jay Green (LGBT, cross-cultural issues) Jay Haley (strategic therapy, communications) Lynn Hoffman (strategic, post-systems, collaborative) Don D. Jackson (systems theory) Sue Johnson (Emotionally focused therapy, attachment theory) Bradford Keeney (cybernetics, resource focused therapy) Walter Kempler (Gestalt psychology) Bernard Luskin (media psychology, Public understanding of issues through media) Cloe Madanes (strategic therapy) Salvador Minuchin (structural) Braulio Montalvo (structural)[citation needed] Virginia Satir (communications, experiential, conjoint and co-therapy) Mara Selvini Palazzoli (Milan systems) Ross Speck (network therapy) Robin Skynner (Group Analysis) Paul Watzlawick (Brief therapy, systems theory) John Weakland (Brief therapy, strategic therapy, systems theory) Carl Whitaker (Family systems, experiential, co-therapy) Michael White (narrative therapy) Lyman Wynne (Schizophrenia, pseudomutuality)
Principal Leaders in the Field:
Salvador Minuchin Jay Haley Murray Bowen Nathan Ackerman Virginia Satir Ivan Boszmormenyi-Nagy
John Elderkin Bell Philip Guerin Don Jackson Carl Whitaker Betty Carter Michael White
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Salvador Minuchin Born and raised in Argentina, Salvador Minuchin began his career as a family therapist in the early 1960's when he discovered two patterns common to troubled families: some are "enmeshed," chaotic and tightly interconnected, while others are "disengaged," isolated and seemingly unrelated. When Minuchin first burst onto the scene, his immediate impact was due to his dazzling clinical artistry. This compelling man with the elegant Latin accent would provoke, seduce, bully, or bewilder families into changing -- as the situation required -- setting a standard against which other therapists still judge their best work. But even Minuchin's legendary dramatic flair didn't have the same galvanizing impact as his structural theory of families. In his classic text, Families and Family Therapy (Minuchin, 1974) Minuchin taught family therapists to see what they were looking at. Through the lens of structural family theory, previously puzzling interactions suddenly swam into focus. Where others saw only chaos and cruelty, Minuchin helped us understand that families are structured in "subsystems" with "boundaries," their members shadowing to steps they do not see. In 1962 Minuchin formed a productive professional relationship with Jay Haley, who was then in Palo Alto. In 1965 Minuchin became the director of the Philadelphia Child Guidance Clinic, which eventually became the world's leading center for family therapy and training. At the Philadelphia Clinic, Haley and Minuchin developed a training program for members of the local black community as paraprofessional family therapists in an effort to more effectively related to the urban blacks and Latinos in the surrounding community. In 1969, Minuchin, Haley, Braulio Montalvo, and Bernice Rosman developed a highly successful family therapy training program that emphasized hands-on experience, on-line supervision, and the use of videotapes to learn and apply the techniques of structural family therapy. Minuchin stepped down as director of the Phildelphia Clinic in 1975 to pursue his interest in treating families with psychosomatic illnesses and to continue writing some of the most influential books in the field of family therapy. In 1981, Minuchin established Family Studies, Inc., in New York, a center committed to teaching family therapists. Minuchin retired in 1996 and currently lives with his wife Patricia in Boston. Jay Haley A brilliant strategist and devastating critic, Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's. He studied under three of the most influential pioneers in the evolution of family therapy - Gregory Bateson, Milton Erickson, and Salvador Minuchin, and combined ideas from each of these innovative thinkers to form his own unique brand of family therapy. In 1953 Haley was studying for a master's degree in communication at Stanford University when Gregory Bateson invited him to work on the schizophrenia project. Haley met with patients and their families to observe the communicative style of schizophrenics in a natural environment. This work had an enormous impact in shaping the development of family therapy. Haley developed his therapeutic skills under the supervision of master hypnotist Milton Erickson from 1954 to 1960. Haley developed a brief therapy model which focused on the context and possible function of the patient's symptoms and used directives to instruct patients to act in ways that were counterproductive to their maladaptive behavior. Haley believed that it was far more important to get patients to actively do something about their problems rather than help them to understand why they had these problems. Haley was instrumental in bridging the gap between strategic and structural approaches to family therapy by looking beyond simple dyadic relationships and exploring his interest in triangular, inter generational relationships, or "perverse triangles." Haley believed that a patient's symptoms arose out of an incongruence between manifest and covert levels of communication with others and served to give the patient a sense of control in their interpersonal relationships. Accordingly, Haley thought that the healing aspect of the patient-therapist relationship involved getting patients to take responsibility for their actions and to take a stand in the therapeutic relationship, a process he called "therapeutic paradox." Haley conducted research at the Mental Research Institute in Palo Alto until he joined Salvador Minuchin at the Philadelphia Child Guidance Clinic in 1967. At the Philadelphia Clinic, Haley pursued his interests in training and supervision in family therapy and was the director of family therapy research for ten years. He
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was also an active clinical member of the University of Pennsylvania's Department of Psychiatry. In 1976, Haley moved to Washington D.C. and founded the Family Therapy Institute with Cloe Madanes, which has become one of the major training institutes in the country. Haley retired in 1995 and currently lives in La Jolla, California. Murray Bowen Among the pioneers of family therapy, Murray Bowen's emphasis on theory and insight as opposed to action and technique distinguish his work from the more behaviorally oriented family therapists (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Bowen's therapy is an outgrowth of psychoanalytic theory and offers the most comprehensive view of human behavior and problems of any approach to family therapy. The core goal underlying the Bowenian model is differentiation of self, namely, the ability to remain oneself in the face of group influences, especially the intense influence of family life. The Bowenian model also considers the thoughts and feelings of each family member as well as the larger contextual network of family relationships that shapes the lie of the family. Bowen grew up in Waverly, Tennessee, the oldest child of a large cohesive family. After graduating from medical school and serving five years in the military, Bowen pursued a career in psychiatry. He began studying schizophrenia and his strong background in psychoanalytic training led him to expand his studies from individual patients to the relationship patterns between mother and child. From 1946 to 1954, Bowen studied the symbiotic relationships of mothers and their schizophrenic children at the Menninger Clinic in Topeka, Kansas. Here he developed the concepts of anxious and functional attachment to describe interactional patterns in the mother-child relationship. In 1954, Bowen became the first director of the Family Division at the National Institute of Mental Health (NIMH). He further broadened his attachment research to include fathers and developed the concept of triangulation as the central building block o relationship systems (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). In his first year at NIMH, Bowen provided separate therapists for each individual member of a family, but soon discovered that this approach fractionated families instead of bringing them together. As a result, Bowen decided to treat the entire family as a unit, and became one of the founders of family therapy. In 1959, Bowen began a thirty-one year career at Georgetown University's Department of Psychiatry where he refined his model of family therapy and trained numerous students, including Phil Guerin, Michael Kerr, Betty Carter, and Monica McGoldrick, and gained international recognition for his leadership in the field of family therapy. He died in October 1990 following a lengthy illness. Nathan Ackerman Nathan Ackerman's astute ability to understand the overall organization of families enabled him to look beyond the behavioral interactions of families and into the hearts and minds of each family member. He used his strong will and provocative style of intervening to uncover the family's defenses and allow their feelings, hopes, and desires to surface. Ackerman's training in the psychoanalytic model is evident in his contributions and theoretical approach to family therapy. Ackerman proposed that underneath the apparent unity of families there existed a wealth of intra psychic conflict that divided family members into factions (Nichols & Schwartz, Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon 1998). Ackerman joined the Menninger Clinic in Topeka, Kansas, and became the chief psychiatrist of the Child Guidance Clinic in 1937. Initially, Ackerman followed the child guidance clinic model of having a psychiatrist treat the child and a social worker see the mother (Nichols & Schwartz, Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon 1998). However, within his first year of work at the clinic, Ackerman became a strong advocate of including the entire family when treating a disturbance in one of its members, and suggested that family therapy be used as the primary form of treatment in child guidance clinics (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Ackerman was committed to sharing his ideas and theoretical approach with other professionals in the field. In 1938 Ackerman published The Unity of the Family and Family Diagnosis: An Approach to the Preschool Child, both of which inspired the family therapy movement. Together with Don Jackson, Ackerman
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founded the first family therapy journal, Family Process, which is still the leading journal of ideas in the field today. In 1955 Ackerman organized the first discussion on family diagnosis at a meeting of the American Ortho psychiatric Association to facilitate communication in the developing field of family therapy. In 1957 Ackerman established the Family Mental Health Clinic in New York City and began teaching at Columbia University. He opened the Family Institute in 1960, which was later renamed the Ackerman Institute after his death in 1971. Virginia Satir Virginia Satir is one of the key figures in the development of family therapy. She believed that a healthy family life involved an open and reciprocal sharing of affection, feelings, and love. Satir made enormous contributions to family therapy in her clinical practice and training. She began treating families in 1951 and established a training program for psychiatric residents at the Illinois State Psychiatric Institute in 1955. Satir served as the director of training at the Mental Research Institute in Palo Alto from 1959-66 and at the Esalen Institute in Big Sur beginning in 1966. In addition, Satir gave lectures and led workshops in experiential family therapy across the country. She was well-known for describing family roles, such as "the rescuer" or "the placator," that function to constrain relationships and interactions in families (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Satir's genuine warmth and caring was evident in her natural inclination to incorporate feelings and compassion in the therapeutic relationship. She believed that caring and acceptance were key elements in helping people face their fears and open up their hearts to others (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Above all other therapists, Satir's was the most powerful voice to wholeheartedly support the importance of love and nurturance as being the most important healing aspects of therapy. Unfortunately, Satir's beliefs went against the more scientific approach to family therapy accepted at that time, and she shifted her efforts away from the field to travel and lecture. Satir died in 1988 after suffering from pancreatic cancer. Ivan Boszmormenyi-Nagy Ivan Boszmormenyi-Nagy's emphasis on loyalty, trust, and relational ethics -- both within the family and between the family and society -- made major contributions to the field of family therapy since its inception in the 1950's (Nichols & Schwartz, Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon 1998). A student of Virginia Satir and an accomplished scholar and clinician, Nagy was trained as a psychoanalyst and his work has encouraged many family therapists to incorporate psychoanalytic ideas with family therapy. Nagy is perhaps best known for developing the contextual approach to family therapy, which emphasizes the ethical dimension of family development. Based on the psychodynamic model, contextual therapy accentuates the need for ethical principles to be an integral part of the therapeutic process. Nagy believes that trust, loyalty, and mutual support are the key elements that underlie family relationships and hold families together, and that symptoms develop when a lack of caring and liability result in a breakdown of trust in relationships (Nichols & Schwartz, Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon 1998). The therapists' role is to help the family work through avoided emotional conflicts and to develop a sense of fairness among family members. In 1957, Nagy established the Eastern Pennsylvania Psychiatric Institute (EPPI) and served as co director and co therapist along with social worker Geraldine Spark. Nagy was also an active researcher of schizophrenia and family therapy and coauthored Invisible loyalties: Reciprocity in intergenerational family therapy (Boszormenyi-Nagy & Spark, 1973). Since the closing of EPPI, Nagy has continued to develop his contextual approach to family therapy and remains associated with Hahnemann University in Pennsylvania.
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John Elderkin Bell Perhaps one of the first family therapists was John Elderkin Bell, who began treating families in the early 1950's. Bell's ingenious approach to family therapy involved developing a step-by-step, easy-to-follow plan of attack to treat family problems in stages. Bell's treatment approach was an outgrowth of group therapy and was aptly named family group therapy. In 1951 Bell discovered that John Bowlby, a well-respected clinician, was applying group psychotherapy techniques to treat individual families. Bell decided to follow Bowlby's approach, and did not discover until many years later that Bowlby had only used this treatment approach with one family. Bell believed that the treatment of families should follow a series of three stages designed to encourage communication among family members and to solve family problems.
In the first stage, the child-centered phase, Bell encouraged children's involvement by facilitating the expression of their thoughts and feelings.
In the parent-centered stage, parents responded to their children's concerns and often related difficulties they experienced with their children's behavior.
The family-centered stage was the final phase of treatment, and Bell continued to stimulate communication among family members and to help solve family problems.
Unfortunately, Bell's pioneering efforts in the field of family therapy are less well-known as compared to other family therapists. Bell did not publish his ideas until the 1960's, and he did not establish family therapy clinics or training centers. Philip Guerin A student of Murray Bowen, Philip Guerin's own innovative ideas led to his developing a sophisticated clinical approach to treating problems of children and adolescents, couples, and individual adults (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Guerin's highly articulated model outlines several therapeutic goals, which emphasize the multigenerational context of families, working to calm the emotional level of family members, and defining specific patterns of relationships within families. Guerin's family systems approach is designed to measure the severity of conflict and to identify specific areas in need of improvement. In 1970 Guerin became the Director of Training of the Family Studies Section at Albert Einstein College of Medicine and Bronx State Hospital, a family therapy training center originally organized by Israel Zwerling and Marilyn Mendelsohn. Guerin's pioneering efforts and exceptional leadership resulted in his establishing an extramural training program in Westchester in 1972 and founding the Center for Family Learning in New Rochelle, New York, one of the most exceptional family therapy programs for training and practice in the nation (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). In addition to being a distinguished clinician, Guerin has authored some of the most influential and valuable books and articles in the field of family therapy. Two of his best are: The Evaluation and treatment of marital conflict: A four-stage approach (Guerin, 1987) and Working with relationship triangles: The onetwo-three of psychotherapy (Guerin, Fogarty, Fay & Kautto, 1996). Don Jackson The vibrant and creative talent of Don Jackson contributed to his success as a writer, researcher, and cofounder of the leading journal in the field of family therapy, Family Process. A 1943 graduate of Stanford University School of Medicine, Jackson strongly rejected the psychoanalytic concepts that formed the basis of his early training. Instead, he focused his interest on Bateson's analysis of communication and behavior, which shaped his most important contributions to the developing field of family therapy. By 1954, Jackson had developed a rudimentary family interactional therapy out of his pioneering work with the Palo Alto group and research on schizophrenia (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Jackson observed the mutual impact of schizophrenic patients and their families in the home environment, and quickly recognized the importance of treating the family unit
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instead of removing patients for individual treatment. His early work centered on the effects of patients' therapy on the entire family, and he developed the concept of family homeostasis to describe how families resist change and seek to maintain redundant patterns of behavior. Jackson also suggested that family members react to schizophrenic members' symptoms in ways that serve to stabilize the family's status quo and often result in inflexible ways of thinking and maintain the symptomatic behavior (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). In 1958, Jackson established the Mental Research Institute and worked with Virginia Satir, Jules Riskin, Jay Haley, John Weakland, Paul Watzlawick and Bateson. By 1963, Jackson's model of the family involved several types of rules that defined the communication patterns and interactions among family members. Jackson believed that family dysfunction was a result of a family's lack of rules for change, and that the therapist's role was to make the rules explicit and to reconstruct rigid which maintained family problems. In 1968, tragically Jackson died by his own hand at the age of 48. Carl Whitaker Carl Whitaker's creative and spontaneous thinking formed the basis of a bold and inventive approach to family therapy. He believed that active and forceful personal involvement and caring of the therapist was the best way to bring about changes in families and promote flexibility among family members. He relied on his own personality and wisdom, rather than any fixed techniques, to stir things up in families and to help family members open up and be more fully themselves (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Whitaker's confrontive approach earned him the reputation as the most irreverent among family therapy's iconoclasts. Whitaker viewed the family as an integrated whole, not as a collection of discrete individuals, and felt that a lack of emotional closeness and sharing among family members resulted in the symptoms and interpersonal problems that led families to seek treatment. He equated familial togetherness and cohesion with personal growth, and emphasized the importance of including extended family members, especially the expressive and playful spontaneity of children, in treatment. A big, comfortable, lanternjawed man, Whitaker liked a crowd in the room when he did therapy. Whitaker also pioneered the use of co therapists as a means of maintaining objectivity while using his highly provocative techniques to turn up the emotional temperature of families (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Beginning in 1946, Whitaker served as Chairman of the Department of Psychiatry at Emory University, where he focused on treating schizophrenics and their families. He also helped to develop some of the first major professional meetings of family therapists with colleagues such as John Warkentin, Thomas Malone, John Rosen, Bateson, and Jackson. In 1955, Whitaker left Emory to enter into private practice, and became a professor of Psychiatry at the University of Wisconsin in 1965 until his retirement in 1982. Whitaker died in April 1995, leaving a heartfelt void in the field of family therapy. Betty Carter An ardent and articulate feminist, Betty Carter was instrumental in enriching and popularizing the concept of the family life cycle and its value in assessing families. Carter entered the field of family therapy after being trained as a social worker, and emphasized the importance of historical antecedents of family problems and the multigenerational aspects of the life cycle that extended beyond the nuclear family. Carter further expanded on the family life cycle concept by considering the stages of divorce and remarriage (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Carter's interest in family therapy was stimulated by taking part in a family therapy field placement at the Ackerman Institute as part of her M.S.W. requirements at Hunter College. She quickly became an avid student of the Bowenian model, and served on the staff of the Family Studies Section at Albert Einstein College of Medicine and Bronx State Hospital with Phil Guerin and Monica McGoldrick. Carter left the Center for Family Learning to become the founding director of the Family Institute of Westchester in 1977. Carter served as Co director of the Women's Project in Family Therapy with Peggy Papp, Olga Silverstein, and Marianne Walters, and has been an outspoken leader about the gender and ethnic inequalities that serve to keep women in inflexible family roles.
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Currently, Carter is an active clinician and specializes in marital therapy and therapy with remarried couples (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Her work with couples focuses on helping her clients to understand their situation and to address unresolved family issues. Carter incorporates tasks, such as letter writing, which serve to intensify and speed up the communication process and help couples move out of rigid patterns of behavior. Michael White Michael White, the guiding genius of narrative family therapy, began his professional life as a mechanical draftsman. But he soon realized that he preferred people to machines and went into social work where he gravitated to family therapy. Following an initial attraction to the cybernetic thinking of Gregory Bateson, White became more interested in the ways people construct meaning in their lives than just with the ways they behaved. In developing the notion that people's lives are organized by their life narratives, White came to believe that stories don't mirror life, they shape it. That's why people have the interesting habit of becoming the stories they tell about their experience. Narrative therapists break the grip of unhelpful stories by externalizing problems. By challenging fixed and pessimistic versions of events, therapists make room for flexibility and which new and more optimistic stories can be envisioned. Finally, clients are encouraged to create audiences of support to witness and promote their progress in restoring their lives along preferred lines. White's innovative thinking helped shape the basic tenets of narrative therapy, which considers the broader historical, cultural and political framework of the family. In the narrative approach, therapists try to understand how clients' personal beliefs and perceptions, or narratives, shape their self-concept and personal relationships. Individual clients of families are then encouraged to reconstruct their narratives to facilitate more adaptive views of themselves and more effective interpersonal interactions. White's leadership of the narrative movement in family therapy is based not only on his imaginative ideas but also on his inspirational persistence in seeing the best in people even when they've lost faith in themselves. White is well-known for his persistence in challenging clients' negative self-beliefs and for his relentless optimism in helping people to develop healthier interpretations of their life experiences. White's tenaciously positive attitude has undoubtedly contributed to his enormous success as a therapist. Currently, White lives in Adelaide, South Australia. Together with his wife, Cheryl, White works at the Dulwich Centre, a training and clinical facility that also publishes the Dulwich Newsletter, which White uses to explore his ideas with the field.
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Models and Schools Family therapists and counselors use a range of methods and over the years a number of models or schools of family therapy have developed. A well-known classification of these approaches is described by Gurman and Kniskern (1991): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Behavioural Family Therapy Bowen theory Brief Therapy: MRI Contextual Therapy Eriscksonian Family Therapy Focal Family Therapy Milan Systemic Therapy Family Psychoeducational Therapy Strategic Therapy Structural Therapy Symbolic-Experiential Therapy
Some contemporary family therapies: Structural Family Therapy (Minuchin, 1974, Colapinto, 1991) In this type of therapy, the structural therapist believes that change of behaviour is most important. Therapy begins with the therapist “joining” with the family. He or she has the purpose to enhance the feeling of worth of individual family members. The therapist must attune himself or herself to the families value systems and existing hierarchies. After “joining”, the therapist challenges “how things are done“ and begins restructuring the family by offering alternative, more functional ways of behaving. Conjoint Family Therapy (Satir, 1967) Conjoint family therapy works with personal experiences and helps experiencing the value of the individual within the family system. Therapists use all levels of communication to express the relational qualities present in the family to achieve change in family system. This approach uses many feeling and communication exercises and games, for example family sculpture. Contextual Therapy (Boszormenyi-Nagy, 1991) In the contextual approach the word “context“ indicates the dynamic connectedness of a person with her or his significant relationships, the long-term relational involvement as well as the person’s relatedness to his or her multigenerational roots. The therapist encourages family members to explore their own multilaterality. Strategic Therapy (Madanes, 1981) In this approach, the therapist considers the therapy in terms of step-by-step change in the way from one type of abnormal organisation to another type before a more normal organisation is finally achieved. For a strategic therapist two questions are basic: How is the symptom “helping” the family to maintain a balance or overcome a crisis? How can the symptom be replaced by a more effective solution of the problem?
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Brief Therapy This name refers not only to the duration of the therapy, but it represents comprehensively a way of orientation in therapeutic practice. Problem formation and maintenance is seen as parts of vicious-circle process, in which maladaptive “solutions“ behaviours maintain the problem. Alteration of these behaviours /or beliefs/ should interrupt the cycle and initiate the resolution of the problem. Milan Systemic Therapy (Boscolo et al, 1987) Basic assumption of Milan Systemic Therapy is that mind is social. The symptomatic behaviour is conceived as a part of the transactional patterns of the system. Significance of any particular behaviour or event may be derived from its social context. The therapists consider that the way to eliminate the symptom which is present in the family is to change the rules and beliefs. Change is achieved in clarifying the ambiguity in relationships. Narrative Therapy (Freedman, Combs, 1996) The followers of the narrative approach consider that experience rooted in the life events is elaborated in the form of a story, which gives to these events a meaning reflecting the systems of belief. In the therapy process, the “life story” of a family is connected with the internal and external culture of the family. Change is enabled by retelling the story, in the course of which meanings attributed to the events can change or alternate. http://www.dmrtk.jgytf.u-szeged.hu/phare/eng/more.htm
Academic resources
Family Process Journal of Child and Family Studies, ISSN: 1062-1024 (Print) 1573-2843 (Online), Springer Journal of Marital and Family Therapy Journal of Family Psychology Family Relations Contemporary Family Therapy Australian & New Zealand Journal of Family Therapy Family Matters, Australian Institute of Family Studies Journal of Comparative Family Studies, ASIN: B00007M2W5, Univ of Calgary/Dept Sociology Journal of Family Studies, ISSN: 1322-9400, eContent Management Pty Ltd Journal of Family Therapy, AFT (Association for family Therapy & Systemic Practice in the UK) Context Magazine, AFT, UK Karnac Systemic Thinking and Practice Series
Professional Organizations
American Association for Marriage and Family Therapy American Family Therapy Academy European Family Therapy Association (EFTA) International Association of Marriage and Family Counsellors National Council on Family Relations The Ackerman Institute for the Family
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Useful Internet links Wikipedia links
Alternative dispute resolution CAMFT Child abuse Conflict resolution Deinstitutionalisation Domestic violence Dysfunctional family Family Life Education Family Life Space
Internal Family Systems Model Interpersonal psychotherapy Interpersonal relationship Mediation Multisystemic Therapy (MST) Positive psychology Relationships Australia Strategic Family Therapy
External links Included in this list are the main professional associations in the US and internationally; they reflect to some degree the different theoretical, ideological, and cross-cultural views of family therapy theory and practice.
American Association for Marriage and Family Therapy: main professional association in US American Family Therapy Academy: main research-oriented professional association in US Association for Family Therapy and Systemic Practice in the UK Australian and New Zealand Journal of Family Therapy: the de facto professional association for Australia and NZ Bowen Theory from the Bowen Centre for the Study of the Family. California Association of Marriage and Family Therapists European Family Therapy Association International Family Therapy Association Historical overview of the field; Therapist profiles; Timeline from Allyn and Bacon/Longman publishing. Family Support Partnership - An Overview of Family Therapy and Mediation Dulwich Centre: Gateway to Narrative Therapy & Community Work "Mind For Therapy" group devoted to creative origins of Family Therapy Glossary of Family Systems and intergenerational concepts MFT at Notre Dame de Namur University, Belmont CA Social Construction Therapies Network
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Brief Strategic Family Therapy From Wikipedia, the free encyclopedia The family is defined by an organizational structure that is characterized by degrees of cohesiveness, love, loyalty, and purpose as well as high levels of shared values, interests, activities, and attention to the needs of its members. Families may be considered a system, organized wholes or units made up of several interdependent and interacting parts. Each member has a significant influence on all other members. For positive change in an identified client, therefore, family members have to change the way they interact. Family therapists work with the present relationships rather than the past. They are interested in the balance families maintain between bipolar extremes that characterize dysfunctional families. Strategic refers to the development of a specific strategy, planned in advance by the therapist, to resolve the presenting problem as quickly and efficiently as possible.
DESCRIPTION Brief Strategic Family Therapy (BSFT) is a short-term, problem-focused therapeutic intervention, targeting children and adolescents 6 to 17 years old, that improves youth behaviour by eliminating or reducing drug use and its associated behaviour problems and that changes the family members’ behaviours that are linked to both risk and protective factors related to substance abuse. The therapeutic process uses techniques of:
PROGRAM BACKGROUND BSFT was developed at the Spanish Family Guidance Center in the Center for Family Studies, University of Miami. BSFT has been conducted at these centers since 1975. The Center for Family Studies is the Nation’s oldest and most prominent center for development and testing of minority family therapy interventions for prevention and treatment of adolescent substance abuse and related behaviour problems. It is also the Nation’s leading trainer of research-proven, family therapy for Hispanic/Latino families.
INDICATED This program was developed for an indicated audience. It targets children with conduct problems, substance use, problematic family relations, and association with antisocial peers.
CONTENT FOCUS ALCOHOL, ANTISOCIAL/AGGRESSIVE BEHAVIOUR, ILLEGAL DRUGS, TOBACCO SOCIAL AND EMOTIONAL COM PETENCE. This program addresses family risk and protective factors to problem behaviour, including substance use among adolescents.
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INTERVENTIONS BY DOMAIN PARENTS AS A PRIMARY TARGET POPULATION: The program involves family systems therapy, involving all family members. It seeks to change the way family members act toward each other so that they will promote each other’s mastery over behaviours that are required for the family to achieve competence and to impede undesired behaviours. INDIVIDUAL: Life and social skills training FAMILY : Home visits, Parent education/family therapy, Parent education/parenting skills training Task-oriented family education sessions combining social skills training to improve family interaction (e.g., communication skills) PEER : Peer-resistance education
KEY PROGRAM APPROACHES PARENT-CHILD INTERACTION: All of the key strategies are focused on improving the interactions between parents and child. PARENT TRAINING: A key change strategy is to empower parents by increasing their mastery of parenting skills. SKILL DEVELOPMENT: The program fosters conflict resolution skills, parenting skills, and communication skills. TECHNIQUES USED Joining—forming a therapeutic alliance with all family members Diagnosis—identifying interactional patterns that allow or encourage problematic youth behaviour Restructuring—the process of changing the family interactions that are directly related to problem behaviours
THERAPY The program involves creating a counsellor-family work team that develops a therapeutic alliance with each family member and with the family as a whole; diagnosing family strengths and problematic interactions; developing change strategies to capitalize on strengths and correct problematic family interactions; and implementing change strategies and reinforcing family behaviours that sustain new levels of family competence. Strategies include reframing, changing alliances, building conflict resolution skills, and parental empowerment. HOW IT WORKS BSFT can be implemented in a variety of settings, including community social services agencies, mental health clinics, health agencies, and family clinics. BSFT is delivered in 8 to 12 weekly 1- to 1.5-hour sessions. The family and BSFT counsellor meet either in the program office or the family’s home. Sessions may occur more frequently around crises because these are opportunities for change.
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There are four important BSFT steps: Step 1: Organize a counsellor-family work team. Development of a therapeutic alliance with each family member and with the family as a whole is essential for BSFT. This requires counsellors to accept and demonstrate respect for each individual family member and the family as a whole. Step 2: Diagnose family strengths and problem relations. Emphasis is on family relations that are supportive and problem relations that affect youths’ behaviours or interfere with parental figures’ ability to correct those behaviours. Step 3: Develop a change strategy Develop a change strategy to capitalize on strengths and correct problematic family relations, thereby increasing family competence. In BSFT, the counsellor is plan- and problem-focused, direction-oriented (i.e., moving from problematic to competent interactions), and practical. Step 4: Implement change strategies and reinforce family behaviours that sustain new levels of family competence. Important change strategies include reframing to change the meaning of interactions; changing alliances and shifting interpersonal boundaries; building conflict resolution skills; and providing parenting guidance and coaching. BARRIERS AND PROBLEMS Problem: The most common problem is engaging and retaining whole families in treatment. Solution: Specialized engagement strategies have been developed to deal with the problem. Problem: A common problem in implementing a whole-family intervention involves limited availability of family members. Solution: Sessions often must occur during evening hours and on weekends.
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Brief Strategic Family Therapy for Adolescent Drug Abuse The National Institute on Drug Abuse (NIDA) is part of the National Institutes of Health (NIH) , a component of the U.S. Department of Health and Human Services. Questions? See our Contact Information
Foreword More than 20 years of research has shown that addiction is clearly treatable. Addiction treatment has been effective in reducing drug use and HIV infection, diminishing the health and social costs that result from addiction, and decreasing criminal behavior. The National Institute on Drug Abuse (NIDA), which supports more than 85 percent of the world's research on drug abuse and addiction, has found that behavioral approaches can be very effective in treating cocaine addiction. To ensure that treatment providers apply the most current scientifically supported approaches to their patients, NIDA has supported the development of the "Therapy Manuals for Drug Addiction" series. This series reflects NIDA's commitment to rapidly applying basic findings in real life settings. The manuals are derived from those used efficaciously in NIDA-supported drug abuse treatment studies. They are intended for use by drug abuse treatment practitioners, mental health professionals, and all others concerned with the treatment of drug addiction. The manuals present clear, helpful information to aid drug treatment practitioners in providing the best possible care that science has to offer. They describe scientifically supported therapies for addiction and provide guidance on session content and how to implement specific techniques. Of course, there is no substitute for training and supervision, and these manuals may not be applicable to all types of patients nor compatible with all clinical programs or treatment approaches. These manuals should be viewed as a supplement to, but not a replacement for, careful assessment of each patient, appropriate case formulation, ongoing monitoring of clinical status, and clinical judgment. The therapies presented in this series exemplify the best of what we currently know about treating drug addiction. As our knowledge evolves, new and improved therapies are certain to emerge. We look forward to continuously bringing you the latest scientific findings through manuals and other science-based publications. We welcome your feedback about the usefulness of this manual series and any ideas you have about how it might be improved. Nora D. Volkow, M.D. Director National Institute on Drug Abuse
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Chapter 1 - Brief Strategic Family Therapy: An Overview Brief Strategic Family Therapy (BSFT) is a brief intervention used to treat adolescent drug use that occurs with other problem behaviors. These co-occurring problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behavior (Jessor and Jessor 1977; Newcomb and Bentler 1989; Perrino et al. 2000). BSFT is based on three basic principles. The first is that BSFT is a family systems approach. Family systems means that family members are interdependent: What affects one family member affects other family members. According to family systems theory, the drug-using adolescent is a family member who displays symptoms, including drug use and related co-occurring problem behaviors. These symptoms are indicative, at least in part, of what else is going on in the family system (Szapocznik and Kurtines 1989). Just as important, research shows that families are the strongest and most enduring force in the development of children and adolescents (Szapocznik and Coatsworth 1999). For this reason, family-based interventions have been studied as treatments for drug-abusing adolescents and have been found to be efficacious in treating both the drug abuse and related co-occurring problem behaviors (for reviews, see Liddle and Dakof 1995; Robbins et al. 1998; Ozechowski and Liddle 2000). The second BSFT principle is that the patterns of interaction in the family influence the behavior of each family member. Patterns of interaction are defined as the sequential behaviors among family members that become habitual and repeat over time (Minuchin et al. 1967). An example of this is an adolescent who attracts attention to herself when her two caregivers (e.g., her mother and grandmother) are fighting as a way to disrupt the fight. In extreme cases, the adolescent may suffer a drug overdose or get arrested to attract attention to herself when her mother and grandmother are having a very serious fight. The role of the BSFT counselor is to identify the patterns of family interaction that are associated with the adolescent's behavior problems. For example, a mother and grandmother who are arguing about establishing rules and consequences for a problem adolescent never reach an agreement because the adolescent disrupts their arguments with self-destructive attempts to get attention. The third principle of BSFT consequently is to plan interventions that carefully target and provide practical ways to change those patterns of interaction (e.g., the way in which mother and grandmother attempt but fail to establish rules and consequences) that are directly linked to the adolescent's drug use and other problem behaviors.
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Why Brief Strategic Family Therapy? The scientific literature describes various treatment approaches for adolescents with drug addictions, including behavioral therapy, multisystemic therapy, and several family therapy approaches. Each of these approaches has strengths. BSFT's strengths include the following:
BSFT is an intervention that targets self-sustaining changes in the family environment of the adolescent. That means that the treatment environment is built into the adolescent's daily family life.
BSFT can be implemented in approximately 8 to 24 sessions. The number of sessions needed depends on the severity of the problem.
BSFT has been extensively evaluated for more than 25 years and has been found to be efficacious in treating adolescent drug abuse, conduct problems, associations with antisocial peers, and impaired family functioning.
BSFT is "manualized," and training programs are available to certify BSFT counselors.
BSFT is a flexible approach that can be adapted to a broad range of family situations in a variety of service settings (e.g., mental health clinics, drug abuse treatment programs, and other social service settings) and in a variety of treatment modalities (e.g., as a primary outpatient intervention, in combination with residential or day treatment, and as an aftercare/continuing-care service to residential treatment).
BSFT appeals to cultural groups that emphasize family and interpersonal relationships.
What Are the Goals of Brief Strategic Family Therapy? In BSFT, whenever possible, preserving the family is desirable. While family preservation is important, two goals must be set: to eliminate or reduce the adolescent's use of drugs and associated problem behaviors, known as "symptom focus," and to change the family interactions that are associated with the adolescent's drug abuse, known as "system focus." An example of the latter occurs when families direct their negative feelings toward the drug-abusing youth. The parents' negativity toward the adolescent directly affects his or her drug abuse, and the adolescent's drug abuse increases the parents' negativity. At the family systems level, the counselor intervenes to change the way family members act toward each other (i.e., patterns of interaction). This will prompt family members to speak and act in ways that promote more positive family interaction, which, in turn, will make it possible for the adolescent to reduce his or her drug abuse and other problematic behaviors. What Are the Most Common Problems Facing the Family of a Drug-Abusing Adolescent? The makeup and dynamics of the family are discussed in terms of the adolescent's symptoms and the family's problems.
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The Family Profile of a Drug-Abusing Adolescent Research shows that many adolescent behavior problems have common causes and that families, in particular, play a large role in those problems in many cases (Szapocznik and Coatsworth 1999). Some of the family problems that have been identified as linked to adolescent problem behaviors include:
Parental drug use or other antisocial behavior Parental under- or over-involvement with the adolescent Parental over- or under-control of the adolescent Poor quality of parent-adolescent communication Lack of clear rules and consequences for adolescent behavior Inconsistent application of rules and consequences for adolescent behavior Inadequate monitoring and management of the adolescent's activities with peers Lack of adult supervision of the adolescent's activities with peers Poor adolescent bonding to family Poor family cohesiveness
Some adolescents may have families who had these problems before they began using drugs (Szapocznik and Coatsworth 1999). Other families may have developed problems in response to the adolescent's problem behaviors (Santisteban et al. in press). Because family problems are an integral part of the profile of drugabusing adolescents and have been linked to the initiation and maintenance of adolescent drug use, it is necessary to improve conditions in the youth's most lasting and influential environment: the family. BSFT targets all of these family problems. The Behavioral Profile of a Drug-Abusing Adolescent Adolescents who need drug abuse treatment usually exhibit a variety of externalizing behavior problems. These may include:
School truancy Delinquency Associating with antisocial peers Conduct problems at home and/or school Violent or aggressive behavior Oppositional behavior Risky sexual behavior
Negativity in the Family Families of drug-abusing adolescents exhibit high degrees of negativity (Robbins et al. 1998). Very often, this negativity takes the form of family members blaming each other for both the adolescent's and the family's problems. Examples might include a parent who refers to her drug-abusing son as "no good" or "a lost cause." Parents or parent figures may blame each other for what they perceive as a failure in raising the child. For example, one parent may accuse the other of having been a "bad example," or for not "being there" when the youngster needed him or her. The adolescent, in turn, may speak about the parent accused of setting a bad example with disrespect and resentment. The communication among family members is contaminated with anger, bitterness, and animosity. To the BSFT counselor, these signs of emotional or affective distress indicate that the work of changing dysfunctional behaviors must start with changing the negative tone of the family members' emotions and the negative content of their interactions. Research shows that when family negativity is reduced early in treatment, families are more likely to remain in therapy (Robbins et al. 1998).
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What Is Not the Focus of Brief Strategic Family Therapy? BSFT has not been tested with adult addicts. For this reason, BSFT is not considered a treatment for adult addiction. Instead, when a parent is found to be using drugs, a counselor needs to decide the severity of the parent's drug problem. A parent who is moderately involved with drugs can be helped as part of his or her adolescent's BSFT treatment. However, if a parent is drug dependent, the BSFT counselor should work to engage the parent in drug abuse treatment. If the parent is unwilling to get drug abuse treatment, the BSFT counselor should work to protect and disengage the adolescent from the drug dependent parent. This is done by creating an interpersonal wall or boundary that separates the adolescent and non-drug-using family members from the drug dependent parent(s). This process is discussed in Chapter 4 in the section on "Working With Boundaries and Alliances". This Manual This manual introduces counselors to concepts that are needed to understand the family as a vital context within which adolescent drug abuse occurs. It also describes strategies for creating a therapeutic relationship with families, assessing and diagnosing maladaptive patterns of family interaction, and changing patterns of family interaction from maladaptive to adaptive. This manual assumes that therapists who adopt these BSFT techniques will be able to engage and retain families in drug abuse treatment and ultimately cause them to behave more effectively. Chapter 2 will discuss the basic theoretical concepts of BSFT. Chapter 3 will present the BSFT diagnostic approach, and Chapter 4 will explain how change is achieved. Chapter 5 is a detailed discussion of how to engage resistant families of drug-abusing adolescents in treatment. Chapter 6 summarizes some of the research that supports the use of BSFT with adolescents. The manual also has two appendices, one on training counselors to implement BSFT and another presenting case examples from the authors' work. Concepts and techniques discussed by Minuchin and Fishman (1981) have been adapted in this BSFT manual for application to drug-abusing adolescents. Additional discussion of BSFT can be found in Szapocznik and Kurtines (1989).
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Chapter 2 - Basic Concepts of Brief Strategic Family Therapy The previous chapter introduced the underlying philosophy of BSFT: to help families help themselves and to preserve the family unit, whenever possible. The remainder of this manual focuses more directly on BSFT as a strategy to treat adolescent drug abuse and its associated behavior problems. This chapter presents the most basic concepts of the BSFT approach. It begins with a discussion of five theoretical concepts that comprise the basic foundation of BSFT. Some of these concepts may be new for drug abuse counselors. The five concepts discussed in this chapter are:
Context Systems Structure Strategy Content versus process
Context The social influences an individual encounters have an important impact on his or her behavior. Such influences are particularly powerful during the critical years of childhood and adolescence. The BSFT approach asserts that the counselor will not be able to understand the adolescent's drug-abusing behavior without understanding what is going on in the various contexts in which he or she lives. Drug-abusing behavior does not happen in a vacuum; it exists within an environment that includes family, peers, neighborhood, and the cultures that define the rules, values, and behaviors of the adolescent. Family as Context Context, as defined by Urie Bronfenbrenner (1977, 1979, 1986, 1988), includes a number of social contexts. The most immediate are those that include the youth, such as family, peers, and neighborhoods. Bronfenbrenner recognized the enormous influence the family has, and he suggested that the family is the primary context in which the child learns and develops. More recent research has supported Bronfenbrenner's contention that the family is the primary context for socializing children and adolescents (for reviews, see Perrino et al. 2000; Szapocznik and Coatsworth 1999). Peers as Context Considerable research has demonstrated the influences that friends' attitudes, norms, and behaviors have on adolescent drug abuse (Brook et al. 1999; Newcomb and Bentler 1989; Scheier and Newcomb 1991). Moreover, drug-using adolescents often introduce their peers to and supply them with drugs (Bush et al. 1994). In the face of such powerful peer influences, it may seem that parents can do little to help their adolescents. However, recent research suggests that, even in the presence of drugusing (Steinberg et al. 1994) or delinquent (Mason et al. 1994) peers, parents can wield considerable influence over their adolescents. Most of the critical family issues (e.g., involvement, control, communication, rules and consequences, monitoring and supervision, bonding, family cohesion, and family negativity) have an impact on how much influence parents can have in countering the negative impact peers have on their adolescents' drug use. Neighborhood as Context The interactions between the family and the context in which the family lives may also be important to consider. A family functions within a neighborhood context, family members live in a particular neighborhood, and the children in the family are students at a particular school. For instance, to effectively manage a troubled 15- year-old's behavioral problems in a particular neighborhood, families may have to work against high drug availability, crime, and social isolation. In contrast, a small town in a semi-rural community may have a community network that includes parents, teachers, grandparents, and civic leaders, all of whom collaborate in raising the town's children. Neighborhood context, then, can introduce additional challenges to parenting or resources that should be considered when working with families.
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Culture as Context Bronfenbrenner also suggested that families, peers, and neighborhoods exist within a wider cultural context that influences the family and its individual members. Extensive research on culture and the family has demonstrated that the family and the child are influenced by their cultural contexts (Santisteban et al. 2003; Szapocznik and Kurtines 1993). Much of the researchers' work has examined the ways in which minority families' values and behaviors have an impact on the relationship between parents and children and affect adolescents' involvement with drug abuse and its associated problems (Santisteban et al. 2003; Szapocznik and Kurtines 1980, 1993; Szapocznik et al. 1978). Counseling as Context The counseling situation itself is a context that is associated with a set of rules, expectations, and experiences. The cultures of the client (i.e., the family), the counselor, the agency, and the funding source can all affect the nature of counseling as can the client's feelings about how responsive the "system" is to his or her needs. Systems Systems are a special case of context. A system is made up of parts that are interdependent and interrelated. Families are systems that are made up of individuals (parts) who are responsive (interrelated) to each other's behaviors. A Whole Organism "Systems" implies that the family must be viewed as a whole organism. In other words, it is much more than merely the sum of the individuals or groups that it comprises. During the many years that a family is together, family members develop habitual patterns of behavior after having repeated them thousands of times. In this way, each individual member has become accustomed to act, react, and respond in a specific manner within the family. Each member's actions elicit a certain reaction from another family member over and over again over time. These repetitive sequences give the family its own form and style. The patterns that develop in a family actually shape the behaviors and styles of each of its members. Each family member has become accustomed to behaving in certain ways in the family. Basically, as one family member develops certain behaviors, such as a responsible, take-control style, this shapes other family members' behaviors. For example, family members may allow the responsible member to handle logistics. At the same time, the rest of the family members may become less responsible. In this fashion, family members complement rather than compete with one another. These behaviors have occurred so many times, often without being thought about, that they have shaped the members to fit together like pieces of a puzzle-a perfect, predictable fit. Family Systemic Influences Family influences may be experienced as an "invisible force." Family members' behavior can vary considerably. They may act much differently when they are with other family members than when they are with people outside the family. By its very presence, the family system shapes the behaviors of its members. The invisible forces (i.e., systemic influences) that govern the behaviors of family members are at work every time the family is together. These "forces" include such things as spoken or unspoken expectations, alliances, rules for managing conflicts, and implicitly or explicitly assigned roles. In the case of an adolescent with behavior problems, the family's lack of skills to manage a misbehaving youth can create a force (or pattern of interaction) that makes the adolescent inappropriately powerful in the family. For example, when the adolescent dismisses repeated attempts by the parents to discipline him or her, family members learn that the adolescent generally wins arguments, and they change their behavior accordingly. Once a situation like this arises in which family expectations, alliances, rules, and so on have been reinforced repeatedly, family members may be unable to change these patterns without outside help.
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The Principle of Complementarity The idea that family members are interdependent, influencing and being influenced by each other, is not unique to BSFT. Using different terminology, the theoretical approach underlying behaviorally oriented family treatments might explain these mutual influences as family members both serving as stimuli for and eliciting responses from one another (Hayes et al. 1999). The theoretical approach underlying existential family treatments might describe this influence as family members either supporting or constraining the growth of other family members (Lantz and Gregoire 2000). What distinguishes BSFT from behaviorally oriented and existential family treatments is its focus on the family system rather than on individual functioning. BSFT assumes that a drug-abusing adolescent will improve his or her behavior when the family learns how to behave adaptively. This will happen because family members, who are "linked" emotionally, are behaviorally responsive to each other's actions and reactions. In BSFT, the Principle of Complementarity holds that for every action by a family member there is a corresponding reaction from the rest of the family. For instance, often children may have learned to coerce parents into reinforcing their negative behavior--for example, by throwing a temper tantrum and stopping only when the parents give in (Patterson 1982; Patterson and Dishion 1985; Patterson et al. 1992). Only when the parents change their behavior and stop reinforcing or "complementing" negative behavior will the child change. Structure: Patterns of Family Interaction An exchange among family members, either through actions or conversations, is called an interaction. In time, interactions become habitual and repetitive, and thus are referred to as patterns of interaction (Minuchin 1974). Patterns of family interaction are the habitual and repeated behaviors family members engage in with each other. More specifically, the patterns of family interaction are comprised of linked chains of behavior that occur among family members. A simple example can be illustrated by observing that family members choose to sit at the same place at the dinner table every day. Where people sit may make it easier for them to speak with each other and not with others. Consequently, a repetitive pattern of interaction reflected in a "sitting" pattern is likely to predict the "talking" pattern. A large number of these patterns of interaction will develop in any system. In families, this constellation of repetitive patterns of interaction is called the family "structure." The repetitive patterns of interaction that make up a family's structure function like a script for a play that the actors have read, memorized, and re-enact constantly. When one actor says a certain line from the script or performs a certain action, that is the cue for other actors to recite their particular lines or perform their particular actions. The family's structure is the script for the family play. Families of drug-abusing adolescents tend to have problems precisely because they continue to interact in ways that allow the youths to misbehave. BSFT counselors see the interactions between family members as maintaining or failing to correct problems, and so they make these interactions the targets of change in therapy. The adaptiveness of an interaction is defined in terms of the degree to which it permits the family to respond effectively to changing circumstances.
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Strategy: The Three Ps of Effective Strategy As its second word suggests, a fundamental concept of Brief Strategic Family Therapy is strategy. BSFT interventions are strategic (Haley 1976) in that they are practical, problem-focused, and planned. Practical BSFT uses strategies that work quickly and effectively, even though they might seem unconventional. BSFT may use any technique, approach, or strategy that will help change the maladaptive interactions that contribute to or maintain the family's presenting problem. Some interventions used in BSFT may seem "outside the theory" because they may be borrowed from other treatment modalities, such as behavior modification. For example, behavioral contracting, in which patients sign a contract agreeing to do or not to do certain things, is used frequently as part of BSFT because it is one way to re-establish the parent figures as the family leaders. Frequently, the counselor's greatest challenge is to get the parent(s) to behave in a measured and predictable fashion. Behavioral contracting may be an ideal tool to use to accomplish this. The BSFT counselor uses whatever strategies are most likely to achieve the desired structural (i.e., interactional) changes with maximum speed, effectiveness, and permanence. Often, rather than trying to capture every problematic aspect of a family, the BSFT counselor might emphasize one aspect because it serves to move the counseling in a particular direction. For example, a counselor might emphasize a mother's permissiveness because it is related to her daughter's drug abuse and not emphasize the mother's relationship with her own parents, which may also be problematic. Problem-Focused The BSFT counselor works to change maladaptive interactions or to augment existing adaptive interactions (i.e., when family members interact effectively with one another) that are directly related to the presenting problem (e.g., adolescent drug use). This is a way of limiting the scope of treatment to those family dynamics that directly influence the adolescent's symptoms. The counselor may realize that the family has other problems. However, if they do not directly affect the adolescent's problem behaviors, these other family problems may not become a part of the BSFT treatment. It is not that BSFT cannot focus on these other problems. Rather, the counselor makes a choice about what problems to focus on as part of a timelimited counseling program. For example, the absence of clear family rules about appropriate and inappropriate behavior may directly affect the adolescent's drug-using behavior, but marital problems might not need to be modified to help the parents increase their involvement, control, monitoring and supervision, rule setting, and enforcement of rules in the adolescent's life. Most families of drug-abusing adolescents are likely to experience multiple problems in addition to the adolescent's symptoms. Frequently, counselors complain that "this family has so many problems that I don't know where to start." In these cases, it is important for the counselor to carefully observe the distinction between "content" and "process" (see "Content Versus Process: A Critical Distinction," p. 13). Normally, families with many different problems (a multitude of contents) are unable to tackle one problem at a time and keep working on it until it has been resolved (process). These families move (process) from one problem to another (content) without being able to focus on a single problem long enough to resolve it. This is precisely how they become overwhelmed with a large number of unresolved problems. It is their process, or how they resolve problems, that is faulty. The counselor's job is to help the family keep working on (process) a single problem (content) long enough to resolve it. In turn, the experience of resolving the problem may help change the family's process so that family members can apply their newly acquired resolution skills to other problems they are facing. If the counselor gets lost in the family's process of shifting from one content/ problem to another, he or she may feel overwhelmed and, thus, be less likely to help the family resolve its conflicts. Planned In BSFT, the counselor plans the overall counseling strategy and the strategy for each session. "Planned" means that after the counselor determines what problematic interactions in the family are contributing to the problem, he or she then makes a clear and well-organized plan to correct them.
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Content Versus Process: A Critical Distinction In BSFT, the "content" of therapy refers to what family members talk about, including their explanations for family problems, beliefs about how problems should be managed, perspectives about who or what causes the problems, and other topics. In contrast, the "process" of therapy refers to how family members interact, including the degree to which family members listen to, support, interrupt, undermine, and express emotion to one another, as well as other ways of interacting. The distinction between content and process is absolutely critical to BSFT. To be able to identify repetitive patterns of interaction, it is essential that the BSFT counselor focus on the process rather than the content of therapy. Process is identified by the behaviors that are involved in a family interaction. Nonverbal behavior is usually indicative of process as is the manner in which family members speak to one another. Process and content can send contradictory messages. For example, while an adolescent may say, "Sure Mom, I'll come home early," her sarcastic gesture and intonation may indicate that she has no intention of following her mother's request that she be home early. Generally, the process is more reliable than the content because behaviors or interactions (e.g., disobeying family rules) tend to repeat over time, while the specific topic involved may change from interaction to interaction (e.g., coming home late, not doing chores, etc.). The focus of BSFT is to change the nature of those interactions that constitute the family's process. The counselor who listens to the content and loses sight of the process won't be able to make the kinds of changes in the family that are essential to BSFT work. Frequently, a family member will want to tell the counselor a story about something that happened with another family member. Whenever the counselor hears a story about another family member, the counselor is allowing the family to trap him or her in content. If the counselor wants to refocus the session from content to process, when Mom says, "Let me tell you what my son did...," the counselor would say: "Please tell your son directly so that I can hear how you talk about this." When Mom talks to her son directly, the therapist can observe the process rather than just hear the content when Mom tells the therapist what her son did. Observations like these will help the therapist characterize the problematic interactions in the family.
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Chapter 3 - Diagnosing Family System Problems The BSFT approach to assessing and diagnosing family system problems differs drastically from that used by other kinds of psychotherapies. Unlike other psychotherapies that assess and diagnose by focusing on content, such as talking about a family's history, BSFT assesses and diagnoses by identifying the current family process. BSFT focuses on the nature and characteristics of the interactions that occur in the family and either help or hinder the family's attempts to get rid of the adolescent's problem behaviors. The following six elements of the family's interactions are examined in detail:
Organization Resonance Developmental stages Life context Identified patient Conflict resolution Organization
As repetitive patterns of interaction in a family occur over time, they give the family a specific form, or "organization." Three aspects of this organization are examined below: leadership, subsystem organization, and communication flow. Leadership Leadership is defined as the distribution of authority and responsibility within the family. In functional twoparent families, leadership is in the hands of the parents. In modern societies, both parents usually share authority and decisionmaking. Frequently, in one-parent families, the parent shares some of the leadership with an older child. The latter situation has the potential for creating problems. In the case of a single parent living within an extended family framework, leadership may be shared with an uncle, aunt, or grandparent. In assessing whether leadership is adaptive, BSFT counselors look at hierarchy, behavior control, and guidance. Counselors look at the hierarchy, or the way a family is ranked, to see who is in charge of leading the family and who holds the family's positions of authority. BSFT assumes that the leadership should be with the parent figures, with supporting roles assigned to older family members. Some leadership responsibilities can be delegated to older children, as long as those responsibilities are not overly burdensome, are ageappropriate, and are delegated by parent figures rather than usurped by the children. BSFT counselors look at behavior control in the family to see who, if anyone, keeps order and doles out discipline in the family. Effective behavior control typically means that the parents are in charge and the children are acting in accordance with parental rules. Guidance refers to the teaching and mentoring functions in the family. BSFT assesses whether these roles are filled by appropriate family members and whether the youngsters' needs for guidance are being met. Subsystem Organization Families have both formal subsystems (e.g., spouses, siblings, grandparents, etc.) and informal subsystems (e.g., the older women, the people who manage the money, the people who do the housekeeping, the people who play chess). Important subsystems must have a certain degree of privacy and independence. BSFT looks at issues such as the adequacy or appropriateness of the subsystems in a family. It also assesses the nature of the relationships that give rise to these subsystems and especially looks at subsystem membership, triangulation, and communication flow, which are discussed below. Subsystem Membership BSFT identifies the family's subsystems, which are small groups within the family that are composed of family members with shared characteristics, such as age, gender, role, interests, or abilities. BSFT counselors pay particular attention to the appropriateness of each subsystem's membership and to the boundaries between subsystems. For example, parent figures should form a subsystem, while siblings of similar ages should also form a subsystem, and each of these subsystems should be separate from the others.
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Subsystems that cross generations (e.g., between a parent and one child) cause trouble because such relationships blur hierarchical lines and undermine a parent's ability to control behavior. Relationships in which one parent figure and a child unite against another parent figure are called "coalitions." Coalitions are destructive to family functioning and are very frequently seen in families of drug-abusing adolescents. In these cases, the adolescent has gained so much power through this relationship that he or she dares to constantly challenge authority and gets away with it. The adolescent has this power to be rebellious, disobedient, and out of control by having gained the support of one parent who, to disqualify the other parent, enables the adolescent's inappropriate behavior. Triangulation Sometimes when two parental authority figures have a disagreement, rather than resolving the disagreement between themselves, they involve a third, less powerful person to diffuse the conflict. This process is called "triangulation." Invariably this triangulated third party, usually a child or an adolescent, experiences stress and develops symptoms of this stress, such as behavior problems. Triangles always spell trouble because they prevent the resolution of a conflict between two authority figures. The triangulated child typically receives the brunt of much of his or her parents' unhappiness and begins to develop behavior problems that should be understood as a call for help. Communication Flow The final category of organization looks at the nature of communication. In functional families, communication flow is characterized by directness and specificity. Good communication flow is the ability of two family members to directly and specifically tell each other what they want to say. For example, a declaration such as, "I don't like it when you yell at me," is a sign of good communication because it is specific and direct. Indirect communications are problematic. Take, for example, a father who says to his son, "You tell your mother that she better get here right away," or the mother who tells the father, "You better do something about Johnny because he won't listen to me." In these two examples, the communication is conducted through a third person. Nonspecific communications are also troublesome, as in the case of the father who tells his son, "You are always in trouble." The communication would be more constructive if the father would explain very clearly what the problem is. For example: "I get angry when you come home late." Resonance "Resonance" defines the emotional and psychological accessibility or distance between family members. A 6-year-old son who hangs onto his mother's skirt at his birthday party may be said to be overly close to her. A mother who cries when her daughter hurts is emotionally very close. A father who does not care that his son is in trouble with the law may be described as psychologically and emotionally distant. One of the key concepts related to resonance is boundaries. An interpersonal boundary, just as the words imply, is a way of denoting where one person or group of people ends and where the next one begins. People set their own boundaries when they let others know which behaviors entering their personal space they will allow and which ones they will not allow. In families, resonance refers to the psychological and emotional closeness or distance between any two family members. This psychological and emotional distance is established and maintained by the boundaries that exist between family members. In particular, the boundaries between two family members determine how much affect, or emotion, can get through from one person to the other. If the boundaries between two people are very permeable, then a lot gets through, and there is high resonance-- great psychological and emotional closeness--between them. One's happiness becomes the other's happiness. If the boundaries between two people are overly rigid, then each person may not even know what the other is feeling. Enmeshment and Disengagement The firmness and clarity of boundaries reflect the degree of differentiation within a family system. At one extreme, boundaries can be extremely impermeable. If this is the case, the emotional and psychological distance between family members is too large, and these family members are said to be "disengaged" from each other. At the other extreme, boundaries can be far too permeable or almost nonexistent. When boundaries are that permeable, the emotional and psychological closeness between people is too great, and these family members are said to be "enmeshed." Each of these extremes is problematic and becomes a target for intervention.
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Interactions that are either enmeshed or disengaged can cause problems. When these interactions cause problems, they need to be altered to establish a better balance between the closeness and distance that exists between different family members. For each family, there is an ideal balance between closeness and distance that allows cooperation and separation. Resonance and Culture Resonance needs to be assessed in the context of culture. This is important because some cultures encourage family members to be very close with each other, while other cultures encourage greater distance. One important aspect of culture involves the racial or ethnic groups with which families identify themselves. For example, Hispanics are more likely than white Americans to be close and, thus, appear more enmeshed (have higher resonance) (e.g., Woehrer 1989). Similarly, an Asian father may be quite distant or disengaged from the women in his family, which is considered natural in his culture (Sue 1998). However, whether the culture dictates the distance between family members, it is important for counselors to question if a particular way of interacting is causing problems for the family. In other words, even if an interaction is typical of a culture, if it is causing symptoms, then it may need to be changed. This type of situation must be handled with great knowledge and sensitivity to demonstrate respect for the culture and to allow family members to risk making a change that is foreign to their culture. Enmeshment (high resonance) and Disengagement (low resonance) Sometimes "enmeshment" (excessive closeness) and "disengagement" (excessive distance) can occur at the same time within a single family. This happens frequently in families of drug-abusing youths, when one parent is sometimes very protective and is closely allied with the youth (i.e., enabling), while the other parent may be somewhat disinterested and distant. BSFT counselors look for certain behaviors in a family that are telltale signs of either enmeshment or disengagement. Obviously, some of these behaviors may happen in any family. However, when a large number of these behaviors occur or when some occur in an extreme form, they are likely to reflect problems in the family's patterns of interaction. Easily observable symptoms of enmeshment include one person answering for another, one person finishing another's statements, and people interrupting each other. Observable symptoms of disengagement include one family member who wants to be separated from another or a family member who rarely speaks or is spoken about. Developmental Stages Individuals go through a series of developmental stages, ranging from infancy to old age. Certain conditions, roles, and responsibilities typically occur at each stage. Families also go through a series of developmental stages. For family members to continue to function adaptively at each developmental stage, they need to behave in ways that are appropriate for the family's developmental level. Each time a developmental transition is reached, the family is confronted by a new set of circumstances. As the family attempts to adapt to the new circumstances, it experiences stress. Failure to adapt, to make the transition, to give up behaviors that were used successfully at a previous developmental stage, and to establish new behaviors that are adaptive to the new stage will cause some family members to develop new behavior problems. Perhaps one of the most stressful developmental changes occurs when children reach adolescence. This is the stage at which a large number of families are not able to adapt to developmental changes (e.g., from direct guidance to leadership and negotiation). Parents must be able to continue to be involved and monitor their adolescent's life, but now they must do it from a distinctly different perspective that allows their daughter or son to gain autonomy. At each developmental stage, certain roles and tasks are expected of different family members. One way to determine whether the family has successfully overcome the various developmental challenges that it has confronted is to assess the appropriateness of the roles and tasks that have been assigned to each family member, considering the age and position of each person within the family.
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When a family's developmental stage is analyzed, four major sets of tasks and roles must be assessed: (1) Parenting tasks and roles are concerned with the parent figures' ability to act as parents at a level consistent with the age of the children; (2) Marital tasks and roles assess how well spouses cooperate and share parenting functions; (3) Sibling tasks and roles assess whether the children and adolescents are behaving in an age-appropriate fashion; and (4) Extended family's tasks and roles target the support for and intrusion into parenting functions from, for example, grandparents, aunts, and uncles, if extended family members are part of the household or share in parenting responsibilities. Developmental transitions may be stressful. They are likely to cause family shake-ups because families may continue to approach new situations in old ways, thus making it possible for conflict to develop. Most often, families come to the attention of counselors precisely at these times. Of all of these developmental milestones, reaching adolescence appears to be one of the most risky and critical stages in which drug abuse can occur in most ethnic groups (Steinberg 1991; Vega and Gil 1999). Although the adolescent is the family member who is most likely to behave in problematic ways, often other members of the family, such as parents, also exhibit signs of troublesome or maladaptive behaviors and feelings (Silverberg 1996). Assessing Appropriate Developmental Functioning Careful judgments are needed to determine what is developmentally appropriate and/or inappropriate for each family member. It is particularly difficult to make these judgments when assessing the tasks and roles of children and extended family members. In every instance, the BSFT counselor should take into account the family's cultural heritage when making these judgments. For example, it is useful to know that some traditional African-American and Hispanic families tend to protect their children longer than non-Hispanic whites do (White 1994). Thus, it would not be unusual for children to have a longer period of dependence among traditional Hispanic groups than among non-Hispanic white families. Similarly, it would not be unusual for the African-American caretaker of a 12-year-old to continue to behave in an authoritarian manner without the child rebelling or considering it odd. In fact, researchers have suggested that AfricanAmerican inner city youths experience an authoritarian command as caring, while a child from another cultural group might experience it as rejecting (Mason et al. 1994). However, as suggested earlier, as an adolescent in the United States grows older, his or her parent, who may be from any culture and in any setting, may have to moderate his or her level of control and increase his or her authoritative parenting, or the youth may rebel. Common Problems in Assessing Appropriateness of Developmental Stage It is often difficult for parents to determine what is developmentally appropriate for children of different ages; for example, how much or how little responsibility should a child 6, 10, or 16 years old have in a household? In families of drug-abusing and conduct-disordered adolescents, parents and their children often have a difficult time determining what is developmentally appropriate for a child's age. One of the main problems family members encounter is how to determine the degree of supervision and autonomy that children should have at each age level. This is a highly complex and conflictive area, even for the best of parents, because as children grow older, they experience considerable pressure from their peers to demonstrate increasing independence. It is also complex because many parents are not aware of what might be the norm in today's society. Therefore, they may allow too little or too much autonomy, based either on their own comfort or discomfort level, their own experience, and/or their culture. Moreover, children's peer groups may vary considerably in the level of autonomy they expect from parents. In working with the notion of "developmental appropriateness," a BSFT counselor needs to examine issues such as roles and functions, rights and responsibilities, limits and consequences, as they are applied to the adolescents in the family. Examples of these standards are available from adolescent development research (Steinberg 1998).
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Life Context While the dimensions of family functioning discussed up to now are all within the family, life context refers to what happens in the family's relationship to its social context. The life context of the family includes the extended family, the community, the work situation, adolescent peers, schools, courts, and other groups that may have an impact on the family, either as stressors or as support systems. Antisocial Peers A careful analysis of the life context is useful in many situations involving the treatment of substance abuse. For example, a youngster who uses drugs may be involved with a deviant or antisocial peer group. These friendships affect the youth and family in an adverse way and will certainly need to be modified to successfully eliminate the youth's drug use. Parents need help to identify less acceptable and more acceptable adolescent peers so that they can encourage their teens to associate with more desirable peers and discourage them from associating with less desirable peers. Parent Support Systems and Social Resources Parenting is a difficult task. Parents often lack adequate support systems for parenting. Parents need support from friends, extended family members, and other parents (Henricson and Roker 2000). The availability of support systems needs to be assessed, particularly in the case of single-parent families. The availability of social resources needs to be assessed, both in terms of what is already being used or what could potentially be used. Juvenile Justice System Increasingly, probation officers and the courts have become critical players in the families of drug-abusing adolescents. It is the BSFT counselor's job to assess how juvenile justice representatives such as probation officers interact with the family to determine whether they are supporting or undermining the family. One way to assess the probation officer's role, for example, is to invite him or her to participate in a family therapy session. Identified Patient The "identified patient" is the family member who has been branded by the family as the problem. The family blames this person, usually the drug-abusing adolescent, for much of its troubles. However, as discussed earlier, the BSFT view of the family is that the symptom is only that: a symptom of the family's problems. The more that family members insist that their entire problem is embodied in a single person, the more difficult it will be for them to accept that it is the entire family that needs to change. On the other hand, the family that recognizes that several of its members may have problems is far healthier and more flexible and will have a relatively easier time of making changes through BSFT. The BSFT counselor believes that the problem is in the family's repetitive (habitual, rigid) patterns of interaction. Thus, the counselor not only will try to change the person who exhibits the problem but also to change the way all members of the family behave with each other. The other aspect to understanding a family's identified patient is that usually families with problematic behaviors identify only one aspect of the identified patient as the source of all the pain and worry. For example, families of drug-abusing youths tend to focus only on the drug use and possibly on accompanying school and legal troubles that are directly and overtly related to the drug abuse. These families usually overlook the fact that the youngster may have other symptoms or problems, such as depression, attention deficit disorder, and learning deficits.
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Conflict Resolution While solving differences of opinion is always challenging, it is much more challenging when it is done in the context of a conflictive relationship that is high in negativity. The following are five different ways in which families can approach or manage conflicts. Some are adaptive and some are not. In the case of drugabusing adolescents, with few exceptions, the first four tend to be ineffective, whereas the fifth tends to be effective in most situations:
Denial Avoidance Diffusion Conflict emergence without resolution Conflict emergence with resolution
Denial "Denial" refers to a situation in which conflict is not allowed to emerge. Sometimes this is done by adopting the attitude that everything is all right. At other times, conflict is denied by arranging situations to avoid confrontation or establishing unwritten rules with which no one dares to disagree outwardly, regardless of how they feel. The classic denial case is the one in which the family says: "We have no problems." Avoidance "Avoidance" refers to a situation in which conflict begins to emerge but is stopped, covered up, or inhibited in some way that prevents it from emerging. Examples of avoidance include postponing ("Let's not have a fight now."), humor ("You're so cute when you're mad."), minimizing ("That's not really important."), and inhibiting ("Let's not argue; you know what can happen.").
Diffusion "Diffusion" refers to situations in which conflict begins to emerge, but discussion about the conflict is diverted in another direction. This diversion prevents conflict resolution by distracting the family's attention away from the original conflict. This change of subject is often framed as a personal attack against the person who raised the original issue. For example, a mother says to her husband, "I don't like it when you get home late," but the husband changes the topic by responding: "What kind of mother are you anyway, letting your son stay home from school today when he is not even sick!"
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Conflict Emergence Without Resolution "Conflict emergence" without resolution occurs when different opinions are clearly expressed, but no final solution is accepted. Everyone knows exactly where everyone else stands, but little is done to reach a negotiated agreement. Sometimes this occurs because the family, while willing to discuss the problem, simply does not know how to negotiate a compromise. Conflict Emergence With Resolution Emergence of the conflict and its resolution is generally considered to be the best outcome. Separate accounts and opinions regarding a particular conflict are clearly expressed and confronted. Then, the family is able to negotiate a solution that is acceptable to all family members involved. A Caveat In some cases, conflicts need to be postponed for more appropriate times. For example, if a family member is very angry, tired, or sick, it may be reasonable to table the conflict until he or she is ready to have a meaningful discussion. However, in such instances, it is critical that the family set a specific time to address the conflict. Indefinitely postponing conflict resolution is a sign of avoidance. A postponement for a definite amount of time is adaptive. In other instances, a person may decide that the issue at hand is not worth having an argument about. For example, one person may want to stay home while his or her partner wants to go dancing. Either partner may opt to compromise by agreeing to the other's preference. So long as partners take turns compromising, this is adaptive and balanced. However, if the same person is always the one to give in, this may reflect the use of denial by one partner to avoid conflict with the other.
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Chapter 4 - Orchestrating Change This chapter describes the BSFT approach to orchestrating change in the family. The first section describes how BSFT counselors establish a therapeutic relationship, including the importance of joining with the family, the role of tracking family interactions, and what is involved in building a treatment plan. The second section describes strategies for producing change in the family, including focusing on the present, reframing negativity in the family, shifting patterns of interaction through reversals of usual behavior, changing family boundaries and alliances, "detriangulating" family members caught in the middle of others' conflicts, and opening up closed family systems or subsystems by directing new interactions. Establishing a Therapeutic Relationship The counselor's first step in working with a family is to establish a therapeutic relationship with the family, beginning with the very first contact with family members. The quality of the relationship between the counselor and the family is a strong predictor of whether families will come to, stay in, and improve in treatment (Robbins et al. 1998). In general, studies have found that the therapeutic relationship is a strong predictor of success in many forms of therapy (Rector et al. 1999; Stiles et al. 1998). Validating and supporting the family as a system and attending to each individual family member's experience are particularly important aspects of developing and maintaining a good therapeutic relationship (Diamond et al. 1999; Diamond and Liddle 1996). Establishing a therapeutic relationship means that the BSFT counselor needs to form a new system--a therapeutic system--made up of the counselor and the family. In this therapeutic system, the counselor is both a member and its leader. One challenge for the BSFT counselor is to establish relationships with all family members, some of whom are likely to be in conflict with each other. For example, drug-abusing adolescents generally begin treatment in conflict with their parent(s) or guardian(s). Both parties approach counseling needing support from the counselor. The counselor's job is to find ways to support the individuals on either side of the conflict. For example, the counselor might say to the adolescent, "I am here to help you explain to your something he or she would like to achieve, the counselor is able to establish a therapeutic alliance with the whole family. The BSFT approach is based on the view that building a good therapeutic relationship is necessary to bring about change in the family. Several strategies for building a therapeutic relationship, joining, tracking, and building a treatment plan, are discussed below. Joining A number of techniques can be used to establish a therapeutic relationship. Some of these techniques fall into the category of "joining," or becoming a temporary member of the family. Definition of Joining In BSFT, joining has two aspects. Joining it is the steps a counselor takes to prepare the family for change. Joining also occurs when a therapist gains a position of leadership within the family. Counselors use a number of techniques to prepare the family to accept therapy and to accept the therapist as a leader of change. Some techniques that the therapist can use to facilitate the family's readiness for therapy include presenting oneself as an ally, appealing to family members with the greatest dominance over the family unit, and attempting to fit in with the family by adopting the family's manner of speaking and behaving. A counselor has joined a family when he or she has been accepted as a "special temporary member" of the family for the purpose of treatment. Joining occurs when the therapist has gained the family's trust and has blended with family members. To prepare the family for change and earn a position of leadership, the counselor must show respect and support for each family member and, in turn, earn each one's trust. One of the most useful strategies a counselor can employ in joining is to support the existing family power structure. The BSFT counselor supports those family members who are in power by showing respect for them. This is done because they are the ones with the power to accept the counselor into the family; they have the power to place the counselor in a leadership role, and they have the power to take the family out of counseling. In most families, the most powerful member needs to agree to a change in the family, including changing himself or herself. For that reason, the counselor's strongest alliance must initially be with the most powerful family member. BSFT counselors must be careful not to defy those in power too early in the
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process of establishing a therapeutic relationship. Inexperienced family counselors often take the side of one family member against another, behaving as though one were right and the other were obviously wrong. In establishing relationships with the family, the counselor must join all family members, not just those with whom he or she agrees. In fact, frequently, the person with whom it is most critical to establish an alliance or bond is the most powerful and unlikable family member. Many counselors in the drug abuse field feel somewhat hopeless about helping the families of drug-abusing youths because these families have many serious problems. Counselors who feel this way may find a discussion about becoming a member of the family unhelpful because their previous efforts to change families have been unsuccessful. BSFT teaches counselors how to succeed by approaching families as insiders, not as outsiders. As outsiders, counselors typically attempt to force change on the family, often through confrontation. However, the counselor who has learned how to become part of the system and to work with families from the inside should seldom need to be confrontational. Confrontation erodes the rapport and trust that the counselor has worked hard to earn. Confrontation can change the family's perception of the counselor as being an integral part of the therapeutic system to being an outsider. The Price of Failed Joining An example may help illustrate what is meant by powerful family members. The court system referred a family to counseling because its oldest child had behavior problems. The mother was willing to come to counseling with her son, but the mother's live-in boyfriend did not want the family to be in counseling. The counselor advised the mother to come to therapy with the adolescent anyway. The boyfriend felt that his position of power had been threatened by the potential alliance between the mother and the counselor. As a result, the boyfriend reasserted himself, demanding that she stop participating in counseling. She then dropped out of counseling. This is clearly a case in which the counselor's early challenge of the family's way of "operating" caused the entire family to drop out of treatment. The counselor could and should have been more aware and respectful of the family's existing power structure. Respect, in this case, does not mean that the counselor approves of or agrees with the boyfriend's behavior. Rather, it means that the counselor understands how this family is organized and works his or her way into the family through the existing structure. A more adaptive counseling strategy might be to call the mother's boyfriend, with the mother's permission, to recognize his position of power in the family and request his help with his girlfriend's son. A Cautionary Note: Family Secrets As was already stated, joining is about establishing a relationship with every member of the family. Sometimes a family member will try to sabotage the joining process by using family secrets. Some secrets can cause the counselor such serious problems that he or she is forced to refer the family he or she had intended to help to another counselor. Secrets are best dealt with up front. The counselor should not allow himself or herself to get trapped in a special relationship with one family member that is based on sharing a secret that the other family members do not know. A counselor who keeps a secret is caught between family members. The counselor has formed an alliance with one family member to the exclusion of others. In some cases, it is not just an alliance with one family member but also an alliance with one family member against another family member. It means that the family member with the secret can blackmail the counselor with the threat of revealing that the counselor knows this secret and didn't address it with the family. Consequently, a family secret is a very effective strategy that family members can use to sabotage the treatment, if counselors let them. For these reasons, counselors should make it a rule to announce to each family at the onset of counseling that he or she will not keep secrets. The counselor should also say that if anyone shares special information with the counselor, the counselor will help them share it with the appropriate people in the family. For example, if a wife calls and tells the counselor that she is having an affair, her spouse will need to know, although the children do not need to know the parents' marital issues. In this case, the counselor would say, "This affair is indicative of a problem in your marriage. Let me help you share it with your husband." The counselor must do whatever is needed to continue to help the wife see that affairs are symptoms of marital problems. The affair can be reframed as a cry for help, a call for action, or a basic discontent. If so, these marital issues or problems need to be discussed.
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It is possible that despite all the counselor's efforts, the wife will respond with an absolute, "No, I don't want to tell him. He would leave me. Besides, this affair doesn't mean all that much." Typically BSFT therapy only gets into marital issues to the extent that the marital problems are interfering with the parents' abilities to function effectively as parents. However, the counselor has no choice but to help the wife tell her husband about the affair. If the wife absolutely refuses, then the counselor has lost his or her bid for leadership in the counseling process. The wife now has control over the counseling process. For that reason, the counselor must refer the family to another counselor. Tracking In the example on p. 27 about the mother's powerful boyfriend, it was recommended that the counselor use the way in which the family is organized, or interacts, with the father figure in a position of power, as a vehicle for getting the family into treatment. This strategy in which the counselor learns how the family interacts and then uses this information to establish a therapeutic plan of action is called "tracking." Tracking is a technique in which the counselor respects how the family interacts but, at the same time, takes advantage of those family interactions for therapeutic purposes. Sometimes families interact spontaneously, permitting the counselor to observe the family dynamics. When this does not happen spontaneously, the counselor must encourage the family to interact. Encouraging the Family to Interact When a family is in counseling, family members like to tell the counselor stories about each other. For example, a mother might say to the counselor, "My son did so and so." In contrast to the way in which the counselor functions in other therapy models, the BSFT counselor is not interested in the content of the family members' stories. Instead, the counselor is interested in observing (and correcting) problematic interactions. To observe the family's patterns of interaction, the counselor must ask family members to talk directly to each other about the problem. When this occurs, the counselor can observe or track what happens when the family members discuss the issue. The counselor can then watch the family's interactions: fighting, disagreeing, and struggling with their issues. By tracking, the counselor will not only be able to identify the interactive patterns in the family, but also will be able to determine which of these patterns may be causing the family's problems or symptoms. The added benefit of this kind of tracking is that the counselor shows respect for the family's ways of interacting. Tracking Content and Process The difference between "content" and "process" was discussed in Chapter 2 (see p. 13). Content is the subject matter that is being discussed. Process refers to the interactions that underlie the communication. By observing the process, the counselor learns who is dominant, who is submissive, what emotions are expressed in the interaction, and the unwritten rules that appear to guide the family's communication and organization. For example, a mother may mention that her son's drug problem is a concern. The grandmother responds by shouting that the mother is overreacting and needs to back off. The content of the interaction--the son's drug problem--is not nearly as important as the process being displayed--the grandmother undermining the mother and shutting her down. Often the counselor will track or use the family's content because it represents a topic that is important to the family. In this example, the counselor might keep the focus of the counseling session on the son's drug problem because it is an important topic in this family. However, the focus of BSFT is entirely on changing process. What needs to be changed here, as a first step, is the parent figures' inability to agree on the existence of a problem, and, more generally, the grandmother's tendency to invalidate the mother's concerns. Mimesis "Mimesis" is a form of tracking for the purpose of joining. It refers to mimicking the family's behavior in an effort to join with the family. Mimesis can be used to join with the whole family. For example, a counselor can act jovial with a jovial family. Mimesis also can be used to join with one family member. Mimesis is used in everyday social situations. For example, by attending to how others dress for a particular activity so that one can dress appropriately, one is attempting to gain and demonstrate acceptance by mimicking the type of dress that is worn by others (e.g., casual). People mimic other people's moods when they act like the other people do in certain situations. For example, at a funeral they would act sad as others do and at a celebration they would act joyful. When the counselor validates a family by mimicking its behavior, family members are more likely to accept the counselor as one of their own.
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Mimesis also refers to using a family's own ways of speaking to join with the family. Each family and each family member has its, his, or her own vocabulary and perspective. For instance, if a family member is a carpenter, it might be useful to use the language of carpentry. The therapist might say, "Dealing with your son requires lots of different tools, just like jobs at work do. Sometimes you need to use a hammer and use a lot of force, and sometimes you need to use a soft cloth for a more gentle job." If a family member is an accountant, it may be helpful to speak in terms of assets and liabilities. If a person is religious, it may be helpful to speak of God's will. Whatever language a family uses should be the language the counselor uses to converse with that family. The counselor should not talk to a family using vocabulary that is found in this manual--words such as "interactions," "restructuring," and "systems." Instead, the BSFT counselor should use the "pots and pans" language that each of the family members uses in his or her everyday life. For example, if families are uncomfortable with the term "counseling," the term "meetings" might be used. Much of the work the counselor does to establish the therapeutic relationship involves learning how the family interacts to better blend with the family. However, the counselor cannot learn the ways in which the family interacts unless he or she sees family members interacting as they would when the counselor is not present. Getting family members to interact can be difficult because families often come into counseling thinking that their job is to tell the counselor what happened. Therefore, it is essential that counselors decentralize themselves by discouraging communications that are directed at them, and instead encouraging family members to interact so that they can be observed behaving in their usual way. Building a Treatment Plan BSFT diagnoses are made to identify adaptive and maladaptive patterns of family interaction so that the counselor can plan practical, strategically efficient interventions. The purpose of the intervention is to improve the family interactions most closely linked to the adolescent's symptoms. This, in turn, will help the family to manage those symptoms. Enactment: Identifying Maladaptive Interactions In BSFT, the counselor assesses and diagnoses the family's interactions by allowing the family to interact in the counseling session as it normally does at home. To begin, the counselor asks the family to discuss something. When a family member speaks to the counselor about another family member who is present, the counselor asks the family member who is speaking to repeat what was said directly to the family member about whom it was said. Family interactions that occur as they would at home and that show the family's typical interactional patterns are called "enactments." An enactment can either occur spontaneously, or the counselor can initiate it by asking family members to discuss something among themselves. Creating enactments of family interactions is like placing the counselor on the viewing side of a oneway mirror and letting the family "do its thing" while the counselor observes. Different therapy models have different explanations for why a family or adolescent is having difficulty, and so they have different targets of intervention. BSFT targets interactional patterns. Because BSFT is a problem-focused therapy approach, it targets those interactional patterns that are most directly related to the symptom for which the family is seeking treatment. Targeting patterns most directly related to the symptom allows BSFT to be brief and strengthens a therapist's relationship with a family by demonstrating that the therapist will help the family solve the problems family members have identified. Families that develop symptoms tend to be organized or to function around those symptoms. That's because a symptom works like a magnet, organizing the family around it. This is especially true if the symptom is a serious, life-threatening one, such as drug abuse. Therefore, it is most efficient to work with the family by focusing on the symptom around which the family has already organized itself. Family Crises as Enactments Enactments are used to observe family interactions in the present and to identify family interactional problems. Family crises are particularly opportune types of enactments because they are highly charged, and family members are emotionally available to try new behaviors. Therefore, families in crisis should be seen immediately. In addition to gaining valuable information about problematic family interactions, the
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counselor gains considerable rapport with families because he or she is willing to be of service at a time of great need. A Cautionary Note: Adolescents Attending Therapy Sessions on Drugs Counselors usually refuse to work with a client who comes into the therapy session on drugs because the client is viewed as "not being all there" to do the treatment work. However, in the case of a family therapy such as BSFT, determining whether to conduct the session is a strategic decision the counselor must make. One possibility in BSFT is to view the adolescent on drugs as an enactment of what the family confronts at home all the time. Thus, when an adolescent comes to therapy on drugs, it can be viewed as an opportunity for the counselor to teach the family how to respond to the adolescent when he or she takes drugs. The BSFT counselor can see how each family member responds to this situation and look for the maladaptive interactions that allow the adolescent to continue this behavior. The counselor can then work with the nondrug-using family members to change their usual way of responding to the adolescent on drugs. Hence, the work in this session is not with the adolescent but with the other family members. From Diagnosis to Planning Once a therapeutic relationship has been established and a diagnosis has been formulated, the counselor is ready to develop a treatment plan. The treatment plan lays out the interventions that will be necessary to change those family maladaptive interactional patterns that have been identified as related to the presenting symptom. Problematic patterns of family interaction are diagnosed using the six dimensions of family interaction discussed in Chapter 3 (organization, resonance, developmental stages, life context, identified patient, and conflict resolution). Often some dimensions are more problematic than others. The interventions need to focus more on the most problematic interactions than on the others. The six dimensions of the family's interactions operate in an interdependent fashion. For this reason, it may not be necessary to plan a separate intervention to address each problem that has been diagnosed. For example, addressing a family's tendency to blame its problems on the adolescent (i.e., the identified patient) may bring the family's ineffective conflict resolution strategies to light. In a similar fashion, addressing a son's role as his mother's confidant (i.e., inappropriate developmental stage) may bring out the rigid and inflexible boundary between the parent figures. Producing Change As was stated earlier, the focus of BSFT is to shift the family from maladaptive patterns of interaction to adaptive ones. Counselors can use a number of techniques to facilitate this shift. These techniques, all of which are used to encourage family members to behave differently, fall under the heading of "restructuring." In restructuring, the counselor orchestrates and directs change in the family's patterns of interaction (i.e., structure). Some of the most frequently used restructuring techniques are described in this chapter. When the family's structure has been shifted from maladaptive toward adaptive, the family develops a mastery of communication and management skills. In turn, this mastery will help them solve both present and future problems. To help family members master these skills, the BSFT counselor works with them to develop new behaviors and use these new behaviors to interact more constructively with one another. After these more adaptive behaviors and interactions occur, the BSFT counselor validates them with positive reinforcements. Subsequently, the counselor gives the family the task of practicing these new behaviors/interactions in naturally occurring situations (e.g., when setting a curfew or when eating meals together) so that family members can practice mastering these skills at home. Mastering more adaptive interactions provides families with the tools they need to manage the adolescent's drug abuse and related problem behaviors. Some adaptive behaviors/interactions that validate individual family members are self-reinforcing. However, the counselor needs to reinforce those behaviors/interactions that initially are not strongly self-reinforcing (i.e., validated) to better ensure their sustainability. As family members reinforce each other's more adaptive skills, they master the skills needed to behave in adaptive ways. It is very important to note that mastery of adaptive skills is not achieved by criticizing, interpreting, or belittling the individual. Rather, it is achieved by incrementally shaping positive behavior.
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Seven Frequently Used Restructuring Techniques The rest of this chapter describes seven frequently used restructuring techniques (i.e., to change families' patterns of interaction). These techniques will give a counselor the basic tools needed to help a family change its patterns of interaction. The seven restructuring techniques are: 1. 2. 3. 4. 5. 6. 7. 8.
Working in the present Reframing negativity Reversals Working with boundaries and alliances Detriangulation Opening up closed systems Tasks Working in the Present
Although some types of counseling focus on the past (Bergin and Garfield 1994), BSFT focuses strictly on the present. In BSFT, families do not simply talk about their problems, because talking about problems usually involves telling a story about the past. Working in the present with family interactional processes that are maintaining the family's symptoms is necessary to bring about change in BSFT. Consequently, the BSFT counselor wants the family to engage in interactions within the therapy session--in the same way that it would at home. When this happens and family members enact the way in which they interact routinely, the counselor can respond to help the family members reshape their behavior. Several techniques that require working in the present with family processes are found in subsequent sections within this chapter. 1. Working in the present Does BSFT Ever Work in the Past? Counselors work with the past less than 5 percent of the counseling time. One important example of working in the past can be illustrated by an early counseling session in which the parent and adolescent are in adversarial roles. The parent may be angry or deeply hurt by the youth's behavior. One strategy to overcome this impasse in which neither family member is willing to bend is to ask the parent, "Can you remember when Felix was born? How did you feel?" The parent may say nostalgically: "He was such a beautiful child. The minute I saw him, I was enchanted. I loved him so much I thought my heart would burst." This kind of intervention is called "reconnection" (cf. Liddle 1994, 1995, 2000). When the parent is hardened by the very difficult experiences he or she has had with a troublesome adolescent, counselors sometimes use the strategy of reconnection to overcome the impasse in which neither the parent nor the youth is willing to bend first. Reconnection is an intervention that helps the parent recall the positive feeling (love) that he or she once had for the child. After the parent expresses his or her early love for the child, the counselor turns to the youth and says: "Did you know your mother loves you so very much? Look at the expression of bliss on her face." As can be seen, the counseling session digressed into the past for a very short time to reconnect the parent. This was necessary to change the here-and-now interaction between two family members. The reconnection allowed the counselor to transform an interaction characterized by resentment into an interaction characterized by affection. Because the feelings of affection and bonding do not last long, the counselor must move quickly to use reconnection as a bridge that moves the counseling to a more positive interactional terrain. 2. Reframing: Systemic Cognitive Restructuring To "reframe," a counselor creates a different perspective or "frame" of reality than the one within which the family has been operating. He or she presents this new frame to the family in a convincing manner --that is, "selling" it to the family and then using this new frame to facilitate change. The purpose of systemsoriented, cognitive restructuring (reframing) is to change perceptions and/or meaning in ways that will enable family members to change their interactions. Most of the time, in families of adolescent drug abusers, negativity needs to be reframed. Negativity is usually exhibited as blaming, pejorative, and invalidating statements ("You are no good." "I can't trust you."), and, in general, "angry fighting."
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Reframing negativity might involve describing a mother's criticism of her teenage son as her desire that he be successful, or reframing fighting as an attempt to have some sort of connection with another family member. It has been suggested that "... high levels of negativity interfere with effective problem-solving and communication within the family" (Robbins et al. 1998, p. 174). Robbins and colleagues report that negativity in family therapy sessions is linked to dropping out of family therapy. For those who remain in therapy, negativity is linked to poor family therapy outcomes. Because negativity is bad for the family and for the therapy, most contemporary family therapies target negativity (Alexander et al. 1994). The bestknown strategy for transforming negative interactions into positive ones is reframing (Robbins et al. 2000). While the counselor is encouraged to permit family members to interact with each other in their usual way and to join before orchestrating change, a caveat is necessary when intense negative feelings accompany conflictive interactions. If the family is to remain in counseling, family members must experience some relief from the negative feelings soon after counseling begins. Therefore, counselors are encouraged to use reframing abundantly, if necessary, in the first and perhaps the first few sessions to alleviate the family's intensive negative feelings. Such reframes also may allow family members to discuss their pain and grievances in a meaningful way. An example will help illustrate the use of reframing negative feelings to create more positive feelings among family members. Anger is a fairly common emotion among families with an adolescent who is involved in antisocial activities. The parents may feel angry that their attempts to guide their child down the "right" path have failed and that the child disrespects their guidance. The adolescent is likely to interpret this anger as uncaring and rejecting. Both parties may feel that the other is an adversary, which severely diminishes the possibility that they can have a genuine dialogue. The particular reframe that needs to be used is one that changes the emotions from anger, hurt, and fighting (negative) to caring and concern (positive). The counselor must create a more positive reality or frame. The counselor, for example, might say to the parent, "I can see how terribly worried you are about your son. I know you care an awful lot about him, and that is why you are so frustrated about what he is doing to himself." With this intervention, the counselor helps move both the parent's and the child's perceptions from anger to concern. Typically, most parents would respond by saying, "I am very worried. I want my child to do well and to be successful in life." When the youth hears the parent's concern, he or she may begin to feel less rejected. Instead of rejecting, the parent is now communicating concern, care, and support for the child. Hence, by creating a more positive sense of reality, the counselor transforms an adversarial relationship between the parent(s) and the adolescent, orchestrating opportunities for new channels of communication to emerge and for new interactions to take place between them. Reframing is among the safest interventions in BSFT, and, consequently, the beginning counselor is encouraged to use it abundantly. Reframing is an intervention that usually does not cause the counselor any loss of rapport. For that reason, the counselor should feel free to use it abundantly, particularly in the most explosive situations. Affect: Creating Opportunities for New Ways of Behaving In BSFT, counselors are interested in affect (a feeling or an emotion) as it is reflected in interactions. In BSFT, the counseling strategy is to use emotion as an opportunity to "move" the family to a new, more adaptive set of interactions. One of many possible ways of working with emotion is found in the following example. When a mother cries, the counselor might suggest to the drug-abusing youngster, "Ask your mom to tell you about her tears." An alternative would be, "What do you think your mom's tears are trying to say?" If the youth responds, "I think it is...," the counselor would follow with a directive to the youth, "Ask your mother if what you think her tears mean is why she is crying." In this way, the crying is used to initiate an interaction among family members that acknowledges not only the emotion in crying but also the experience underlying the crying. In other words, the crying is used to promote interactions that show respect for the emotion as well as promote a deeper level of understanding among family members. In another example, a drug-abusing adolescent and her family come to their first BSFT counseling session. The parents proceed to describe their daughter as disobedient, rebellious, and disrespectful-- a girl who is
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ruining her life and going nowhere. They are angry and reject this young girl, and they blame her for all the pain in the family. In this instance, the BSFT counselor recognizes that the family is "stuck" about what to do with this girl and that their inability to decide what to do is based on the view they have developed about her and her behavior. To "open up" the family to try new ways to reach the youngster, the BSFT counselor must present a new "frame" or perspective that will enable the family to react differently toward the girl. The BSFT counselor might tell the family that, although she realizes how frustrated and exasperated they must feel about their daughter's behavior, "it is my professional opinion that the main problem with this girl is that she is very depressed and is in a lot of pain that she does not know how to handle." Reframing is a practical tool used to stimulate a change in family interactions. With this new frame, the family may now be able to behave in new ways toward the adolescent, which can include communicating in a caring and nurturing manner. A more collaborative set of relationships within the family will make it easier for the parents to discuss the daughter's drug abuse, to address the issues that may be driving her to abuse drugs, and to develop a family strategy to help the adolescent reduce her drug use. 3. Reversals When using the technique called "reversal," the counselor changes a habitual pattern of interacting by coaching one member of the family to do or say the opposite of what he or she usually would. Reversing the established interactional pattern breaks up previously rigid patterns of interacting that give rise to and maintain symptoms, while allowing alternatives to emerge. If an adolescent gets angry because her father nagged her, she yells at her father, and the father and daughter begin to fight, a reversal would entail coaching the father to respond differently to his daughter by saying, "Rachel, I love you when you get angry like that," or "Rachel, I get very frightened when you get angry like that." Reversals make family members interact differently than they did when the family got into trouble. 4. Working With Boundaries and Alliances Certain alliances are likely to be adaptive. For example, when the authority or parent figures in the family are allied with each other, they will be in a better position to manage the adolescent's problem behaviors. However, when an alliance forms between a parent figure and one of the children against another parent figure, the family is likely to experience trouble, especially with antisocial adolescent behavior. An adolescent who is allied with an authority figure has a great deal of power and authority within the family system. Therefore, it would be difficult to place limits on this adolescent's problem behavior. One goal of BSFT is to realign maladaptive alliances. One important determinant of alliances between family members is the psychological barrier between them, or the metaphorical fence that distinguishes one member from another. BSFT counselors call this barrier or fence a "boundary." Counselors aim to have clear boundaries between family members so that there is some privacy and some independence from other family members. However, these should not be rigid boundaries, with which family members would have few shared experiences. By shifting boundaries, BSFT counselors change maladaptive alliances across the generations (e.g., between parent figures and child). For example, in a family in which the mother and the daughter are allied and support each other on almost all issues while excluding the father, the mother may no longer be powerful enough to control her daughter when she becomes an adolescent and may need help. In this case, an alliance between the mother and the father needs to be re-established, while the cross-generational coalition between mother and daughter needs to be eliminated. It is the BSFT counselor's job to shift the alliances that exist in the family. This means restoring the balance of power to the parents or parent figures so that they can effectively exercise their leadership in the family and control their daughter's behavior. The counselor attempts to achieve these alliance shifts in a very smooth, subtle, and perhaps even sly fashion. Rather than directly confronting the alliance of the mother and daughter, for example, the counselor may begin by encouraging the father to establish some form of interaction with his daughter. Boundary shifting is accomplished in two ways. Some boundaries need to be loosened, while others need to be strengthened. Loosening boundaries brings disengaged family members (e.g., father and daughter) closer together. This may involve finding areas of common interest between them and encouraging them to pursue these interests together. For instance, in the case of a teenaged son enmeshed with his mother and disengaged from his father, the counselor may direct the father to involve his son in a project or to take his
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son on regular outings. The counselor also may arrange the seating in counseling sessions to help strengthen some alliances and loosen others. In addition to bringing family members closer together, the counselor may need to strengthen the boundaries between enmeshed family members to create more separation. One example is the mothergrandmother parenting system in which the grandmother enables her grandson's drug use by protecting him from his mother's attempts to set limits. Rather than confronting the grandmother-adolescent alliance directly, the counselor may first encourage the mother and grandmother to sit down together and design a set of rules and responsibilities for the adolescent. This process of designing rules often requires the parent figures to work out some of the unresolved conflict(s) in their relationship, without the counselor having to address that relationship directly. This brings the mother closer to the grandmother and distances the grandmother from the adolescent, thereby rearranging the family's maladaptive hierarchy and subsystem composition. It should be noted that, in this case, the counselor tracks the family's content (grandmother hiding adolescent's drug use from mother) as a maneuver to change the nature of the interaction between the mother and the grandmother from an adversarial relationship to one in which they agree on something. The adolescent's drug use provides the content necessary to strengthen the boundaries between the generations and to loosen the boundaries between the parent figures. Clearly, bringing the mother and grandmother together to the negotiating table is only an intermediate step. After that, the tough work of helping mother and grandmother negotiate their deep-seated resentments and grievances against each other begins. Because the counselor follows a problem-focused approach, he or she does not attempt to resolve all of the problems the parent figures encounter. Instead, the counselor tries to resolve only those aspects of their difficulties with each other that interfere with their ability to resolve the problems they have with the adolescent in the family. Behavioral Contracting as a Strategy for Setting Limits for Both Parent and Adolescent From a process perspective, setting clear rules and consequences helps develop the demarcation of boundaries between parent(s) and child(ren). Sometimes when a parent and an adolescent have a very intense conflictive relationship in which there is a constant battle over the violation of rules, the rules and their consequences are vague, and there is considerable lack of consistency in their application. In these cases, it is recommended that the counselor use behavioral contracting to help the parent(s) and the adolescent agree on a set of rules and the resulting consequences if he or she fails to follow these rules. The counselor encourages the parent(s) and the adolescent to negotiate a set of clearly stated and enforceable rules, and encourages both parties to commit to maintaining and following these rules. Helping parents use behavioral contracting to establish boundaries for themselves in relationship to their adolescent is of tremendous therapeutic value. Parents who have established boundaries can no longer respond to the adolescent's behavior/misbehavior according to how they feel at the time (lax, tired, frustrated, angry). The parents have committed themselves to respond according to agreed-upon rules. From a BSFT point of view, it is very important for the counselor to begin to help the parents develop adequate boundaries with their adolescent children who have behavior problems. In families that have problems with boundaries, the counselor's most difficult task is to get the parents to stick to their part of the contract. Counselors expect that the adolescent will not keep his or her part of the contract and instead will try to test whether his or her parents will try to stick to their part of the contract. When the adolescent misbehaves, parents tend to behave in their usual way, which may be a reaction to the way they feel at the moment. The counselor's job is to make the parents uphold their side of the agreement. Once parents have set effective boundaries with their adolescent children, most misbehavior quickly diminishes. (Of course, sometimes rules and consequences need to be renegotiated as parents and adolescents begin to acquire experience with the notion of enforceable rules and consequences.) Boundaries Between the Family and the Outside World It is important not only to understand the nature of the alliances and boundaries that occur within the family but also to understand the boundaries that exist between the family and the outside world. (See Chapter 3, p. 21 on life context.)
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Some families have very rigid boundaries around themselves, prohibiting their members from interacting with the outside world. Other families have very weak boundaries around themselves that allow outsiders to have an undue influence on family members. Either of these extremes can be problematic and is fair ground for BSFT intervention. For example, if parents are uninvolved with their children's school or friends (rigid boundaries), the BSFT counselor works to get the parents to participate more fully in their child's school life and to interact more with their child's friends. 5. Detriangulation As was said earlier, triangles occur when a third, usually less powerful, person gets involved in a conflict between two others. It is a basic assumption of BSFT that the only way conflict between two people (called a "dyad") can be resolved is by keeping the conflict between them. Bringing in a third person and forming a triangle becomes an obstacle to resolving the conflict. The third person usually is drawn into a coalition with one of the parties in conflict and against the other. This coalition results in an imbalance within the original dyad. The issues involved in the conflict are detoured through the third person rather than dealt with directly. For example, when parent A has a fight with parent B, parent B may attack the adolescent in retaliation for parent A's behavior (or attempt to enlist the youth's support for his or her side of the argument) rather than expressing his or her anger directly to parent A. Such triangulated adolescents are often blamed for the family's problems, and they may become identified patients and develop symptoms such as drug abuse. Because triangulation prevents the involved parties from resolving their conflicts, the goal of counseling is to break up the triangle. Detriangulation permits the parents in conflict to discuss issues and feelings directly and more effectively. Detriangulation also frees the third party, the adolescent, from being used as the escape valve for the parents' problems. One of the ways in which a BSFT counselor achieves detriangulation is by keeping the third party (i.e., the adolescent) from participating in the discussions between the dyad. Another way to set boundaries to detriangulate is to ask the third party not to attend a therapy session so that the two conflicting parties can work on their issues directly. For example, when working with a family in which the son begins to act disrespectfully whenever his parents begin to argue, the counselor might instruct the parents to ignore the son and continue their discussion. If the son's misbehavior becomes unmanageable, the counselor may ask the son to leave the room so that the parents can argue without the son's interference. Eventually, the counselor will ask the parents to collaborate in controlling the son. Attempts by the Family to Triangulate the Counselor Triangulation does not necessarily have to involve only family members. Sometimes a counselor can become part of a triangle as well. One of the most common strategies used by family members is to attempt to get the counselor to ally himself or herself with one family member against another. For example, one family member might say to the counselor, "Isn't it true that I am right and he is wrong?" "You know best, you tell him." "We were having this argument last night, and I told her that you had said that...." Triangulation is always a form of conflict avoidance. Regardless of whether it is the counselor or a family member who is being triangulated, triangulation prevents two family members in conflict from reaching a resolution. The only way two family members can resolve their conflicts is on a one-to-one basis. An important reason why the counselor does not want to be triangulated is that the person in the middle of a triangle is either rendered powerless or symptomatic. In the case of the counselor, the "symptom" he or she would develop would be ineffectiveness as a therapist, that is an inability to do his or her job well because his or her freedom of movement (e.g., changing alliances, choosing whom to address, etc.) has been restricted. A triangulated counselor is defeated. If the counselor is unable to get out of the triangle, he or she has no hope of being effective, regardless of what else he or she does or says. When a family member attempts to triangulate the counselor, the counselor has to bring the conflict back to the people who are involved in it. For example, the counselor might say, "Ultimately, it doesn't matter what I think. What matters is what the two of you agree to, together. I am here to help you talk, negotiate, hear each other clearly, and come to an agreement." In this way, the counselor places the focus of the interaction back on the family. The counselor also might respond, "I understand how difficult this is for you, but this is your son, and you have to come to terms with each other, not with me."
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6. Opening Up Closed Systems Families in which conflicts are not openly expressed need help in discussing the conflict so that it can be a target for change. Sometimes a counselor can work with a family member who has an unexpressed or implicit conflict and help that person discuss the problem so that it can be resolved. This brings conflicts out into the open and facilitates their resolution by intensifying and focusing on covert emotional issues. In families of drug-abusing adolescents, a typical example of unexpressed or suppressed conflict involves disengaged fathers who tend to deny or avoid any discussion of the youth's problems. Asking a surly or sulking adolescent to express what is on his or her mind whenever the father is addressed may help the father break through his denial. 7. Tasks Central Role The use of "tasks" or assignments is central to all work with families. The counselor uses tasks both inside and outside the counseling sessions as the basic tool for orchestrating change. Because the emphasis in BSFT is in promoting new skills among family members, at both the level of individual behaviors and in family interactional relations, tasks serve as the vehicle through which counselors choreograph opportunities for the family to behave differently. In the example in which mother and son were initially allied and the father was left outside of this alliance, father and son were first assigned the task of doing something together that would interest them both. Later on, the mother and father were assigned the collaborative task of working together to define rules regarding the types of behaviors they would permit in their son and the consequences that they would assign to their son's behavior and misbehavior. General Rule It is a general rule that the BSFT counselor must first assign a task for the family to perform in the therapy session so that the counselor has an opportunity to observe and help the family successfully carry out the task. Only after a task has been accomplished successfully in the therapy session can a similar followup task be assigned to the family to be completed outside of therapy. Moreover, the counselor's aim is to provide the family with a successful experience. Thus, the counselor should try to assign tasks that are sufficiently doable at each step of the counseling process. The counselor should start with easy tasks and work up to more difficult ones, slowly building a foundation of successes with the family before attempting truly difficult restructuring moves. Hope for the Best; Be Prepared for the Worst Counselors should never expect the family to accomplish the assigned tasks flawlessly. In fact, if family members were skillful enough to accomplish all assigned tasks successfully, they would not need to be in counseling. When tasks are assigned, counselors should always hope for the best but be prepared for the worst. After all, a task represents a new way of behaving for the family and one that may be difficult given that they have had years of practice engaging in the old ways of behaving. As the family attempts to carry out a task, the counselor should help the family overcome obstacles it may encounter. However, in spite of the counselor's best efforts, the task is not always accomplished. The counselor's job is to observe and/or uncover what happened and identify the obstacles that prevented the family from achieving the task. When a task fails, the counselor starts over and works to overcome the newly identified obstacles. Unsuccessful attempts to complete tasks are a great source of new and important information regarding the interactions that prevent a family from functioning optimally. The first task that family counselors give to all of their cases is to bring everyone into the counseling session. Every counselor who works with problem youths and their families knows very well that most of the families who need counseling never reach the first counseling session. Therefore, these families can be described as having failed the first task given them, to come in for counseling. This task, called engagement, is so important that we have devoted the next chapter to it.
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Chapter 5 - Engaging the Family Into Treatment Previous chapters have described the basic concepts of BSFT, how to assess and diagnose maladaptive interactions and their relationship to symptoms, and the intervention strategies characteristic of this approach. These concepts also are the building blocks for the techniques that are used to engage resistant families into counseling. This chapter defines, in systems terms, the nature of the problem of resistance to treatment and redefines the nature of BSFT joining, diagnosing, and restructuring interventions in ways that take into account those patterns of interaction that prevent families from entering treatment. The Problem Regardless of their professional orientation and where or how they practice, all counselors have had the disappointing and frustrating experience of encountering "resistance to counseling" in the form of missed or cancelled first appointments. For BSFT counselors, this becomes an even more common and complex issue because more than one individual needs to be engaged to come to treatment. Unfortunately, some counselors handle engagement problems by accepting the resistance of some family members. In effect, the counselor agrees with the family's assessment that only one member is sick and needs treatment. Consequently, the initially well-intentioned counselor agrees to see only one or two family members for treatment. This usually results in the adolescent and an overburdened mother following through with counseling visits. Therefore, the counselor has been co-opted into the family's dysfunctional process. Not only has the counselor "bought" the family's definition of the problem, but he or she also has accepted the family's ideas about who is the identified patient. When the counselor agrees to see only one or two family members, instead of challenging the maladaptive family interaction patterns that kept the other members away, he or she is reinforcing those family patterns. In the example in which a mother and son are allied against the father, if the counselor accepts the mother and son into counseling, he or she is reinforcing the father figure's disengagement. At a more complex level, there are serious clinical implications for the counselor who accepts the family's version of the problem. In doing this, the counselor surrenders his or her position as the expert and leader. If the counselor agrees with the family's assessment of "who's got the problem," the family will perceive his or her expertise and ability to understand the issues as no greater than its own. The counselor's credibility as a helper and the family's perception of his or her competence will be at stake. Some family members may perceive the counselor as unable to challenge the status quo in the family because, in fact, he or she has failed to achieve the first and defining reframe of the problem. When the counselor agrees to see only part of the family, he or she may have surrendered his or her authority too early and may be unable to direct change and to move freely from one family member to another. Thus, by beginning counseling with only part of the family, excluded family members may see the counselor as being in a coalition with the family members who originally participated in therapy. Therefore, the family members who didn't attend the initial sessions may never come to trust the counselor. This means that the counselor will not be able to observe the system as a whole as it usually operates at home because the family members who were not involved in therapy from the beginning will not trust the counselor sufficiently to behave as they would at home. The counselor, then, will be working with the family knowing only one aspect of how the family typically interacts. Some counselors respond to the resistance of some family members to attend counseling by agreeing to see only those who wish to come. Other family counselors have resolved the dilemma of what to do when only some family members want to go to counseling by taking a more alienated stance saying: "There are too many motivated families waiting for help; the resistant families will call back when they finally feel the need; there is no need to get involved in a power struggle." The reality is that these resistant families will most likely never come to counseling by themselves. Ironically, the families who most need counseling are those families whose patterns and habits interfere with their ability to get help for themselves.
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Dealing With Resistance to Engagement When some family members do not want to participate in treatment, has called the counselor asking for help, that parent is not powerful enough to bring the adolescent into counseling. If the counselor wants the family to be in counseling, he or she will have to recognize that the youth (or a noncooperative parent figure) is the most powerful person in the family. Once the reason the family is not in treatment is understood, the counselor can draw upon the concept of tracking (as defined in Chapter 4) to find a way to reach this powerful person directly and negotiate a treatment contract to which the person will agree. Counselors should not become discouraged at this stage. Their mission now is to identify the obstacles the family faces and help it surmount them. It is essential to keep in mind that a family seeks counseling because it is unable to overcome an obstacle without help. Failed tasks, such as not getting the family to come in for treatment, tend to be a great source of new and important information regarding the reasons why a family cannot do what is best for them. The most important question in counseling is, "What has happened that will not allow some families to do what may be best for them?"
In trying to engage the family in treatment, the counselor should apply the concept of repetitive patterns of maladaptive interaction, which give rise to and maintain symptoms, to the problem of resistance to entering treatment. The very same principles that apply to understanding family functioning and treatment also apply to understanding and treating the family's resistance to entering counseling. When the family wishes to get rid of the youth's drug abuse symptom by seeking professional help, the same interactive patterns that prevented it from getting rid of the adolescent's symptom also prevent the family from getting help. The term "resistance" is used to refer to the maladaptive interactive patterns that keep families from entering
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treatment. From a family-systems perspective, resistance is nothing more than the family's display of its inability to adapt effectively to the situation at hand and to collaborate with one another to seek help. Thus, the key to eliminating the resistance to counseling lies within the family's patterns of interaction; overcome the resistance in the interactional patterns and the family will come to counseling. In working to overcome resistant patterns of family interaction, tasks play a particularly vital role because they are the only BSFT intervention used outside the therapy session. For this reason, tasks are particularly well-suited for use during the engagement period, when crucial aspects of the family's work in overcoming resistance to counseling need to take place outside the office--obviously--because the family has not yet come in. The central task around which engagement is organized is getting the family to come to therapy together. Thus, in engagement, the counselor assigns tasks that involve doing whatever is needed to get the family into treatment. For example, a father calls a BSFT counselor and asks for help with his drug-abusing son. The counselor responds by suggesting that the father bring his entire family to a session so that he or she can involve the whole family in fixing the problem. The father responds that his son would never come to treatment and that he doesn't know what to do. The first task that the counselor might assign the father is to talk with his wife and involve her in the effort to bring their son into treatment. The Task of Coming to Treatment The simple case. The counselor gives the task of bringing the whole family into counseling to the family member who calls for help. The counselor explains why this task is a good idea and promises to support the family as it works at this task. Occasionally, this is all that is needed. Often people do not request family counseling simply because family counseling is not well known, and thus it does not occur to them to take such action. Fear, an obstacle that might easily be overcome. Sometimes, family members are afraid of what will happen in family therapy. Some of these fears may be real; others may be simply imagined. In some instances, families just need some reassuring advice to overcome their fears. Such fears might include, "They are going to gang up on me," or "Everyone will know what a failure I am." Once these family members have been helped to overcome their fears, they will be ready to enter counseling. Tasks to change how family members act with each other. Very often, however, simple clarification and reassurance is not sufficient to mobilize a family. It is at this point that tasks that apply joining, diagnostic, and restructuring strategies are useful in engaging the family. The counselor needs to prescribe tasks for the family members who are willing to come to therapy. These need to be tasks that attempt to change the ways in which family members interact when discussing coming to therapy. In the process of carrying out these tasks, the family's resistance will come to light. When that happens, the counselor will have the diagnostic information needed to get around the family's patterns of interaction that are maintaining the symptom of resistance. Once these patterns are changed, the family will come to therapy. It should not be a surprise that families fail to accomplish the task of getting all of their members to counseling. In fact, the therapist's job is to help the families accomplish tasks that they are not able to accomplish on their own. As discussed earlier, when assigning any task, the counselor must expect that the task may not be performed as requested. This is certainly the case when the family is asked to perform the task of coming together to counseling. The application of joining, diagnosing, and restructuring techniques to the engagement of resistant families is discussed separately below. However, these techniques are used simultaneously during engagement, as they are during counseling. Joining Joining the resistant family begins with the first contact with the family member who calls for help and continues throughout the entire relationship with the family. With resistant families, the joining techniques described earlier have to be adapted to match the goal of this phase of therapy. For example, in tracking the resistant family members to engage them, it is necessary to track through the caller or initial help seeker and any other family members who may be involved in the process of bringing the family to counseling. The counselor tracks by "following" from the first family
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member to the next available family member to the next one and so on. This following, or tracking, is done without challenging the family patterns of interaction. Rather, tracking is accomplished by gaining the permission of one family member to reach the others. Establishing a Therapeutic Alliance An effective way for the counselor to establish a therapeutic alliance they want to solve their problems and that the counselor wants the same thing. It must be recognized, however, that each family member may view the problem differently. For example, the mother may want to get her son to quit using drugs, while the son may want peace at home. A therapeutic alliance is built around individual goals that family members can reach in therapy. Ideally, the counselor and the family members agree on a goal, and therapy is offered in the framework of achieving that goal. However, in families in which members are in conflict over their goals, it is necessary to find something for each of them to achieve in therapy. For example, the counselor can say to the mother that therapy can help her son stop using drugs, to the son that therapy can help him get his mother off his back and stop her nagging, and to the father that therapy can help stop his being called in constantly to play the "bad guy." In each case, the counselor can offer counseling as a means for each family member to achieve his or her own personal goal. In engaging resistant families, the counselor initially works with and through only one or a few family members. Because the entire family is not initially available, the counselor will need to form a bond with the person who called for help and any other family members that make themselves available. However, the focus of this early engagement phase is strictly to work with these people to bring about the changes necessary to engage the entire family in counseling. The focus is not to talk about the problem but rather to talk about getting everyone to help solve the problem by coming to therapy. By using the contact person as a vehicle (via tracking) for joining with other members of the family, the counselor can eventually establish a therapeutic alliance with each family member and thereby elicit the cooperation of the entire family in the engagement effort. Diagnosing the Interactions That Keep the Family From Coming Into Treatment In engagement, the purpose of diagnosis is to identify those particular patterns of interaction that permit the resistant behavior to continue. However, because it isn't possible to observe the entire family, the BSFT counselor works with limited information to diagnose those patterns of interaction that are supporting the resistance. To identify the maladaptive patterns responsible for the resistance, diagnosis begins prior to therapy, when a family member first calls the counselor. Because it is not possible to encourage and observe enactments of family members interacting before they enter counseling, engagement diagnosis has been modified so that it can be used during engagement to collect the diagnostic information in other ways. First, the counselor asks the contact person interpersonal systems questions that allow him or her to infer what the family's interactional patterns may be. For example, the counselor may ask, "How do you ask your husband to come to treatment?" "What happens when you ask your husband to come to treatment?" "When he gets angry at you for asking him to come to treatment, what do you do next?" Through these questions, the counselor tries to identify the interplay between these spouses that contributes to the resistance. For example, is it possible that the wife is asking the husband to come to treatment in an accusatory way, which causes him to get angry? An example might be, "It is your fault that your son is in trouble because you are sick. You have to go to treatment." As was indicated earlier, counselors do not like to rely on what family members tell them because each family member is very invested in his or her own viewpoints and probably cannot provide a systemic or objective account of family functioning. However, when counselors have access to only one person, they work with the person they have, strictly for the purpose of engaging that person in treatment. Second, counselors explore the family system for resistances to the task of coming to therapy. This is done by assigning exploratory tasks to uncover resistances that cause the family to fail at the task of coming to therapy. For example, in the case above, the counselor might suggest to the wife that she ask her husband to come for her sake and not because there is anything wrong with him. At that point, the wife may say to the
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counselor, "I can't really ask him for my sake because I know he's too busy to come to the family meetings." This statement suggests that the wife is not completely committed to getting the husband to come to treatment. On the one hand, she claims to want him to come to treatment, but on the other, she gives excuses for why he cannot. The purpose of exploring the resistance, beginning with the first phone call, is to identify as early as possible the obstacles that may prevent the family from coming to therapy, with the aim of intervening in a way that gets around these obstacles. Complementarity: Understanding How the Family "Pieces" Fit Together to Create Resistance What makes this type of early diagnostic work possible is an understanding of the Principle of Complementarity, which was described in Chapter 2. As noted earlier, for a family to work as a unit (even maladaptively), the behaviors of each family member must "fit with" the behaviors of every other family member. Thus, for each action within the family, there is a complementary action or reaction. For example, in the case of resistance, the husband doesn't want to come to treatment (the action), and the wife excuses him for not coming to treatment (the complementary action). Similarly, a caller tells the counselor that whenever she says anything to her husband about counseling (the action), he becomes angry (the complementary reaction). The counselor needs to know exactly what the wife's contribution is to this circular transaction, that is, what her part is in maintaining this pattern of resistance. Restructuring the Resistance In the process of engaging resistant families, the counselor initially sees only one or a few of the family members. It is still possible, through these individuals, to bring about short-term changes in interactional patterns that will allow the family to come for therapy. A variety of change-producing interventions have already been described in Chapter 4: reframing, reversals, detriangulation, opening up closed systems, shifting alliances, and task setting. The counselor can use all of these techniques to overcome the family's resistance to counseling. In the process of engaging resistant families, task setting is particularly useful in restructuring. The next section discusses the types of resistant families that have been identified, the process of getting the family into counseling, and the central role that tasks may play in achieving this goal. Much of counseling work with resistant families has been done with families in which the parents knew or believed the adolescent was using drugs and engaging in associated problem behaviors such as truancy, delinquency, fighting, and breaking curfew. These types of families are typically difficult to engage in therapy. However, the examples are not intended to represent all possible types of configurations of family patterns of interaction that work to resist counseling. Counselors working with other types of problems and families are encouraged to review their caseload of difficult-to-engage families and to carefully diagnose the systemic resistances to therapy. Some counselors may find that the resistant families they work with are similar to those described here, and some may find different patterns of resistance. In any case, counselors will be better equipped to work with these families if they have some understanding of the more common types of resistances in families of adolescent drug abusers. Types of Resistant Families There are four general types of family patterns of interaction that emerge repeatedly in work with families of drug-abusing adolescents who resist engagement to therapy. These four patterns are discussed below in terms of how the resistant patterns of interaction are manifested, how they come to the attention of the counselor, and how the resistance can be restructured to get the family into therapy. Powerful Identified Patient The most frequently observed type of family resistance to entering treatment is characterized by an identified patient who has a powerful position in the family and whose parents are unable to influence him or her. This is a problem, particularly in cases that are not courtreferred and in which the adolescent identified patient is not required to engage in counseling. Very often, the parent of a powerful identified patient will admit that he or she is weak or ineffective and will say that his or her son or daughter flatly refuses to come to counseling. Counselors can assume that the identified patient resists counseling for two reasons: It threatens his or her position of power, and counseling is on the parent's agenda and compliance would strengthen the parent's power.
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As a first step in joining and tracking the rules of the family, the counselor shows respect for and allies with the adolescent. The counselor contacts the drug-abusing adolescent by phone or in person (perhaps on his or her own turf, such as after school at the park). The counselor listens to the powerful adolescent's complaints about his or her parents and then offers to help the youth change the situation at home so that the parents will stop harassing him or her. This does not threaten the adolescent's power within the family and, thus, is likely to be accepted. The counselor offers respect and concern for the youth and brings an agenda of change that the adolescent will share by virtue of the alliance. To bring these families who resist entering treatment into treatment, the counselor does not directly challenge the youth's power in the family. Instead, the counselor accepts and tracks the adolescent's power. The counselor allies himself or herself with the adolescent so that he or she may later be in a position to influence the adolescent to change his or her behavior. Initially, in forming an alliance with the powerful adolescent, the counselor reframes the need for counseling in a manner that strengthens the powerful adolescent in a positive way. This is an example of tracking--using the power of the adolescent to bring him or her into therapy. The kind of reframing that is most useful with powerful adolescents is one that transfers the symptom from the powerful adolescent/identified patient to the family. For example, the counselor may say, "I want you to come into counseling to help me change some of the things that are going on in your family." Later, once the adolescent is in counseling, the counselor will challenge the adolescent's position of power. It should be noted that in cases in which powerful adolescents have less powerful parents, forming the initial alliance with the parents is likely to be ineffective because the parents are not strong enough to bring their adolescent into counseling. Their failed attempts to bring the adolescent into counseling would render the parents even weaker, and the family would fail to enter counseling. Furthermore, the youth is likely to perceive the counselor as being the parents' ally, which would immediately make the adolescent distrust the weak counselor. Contact Person Protecting Structure The second most common type of resistance to entering treatment is characterized by a parent who protects the family's maladaptive patterns of interaction. In these families, the person (usually the mother) who contacts the counselor to request help is also the person who is-- without realizing it--maintaining the resistance in the family. The way in which the identified patient is maintained in the family is also the way in which counseling is resisted. The mother, for example, might give conflicting messages to the counselor, such as, "I want to take my family to counseling, but my son couldn't come to the session because he forgot and fell asleep, and my husband has so much work he doesn't have the time." The mother is expressing a desire for the counselor's help while protecting and allying herself with the family's resistance to being involved in solving the problem. The mother protects this resistance by agreeing that the excuses for noninvolvement are valid. In other words, she is supporting the arguments the other family members are using to maintain the status quo. It is worthwhile to note that ordinarily this same conflicting message that occurs in the family maintains the symptomatic structure. In other words, someone complains about the problem behavior, yet supports the maintenance of the behaviors that nurture the problem. This pattern is typical of families in which the caller (e.g., the mother) and the identified patient are enmeshed. To bring these families into treatment, the counselor must first form an alliance with the mother by acknowledging her frustration in wanting to get help and not getting any cooperation from the other family members to get it. Through this alliance, the counselor asks the mother's permission to contact the other family members "even though they are busy and the counselor recognizes how difficult it is for them to become involved." With the mother's permission, the counselor calls the other family members and separates them from the mother in regard to the issue of coming to counseling. The counselor develops his or her own relationship with other family members in discussing the importance of coming to counseling. In doing so, he or she circumvents the mother's protective behaviors. Once the family is in counseling, the mother's overprotection of the adolescent's misbehavior and of the father's uninvolvement (and the adolescent's and father's eagerness that she continue to protect them) will be addressed because it also may be related to the adolescent's problem behaviors.
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Disengaged Parent These family structures in which one parent protects the family's maladaptive patterns of behavior are characterized by little or no cohesiveness and lack of an alliance between the parents or parent figures as a subsystem. One of the parents, usually the father, refuses to come into therapy. This is typically a father who has remained disengaged from the problems at home. The father's disengagement not only protects him from having to address his adolescent's problems but also protects him from having to deal with the marital relationship, which is most likely the more troublesome of the two relationships he is avoiding. Typically, the mother is over-involved (enmeshed) with the identified patient and either lacks the skills to manage the youth or is supporting the identified patient in a covert fashion. For example, if the father tries to control the adolescent's behavior, the mother complains that he is too tough or makes her afraid that he may become violent.2 The father does not challenge this portrayal of himself. He is then rendered useless and again distances himself, re-establishing the disengagement between husband and son and between husband and wife. In this family, the dimension of resonance is of foremost importance in planning how to change the family and bring it into therapy. The counselor must use tasks to bring the mother closer to the father and distance her from the son. That is, the boundary between the parents needs to be loosened to bring them closer together, and the boundary between mother and son needs to be strengthened to create distance between them. To engage these families into treatment, the counselor must form an alliance with the person who called for help (usually the mother). The counselor then must begin to direct the mother to change her patterns of interaction with the father to improve their cooperation, at least temporarily, in bringing the family into treatment. The counselor should give the mother tasks to do with her husband that pertain only to getting the family into treatment and taking care of their son's problems. The counselor should assign tasks in a way that is least likely to spark the broader marital conflict. To set up the task, the counselor may ask the mother what she believes is the real reason her husband does not want to come to counseling. Once this reason is ascertained, the counselor coaches the mother to present the issue of coming to treatment in a way that the husband can accept. For example, if he doesn't want to come because he has given up on his son, she may be coached to suggest to him that coming to treatment will help her cope with the situation. Although the pattern of resistance is similar to that of the contact person protecting the structure, in this instance, the resistance emerges differently. In this case, the mother does not excuse the father's distance. To the contrary, she complains about her spouse's disinterest; this mother is usually eager to do something to involve her husband; she just needs some direction to be able to do it. Families With Secrets ometimes counseling is threatening to one or more individuals in the family. Sometimes the person who resists coming to counseling is either afraid of being made a scapegoat or afraid that dangerous secrets (e.g., infidelity) will be revealed. These individuals' beliefs or frames about counseling are usually an extension of the frame within which the family is functioning. That is, it is a family of secrets. The counselor must reframe the idea or goal of counseling in a way that eliminates its potential negative consequences and replaces them with positive aims. One example of how to do this is to meet with the person who rejects counseling the most and assure him or her that counseling does not have to go where he or she does not want it to go. The counselor needs to make it clear that he or she will make every effort to focus on the adolescent's problems instead of the issues that might concern the unwilling family member. The counselor also should assure this individual that in the counseling session, "We will deal only with those issues that you want to deal with. You'll be the boss. I am here only to help you to the extent that you say."
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Chapter 6 - Clinical Research Supporting Brief Stategic Family Therapy This chapter describes past research on the effectiveness of BSFT with drug-abusing adolescents with behavioral problems. BSFT has been found to be effective in reducing adolescents' conduct problems, drug use, and association with antisocial peers and in improving family functioning. In addition, BSFT engagement has been found to increase engagement and retention in therapy. Additional studies testing an ecological version of BSFT with this population are currently underway. As presented in this manual, BSFT's primary emphasis is on identifying and modifying maladaptive patterns of family interaction that are linked to the adolescent's symptoms. The ecological version of BSFT, BSFTecological (Robbins et al. in press) applies this principle of identifying and modifying maladaptive patterns of interaction to the multiple social contexts in which the adolescent is embedded (cf. Bronfenbrenner 1979). The principal social contexts that are targeted in BSFT-ecological are family, family-peer relations, family-school relations, family-juvenile justice relations, and parent support systems. Joining, diagnosing, and restructuring, as developed in BSFT to use within the family system, are applied to these other social contexts or systems that influence the adolescent's behaviors. For instance, the BSFT counselor assesses the maladaptive, repetitive patterns of interaction that occur in each of these systems or domains. As an example, the BSFT counselor would diagnose the family-school system in the same way that he or she would diagnose the family system. In diagnosing structure, the counselor would ask, "Do parents provide effective leadership in their relationship with their child's teachers?" In diagnosing resonance, the counselor would ask, "Are parents and teachers disengaged?" In diagnosing conflict resolution, the counselor's questions would be, "What is the conflict resolution style in the parentteacher relationship? Might parents and teachers avoid conflict with each other (by remaining disengaged) or diffuse conflicts by blaming each other?" In BSFT-ecological, joining the teacher in the parentteacher relationship employs the same joining techniques developed for BSFT. Similarly, in BSFT-ecological, BSFT restructuring techniques are used to modify the nature of the relationship between a parent and his or her child's teacher. Outpatient Brief Strategic Family Therapy Versus Outpatient Group Counseling A recent study (Santisteban et al. in press) examined the efficacy of BSFT in reducing an adolescent's behavioral problems, association with antisocial peers, and marijuana use, and in improving family functioning. In this study, outpatient BSFT was compared to an outpatient group counseling control treatment. Participants were 79 Hispanic families with a 12- to 18-year-old adolescent who was referred to counseling for conduct and antisocial problems by either a school counselor or a parent. Families were randomly assigned to either BSFT or group counseling. Analyses of treatment integrity revealed that interventions in both therapies adhered to treatment guidelines and that the two therapies were clearly distinguishable. Conduct disorder and association with antisocial peers Conduct disorder and association with antisocial peers were assessed using the Revised Behavior Problem Checklist (RBPC) (Quay and Peterson 1987), which is a measure of adolescent behavior problems reported by parents. Conduct disorder was measured using 22 items, and association with antisocial peers was measured using 17 items. Each item asks the parent(s) to rate whether a specific aspect of the adolescent's behavior (e.g., fighting, spending time with "bad" friends) is no problem (0), a mild problem (1), or a severe problem (2). Ratings for all items on each scale are then added together to derive a total score. The effects of BSFT on conduct disorder, association with antisocial peers, and marijuana use were evaluated in two ways. First, analyses of variance were conducted to examine whether BSFT reduced conduct disorder, association with antisocial peers, and marijuana use to a significantly greater extent than did group counseling. Second, exploratory analyses were conducted on clinically significant changes in conduct problems and association with antisocial peers. These exploratory analyses used the twofold clinical significance criteria recommended by Jacobson and Truax (1991). To be able to classify a change in symptoms for a given participant as clinically significant, two conditions have to occur. First, the magnitude of the change must be large enough to be reliable--that is, to rule out random fluctuation as a plausible explanation. Second, the participant must "recover" from clinical to nonclinical levels, i.e., cross the diagnostic threshold.
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Conduct Disorder. Analyses of variance indicated that conduct disorder scores for adolescents in BSFT compared to those for adolescents in group counseling were significantly reduced between pre- and posttreatment. In the clinical significance analyses, a substantially larger proportion of adolescents in BSFT than in group counseling demonstrated clinically significant improvement. At intake, 70 percent of adolescents in BSFT had conduct disorder scores that were above clinical cutoffs. That is, they scored above the empirically established threshold for clinical diagnoses of conduct disorder. At the end of treatment, 46 percent of these adolescents showed reliable improvement, and 5 percent showed reliable deterioration. Among the 46 percent who showed reliable improvement, 59 percent recovered to nonclinical levels of conduct disorder. In contrast, at intake, 64 percent of adolescents in group counseling had conduct disorder scores above the clinical cutoff. Of these, none showed reliable improvement, and 11 percent showed reliable deterioration. Therefore, while adolescents in BSFT who entered treatment at clinical levels of conduct disorder had a 66 percent likelihood of improving, none of the adolescents in group counseling reliably improved. Association With Antisocial Peers. Analyses of variance indicated that, for adolescents in BSFT, scores for association with antisocial peers were significantly reduced between pre- and post-treatment, compared to those for adolescents in group counseling. In the clinical significance analyses, 79 percent of adolescents in BSFT were above clinical cutoffs for association with antisocial peers at intake. Among adolescents in BSFT meeting clinical criteria for association with antisocial peers, 36 percent showed reliable improvement, and 2 percent showed reliable deterioration. Of the 36 percent of adolescents in BSFT with reliable improvement, 50 percent were classified as recovered. Among adolescents in group counseling, 64 percent were above clinical cutoffs for association with antisocial peers at intake. Among adolescents in group counseling meeting these clinical criteria at intake, 11 percent reliably improved, and none reliably deteriorated. Of the 11 percent of adolescents in group counseling evidencing reliable improvement in association with antisocial peers, 50 percent recovered to nonclinical levels. Hence, adolescents in BSFT who entered treatment at clinical levels of association with antisocial peers were 2.5 times more likely to reliable improve than were adolescents in group treatment. Marijuana Use. Analyses of variance revealed that BSFT was associated with significantly greater reductions in self-reported marijuana use than was group counseling. To investigate whether clinically meaningful 3 changes in marijuana use occurred, four use categories from the substance use literature (e.g., Brooks et al.1998) were employed. These categories are based on the number of days an individual uses marijuana in the 30 days before the intake and termination assessments:
abstainer - 0 days weekly user - 1 to 8 days frequent user - 9 to 16 days daily user - 17 or more days
In BSFT, 40 percent of participants reported using marijuana at intake and/or termination. Of these, 25 percent did not show change, 60 percent showed improvement in drug use, and 15 percent showed deterioration. Of the individuals in BSFT who shifted into less severe categories, 75 percent were no longer using marijuana at termination. In group counseling, 26 percent of participants reported using marijuana at intake and/or termination. Of these, 33 percent showed no change, 17 percent showed improvement, and 50 percent deteriorated. The 17 percent of adolescents in group counseling cases that showed improvement were no longer using marijuana at termination. Hence, adolescents in BSFT were 3.5 times more likely than were adolescents in group counseling to show improvement in marijuana use. Treatments also were compared in terms of their influence on family functioning. Family functioning was measured using the Structural Family Systems Ratings (Szapocznik et al. 1991). This measure was constructed to assess family functioning as defined in Chapter 3. Based on their scores when they entered therapy, families were separated by a median split into those who had good and those who had poor family functioning. Within each group (i.e., those with good and those with poor family functioning), a statistical test that compares group means (analysis of variance) tested changes in family functioning from before to after the intervention.
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Among families who were admitted with poor family functioning, the results showed that those assigned to BSFT had a significant improvement in family functioning, while those families assigned to group counseling did not improve significantly. Among families who were admitted with good family functioning, the results showed that those assigned to BSFT retained their good levels of family functioning, while families assigned to group counseling showed significant deterioration. These findings suggest that not all families of drug-abusing youths begin counseling with poor family functioning, but if the family is not given adequate help to cope with the youth's problems, the family's functioning may deteriorate. One Person Brief Strategic Family Therapy With the advent of the adolescent drug epidemic of the 1970s, the vast majority of counselors who worked with drug-using youths reported that, although they preferred to use family therapy, they were not able to bring whole families into treatment (Coleman and Davis 1978). In response, a procedure was developed that would achieve the goals of BSFT (to change maladaptive family interactions and symptomatic adolescent behavior) without requiring the whole family to attend treatment sessions. The procedure is an adaptation of BSFT called "One Person" BSFT (Szapocznik et al. 1985; Szapocznik and Kurtines 1989; Szapocznik et al. 1989a). One Person BSFT capitalizes on the systemic concept of complementarity, which suggests that when one family member changes, the rest of the system responds by either restoring the family process to its old ways or adapting to the new changes (Minuchin and Fishman 1981). The goal of One Person BSFT is to change the drug-abusing adolescent's participation in maladaptive family interactions that include him or her. Occasionally, these changes create a family crisis as the family attempts to return to its old ways. The counselor uses the opportunity created by these crises to engage reluctant family members. A clinical trial was conducted to compare the efficacy of One Person BSFT to Conjoint (full family) BSFT (Szapocznik et al. 1983, 1986). Hispanic families with a drug-abusing 12- to 17-year-old adolescent were randomly assigned to the One Person or Conjoint BSFT modalities. Both therapies were designed to use exactly the same BSFT theory so that only one variable (one person vs. conjoint meetings) would differ between the treatments. Analyses of treatment integrity revealed that interventions in both therapies adhered to guidelines and that the two therapies were clearly distinguishable. The results showed that One Person was as efficacious as Conjoint BSFT in significantly reducing adolescent drug use and behavior problems as well as in improving family functioning at the end of therapy. These results were maintained at the 6-month followup (Szapocznik et al. 1983, 1986). One Person BSFT is not discussed in this manual because it is considered a very advanced clinical technique. More information on One Person BSFT is available in Szapocznik and Kurtines (1989). Brief Strategic Family Therapy Engagement As discussed in Chapter 5, in response to the problem of engaging resistant families, a set of engagement procedures based on BSFT principles was developed (Szapocznik and Kurtines 1989; Szapocznik et al. 1989b). These procedures are based on the premise that resistance to entering treatment can be understood in family interactional terms. One Person BSFT techniques are useful in this initial phase. That's because the person who contacts the counselor to request help may become the one person through whom work is initially done to restructure the maladaptive family interactions that are maintaining the symptom of resistance. The success of the engagement process is measured by the family's and the symptomatic youth's attendance in family therapy. In part, success in engagement permits the counselor to redefine the problem as a family problem in which all family members have something to gain. Once the family is engaged in treatment, the focus of the intervention is shifted from engagement to removing the adolescent's presenting symptoms. The efficacy of BSFT engagement has been tested in three studies with Hispanic youths (Szapocznik et al. 1988; Santisteban et al. 1996; Coatsworth et al. 2001). The first study (Szapocznik et al. 1988) included mostly Cuban families with adolescents who had behavior problems and who were suspected of or observed using drugs by their parents or school counselors. Of those engaged, 93 percent actually reported drug use. Families were randomly assigned to one of two therapies: BSFT engagement or engagement as usual (the control therapy). The engagement-as-usual therapy consisted of the typical engagement methods used by community treatment agencies, which were identified prior to the study using a community survey of
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outpatient agencies serving drug-abusing adolescents. All families who were successfully engaged received BSFT. In the experimental therapy, families were engaged and retained using BSFT engagement techniques. Successful engagement was defined as the conjoint family (minimally the identified patient and his or her parents and siblings living in the same household) attending the first BSFT session, which was usually to assess the drug-using adolescent and his or her family. Treatment integrity analyses revealed that interventions in both engagement therapies adhered to prescribed guidelines using six levels of engagement effort that were operationally defined and that the therapies were clearly distinguishable by level of engagement effort applied. The six levels of engagement effort The six levels of engagement effort, as enumerated in Szapocznik et al. (1988, p. 554), are: Level 0 - expressing polite concern, scheduling an intake appointment, establishing that cases met criteria for inclusion in the study, and making clear who must attend the intake assessment; Level 1 - attempting minimal joining, encouraging the caller to involve the family, asking about the depth and breadth of adolescent problems, and asking about family members; Level 2 - attempting more thorough joining; asking about family interactions; seeking information about the problems, values, and interests of family members; supporting and establishing an alliance with the caller; beginning to establish leadership; and asking whether all family members would be willing to attend the intake appointment; Level 3 - restructuring for engagement through the caller, advising the caller about negotiating and reframing, and following up with family members (either over the phone or personally with the caller at the therapist's office) to be sure that intake appointments would be kept; Level 4 - conducting lower level ecological engagement interventions, joining family members or conducting intrapersonal restructuring (with family members other than the original caller) over the phone or in the therapist's office, and contacting significant others (by phone) to gather more information; and Level 5 - conducting higher level ecological interventions, making out-of-office visits to family members or significant others, and using significant others to help conduct restructuring. Level 0-1 behaviors were permitted for both the BSFT engagement and engagement-as-usual conditions. Level 2-5 behaviors were permitted only for the BSFT engagement condition. Efficacy was measured in rates of both family treatment entry as well as retention to treatment completion. Efficacy of methods of engagement The efficacy of the two methods of engagement was measured by the percentage of families who entered treatment and the percentage of families who completed the treatment. The results revealed that 42 percent of the families in the engagement-as-usual therapy and 93 percent of the families in the BSFT engagement therapy were successfully engaged. In addition, 25 percent of engaged cases in the engagement-as-usual treatment and 77 percent of engaged cases in the BSFT engagement treatment successfully completed treatment. These differences in engagement and retention between the two methods of engagement were both statistically significant. Improvements in adolescent symptoms occurred but were not significantly different between the two methods of engagement. Thus, the critical distinction between the treatments was in their different rates of engagement and retention. Therefore, BSFT engagement had a positive impact on more families than did engagement as usual. In addition to replicating the previous engagement study, the second study (Santisteban et al. 1996) also explored factors that might moderate the efficacy of the engagement interventions. In contrast to the previous engagement study, Santisteban et al. (1996) more stringently defined the success of engagement as a minimum of two office visits: the intake session and the first therapy session. The researchers randomly assigned 193 Hispanic families to one experimental and two control treatments. The experimental therapy was BSFT plus BSFT engagement. The first control therapy was BSFT plus engagement as usual, and the second was group counseling plus engagement as usual. In both control treatments, engagement as usual involved no specialized engagement strategies.
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Results showed that 81 percent of families were successfully engaged in the BSFT plus BSFT engagement experimental treatment. In contrast, 60 percent of the families in the two control therapies were successfully engaged. These differences in engagement were statistically significant. However, the efficacy of the experimental therapy procedures was moderated by the cultural/ethnic identity of the Hispanic families in the study. Among families assigned to BSFT engagement, 93 percent of the non-Cuban Hispanics (composed primarily of Nicaraguan, Colombian, Puerto Rican, Peruvian, and Mexican families) and 64 percent of the Cuban Hispanics were engaged. These findings have led to further study of the mechanism by which culture/ethnicity and other contextual factors may influence clinical processes related to engagement (Santisteban et al. 1996; Santisteban et al. in press). The results of the Szapocznik et al. (1988) and Santisteban et al. (1996) studies strongly support the efficacy of BSFT engagement. Further, the second study with its focus on cultural/ethnic identity supports the widely held belief that therapeutic interactions must be responsive to contextual changes in the treatment population (Sue et al. 1994; Szapocznik and Kurtines 1993). A third study (Coatsworth et al. 2001) compared BSFT to a community control intervention in terms of its ability to engage and retain adolescents and their families in treatment. An important aspect of this study was that an outside treatment agency administered the control intervention. Because of that, the control intervention (e.g., usual engagement strategies) was less subject to the influence of the investigators. Findings in this study, as in previous studies, showed that BSFT was significantly more successful, at 81 percent, in engaging adolescents and their families in treatment than was the community control treatment, at 61 percent. Likewise, among those engaged in treatment, a higher percentage of adolescents and their families in BSFT, at 71 percent, were retained in treatment compared to those in the community control intervention, at 42 percent. In BSFT, 58 percent of adolescents and their families completed treatment compared to 25 percent of those in the community control intervention. Families in BSFT were 2.3 times more likely both to be engaged and retained in treatment than were families randomized to the community control treatment. An additional finding of the Coatsworth et al. (2001) study warrants special mention. In BSFT, families of adolescents with more severe conduct problem symptoms were more likely to remain in treatment than were families of adolescents whose conduct problem symptoms were less severe. The opposite pattern was evident in the community control intervention, with families that were retained in treatment showing lower intake levels of conduct problems than did families who dropped out. These findings are particularly important because they suggest that adolescents who are most in need of services are more likely to stay in BSFT than in traditional community treatments.
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Solution focused brief therapy From Wikipedia, the free encyclopedia Solution focused brief therapy (SFBT), often referred to as simply 'solution focused therapy' or 'brief therapy', is a type of talking therapy that is based upon social constructionist philosophy. It focuses on what clients want to achieve through therapy rather than on the problem(s) that made them to seek help. The approach does not focus on the past, but instead, focuses on the present and future. The therapist/counsellor uses respectful curiosity to invite the client to envision their preferred future and then therapist and client start attending to any moves towards it whether these are small increments or large changes. To support this, questions are asked about the client’s story, strengths and resources, and about exceptions to the problem. Solution focused therapists believe that change is constant. By helping people identify the things that they wish to have changed in their life and also to attend to those things that are currently happening that they wish to continue to have happen, SFBT therapists help their clients to construct a concrete vision of a preferred future for themselves. The SFBT therapist then helps the client to identify times in their current life that are closer to this future, and examines what is different on these occasions. By bringing these small successes to their awareness, and helping them to repeat these successful things they do when the problem is not there or less severe, the therapists helps the client move towards the preferred future they have identified. Solution focused work can be seen as a way of working that focuses exclusively or predominantly at two things. 1) Supporting people to explore their preferred futures. 2) Exploring when, where, with whom and how pieces of that preferred future are already happening. While this is often done using a social constructionist perspective the approach is practical and can be achieved with no specific theoretical framework beyond the intention to keep as close as possible to these two things.
Contents
1 Basic Principles 2 Questions 3 Resources 4 History of Solution Focused Brief Therapy 5 Solution-Focused counselling 6 Solution-Focused consulting 7 References
Basic Principles: Clients have resources and strengths to resolve complaints It is therapist’s task to access these abilities and help clients put them to use. Change is constant
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Therapists can do a great deal to influence client’s perceptions regarding the inevitability of change and what is supposed to happen during the therapy session. The therapist’s job is to identify and amplify change He/She accomplishes this through choice of questions, topics focused on or ignored. “Focus on what seems to be working however small, to label it as worthwhile, and to work toward amplifying it.” If [the change] is in a crucial area, it can change the whole system. It is usually unnecessary to know a great deal about the complaint in order to resolve it What is significant is what the clients are doing that is working. Learn from clients’ identifying when the problem is not troublesome. Clients can learn to function that way again to solve the problem. It is not necessary to know the cause or function of a complaint to resolve it Even the most creative hypotheses about the possible function of a symptom will not offer therapists a clue about how people can change. It simply suggests how people’s lives have become static. Ask those who want to know why they have a symptom: “Would it be enough if the problem were to disappear and you never understood why had it?” A small change is all that is necessary: A change in one part of the system can affect change in another part of the system “We have the sense that positive changes will at least continue and may expand and have beneficial effects in other areas of the person’s life. Clients define the goal Do not assume that therapists are better equipped to decide how their clients should live their lives; ask people to establish their own goals for treatment. Rapid change or resolution of problems is possible “We believe that, as a result of our interaction during the first session, our clients will gain a more productive and optimistic view of their situations.” Therapists expect them to go home and do what is necessary to make their lives more satisfying (p. 45). Average length of treatment is less than 10 sessions, usually 4 to 5, occasionally only 1. There is no one “right” way to view things; Different views may be just as valid and may fit the facts just as well Views that keep people stuck are simply not useful. Sometimes all that is necessary to initiate significant change is a shift in the person’s perception of the situation.” Focus on what is possible and changeable rather than what is impossible and intractable Focus on aspects of a person’s situation that seem most changeable. This imparts a sense of hope and power
Questions The miracle question The miracle question is a method of questioning that a coach, therapist, or counsellor uses to aid the client to envision how the future will be different when the problem is no longer present. Also, this may help to establish goals. A traditional version of the miracle question would go like this: "Suppose our meeting is over, you go home, do whatever you planned to do for the rest of the day. And then, some time in the evening, you get tired and go to sleep. And in the middle of the night, when you are fast asleep, a miracle happens and all the problems that brought you here today are solved just like that. But since the miracle happened overnight nobody is telling you that the miracle
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happened. When you wake up the next morning, how are you going to start discovering that the miracle happened? ... What else are you going to notice? What else?" Whilst relatively easy to state the miracle question requires considerable skill to ask well. The question must be asked slowly with close attention to the person's non-verbal communication to ensure that the pace matches the person's ability to follow the question. Initial responses frequently include a sense of "I don't know." To ask the question well this should be met with respectful silence to give the person time to fully absorb the question. Once the miracle day has been thoroughly explored the worker can follow this with scales, on a scale where 0 = worst things have ever been and 10 = the miracle day where are you now? Where would it need to be for you to know that you didn't need to see me any more? What will be the first things that will let you know you are 1 point higher. In this way the miracle question is not so much a question as a series of questions. There are many different versions of the miracle question depending on the context and the client. In a specific situation, the counsellor may ask, "If you woke up tomorrow, and a miracle happened so that you no longer easily lost your temper, what would you see differently?" What would the first signs be that the miracle occurred?" The client (a child) may respond by saying, "I would not get upset when somebody calls me names." The counsellor wants the client to develop positive goals, or what they will do, rather than what they will not do--to better ensure success. So, the counsellor may ask the client, "What will you be doing instead when someone calls you names?" Scaling Questions Scaling questions are tools that are used to identify useful differences for the client and may help to establish goals as well. The poles of a scale can be defined in a bespoke way each time the question is asked, but typically range from "the worst the problem has ever been" (zero or one) to "the best things could ever possibly be" (ten). The client is asked to rate their current position on the scale, and questions are then used to help the client identify resources (e.g. "what's stopping you from slipping one point lower down the scale?"), exceptions (e.g. "on a day when you are one point higher on the scale, what would tell you that it was a 'one point higher' day?") and to describe a preferred future (e.g. "where on the scale would be good enough? What would a day at that point on the scale look like?") Exception Seeking Questions Proponents of SFBT insist that there are always times when the problem is less severe or absent for the client. The counsellor seeks to encourage the client to describe what different circumstances exist in that case, or what the client did differently. The goal is for the client to repeat what has worked in the past, and to help them gain confidence in making improvements for the future. Coping questions Coping questions are designed to elicit information about client resources that will have gone unnoticed by them. Even the most hopeless story has within it examples of coping that can be drawn out: "I can see that things have been really difficult for you, yet I am struck by the fact that, even so, you manage to get up each morning and do everything necessary to get the kids off to school. How do you do that?" Genuine curiosity and admiration can help to highlight strengths without appearing to contradict the clients view of reality. The initial summary "I can see that things have been really difficult for you" is for them true and validates their story. The second part "you manage to get up each morning etc.", is also a truism, but one that counters
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the problem focused narrative. Undeniably, they cope and coping questions start to gently and supportively challenge the problem-focused narrative. Problem-free talk In solution-focused therapy, problem-free talk can be a useful technique for identifying resources to help the person relax, or be more assertive, for example. Solution focused therapists will talk about seemingly irrelevant life experiences such as leisure activities, meeting with friends, relaxing and managing conflict. The therapist can also gather information on the client's values and beliefs and their strengths. From this discussion the therapist can use these strengths and resources to move the therapy forward. For example; if a client wants to be more assertive it may be that under certain life situations they are assertive. This strength from one part of their life can then be transferred to the area with the current problem. Or if a client is struggling with their child because the child gets aggressive and calls the parent names and the parent continually retaliates and also gets angry, then perhaps they have an area of their life where they remain calm even under pressure; or maybe they have trained a dog successfully that now behaves and can identify that it was the way they spoke to the dog that made the difference and if they put boundaries in place using the same firm tonality the child might listen. Dan Jones, in his Becoming a Brief Therapist book writes: '...it is in the problem free areas you find most of the resources to help the client. It also relaxes them and helps build rapport, and it can give you ideas to use for treatment...Everybody has natural resources that can be utilised. These might be events...or talk about friends or family...The idea behind accessing resources is that it gives you something to work with that you can use to help the client to achieve their goal...Even negative beliefs and opinions can be utilised as resources '
Resources A key task in SFBT is to help clients identify and attend to their skills, abilities, and external resources (e.g. social networks). This process not only helps to construct a narrative of the client as a competent individual, but also aims to help the client identify new ways of bringing these resources to bear upon the problem. Resources can be identified by the client and the worker will achieve this by empowering the client to identify their own resources through use of scaling questions, problem-free talk, or during exceptionseeking. Resources can be Internal: the client's skills, strengths, qualities, beliefs that are useful to them and their capacities. Or, External: Supportive relationships such as, partners, family, friends, faith or religious groups and also support groups.
History of Solution Focused Brief Therapy Solution Focused Brief Therapy is one of a family of approaches, known as systems therapies, that have been developed over the past 50 years or so, first in the USA, and eventually evolving around the world, including Europe. The title SFBT, and the specific steps involved in its practice, are attributed to husband and wife Steve de Shazer and Insoo Kim Berg and their team at the Brief Family Therapy Center in Milwaukee, USA. Core members of this team were Eve Lipchik, Wallace Gingerich, Elam Nunnally, Alex Molnar, and Michele Weiner-Davis. Their work in the early 1980s built on that of a number of other innovators, among them Milton Erickson, and the group at the Mental Research Institute at Palo Alto – Gregory Bateson, Donald deAvila Jackson, Paul Watzlawick, John Weakland, Virginia Satir, Jay Haley, Richard Fisch, Janet Beavin Bavelas and others. The concept of brief therapy was independently discovered by several therapists in their own practices over several decades (notably Milton Erickson), was described by authors such as Haley in the 1950s, and
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became popularized in the 1960s and 1970s. Richard Bandler, John Grinder and Stephen R Lankton have also been credited, at least in part, with the inspiration for and popularization of brief therapy, particularly through their work with Milton Erickson. While Jay Hayley and the team at the Mental Research Institute at Palo Alto aimed to uncover the principles that underpinned Erickson's approach to brief therapy, John Grinder and Richard Bandler provided practical guidelines for the application of some of the hypnotic techniques of Erickson. Solution Focused Brief Therapy has branched out in numerous spectrums - indeed, the approach is now known in other fields as simply Solution Focus or Solutions Focus. Most notably, the field of Addiction Counselling has begun to utilize SFBT as an effective means to treat problem drinking. The Center for Solutions in Cando, ND has implemented SFBT as part of their program, wherein they utilize this therapy as part of a partial hospitalization and residential treatment facility for both adolescents and adults.
Solution-Focused counselling Solution-Focused counselling is a solution focused brief therapy model. Various similar, yet distinct, models have been referred to as solution-focused counselling. For example, Jeffrey Guterman developed a solution-focused approach to counselling in the 1990s. This model is an integration of solution-focused principles and techniques, postmodern theories, and a strategic approach to eclecticism.
Solution-Focused consulting Solution-Focused consulting is an approach to organizational change management that is built upon the principles and practices of Solution-Focused therapy. While therapy is for individuals and families, Solution-Focused consulting is being used as a change process for organizational groups of every size, from small teams to large business units.
References
Jones, Dan Becoming a Brief Therapist: Special Edition The Complete Works, Lulu.com, 2008, page 451, ISBN 1-409-23031-7 See page 671 in Steenbarger (2002) "Single-session therapy: Theoretical underpinnings" In Elsevier Encyclopedia of Psychotherapy (Shazer 1982 p.22) Shazer, SD. (1982) Patterns of brief family therapy: an ecosystemic approach. Guilford Press. I.K.Berg and S.deShazer: Making numbers talk: Language in therapy. In S. Friedman (Ed.), "The new language of change: Constructive collaboration in psychotherapy." New York:Guilford, 1993. I.K.Berg, "Family based services: A solution-focused approach." New York:Norton. 1994. I.K.Berg; "Solution-Focused Therapy: An Interview with Insoo Kim Berg." Psychotherapy.net, 2003. B.Cade and W.H. O’Hanlon: A Brief Guide to Brief Therapy. W.W. Norton & Co 1993. D. Denborough; Family Therapy: Exploring the Field's Past, Present and Possible Futures. Adelaide, South Australia: Dulwich Centre Publications, 2001. Brief Therapy Strategies – George Carpetto http://www.pearsonhighered.com/samplechapter/0205490786.pdf
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Brief (psycho-) therapy From Wikipedia, the free encyclopedia And “Brief Therapy Strategies” by George Carpetto Brief psychotherapy or Brief therapy is an umbrella term for a variety of approaches to psychotherapy. It differs from other schools of therapy in that it emphasises (1) a focus on a specific problem and (2) direct intervention. In brief therapy, the therapist takes responsibility for working more pro-actively with the client in order to treat clinical and subjective conditions faster. It also emphasizes precise observation, utilization of natural resources, and temporary suspension of disbelief to consider new perspectives and multiple viewpoints. Rather than the formal analysis of historical causes of distress, the primary approach of brief therapy is to help the client to view the present from a wider context and to utilize more functional understandings (not necessarily at a conscious level). By becoming aware of these new understandings, successful clients will de facto undergo spontaneous and generative change. Brief therapy is often highly strategic, exploratory, and solution-based rather than problem-oriented. It is less concerned with how a problem arose than with the current factors sustaining it and preventing change. Brief therapists do not adhere to one "correct" approach, but rather accept that there being many paths, any of which may or may not in combination turn out to be ultimately beneficial.
Founding proponents of Brief Therapy Milton Erickson was a master of brief therapy, using clinical hypnosis as his primary tool. To a great extent he developed this himself. His approach was popularized by Jay Haley, in the book "Uncommon therapy: The psychiatric techniques of Milton Erickson M.D." "The analogy Erickson uses is that of a person who wants to change the course of a river. if he opposes the river by trying to block it, the river will merely go over and around him. But if he accepts the force of the river and diverts it in a new direction, the force of the river will cut a new channel." (Haley, "Uncommon therapy", p.24, emphasis in original) Richard Bandler, the co-founder of neuro-linguistic programming, is another firm proponent of brief therapy. After many years of studying Erickson's therapeutic work, he wrote: "It's easier to cure a phobia in ten minutes than in five years... I didn't realize that the speed with which you do things makes them last... I taught people the phobia cure. They'd do part of it one week, part of it the next, and part of it the week after. Then they'd come to me and say "It doesn't work!" If, however, you do it in five minutes, and repeat it till it happens very fast, the brain understands. That's part of how the brain learns... I discovered that the human mind does not learn slowly. It learns quickly. I didn't know that." (Time for a change, 1993, p.20)
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Short-term counselling with lasting results An Overview of Brief Therapy Brief Therapy is a model of therapy that focuses strongly on your present and future, as opposed to your past. Traditional psychotherapy tends to focus on the past and looks for the cause of problems. In contrast, Brief Therapy focuses on the solution to problems, which is why it is often called solution-oriented therapy. Some Brief Therapy experts would go so far as to say they don't even need to know what the past problems were to help the client. Although this is an extreme view, it does illustrate that Brief Therapy is firmly rooted in the present with an eye toward changing the future. The brief therapy solution-focused approach can be summed up in three stages, according to Peller and Walter (1992): 1. Find out what you (the client) want 2. Determine what is currently working for you and do more of that 3. Do something different. The simplicity of these stages belies their effectiveness. Consider, for example, the seemingly simple task of finding out what you want to achieve in therapy. Most people go into therapy knowing all too well what they don't want, what has been troubling them, or how frustrated they are by their problems. In the solutionfocused model, our goal is to help you find out what you do want. Identifying your goal (or goals) is perhaps the single most important thing you will do in your Brief Therapy sessions. In effect, the goals that you articulate will guide you through the rest of your sessions, and they will be the mark against which you will measure your success. In the next stage, the emphasis is on finding out what parts of your life are working just fine. Brief Therapists are strong adherents to the "if it ain't broke don't fix it" philosophy. When we find out what parts of your life you're happy with, we can use them as a strong foundation upon which you can build an improved lifestyle. In traditional therapy, by contrast, the focus is on diagnosing what is wrong with you or what is not working for you. In Brief Therapy you will present your problems, but you will solve them by using the strengths that you already have. The last stage (Do something different) will help you when if you realize that one approach is not working effectively. Because everyone has an almost infinite capacity for creative solutions (even if you don't realize it now) we won't waste time on any approach that's not working for you. Since our time frame is measured in weeks and months (as opposed to years) we want to find a solution that works in the shortest time possible. Brief Therapy emphasizes the client as the expert. You will be in charge of your own therapy and you will decide when you have attained your goals. Your therapist will listen to what you have to say, and together you will develop goals and work collaboratively to find solutions. Perhaps the most important thing to remember is that Brief Therapy is effective because people are capable of change in a short amount of time.
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Strategic Family Therapy From Wikipedia, the free encyclopedia Strategic family therapy is a family-oriented therapy that involves a patient's daily family environment as a major part of treatment. Pressure from family, society and peers can create rifts in even the strongest families creating dysfunction. Strategic family therapy seeks to address specific problems that can be addressed in a shorter time frame than other therapy modalities. It is one of the major models of both family and brief psychotherapy. Jay Haley of the the Strategic Family Therapy Center says that it is known as Strategic Therapy because "it is a therapy where the therapist initiates what happens during therapy, designs a specific approach for each person's presenting problem, and where the therapist takes responsibility for directly influencing people." Strategic Family Therapy (Madanes and Haley) designs a strategy for each specific problem. Clear goals set, symptoms deprived of their relationship-controlling function. Therapist controls the therapy. The goal is to fix the problem creating disruption and preserving the family unit no matter what. Every interaction is a struggle for control of the relationship's definition. Symmetrical (similar, often competitive) vs. complementary (different, often counter responding) interactions. Meta communication and repetitive interactions examined. Prescriptive and descriptive paradoxical assignments. Madanes: "pretend techniques." Circular questioning. Positive connotation (as reframe of symptomatic behaviour). The goal is to fix the problem creating disruption and preserving the family unit no matter what.
Inspiration The concept was inspired by the work of Milton Erickson, MD and Don Jackson, MD and has been associated with (but not limited to) the work of Jay Haley and Cloe Madanes (founders of Family Therapy Institute of Washington, DC in 1976), the Brief Therapy Team at the Mental Research Institute (John Weakland, Dick Fisch, and Paul Watzlawick), the Milan School of Family Therapy, and the work of Giorgio Nardone. The theory of strategic family therapy evolved from many of the gains in early family therapy models that were made by Milton Erickson and Don Jackson, with many other influences from such therapists as Salvador Minuchin, Gregory Bateson, and other prominent early family therapists. Strategic family therapy grew along with, and out of, other theories, most importantly, structural family therapy in the late 1960s and early 1970s at the Mental Research Institute in Palo Alto, and later at the Philadelphia Child Guidance Center. Many early family therapy theories were growing and influencing each other between the late 1950s and late 1970s. At first glance these theories don’t seem to have direct connections,[according to whom?] but many of the influential therapists of the time worked with each other and there was a natural give and take between these theories. Strategic family therapy was no exception to this organic growth of the theory. The main proponents and creators of the theory were Jay Haley and Cloe Mandanes. Jay Haley had worked at the Mental Research Institute in Palo Alto and the Philadelphia Child Guidance Center, and had worked directly with Erickson and Minunchin. Haley and Mandanes took their knowledge of structural therapy and the ideas of how families work on a structural level, but added ideas like making the therapist take more initiative and control over the client’s problems. The therapist seeks to identify the symptoms within the family that are the cause of the family’s current problems, and fix these problems. In strategic family therapy the problems of the clients stem not from their family’s behaviors toward the client, but instead it is the symptoms of the family that need to be corrected. In strategic terms a symptom is “the repetitive sequence that keeps the process going. The symptomatic person simply denies any intent to control by claiming the symptom is involuntary.”
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Haley Model Jay Haley and Salvador Minuchin are considered the pioneers of strategic family therapy. In the 1950s and 1960s, Haley and other therapists began experimenting with alternative models of working with families that relied on solution-focused techniques. The solution-focused approach was favored over traditional psychoanalysis. The therapy is based on the idea that people don't develop problems in isolation. Strategic therapy implements techniques that meet the specific need of a family and their interaction.
Behavior Problems Children between the ages eight and 17 are vulnerable to developing behavior problems. When this happens it can throw family dynamics into a state of chaos. Strategic family therapy is a solution-oriented approach. They focus on getting to the root of the problem rather than what caused it. The therapist works on helping their clients turn their lives around by creating a carefully planned strategy, execution and monitoring progress. The therapy is based on five stages: 1. 2. 3. 4. 5.
identify problems that can be solved, establish goals, create interventions that meet these objectives, analyze the responses, and examine the results.
The therapy emphasis is on the social situation not the individual. Solving problems, meeting family goals and help change a person's dysfunctional behavior.
Family Interaction Strategic family therapy considers the family unit as a system. Families function just like any other system. They naturally establish rules and interactions that affect every member. When the affected family member's problems are recognized and addressed, the entire family becomes part of the solution process. The idea behind this method is that the family has the most influence on a person's life.
Therapy All the family members participate within a safe, therapeutic setting. The therapist attempts to recreate typical family interactions and conversation through provocative questioning techniques so that the problems can be presented and addressed accordingly. It also give family members a chance to see how their interactions and responses can contribute to a dysfunctional situation. The therapy works on helping families discover their unique ability to solve their problems using internal resources they weren't aware they had.
Concepts and processes There are a number of concepts and processes that must be applied that are instrumental for SFT to succeed. The initial session is one of these processes, and is broken down into five different parts, the brief social stage, the problem stage, the interactional stage, goal-setting stage, and finally the task-setting stage. The brief therapy stage seeks to observe the family’s interactions, create a calm and open mood for the session, and attempts to get every family member to take part in the session. The problem stage is where the therapist poses questions to the clients to determine what their problem is and why they are there. The interactional stage is where the family is urged to discuss their problem so the therapist can better understand their issues and understand the underlying dynamics within the family. Some of the dynamics that strategic family therapists seek to understand are: hierarchies within a family, coalitions between family members, and communication sequences that exist.
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The goal-setting stage is used to highlight the specific issue that needs to be addressed, this issue is both identified by the family members and the therapist. In addition when discussing the presenting problem initially identified by the family, the family and the therapist work together to come up with goals to fix the problem, and better define the parameters for attaining those goals. The final stage of the initial session is the task-setting stage. In the task-setting stage the therapist wraps up the session by coming up with concrete homework assignments or directives the family can do outside of therapy to start to change their problems. Additional therapy sessions seek to further gain understanding to a family’s problems, dynamics, and to dig deeper in addressing their needs through a confident, controlling, and compassionate therapist.
Homework assignments In SFT the assigning of homework or directives that take place outside of therapy is essential to the therapy having a successful outcome. The underlying goal of the homework is to try to change the way the family dynamics function around the presenting problem that was identified in session. Different from other theories, the therapists take a more active and controlling approach in dealing with the family. They seek to impose upon the family new directives that fundamentally alter the way the family functions. The therapists use the initial session to gain trust and understanding with the family so that the therapists' commands to the family are followed through in a manner where the family has confidence and trust in the therapists' intentions. There are some specific assumptions for family communications that SFT utilizes that are unique to SFT. The communication models utilized are; “Every communication has a content report, and a relationship command aspect.”, “Relationships are defined by commanding messages.”, “Relationships may be described as symmetrical or complementary.”, and “Symmetrical relationships run the risk of becoming competitive.” Once a therapist establishes the mechanisms of control, and command in a family, the methods of communication can be further broken down by identifying double-binds in a family and paradoxical injunctions. These are forms of unhealthy communication that send two messages at the same time, and that contradict one another. Since SFT seeks to change family dynamics on multiple levels that may contradict one another, understanding how to achieve first-order change and second-order change are key for SFTs success. Firstorder change, are those symptoms that are superficial and obvious to correct. For example pointing out body language within the family. Second-order change would be the more difficult to achieve changes within the very basic construct of a family structure, to bring about positive changes.
Interventions Some less complicated but often used interventions in SFT would be, prescribing the symptom, relabeling, and paradoxical interventions. Prescribing the symptom would be when the therapist attempts to exaggerate a specific symptom within the family to help the family understand how damaging that symptom is to the family. The relabeling intervention is done within the session by the therapist to change the connotation of one symptom from negative to positive. In this way the family can view the symptom in a new context or have a new conceptual understanding of the symptom. Finally a paradoxical intervention is similar to prescribing the symptom, but is a more in depth intervention than prescribing the symptom. Initially the therapist tries to change the family’s low expectations to one where change within the family can happen. Second, the issue that the family wishes to fix is identified in a clear and concise manner. Third, and in line with the goal-setting stage, the therapist seeks to get the family to agree to exactly what their goals are in addressing their problem. Fourth, the therapist comes up with very specific plans for the family to address their issue.
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Fifth, the therapist discredits whomever is the controlling figure of the issue. Next the therapist replaces the controlling figure with their own authority and issues a new directive to fix the family’s identified problem. The new directive for the family is usually to paradoxically do more of the problem symptom, and thereby to highlight it more within the family. Finally the therapist learns the outcome of the directive and seeks to push the paradox even further until the family rebels, or change occurs within the family.
Hands-on approach Strategic family therapy differs from many other models of therapy in that the therapist takes a more hands on approach to fixing the family’s problems, and attempts to insert themselves into the problem as part of the solution to the family’s problems. Most other models of therapy stay away from a format like this, because of the inherent dangers within the practice, such as the family not following along with the therapist, or the therapist losing sight of their proper role within the family. Strategic family therapy appears to be a therapy that when utilized correctly can be used to address long standing family issues in a new and imaginative manner, but comes along with many pitfalls if the therapist isn’t able to control the sessions as the theory dictates.
Who Does it Help? All families face challenges. ADD/ADHD, depression and substance abuse are a few of examples of issues that can affect a family unit. If a child were dealing with any of the previous issues and had become estranged from the family, the therapist would bring everyone together in a clinical setting to watch how they interact. Then he could work closely with everyone in the family to implement and execute solutions to help correct the dysfunctional behavior.
References 1.http://www.mri.org/strategic_family_therapy.html 2.Goldenbeg, Goldenberg, 2008
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Bowen’s Strategic Family Therapy Contents
Introduction Differentiation of Self Triangles The Nuclear Family Emotional Processes The Family Projection Process The Multigenerational Transmission Process Sibling Position Emotional Cutoff Societal Emotional Processes Normal Family Development Family Disorders Goals of Therapy Techniques Family Therapy with One Person
Introduction The pioneers of family therapy recognized that current social and cultural forces shape our values about ourselves and our families, our thoughts about what is "normal" and "healthy," and our expectations about how the world works. However, Bowen was the first to realize that the history of our family creates a template which shapes the values, thoughts, and experiences of each generation, as well as how that generation passes down these things to the next generation. Bowen was a medical doctor and the oldest child in a large cohesive family from Tennessee. He studied schizophrenia, thinking the cause for it began in mother-child symbiosis, which created an anxious and unhealthy attachment. He moved from studying dyads (two way relationships like parent-child and parentparent) to triads (three way relationships like parent-parent-child and grandparent-parent-child) afterward. At a conference organized by Framo, one of his students, he explained his theory of how families develop and function, and presented as a case study his own family. Bowen's theory focuses on the balance of two forces. The first is togetherness and the second is individuality. Too much togetherness creates fusion and prevents individuality, or developing one's own sense of self. Too much individuality results in a distant and estranged family. Bowen introduced eight interlocking concepts to explain family development and functioning, each of which is described below. The family systems theory is a theory introduced by Dr. Murray Bowen that suggests that individuals cannot be understood in isolation from one another, but rather as a part of their family, as the family is an emotional unit. Families are systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system.
The family system According to Bowen, a family is a system in which each member has a role to play and rules to respect. Members of the system are expected to respond to each other in a certain way according to their role, which is determined by relationship agreements. Within the boundaries of the system, patterns develop as certain family member's behaviour is caused by and causes other family member's behaviours in predictable ways. Maintaining the same pattern of behaviours within a system may lead to balance in the family system, but also to dysfunction. For example, if a husband is depressive and cannot pull himself together, the wife may need to take up more responsibilities to pick up the slack. The change in roles may maintain the stability in the relationship, but it
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may also push the family towards a different equilibrium. This new equilibrium may lead to dysfunction as the wife may not be able to maintain this overachieving role over a long period of time. There are eight interlocking concepts in Dr. Bowen's theory: 1) Differentiation of self:
The variance in individuals in their susceptibility to depend on others for acceptance and approval. 2) Triangles:
The smallest stable relationship system. Triangles usually have one side in conflict and two sides in harmony, contributing to the development of clinical problems. 3) Nuclear family emotional system:
The four relationship patterns that define where problems may develop in a family. - Marital conflict - Dysfunction in one spouse - Impairment of one or more children - Emotional distance 4) Family projection process:
The transmission of emotional problems from a parent to a child. 5) Multigenerational transmission process:
The transmission of small differences in the levels of differentiation between parents and their children. 6) Emotional cut-off:
The act of reducing or cutting off emotional contact with family as a way of managing unresolved emotional issues. 7) Sibling position:
The impact of sibling position on development and behaviour. 8) Societal emotional process:
The emotional system governs behaviour on a societal level, promoting both progressive and regressive periods in a society.
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1. Differentiation of Self The first concept is Differentiation of Self, or the ability to separate feelings and thoughts. Undifferentiated people can not separate feelings and thoughts; when asked to think, they are flooded with feelings, and have difficulty thinking logically and basing their responses on that. Further, they have difficulty separating their own from other's feelings; they look to family to define how they think about issues, feel about people, and interpret their experiences. Differentiation is the process of freeing yourself from your family's processes to define yourself. This means being able to have different opinions and values than your family members, but being able to stay emotionally connected to them. It means being able to calmly reflect on a conflicted interaction afterward, realizing your own role in it, and then choosing a different response for the future. Families and other social groups tremendously affect how people think, feel, and act, but individuals vary in their susceptibility to a "group think" and groups vary in the amount of pressure they exert for conformity. These differences between individuals and between groups reflect differences in people's levels of differentiation of self. The less developed a person's "self," the more impact others have on his functioning and the more he tries to control, actively or passively, the functioning of others. The basic building blocks of a "self" are inborn, but an individual's family relationships during childhood and adolescence primarily determine how much "self" he develops. Once established, the level of "self" rarely changes unless a person makes a structured and long-term effort to change it. People with a poorly differentiated "self" depend so heavily on the acceptance and approval of others that either they quickly adjust what they think, say, and do to please others or they dogmatically proclaim what others should be like and pressure them to conform. Bullies depend on approval and acceptance as much as chameleons, but bullies push others to agree with them rather than their agreeing with others. Disagreement threatens a bully as much as it threatens a chameleon. An extreme rebel is a poorly differentiated person too, but he pretends to be a "self" by routinely opposing the positions of others. A person with a well-differentiated "self" recognizes his realistic dependence on others, but he can stay calm and clear headed enough in the face of conflict, criticism, and rejection to distinguish thinking rooted in a careful assessment of the facts from thinking clouded by emotionality. Thoughtfully acquired principles help guide decision-making about important family and social issues, making him less at the mercy of the feelings of the moment. What he decides and what he says matches what he does. He can act selflessly, but his acting in the best interests of the group is a thoughtful choice, not a response to relationship pressures. Confident in his thinking, he can either support another's view without being a disciple or reject another view without polarizing the differences. He defines himself without being pushy and deals with pressure to yield without being wishy-washy. Every human society has its well-differentiated people, poorly differentiated people, and people at many gradations between these extremes. Consequently, the families and other groups that make up a society differ in the intensity of their emotional interdependence depending on the differentiation levels of their members. The more intense the interdependence, the less the group's capacity to adapt to potentially stressful events without a marked escalation of chronic anxiety. Everyone is subject to problems in his work and personal life, but less differentiated people and families are vulnerable to periods of heightened chronic anxiety which contributes to their having a disproportionate share of society's most serious problems. Example: The description that follows is of how this triangle would play out for Michael, Martha and Amy if they were (more) differentiated people. Michael and Martha were quite happy during the first two years of their marriage. He liked making the major decisions, but did not assume he knew "best." He always told Martha what he was thinking and he listened carefully to her ideas. Their exchanges were usually thoughtful and led to decisions that respected the vital interests of both people. Martha had always been attracted to Michael's sense of responsibility and willingness to make decisions, but she also lived by a principle that she was responsible for thinking things
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through for herself and telling Michael what she thought. She did not assume Michael usually knew "best." [Analysis: Because the level of stress on a marriage is often less during the early years, particularly before the births of children and the addition of other responsibilities, the less adaptive moderately differentiated marriage and the more adaptive well-differentiated marriage can look similar because the tension level is low. Stress is necessary to expose the limits of a family's adaptive capacity.] Martha conceived during the third year of the marriage and had a fairly smooth pregnancy. She had a few physical problems, but dealt with them with equanimity. She was somewhat anxious about being an adequate mother but felt she could manage these fears. When she talked to Michael about her fears, she did not expect that he would solve them for her, but she thought more clearly about her fears when she talked them out with him. He listened but was not patronizing. He recognized his own fears about the coming changes in their lives and acknowledged them to Martha. [Analysis: The stresses associated with the real and anticipated changes of the pregnancy trigger some anxiety in both Michael and Martha, but their interaction does not escalate the anxiety and make it chronic. Martha had somewhat heightened needs and expectations of Michael, but she takes responsibility for managing her anxiety and has realistic expectations about what he can do for her. Michael does not get particularly reactive to Martha's expectations and recognizes he is anxious too. Each remains a resource to the other.] A female infant was born after a fairly smooth labor. They named her Amy. Martha weathered the delivery fairly well and was ready to go home when her doctor discharged her. The infant care over the next few months was physically exhausting for Martha, but she was not heavily burdened by anxieties about the baby or about her adequacy as a mother. She continued to talk to Michael about her thoughts and feelings and still did not feel he was supposed to do something to make her feel better. Although Michael had increasing work pressures he remained emotionally available to her, even if only by phone at times. He worried about work issues, but did not ruminate about them to Martha. When she asked how it was going, he responded fairly factually and appreciated her interest. He occasionally wished Martha would not get anxious about things, but realized she could manage. He was not compelled to "fix" things for her. [Analysis: Sure of herself as a person, Martha is able to relate to Amy without feeling overwhelmed by responsibilities and demands and without unfounded fears about the child's well-being. Sure of himself, Michael can meet the reality demands of his job without feeling guilty that he is neglecting Martha. Each spouse recognizes the pressure the other is under and neither makes a "federal case" about being neglected. Each is sufficiently confident in the other's loyalty and commitment that neither needs much reassurance about it. By the parents relating comfortably to each other, Amy is not triangled into marital tensions. She does not have a void to fill in her mother's life related to distance between her parents.] After a few months, Michael and Martha were able to find time to do some things by themselves. Martha found that her anxieties about being a mother toned down and she did not worry much about Amy. As Amy grew, Martha did not perceive her as an insecure child that needed special attention. She was positive about Amy, but not constantly praising her in the name of reinforcing Amy's self-image. Michael and Martha discussed their thoughts and feelings about Amy, but they were not preoccupied with her. They were pleased to have her and took pleasure in watching her develop. Amy grew to be a responsible young child. She sensed the limits of what was realistic for her parents to do for her and respected those limits. There were few demands and no tantrums. Michael did not feel critical of Amy very often and Martha did not defend Amy to him when he was critical. Martha figured Michael and Amy could manage their relationship. Amy seemed equally comfortable with both of her parents and relished exploring her environment. [Analysis: Michael and Martha can see Amy as a separate and distinct person. The beginning differentiation between Amy and her parents is evident when Amy is a young child. They have adapted quite successfully to the anxieties they each experienced associated with the addition of a child and the increased demands in Michael's work life. Their high levels of differentiation allow the three of them to be in close contact with little triangling.]
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2. Triangles Triangles are the basic units of systems. Dyads are inherently unstable, as two people will vacillate between closeness and distance. When distressed or feeling intense emotions, they will seek a third person to triangulate.
Think about a couple who has an argument, and afterward, one of the partners calls their parent or best friend to talk about the fight. The third person helps them reduce their anxiety and take action, or calm their strong emotions and reflect, or bolster their beliefs and make a decision.
People who are more undifferentiated are likely to triangulate others and be triangulated. People who are differentiated cope well with life and relationship stress, and thus are less likely to triangulate others or be triangulated.
Think of the person who can listen to the best friend's relationship problems without telling the friend what to do or only validating the friend's view. Instead, the differentiated person can tell the best friend "You know, you can be intimidating at those times..." or "I agree with you but you won't change your partner; you either have to learn to accept this about them, or have to call this relationship quits..."
A triangle is a three-person relationship system. It is considered the building block or "molecule" of larger emotional systems because a triangle is the smallest stable relationship system. A two-person system (dyad) is unstable because it tolerates little tension before involving a third person. A triangle can contain much more tension without involving another person because the tension can shift around three relationships. If the tension is too high for one triangle to contain, it spreads to a series of "interlocking" triangles. Spreading the tension can stabilize a system, but nothing gets resolved. People's actions in a triangle reflect their efforts to ensure their emotional attachments to important others, their reactions to too much intensity in the attachments, and their taking sides in the conflicts of others. Paradoxically, a triangle is more stable than a dyad, but a triangle creates an "odd man out," which is a very difficult position for individuals to tolerate. Anxiety generated by anticipating or being the odd one out is a potent force in triangles. The patterns in a triangle change with increasing tension. In calm periods, two people are comfortably close "insiders" and the third person is an uncomfortable "outsider." The insiders actively exclude the outsider and the outsider works to get closer to one of them. Someone is always uncomfortable in a triangle and pushing for change. The insiders solidify their bond by choosing each other in preference to the less desirable outsider. Someone choosing another person over oneself arouses particularly intense feelings of rejection. If mild to moderate tension develops between the insiders, the most uncomfortable one will move closer to the outsider. One of the original insiders now becomes the new outsider and the original outsider is now an insider. The new outsider will make predictable moves to restore closeness with one of the insiders. At moderate levels of tension, triangles usually have one side in conflict and two sides in harmony. The conflict is not inherent in the relationship in which it exists but reflects the overall functioning of the triangle. At a high level of tension, the outside position becomes the most desirable. If severe conflict erupts between the insiders, one insider opts for the outside position by getting the current outsider fighting with the other insider. If the manoeuvring insider is successful, he gains the more comfortable position of watching the other two people fight. When the tension and conflict subside, the outsider will try to regain an inside position. Triangles contribute significantly to the development of clinical problems. Getting pushed from an inside to an outside position can trigger a depression or perhaps even a physical illness. Two parents intensely focusing on what is wrong with a child can trigger serious rebellion in the child.
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Example: Michael and Martha were extremely happy during the first two years of their marriage. Michael liked making major decisions and Martha felt comforted by Michael's "strength." After some difficulty getting pregnant, Martha conceived during the third year of the marriage, but it was a difficult pregnancy. She was quite nauseous during the first trimester and developed blood pressure and weight gain problems as the pregnancy progressed. She talked frequently to Michael of her insecurities about being a mother. Michael was patient and reassuring, but also began to feel critical of Martha for being "childlike." [Analysis: The pregnancy places more pressure on Martha and on the marital relationship. Michael is outwardly supportive of Martha but is reactive to hearing about her anxieties. He views her as having a problem.] A female infant was born after a long labor. They named her Amy. Martha was exhausted and not ready to leave the hospital when her doctor discharged her. Over the next few months, she felt increasingly overwhelmed and extremely anxious about the well-being of the young baby. She looked to Michael for support, but he was getting home from the office later and Martha felt that he was critical of her problems coping and that he dismissed her worries about the child. There was much less time together for just Michael and Martha and, when there was time, Michael ruminated about work problems. Martha became increasingly preoccupied with making sure her growing child did not develop the insecurities she had. She tried to do this by being as attentive as she could to Amy and consistently reinforcing her accomplishments. It was easier for Martha to focus on Amy than it was for her to talk to Michael. She reacted intensely to his real and imagined criticisms of her. Michael and Martha spent more and more of their time together discussing Amy rather than talking about their marriage. [Analysis: Martha is the most uncomfortable with the increased tension in the marriage. The growing emotional distance in the marriage is balanced by Martha getting overly involved with Amy and Michael getting overly involved with his work. Michael is in the outside position in the parental triangle and Martha and Amy are in the inside positions.] As Amy grew, she made increasing demands on her mother's time. Martha felt she could not give Amy enough time, that Amy would never be satisfied. Michael agreed with Martha that Amy was too selfish and resented Amy's temper tantrums when she did not get her way. However, if Michael got too critical of Amy, Martha would defend Amy, telling Michael he was exaggerating. Yet, whenever tensions developed between Martha and Amy, Martha would press Michael to spend more time with Amy to reassure her that she was loved. He gave into Martha's pleas, but inwardly felt that they were following a policy of appeasement that was making Amy more demanding. Michael felt that if Martha had his maturity, Amy would be less of a problem, but, despite this attitude, Michael usually followed Martha's lead in relationship to Amy. [Analysis: When tension builds between Martha and Amy, Michael sides with Martha by agreeing that Amy is the problem. The conflictual side of the triangle then shifts from between Martha and Amy to between Michael and Amy. If the conflict gets too intense between Michael and Amy, Martha sides with Amy, the conflict shifts into the marriage, and Amy gains the more comfortable outside position.]
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3. The Nuclear Family Emotional Processes These are the emotional patterns in a family that continue over the generations.
Think about a mother who lived through The Great Depression, and taught her daughter to always prepare for the worst case scenario and be happy simply if things are not that bad. The daughter thinks her mother is wise, and so adopts this way of thinking. She grows up, has a son, and without realizing it, models this way of thinking. He may follow or reject it, and whether he has a happy or distressed relationship may depend on the kind of partner he finds. Likewise, think of a daughter who goes to work for her father, who built his own father's small struggling business into a thriving company. He is seen in the family as a great businessperson as he did this by taking risks in a time of great economic opportunity. He teaches his daughter to take risks, "spend money to make money," and assume a great idea will always be profitable. His daughter may follow or reject her father's advice, and her success will depend on whether she faces an economic boom or recession.
In both cases, the parent passes on an emotional view of the world (the emotional process), which is taught each generation from parent to child, the smallest possible "unit" of family (the nuclear unit). Reactions to this process can range from open conflict, to physical or emotional problems in one family member, to reactive distancing (see below). Problems with family members may include things like substance abuse, irresponsibility, depression.... The concept of the nuclear family emotional system describes four basic relationship patterns that govern where problems develop in a family. People's attitudes and beliefs about relationships play a role in the patterns, but the forces primarily driving them are part of the emotional system. The patterns operate in intact, single-parent, step-parent, and other nuclear family configurations. Clinical problems or symptoms usually develop during periods of heightened and prolonged family tension. The level of tension depends on the stress a family encounters, how a family adapts to the stress, and on a family's connection with extended family and social networks. Tension increases the activity of one or more of the four relationship patterns. Where symptoms develop depends on which patterns are most active. The higher the tension, the more chance that symptoms will be severe and that several people will be symptomatic. The four basic relationship patterns are: Marital conflict As family tension increases and the spouses get more anxious, each spouse externalizes his or her anxiety into the marital relationship. Each focuses on what is wrong with the other, each tries to control the other, and each resists the other's efforts at control. Dysfunction in one spouse One spouse pressures the other to think and act in certain ways and the other yields to the pressure. Both spouses accommodate to preserve harmony, but one does more of it. The interaction is comfortable for both people up to a point, but if family tension rises further, the subordinate spouse may yield so much selfcontrol that his or her anxiety increases significantly. The anxiety fuels, if other necessary factors are present, the development of a psychiatric, medical, or social dysfunction. Impairment of one or more children The spouses focus their anxieties on one or more of their children. They worry excessively and usually have an idealized or negative view of the child. The more the parents focus on the child the more the child focuses on them. He is more reactive than his siblings to the attitudes, needs, and expectations of the parents. The process undercuts the child's differentiation from the family and makes him vulnerable to act out or internalize family tensions. The child's anxiety can impair his school performance, social relationships, and even his health.
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Emotional distance This pattern is consistently associated with the others. People distance from each other to reduce the intensity of the relationship, but risk becoming too isolated. The basic relationship patterns result in family tensions coming to rest in certain parts of the family. The more anxiety one person or one relationship absorbs, the less other people must absorb. This means that some family members maintain their functioning at the expense of others. People do not want to hurt each other, but when anxiety chronically dictates behaviour, someone usually suffers for it. Example: The tensions generated by Michael and Martha's interactions lead to emotional distance between them and to an anxious focus on Amy. Amy reacts to her parents' emotional over involvement with her by making immature demands on them, particularly on her mother. [Analysis: A parent's emotional over involvement with a child programs the child to be as emotionally focused on the parent as the parent is on the child and to react intensely to real or imagined signs of withdrawal by the parent.] When Amy was four years old, Martha got pregnant again. She wanted another child, but soon began to worry about whether she could meet the emotional needs of two children. Would Amy be harmed by feeling left out? Martha worried about telling Amy that she would soon have a little brother or sister, wanting to put off dealing with her anticipated reaction as long as possible. Michael thought it was silly but went along with Martha. He was outwardly supportive about the pregnancy, he too wanted another child, but he worried about Martha's ability to cope. [Analysis: Martha externalizes her anxiety onto Amy rather than onto her husband or rather than internalizing it. Michael avoids conflict with Martha by supporting the focus on Amy and avoids dealing with his own anxieties by focusing on Martha's coping abilities.] Apart from her fairly intense anxieties about Amy, Martha's second pregnancy was easier than the first. A daughter, Marie, was born without complications. This time Michael took more time away from work to help at home, feeling and seeing that Martha seemed "on the edge." He took over many household duties and was even more directive of Martha. Martha was obsessed with Amy feeling displaced by Marie and gave in even more to Amy's demands for attention. Martha and Amy began to get into struggles over how available Martha could be to her. When Michael would get home at night, he would take Amy off her mother's hands and entertain her. He also began feeling neglected himself and quite disappointed in Martha's lack of coping ability.. Martha had done some drinking before she married Michael and after Amy was born, but stopped completely during the pregnancy with Marie. When Marie was a few months old, however, Martha began drinking again, mostly wine during the evenings, and much more than in the past. She somewhat tried to cover up the amount of drinking she did, feeling Michael would be critical of it. He was. He accused her of not trying, not caring, and being selfish. Martha felt he was right. She felt less and less able to make decisions and more and more dependent on Michael. She felt he deserved better, but also resented his criticism and patronizing. She drank more, even during the day. Michael began calling her an alcoholic. [Analysis: The pattern of sickness in a spouse has emerged, with Martha as the one making the most adjustments in her functioning to preserve harmony in the marriage. It is easier for Martha to be the problem than to stand up to Michael's diagnosing her and, besides, she feels she really is the problem. As the pattern unfolds, Michael increasingly over functions and Martha increasingly under functions. Michael is as allergic to conflict as Martha is, opting to function for her rather than risk the disharmony he would trigger by expecting her to function more responsibly.] By the time Amy and Marie were both in school, Martha reached a serious low point. She felt worthless and out of control. She felt Michael did everything, but that she could not talk to him. Her doctor was concerned about her physical health. Finally, Martha confided in him about the extent of her drinking. Michael had been pushing her to get help, but Martha had reached a point of resisting almost all of Michael's directives. However, her doctor scared her and she decided to go to Alcoholics Anonymous. Martha felt completely
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accepted by the A.A. group and greatly relieved to tell her story. She stopped drinking almost immediately and developed a very close connection to her sponsor, an older woman. She felt she could be herself with the people at A.A. in a way she could not be with Michael. She began to function much better at home, began a part-time job, but also attended A.A. meetings frequently. Michael had complained bitterly about her drinking, but now he complained about her preoccupation with her new found A.A. friends. Martha gained a certain strength from her new friends and was encouraged by them "to stand up" to Michael. She did. They began fighting frequently. Martha felt more like herself again. Michael was bitter. [Analysis: Martha's involvement with A.A. helped her stop drinking, but it did not solve the family problem. The level of family tension has not changed and the emotional distance in the marriage has not changed. Because of "borrowing strength" from her A.A. group, Martha is more inclined to fight with Michael than to go along and internalize the anxiety. This means the marital pattern has shifted somewhat from dysfunction in a spouse to marital conflict, but the family has not changed in a basic way. In other words, Martha's level of differentiation of self has not changed through her A.A. involvement, but her functioning has improved.]
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4. The Family Projection Process This is an extension of The Nuclear Family Emotional Process in many ways. The family member who "has" the "problem" is triangulated and serves to stabilize a dyad in the family.
Thus, the son who rejects his mother's pessimistic view may find his mother and sister become closer, as they agree that he is immature and irresponsible. The more they share this view with him, the more it makes him feel excluded and shapes how he sees himself. He may act in accord with this view and behave more and more irresponsibly. He may reject it, constantly trying to "prove" himself to be mature and responsible, but failing to gain his family's approval because they do not attribute his successes to his own abilities ("He was so lucky that his company had a job opening when he applied..." or "It's a good thing the loan officer felt sorry for him because he couldn't have managed it without that loan..."). He might turn to substance abuse as he becomes more and more irresponsible, or as he struggles with never meeting his family's expectations. Similarly, the daughter who faces harsh economic times and is more fiscally conservative than her father is seen by the parents as too rigid and dull. They join together to worry that she'll never be happily married. She might accept this role and become a workaholic who has only superficial relationships, or reject it and take wild risks that fail. In the end, she may become depressed as she works more and more, or as she fails to live up to her father's reputation as a creative and successful business person.
The family member who serves as the "screen" upon which the family "projects" this story will have great trouble differentiating. It will be hard for the son or daughter above to hold their own opinions and values, maintain their emotional strength, and make their own choices freely despite the family's view of them. The family projection process describes the primary way parents transmit their emotional problems to a child. The projection process can impair the functioning of one or more children and increase their vulnerability to clinical symptoms. Children inherit many types of problems (as well as strengths) through the relationships with their parents, but the problems they inherit that most affect their lives are relationship sensitivities such as heightened needs for attention and approval, difficulty dealing with expectations, the tendency to blame oneself or others, feeling responsible for the happiness of others or that others are responsible for one's own happiness, and acting impulsively to relieve the anxiety of the moment rather than tolerating anxiety and acting thoughtfully. If the projection process is fairly intense, the child develops stronger relationship sensitivities than his parents. The sensitivities increase a person's vulnerability to symptoms by fostering behaviours that escalate chronic anxiety in a relationship system. The projection process follows three steps: (1) the parent focuses on a child out of fear that something is wrong with the child; (2) the parent interprets the child's behaviour as confirming the fear; and (3) the parent treats the child as if something is really wrong with the child. These steps of scanning, diagnosing, and treating begin early in the child's life and continue. The parents' fears and perceptions so shape the child's development and behaviour that he grows to embody their fears and perceptions. One reason the projection process is a self-fulfilling prophecy is that parents try to "fix" the problem they have diagnosed in the child; for example, parents perceive their child to have low self-esteem, they repeatedly try to affirm the child, and the child's self-esteem grows dependent on their affirmation. Parents often feel they have not given enough love, attention, or support to a child manifesting problems, but they have invested more time, energy, and worry in this child than in his siblings. The siblings less involved in the family projection process have a more mature and reality-based relationship with their parents that fosters the siblings developing into less needy, less reactive, and more goal-directed people. Both parents participate equally in the family projection process, but in different ways. The mother is usually the primary caretaker and more prone than the father to excessive emotional involvement with one or more of the children. The father typically occupies the outside position in the parental triangle, except during periods of heightened tension in the mother-child relationship. Both parents are unsure of themselves in relationship to the child, but commonly one parent acts sure of himself or herself and the other parent
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goes along. The intensity of the projection process is unrelated to the amount of time parents spend with a child. Example: The case of Michael, Martha, and Amy illustrates the family projection process. Martha's anxiety about Amy began before Amy was born. Martha feared she would transfer inadequacies she had felt as a child, and still felt, to her own child. This was one reason Martha had mixed feelings about being a mother. Like many parents, Martha felt a mother's most important task was to make a child feel loved. In the name of showing love, she was acutely responsive to Amy's desires for attention. If Amy seemed bored and out of sorts, Martha was there with an idea or plan. She believed a child's road to confidence and independence was in the child feeling secure about herself. Martha did not recognize how sensitive she was to any sign in Amy that she might be upset or troubled and how quickly she would move in to fix the problem. Martha loved Amy deeply. She and Amy often seemed like one person in the way they were attuned to each other. As a very small toddler, Amy was as sensitive to her mother's moods and wants as Martha was to Amy's moods and wants. [Analysis: Martha's excessive involvement programs Amy to want much of her mother's attention and to be highly sensitive to her mother's emotional state. Both mother and child act to reinforce the intense connection between them.] At some point in the unfolding of their relationship, Martha began to feel irritated at times by what Martha regarded as Amy's "insatiable need" for attention. Martha would try to distance from Amy's neediness, but not very successfully because Amy had ways to involve her mother with her. Martha flip-flopped between pleading with and cajoling Amy one minute and being angry at and directive of her the next. It seemed to lock them together even more tightly. Martha looked to Michael to take over at such times. Despite calling Amy's need for attention insatiable, Martha felt Amy really needed more of her time and she faulted herself for not being able to give enough. She wanted Michael to help with the task. It bothered Martha if Amy seemed upset with her. Amy's upsets triggered guilt in Martha and a fear that they were no longer close companions. She wanted to soothe Amy and feel close to her. [Analysis: Martha blames Amy for the demands she makes on her, but at the same time feels she is failing Amy. Martha tries to "fix" Amy's problem by doing more of what she has already been doing and solicits Michael's help in it. Martha is meeting many of her own needs for emotional closeness and companionship through Amy, thus gets very distressed if Amy seems unhappy with her. The marital distance accentuates Martha's need for Amy.] Martha's second pregnancy changed a reasonably manageable situation into an unmanageable one. The dilemma of meeting the needs of both children seemed impossible to Martha. She felt Amy was already showing signs of "inheriting" her insecurities. How had she failed her? When it was time for Amy to start school, Martha sought long conferences with the kindergarten teacher to plan the transition. If Amy balked at going to school, Martha became frightened, angry, exasperated, and guilty. The kindergarten teacher felt she understood children like Amy and took great interest in her. Amy was bright, thrived on the teacher's attention, and performed very well in school. Martha had none of these fears when Marie started school and, not surprisingly, none of the school transition problems occurred with her. Marie did not seem to require so much of the teacher's attention; she just pursued her interests. As Amy progressed through grade school, her adjustment to school seemed to depend heavily on the teacher she had in a particular year. If the teacher seemed to take an unusual interest in her, she performed very well, but if the teacher treated her as one of the group, she would lose interest in her work. Martha focused on making sure Amy got the "right" teacher whenever possible. Marie's performance did not depend on a particular teacher. [Analysis: Martha's difficulty being a "self" with her children is reflected in her feeling inordinately responsible for the happiness of both children. This makes it extremely difficult for her to interact comfortably with two children. Amy transfers the relationship intensity she has with her mother to her teachers. When a teacher makes her special, Amy performs very well, but without that type of relationship,
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Amy performs less well. Marie is less involved with her mother and, consequently, her performance is less dependent on the relationship environment at school and at home.] If Amy complained about the ways other kids treated her in school, Martha and Michael would talk to her about not being so sensitive, telling her she should not care so much about what other people think. If Amy had a special friend, she was extremely sensitive to that friend paying attention to another little girl. Martha lectured Amy about being less sensitive but also planned outings and parties designed to help Amy with her friendships. Michael criticized Martha for this, saying Amy should work out these problems for herself, but he basically went along with all of Martha's efforts. [Analysis: The parents' words do not match their actions. They lecture Amy about being less sensitive, but the frequent lectures belie their own anxieties about such issues and their doubts about Amy's ability to cope. Amy's sensitivity to being in the outside position in a triangle with her playmates reflects her programming for such relationship sensitivities in the parental triangle.] Martha and Amy had turmoil in their relationship during Amy's elementary school years, but things got worse in middle school. Amy began having academic problems and complained about feeling lost in the larger school. She seemed unhappy to Martha. Martha talked to Michael and to the paediatrician about getting therapy for Amy. They hired tutors for Amy in two of her subjects, even though they knew that part of the problem was Amy not working hard in those subjects. When Amy's grades did not improve, Michael criticized her for not taking advantage of the help they were giving and not appreciating them as parents. Martha scolded Michael for being too hard on Amy, but inwardly she felt even more critical of her than Michael did. She had worked hard to prevent these very problems in Amy. How could Amy disappoint her so much? In the summers when there were no academic pressures, Martha and Amy got along much better. [Analysis: Commonly parents get critical of a child with whom they have been excessively involved if the child's performance drops. They push for the child to have therapy or tutors rather than think about the changes they themselves need to make. Medicine, psychiatry, and the larger society usually reinforce the child focus by defining the problem as being in the child and by often implying that the parents are not attentive and caring enough.] The big changes occurred when Amy started high school. Martha felt Amy was telling her less of what was happening in her life and that she was more sullen and withdrawn. Amy also had a new group of girlfriends that seemed less desirable to Martha. Amy had also found boys. Martha and Amy got into more frequent conflicts. Amy felt controlled by her parents, not given the freedom to make her own decisions, pick her own friends. She resented her mother's obvious intrusions into her room when she was out. She began lying to her mother in an effort to evade her rules. Martha was no longer drinking herself at this point, but worried that Amy was using drugs and alcohol. She challenged Amy about it, but her challenges were met with denials. When Martha felt particularly overwhelmed by the situation, Michael would step in and try to lay down the law to Amy. He accused Amy of not appreciating all they had done for her and of deliberately trying to hurt them. He wanted to know "why" she disobeyed them. Amy would lash back at her father in these discussions, at which point Martha would intervene. Amy stayed away from the house more, told her parents less and less, and got in with a fairly wild crowd. She acted out some of her parents worst fears, but did not feel particularly good about herself and about what she was doing. Amy felt alienated from her parents. The parents' focus on her deteriorating grades included lectures and groundings, but Amy easily evaded these efforts to control and change her. [Analysis: The more intense the family projection process has been, the more intense the adolescent rebellion. Parents typically blame the rebellion on adolescence, but the parents reactivity to the child fuels the rebellion as much as the child's reactivity. When the parents demand to know "why" Amy acts as she does, they place the problem in Amy. Similarly, parents often blame the influence of the peer group, which also places the problem outside themselves. Peers are an important influence, but a child's vulnerability to peer pressure is related to the intensity of the family process. The intense family process closes down communication and isolates Amy from the family. This is why a child who is very intensely connected to her parents can feel distant from them. The siblings who are less involved in the family problem navigate adolescence more smoothly.]
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Michael and Martha became increasingly critical of Amy, but also latched onto any signs she might be doing a little better. They gave her her own phone, bought the clothes she "just had to have," and gave her a car for her sixteenth birthday. Many of these things were done in the name of making Amy feel special and important, hoping that would motivate her to do better. Throughout all the turmoil surrounding Amy, Marie presented few problems. [Analysis: The parents' permissiveness is just as important in perpetuating the problems in Amy as the critical focus on her. As a teenager, Amy is just as critical of her parents as they are of her. Marie is a more mature person than Amy, but she is not free of the family problem; for example, she sides with her parents in blaming Amy for the family turmoil.]
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5. The Multigenerational Transmission Process This process entails the way family emotional processes are transferred and maintained over the generations. This captures how the whole family joins in The Family Projection Process, for example, by reinforcing the beliefs of the family. As the family continues this pattern over generations, the also refer back to previous generations ("He's just like his Uncle Albert - he was always irresponsible too" or "She's just like your cousin Jenny - she was divorced four times."). The concept of the multigenerational transmission process describes how small differences in the levels of differentiation between parents and their offspring lead over many generations to marked differences in differentiation among the members of a multigenerational family. The information creating these differences is transmitted across generations through relationships. The transmission occurs on several interconnected levels ranging from the conscious teaching and learning of information to the automatic and unconscious programming of emotional reactions and behaviours. Relationally and genetically transmitted information interact to shape an individual's "self." The combination of parents actively shaping the development of their offspring, offspring innately responding to their parents' moods, attitudes, and actions, and the long dependency period of human offspring results in people developing levels of differentiation of self similar to their parents' levels. However, the relationship patterns of nuclear family emotional systems often result in at least one member of a sibling group developing a little more "self" and another member developing a little less "self" than the parents. The next step in the multigenerational transmission process is people predictably selecting mates with levels of differentiation of self that match their own. Therefore, if one sibling's level of "self" is higher and another sibling's level of "self" is lower than the parents, one sibling's marriage is more differentiated and the other sibling's marriage is less differentiated than the parents' marriage. If each sibling then has a child who is more differentiated and a child who is less differentiated than himself, one three generational line becomes progressively more differentiated (the most differentiated child of the most differentiated sibling) and one line becomes progressively less differentiated (the least differentiated child of the least differentiated sibling). As these processes repeat over multiple generations, the differences between family lines grow increasingly marked. Level of differentiation of self can affect longevity, marital stability, reproduction, health, educational accomplishments, and occupational success. This impact of differentiation on overall life functioning explains the marked variation that typically exists in the lives of the members of a multigenerational family. The highly differentiated people have unusually stable nuclear families and contribute much to society; the poorly differentiated people have chaotic personal lives and depend heavily on others to sustain them. A key implication of the multigenerational concept is that the roots of the most severe human problems as well as of the highest levels of human adaptation are generations deep. The multigenerational transmission process not only programs the levels of "self" people develop, but it also programs how people interact with others. Both types of programming affect the selection of a spouse. For example, if a family programs someone to attach intensely to others and to function in a helpless and indecisive way, he will likely select a mate who not only attaches to him with equal intensity, but one who directs others and make decisions for them. Example: The multigenerational transmission process helps explain the particular patterns that have played out in the nuclear family of Michael, Martha, Amy, and Marie. Martha is the youngest of three daughters from an intact Midwestern family. From her teen years on, Martha did not feel especially close to either of her parents, but especially to her mother. She experienced her mother as competent and caring but often intrusive and critical. Martha felt she could not please her mother. Her sisters seemed to feel more secure and competent than Martha. She asked herself how she could grow up in a seemingly "normal" family and have so many problems, and answered herself that there must be something wrong with her. When she faced important dilemmas in her life and had decisions to make, her mother got involved and strongly influenced Martha's choices. Her mother said Martha should make her own decisions, but her mother's actions did not match her words. One of her mother's biggest fears was that
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Martha would make the wrong decision. In time, Martha's sisters came to view her much like their mother did and treated her as the baby of the family, as one needing special guidance. Martha's father was sympathetic with her one-down position in the family, but he distanced from family tensions. Martha detested herself for needing the acceptance and approval of others to function effectively and for feeling she could not act more independently. She worried about making the wrong decision and turned frequently to her mother for help. [Analysis: The primary relationship pattern in Martha's family of origin was impairment of one or more children, and the projection process focused primarily on Martha. The mother's over functioning promoted Martha's under functioning, but Martha largely blamed herself for her difficulties making decisions and functioning independently. Martha's intense need for approval and acceptance reflected the high level of involvement with her mother. She managed the intensity with her mother with emotional distance. These basic patterns were later replicated in her marriage and with Amy.] Martha's mother is the oldest child in her family and functioned as a second parent to her three younger siblings. Martha's mother's mother became a chronic invalid after her last child was born. As a child, Martha's mother functioned as a second mother in her family and, with the encouragement of her father, did much of the caretaking of her invalid mother. Martha's mother basked in the approval she gained from both of her parents, especially from her father. Her father was often critical of his wife, insisting she could do more for herself if she would try. Martha's grandmother responded to the criticism by taking to bed, often for days at a time. Martha's mother learned to thrive on taking care of others and being needed. [Analysis: Martha's mother probably had almost as intense an involvement with her parents as she subsequently had with Martha, but the styles of the involvements were different. Two relationship patterns dominated Martha's mother's nuclear family: dysfunction in one spouse and over involvement with a child. Martha's mother was intensely involved in the triangles with her parents and younger siblings and in the position of over functioning for others. In other words, she learned to meet her strongly programmed needs for emotional closeness by taking care of others, a pattern that played out with Martha.] Michael grew up as an only child in an intact family from the Pacific Northwest. He met Martha when he attended college in the Midwest. Michael's mother began having frequent bouts of serious depression about the time he started grade school. She was twice hospitalized psychiatrically, once after an overdose of tranquilizers. Michael felt "allergic" to his mother's many problems and kept his distance from her, especially during his adolescence. He cared about her and felt she would help him in any way she could, but viewed her as helpless and incompetent. He resented her "not trying harder." He had a reasonably comfortable relationship with his father, but felt his father made the family situation worse by opting for "peace at any price." It was easier for his father to give in to his wife's sometimes childish demands than to draw a line with her. Michael related to his mother almost exactly like his father did. His mother expressed resentment about her husband's passivity. She accused him of not really caring about her, only doing things for her because she demanded it. Michael's mother worshiped Michael and was jealous of interests and people that took him away from her. [Analysis: Interestingly, Michael's parental triangle was similar to Martha's mother's parental triangle. His mother was intensely involved with him and it programmed Michael both to need this level of emotional support from the important female in his life, but also to react critically to the female's neediness. Michael's parental triangle also fostered a belief that he knew best.] Michael's mother had been a "star" in her family when she was growing up. She was an excellent student and athlete. She had a very conflictual relationship with her mother and an idealized view of her father. She met Michael's father when they were both in college. He was two years older than she and when he graduated, she quit school to marry him. Her parents were very upset about the decision. Michael's father had been at loose ends when he met his future wife, but she was what he needed. He built a very successful business career with her emotional support. He functioned higher in his work life than in his family life. [Analysis: Michael's father functioned on a higher level in his business life than in his family life, a discrepancy that is commonly present in people with mid-range levels of differentiation of self.]
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6. Sibling Position Bowen stressed sibling order, believing that each child had a place in the family hierarchy, and thus was more or less likely to fit some projections. The oldest sibling was more likely to be seen as overly responsible and mature, and the youngest as overly irresponsible and immature for example. Think of the oldest sibling who grows up and partners with a person who was also an oldest sibling.
They may be drawn to each other because both believe the other is mature and responsible. Alternately, an oldest sibling might have a relationship with someone who was a youngest sibling. When one partner behaves a certain way, the other might think "This is exactly how my older/younger sibling used to act." Bowen theory incorporates the research of psychologist Walter Toman as a foundation for its concept of sibling position. Bowen observed the impact of sibling position on development and behaviour in his family research. However, he found Toman's work so thorough and consistent with his ideas that he incorporated it into his theory. The basic idea is that people who grow up in the same sibling position predictably have important common characteristics. For example, oldest children tend to gravitate to leadership positions and youngest children often prefer to be followers. The characteristics of one position are not "better" than those of another position, but are complementary. For example, a boss who is an oldest child may work unusually well with a first assistant who is a youngest child. Youngest children may like to be in charge, but their leadership style typically differs from an oldest's style. Toman's research showed that spouses' sibling positions affect the chance of their divorcing. For example, if an older brother of a younger sister marries a younger sister of an older brother, less chance of a divorce exists than if an older brother of a brother marries an older sister of a sister. The sibling or rank positions are complementary in the first case and each spouse is familiar with living with someone of the opposite sex. In the second case, however, the rank positions are not complementary and neither spouse grew up with a member of the opposite sex. An older brother of a brother and an older sister of a sister are prone to battle over who is in charge; two youngest children are prone to struggle over who gets to lean on whom. People in the same sibling position, of course, exhibit marked differences in functioning. The concept of differentiation can explain some of the differences. For example, rather than being comfortable with responsibility and leadership, an oldest child who is anxiously focused on may grow up to be markedly indecisive and highly reactive to expectations. Consequently, his younger brother may become a "functional oldest," filling a void in the family system. He is the chronologically younger child, but develops more characteristics of an oldest child than his older brother. A youngest child who is anxiously focused on may become an unusually helpless and demanding person. In contrast, two mature youngest children may cooperate extremely effectively in a marriage and be at very low risk for a divorce. Middle children exhibit the functional characteristics of two sibling positions. For example, if a girl has an older brother and a younger sister, she usually has some of the characteristics of both a younger sister of a brother and an older sister of a sister. The sibling positions of a person's parents are also important to consider. An oldest child whose parents are both youngests encounters a different set of parental expectations than an oldest child whose parents are both oldests. Example: Knowledge of Michael and Martha Michael is an only child who, like Martha's mother, was raised in a family with a mother who had many problems. Michael's father is the younger brother of a sister and his mother is the older sister of a brother. Michael's mother was the more focused on child when she was growing up, a focus that took the form of high performance expectations coupled with considerable family anxiety about her ability to meet those expectations. In many ways, Michael's Martha's sibling positions and those of their parents adds to the understanding of how things played out in their lives. Martha is the youngest of three girls and was the most
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intensely focused on child in her family. Furthermore, Martha's mother is the oldest of four siblings and was raised in a family with a mother who was a chronic invalid. Martha's mother was a not very well differentiated oldest daughter. Her life energy focused on taking care of and directing others to the point that she unwittingly undermined the functioning of her youngest daughter. Martha played out the opposite side of the problem by becoming an indecisive, helpless, and mostly self-blaming person. Martha's father was the youngest brother in a family of five children. [Analysis: Martha, by virtue of her mother's focus on her, has the moderately exaggerated traits of a youngest child. Furthermore, her father being a youngest and her mother an oldest favored her mother's functioning setting the tone in the family. In other words, her mother was quicker to act than her father in face of problems.] father was quite dependent on his wife for affirmation and direction, even when she was depressed and overwhelmed. As an only child, the pattern of functioning of the triangle with his parents was the major influence on Michael's development. His emotional programming in that triangle made him a perfect fit with Martha. [Analysis: Michael's only child position makes him a somewhat reluctant leader in his nuclear family. He wants Martha to function better and to take more responsibility. He is unhappy feeling the pressure himself. Despite being in the one-up position in the marriage, he is as dependent on Martha as his father was dependent on his wife.]
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7. Emotional Cut-off This refers to an extreme response to The Family Projection Process. This entails a complete or almostcomplete separation from the family. The person will have little, if any, contact, and may look and feel completely independent from the family. However, people who cut off their family are more likely to repeat the emotional and behavioural patterns they were taught.
In some cases, they model the same values and coping patterns in their adult family that they were taught in their childhood family without realizing it. They do not have another internal model for how families live, and so it is very hard to "do something different." Thus, some parents from emotionally constrained families may resent how they were raised, but they do not know how to be "emotionally free" and raise a family as they believe other families would.
In other cases, they consciously attempt to be very different as parents and partners; however, they fail to realize the adaptive characteristics of their family and role models, as well as the compensatory roles played in a complex family. Thus, some parents from emotionally constrained childhood families might discover ways to be "emotionally unrestrained" in their adult families, but may not recognize some of the problems associated with being so emotionally unrestrained, or the benefits of being emotionally constrained in some cases. Because of this, Bowen believed that people tend to seek out partners who are at about the same level of individuation.
The concept of emotional cut-off describes people managing their unresolved emotional issues with parents, siblings, and other family members by reducing or totally cutting off emotional contact with them. Emotional contact can be reduced by people moving away from their families and rarely going home, or it can be reduced by people staying in physical contact with their families but avoiding sensitive issues. Relationships may look "better" if people cut-off to manage them, but the problems are dormant and not resolved. People reduce the tensions of family interactions by cutting off, but risk making their new relationships too important. For example, the more a man cuts off from his family of origin, the more he looks to his spouse, children, and friends to meet his needs. This makes him vulnerable to pressuring them to be certain ways for him or accommodating too much to their expectations of him out of fear of jeopardizing the relationship. New relationships are typically smooth in the beginning, but the patterns people are trying to escape eventually emerge and generate tensions. People who are cut off may try to stabilize their intimate relationships by creating substitute "families" with social and work relationships. Everyone has some degree of unresolved attachment to his or her original family, but well-differentiated people have much more resolution than less differentiated people. An unresolved attachment can take many forms. For example, (1) a person feels more like a child when he is home and looks to his parents to make decisions for him that he can make for himself, or (2) a person feels guilty when he is in more contact with his parents and that he must solve their conflicts or distresses, or (3) a person feels enraged that his parents do not seem to understand or approve of him. An unresolved attachment relates to the immaturity of both the parents and the adult child, but people typically blame themselves or others for the problems. People often look forward to going home, hoping things will be different this time, but the old interactions usually surface within hours. It may take the form of surface harmony with powerful emotional undercurrents or it may deteriorate into shouting matches and hysterics. Both the person and his family may feel exhausted even after a brief visit. It may be easier for the parents if an adult child keeps his distance. The family gets so anxious and reactive when he is home that they are relieved when he leaves. The siblings of a highly cut-off member often get furious at him when he is home and blame him for upsetting the parents. People do not want it to be this way, but the sensitivities of all parties preclude comfortable contact.
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Example: Neither Michael nor Martha wanted to live near their families. When Michael got a good job offer on the East coast, both of them were eager to move east. They told their families they were moving away because of Michael's great job offer, but they welcomed the physical distance from their families. Michael felt guilty about living far away from his parents and his parents were upset about it, especially Michael's mother. Michael called home every weekend and managed to combine business trips with brief stays with his parents. He did not look forward to the phone calls and usually felt depressed after them. He felt as if his mother deliberately put him on "guilt trips" by emphasizing how poorly she was doing and how much she missed seeing him. She never failed to ask if his company could transfer him closer to home. It was much less depressing for Michael to talk to his father, but they talked mostly about Michael's job and what his Dad was doing in retirement. [Analysis: Michael blamed his mother for the problems in their relationship and, despite his guilt, felt justified distancing from her. People commonly have a "stickier" unresolved emotional attachment with their mothers than with their fathers because the way a parental triangle usually operates is that the mother is too involved with the child and the father is in the outside position.] In the early years, Martha would sometimes participate in Michael's phone calls home but, as her problems mounted, she usually left the calls to Michael. Michael did not say much to his parents about Martha's drinking or about the tensions in their marriage. He would report on how the kids were doing. Michael, Martha, and the kids usually made one visit to Michael's parents each year. They did not look forward to the four days they would spend there, but Michael's mother thrived on having them. Martha never said anything to Michael's parents about her drinking or the marital tensions, but she talked at length about Amy to Michael's mother. Amy often developed middle ear infections during or soon after these trips. [Analysis: Frequently one or more family members get sick leading up to, during, or soon after trips home. Amy was more vulnerable because of the anxious focus on her.] Martha followed a pattern similar to Michael's in dealing with her family. One difference was that her parents came east fairly often. When they came, Martha's mother would get more worried about Martha and critical of both her drinking and of how she was raising Amy. Martha dreaded these exchanges with her mother and complained to Michael for days after her parents returned home. Deep down, however, Martha felt her mother was right about her deficiencies. Martha's mother pumped Michael for information about Martha when Martha was reluctant to talk. Michael was all too willing to discuss Martha's perceived shortcomings with her mother. [Analysis: Given the striking parallels between the unresolved issues in Michael's relationship with his family, Martha's relationship with her family, and the issues in their marriage, emotional cut-off clearly did not solve any problems. It simply shifted the problems to their marital relationship and to Amy.]
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8. Societal Emotional Processes These processes are social expectations about racial and class groups, the behaviours for each gender, the nature of sexual orientation... and their effect on the family. In many ways, this is like The Family Projection Process scaled up to the level of a society as a whole. Families that deal with prejudice, discrimination, and persecution must pass on to their children the ways they learned to survive these factors. The coping practices of the parents and extended family may lead to more or less adaptive emotional health for the family and its members. Each concept in Bowen theory applies to nonfamily groups, such as work and social organizations. The concept of societal emotional process describes how the emotional system governs behaviour on a societal level, promoting both progressive and regressive periods in a society. Cultural forces are important in how a society functions but are insufficient for explaining the ebb and flow in how well societies adapt to the challenges that face them. Bowen's first clue about parallels between familial and societal emotional functioning came from treating families with juvenile delinquents. The parents in such families give the message, "We love you no matter what you do." Despite impassioned lectures about responsibility and sometimes harsh punishments, the parents give in to the child more than they hold the line. The child rebels against the parents and is adept at sensing the uncertainty of their positions. The child feels controlled and lies to get around the parents. He is indifferent to their punishments. The parents try to control the child but are largely ineffectual. Bowen discovered that during the 1960s the courts became more like the parents of delinquents. Many in the juvenile court system considered the delinquent as a victim of bad parents. They tried to understand him and often reduced the consequences of his actions in the hope of effecting a change in his behaviour. If the delinquent became a frequent offender, the legal system, much like the parents, expressed its disappointment and imposed harsh penalties. This recognition of a change in one societal institution led Bowen to notice that similar changes were occurring in other institutions, such as in schools and governments. The downward spiral in families dealing with delinquency is an anxiety-driven regression in functioning. In a regression, people act to relieve the anxiety of the moment rather than act on principle and a long-term view. A regressive pattern began unfolding in society after World War II. It worsened some during the 1950s and rapidly intensified during the 1960s. The "symptoms" of societal regression include a growth of crime and violence, an increasing divorce rate, a more litigious attitude, a greater polarization between racial groups, less principled decision-making by leaders, the drug abuse epidemic, an increase in bankruptcy, and a focus on rights over responsibilities. Human societies undergo periods of regression and progression in their history. The current regression seems related to factors such as the population explosion, a sense of diminishing frontiers, and the depletion of natural resources. Bowen predicted that the current regression would, like a family in a regression, continue until the repercussions stemming from taking the easy way out on tough issues exceeded the pain associated with acting on a long-term view. He predicted that will occur before the middle of the twentyfirst century and should result in human beings living in more harmony with nature. Example: It is more difficult for families to raise children in a period of societal regression than in a calmer period. A loosening of standards in society makes it more difficult for less differentiated parents like Michael and Martha to hold a line with their children. The grade inflation in many school systems makes it easier for students to pass grades with less work. In the litigious climate, if schools try to hold the line on what they can realistically do for their students, they often face lawsuits from irate parents. The prevalence of drug and alcohol abuse gives parents more things to worry about with their adolescents. The current societal regression is characterized by an increased child focus in the culture. Much anxiety exists about the future generation. Parents are criticized for being too busy with their own pursuits to be adequately available to their children, both to support them and to monitor their activities. When children like Amy report that they feel distant from their parents and alienated from their values, the parents' critics
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fail to appreciate the emotional intensity that generates such alienation. The critics prod the parents to do more of what they have already been doing. People who advocate more focus on the children cite the many problems young people are having as justification for their position. Using the child's problems as justification for increasing the focus on them is precisely what the child focused parents have been doing all along. An increase in the problems young people are having is part of an emotional process in society as a whole. A more constructive direction would be for people to examine their own contributions to societal regression and to work on themselves rather than focus on improving the future generation.
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Murray Bowen’s approach operates on the premise that a family can best be understood when it is analyzed from at least a three-generation perspective, because a predictable pattern of interpersonal relationships connects the functioning of family members across generations. According to Bowen, the cause of an individual's problems can be understood only by viewing the role of the family as an emotional unit. A basic assumption in Bowen family therapy is that unresolved emotional fusion (or attachment) to one's family must be addressed if one hopes to achieve a mature and unique personality.
Areas of assessment Bowen (1966, 1976) identifies eight key concepts as being central to his theory that can be grouped into four areas of assessment: 1) 2) 3) 4)
Spousal relationships de-triangulation (triangulation) differentiation (differentiation of the self, sibling position, emotional cutoff). emotional systems (the nuclear family emotional system, societal regression, the family projection process and the multigenerational transmission process, sibling position),
Of these, the major contributions of Bowen's theory are the core concepts of differentiation of the self and triangulation. He focused on helping families develop individual identities for each member while maintaining a sense of closeness and togetherness with their families.
1) Spousal relationships Bowen paid attention to the spousal relationship and the definition and clarification of the couple's relationship. Interrelations emphasized more than components; system wide ripples ("these cause each other") emphasized more than linearity (this causes that). Whatever its components, unresolved stress between parents reverberates down through all family interrelations and normally results in coalitions, emotional parent-child alignments against the other parent and perhaps other children. Example: Mom is a rageaholic, so when she explodes, Dad and Brother console one another and perhaps agree that she's nuts. A linear approach would emphasize Mom's upbringing and lack of anger management skills and thereby ignore the coalition process itself and reinforce its tendency to scapegoat, whereas a systems approach would focus on the present-time context of Mom's explosions, looking at the interactions leading up to it and encouraging Dad and Mom to work out new, non escalating ways to talk and negotiate--perhaps in couples therapy--rather than blaming her or him or failing to confront and defuse alliances forming elsewhere in the family.
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2)
De – Triangulation
Triangulation – A situation in which two family members involve a third family member in a conflictual scenario. Bowen considers de-triangulation of self from the family emotional system. Triangulation and Nuclear Family Emotional System. Bowen (1976) notes that anxiety can easily develop within intimate relationships. Under stressful situations, two people may recruit a third person into the relationship to reduce the anxiety and gain stability. This is called triangulation.
When tension arises between two people and a third is engaged to relieve the tension it is called triangulation . When tension is greater than what the three person system can handle, a series of interlocking triangles is created. For example, three people create one triangle, four people create four interlocking triangles and five people create nine interlocking triangles etc. Each triangle has two positive sides and one negative side. Bowen (1978) identifies two variables important in determining why triangles occur in relationships. The first is the level of differentiation . This refers to the degree to which individuality is maintained in a system. The second variable is the level of anxiety . This refers to the amount of emotional tension in a system. A low level of differentiation, or a higher level of anxiety produce more triangling. Anticipating and diffusing triangulating maneuvers forces the parties to focus on the problem. Other successful strategies in remaining de-triangled are seriousness and humor.
Although triangulation may lessen the emotional tension between the two people, the underlying conflict is not addressed, and in the long run the situation worsens: What started as a conflict in the couple evolves into a conflict within the nuclear family emotional system. Family Projection Process and Multigenerational Transmission. The most common form of triangulation occurs when two parents with poor differentiation fuse, leading to conflict, anxiety and ultimately the involvement of a child in an attempt to regain stability. When a parent lacks differentiation and confidence in her or his role with the child, the child also becomes fused and emotionally reactive. The child is now declared to “have a problem,” and the other parent is often in the position of calming and supporting the distraught parent. Such a triangle produces a kind of pseudo stability for a while: the emotional instability in the couple seems to be diminished, but it has only been projected onto the child. This family projection process makes the level of differentiation worse with each subsequent generation (Papero, 2000). When a child leaves the family of origin with unresolved emotional attachments, whether they are expressed in emotional fusion or emotional cutoff, they will tend to couple and create a family in which these unresolved issues can be re-enacted. The family projection process has now become the foundation for multigenerational transmission. E.g.: when parents have unresolved and intense conflicts, they may focus on their offspring. Thus one or more children may become problematic as a result of being triangulated into their parents’ relationship. Instead of fighting with each other, the parents are temporarily distracted by riveting their attention on their child(ren). Similarly, the conflict between the parents also may involve the triangulation of the child(ren) as interpreters of one to the other. Thomas Fogarty introduced to Bowen theory a distinction between triangles and triangulation. For him, the former was a structure that existed in all families while the latter was an emotional process. His focus on couples led him to believe that there was directional movement within family triangles that almost always included a pursuer and a distancer.
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These were complementary relational positions whereby - the pursuer is someone who wants lots of relational contact, especially during times of stress; - the distancer is less expressive of thoughts and feelings, and often finds comfort in necessary tasks rather than relationship.
3) Differentiation Of The Self and Emotional Cutoff. The cornerstone of Bowen's theory is differentiation of the self, which involves both the psychological separation of intellect and emotion and independence of the self from others. Differentiated individuals are able to choose to be guided by their thoughts rather than their feelings. Undifferentiated people have difficulty in separating themselves from others and tend to fuse with dominant emotional patterns in the family. - These people have a low degree of autonomy, - They are emotionally reactive, and - They are unable to take a clear position on issues: -
they have a pseudo-self.
Self-differentiation was Bowen’s principal goal of family therapy. Bowen would model differentiation to his clients by using "I" statements and taking ownership of his own thoughts, feelings, and behaviours. Differentiation – The ability of an individual to separate rational and emotional selves. Functional families are characterized by each member's success in finding the healthy balance between belonging to a family and maintaining a separate identity. One way to find the balance between family and individual identity is to define and clarify the boundaries that exist between the subsystems. A family may have several subsystems such as a spouse, sibling, and parent-child subsystem. Each subsystem contains its own subject matter that is private and should remain within that subsystem. Boundaries between subsystems range from rigid to diffuse. One of the most common family problems is a weak boundary between subsystems Diffuse boundaries can lead to over-enmeshment. Enmeshment: inappropriate, boundary-violating closeness in which family members are emotionally overreactive to one another Rigid boundaries allow too little interaction between family members, which may result in disengagement. (Disengagement: too much emotional distance between family members.) Overall, human systems tend to work best when subsystem boundaries are clear (neither too open nor too closed), interactions are clear and nonrepetitive, lines of authority are visible, rules are overt and flexible, changing alignments replace rigid coalitions, and stressors are confronted instead of pushed onto scapegoats Families who understand and respect differences between healthy and unhealthy subsystem boundaries and rules function successfully. Families who do not understand and respect these differences find themselves in a dysfunctional state of conflict.
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People who are fused to their families of origin tend to marry others to whom they can become fused; that is, people at similar levels of differentiation tend to seek out and find each other when coupling. One pseudo-self relies on another pseudo-self for emotional stability. Unproductive family dynamics of the previous generation are transmitted from one generation to the next through such a marriage (Becvar & Becvar, 2003). In family systems theory, the key to being a healthy person encompasses both a sense of belonging to one's family and a sense of separateness and individuality. Differentiation from the family of origin allows one to accept personal responsibility for one’s thoughts, feelings, perceptions, and actions. Simply leaving one’s family of origin physically or emotionally, however, does not imply that one has differentiated. Indeed, Bowen’s phrase for estrangement or disengagement is emotional cutoff, a strong indication of an undifferentiated self. Individuation, or psychological maturity, is a lifelong developmental process that is achieved relative to the family of origin through re examination and resolution of conflicts within the individual and relational contexts. The distinction between emotional reactivity and rational thinking can be difficult to discern at times. Those who are not emotionally reactive experience themselves as having a choice of possible responses; their reactions are not automatic but involve a reasoned and balanced assessment of self and others. Emotional reactivity, in contrast, is easily seen in clients who present themselves as paranoid, intensely anxious, panic stricken, or even “head over heels in love.” In these cases, feelings have overwhelmed thinking and reason, and people experience themselves as being unable to choose a different reaction. Emotional reactivity in therapists almost always relates to unresolved issues with family-of-origin members. For example, the sound of a male’s voice in a family session reminds the therapist of his father and immediately triggers old feelings of anger and anxiety as well as an urgency to express them. Clarity of response in Bowen’s theory is marked by a broad perspective, a focus on facts and knowledge, an appreciation of complexity, and a recognition of feelings, rather than being dominated by them: Such people achieve what Bowen sometimes referred to as a solid self (Becvar & Becvar, 2003).
4) Understanding family emotional systems. Understanding family emotional systems and how they work is central to Bowen's theory. The nuclear emotional process refers to how the family system operates in a crisis. The family projection process refers to how parents pass good and bad things on to their children. The multigenerational transmission process refers to how a family passes its good and baggage between generations Bowen focused on how family members could maintain a healthy balance between -
being enmeshed (overly involved in each other’s lives) and being disengaged (too much detachment from each other).
Although all family therapists are interested in resolving problems presented by a family and decreasing symptoms, Bowen therapists are mainly interested in changing the individuals within the context of the system.
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They contend that problems that are manifest in one's current family will not significantly change until relationship patterns in one's family of origin are understood and addressed. Emotional problems will be transmitted from one generation to the next until unresolved emotional attachments are dealt with effectively. Change must occur with other family members and cannot be done by an individual in a counseling room. Living systems and all the other system-related processes--move forward through key "horizontal" transitional stages (brought about by time and change). Symptoms occur when vertical stressors (old issues, past mistakes, emotional legacies) impinge on the system during a transition. Families are likeliest to be conflicted and symptomatic when key horizontal transitions like marriage, the birth of children, children going to school, children moving away from home, changes of jobs, etc. coincide with a resurfacing of vertical stressors like old emotional baggage. Example: a workaholic husband driven to succeed by high internalized standards that equate esteem with production (vertical stressor) puts in even more overtime to stuff the loneliness he feels when his eldest son leaves for college (horizontal stressor). In this case, part of the therapeutic agenda would include giving the family tools for negotiating the "empty nest syndrome" while helping the husband get in touch with his mourning, examine his expectations of himself, and reconnect with his family. Calibration: setting of a present-oriented, systemwide range limit around a comfortable emotional "bias." A typical situation: an unintense family with a cool emotional atmosphere unconsciously selects a member to turn up the heat; brother and sister start fighting. This turns into an argument between the parents, the drama escalates, and then, before it gets too hot, a child who plays the role of family ambassador calms everybody down. In that family the bias, the emotional level setting, is too low; a good dose of constructive intensity might recalibrate the bias and make explosions unnecessary. Self-regulating via feedback loops--negative (toward stability) and positive (toward change)--that maintain the bias. Every seasoned drug and alcohol counsellor knows that when one member of the family stops drinking or using, the family will subtly try to push him back into his old vices--not because they want him sick, but because families, like other organisms, naturally resist changes that might further destabilize the system. So one day the husband says to his abstaining wife, "Why not skip your AA meeting tonight so we can catch a movie?" Or the mother of a teen who's quit using congratulates him on finding a job--in a head shop. Introducing positive (= system-changing) feedback loops into these families might include warning them about enabling, relapses and resistance to change and examining what family members gain from having a malfunctioning member (control? A scapegoat? Distraction from other conflicts? Someone to rescue?).
5) Sibling Position. Bowen adopted Toman’s (1993) conceptualization of family constellation and sibling (or birth) position. Toman believed that position determined power relationships, and gender experience determined one’s ability to get along with the other sex.
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In addition to noting the unique positions of only children and twins, Toman focused on ten power/sex positions: 1. the oldest brother of brothers; 2. the youngest brother of brothers; 3. the oldest brother of sisters; 4. the youngest brother of sisters; 5. the male only child; 6 – 10 and the same five configurations for females in relation to sisters and brothers. Under this conceptualization, the best possible marriage, for example, is hypothesized to be the oldest brother of sisters marrying the youngest sister of brothers; in this arrangement, both parties would enter the marriage with similar expectations about power and gender relationships. Conversely, the worst marriage would occur between the oldest brother of brothers and the oldest sister of sisters. In this case, both parties would seek and want power positions, and neither would have had enough childhood experience with the other sex to have adequate gender relationships. Toman supported his hypothesis by noting that the divorce rate among couples comprised of two oldest children was higher than any other set of birth positions. The absence of divorce, however, is not the same as a happy marriage. When we consider the critical traits in a happy marriage, his predictions based on birth order start to lose credibility. Happiness in coupling or marriage is demonstrably more related to attitudinal and behavioural interactions within the spousal system—especially during periods of family stress—than to birth order (Gottman, 1994, Walsh, 2003). Guerin (2002) discussed the importance of what he called the “sibling cohesion factor” (p. 135), especially when there were more than two children in the sibling subsystem, allowing for triangles to form. The sibling cohesion factor is the capacity of the children within the sibling subsystem to meet without their parents and discuss important family issues, including their evaluation of their parents. Healthier families tend to have this factor as part of the family process; the lack of it suggests to Guerin that there is intense triangulation between the parents and children.
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Normal Family Development To Bowen, all families lie along a continuum. While you might try to classify families as falling into discreet groups, there really are no "types" of families, and most families of one type could become a family of another type if their circumstances changed. In many ways, Bowen was among the first of the culturally sensitive family therapists. Bowen believed that optimal family development occurs when family members are differentiated, feel little anxiety regarding the family, and maintain a rewarding and healthy emotional contact with each other. Fogarty offers that adjusted families
are balanced in terms of their togetherness and separateness, and can adapt to changes in the environment view emotional problems as coming largely from the greater system but as having some components in the individual member are connected across generations to extended family have little emotional fusion and distance have dyads that can deal with problems between them without pulling others into their difficulties tolerate and support members who have different values and feelings, and thus can support differentiation are aware of influences from outside the family (such as Societal Emotional Processes) as well as from within the family allow each member to have their own emptiness and periods of pain, without rushing to resolve or protect them from the pain and thus prohibit growth preserve a positive emotional climate, and thus have members who believe the family is a good one have members who use each other for feedback and support rather than for emotional crutches
Family Disorders Bowen believed that family problems result from emotional fusion, or from an increase in the level of anxiety in the family. Typically, the member with "the symptom" is the least differentiated member of the family, and thus the one who has the least ability to resist the pull to become fused with another member, or who has the least ability to separate their own thoughts and feelings from those of the larger family. The member "absorbs" the anxiety and worries of the whole family and becomes the most debilitated by these feelings. Families face two kinds of problems. Vertical problems are "passed down" from parent to child. Thus, adults who had cold and distant relationships with their parents do not know how to have warm and close relationships with their children, and so pass down their own problems to their children. Horizontal problems are caused by environmental stressors or transition points in the family development. This may result from traumas such as a chronic illness, the loss of the family home, or the death of a family member. However, horizontal stress may also result from Social Emotional Processes, such as when a minority family moves from a like-minority neighbourhood to a very different neighbourhood, or when a family with traditional gender roles immigrates to a culture with very different views, and must raise their children there. The worst case for the family is when vertical and horizontal problems happen at once.
Family Therapy with One Person Family therapy can be done with one person. Such therapy typically focuses on differentiation of the person from the family. The therapist helps the individual stop seeing family members in terms of the roles (parent, sibling, caretaker...) they played, and start seeing them as people with their own needs, strengths, and flaws. The individual learns to recognize triangulation, and take some ownership in allowing or halting it when it happens. The individual client should have good insight into the family (genograms may be especially helpful in this), and be very motivated to make changes either in his or her own life, or in the family.
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Goals of Therapy The practice of Bowen family therapy is governed by the following two goals: (1) lessening of anxiety and symptom relief and (2) an increase in each family member's level of differentiation of the self (Kerr & Bowen, 1988). To bring about significant change in a family system, it is necessary to open closed family ties and to engage actively in a detriangulation process (Guerin, Fogarty, Fay, & Kautto, 1996). Although problems are seen as residing in the system rather than in the individual, the route to changing oneself is through changing in relationship to others in the family of origin. Bowen encouraged his clients to come to know others in their family as they are. He helped individuals or couples gather information, and he coached or guided them into new behaviours by demonstrating ways in which individuals might change their relationships with their parents, siblings, and extended family members. He instructed them how to be better observers and also taught them how to move from emotional reactivity to increased objectivity. He did not tell clients what to do, but rather asked a series of questions that were designed to help them figure out their own role in their family emotional process Treatment entails
reframing the presenting problem as a multigenerational problem that is caused by factors beyond the individual lowering anxiety and the "emotional turmoil" that floods the family so they can reflect and act more calmly increasing differentiation, especially of the adult couple, so as to increase their ability to manage their own anxiety, transition more effectively to parenthood, and thus fortify the entire family unit's emotional wellbeing using the therapist as part of a "healthy triangle" where the therapist teaches the couple to manage their own anxiety, distance, and closeness in healthy ways forming relationships with the family member with "the problem" to help them separate from the family and resist unhealthy triangulation and emotional fusion opening closed ties with cut off members focusing on more than "the problem" and including the overall health and happiness of the family evaluating progress of the family in terms of how they function now, as well as how adaptive they can be to future changes addressing the power differential in heterosexual couple based on differences, for example, in economic power and gender role socialization (this is a contribution of those who have reconsidered Bowen's theory through a feminist lens)
In general, the therapist accomplishes this by giving less attention to specific problem they present with, and more attention to family patterns of emotions and relationships, as well as family structures of dyads and triangles. More specifically, the therapist
tries to lower anxiety (which breeds emotional fusion) to promote understanding, which is the critical factor in change; open conflict is prohibited as it raises the family members' anxiety during future sessions remains neutral and detriangulated, and in effect models for the parents some of what they must do for the family promotes differentiation of members, as often a single member can spur changes in the larger family; using "I" statements is one way to help family members separate their own emotions and thoughts from those of the rest of the family develops a personal relationships with each member of the family and encourages family members to form stronger relationships too
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encourages cut off members to return to the family may use descriptive labels like "pursuer-distancer," and help members see the dynamic occurring; following distancers only causes them to run further away, while working with the pursuer to create a safe place in the relationship invites the distancer back. coaches and consults with the family, interrupts arguments, and models skills...
Techniques Bowen did not believe in a "therapeutic bag of tricks." Questioning the family and constructing a family genogram are the closest things to basic techniques all Bowenian therapists would use. Carter has assigned tasks to the adult couple to help them realize more about their family history, and encourages letter writing to distant members, visiting mother-in-laws... to speed things up. Guerin accepts the family's opinion of who "has the problem" and works from there with a variety of techniques to help all family members own some responsibility for helping that sick member get better. He will also use stories or films to present another real or imaginary family with the same problem as the family in therapy, and highlight how the family in the story or film overcame their difficulties. Other concepts: Emotional divorce (like when a sick child holds the parents together); theory is important; no one ever really leaves the family system; mother-child symbiosis when unresolved predisposes to schizophrenia; solid self vs. pseudo self; over- under adequate reciprocity. Two natural forces: growth of individual and emotional connection. Emphasized the first. Fusion breeds anxiety and increases emotional reactivity. Three outcomes of fusion: physical or mental dysfunction in a spouse; in a child; chronic marital conflict. Dysfunctional reciprocal relationships: include over adequate/under adequate, decisive/indecisive, dominant/submissive, hysterical/obsessive, schizoid/conflict, or cut-off between spouses.
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MORE ABOUT TRIANGLES 1. Cross-generational coalitions Cross-generational coalitions (i.e. mother-father-child triangles) are associated with child behaviour problems. In studies of adolescent antisocial behaviour, differences in dyadic interaction between families with a child with behaviour problems and families with a well adjusted child have been evaluated. Empirical studies show that on average:
Children with behaviour problems are more aligned with their mothers and more disengaged from their fathers than are the well-adjusted adolescents.
Parents of children with behaviour problems have more discordant relations than the parents of welladjusted adolescents.
Within families of well-adjusted adolescents, the parents are more supportive of each other than the adolescent.
This suggests that strengthening the parental dyad through the resolution of marital problems, and promoting more positive father-adolescent relations will weaken the cross-generational coalition and ameliorate the symptomatic behaviour. In another study , the family triangle was defined as a family systems construct used to describe family communication patterns in which a dyad cannot cope with demands for intimacy or conflict resolution. As such, triangles occur to reduce tension between two people, but are problematic because they do not provide solutions.
2. The authors reviewed three family triangles:
Triangulation: occurs when a parent demands that a child side with her or him against the other parent.
Detouring: occurs when spouses ignore the issues in their own relationship and focus on the child's issues.
Cross-generational coalition: exists when one parent sides with a child against another parent. This differs from triangulation because it is the parent who initiates the coalition and the attachment between the parent and the child exceeds that between the parents.
All three family triangles are considered to have negative developmental effects on the child.
They create a false sense of attachment and security and do not give the child the opportunity to develop a healthy separate identity. For this reason the study considers the "impact of crossgenerational coalitions on interpersonal intimacy and view intimacy as a developmental task relevant to young adults" Children with a cross-generational attachment have larger intellectual-intimacy, emotional-intimacy and sexual-intimacy discrepancy scores. Cross-generational coalitions also affect the ability to successfully negotiate psycho-social developmental tasks. Tests reveal that, even while away from home, children are still affected by the family triangle. "Detriangulating" can contribute considerably in resolving intimacy issues. Detriangulating involves: a) not talking with one parent about the other parent, b) teaching the client about triangulation patterns, c) the client becoming more objective and less emotional with his or her parents.
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Because the family is not a static entity, a change in one part of the system affects the actions of all others involved. Bowen sometimes worked with one member of a conflictual dyad (or couple). He did not require that every family member be involved in the therapy sessions. Bowen tended to work from the inside out: Starting with the spousal relationship, he helped the two adults establish their own differentiation. As a therapist, he attempted to maintain a stance of neutrality. If the therapist becomes emotionally entangled with any one family member, the therapist loses effectiveness and becomes part of a triangulated relationship. Bowen maintains that, to be effective, family therapists have to have a very high level of differentiation. If therapists still have unresolved family issues and are emotionally reactive, they are likely to revisit those difficulties in every family they see. 3. Vogel, E.F. and Bell, N.W. (1968). The Emotionally Disturbed Child as the Family Scapegoat. The purpose of this study was to learn more about how "the emotionally disturbed child used as a scapegoat for the conflicts between parents and what the functions and dysfunctions of this scapegoating are for the family." (p. 412) When parents experience crises for which they have no adequate coping mechanisms, they look for ways to discharge some of the tension. One of the most common methods is to involve a third person. When the third person is their child, parents often project their problems on to the child. They focus their attentions on the problems of the child so they can avoid the pain of admitting their own problems. This is what Vogel and Bell call "scapegoating". There were many reasons why the child was selected as the scapegoat.
First, the child was relatively powerless to leave the family nor to counter the parents triangulation. The child's personality is very flexible and adopts quickly to the assigned role of scapegoat. The child has few task which are vital in the maintenance of the family. "The cost in dysfunction of the child is low relative to the functional gains for the whole family." Often, the chosen child would best symbolize the parental conflicts. For example, if the conflict was over achievement, the child who stood out most (for either over- or under-achieving) would be targeted. Children were also picked because they possessed the same undesirable traits (either physically, behaviourally or emotionally) as the parent. The study also found that the scapegoated child had a (considerably) lower IQ than the other children. Many had physical abnormalities. All of the parents reported having had tensions since early in the marriage.
Once the child is selected she or he must carry out the role of the problem child. The authors found that the problem behaviour was reinforced through inconsistent parenting. The dysfunction would be both supported and criticized. In some cases, parents would encourage opposing types of behaviour. In other instances parents promoted different norms. This set up a self-perpetuating cycle which "normalized" the child's problems. The dysfunction became part of the family. The families used rationalizations to maintain the equilibrium attained when the child took on the parents' problems.
One rationalization was that the parents, rather than the children, were the victims.
Another was to emphasize how fortunate the child was, because their life was better than the parents. The parents felt justified in depriving the children of things they wanted and then used the complaints to reinforce the scapegoating.
Another common belief was that the child could behave if she or he wanted to. This rationalized sever punishment.
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The authors point out that there are both functions and dysfunctions of scapegoating.
For the parents, scapegoating serves to stabilize their relationship. They were also better able to live up to the societal expectations of a happy marriage. Scapegoating permits the family to maintain its solidarity. At the same time, communities can scapegoat the family with the dysfunctional child. One of the dysfunctions is that scapegoating creates "realistic problems and extra tasks" for the family. Another is that the child often becomes very adept at fighting back and usually directs their aggression towards the ever-present mother.
4. Marks, S. (1989). Towards a systems theory of marital quality. Marks (1989) suggests that relationships can be understood in terms of two intersecting triangles. He has borrowed Margaret Mead's concept of "I" and "me" in describing the nature of the triangle. The "I" is the presentation of the self at that moment or in that situation. This contrasts with the "me" which is an organization of tendencies. The situation brings the "I" out of the "me". The triangle is three points and those can be understood as three tendencies, or three "me" corners. At any given moment one corner will be the focus of energy. That corner will then be the "I", the present manifestation of the tendencies. In therapy, the placement of the "I" structures the future. Each triangle has three corners. 1) The first corner is the Inner-self (I-corner), the driving force. 2) The second is the Partnership (P-corner) corner. This coordinates the self with a primary partner. 3) The third corner is any area where the self concentrates energy that is different from the first two corners, e.g. job, children, religion, friends etc. Marks' conception differs from Bowen's view of triangles in marriage. Bowen sees the couple as two corners of the triangle. The couple uses the third corner as a buffer against their tension. The third corner provides a distraction and relieves the marital pressure. In a marital therapy situation, the therapist can act as the third corner. The "Three Corners" model is a systems theory of the self in marriage. A traditional concept in marriage therapy is "marital quality". Marks states "Quality of marriage is a consequence of the way married selves are systematically organized. A person whose "I" maintains some regular motion around and between all three corners has a high quality marriage." The article introduces seven different manifestations of the dual triangle construct. The first three are low quality relationships. These are characterized by a concentration of energy on one corner without a flow of energy to all parts. 1) The first triangle is the "Romantic Fusion", wherein all the energy is focused on the P . This is the traditional beginnings of a relationship. This becomes unhealthy after a while because other areas of the self are neglected. 2) The second is the "Dependency-Distancing" relationship. This is a traditional unhealthy female-male situation where the woman places energy on the partner and the partner (the man) places energy on the 3rd corner, usually work. 3) The third is the "Separated" relationship where both people focus their energy on their 3rd corner. Marks says that while this can be very healthy and stable, as a marriage is concerned it is low quality.
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The last four triangles represent high quality marriages. There is a radical shift in the conception of the triangle. Because there is a constant flow of energy, the three points are connected by rounded lines, making a circle. This represents uninterrupted energy flow between the "me's". In a high quality marriage there is a multiplicity of healthy connections which are as dynamic and fluid as the energy. 4) The fourth is the "Balanced Connection" which has an equal concentration of energy. 5) The fifth is "Couple Centered". The energy is focused on the P , but differs from the second triangle in that the other "me's" receive energy. 6) The sixth is "Family Centered". Both people focus their energy on the family, which would be a joint 3rd interest. 7) The seventh is "Loose". The energy is focused on the 3rd , without detriment to the stability of the couple because, again, there is a steady flow of energy to the other corners. Marks' (1989) concept of the self as a triangle is very useful and deserves more attention. A useful application would be in Slater's (1994) article on triangles in committed lesbian relationships. In his article, Marks does not discuss the possibility of energy revolving around the "I". This might reflect an assumption that there is a sufficient concentration on the "I" naturally, that the inner-self is the base of all the external interactions. This assumes a degree of differentiation that, developmentally, is traditionally more male than female. Slater points out that the affected partner needs consolidate her sense of identity and perceive it as originating within herself. This would result in the "I" in Marks' model to be the focus of energy. Without this option, the therapist would concentrate the affected partner on the "P" and miss the opportunity for individual growth. Criticisms on the triangle theory As exciting and varied as triangle theory is, there are valid criticisms. One is that the majority of the studies focused on dependence as being the dominant catalyst for problems. A good example is West (1986) who states : “In this enmeshed situation the child seems to experience a distorted sense of attachment, involvement, or belonging with the family and fails to experience a secure sense of separateness, individuality or autonomy. “ This implies that independence is more important than attachment, and given what we know about gender roles, that male characteristics are more important than female characteristics. The possible gender bias could be addressed by a study on the role of an overly-detached family member on the creation of triangles. This would look at the role that stereotypical male behaviour has on the other two members.
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Salvador Minuchin’s Structural Family Therapy From Wikipedia, the free encyclopedia And http://www.allpsychologycareers.com/topics/family-systems-therapy.html AllPsychologyCareers.com - © 2008-2013 AllPsychologyCareers.com. All Rights Reserved. This site is for informational purposes and is not a substitute for professional help. Structural Family Therapy (SFT) is a method of psychotherapy developed by Salvador Minuchin which addresses problems in functioning within a family. Structural Family Therapists strive to enter, or "join", the family system in therapy in order to understand the invisible rules which govern its functioning, map the relationships between family members or between subsets of the family, and ultimately disrupt dysfunctional relationships within the family, causing it to stabilize into healthier patterns. Minuchin contends that pathology rests not in the individual, but within the family system. SFT utilizes, not only a unique systems terminology, but also a means of depicting key family parameters diagrammatically. Its focus is on the structure of the family, including its various substructures. In this regard, Minuchin is a follower of systems and communication theory, since his structures are defined by transactions among interrelated systems within the family. He subscribes to the systems notions of wholeness and equifinality, both of which are critical to his notion of change. An essential trait of SFT is that the therapist actually enters, or "joins", with the family system as a catalyst for positive change. Joining with a family is a goal of the therapist early on in his or her therapeutic relationship with the family.
Contents
1 Family Rules 2 Therapeutic Goals and Techniques 3 See also 4 References
Family Rules Consider the human body’s complexity and how a change in one physiological component alters and impacts so many other parts. The interrelation and interdependence of parts are integrally related so that the body’s ability to function at all depends on an intricate web of connectedness. Now consider a family, perhaps a mother, father, and child (or children), and think of them as one human body – an organism, or a whole. One component of the family, or one individual, simply cannot be separated or understood in isolation. One individual affects all others; everyone’s deeply embedded emotional and behavioral processes seamlessly wired together. Family systems professionals and therapists describe the family as a complex and interconnected system. Maladaptive behaviors are connected, and therefore likely to affect and create “dis-ease” in other areas – if not appropriately treated. When a change occurs in one part of the system, such as a mental health or behavioral issue, therapists must treat the entire family to help the individual regain healthy functioning. Additionally, the entire system or family can become plagued with maladaptive interactions so that it seems to literally stop functioning.
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Assumptions of family systems A Juvenile Justice Bulletin published by the U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention, summarized the main aspects of family systems therapy as follows:
A family is a system composed of interdependent and interrelated parts. The behavior of one family member is only understood by examining the context (i.e., family) in which it occurs. Interventions must be implemented at the family level and must take into account the complex relationships within the family system.
Includes all types of families : During the 1950s and 1960s, family systems therapy began with a focus on the traditional family unit, but has expanded to include therapy for all types of familial relationships, including gay and lesbian couples and families, extended families related through divorce and re-marriage, and other family units that don’t necessarily include a biological mother and father. Whatever the composition of individual members, a group that calls itself a family, and lives like a family, can be treated by family systems therapists. In SFT, family rules are defined as an invisible set of functional demands that persistently organizes the interaction of the family. Important rules for a therapist to study include coalitions, boundaries, and power hierarchies between subsystems. According to Minuchin, a family is functional or dysfunctional based upon its ability to adapt to various stressors (extra-familial, idiosyncratic, developmental), which, in turn, rests upon the clarity and appropriateness of its subsystem boundaries. Boundaries are characterized along a continuum from enmeshment through semi-diffuse permeability to rigidity. Additionally, family subsystems are characterized by a hierarchy of power, typically with the parental subsystem "on top" vis-à-vis the offspring subsystem. In healthy families, parent-children boundaries are both clear and semi-diffuse, allowing the parents to interact together with some degree of authority in negotiating between themselves the methods and goals of parenting. From the children’s side, the parents are not enmeshed with the children, allowing for the degree of autonomous sibling and peer interactions that produce socialization, yet not so disengaged, rigid, or aloof, ignoring childhood needs for support, nurturance, and guidance. Dysfunctional families exhibit mixed subsystems (i.e., coalitions) and improper power hierarchies, as in the example of an older child being brought in to the parental subsystem to replace a physically or emotionally absent spouse.
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The family – homeostasis & change The family is conceptualized as a living open system. In every system the parts are functionally interdependent in ways dictated by the supra-individual functions of the whole. In a system AB, A’s passivity is read as a response to B’s initiative (interdependence), while the pattern passivity! initiative is one of the ways in which the system carries on its function (for example, the provision of a nurturing environment for A and B). The set of rules regulating the interactions among members of the system is its structure. As an open system the family is subjected to and impinges on the surrounding environment. This implies that family members are not the only architects of their family shape; relevant rules may be imposed by the immediate group of reference or by the culture in the broader sense. When we recognize that Mr. Brown’s distant relationship to Jimmy is related to Mrs. Brown’s over-involvement with Jimmy, we are witnessing an idiosyncratic family arrangement but also the regulating effects of a society that encourages mothers to be closer to children and fathers to keep more distance. Finally, as a living system the family is in constant transformation: transactional rules evolve over time as each family group negotiates the particular arrangements that are more economical and effective for any given period in its life as a system. This evolution, as any other, is regulated by the interplay of homeostasis and change. Homeostasis designates the patterns of transactions that assure the stability of the system, the maintenance of its basic characteristics as they can be described at a certain point in time; homeostatic processes tend to keep the status quo (Jackson, 1957, 1965). The two-way process that links A’s passivity to B’s initiative serves a homeostatic purpose for the system AB, as do father’s distance, mother’s proximity and Jimmy’s eventual symptomatology for the Browns. When viewed from the perspective of homeostasis, individual behaviors interlock like the pieces in a puzzle, a quality that is usually referred to as complementarity. Change, on the other hand, is the reaccommodation that the living system undergoes in order to adjust to a different set of environmental circumstances or to an intrinsic developmental need. A’s passivity and B’s initiative may be effectively complementary for a given period in the life of AB, but a change to a different complementarity will be in order if B becomes incapacitated. Jimmy and his parents may need to change if a second child is born. Marriage, births, entrance to school, the onset of adolescence, going to college or to a job are examples of developmental milestones in the life of most families; loss of a job, a sudden death, a promotion, a move to a different city, a divorce, a pregnant adolescent are special events that affect the journey of some families. Whether universal or idiosyncratic, these impacts call for changes in patterns, and in some cases—for example when children are added to a couple— dramatically increase the complexity of the system by introducing differentiation. The spouse subsystem coexists with parent-child subsystems and eventually a sibling subsystem, and rules need to be developed to define who participates with whom and in what kind of situations, and who are excluded from those situations. Such definitions are called boundaries; they may prescribe, for instance, that children should not participate in adults’ arguments, or that the oldest son has the privilege of spending certain moments alone with his father, or that the adolescent daughter has more rights to privacy than her younger siblings. In the last analysis homeostasis and change are matters of perspective. If one follows the family process over a brief period of time, chances are that one will witness the homeostatic mechanisms at work and the system in relative equilibrium; moments of crisis in which the status quo is questioned and rules are challenged are a relative exception in the life of a system, and when crises become the rule, they may be playing a role in the maintenance of homeostasis. Now if one steps back so as to visualize a more extended period, the evolvement of different successive system configurations becomes apparent and the process of change comes to the foreground. But by moving further back and encompassing the entire life cycle of a system, one discovers homeostasis again: the series of smooth transitions and sudden recommendations of which change is made presents itself as a constant attempt to maintain equilibrium or to recover it. Like the donkey that progresses as it reaches for the carrot that will always be out of reach, like the monkeys that turned into humans by struggling to survive as monkeys, like the aristocrats in Lampeduza’s Il Gatorade who wanted to change everything so that nothing would change, families fall for the bait that is the paradox of evolution: they need to accommodate in order to remain the same, and accommodation moves them into something different.
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This ongoing process can be arrested. The family can fail to respond to a new demand from the environment or from its own development: it will not substitute new rules of transactions for the ones that have been patterning its functioning. AB find it impossible to let go of the passivity/initiative pattern even if B is now incapacitated Jimmy and mother find it impossible to let go of a tight relationship that was developmentally appropriate when Jimmy was 2 but not now that he is 18. Maybe Jimmy started showing trouble in school when he was 12, but the family insisted on the same structure with mother monitoring all communications around Jimmy and the school, so that Jimmy was protected from father’s anger and father from his own disappointment.
When families get stagnated in their development their transactional patterns become stereotyped. Homeostatic mechanisms exacerbate as the system holds tightly to a rigid script. Any movement threatening a departure from the status quo is swiftly corrected. If father grows tougher on Jimmy, mother will intercede and father will withdraw. Intergenerational coalitions that subvert natural hierarchies (for example, mother and son against father), triangular patterns where parents use a child as a battleground, and other dysfunctional arrangements serve the purpose of avoiding the onset of open conflict within the system. Conflict avoidance, then, guarantees a certain sense of equilibrium but at the same time prevents growth and differentiation, which are the offspring of conflict resolution. The higher levels of conflict avoidance are found in enmeshed families— where the extreme sense of closeness, belonging, and loyalty minimize the chances of disagreement—and, at the other end of the continuum, in disengaged families, where the same effect is produced by excessive distance and a false sense of independence. In their efforts to keep a precarious balance, family members stick to myths that are very narrow definitions of themselves as a whole and as individuals— constructed realities made by the interlocking of limited facets of the respective selves, which leave most of the system’s potentials unused. When these families come to therapy they typically present themselves as a poor version of what they really are. In the figure at the right side, the white area in the center of the figure represents the myth: “I am this way and can only be this way, and the same is true for him and for her, and we can not relate in any other way than our way,” while the shaded area contains the available but as yet not utilized alternatives. The presenting problem Structural family therapy conceptualizes the problem behavior as a partial aspect of the family structure of transactions. The complaint, for instance, that Jimmy is undisciplined and aggressive, needs to be put in perspective by relating it to the context of Jimmy’s family. For one thing, the therapist has to find out the position and function of the problem behavior: When does Jimmy turn aggressive? What happens• immediately before? How do others react to his misbehavior? Is Jimmy more undisciplined toward mother than toward father? Do father and mother agree on bow to handle him? What is the homeostatic benefit from the sequential patterns in which the problem behavior is imbedded? The individual problem is seen as a complement of other behaviors, a part of the status quo, a token of the system’s dysfunction; in short, the system as it is supports the symptom. The therapist also has to diagnose the structure of the system’s perceptions in connection with the presenting problem. Who is more concerned about Jimmy’s lack of discipline? Does everybody concur that be is aggressive? That his behavior is the most troublesome problem in the family? Which are the other, more positive facets in Jimmy’s self that go unnoticed? Is the family exaggerating in labeling as “aggressive” a child that maybe is just more exuberant than his siblings? Is the family failing to accommodate their perceptions and expectations to the fact that Jimmy is now 18 years old? Does the system draw a homeostatic gain from perceiving Jimmy primarily as a symptomatic child? An axiom of structural family therapy, illustrated by Figure 1, is that a vast area of Jimmy’s self is out of sight for both his relatives and himself, and that there is a systemic support for this blindness.
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So the interaccional network knitted around the motive of complaint is the real “presenting problem” for the structural family therapist. The key element in this view is the concept of systemic support. The model does not claim a direct causal line between system and problem behavior; the emphasis is on maintenance rather than on causation. Certainly, sometimes one observes families and listens to their stories and can almost see the pathways leading from transactional structure to symptomatology. But even in these cases the model warns us that we are dealing with current transactions and current memories, as they are organized now, after the problem has crystallized. Thus, instead of a simplistic, one-way causal connection the model postulates an ongoing process of mutual accommodation between the system’s rules and the individual’s predispositions and vulnerabilities. Maybe Jimmy was born with a “strong temperament” and to a system that needed to pay special attention to his temper tantrums, to highlight his negative facets while ignoring the positive ones. Within this context Jimmy learned about his identity and about the benefits of being perceived as an aggressive child. By the time he was 9, Jimmy was an expert participant in a mutually escalating game of defiance and punishment. These mechanisms —selective attention, deviance amplification, labeling, counter escalation— are some of the ways in which a system may contribute to the etiology of a “problem.” Jimmy’s cousin Fred was born at about the same time and with the same “strong temperament,” but he is now a class leader and a junior tennis champ. Discussions around etiological history, in any case, are largely academic from the~ perspective of structural family therapy, whose interest is focused on the current supportive relation between system and problem behavior. The model shares with other systemic approaches the radical idea that knowledge of the origins of a problem is largely irrelevant for the process of therapeutic change (Minuchin & Fishman, 1979). The identification of etiological sequences may be helpful in preventing problems from happening to families, but once they have happened and are eventually brought to therapy, history has already occurred and can not be undone. An elaborate understanding of the problem history may in fact hinder the therapist’s operation by encouraging an excessive focus on what appears as not modifiable.
The Process of Therapeutic Change Consistent with its basic tenet that the problems brought to therapy are ultimately dysfunctions of the family structure, the model looks for a therapeutic solution in the modification of such structure. This usually requires changes in the relative positions of family members: more proximity may be necessary between husband and wife, more distance between mother and son. Hierarchical relations and coalitions are frequently in need of a redefinition. New alternative rules for transacting must be explored: mother, for instance, may be required to abstain from intervening automatically whenever an interaction between her husband and her son reaches a certain pitch, while father and son should not automatically abort an argument just because it upsets Morn. Frozen conflicts have to be acknowledged and dealt with so that they can be solved —and the natural road to growth reopened. Therapeutic change is then the process of helping the family to outgrow its stereotyped patterns of which the presenting problem is a part. This process transpires within a special context, the therapeutic system which offers a unique chance to challenge the rules of the family. The privileged position of the therapist allows him to request from the family members different behaviors and to invite different perceptions, thus altering their interaction and perspective. The family then has an opportunity to experience transactional patterns that have not been allowed under its prevailing homeostatic rules. The system’s limits are probed and pushed, its narrow self-definitions are questioned; in the process, the family’s capacity to tolerate and handle stress or conflict increases, and its perceived reality becomes richer, more complex. In looking for materials to build this expansion of the family’s reality -alternative behaviors, attitudes, perceptions, affinities, expectations- the structural family therapist has one primary source from which to draw: the family itself. The model contends that beyond the systemic constraints that keep the family functioning at an inadequate level there exists an as yet underutilized pool of potential resources. Releasing these resources so that the system can change, and changing the system so that the resources can be released, are simultaneous processes that require the restructuring input of the therapist. His role will be discussed at some length in the following section.
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Therapeutic Goals and Techniques Minuchin’s goal is to promote a restructuring of the family system along more healthy lines, which he does by entering the various family subsystems, "continually causing upheavals by intervening in ways that will produce unstable situations which require change and the restructuring of family organization... Therapeutic change cannot occur unless some pre-existing frames of reference are modified, flexibility introduced and new ways of functioning developed." To accelerate such change, Minuchin manipulates the format of the therapy sessions, structuring desired subsystems by isolating them from the remainder of the family, either by the use of space and positioning (seating) within the room, or by having non-members of the desired substructure leave the room (but stay involved by viewing from behind a one-way mirror). The aim of such interventions is often to cause the unbalancing of the family system, in order to help them to see the dysfunctional patterns and remain open to restructuring. He believes that change must be gradual and taken in digestible steps for it to be useful and lasting. Because structures tend to self-perpetuate, especially when there is positive feedback, Minuchin asserts that therapeutic change is likely to be maintained beyond the limits of the therapy session. One variant or extension of his methodology can be said to move from manipulation of experience toward fostering understanding. When working with families who are not introspective and are oriented toward concrete thinking, Minuchin will use the subsystem isolation—one-way mirror technique to teach those family members on the viewing side of the mirror to move from being an enmeshed participant to being an evaluation observer. He does this by joining them in the viewing room and pointing out the patterns of transaction occurring on the other side of the mirror. While Minuchin doesn’t formally integrate this extension into his view of therapeutic change, it seems that he is requiring a minimal level of insight or understanding for his subsystem restructuring efforts to "take" and to allow for the resultant positive feedback among the subsystems to induce stability and resistance to change. Change, then, occurs in the subsystem level and is the result of manipulations by the therapist of the existing subsystems, and is maintained by its greater functionality and resulting changed frames of reference and positive feedback.
See also
Family systems therapy Salvador Minuchin Systems theory
References 1. Minuchin, S. (1974). Families and Family Therapy. Harvard University Press. 2. Seligman, Linda (2004). Diagnosis and Treatment Planning in Counseling. New York: Kluwer Academic. ISBN 0306485141., p. 246
Minuchin, S. & Fishman, H. C. (2004). Family Therapy Techniques. Harvard University Press. Piercy, Fred (1986). Family Therapy Sourcebook. New York: Guilford Press. ISBN 0898629136. Will, David (1985). Integrated Family Therapy. London: Tavistock. ISBN 042279760X.
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Definitions Structure, subsystems and boundaries The theoretical base of structural family therapy is the three constructs of structure, subsystems and boundaries. As is the nature of constructs, they are noted through the presence of persistent, observable patterns, interactions and relational styles in a family. Family Structure – “organized pattern in which family members interact” - Reflects the division of tasks among the various subsystems and the way units are coordinated within. Established patterns make way for expectations and limitations in expressed behaviors in various given situations The beginnings of the idea of changing the structure to alleviate symptoms lie here. Subsystems – divisions or subgroups based on factors such as age, spousal relation, generation, etc… Interactions, patterns and divisions of subsystems are often a little difficult to find amidst initial chaos brought to therapy by the family. Boundaries – “invisible barriers that regulate contact with others” - Range of boundaries: diffuse <-> rigid Also affects dependence on outside systems and level of interpersonal engagement within the subsystem
Rigid Boundary : Disengagement - disengaged subsystem – independent yet isolated Clear Boundary : Normal Range - subsystem with a clear boundary – a balance of independence and dependence, and outside contact and isolation. Diffuse Boundary : Enmeshment - enmeshed subsystem – lacks independent competence but offers closeness and support
Examples demonstrating boundaries and subsystems Minuchin used the example of a spousal subsystem to demonstrate the need for distinct boundaries A spousal relationship demonstrates complementarity between members of a subsystem and patterns of accommodation. Boundary defined by functions not shared with other subsystems, such as lovemaking. Such a boundary also helps define a hierarchical structure within the family, with parents as heads of the home. Minuchin also made clear the consideration of ecology outside the family as a contributor to family problems. Normal Family Development: “What distinguishes a normal family isn’t the absence of problems but a functional structure for dealing with them.” Assumedly, the spousal subsystem is mentioned first since that is more or less the starting point of a nuclear family. As hinted at before, accommodation leads to the prevalent patterns of the spousal subsystem and eventual formation of family hierarchy, upon development of parent-child boundary. Boundaries also form between new family and outside systems, including families of origin. Minuchin notices that “growing pains” are part of adjustment to an expanding family and are not a sign of pathology. Development of behaviour disorders Shifts in the family structure should be done in response to the introduction of external stressors, as experienced by one or more of the family members
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Reaction to change: Healthy families Healthy families accommodate to changed circumstances Both enmeshed and disengaged families express fear of change through conflict avoidance. - Disengaged families accomplish this by avoiding contact - Enmeshed families squabble, or deny their personal differences. One special case where structural change is inherently part of family difficulty is in the formation of “blended families”. Remarriage of divorcee or widower parents is both the introduction of an external stressor and the restructuring of the family. Example: rigid boundary forming between stepparent and biological parent/child (enmeshed) subsystem Disengaged families Disengaged families increase the rigidity of structures that are no longer functional In disengaged families, preoccupation with other matters rather than current, pressing needs is commonplace - Lack of awareness due to preoccupation Enmeshed families In enmeshed families, boundaries are diffuse and members become overly dependent on one another Example – intrusive parents hindering the development of their own children Excessive involvement in minor conflicts, not allowing their young to solve their own problems. It is difficult to categorize a subsystem as either disengaged or enmeshed, as the two concepts can be reciprocal. One person in a relationship can be disengaged and the other enmeshed, as can happen in a spousal subsystem. “enmeshed mother/disengaged father syndrome,” a concept facing criticism As with boundaries, hierarchies can be either be too rigid or too weak Lack of control or guidance, excessive power struggles and other deficits in family stability are possible Salvador Minuchin’s Style Salvador Minuchin’s Structural Family Therapy is a directive therapy, change-oriented through changing the family structure (transaction-governing rules of a family). A symptom services and is rooted in dysfunctional transactions, structure (boundaries).
Salvador Minuchin’s style was to get the family to talk briefly until he identified a central theme of concern and the leading and supporting roles in the theme. Next he examined boundaries or family rules that define the participants, the areas of responsibility, the decision making and privacy rules. The idea is to change the immediate context of the family situation and thereby change the family members’ positions. His approach was both active and directive. He would shift the family focus from the identified client to the therapist to allow the identified client to rejoin the family.
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When treatment is complete, the therapist moves outside the family structure and leaves the family intact and connected without the loss of individual family member identities.
Family member behaviour can be understood only in the family context. The Structural Family Therapy is a type of family therapy, based on the assumption that family member behaviour is ongoing and repetitive and can be understood only in the family context. This therapy may be characterized by the highly active therapist who gives specific directives for behaviour change that are carried out as homework assignments. Paradoxical interventions are often used to harness the strong resistance clients have to change and to taking directives. Clients may be asked to intensify the problem as one way of using paradox. Another way is for the therapists to take a "one-down" position, encouraging the client not to do too much too soon. Counselors must differentiate between first-order and second-order changes. First-order changes are those that help the system stay at its current level of functioning. They occur when the symptom is temporarily removed, only to reappear later because the family system has not been changed. Second-order changes restructure the system to bring it to a different level. They occur when symptom and system are repaired and the need for the symptom does not reappear. E.g.: Teaching family members how to use "I" statements and listen empathically demonstrate first-order changes that enhance the family's current functioning. Coaching a widow through the loss of her husband, helping a couple let go of the last child to leave the nest, and restructuring an alcoholic family to eliminate drinking are second-order changes that alter the family fundamentally, bringing it to an entirely new structure and psychological place. Key concepts:
Enmeshment: encourages somatisation, and disengagement, acting out. High resonance. Ecological context: the family's church, schools, work, extended family members. Sick child: family conflict defuser. Common boundary problem: parents confuse spouse functions with parent functions. Rules: generic and idiosyncratic rules that regulate transactions govern structure. Boundaries: can be diffuse (enmeshed), rigid (disengaged), or clear. Power: determined by authority and responsibility for acting on it. Coalitions: can be stable or detouring.
Transitional anxieties:
Reaction to therapist probes: A family will either dismiss the therapist's probes, assimilate to previous transaction patterns, or respond as to a novel situation, in which case stress increases and the probe is restructuring.
Rigid triad:
where parents habitually use a child to lightning rod conflict. Rigid boundary around the triad; common when the children have severe psychosomatic problems.
Dysfunctional families:
A dysfunctional family is one that responds to inner or outer demands for change by stereotyping its functioning.
Families are constantly in transition, and transitional anxieties and lack of differentiation are sometimes mislabelled pathological.
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Three reasons that make clients move: They are challenged in their perception of their reality, given alternative possibilities that make sense, or self-reinforcing new relationships appear once they've tried out new alternatives. People need some support within a family to move into the unknown. Conditions for behaviour change Much like the formation of a new family, the joining of a therapist into the family system involves accommodating to the current family members. Accommodation allows for restructuring to occur, with a minimized risk of rejection by the family. The opposite is a possible danger as well, with a therapist becoming too close of a family member, with his changes being assimilated into current maladaptive patterns with no change. Family members must be assured of the acceptance and respect of their lifestyle by the therapist, in order for him to successfully join the family system. A therapist listens to a family’s views of their situation and reframes them in the context of a family’s structure Enactments: prompting a family to demonstrate how a particular problem is handled The family is then directed to continue the enactment or a therapist comments on what went wrong within the enactment. Spontaneous behaviour sequences: “like focusing a spotlight on action that occurs without direction” If acted on early enough, allows for considerable progress through possible therapeutic distractions. Four sources of family stress: One member with extra familial forces, whole family with extra familial forces, transition points in the family's evolution, idiosyncratic problems. Sets: Repeated family reactions to stress. Spontaneous sets: interpreted like enactments. Goals:
clear boundaries as gatekeepers, clear lines of authority, systems and subsystems (the parental one is where pathology begins), increase flexibility to alternative transactions, help negotiate family life cycle transitions. Family mapping via diagram of current structure.
“Structural family therapists believe that problems are maintained by a dysfunctional family organization.” Therapy is therefore directed toward changing the structure to alleviate problems, and activating long inactive structures already present in a family. Critics wrongfully see this viewpoint as portraying a “pathological core” in the family, an inherent flaw. In effect, a structural therapist becomes a part of the system to help its members change it from within. Boundaries and subsystems are shifted, so the family will have the capacity to solve their own problems. Enmeshed families will strengthen the boundaries around them while disengaged families will aim to loosen them.
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Goals to keep in mind, besides the aforementioned structural shift, include formation of a functional family hierarchy. Parents will operate on the same page, especially when making decisions as family leaders. Assertion of boundaries of parental subsystem is important to this goal. How therapy addresses boundaries Much of the therapeutic work in family systems centres on boundaries, not the physical boundaries of walls and borders, but psychological boundaries. These types of boundaries can’t be seen or touched, but instead shape themselves in the form of beliefs, perceptions, convictions, and understandings. Individuals form selfconcepts, for example, based on beliefs regarding who they are, and these beliefs “surround” individuals, distinguishing them from others – creating a sense of “otherness.” These invisible and impactful boundaries are also drawn around groups and subgroups of people. For instance, parents or couples surround themselves with boundaries that separate them from other couples, their parents, and their children. Managers in a corporation have boundaries that separate them from coworkers. Hierarchies are established for a reason, for the proper functioning of the group or organization, to delegate tasks, and to ensure the proper checks and balances. Children also form a subgroup within a family, forming a boundary around themselves separate from their parents. Ideally, the child subgroup holds less power than the parents. Family systems therapists confront families and situations where boundaries have become crossed, distorted, or nonexistent. These types of situations lead to dysfunctional and unhealthy relational patterns. A mother complaining to her child about her spouse - the child’s father - is one example of a crossed boundary. Another example of a crossed boundary are parents who perhaps share information about their sexual relationship with their children. These are two examples of distorted boundaries or inappropriate boundaries that lead to dysfunctional interactions. No family is perfect, and mistakes often happen. Sometimes more is shared or not enough is shared among family members, but most families work for an appropriate balance. However, families who allow boundaries to be constantly, routinely crossed, who set up patterns of interaction and form a family process that lacks self-regulating behaviours, need help at re-forming boundaries. Enmeshed and Disengaged families There are many types of boundary problems - as many problems as there are families. Family systems therapists assess families for boundary problems along a spectrum, placing boundary problems between the following two extremes: ◦Enmeshed families. An enmeshed family exhibits signs of smothering, over-sharing, and caring that reaches beyond normalcy. In enmeshed families, boundaries do not allow for individuation; they are too fluid, and have become crossed and often distorted. Boundaries are constantly crossed in numerous ways. ◦Disengaged or detached. Families that share little to nothing, typically overly rigid families, are described as detached. There’s little to no communication – and no flexibility in family patterns to accommodate effective support and guidance.
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Interventions:
Joining and accomodating (same process: joining emphasizes therapist's outer adjustment to family, accomodating therapist's inner adjustment; adopting family's affective style; joining from a distant position = teaching, advice), mimesis (imitation, or joining from a close position), tracking (of family communications and behaviour, or joining from a median position), enactments that simulate transactions to be changed, detriangulation of IP by forming a coalition with him against a parent, maintenance (of the family's current structure), marking boundaries (when they are strengthened, the subsystem's functioning will increase), mimic IP to show that he's like the powerful therapist rather than deviant, make the IP a cotherapist to the overfunctioner, reframing in terms of structure or interaction, unbalancing by escalating stress, general restructuring techniques (e.g., rearranging how they sit, blocking certain transactions, working as a family insider)..
Assessment of therapy A structural therapist strategically chooses who to talk to first to both facilitate their joining the family and to gain information on the family’s situation. Once there is comfort with the presenting problem the therapist expands to the whole family and starts making intelligent guesses about structural concerns. A family’s responses to exploring the presenting problem are useful in assessing structure. Time is taken to assess the relationship of the parents in the family. Four steps identified by Minuchin and his colleagues. 1. Ask questions about the initial complaint so the family begins to see that the problem extends to the whole family and not just the “problem member.” 2. Help the family see how their interactions may be unintentionally furthering the family’s problems. 3. Briefly explore the family past, particularly to determine how adults have developed the perspectives currently contributing to the presenting problem. 4. Explore options encouraging productive family interaction, in order to encourage structural change. Therapy techniques : The seven steps of family therapy Step 1: joining and accommodating Unlike individual therapy, a therapist is seen as an outsider to the system initially. Building an alliance, disarming defences, and offering empathy and expression time to everyone in the group is essential to joining. Gentle, understanding, and simple interactions with children are preferred. Considering who is influential in the family and attempting to join with doubters is especially important in bypassing resistance.
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Step 2: Enactment Give each member a chance to talk, to spark enactment. Enactment, as explained previously, allows for clearer structural inferences due to more direct demonstration. Enmeshed families tend to interrupt each other, while disengaged families are more passive while one or more members are expressing themselves. Therapists can also view deficiencies in executive control on the part of parents. Step 3: structural mapping Broadening the problem from the identified patient to the family structure. Assertions and observations of structure based on initial sessions are refined over time, especially as the family becomes more familiar with the therapist, and works through initial chaos. A combination of the presenting problem and structural observations is the main effort taken in this step. Step 4: highlighting and modifying interactions It is important to know when to intervene, and be forceful. Intensity: using a strong and forceful manner of speaking to exceed familial thresholds of not acknowledging challenges to the way they view their current situation. This is a skill involving controlling speaking volume, choice of words, conversational pacing, tone and other elements of speech. Sometimes this is a matter of repetition across multiple contexts. shaping competence: “like altering the direction of the flow.” : Reinforcement of desirable patterns and interactions, in order to highlight the already present functional choices in a client’s repertoire. Initial therapist mistake is to point out mistakes and give criticism without looking for successes to be reinforced. This is made up for through observational practice and situational awareness of such successes. Therapists should avoid taking over for the parents, though some limited argument can be made for “modelling” of ideal behaviours. Step 5: boundary making Strengthening weak boundaries, loosening rigid ones, and establishing parental hierarchy. In enmeshed families, conversational interruptions and intrusions are prevented. Individual or subgroup sessions, separate from the rest of the family, may also help Disengaged families are challenged to not avoid conflict: Differences must be discussed before such families can come closer. Members of such families have difficulty seeing how their behavior affects others in the group. Challenging family members to help each other change is one method of fostering improvement in disengaged families. Step 6: unbalancing As opposed to changes between subsystems, unbalancing aims to change relationships within a subsystem. Members in conflict and balanced in opposition are stuck, not moving toward progress. A therapist joins an individual or subsystem and takes sides to unbalance the situation. What may seem like antagonism from the therapist is actually a challenge for the clients to confront their fear of change. Unbalancing underscores the key point that families have to be in action to change.
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Step 7: challenging unproductive assumptions “Changing the way family members relate to each other offers alternative views of their situation.” The inverse is also true. This step is accomplished by giving advice or suggestions, with the intention of both familial restructuring and shaping client perceptions. “Push” vs. “kick” Paradoxes are infrequently used by structural therapists, but expression of scepticism of client change can sometimes help. Conclusion While not asserting preference of one method over another, there seems to be support for the effectiveness of structural therapy in families with drug problems, according to the text. Families dealing with adolescents with various behavioural problems have been helped. This includes ADHD, conduct disorder and eating disorders. Ultimately keep in mind looking beyond dynamics and content and into underlying structure and family organization.
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Virginia Satir’s Humanistic Family Therapy One of the founders of the MRI communications school. Emphasized the importance of giving families hope and building self-esteem in family members. **** Also read: Behavioural and Conjoint Family Therapy ****
Key concepts:
Turn roles into relationships, rules into guidelines.
Our similarities unite us, and our differences make us grow.
A symptom may be distorting self-growth by trying to alleviate family pain; symptoms are a light on the dashboard or a ticket into therapy. Broken families follow broken rules. Pathology is a deficit in growth. What growth price does each part of the system pay to keep the overall balanced? "Rupture point": where coping skills fail and family needs to change.
Primary triad (mother, father, child) is source of self-identity.
Mind, soul, body triad: a current basis of self-identity.
Self, the core, has eight levels: physical, intellectual, emotional, sensual, interactional, contextual, nutritional, and spiritual. A good therapist works on all levels.
Three parts to every communication: Me, you, context. Dysfunctional communications leave one of these out of account.
Games: rescue games, coalition games, lethal games, growth games.
The five freedoms: To see and hear what is here instead of what should be, was, or will be; To say what one feels and thinks, instead of what one should; To feel what one feels, instead of what one ought; To ask for what one wants, instead of always waiting for permission; To take risks in one's own behalf, instead of choosing to be only "secure" and not rocking the boat.
Maturation: development of a clear identity and power of choice; self-relatedness; ability to communicate with others. Coping skills increase with self-esteem.
"Threat and Reward" (rule-makers/followers; rigid roles) vs. "Seed" (innate growth potential) worldviews.
Five components of self-esteem: Security, belonging, competence, direction, selfhood.
In a dysfunctional family, symptomatic behaviour makes sense. It is also covertly rewarded.
Interventions:
Reduce individual and family pain. Family life chronology (three generations). Communication work and esteem building. Growth. Identification of family roles, and turning these into relationships. Family reconstruction: an exercise in which roles in significant family historical events are directed by the Explorer, who is led by the Guide. Look at implicit premises that guide perceptions and interactions. Analysis of how family members handle differentness.
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Cut games, straighten transactions. Self-manifestation (congruence) analysis. Model analysis of which models have impacted early on. Expand experiencing and choice-making. Parts party: awareness and exercise of mind and body. Sculpting (group posture) technique. Labeling assets. Use of drama, metaphor, art, stories, self.
Criteria for termination: When family members can complete transactions, check, ask; can interpret hostility; can see how others see them; can see how they see themselves; can tell each other how he manifests himself; can tell other member what he hopes, fears, expects from the other; can disagree; can make choices; can learn through practice; can free selves from harmful effects of past models; can give a clear message, be congruent.
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Behavioural & Conjoint Family Therapy Family therapists following a communications approach to family therapy hold the view that accurate communication is the key to solving family problems. (Conjoint family therapy = The involvement of two or more members of a family in therapy at the same time.) An open and honest manner of communicating rather than using phony or manipulative roles characterizes good problem-solving families.
Matching intent and impact of communication. Gottman built his approach on matching intent and impact of communication. He used a behavioural interviewing method to teach people about what they are doing that is not working and to help them correct the situation by learning how to get the impact they want from their communication. His stages include 1) exploration, 2) identification of goals, 3) perceptions of issues, 4) selection of one issue for discussion, 5) an analysis of interactions, 6) negotiation of a contract. Virginia Satir considered herself a detective who helps children figure out their parents. She thought 90% of what happens in a family is hidden. The family's needs, motives, and communication patterns are included in this 90%. She believed that whatever people are doing represents the best they are aware of and the best they can do. She considered people geared to surviving, growing, and developing close relationships with others. Self-esteem plays a prominent role in Satir's system. She viewed mature people as being in touch with their feelings, communicating clearly and effectively, and accepting differences in others as a chance to learn. She believed
The four components in a family situation that are subject to change are 1) 2) 3) 4)
the members' feelings of self-worth, the family's communication abilities, the system, and the rules of the family.
The three keys to Satir’s system are 1) to increase the self-esteem of all family members, 2) help family members better understand their encounters 3) and use experiential learning to improve interactions.
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Communication and Response Patterns Communication is the most important factor in Satir's system and determines the kinds of relationships people have with one another and how people adjust. She discussed response patterns to which people resort as a reaction to anxiety. These universal response roles or communication stances are: Five roles: placater, blamer, super-reasonable, irrelevant, and congruent (or leveling) communicator. The first four are mostly poses covering lack of self-worth. 1) the placater 2) the blamer 3) the computer 4) the distractor 5) the leveler feelings are
: an individual who avoids conflict at the cost of his/her integrity : a person who places blame on others and does not take responsibility for what is happening. : the super reasonable individual who denies his emotions : takes irrelevant stances : Communicates in a congruent way in which genuine expression’s of one’s made in an appropriate context.
Leveling helps people develop healthy personalities; all the others hide real feelings for fear of rejection. Satir divided families into two types: nurturing and troubled. Each type had varying degrees. Her main objective for her clients was recognition of their type and then change from type or degree.
The counseling method of conjoint family therapy involves 1) communication, 2) interaction, 3) and general information for the entire family. She used several techniques to reach her goals of establishing proper environments and assisting family members in clarifying what they want or hope for themselves and for the family. Her method is designed to help family members discover what patterns of communication do not work and how to understand and express their feelings in an open, level manner.
Games Simulated family games, systems games, and communication games are some of the methods she developed to deal with family behaviour. Some of Satir’s games are :
Growth model – assumes that an individual’s behaviour changes due to interactions with other people.
Medical model – purports that the cause of the problem is an illness of the individual.
Sick model – proposes that the individual’s thinking and attitudes are wrong and must be changed.
Filial therapy is a play therapy method based on the principles of child-centered therapy. The goals of filial therapy are to reduce the child’s problem behaviours, to help parents gain the skills of childcentered therapist to use as the parents relate to their children and to improve the parent-child relationship.
Strategic family play therapy is a form of counseling in which all family members and the counsellor play.
Theraplay is a treatment method modeled after the healthy parent-child interaction in which parents are involved first as observers and then as co-therapists.
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The Counsellor’s Role The counsellor's role in this model is of a facilitator who gives total commitment and attention to the process and the interactions. The counsellor intervenes to assist leveling and taking responsibility for one's own actions and feelings. Play therapy with families has the advantage of helping children communicate their story to the therapist. Dynamic family play therapy engages family members in creative activity by using natural play. The counsellor’s goal is to help the family develop and increase spontaneity.
Key Concepts 1.
The individual is considered as part of a family and the interactions and relationships within the family are the focus of therapy.
2.
The systems approach to family therapy is focused on how family members can maintain a healthy balance between being enmeshed and being disengaged.
3.
Structural family therapy is based on the idea that the family is an evolving, hierarchical organization made up of several subsystems with rules and behaviour patterns for interacting across and within those subsystems.
4.
According to structural theorists, defining and clarifying boundaries that exist between subsystems is imperative.
5.
Minuchin's approach is directed toward changing the family structure or organization as a way of modifying family members' behaviour.
6.
Strategic family therapy is based on the assumption that the family's ineffective problem solving develops and maintains symptoms.
7.
Conjoint family therapy is based on honest communication, members’ feelings of self-worth, and the rules of the family.
8.
Some of the family play therapy approaches include dynamic family play therapy, filial therapy, strategic family play therapy and thera-play.
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Milan Systemic Family Therapy or “Long Brief Therapy” Led by Mara Selvini-Palazzoli. Sessions held about once a month to let things incubate; families wanting more are trying to control the therapy. Neutral, nonreactive therapist who asks family to generate its own solutions.
Key Concepts: Emphasis on information, paradox, circular feedback loops. Repetitive interactions: games by which members try to control one another. Change the interactions and the behaviour will too. Dysfunctional families make an "epistemological error" that can be corrected.
Therapy: one or two therapists see the family while a team watches from behind a mirror. Sessions broken by an intersession during which the therapist talks to the team away from the family.
Interventions:
Counterparadox. Pre-session hypothesizing. Circular and triadic questioning. Positive connotation of a behaviour's intent. Assignment of rituals. Invariant prescription to loosen parent-child collusion.
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Excerpt from an Article by Lorraine M. Wright and Wendy L. Watson, University of Calgary: Systemic family therapy owes its origins to the brilliantly creative and innovative clinics team of M. Selvini-Palazzoli, L. Boscolo. G. Cecchin. and G. Prata (1978 - 1980). These four Italian psychiatrists have had an enormous impact on the conceptualization and practice of Family Therapy in the I98Os in North America and throughout the world. Systemic family assessments focus on family relationships, family development, alliances/coalitions and the process of communication between family members. The three fundamental principles necessary to conducting a systemic interview are hypothesizing, circularity, and neutrality (Selvini-Palazzoli et al. 1980). All three of these principles are interrelated. Assessment The assessment process is based on the formulation of hypotheses by the therapist about the family organizational patterns connected to the problem. The therapist first gleans information about a family - From intake data. - From previous experience with other clinical families, and - From various theories and research regarding the presenting problem or the "type" of family and then generates one or two initial working hypotheses (Fleuridas. Nelson, Nr Rosenthal, 1986). Family development theories can be useful in pointing the therapist to "tasks" and attachments that may be taxing the presenting family. Throughout an interview, questions are asked in order to validate or invalidate alternative hypotheses. Based on the information gathered from the family, the therapist modifies or alters his or her hypotheses about the problem and about the family and continually moves to a more "useful" understanding of the family. In our view, the hardest work that occurs in systemic therapy is in developing systemic hypotheses. Linear hypotheses are so much easier to generate, particularly judgmental linear hypotheses (e.g. a mother is too controlling of a father). Systemic hypotheses connect the behaviors of all family members in a meaningful manner (Tomm, 1984b). (For example, a father shows little initiative or concern regarding his future. The less concern he shows, the more concern his wife shows: eventually, she directs him in what to do. The more she directs him, the less he directs himself. And vice versa). "Circularity" refers to the therapist's ability to develop systemic hypotheses about the family based on the feedback obtained during questioning about relationships (Selvini-Palazzoli et al., 1980). Circularity is based on Bateson's (1979) idea that "information consists of differences that make a difference" (p. 99). Differences between perceptions/objects/events ideas/etc. are regarded as the basic source of all information and consequent knowledge. On closer examination, one can see that such relationships are always reciprocal or circular. If she is shorter than he, then he is taller than she. If she is dominant, then he is submissive. If one member of the family is defined as being bad, then the others are being defined as being good. Even at a very simple level, a circular orientation allows implicit information to become more explicit and offers alternative points of view. A linear orientation on the other hand is narrow and restrictive and tends to mask important data. (Tornm. 1981, p. 93) Circular questioning involves the ability of the therapist to conduct the assessment on the basis of obtaining information about relationships (Selvini- PalazzoIi et al, 1980). Linear questions tend to explore individual characteristics or events (e.g., How long have you had angina'!), whereas circular questions tend to explore relationships or differences (e.g., Who in your family is the most confident that you can manage your heart problem? (Selvini-PalazzoIi, et al., 1980; Tomm, 1981, 1985). If the therapist wants to validate or invalidate the hypothesis that a family is having trouble launching the eldest daughter, a useful circular question, directed to other children in the family, could be, "What will be different in the family when Susan leaves home'!"
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Interventive (reflexive) questions induce a family to reflect and therefore think and act in a new way (Tomm, 19871). Although many kinds of questions have the potential for inducing new cognition, affect, and behavior, all questions are not created equal! Using the preceding family situation, consider the fallowing interventive developmental question, directed to the parents of Susan: "If you decided to convince Susan that she was ready to leave home, how would you go about it?" "Neutrality,” the third principle of systemic assessments, refers to the ability of the therapist to respond without judgment or blame to problems, change, persons, and various descriptions of relationships. For example, if a family makes a connection between a developmental problem, such as a young adult's reluctance to leave home, and their belief that it is due to the young adult's having a chronic illness, the therapist would be as neutral as possible in his or her reactions to this description, but it does not mean that the therapist has to accept this connection. The assessment information obtained through circular questioning about the meaning and belief of developmental problems will greatly assist the therapist in intervening. However, it must be emphasized chat it is necessary to intervene only if particular beliefs interfere with or block the problem-solving efforts. Family Development through a systemic lens In the systemic approach, families are viewed as self-regulating systems controlled by rules established over time through a process of trial and error (Selvini-Rlazzoli et al., 1978). If the rules do not allow for a natural progression through various family life cycle stages or for an accidental shift (e.g., chronic illness, divorce), a family member may develop a symptom as a "solution" to helping the family progress along its evolutionary path (Hoffman, 1981; Tomm, 1984a). The symptom, or presenting problem, represents an interactional dilemma chat is derived from particular family beliefs. In this model, one of the therapist's goals is to offer the family an alternate "belief' or "reality" about the problem, which may then allow the family to discover its own solutions. More specifically, the therapist aims first at understanding the family's reality surrounding the problem and then at challenging this reality by introducing "new connections" between relationships, beliefs and behaviors. The family finds its own solutions once its ability to change has increased. This is accomplished following a change in the "reality" of, or in the beliefs about, the problem: new views of old problems (Ugazzio (1985) emphasizes that the first phase of any systemic interview should focus on the family's interpersonal belief system and should explore family members' explanations, interpretations and attributions of meaning and intentionality for their own and other members' behaviours. We concur with this focus and make it a routine pattern of our clinical practice to explore consciously and deliberately family members' beliefs about and meanings for the presenting problem (i.e., cause. cure, consequences). Systemic therapists do not adhere to the belief that the past determines the present or the future. Rather, they find it more helpful, from a systems view, to believe that the past can illuminate the present and vice versa. The systemic lens enhances the therapist’s ability to view the past in a variety of ways. Most family life cycle stages are highlighted by the addition and/or departure of family members. The stage of families launching children is perhaps the most dramatic and traumatic in this respect. It is punctuated with numerous entries and exits of family members: the departure of young adult children, the addition of sons- or daughters-in-law and the attrition by death of the grandparent generation. Families frequently find themselves involved in a series of adjustments and readjustments at this stage of development. How families cope with this particular stage is hest understood if a three generational view is taken (McCullough. 1980). For example, the amount of success parents encountered in dealing with autonomy and separation issues with their families of origin will, in turn have a definite impact on their ability to deal successfully with these issues with their own grown children (McCullough.1980). When a family encounters difficulty in accomplishing the task of parent-child separation, it is usually manifested in one of two ways (Wright, Hall, O'Connor, Perry. & Murphy, 1982), Wright et al (1982) indicate that one common response is for parents and children to be so loyal to the nuclear family that they
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disregard their own individual development. In families characterized by a high degree of loyalty, it is often difficult for the young adult to individuate because individuation may be seen by the family as a form of rejection. Some young adults respond to this dilemma by remaining highly dependent on their parents for emotional and – sometimes - economic support and they often provide companionship and nurturing for one or both parents. The second extreme response of families negotiating the launching stage is for parents and children to distance themselves emotionally from each other to such an extent that they appear to be totally disinterested in each other and totally consumed by self-interest. For example, young adults may declare their independence and cut ties completely with their family in an effort to individuate. Determining what direction a relationship should take is not the primary goal of the clinicians. Rather, the aim of the systemic therapy team is to create a context for change and to offer an alternate epistemology of the problem so that the family can discover their own solutions. Therapists must trust the solutions that families find and must recognize that the pace the family takes roward problem solving is often different from that which the therapist might establish (e.g., sometimes much slower, sometimes much Faster). One way a therapist can induce a family system to find the direction and pace of its solutions, is to accept each family member's perception of the problem and to offer an alternate view, or "reality," of the problem, The aim of this systemic perturhation is to enhance the autonomy of the system. The challenge for the therapist is not to become "married" to the alternate reality that is presented to the family or lo think it more correct than the view a famiIy holds. It is, at best, a more useful view, in the sense that the new reality frees up the problem-solving ability of the system. There are more realities than there are families and these realities only need to be modified when they inhibit individual or family development. An important difference between this model and other family therapy models is that the systemic approach utilizes a non-normative model of family functioning while recognizing that there clearly exist various developmental transitions and stages. (It is intriguing to us that an understanding of a normative model enhances the learning of a non-normative rnodel). However, systemic therapists work against the impulse to direct families as to how they should function or develop. The use of the split-opinion intervention in which one therapist supports the solution of one family member, a second team member supports the solution of another family member and a third therapist advances an alternative solution, is an excellent illustration of how to intervene not only with the family , but also with the therapeutic team, to prevent the latter from pushing the family to change in a particular direction and/or at a particular pace. If famiIies are influenced in a particular direction, that will, in turn, direct family development and/or fami!y functioning. The process of change To facilitate change in a family system is he most challenging and exciting aspect of family therapy. The process of change is a fascinating phenomenon, and various ideas exist about how and what constitutes change in family systems. Liddle (1982) has suggested that one of the basic issues of all of us who engage in family therapy is the interviewer's theory of change, that is: what mechanisms permit or force change to occur? Even more basic: what is the nature of change itself according to one's own model? (p. 248). We concur with Bateson's (1979) notion that systems of relationships appear to possess a tendency toward progressive change. However, there is n French proverb that states, "plus ça change, plus c'est la même chose" ("The more something changes, the more it remains the same.") This highlights the quandary frequently faced in working with families. Systemic therapists must learn to accept the challenge posed by the relationship between persistence (stability) and change. Watzlawick, Weakland and Fisch (1974) suggest that persistence and change need to be considered to together despite their opposing natures. They have offered a notion of change that is accepted by most systemic therapists, which is that there are two different types or levels of change. One type they refer to is first-order change, or change that occurs within a given system. That is, in the elements or parts of the system, without changing the system itself. It is a change in quantity, not quality. First-order change involves using the same problem-solving strategies over and over again. If a solution to a problem is difficult to find, more old strategies are used, and they are usually applied more zealously.
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Second-order change is change that alters the system itself. This type of change is thus a "change of change." It appears that the French proverb is applicable only to first-order change. In second-order change, there are actual changes in the rules governing the system, and therefore the system is transformed structurally and/or communicationally. Second-order change always involves a discontinuity and tends to be sudden and radical: it represents a quantum leap in the system to a different level of functioning. Systemic therapy focuses on facilitating second-order change. Our case example beautifully exemplified changes that were dramatic and rapid. A change occurred in the system itself, in addition to a change in the presenting problem. In summary, we concur with Bateson (1979) that change is constantly evolving in families and that frequently we are unaware or change. This is the type of continuous or spontaneous change that occurs with everyday living and with progression through individual and family stages of development. These changes may or may not occur with professional input. We also believe that major transformations of an entire family system can he precipitated by major life events and / or interventions by family therapists. We view change as a systems/cybernetic phenomenon; that is, change within a family may occur within the cognitive, affective, or behavioral domains, hut change in any one domain will have an impact on the other domains. However, we believe that the most profound and sustaining change will be that which occurs within the family's belief system (cognition). There are certain concepts regarding change we have found particularly useful in our systemic clinical work with Families. We will discuss the two most salient concepts here. First, the ability to alter one's perception of a problem enhances the ability for change (Wright & Leahey, 1984). It is essential that both family members and family therapists alter their perceptions of a problem. If a therapist agrees with the way a family views a problem, then nothing new will be offered. How we, as therapists, perceive and conceptualize a particular problem determines how we will intervene. When a therapist conceptualizes developmenta1 problems from systems/ cybernetic perspective, his or her perceptions will be based on a completely different conception of "reality" as a result of these theoretical assumptions. Our clinical practice with families who present at the FNU with developmental problems is based on a systemic-cybernetic-communicational theoretical foundation. Interventions are based primarily on the systemic model (Selvini-Palazzoli et al, 1980; Tomm. 1984a, 1984b). These are some of our efforts to think systemically. But what of families? Individual family members construct their own realities of a situation based on personal beliefs and assumptions. Families and family members need assistance in moving from a linear perspective of the problem to a circular one. This is possible only if the therapist doesn't become caught in linear thinking when attempting to understand family dynamics. We have found that one way to avoid becoming linear in conceptualizing developmental problems is to avoid thinking that the view of a particular family member or of all family members are "right" or correct.'' The challenging position of the therapist is to offer an alternate perception, reality, or epistemology that will free the family to develop is own solutions to the problems. This alternate reality is usually redefined as an interpersonal or relationship problem. The second salient concept is that change does not occur as a result of therapeutic elaboration of a family's understanding of developmental problems. In our clinical experience, we have rarely found that changes or improvements regarding developmental issues occur by embellishing a family's view of the problem. Rather, we have observed that the solutions to problems change as the family's beliefs and interactional patterns change whether or not this is accompanied by further insight. Systemic therapy avoids the search for lineal causes and seeks, instead, to provide systemic explanations of problems and impasses.
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Roadblocks to family developmental change Family therapists regardless of theoretical orientation have noticed that many families have not progressed smoothly or automatically from one life cycle stage to another. Their clinical interventions focus on the stressful transition points between stages. Certainly, in our own clinical work, we have sometimes succumbed to the temptation to focus on particular transition points that have become problematic. The potential trap is for systemic therapists to become too purposive, that is: to become too invested in a particular outcome and to then direct the family to function or be restructured in a particular way. Systemic therapists try not to "get in the way" of family development by not being directly directive. Thus the notion that families must progress smoothly through the famity life cycle stages must he confronted. Smooth progression, in our estimation, is not characteristic of a developing family. However. there are occasions when families have "derailments from the family life cycle" (Caster & McGoldrick, 1980 p. 9). This notion of derailments is useful, because it conjures up a much more optimistic view of family life cycle difficulties. One of the most common derailments that we encounter in our practice is the derailment by illness. The impact on the family of a chronic or life-threatening illness does not automatically result in a derailment, but it almost always interferes with roles, rules and rituals. From a systemic perspective, a derailment also frequently occurs when family members are attempting to obtain meaning and clarification in a relationship. The greater the ambiguity regarding relationships, particularly at various developmental junctures throughout the family life cycle, the greater the chance for family and individual symptoms. With any derailment, it should not necessarily be the therapist's goal to have the family return to the original "track." Rather, it behooves the therapist to create a context for change for the family to allow them to decide which track will provide the greatest opportunity for reduced stress and increased growth. Interventions that create a context for developmental change. There are numerous interventions that can be utilized to facilitate or create a context for change. However, we will discuss only systemic interventions that create a context for developmental change. Offering alternate realities Systemic family therapists frequently offer beliefs, opinions or conceptions about problems without regarding them as interventions. However, when strategically thought out and planned, these various types of opinions serve as potent and useful interventions offering an alternate reality to those experiencing particular problems. 1. Information and advice. Families find advice and information about developmental problems valuable and beneficial. Frequently, Information about developmental issues e.g., elderly parents' needs for "spatial but not social isolation" and for "autonomy with contact" (Banziger, 1979) can liberate a family so that the members are then able to resolve their own problems. 2. Systemic opinion (reframing) Presenting symptoms may serve a positive function for a family. A systemic opinion is offered by conceptualizing the presenting symptom as a solution to some other hypothetical or implied problem that would or could occur should the symptom not be present (Tomm, 1984b). In the case example, the intense inter-generational conflict was positively connoted as a distance regulator in an overly close parent-child relationship. The symptomatic behavior is systemically reframed by connecting it to other behaviors in the system. The connections are based on the information derived in the assessment through the process of circular questioning. It is essential. when offering a systemic opinion to a family, that the reclusiveness of the symptom be delineated: The symptom serves a positive function for the system while at the same time the system serves a function by contributing and maintaining the symptom (Wright & Leahey. 1987). 3. Redefinition of the context of therapy A powerful opinion can be given by redefining the context in which family therapy is provided. If a family objects to attending sessions for what they have defined as Family therapy, then, based on the assessment,
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the family could be told that family therapy sessions will be discontinued and that developmental sessions will begin (Wright & Watson, 1982). It is not that the nature of the work between the therapist and the family changes, but rather that the context, or "name," of the work is made more palatable. With the family described in the case example the nature OF our work was named research rather than therapy. 4. Commendation for family and individual strength Following a recent analysis, by three observers, of 28 sessions we conducted with Tour families in a hypertension project, one of the common themes identified was our routine practice of commending families on particular strengths at the end of interviews. Feedback from both research observers and families has made us cognizant that this practice involves more than just being courteous-it represents a significant intervention that can alter family members' realities of themselves. 5. Split option. We have found the split-opinion to be a most powerful systemic intervention. Normally, a split opinion offers the family two or more different and opposing views. Each point of view is equally valued and the family is left to struggle with the various views or reality. The split-option enables each participating family member to have their view of reality strongly supported while at the same time providing each with the opportunity to entertain a totally new epistemology with regard to the presenting problem. This intervention creates a context for change that has previously been impossible, possibly because of the extreme rigidity of each family member's beliefs. In designing and prescribing a ritual, a therapist requires that a family engage in behaviors that have not been part of their usual patterns of interaction. The existence of contusion is normally an indicator for the use of the ritual intervention. The confusion is due to the simultaneous presentation of incompatible injunctions within the family. Rituals introduce more clarity into the family system. In systemic work, the actual execution of the ritual is not as important as the feedback about what new connections the family has made and consequently what new beliefs or realities the family now entertains. In a case, two rituals were prescribed: The "meeting of the hearts" technique, which involves ritualizing a talking-listening session. The "burial of the hurts so the hearts can heal", which provides a forum for further purging. The second ritual was not executed because the parties involved stated that “there ere no more bad feelings left” Selvini-Palazzoli (1986) indicated that some families respond just to the idea of doing something unusual. Thus the enactment of the prescribed ritual may not be essential to induce a change in the family system. Useful information to the family and the therapist may he provided through just the description/prescription of a ritual. Conclusion Traditional life cycle theorists and therapists imply with their clearly demarcated stages, tasks, and attachments, "WE know how your family should function.'' Systemic therapists use life cycle information to generate ( I ) working hypotheses about the connection between the symptom and the system and (2) questions to perturb the family system, so that the family can answer its own question, "What is the most useful way for our family to function at this time'?"
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Response-based Family Therapy From Wikipedia, the free encyclopedia Response-based therapy is a relatively new psychotherapeutic approach to treating psychological trauma resulting from violence, based on the theory that whenever people are treated badly, they resist. Incorporating elements of Solution focused brief therapy, Narrative therapy, and discourse analysis. It was first proposed by a Canadian family therapist and researcher, Dr. Allan Wade, in his 1997 article "Small Acts of Living: Everyday Resistance to Violence and Other Forms of Oppression.
Therapeutic Methods Therapeutic methods of response-based therapy are based on two theoretical foundations: (1) That alongside accounts of violence in history, there exists an often-unrecognized parallel history of "determined, prudent, and creative resistance," and (2) Language is frequently used in a manner that (a) conceals violence, (b) obscures and mitigates perpetrator responsibility, (c) conceals victims' resistance, and (d) blames or pathologizes victims. This second principle employs "discourse analysis" and is referred to in response based therapy as the "four discursive operations." This presupposition of resistance as a natural response to violence is used to engage clients in in-depth conversations about how they responded to specific acts of violence. In response-based literature, resistance is defined and examples given: “Any mental or behavioural act through which a person attempts to expose, withstand, repel, stop, prevent, abstain from, strive against, impede, refuse to comply with, or oppose any form of violence or oppression (including any type of disrespect), or the conditions that make such acts possible, may be understood a a form of resistance.” (Wade, 1997, p. 25) “Whenever people are abused, they do many things to oppose the abuse and to keep their dignity and their self-respect. This is called resistance. The resistance might include not doing what the perpetrator wants them to do, standing up against, and trying to stop or prevent violence, disrespect, or oppression. Imagining a better life may also be a way that victims resist abuse.” (Calgary Women’s Emergency Shelter, 2007) Therapy consists of using language to (1) expose violence, (2) clarify perpetrators' responsibility, (3) elucidate and honor victims' resistance, and (4) contest victim blaming . In response-based therapy, the client is viewed as an "agent" who has the capability to respond to an act, rather than a passive "object" that is "acted upon." Example: the response-based therapist would not ask a victim "How did that make you feel?", but instead would ask "When [act of violence] was done to you, how did you respond? What did you do?"
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References 1. 2. 3. 4.
^ Wade, 1997, p. 23 ^ Wade, A. (1997). Small acts of living: Everyday resistance to violence and other forms of oppression. Contemporary Family Therapy, 19(1), 23-39 ^ Coates, L., & Wade, A. (2004). Telling It Like It Isn’t: Obscuring Perpetrator Responsibility for Violent Crime. Discourse and Society, 15(5), 3-30. ^ Todd, N. & Wade, A. (2003) 'Coming to Terms with Violence and Resistance: From a Language of Effects to a Language of Responses', in T. Strong & D. Pare (eds), Furthering Talk: Advances in the Discursive Therapies, New York: Kluwer Academic Plenum. p. 152.
Related Reading •
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Calgary Women's Emergency Shelter. (2007). Honouring Resistance: How Women Resist Abuse in Intimate Relationships (formerly Resistance to Violence and Abuse in Intimate Relationships: A Response-Based Perspective) Available from Calgary Women's Emergency Shelter, P.O. Box 52051 Edmonton Trail N., Calgary, Alberta T2E 8K9. Coates, L. & Wade, A. (2004). Telling It Like It Isn’t: Obscuring Perpetrator Responsibility for Violent Crime. Discourse and Society, 15(5), 3-30. Coates, L. & Wade, A. (2007). Language and Violence: Analysis of Four Discursive Operations. Journal of Family Violence, 22(7), 511-522. Todd, N. and Wade, A. (2001). The Language of Responses Versus the Language of Effects: Turning Victims into Perpetrators and Perpetrators into Victims, unpublished manuscript, Duncan, British Columbia, Canada. Todd, N. & Wade, A. (2003). 'Coming to Terms with Violence and Resistance: From a Language of Effects to a Language of Responses', in T. Strong & D. Pare (eds), Furthering Talk: Advances in the Discursive Therapies, New York: Kluwer Academic Plenum. Wade, A. (1997). Small Acts of Living: Everyday Resistance to Violence and Other Forms of Oppression, Journal of Contemporary Family Therapy, 19, 23–40. Wade, A. (1999). Resistance to Interpersonal Violence: Implications for the practice of therapy. University of Victoria, Ph.D. Dissertation, Department of Psychology. Wade, A. (2007a). Despair, resistance, hope: Response-based therapy with victims of violence. In C. Flaskas, I. McCarthy, and J. Sheehan (Eds.), Hope and despair in narrative and family therapy: Adversity, forgiveness and reconciliation (pp. 63–74). New York , NY : Routledge/Taylor & Francis Group. HF Wade, A. (2007b). Coming to Terms with Violence: A Response-Based Approach to Therapy, Research and Community Action. Yaletown Family Therapy: Therapeutic Conversations. [2] Weaver, J., Samantaraya, L., & Todd. N. (2005). The Response-Based Approach in Working with Perpetrators Of Violence: An Investigation. Calgary Women's Emergency Shelter [3]
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Contextual Family Therapy Approach “Without a moral vocabulary, we cannot act out of conviction, merely out of habit.” (Susan Neiman) The field of this essay is the Contextual Approach to Family Therapy, developed in the mid-20th century. Its founder, Iván Böszörményi-Nagy (1920-2007) was born in Budapest into a family of prominent judges, graduated with a Degree in Psychiatry in 1948 and immigrated to the US, in disagreement with unjust Communist regime in post - WWII Hungary. Family Therapy started developing in 1950s, when several American therapists, including Böszörményi-Nagy “began to look beyond individual psychology to understand and try to treat severe mental disorders...” (Carey (2007)) During clinical work, Böszörményi-Nagy noticed destructive patterns of family interactions being frequently passed on through generations. This observation later contributed to the Contextual Approach, which equipped Family Therapy with new theoretical principles and practical applications. The word “Context” has significant meaning within Contextual Approach in general and the Relational Ethics in particular. It differs from the ordinary one in the idea of responsibility of everybody participating in the relationship for the latter. “Context” indicates that clients are dynamically connected to their long-term relational involvements and multigenerational roots. It refers to network of contacts, built in the process of giving and receiving and Interdependence, created as a result. Relational Ethics through Multi-generational Perspective focuses on both intra- and inter-generational functions and roles of Loyalty to both Family and Society (rather than submission to power), Legacy, Fairness, Accountability, Trustworthiness and Reciprocity. Deriving from basic needs and individual experiences, Relational Ethics are more than a code of socially accepted behrs. In all its complexity mankind can be legitimately seen as either essentially selfish, or altruistic and good natured, or morally ambivalent. However, “our evolutionary inheritance shows that “we are moral beings to the core” (de Waal, cited by Labanyi (2009), p.21) Therefore, in the opinions of many, Relational Ethics is naturally present in individuals, Families and broader society
The core of Contextual Approach rests on two postulates. Firstly it holds that all Family members bare consequences of each other's actions or inactions. Secondly it states that “quality of one's relationships is inseparable from the responsible consideration of those consequences for others.” (Fowers, Wagner (1997))
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Four-Dimensional Interventions As both a guide for therapeutic interventions and a theoretical concept, Contextual Approach originally proposed four inter-connected, but not equitable or reducible to each other dimensions of Relational Reality; namely
Facts, Individual Psychology, Transactions and Relational Ethics.
Böszörményi-Nagy introduced the fifth, “ontic dimension” in 2000, although it was implicitly present within the original theory. (Kalayjian, Paloutzian (2009), p.43)
Facts The first dimension - Facts - consists of factual reality and biological determines, over which we have limited or no control. Many facts and events occurring in the Families or Societies (immigration, large lotto winnings, unemployment, adoptions, particularly intercultural ones, births, deaths, ethnic and religious conflicts) impact on the Family relationships, change interaction patterns, and deeply affect both individual and Family goals. Along with biological and historical determines this can create conflicts within the Family, which, if unresolved can become factual realities, creating grounds for “split-loyalty.” (Krasner, Joyce (1995), p.19) When more than one generation of the Family become involved in such unresolved conflict, consequences of action or inaction of one generation can become a legacy, passed down to descendants. These events were termed “created realities.” (Fowers, Wagner (1997)) This Multi-generational Perspective bears huge significance within all dimensions of Contextual Approach, and has become probably one of the most important contributions of Böszörményi-Nagy to Contextual Approach. It empowers Family Therapy with new keys to understanding Family development and interactions. Shpungina (2009) describes how limitations of civil rights of Jews in Russian Empire in 18th19th centuries resulted in formation of closer bonds within Families, which have been passed down through generations. These traits are present in many Families of their descendants until now. On the contrary Voronov (2009) gives examples of Family disintegration as a result of individual Family members' loyalties being split between Family and Society in 1920s Russia.
Individual Psychology The second dimension of Contextual Approach - Individual Psychology - refers to the internal world of individual Family members and “includes cognitions, emotions, fantasies and other symbolic processes.” (Böszörményi-Nagy (1991), cited by Piercy, Sprenkle, Wetchler (1996), p. 28) Opposite “to the Systemic Approach, where the individual was often lost,” (Gangamma, p. 11 ) Contextual Theory holds that the same processes affect developments of both Family and individual Family members. People differ in strengths and limitations, cognitive and coping abilities and techniques. In the Therapeutic setting “failing to see individual’s personal concerns, thoughts, wishes, hopes, past hurts, and disappointments can lead … to ... errors” (Goldenthal (2005), p. 23) in Family therapy as much as in individual one. Within this discovery lies yet another contribution of Böszörményi-Nagy, a trained Psychoanalyst, to Contextual Approach – incorporation of elements of the Psychoanylatic theories within the Systemic Theories in the form of recognition of influence of an individual on the Family development and responsibility for facilitating change in Therapy process. It is important to emphasise that according to Böszörményi-Nagy's Contextual Approach, individual factors are always looked at in the relational context, because “to be is to be relational.” (Lothstein (1996) cited by Gangamma, p. 11) This contribution of Böszörményi-Nagy found its practical application in Therapy in forms of Acknowledgement and Assessment of individual psychological differences.
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Transactions The third dimension of Contextual Theory – Transactions - refers to the interaction patterns in Families that are reciprocally affected by its members. Although both Contextual and Systemic Approaches agree on circular nature of relationships, the former sees Families as dynamic self-regulatory systems (Whitchurch & Constantine (1993) cited by Gangamma, p. 12) in the state of permanent fluctuation of structure, roles and communication patterns, functioning to produce change in patterns or to maintain status quo. According to the Contextual Approach, every individual strives for identity and boundaries. Our identities only exist in comparison to others. As social beings we need complementarity in meaningful relationships in the Family, when “the other would no longer be seen as superior or inferior ...”, which produces “...a less rigid form of identity with which we make contrast between “us” and “them.” (Chaplin (2008), p.25) In this context the fulfilment of goals and needs of both the individual and the Family defines a healthy family in the framework of Contextual Approach.
Relational Ethics Probably the most significant contribution of Böszörményi-Nagy to Contextual Approach is the development of its forth dimension – the ground breaking concept of Relational Ethics. Böszörményi-Nagy strongly believed that our evolution, health and even survival depend on quality of human relationships. In this context Relational Ethics consider mutual Trust, Loyalty, and Sincerity to be the key conditions of strong relationships and united Families. Böszörményi-Nagy was among the first Theorists who acknowledged that “Family Therapy and moral questions are inseparable,” and to locate the “ethical dimension of family life and therapy at the centre.” (Fowers, Wagner, (1997)) He also contributed to the field of Family Therapy by offering “positive practical recommendations about the way to approach the moral dimension of Family Therapy.” (Fowers, Wagner, (1997))
Critics Some authors see Böszörményi-Nagy's emphasis on universally appealing ideas of Trustworthiness and Fairness as a limitation rather than a strength, because it “provides a limited view of the good in Family life.” (Fowers, Wagner, (1997)) When it comes to defining Fairness and Justice, Böszörményi-Nagy leaves it to Families. This allows for “value-neutrality,” which in our age of “political correctness” is seen by many as a strength of the Approach. However, Labanyi (2009, p. 22) argues that being a Therapist means to be “willing to extend our thinking beyond our “safe” and introverted rituals.” Value - neutrality always raises questions. If Justice can be defined by mutual agreement of Family members, why the centuries-long debate on it is not yet resolved? Would children, elderly and disabled have their say in the discussion? Would the negotiation allow for gender equality and split loyalties? The same applies to Fairness. Their definitions vary in Families and societies of different backgrounds. Ulitskaya (2007) gives examples of irreconcilable differences in definition of Justice and Loyalty in multi– cultural immigrant families in Israel in 1960s. Importance of Connectedness and Trustworthiness can be reduced to zero in favour of other socially accepted values. Changes in the value of Honour and Obedience
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versus Connectedness and Trust over time within ethnic minorities in England and in Afganistan are discussed by Sanghera (2009) and Hosseini (2007). Despite undeniable importance of Böszörményi-Nagy's Ethical concepts, inability to provide practical solutions for reconciliation of legitimate differences in understanding of morals can be seen as one of the limitations of the Approach. It is not entirely free of distortions and biases, therefore the Relational Ethics, operating within “none-imposed,” but latently present Western moral code fails to provide the “general approach to moral considerations in therapy.” (Fowers, Wagner, (1997)) Despite being open to interpretations all Family interactions are acts of giving and receiving. Each of the them brings a new balance or imbalance to the Ledgers of entitlement and indebtedness. This accounting metaphor is used by Böszörményi-Nagy to discuss the balance of give and take in the Family. Because Contextual Approach defines the Trustworthy relationships as mature and free of exploitation, in its framework a Ledger is balanced when Family members take responsibility for making an honest effort to consider each other's interests, rather than make a contribution of “equal value.”
Entitlement Deriving from the metaphor of “Ledger,” the concept of Entitlement relates to Family members' ability to prioritise other's needs, welfare, and interests over their own. In a fair exchange of give and take a constructive Entitlement is earned. Those subjected to unjust factual realities acquire destructive Entitlements and are more than likely to compensate for this violations. Although both experiences will probably be brought forward, understandably compensations for destructive entitlements spanning trough generations are spoken about more often. Böszörményi-Nagy believed that his Approach applied to all relationship, including society as a whole. According to Kurimay, he holds that all relational conflicts are results of destructive Entitlements, whether it is “ethnic war in Sarajevo, race riots in Los Angeles, substance abuse on the street corner, or unhappy “adult children” in your house.” In another words, Böszörményi-Nagy's contributes to the Approach by offering a logical explanation as to why some individuals are “predisposed to engage in repetitive and harmful behaviours that often affect those that did not victimize them and therefore are innocent.” ( Böszörményi-Nagy's & Krasner (1986), cited by Gangamma (2008), p.2) Böszörményi-Nagy believed in the usefulness of the Contextual Approach so strongly, that he suggested the use of it for “the possible mediation between cultures and religions after 9/11.” (Kurimay) Whether or not it is too naive to suggest that Contextual Approach can be as successful in resolution of international conflicts as it is in resolution of Family ones remains to be seen. Even if strength of the Approach can not be stretched that far, it is undoubtedly a useful tool for many areas of Therapy. For instance, according to Adkins (2010) Contextual Approach “offers a new lens through which one can explain Intimate Partner Violence,” (p 29-30) and fills many other gaps in the existing theories, attempting to explain “femail's violence toward male partners and violence in same-sex relationships.” (p. 30) Placing a high value on Closeness between Family members and their significance for the development of relationships, Böszörményi-Nagy proposed the fifth – Ontic - dimension of Contextual Approach, which refers to the nature of the interconnectedness between people that allows an individual to exist decisively as a person, and not just a “self.” Although as any theory Contextual Approach has both its strengths and limitations, contributions of Böszörményi-Nagy to its development can hardly be overstated. He was probably the first one to recognise inseparability of behavioural and Ethical dimensions. The latter has become an important and integral part of many Approaches to both Family and Individual Therapy. Perhaps because of this discovery Contextual Approach seems to capture nature of Family relationships in all their complexity, including multigenerational dynamic, “better than any other major Family Therapy Approaches.” (Fowers, Wagner (1997)) In the opinion of the student, who herself comes from a multi-cultural and multi-denominational family of origin, from the country with a long and dramatic history of social and ethnic conflicts, BöszörményiNagy's Contextual Approach casts a new light on fluctuations of family and individual goals, “split loyalties” and legacies of “created realities,” passed down through generations.
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Incorporating the value of an individual with the Systemic Approach and the Multi-generational Perspective, Böszörményi-Nagy's Contextual Theory offers a unique explanation for the disturbing phenomena of the inter-generational transmission of violence (both in Family and broader societal contexts) through its main concepts of Trust, Loyalty, Justice, and Entitlement. Perhaps with further research and development Böszörményi-Nagy's belief in suitability of his Contextual Approach for resolution of international conflicts will become reality and the everlasting debates on the definition of basic yet crucial for our wellbeing concepts of Justice and Fairness will come to the successful resolution both on Family and Societal levels.
References and Bibliography �
Anderson H., Goolishan H. A., (1988), Human Systems as Linguistic Systems: Preliminary and Evolving Ideas About the Implications of Clinical Theory, Family Process, Vol 27, No 4.
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Böszörményi-Nagy I., Krasner B.R. (1986), Between Give and Take, USA, Brunner/ Mazel Publications.
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Böszörményi-Nagy I., Spark G. (1973), Invisible Loyalties, USA, Harper & Row Publications.
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Böszörményi-Nagy I., Ulrich D.N. (1981), Contextual Family Therapy, In Gurman A.S., Kniskern D.P. (Editors), Handbook of Family Therapy, USA, Brunner & Mazel Publications.
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Chaplin J., Deep Equality, Eisteach, Quarterly Journal of Counselling and Psychotherapy, Vol 8, No 4, Winter 2008.
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Goldberg H., Goldberg I., (2008) Family Therapy: An Overview, USA, Thomson Brook/ Cole Publications.
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Goldenthal P. (2005), Helping Children and Families: A New Treatment Model Integrating Psychodinamic, Behavioral, and Contextual Approaches, USA, Wiley, John & Sons.
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Hosseini K. (2007), A Sousan Splendid Suns, UK, Bloomsbury.
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Kalayjian A, Paloutzian R. F (2009), Forgiveness and Reconciliation: Psychological Pathways to Conflict Transformation and Pace Building, USA, Springer Publications.
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Krasner B.R., Joyce A.J. (1995), UK, Truth, Trust and Relationships: Healing Interventions in Contextual Therapy, Routledge Publications.
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Labanyi P., Rediscovering What Really Matters. Judjement, Authenticity and the Moral Code of Psychotherapy, Eisteach, Quarterly Journal of Counselling and Psychotherapy, Vol 9, No 2, Summer 2009.
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O'Donnchadha R, Children and Loss, Eisteach, Quarterly Journal of Counselling and Psychotherapy, Vol 8, No 3, Autumn 2008.
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Piercy F. P., Sprenkle D. H., Wetchler J. L. (1996), Family therapy sourcebook, USA, Guilford Press.
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Sanghera J., (2009), Daughters of Shame, UK, Hodder & Stoughton Publications.
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Shpungina E. (2009), Jews in Latvia, Latvia, Latvian Council of Jewish Communities.
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Воронов Б. (2009), По уставу... и без... (семейно-служебная хроника), Латвия, Dobums (Voronov B. (2009), By the Rules, Against the Rules, Latvia, Dobums.)
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Улицкая Л. (2007), Даниэль Штайн, переводчик, Россия, издательство "Эскимо" (Ulitskaya L. (2007), Daniel Stein, Interpreter, Russia, Eskimo Press.)
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Narrative Family Therapy From Wikipedia, the free encyclopedia Narrative Therapy is a form of psychotherapy using narrative. It was initially developed during the 1970s and 1980s, largely by Australian Michael White and his friend and colleague, David Epston, of New Zealand. Their approach became prevalent in North America with the 1990 publication of their book, Narrative Means to Therapeutic Ends, followed by numerous books and articles about previously unmanageable cases of anorexia nervosa, ADHD, schizophrenia, and many other problems. In 2007 White published Maps of Narrative Practice, a presentation of six kinds of key conversations.
Contents
1 Overview 2 Narrative therapy topics o 2.1 Concept o 2.2 Narrative approaches o 2.3 Common elements o 2.4 Method o 2.5 Outsider Witnesses 3 Criticisms of Narrative Therapy 4 See also 5 References 6 External links
Overview The term "narrative therapy" has a specific meaning and is not the same as narrative psychology, or any other therapy that uses stories. Narrative therapy refers to the ideas and practices of Michael White, David Epston, and other practitioners who have built upon this work. The narrative therapist focuses upon narrative and situated concepts in the therapy. The narrative therapist is a collaborator with the client in the process of discovering richer (or "thicker") narratives that emerge from disparate descriptions of experience, thus destabilizing the hold of negative ("thin") narratives upon the client. By conceptualizing a non-essentialized identity, narrative practices separate persons from qualities or attributes that are taken-for-granted essentialisms within modernist and structuralist paradigms. This process of externalization allows people to consider their relationships with problems, thus the narrative motto: “The person is not the problem, the problem is the problem.” So-called strengths or positive attributes are also externalized, allowing people to engage in the construction and performance of preferred identities. Operationally, narrative therapy involves a process of deconstruction and "meaning making" which are achieved through questioning and collaboration with the client. While narrative work is typically located within the field of family therapy, many authors and practitioners report using these ideas and practices in community work, schools and higher education. Although narrative therapists may work somewhat differently (for example, Epston uses letters and other documents with his clients, though this particular practice is not essential to narrative therapy), there are several common elements that might lead one to decide that a therapist is working "narratively" with clients.
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Narrative therapy topics Concept Narrative therapy holds that our identities are shaped by the accounts of our lives found in our stories or narratives. A narrative therapist is interested in helping others fully describe their rich stories and trajectories, modes of living, and possibilities associated with them. At the same time, this therapist is interested in co-investigating a problem's many influences, including on the person himself and on their chief relationships. By focusing on problems' effects on people's lives rather than on problems as inside or part of people, distance is created. This externalization or objectification of a problem makes it easier to investigate and evaluate the problem's influences. Another sort of externalization is likewise possible when people reflect upon and connect with their intentions, values, hopes, and commitments. Once values and hopes have been located in specific life events, they help to “re-author” or “re-story” a person's experience and clearly stand as acts of resistance to problems. The term “narrative” reflects the multi-storied nature of our identities and related meanings. In particular, re-authoring conversations about values and re-membering conversations about key influential people are powerful ways for people to reclaim their lives from problems. In the end, narrative conversations help people clarify for themselves an alternate direction in life to that of the problem, one that comprises a person's values, hopes, and life commitments. Narrative approaches Briefly, narrative approaches hold that identity is chiefly shaped by narratives or stories, whether uniquely personal or culturally general. Identity conclusions and performances that are problematic for individuals or groups signify the dominance of a problem-saturated story. Problem-saturated stories gain their dominance at the expense of preferred, alternative stories that often are located in marginalized discourses. These marginalized knowledges and identity performances are disqualified or invisibilized by discourses that have gained hegemonic prominence through their acceptance as guiding cultural narratives. Examples of these subjugating narratives include capitalism; psychiatry/psychology; patriarchy; heterosexism; and Eurocentricity. Furthermore, binaries such as healthy/unhealthy; normal/abnormal; and functional/dysfunctional ignore both the complexities of peoples’ lived experiences as well as the personal and cultural meanings that may be ascribed to their experiences in context.
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Common elements Common elements in narrative therapy are:
The assumption that narratives or stories shape a person's identity, as when a person assesses a problem in their life for its effects and influences as a "dominant story"; An appreciation for the creation and use of documents, as when a person and a counsellor co-author "A Graduation from the Blues Certificate"; An "externalizing" emphasis, such as by naming a problem so that a person can assess its effects in her life, come to know how it operates or works in her life, relate its earliest history, evaluate it to take a definite position on its presence, and in the end choose their relationship to it. A focus on "unique outcomes" (a term of Erving Goffman) or exceptions to the problem that wouldn't be predicted by the problem's narrative or story itself. A strong awareness of the impact of power relations in therapeutic conversations, with a commitment to checking back with the client about the effects of therapeutic styles in order to mitigate the possible negative effect of invisible assumptions or beliefs held by the therapist. Responding to personal failure conversations
Method In Narrative therapy a person's beliefs, skills, principles, and knowledge in the end help them regain their life from a problem. In practice a narrative therapist helps clients examine, evaluate, and change their relationship to a problem by acting as an “investigative reporter” who is not at the centre of the investigation but is nonetheless influential; that is, this therapist poses questions that help people externalize a problem and then thoroughly investigate it. Intertwined with this problem investigation is the uncovering of unique outcomes or exceptions to its influences, exceptions that lead to rich accounts of key values and hopes—in short, a platform of values and principles that provide support during problem influences and later an alternate direction in life. The narrative therapist, as an investigative reporter, has many options for questions and conversations during a person's effort to regain their life from a problem. These questions might examine how exactly the problem has managed to influence that person's life, including its voice and techniques to make itself stronger. On the other hand, these questions might help restore exceptions to the problem's influences that lead to naming an alternate direction in life. Here the narrative therapist relies on the premise that, though a problem may be prevalent and even severe, it has not yet completely destroyed the person. So, there always remains some space for questions about a person's resilient values and related, nearly forgotten events. To help retrieve these events, the narrative therapist may begin a related re-membering conversation about the people who have contributed new knowledges or skills and the difference that has made to someone and vice-versa for the remembered, influential person. Outsider Witnesses In this particular narrative practice or conversation, outsider witnesses are invited listeners to a consultation. Often they are friends of the consulting person or past clients of the therapist who have their own knowledge and experience of the problem at hand. During the first interview, between therapist and consulting person, the outsider listens without comment. Then the therapist interviews them with the instructions not to critique or evaluate or make a proclamation about what they have just heard, but instead to simply say what phrase or image stood out for them, followed by any resonances between their life struggles and those just witnessed. Lastly, the outsider is asked in what ways they may feel a shift in how they experience themselves from when they first entered the room[8]
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Next, in similar fashion, the therapist turns to the consulting person, who has been listening all the while, and interviews them about what images or phrases stood out in the conversation just heard and what resonances have struck a chord within them. In the end, an outsider witness conversation is often rewarding for witnesses. But for the consulting person the outcomes are remarkable: they learn they are not the only one with this problem, and they acquire new images and knowledge about it and their chosen alternate direction in life. The main aim of the narrative therapy is to engage in people's problems by providing the alternative best solution.
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DEFINITIONS The identified patient The identified patient (IP) is the family member with the symptom that has brought the family into treatment. Children and adolescents are frequently the IP in family therapy. The concept of the IP is used by family therapists to keep the family from scapegoating the IP or using him or her as a way of avoiding problems in the rest of the system. Homeostasis (Balance) Homeostasis means that the family system seeks to maintain its customary organization and functioning over time, and it tends to resist change. The family therapist can use the concept of homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change. The extended family field. The extended family field includes the immediate family and the network of grandparents and other relatives of the family. This concept is used to explain the intergenerational transmission of attitudes, problems, behaviours, and other issues. Children and adolescents often benefit from family therapy that includes the extended family. Differentiation Differentiation refers to the ability of each family member to maintain his or her own sense of self, while remaining emotionally connected to the family. One mark of a healthy family is its capacity to allow members to differentiate, while family members still feel that they are members in good standing of the family. Triangular relationships Family systems theory maintains that emotional relationships in families are usually triangular. Whenever two members in the family system have problems with each other, they will "triangle in" a third member as a way of stabilizing their own relationship. The triangles in a family system usually interlock in a way that maintains family homeostasis. Common family triangles include a child and his or her parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law. Multisystemic Therapy In the early 2000s, a new systems theory, multisystemic therapy (MST), has been applied to family therapy and is practiced most often in a home-based setting for families of children and adolescents with serious emotional disturbances. MST is frequently referred to as a "family-ecological systems approach" because it views the family's ecology, consisting of the various systems with which the family and child interact (for example, home, school, and community). Several clinical studies have shown that MST has improved family relations, decreased adolescent psychiatric symptoms and substance use, increased school attendance, and decreased re-arrest rates for adolescents in trouble with the law. In addition, MST can reduce out-of-home placement of disturbed adolescents. Calibration: Setting of a range limit (bias) in a system, like a thermostat in a room. The limit of how much change a family will tolerate. (Bias: a family's emotional thermostat. The therapist needs to look into who has the power to reset it.)
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Family Life Cycle: Just like an individual, a family has developmental tasks and key (second-order) transitions like leaving home, joining of families through marriage, families with young children (the key milestone, and one that initiates vertical realignment), families with adolescents, launching children and moving on, families in later life. Key question: "How well did the family do on its last assignment?" Horizontal stressors are those involving these transitional assignments; vertical stressors are transmitted mainly via multigenerational triangling. Symptoms tend to occur when horizontal and vertical stressors intersect. Divorce adds extra developmental steps for all involved families. Centrifugal/centripetal: Tendency of family members to move toward or away from a family. Circular (mutual, reciprocal) causality: When things cause each other rather than just one causing the other (linear causality). Emphasizes present, process over past, content. Open/Closed systems: Open: Those that embrace new information and display negentropy (growth). Closed: Those unfriendly to new information; they tend to have a lot of entropy. Cybernetics: Norbert Weiner (1948) used this term to describe systems that self-regulate via feedback loops. Feedback loops: information pathways that help the system balance and correct itself. Can be negative (maintains the current bias and level of functioning) or positive (changes the bias/level of functioning). Double bind (Bateson, Jackson, Haley, Weakland): when the content and process of a message don't line up and you're not allowed to comment on that. No-talk rule: an unwritten family rule against members commenting on certain uncomfortable issues. Three kinds of therapeutic double-binds or paradoxes: prescribing, restraining ("don't change") , and positioning (exaggerate negative interpretations of the situation). Equifinality / Equipotentiality: Equifinality: things with dissimilar origins can wind up in similar places (e.g., an abuse survivor and someone from a healthy family can both grow up to be good parents). Equipotentiality: things with a common origin can go in very different directions of development (e.g., of two abuse survivors, one heals and the other becomes a criminal). First-order / Second-order change: First-order change: change that helps the system accommodate to its current level of functioning. Second-order change: a change that fundamentally impacts the system, thereby taking it to a new level of functioning. Pseudo mutuality: Wynne, Lyman: noticed that many families exhibit pseudo mutuality (fake togetherness).
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Punctuation: “The selective description of a transaction in accordance with a therapist’s goals”. Therefore, it is verbalizing appropriate behaviour when it happens. Rules: Expectations that govern the system on many levels. Can be covert or overt. Good rules maintain stability while allowing some adaptive changes; rigid ones block even modest attempts to adapt. A therapeutic task is to make the covert rules overt.
Criticisms of Narrative Therapy To date, there have been several formal criticisms of Narrative Therapy over what are viewed as its theoretical and methodological inconsistencies, among various other concerns.
Narrative therapy has been criticised as holding to a social constructionist belief that there are no absolute truths, but only socially sanctioned points of view, and that Narrative therapists therefore privilege their client's concerns over and above "dominating" cultural narratives.
Several critics have posed concerns that Narrative Therapy has made gurus of its leaders, particularly in the light that its leading proponents tend to be overly harsh about most other kinds of therapy. Others have criticized Narrative Therapy for failing to acknowledge that the individual Narrative therapist may bring personal opinions and biases into the therapy session.
Narrative therapy is also criticized for the lack of clinical and empirical studies to validate its many claims. Etchison & Kleist (2000) state that Narrative Therapy's focus on qualitative outcomes is not congruent with larger quantitative research and findings which the majority of respected empirical studies employ today. This has led to a lack of research material which can support its claims of efficacy.
See also Theoretical foundations
Constructivist epistemology Feminism Hermeneutics Postmodernism Poststructuralism
Related types of therapy
Family therapy Response based therapy Solution focused brief therapy
Other related concepts
Dialogical self Lucid dream Questioning
Brief therapy
References 1. 2. 3. 4. 5. 6. 7. 8.
White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: WW Norton. White, M. (2007). Maps of narrative practice. NY: W.W. Norton. Dulwich Centre, 1997, 2000 Winslade, John & Monk, Gerald. (2000) Narrative Mediation: A New Approach to Conflict Resolution. San Francisco: Jossey-Bass. ISBN 0-7879-4192-1 (Lewis & Chesire, 1998) (Nylund and Tilsen, 2006). Narrative Means to Therapeutic Ends; Maps of Narrative Practice; White, M. (2000). Reflections on Narrative Practice Adelaide, South Australia: Dulwich Centre Publications White, M. (2005). Narrative practice and exotic lives: Resurrecting diversity in everyday life. Adelaide: Dulwich Centre Publications. pp 15.
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9. Fish, V., Post Structuralism in Family Therapy: Interrogating the Narrative/Conversational Mode. Journal of Family Therapy 19(3) 221-232 (1993) 10. Minuchin, S., Where is the Family in Narrative Family Therapy? Journal of Marital and Family Therapy, 24(4), 397-403 (1998)
We do not tell stories only: we are stories. Storytelling is now emerging as a critical component of Scottsdale family therapy. There are now quite a number of Scottsdale therapists who have gained positive results in their sessions with individuals facing varied family issues. It is essential that we spend some time and understand some important principles that come into play when storytelling is adopted as a major element of the family therapy approach. Storytelling as a major element of family therapy relays ideas and messages holistically. As a result to this, the listeners are able to receive the message in a simple, logical manner and in one single flow. Storytelling is considered as an age-old form of expressing ideas and emotions. This type of communication is the native language which can be used with persons as young as two years of age. On the other hand, the abstract form of communication becomes effective only to individuals who are at least 8 years old. This method of communication allows the family therapist to communicate in a way that allows him to sort out the elements in logical sequence out from a chaotic setting. This approach connects the individual to time and space, and the direction of the sequence of events becomes clearer enabling the therapist to deliver a more sensible idea or message. Family therapists are able to deliver holistic realities once they adopt storytelling as an integral part of the therapy sessions as opposed to abstract method of communication which normally breaks down the message into fragments. Abstract type of communication forces on our perceived time and space and sets its own framework and applies such mental framework to another individual. What happens to such type of therapy is that the person is limited to just two options- accepting or rejecting the idea relayed by the family therapist. With the abstract communication approach, one ends up with a yes-no, all or nothing type of confrontation. By contrast, storytelling comes out as a collaborative encounter which encourages the listener to participate in an arm-in-arm activity with the family therapist. This narrative element of family therapy is more of a rhythmic dance rather than a communication struggle. What makes this narrative approach a truly effective adjunct of the entire family therapy procedure is that it allows the listener create a parallel event in his own consciousness. This increases the possibility of acceptance more than the rejection that we normally experience in the abstract type of communication. Another critical aspect of storytelling has something to do with tacit knowledge. We know more things than we actually believe we have and it is important to acknowledge the importance of tacit knowledge in the overall scheme of things. Finally, abstract type of communication is in general described as dry and dull because individuals struggle to relate it to reality. As living creatures with unique characteristics we are easily attached to things that are animate and reject inert and inanimate things like abstracted concepts. Individuals always consider the experience of storytelling as lively and entertaining. It is one great way we can accept ideas as it is presented explicitly by a competent family therapist. White, Michael: people's lives are organized by their life narratives. We become the stories we tell about our own experience. Replace unhelpful stories with helpful ones. (Article Source: http://EzineArticles.com/2428390)
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Basic Techniques in Family Therapy The area of marriage and family counselling/therapy has exploded over the past decade. Counsellors at all levels are expected to work effectively with couples and families experiencing a wide variety of issues and problems. Structural, strategic, and trans-generational family therapists at times may seem to be operating alike, using similar interventions with a family. Differences might become clear when the therapist explains a certain technique or intervention. Most of today's practicing family therapists go far beyond the limited number of techniques usually associated with a single theory. Bowen therapists believe that understanding how a family system operates is far more important than using a particular technique. They tend to use interventions such as process questions, tracking sequences, teaching, coaching, and directives with a family. They value information about past relationships as a significant context from which they design interventions in the present. The following select techniques have been used in working with couples and families to stimulate change or gain greater information about the family system. Each technique should be judiciously applied and viewed as not a cure, but rather a method to help mobilize the family. The when, where, and how of each intervention always rests with the therapist's professional judgment and personal skills.
OBSERVATION Family units establish equilibriums to protect the family unit, but that equilibrium can cause an imbalance for individual parts of the family. A clinical psychologist is trained to observed the family dynamic and monitor both verbal and non-verbal cues. During the assessment phase and initial interviews, the family systems psychologist will monitor how the parents interact with each other and how their children react to them. He or she will compare his or her observations with testing data offered in both subjective and objective forms. The subjective test data is gathered during the interview while the objective test data is gathered via clinical tests that family members are requested to fill out and return to the psychologist. Observation is an effective family therapy technique because it offers the psychologist the first real window into the family dynamic. Family therapy may be recommended for any number of causes, but for the psychologist to make a fair and accurate assessment, he or she must get a base measurement of the family's interactions, emotional balance and initial dysfunction. During observation, for example, it may be revealed that a mother's depression and need for anti-anxiety medication is due in part to her husband's unemployment and the economic pressure she is overcompensating to fulfill. To create an effective treatment plan for the family, the therapist needs as much data as possible.
IDENTIFICATION Family therapy techniques are used with individuals and families to address the issues that effect the health of the family system. The techniques used will depend on what issues are causing the most problems for a family and on how well the family has learned to handle these issues. Strategic techniques are designed for specific purposes within the treatment process. Background information, family structuring and communication patterns are some of the areas addressed through these methods.
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I/ INFORMATION-GATHERING TECHNIQUES At the start of therapy, information regarding the family's background and relationship dynamics is needed to identify potential issues and problems. GETTING INFORMATION THROUGH USING OPEN-ENDED QUESTIONS. An open-ended question cannot be answered with a simple "yes" or "no", or with a specific piece of information, and gives the person answering the question scope to give the information that seems to them to be appropriate. Open-ended questions are sometimes phrased as a statement which requires a response. Examples of open-ended questions:
Tell me about your relationship with your husband. How do you see your future? Tell me about the children in this photograph. What is the purpose of this rule? Why did you choose that answer?
THE GENOGRAM Is an information gathering technique used to create a family history, or geneology. The genogram reveals the family's basic structure and demographics. The genogram, is a technique that is often used early in family therapy, provides a graphic picture of the family history. As an informational and diagnostic tool, the genogram is developed by the therapist in conjunction with the family.
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Bowen assumes that multigenerational patterns and influences are central in understanding present nuclear family functioning. A family genogram consists of a pictorial layout of each partner's three-generational extended family. It is a tool for both the therapist and family members to understand critical turning points in the family's emotional processes and to note dates of births, deaths, marriages, and divorces. The genogram also includes additional information about essential characteristics of a family: cultural and ethnic origins, religious affiliation, socioeconomic status, type of contact among family members, and proximity of family members. Names, dates of marriage, divorce, death, and other relevant facts are also included. Siblings are presented in genograms horizontally, oldest to youngest, each with more of a relationship to the parents than to one another. Bowen also integrates data related to birth order and family constellation. By providing an evolutionary picture of the nuclear family, a genogram becomes a tool for assessing each partner's degree of fusion to extended families and to each other. THE FAMILY FLOORPLAN By having family members draw up floor plans of their home, they provide information on territorial issues, rules, and comfort zones between different members. The family floor plan technique has several variations. Parents might be asked to draw the family floor plan for the family of origin. Information across generations is therefore gathered in a nonthreatening manner. Points of discussion bring out meaningful issues related to one's past. Another adaptation of this technique is to have members draw the floor plan for their nuclear family. The importance of space and territory is often inferred as a result of the family floor plan. Levels of comfort between family members, space accommodations, and rules are often revealed. Indications of differentiation, operating family triangles, and subsystems often become evident. Used early in therapy, this technique can serve as an excellent diagnostic tool (Coppersmith, 1980). FAMILY PHOTOS Is an information gathering technique which has the potential to provide a wealth of information about past and present functioning and about how each member perceives the others. One use of family photos is to go through the family album together. Verbal and nonverbal responses to pictures and events are often quite revealing. Adaptations of this method include asking members to bring in significant family photos and discuss reasons for bringing them, and locating pictures that represent past generations. Through discussion of photos, the therapist often more clearly sees family relationships, rituals, structure, roles, and communication patterns.
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II/ JOINING This is the process of coupling that occurs between the therapist and the family, leading to the development of therapeutic system. In this process the therapist allies with family members by expressing interest in understanding them as individuals and working with and for them. Joining is considered one of the most important prerequisites to restructuring. It is a contextual process that is continuous. There are four ways of joining in structural family therapy: tracking, mimesis, confirmation of a family member and accomodation. 1) TRACKING: The tracking technique is a recording process where the therapist keeps notes on how situations develop within the family system. Interventions used to address family problems can be designed based on the patterns uncovered by this technique. In tracking, the therapist follows the content of the family that is the facts. Tracking is best exemplified when the therapist gives a family feedback on what he or she has observed or heard. Most family therapists use tracking. Structural family therapists (Minuchin & Fishman, 1981) see tracking as an essential part of the therapist's joining process with the family. During the tracking process the therapist listens intently to family stories and carefully records events and their sequence. Through tracking, the family therapist is able to identify the sequence of events operating in a system to keep it the way it is. What happens between point A and point B or C to create D can be helpful when designing interventions. 2) MIMESIS: The therapist becomes like the family in the manner or content of their communications. 3) CONFIRMATION OF A FAMILY MEMBER: Using an affective word to reflect an expressed or unexpressed feeling of that family member. 4) ACCOMMODATION: The therapist adapts to a family's communication style. He makes personal adjustments in order to achieve a therapeutic alliance.
III/ DIAGNOSING Diagnosing is done early in the therapeutic process. The goal is to describe the systematic interrelationships of all family members to see what needs to be changed or modified for the family to improve. By diagnosing interactions, therapists become proactive, instead of reactive.
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IV/ FAMILY SYSTEM STRATEGIES A family operates like a system in that each member's role contributes to the patterns of behaviour that make the system what it is. Certain therapy techniques are designed to reveal the patterns that make a family function the way it does. ASKING PROCESS QUESTIONS. The most common Bowen technique consists of asking process questions that are designed to get clients to think about the role they play in relating with members of their family. Bowen's style tended to be controlled, somewhat detached, and cerebral. In working with a couple, for example, he expected each partner to talk to him rather than to talk directly to each other in the session. His calm style of questioning was aimed at helping each partner think about particular issues that are problematic with their family of origin. One goal is to resolve the fusion that may exist between the partners and to maximize each person's self-differentiation both from the family of origin and the nuclear family system. A Bowen therapist is more concerned with managing his or her own neutrality than with having the "right" question at the right time. Still, questions that emphasize personal choice are very important. They calm emotional response and invite a rational consideration of alternatives. A therapist attempting to help a woman who has been divorced by her husband may ask:
"Do you want to continue to react to him in ways that keep the conflict going, or would you rather feel more in charge of your life?"
"What other ways could you consider responding if the present way isn't very satisfying to you and is not changing him?"
"Given what has happened recently, how do you want to react when you're with your children and the subject of their father comes up?"
Notice that these process questions are asked of the person as part of a relational unit. This type of questioning is called circular, or is said to have circularity, because the focus of change is in relation to others who are recognized as having an effect on the person's functioning. FAMILY SCULPTING Family sculpting is a technique that's used to realign relationship patterns within the group. Members are asked to physically arrange where they want each member to be in relation to the others. This technique provides insight into relationship conflicts within the family. Family sculpting provides for recreation of the family system, representing family members relationships to one another at a specific period of time. The family therapist can use sculpting at any time in therapy by asking family members to physically arrange the family. Adolescents often make good family sculptors as they are provided with a chance to nonverbally communicate thoughts and feelings about the family. Family sculpting is a sound diagnostic tool and provides the opportunity for future therapeutic interventions. FAMILY CHOREOGRAPHY In family choreography, arrangements go beyond initial sculpting; family members are asked to position themselves as to how they see the family and then to show how they would like the family situation to be. Family members may be asked to re-enact a family scene and possibly re-sculpt it to a preferred scenario. This technique can help a stuck family and create a lively situation.
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V/ INTERVENTION TECHNIQUES Intervention techniques are directives given by the therapist to guide a family's interactions towards more productive outcomes. Reframing is a method used to recast a particular conflict or situation in a less threatening light. A father who constantly pressures his son regarding his grades may be seen as a threatening figure by the son. Reframing this conflict would involve focusing on the father's concern for his son's future and helping the son to "hear" his father's concern instead of constant demands for improvement. Another technique has the therapist placing a particular conflict or situation under the family's control. What this means is, instead of a problem controlling how the family acts, the family controls how the problem is handled. This requires the therapist to give specific directives as to how long members are to discuss the problem, who they discuss it with, and how long these discussions should last. As members carry out these directives, they begin to develop a sense of control over the problem, which helps them to better deal with it effectively. RELATIONSHIP EXPERIMENTS. “Relationship experiments are behavioural tasks assigned to family members by the therapist to first expose and then alter the dysfunctional relationship process in the family system” (Guerin, 2002, p. 140). Most often, these experiments are assigned as homework, and they are commonly designed to reverse pursuerdistancer relationships and/or address the issues related to triangulation. DETRIANGULATION Relationship experiments are incorporated within Guerin’s five-step process for neutralization of symptomatic triangles in which he (1) identifies the triangle, (2) delineates the triangle’s structure and movement, (3) reverses the direction of the movement, (4) exposes the emotional process, and (5) addresses the emotional process to augment family functionality. COACHING. Bowen used coaching with well-motivated family members who had achieved a reasonable degree of selfdifferentiation. To coach is to help people identify triggers to emotional reactivity, look for alternative responses, and anticipate desired outcomes. Coaching is supportive, but is not a rubber-stamp: It seeks to build individual independence, encouraging confidence, courage, and emotional skill in the person. I-POSITIONS. I-positions are clear and concise statements of personal opinion and belief that are offered without emotional reactivity. When stress, tension, and emotional reactions increase, I-positions help individual family members to step-back from the experience and communicate from a more centred, rational, and stabilized position. Bowen therapists model I-positions within sessions when family members become emotionally reactive, and as family members are able to take charge of their emotions, Bowen therapists also coach them in the use of I-statements. DISPLACEMENT STORIES. Displacement stories are usually implemented through the use of film or videotape, although storytelling and fantasized solutions have also been used. The function of a displacement story is to provide a family or family members with an external stimulus (film, video, book or story) that relates to the emotional process and triangulation present in the family, but allows them to be considered in a less defensive or reactive manner. Films, like “I Never Sang For My Father,” “Ordinary People,” or “Avalon” have all been used by Bowen therapists to highlight family interactions and consequences and to suggest resolutions of a more functional nature.
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TAKING SIDE & MEDIATING. In contrast to Bowen's belief in the importance of neutrality, another influential family therapist, Zuk (1981) discusses practical applications of working with triangles in family therapy. Zuk terms his triadic-based technique go-between process because it relies on the therapists "taking and trading roles... of the mediator and side-taker". The mediator is one person mediating between at least two others. The side-taker joins one person in coalition against another. Zuk (1981) outlines three steps involved in the go-between process (p. 38).
In step 1, the therapist works on initiating conflict. In step 2, the therapists moves into the role of the go-between. In step 3, the therapist assumes the role of side-taker.
In all three steps it is important to keep the interactions focused on the present. Past events preclude the therapist's involvement in mediating or side-taking. Because triangles constantly move around, the current permutation might be different from the past. The goal of the therapist is to change the pathogenic relating around into a more productive way of relating. THE EMPTY CHAIR The empty chair technique, most often utilized by Gestalt therapists (Perls, Hefferline, & Goodman, 1985), has been adapted to family therapy. In one scenario, a partner may express his or her feelings to a spouse (empty chair), then play the role of the spouse and carry on a dialogue. Expressions to absent family, parents, and children can be arranged through utilizing this technique. FAMILY COUNCIL MEETINGS Family council meetings are organized to provide specific times for the family to meet and share with one another. The therapist might prescribe council meetings as homework, in which case a time is set and rules are outlined. The council should encompass the entire family, and any absent members would have to abide by decisions. The agenda may include any concerns of the family. Attacking others during this time is not acceptable. Family council meetings help provide structure for the family, encourage full family participation, and facilitate communication. STRATEGIC ALLIANCES This technique, often used by strategic family therapists, involves meeting with one member of the family as a supportive means of helping that person change. Individual change is expected to affect the entire family system. The individual is often asked to behave or respond in a different manner. This technique attempts to disrupt a circular system or behaviour pattern. PRESCRIBING INDECISION The stress level of couples and families often is exacerbated by a faulty decision-making process. Decisions not made in these cases become problematic in themselves. When straightforward interventions fail, paradoxical interventions often can produce change or relieve symptoms of stress. Such is the case with prescribing indecision. The indecisive behaviour is reframed as an example of caring or taking appropriate time on important matters affecting the family. A directive is given to not rush into anything or make hasty decisions. The couple is to follow this directive to the letter. PUTTING THE CLIENT IN CONTROL OF THE SYMPTOM This technique, widely used by strategic family therapists, attempts to place control in the hands of the individual or system. The therapist may recommend, for example, the continuation of a symptom such as anxiety or worry. Specific directives are given as to when, where, and with whom, and for what amount of time one should do these things. As the client follows this paradoxical directive, a sense of control over the symptom often develops, resulting in subsequent change.
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SPECIAL DAYS, MINI-VACATIONS, SPECIAL OUTINGS Couples and families that are stuck frequently exhibit predictable behaviour cycles. Boredom is present, and family members take little time with each other. In such cases, family members feel unappreciated and taken for granted. "Caring Days" can be set aside when couples are asked to show caring for each other. Specific times for caring can be arranged with certain actions in mind (Stuart, 1980). PROBLEM SOLVING Problem solving is an effective therapy technique not because it teaches the family how to resolve the issue that brought them to see the family systems psychologist, but it teaches them how to identify, develop plans and create resolutions for future problems. Problem solving may seem like a common sense resolution, but it requires a willingness on the parts of all parties to contribute to the solution. Problem solving is a family therapy technique that requires effective communication and often comes later in therapy sessions as the therapist challenges family members to role-play situations previously deemed irresolvable. Family members may also be required to play the part of other family members, parents playing the part of the children or dad taking on the role of mom to a child's dad and a mom's child. By actively role playing other members of the family, each member is required to see that person's point of view. This leads to learning how to disagree in positive and respectful manner and to not allow those disagreements to impede problem solving efforts. FAMILY CONTRACTS The family contract is a therapeutic tool that allows families to negotiate terms and come to an agreement on how they want to handle future family problems and to commit to positive change. A family contract, for example, may detail that a child who copes with an eating disorder commits to talking about her feelings on weight, eating and social perception. Her parents will then commit to listening and not dismissing her feelings. All parties commit to working together to build self-esteem and a healthy lifestyle. Family contracts are a positive tool in the arsenal of a family systems psychologist because they are facilitated agreement that a family makes to avoid future dysfunction. The family contract also helps family members recognize when problems are occurring, particularly if elements of the contract are not being upheld. Effective family therapy techniques treat the entire family as an emotional unit of which each family member is a part of and acknowledges that what affects one member of the family affects the whole family. By treating the whole family as a unit, the family also becomes a part of the solution. REFRAMING Technique used to create a different perception of reality. Reframing is a process in which a perception is changed by explaining a situation in terms of a different context. For example, the therapist can reframe a disruptive behaviour as being naughty instead of incorrigible allowing family members to modify their attitudes toward the individual and even help him or her makes changes. Most family therapists use reframing as a method to both join with the family and offer a different perspective on presenting problems. Specifically, reframing involves taking something out of its logical class and placing it in another category (Sherman & Fredman, 1986). For example, a mother's repeated questioning of her daughter's behaviour after a date can be seen as genuine caring and concern rather than that of a non trusting parent. Through reframing, a negative often can be reframed into a positive. Reframing is altering the meaning or value of something, by altering its context or description Reframing is a powerful change stratagem. It changes our perceptions, and this may then affect our actions. But does changing our symbolic representation of the real world actually change anything in the real world itself? Kolb describes the four basic creative dimensions as Meaning, Value, Relevance and Fact. This is summarized in the diagram above. In these terms, reframing is altering Meaning, Value, Relevance or Fact by altering context or perspective.
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Bandler & Grinder (NLP) identify two forms of reframing: meaning and context. Context reframing takes an undesired attribute and finds a different situation where it would be valuable. In meaning reframing, you take an undesired attribute and find a description where the attribute takes on a positive value. Reframing - Virginia Satir A classic example of a reframe by Virginia Satir concerns a father who complains at the stubbornness of his daughter. This results in a double reframe, in which Satir points out two things to the father: 1. There are situations where she will need stubbornness, to protect herself or achieve something. Reframing switches to a context that makes the stubbornness relevant. 2. It is from the father himself that she has learned to be stubborn. By forcing the father to equate his own stubbornness with hers, this creates a context in which he either has to recognize the value of her stubbornness, or deny the value of his own. Reframing - Milton Erikson One of the common challenges of family therapy is to help the parents to let their children go. Independence is of course a negative goal. The parents have to gradually stop supporting their children, and the children have to gradually stop relying on their parents. Milton Erikson often used the approach of creating an alternative goal for the parents: of preparing themselves to be grandparents. In a typical case, a young woman consulted him; her parents had used their life savings to build an extension to their house, where she was to live, when she got married (At this time, she was away at college, and had no steady boyfriend.) Erikson met the parents, and congratulated them for their willingness to participate so actively in the rearing of their (hypothetical) grandchildren, having babies crying through the night, toddlers crawling through the living rooms, toys strewn across the house, babysitting. He thus created a powerful positive image of the joys of grandparenthood; yet for some reason, the couple decided to rent the extra rooms out to mature lodgers instead, and save the money to support their grandchildren’s education. When the daughter subsequently got married, she lived in a city some distance away with husband and baby, and the grandparents visited frequently, but not too frequently. http://www.blackwellreference.com/public/tocnode?id=g9780631170488_chunk_g978063117048821_ss19 PUNCTUATION Technique used to create a different perception of reality. Punctuation is “the selective description of a transaction in accordance with a therapist’s goals”. Therefore it is verbalizing appropriate behaviour when it happens.
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UNBALANCING Technique used to create a different perception of reality. This is a procedure wherein the therapist supports an individual or subsystem against the rest of the family. When this technique is used to support an underdog in the family system, a chance for change within the total hierarchical relationship is fostered. RESTRUCTURING Technique used to create a different sequence of events. The procedure of restructuring is at the heart of the structural approach. The goal is to make the family more functional by altering the existing hierarchy and interaction patterns so that problems are not maintained. It is accomplished through the use of enactment, unbalancing, and boundary formation. ENACTMENT Technique used to create a different sequence of events. The process of enactment consists of families bringing problematic behavioural sequences into treatment by showing them to the therapist a demonstrative transaction. This method is to help family members to gain control over behaviours they insist are beyond their control. The result is that family members experience their own transactions with heightened awareness. In examining their roles, members often adapt new, more functional ways of acting. BOUNDARY FORMATION Technique used to create a different sequence of events. Part of the therapeutic task is to help the family define, or change the boundaries within the family. The therapist also helps the family to either strengthen or loosen boundaries, depending upon the family’s situation. WORKING WITH SPONTANEOUS INTERACTION In addition to enactment, structural family therapists concentrate on spontaneous behaviours in sessions. It occurs whenever families display behaviours in sessions that are disruptive or dysfunctional, such as members yelling at one another or parents withdrawing from their children. The focus is on process not content. It is important that therapists help families recognize patterns of interaction and what changes they might make to bring about modification. INTENSITY Intensity is the structural method of changing maladaptive transactions by using strong affect, repeated intervention, or prolonged pressure. Intensity works best if done in a direct, unapologetic manner that is goal specific. SHAPING COMPETENCE The family therapists help families and individuals in becoming more functional by highlighting positive behaviours. ADDING COGNITIVE CONSTRUCTIONS Advice & Information are derived from experience and knowledge of the family in therapy. They are used to calm down anxious members of families or reassure these individuals and families about certain actions. Pragmatic fictions are formal expressions of opinion to help families and their members change. Paradox is an apparently sound argument leading to a contradiction. It is used to motivate family members to search or alternatives. Family members may defy the therapists and become better or they may explore reasons why their behaviours are as they are and make changes in the ways members interact. Also used to tell the family what to do with the expectation of noncompliance.
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VI/ COMMUNICATION SKILL BUILDING TECHNIQUES More often than not, it's a family's communication patterns and styles that lead to conflict and division. Communication techniques are used to build skills that allow for effective communication between family members. Some of these methods include reflecting, repeating, fair fighting and nonjudgmental brainstorming. REFLECTING Reflecting is a listening technique which involves having a member express her feelings and concerns, then having another member repeat back what he heard that person say. REPEATING Repeating is also a listening technique. It involves having a member state how he feels, while another member repeats back what was said. Repeating and reflecting techniques allow members to better understand where the other is coming from and why she feels as she does. FAIR FIGHTING Fair fighting techniques focus on attentive listening and expressing feelings and concerns in a nonthreatening manner. TAKING TURNS EXPRESSING FEELINGS taking turns expressing feelings NONJUDGMENTAL BRAINSTORMING nonjudgmental brainstorming
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EFFECTIVE COMMUNICATION If each member of the family is interdependent on other members of the family it stands to reason that dysfunction with one will affect the whole. Effective communication is an important lesson that family systems psychologist incorporate into group and individual family therapy sessions. To create an effective solution to any dysfunction or problem in the group dynamic requires effective communication so that all members of the group or family are in touch with each other. For example, the mother who commits to more and more tasks in order to compensate for her family's overextending commitments may stretch herself to the limits because she lacks the ability to communicate how stretched thin she is. Instead, she promises to do more and more, exerting increasing emotional and mental stress upon herself when she cannot meet all the commitments she is making. This leads to disappointment and disagreement in the family. When other members of the family express their disappointment, this impacts her already damaged sense of self-worth leading to a vicious cycle that may result in depression, generalized anxiety disorder, substance abuse and more. In every way, however, the family is not happy. Therapists teach effective communication skills and the importance for mom to let the family know she is overextended and that she either needs help or they need to rearrange priorities in order to break out of the circular causality of this family's problems. Effective communication allows a family to dialogue on their problems, concerns and feelings without lashing out or feeling obligated to resolve the problems being shared. A large portion of effective communication resides in active listening, a skill that must be learned. Communication patterns and processes are often major factors in preventing healthy family functioning. Faulty communication methods and systems are readily observed within one or two family sessions. The family therapist constantly looks for faulty communication patterns that can disrupt the system.
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Problem - Centered Systems Family Therapy Stages and Steps of Therapy Assessment Orientation Data gathering Problem descriptions Clarification and agreement on a problem list
Contracting Orientation Outlining options Negotiating expectations Contract signing
Treatment Orientation Clarifying priorities Setting tasks Task evaluation
Closure Orientation Summary of treatment Long term goals Follow up (optional)
3. Problem List Family's list Doctor adds his
4. Problem Clarification Obtain agreement on list from above
A Guideline for Family Assessment Areas Covered 1. Orientation Their expectations Our expectations Rationale for seeing the family
2. Data Gathering a. Presenting Problem (for each problem) Nature and history of problem Affective/emotional components Precipitating events Who is involved and how b. General Family Functioning: McMaster model dimensions Problem solving Roles Communication Affective involvement Affective responsiveness Behavior control c. Other Investigationsbiopsy chosocial: medical d. Any other problems?
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Stages of Family Therapy Stage 1: Making Contact � �Reach out to every family member and affirm each one’s individual worth �� Establish trust with and gain acceptance of the family � �Ask questions and observe family process and dynamics � �Offer hypotheses based on therapist observations (in a nonjudgmental manner) and check out observations with the family �� Create an aura of hope and encourage positive energy within the family � �Create a readiness for change � �Develop an assessment plan early to gain the confidence of the family � �Make an informal working contract (agreement) with the family Stage 2: Disturbing the Status Quo �� Develop awareness of communication roles and patterns through experience � �Create new understanding in family members through new or increased awareness � �Disturb the status quo and challenge the family’s homeostasis � �Move the family to reveal protected or defended areas Stage 3: Integration of New Skills � �Re-create an aura of hope and a willingness to do things in a different or new way � �Have family members express and apply these new understandings through experiences within the session �� Have family members use the new behaviors outside the therapy session � �Help the family understand what happened in the “chaos stage” for enhanced learning
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Summary of Dimension Concepts Problem-solving Two types of problems instrumental and affective Seven stages to the process 1. Identification of the problem 2. Communication of the problem to the appropriate person(s) 3. Development of action alternatives 4. Decision of one alternative 5. Action 6. Monitoring the action 7. Evaluation of success Postulated Most effective when all seven stages are carried out. Least effective when cannot identify problem (stop before step 1) Communication Instrumental and affective areas Two independent dimensions 1. Clear and Direct 2. Clear and Indirect 3. Masked and Direct 4. Masked and Indirect Postulated Most effective: clear and direct. - Least effective: masked and indirect Roles Two family function types -necessary and other Two areas of family functions -instrumental and affective
1. Provision of Resources B. Affective 1. Nurturance and Support 2. Adult Sexual Gratification C. Mixed 1. Life Skills Development 2. Systems Maintenance and management Other family functions: -adaptive and maladaptive Role functioning is assessed by considering how the family allocates responsibilities and handles accountability for them. Postulated Most effective when all necessary family functions have clear allocation to reasonable individuals(s), and accountability built in. Least effective when necessary family functions are not addressed and/or allocation and accountability not maintained. Affective Responsiveness Two groupings -welfare emotions and emergency emotions Postulated Most effective when full range of responses are appropriate in amount and quality to stimulus. - Least effective when very narrow range (one or two affects only) and/or amount and quality is distorted, given the context
1. Absence of involvement 2. Involvement devoid of feelings 3. Narcissistic involvement 4. Empathic involvement 5. Over-involvement 6. Symbiotic involvement Postulated Most effective: empathic involvement. - Least effective: -symbiotic and absence of involvement Behavior Control Applies to three situations 1. Dangerous situations 2. Meeting and expressing psychobiological needs and drives (eating, drinking, sleeping, eliminating, sex and aggression) 3. Interpersonal socializing behaviour inside and outside the family Standard and latitude of acceptable behavior determined by four styles 1. Rigid 2. Flexible 3. Laissez-faire 4. Chaotic To maintain the style, various techniques are used and implemented under role functions (systems maintenance and management) Postulated Most effective: flexible behavior control. Least effective: chaotic behaviour control
Necessary family function groupings A. Instrumental
Affective Involvement Six styles identified
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Structure of a Family Therapy Session (From an eHow Contributor ) Family communication is an evolving and complicated issue for most families. Sometimes a family therapy session is the only place where each family member can have a voice. As children grow and marriages evolve, the lack of communication within a family may cause issues, anger and sadness in some family members. Family therapy sessions help with issues like divorce, financial problems, grief, depression, stress and substance abuse. As a counsellor, you will need to have all voices heard to find out what issues or problems each of the family members bring to the family dynamic.
Instructions 1. Research and Background o
1 Ask the family member who initiated the family session why he feels the family needs the therapy.This will give you his perspective on the situation and on what is happening to the family.
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2 Find out which family members are involved, and invite them to the sessions. Let each family member know that the therapy will not be effective if anyone misses a session. It is best to reschedule if one family member cannot make it to a session.
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3 Conduct an individual and private session with each family member before commencing the family session.
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4 Ask all family members why they think they need a family session. Inquire if they have any issues with the family or any individual members of the family.
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5 Take notes on each session. Make sure you write down each family member's thoughts and concerns for future reference.
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6 Recommend individual counseling for those members who have problems stemming from trauma or childhood problems. They will continue to bring their issues to the family dynamic, so it is critical to resolve their issues to help the family unite.
2. Family Session o
1 Review your notes from each session you had with individual family members. This will refresh your memory and let you understand more background information before you conduct your family session.
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2 Set rules for the family therapy session. Ask members to contribute to how the session will be conducted. Some members may insist on having one person at a time speak, or perhaps there may be a time limit set for each person. Let each person contribute.
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3 Begin by asking each member what kind of family dynamic they prefer. You can ask them if they prefer a family that is close, laughs a great deal and takes fun-filled family vacations without drama.
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4 Ensure that each member is allowed to speak without interruption. You will be acting as a mediator on how the session is conducted. You will also be enforcing the rules the family has set in advance.
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5 Start to resolve each individual issue that the family has brought up. Give each family member an opportunity to provide a solution.
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6 Apply values and standards to the solutions to the family issue that fit within that family's value system. Devise a followup to find how the solutions are working, and invite individual family members to contact you to ask questions.
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7 Meet with individual family members to see if the resolution is what they expected. Inquire if they feel problems are resolving. Some issues may be based from family disputes; others may stem from trauma or childhood problems.
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Read more: How to Conduct a Family Therapy Session | eHow.com http://www.ehow.com/how_4912419_conduct-family-therapy-session.html#ixzz1J7TX2G6W
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Structure of Family Therapy Outline by Patty Salehpur
A. Assumptions 1. Family are individuals who effect each other in powerful but unpredicatable ways 2. The consistent repetitive organized and predictable patterns of family behavior are important 3. The emotional boundaries and coalitions are important
B. Salvador Minuchin 1. Always concerned with social issues 2. Developed a theory of family structure and guidelines to organize therapeutic techniques 3. 1970 headed Philadelphia Child Guidance Clinic where family therapists have been trained in structural family therapy ever since 4. Born in Argentina , served in the Israel army as a physician, in the USA trained in child psychiatry and psychoanalysis with Nathan Ackerman, worked in Israel with displaced children, also worked in the USA with Don Jackson with middle class families. 5. Fist generation of family structural therapists: Braulio Montalvo, Jay Haley, Bernie Rosman, Harry Aponte, Carter Umbarger, Marianne Fishman, Cloe Madanes, and Stephen Greenstein.
C. Theoretical formulations - three essential constructs 1. Structure — the organized pattern in which family members interact, predictable sequences of family interaction, patterns of interaction. Structure involves a series of covert rules. There are universal and idiosyncratic constraints. Families may not be able to tell you the family structure, but they will show it to you in their interactions. 2. Subsystems — Families are differentiated into subsystems of members who join together to perform various functions. Each person is a member of one or more subsystems in the family. Some groupings are obvious and based on such factors as generation, gender, age or common interests. Other coalitions may be subtle. Every member may play many roles in various subgroups. 3. Boundaries are invisible barriers that regulate the amount and nature of contact with members. They range from rigid to diffuse, clear to unclear, disengaged to enmeshed
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D. Normal family development 1. Marriage begins with accommodation and boundary making 2. Couples are influenced by the structure of their families of origin 3. Couples also form boundaries with their families of origin 4. The advent of children requires that the structure of the family change
E. The development of behaviour disorders 1. Family dysfunction results from stress and failure to realign the structure to cope with it. 2. Disengaged families have rigid boundaries and excessive emotional distance. They fail to mobilize to deal with the stress. 3. Enmeshed families have diffuse boundaries and family members overreact emotionally and become intrusively involved with one another. These actions hinder mature actions to resolve stress. 4. Subsystems in the family may be disengaged or enmeshed. 5. Power hierarchies may develop which may be weak and ineffective or rigid and arbitrary. 6. Conflict avoidance prevents effective problem solving. 7. Generational coalitions may also prevent effective problem solving. 8. Family structure may fail to adjust to family developmental processes. 9. A major change in family composition demands structural adaptation. 10. Symptoms in one family member may reflect dysfunctional structural relationships or simply individual problems.
F. Goals of therapy 1. Changing family structure - altering boundaries and realigning subsystems 2. Symptomatic change - growth of the individual while preserving the mutual support of the family 3. Short-range goals may be developed to alleviate symptoms especially in life threatening disorders such as anorexia nervosa, but for long-lasting effective functioning the structure must change. Behavioral techniques fit into these short-term strategies.
G. Techniques — join, map, transform structure 1. Joining and accommodating, then taking a position of leadership a. Listen to "I" statements 2. Enactment for understanding and change 3. Working with interaction and mapping the underlying structure a. Looking at the power hierarchies b. Using enactment to understand and clarify c. Looking at the boundary structures 4. Diagnosing a. individual vs. subgroup b. structural diagnosis 5. Highlighting and modifying interpersonal interactions is essential
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a. Control intensity by the regulation of affect, repetition and duration b. Don’t dilute the intensity through overqualifying, apologizing or rambling c. Shape competence, e.g. "It’s too noisy in here. Would you quiet the kids." 6. Boundary making and boundary strengthening a. Seating b. Seeing subgroups or individuals to foster boundaries and indivduation c. Clarify circular causation 7. Unbalancing may be necessary a. Taking sides b. Challenging c. Directives 8. Challenging the family’s assumptions may be necessary a. Teaching may be necessary b. Pragmatic fictions c. Paradoxes d. Therapist sometimes must challenge the way family members perceive reality, changing the way family member relate to each other offers alternative views of reality. 9. Therapists must create techniques to fit each unique family
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Systemic Family Therapy Manual Ms. Helen Pote Dr. Peter Stratton Prof. David Cottrell Ms. Paula Boston Prof. David Shapiro Ms Helga Hanks
Leeds Family Therapy & Research Centre School of Psychology University of Leeds Leeds, LS2 9JT
This manual was developed through an MRC Small Project Grant, Number G9700249
No part of this document should be reprinted without the permission of the authors.
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INDEX 1. Introduction 1.1 Origins of the Manual 1.2 Aims and applicability of the manual 1.3 Notes on use of manual 1.4 Ethical and Culturally Sensitive Practice 1.5Clinical Examples 2. Guiding Principles
186 186 186 187 188 188 189
2.1 Systems Focus 2.2 Circularity 2.3 Connections and Patterns 2.4 Narratives and Language 2.5 Constructivism 2.6 Social Constructionism 2.7 Cultural Context 2.8 Power 2.9 Co-constructed therapy 2.10 Self-Reflexivity 2.11 Strengths and Solutions
189 189 189 190 190 190 190 190 191 191 191
3. Outline of Therapeutic Change
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3.1 Models of Therapeutic Change 3.2 Overview of Specific Goals 4. Outline of Therapist Interventions 4.1 Linear Questioning 4.2 Circular Questions 4.3 Statements 4.4 Reflecting Teams 4.5 Child Centred Interventions 5. Therapeutic Setting 5.1 Convening Sessions 5.2 Team 5.3 Video 5.4 Pre-therapy Preparation 5.5 Pre and Post Session Preparation 5.6 Correspondence 5.7 Case Notes
192 193 194 194 194 195 196 198 199 199 199 200 200 201 202 202
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5.8 Session Notes 6. Initial sessions
202 203
6.1 Outline Therapy Boundaries & Structure 6.2 Engage and Involve all family members 6.3 Gather and Clarify Information 6.4 Establish Goals and Objectives of Therapy
203 204 205 205
� Initial Session Checklist for Therapists
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7. Middle sessions
207
7.1 Develop engagement 7.2 Gather Information and Focus Discussion 7.3 Identify & Explore Beliefs 7.4 Work towards change at the level of behaviours and beliefs 7.5 Return to Objectives and Goals of Therapy
207 207 208 208 208
� Middle Sessions Checklist for Therapists
208
8. End sessions
209
8.1 Gather Information and Focus Discussion 8.2 Continue to work towards change at the level of behaviours and beliefs 8.3 Develop family understanding about behaviours and beliefs 8.4 Collaborative ending decisions 8.5 Review the process of therapy
209 210 210 211 212
� End Session Checklist for Therapists
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9. Indirect Work 9.1 Child Protection 9.2 Clarifying therapy with referrer present 9.3 Identifying network and clarifying relationships 9.4 Assessing risk 9.5 Correspondence
10. Proscribed Practices 10.1 10.2 10.3 10.4 10.5 10.6
Advice Interpretation Un-transparent/Closed Practice Therapist monologues Consistently siding with one person Working in the transference
214 214 214 214 215 215
216 216 216 216 216 216 217
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10.7 Inattention to use of language 10.8 Reflections 10.9 Polarised position 10.10 Sticking in one time frame 10.11 Agreeing / not challenging ideas 10.12 Ignoring information that contradicts hypothesis 10.13 Dismissing ideas 10.14 Inappropriate affect 10.15 Ignoring family affect 10.16 Ignoring difference
217 217 217 217 217 217 218 218 218 218
Appendixes Appendix 1: Sample Appointment Letter Appendix II: Sample Video Consent Form Appendix III: Sample Referrer letter Appendix IV: Post-assessment letter to referrer Appendix V: Closing letter to referrer
219 220 221 222 223
Illustrations Figure 1: Models of Therapeutic Change
Tables Table 1: Perceptions that are helpful in achieving change
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1. Introduction 1.1 Origins of the Manual The manual was developed through a research project funded by the Medical Research Council. The team developing the manual comprised of a group of experienced family therapists working at Leeds Family Therapy & Research Centre (LFTRC). LFTRC is a centre working systemically with individuals, couples and families across the age span, as well as with professional systems. The therapists contributing to this manual have historically been influenced by Milan Systemic family therapy models, and would now describe their practice as being influenced by Post-Milan and Narrative Models. 1.2 Aims and applicability of the manual The manual is principally designed as a research tool for outcome studies in which the effectiveness of systemic therapy can be assessed. It therefore aims to offer a framework and guidelines for the implementation of systemic family therapy, so that therapists can offer a unified version of therapy, with some flexibility to express their own creativity. For this purpose the manual should be used in conjunction with the accompanying adherence protocol. This is designed to assess the degree to which therapists are able to adhere to the methods outlined throughout the manual. For research purposes the manual is designed for use by trained family therapists or other trained therapists with experience in family therapy. The manual’s function is to guide therapeutic work with families in a clinic setting. Therapists using the manual will be expected to be working as part of a systemic family therapy team. Details on the composition of therapy teams are outlined later. Section 5.2 The manual can also be used less formally as a framework for training and supervision, in developing skills for trainee family therapists. 1.3 Notes on use of manual As with any interpersonally focused therapy, systemic family therapy does not follow a rigidly prescribed treatment sequence (Lambert & Ogles 1988). In using the manual therapists should consider the following guidelines:
Therapists should first become familiar with the guiding principles which will influence all aspects of the therapy that they carry out using this manual. They should consider the guiding principles which are influencing them currently and the connections they make between these principles. Section 2.
They should then consider the section concerning models of change, and consider the model of change that is influencing their own therapeutic practice. Section 3.
After these more theoretical aspects have been addressed, the therapist should begin to consider the general interventions used, thinking carefully about the descriptions of these interventions, and how they may translate into their own practice. Section 4.
The manual then turns to guidelines for convening sessions, and setting up the therapy itself. Therapists should therefore begin to follow the guidelines of the manual from the moment they take referrals, in order to consider systemic issues in convening therapy. Section 5.
Therapists should then use the manual to more specifically guide therapy sessions, reading the practical guidelines outlined for the beginning middle and end of therapy, and following the goals defined for each of these stages. Therapists’ checklists are provided at the end of each of these sections to help therapists consider whether they have covered all aspects of the guidelines.
Therapists should go on to consider the aspects of indirect work that support the family therapy which
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should still be managed following the systemic guiding principles. Section 9. Finally, therapists should consider the proscribed practices which should not form a significant proportion of their work, and refer back to these during the course of therapy to ensure proscribed practices do not emerge during the course of therapy. Section 10.
This manual has an accompanying questionnaire for therapists and an adherence protocol to assess the degree to which therapist practice reflects that of the manual. This may be used as a personal check for therapists or trainers using the manual, or more formally by an independent researcher to assess adherence when the manual is being used as a research tool. 1.4 Ethical & Culturally Sensitive Practice In using this manual therapists should pay keen attention to ensuring their practice is both ethical and culturally sensitive. Their practice should comply with the Association for Family Therapy and Systemic Practice (AFT): Code of Conduct and Ethical Guidelines. Therapists should remain curious and open minded in working with families, and this may be especially important where the individuals/families are of a different gender, cultural or societal background to that of the therapist. Care should be taken in the assumptions and agendas therapists develop during therapy in this regard. 1.5 Clinical Examples All of the clinical material used in this manual has been adapted from extracts of therapy undertaken at Leeds Family Therapy & Research Centre. Identifying details have been removed from the material, and the dialogue modified to protect confidentiality. We would like to thank all of the families and therapists who have given permission for the therapy they undertook to be used for research. Without this permission the research project to develop this manual would not have been possible.
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2. Guiding Principles These principles are based at the level of theory, and should be used to guide therapists’ practice whilst using this manual in work with families. Therapists should be familiar with all of the principles though they may privilege different principles according to their current interests and the needs of the family with which they are working. The therapist should consider the principles flexibly and decide which might best fit with the issues with which the family are struggling and the therapists own current constructions. The principle of self-reflexivity may be particular helpful in enabling the therapist to reach this. Section 2.10 In devising this manual therapists considered their own constructions of how these principles might connect. Therapists should consider for themselves the connections they are currently making between these principles and the effect this may have on their work with families. 2.1 Systems Focus In working systemically the central focus should be upon the system rather than the individual, particularly in relation to the difficulties and issues that the family system brings to therapy. The system may be A consistent view is that these difficulties do not arise within individuals but in the relationships, interactions and language that develop between individuals. 2.2 Circularity Patterns of behaviour develop within systems, which are repetitive and circular in nature and also constantly evolving. Behaviour and beliefs that are perceived as difficulties will also therefore develop in a circular fashion, being affected by and affecting all members of the system. 2.3 Connections and Patterns In understanding relationships and difficulties within systems it will be important for the therapist to consider the connections between circular patterns of behaviour, and the connections between the beliefs and behaviours within systems. The process of therapy should enable family members to consider these connections from new and/or different perspectives. 2.4 Narratives and Language Behaviours and beliefs form the basis of stories or narratives, which are constructed by, around, and between individuals and the system itself. The language that is used to describe these narratives and the interactions between individuals constructs the reality of their everyday lives. The stories that people live often match the stories that are told about individuals, but at times when stories lived and stories told are incongruous change may occur, at the levels of lived behaviours and/or the construction of new narratives. 2.5 Constructivism This is the idea that people form autonomous meaning systems and will interpret and make sense of information from this frame of reference. In social interactions understanding is constrained and affected by this meaning system, and people cannot make assumptions about what meaning will be attributed to the information they offer/contribute to others. Thus there is only the possibility of perturbing other people’s meaning systems. 2.6 Social Constructionism In working with systems in the process of change at the level of behaviour or narratives, it will be important to consider ideas of social constructionism. Relevant is the idea that meaning is created in the social interactions that take place between people and is thus context dependent and constantly changing, this takes precedence over the concept of a single external reality. 2.7 Cultural Context The therapist should consider the importance of context, in relation to the cultural meanings and narratives within which people live their lives, including issues of race, gender, disability and class etc. The relationship between these narratives, the therapeutic relationship and its context, as well as the wider context for the therapeutic team and the family should be an important consideration at the point of referral and throughout the therapy.
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2.8 Power The therapist should take a reflexive stance in relation to the power differentials that exist within the therapeutic relationship, and within the family relationships. 2.9 Co-constructed therapy In therapeutic interactions reality is co-constructed between the therapist (and team) and the people with whom they meet. They form part of the same system, and share responsibility for change and the process of therapy. Particular attention should thus be paid to the contributions that all members of the therapeutic system make in the process of change. 2.10 Self-Reflexivity The therapist should aim to apply systemic thinking to themselves and thus reject any thinking about families and their processes that does not also apply to therapists and therapy. Self-reflexivity focuses especially on the effect of the therapy process on the therapist and the way that this is a source of (resource for) change in the family. In order to use self-reflexivity it will be necessary for the therapist to be alert to their own constructions, functioning and prejudices so that they can use their self effectively with the family. 2.11 Strengths and Solutions The therapist should take a non-pathologising, positive view of the family system, and the current difficulties they are struggling with. A family system that enters the therapeutic system should be considered as a system that owns a wealth of strengths and solutions in the face of difficult situations. It is important for the therapist to recognise that there is a multi-versa of possibilities available for each family in the process of change, and the family themselves will be in the best position to generate suitable solutions. The therapist can facilitate this process by attending to the strengths and solutions in the stories that the family system brings to therapy.
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3. Outline of Therapeutic Change 3.1 Models of Therapeutic Change In systemic work many different models of change have been hypothesised. In using this manual therapists should consider the model of change outlined in Figure 1. Figure 1. Model of Therapeutic Change
Cybernetics
Narratives
Redundant patterns / beliefs
Meaning through Langauge
Understand patterns / beliefs / stories
Develop different patterns / beliefs / stories Amplify change Therapists are working with families to understand the patterns of behaviour, beliefs or stories that have developed in family systems, and the wider context in which they live. Through the process of understanding these behaviour patterns, beliefs or stories, therapists will begin to introduce new or different information. Therapists may also use active strategies to introduce this new information. The information will affect the development of behavioural patterns, beliefs and stories and the influence they have on the family. It therefore helps the family to develop new perceptions or actions that they can use to tackle the difficulties with which they are struggling. New perceptions that are often helpful to families in achieving change, are outlined in Table 1. Once change is beginning to occur, therapists highlight this process to families, enabling them to develop further changes and develop their understanding of how change was possible. This will develop the family’s resources in coping with future struggles. It will be important for therapists to consider the model of change with which they are currently working and consider what aspects of this model of change they are currently privileging. What is their overall aim during the process of therapy?
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Table 1: Perceptions that are helpful in achieving change Initial Perception of Struggles
Developing Perception of Struggles
Located in the individual
Arising from the system
Uncontrollable/Unchangeable
Temporary
Intrinsic
Accidental
Blameworthy
Redundant
Sinister
Well meaning but mistaken
Linear
Circular
Partisan
Neutral
3.2 Overview of Specific Goals Within each stage of therapy there are also specific goals that the therapist should be considering. The goals are listed here and elaborated within sections 6, 7 & 8. Goals during initial session 1. 2. 3. 4.
Outline Therapy Boundaries & Structure Engage and Involve all family members Gather and Clarify Information Establish Goals and Objectives of Therapy
Goals during middle sessions 1. 2. 3. 4. 5.
Develop and Monitor Engagement Gather Information and Focus Discussion Identify & Explore Beliefs Work towards change at the level of beliefs and behaviours Return to Objectives and Goals of Therapy
Goals during ending sessions 1. 2. 3. 4. 5.
Gather Information and Focus Discussion Continue to work towards change at the level of behaviours and beliefs Develop family understanding about behaviours and beliefs Secure Collaborative Decision re: Ending Review the process of therapy
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4. Outline of Therapist Interventions Therapists have a range of interventions open to them in working with the family to co-create change. The 4 interventions listed below are those which are most commonly used in systemic family therapy and should be used in therapist’s practice throughout the course of therapy. The degree to which each of these interventions will be used will vary throughout the course of therapy, and therapists’ should follow the guidelines below regarding this. Additional interventions that are used less frequently are highlighted in the appropriate stage of therapy. Sections 6, 7, & 8. 4.1 Linear Questioning Direct linear questions can often be useful in gathering information from the system and clarifying information given, especially at the beginning of therapy. Linear questions can be built up in a circular manner around the family by asking different family members the same/similar linear questions.
Linear Questions Examples
How old are you? Where do you go to school? What do you do if you are upset? What do you do after that?
4.2 Circular Questions Circular questions are aimed at looking at difference and therefore are a way of introducing new information into the system. They are effective at illuminating the interconnectedness of the family subsystems and ideas. A variety of circular questions may be used by the therapist as outlined in Table 2. These may be more or less appropriate as therapy progresses. The use of particular types of circular questioning at different stages of the therapy will be highlighted throughout the manual. The time scale of circular questions often changes fluidly between the past, present, future.
Circular Question Examples Type of Circular Question
Examples
About another’s state / behaviour / What do you think John is feeling? beliefs What do you think John is feeling when he shouts at you? What ideas do you think John might have about that? Offering alternative perspectives
What does John think of your school performance? If I asked a teacher what would they say about it?
About relationships - direct - indirect
Do the girls really dislike each other? How do the children react when they see you arguing?
Circular Definitions
When you and John raise your voices and Jill starts crying what does John do then?
About possible futures
What will you think in 5 years time? Miracle question: Imagine you woke up tomorrow morning and all the difficulties you were experiencing currently had disappeared,
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how would things be different? What effect would that have upon your relationship with x? Ranking
Who is most likely to get upset when father is away, and who next is most upset? On a scale of one to ten, how close do you think James and Sue feel when they argue?
Though many family members will be able to answer circular questions, and think about information in a circular manner, younger children or those with developmental difficulties, may find it cognitively impossible to view events from another person’s perspective. Section 4.5 4.3 Statements Statements are used by the therapist for 3 main functions: To clarify and acknowledge a communication from the family To comment on the position or emotional state of a member of the family To introduce therapist/team ideas, directly or in the form of a reflecting team. Section 4.4 In using statements therapists should ensure that they are not of long duration, and do not become therapist monologues. Statements should also be delivered in such a manner that they are open to question or comment from the family and not viewed as conclusive statements. Statements are sometimes used as a way of organising information before a question is formulated to the family.
Statement Examples
So let me make sure I have understood this, you feel if you didn’t go out at all, your mum and dad would feel reassured that you would be safe. Have I got that right? I can see this is very upsetting, and remains an area of great distress for you. Who would be most likely to comfort you when you are feeling like this? You were talking a lot about trust, and about how sometimes you had struggled with developing trust as a child, and later as an adult. How much do you feel trust is around now in your relationship with John?
4.4 Reflecting Teams Reflecting teams aim to introduce the therapy team’s ideas into the therapy in a reflexive manner. There are many different models for reflecting teams, and in turn these are often adapted to suit the wishes and needs of the family in therapy. A general model for introducing and implementing reflecting teams is outlined below. 1.
Reflecting teams can be introduced during the therapy session or at the end of the session.
2.
The format of the reflecting team should be negotiated with the family.
3.
The reflecting team may consist of some or all of the therapy team as seems appropriate relative to the size of the team and wishes of the family.
4.
The family should be offered a range of formats including: Reflecting team joining family and therapist in room. Family and therapist observing reflecting team through the one way screen.
5.
In offering their reflections to the family, team members should ensure they:
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are respectful of family, therapist and team members, hold a tentative and curious stance, stay connected to the ideas of the previous contributor, stay connected with the language used by the family, use age appropriate language, do not overwhelm the family with too many ideas, keep the duration of the reflecting team to no more than 10 minutes.
6.
The therapist should take responsibility for monitoring the effect of the reflecting team on the family.
7.
The family should always be given the opportunity to offer their comments on the therapy team’s reflections and ideas.
8.
Feedback should be gained from the family about how comfortable and useful they found the process of the reflecting team, and the ideas the reflecting team shared. Reflecting Team Example
A reflecting team is used at the end of a session with a father, stepmother, and their two teenage children. Much of the session has been focused on the difficulties the parents are experiencing in setting consistent boundaries for the children, especially as they have different parenting styles. They have touched on the transition to becoming a stepfamily. RT1: I suppose what struck me in listening to the discussion today was how much Jean and John seem to have been thinking about pulling together as parents to help give Jack and Jodie clear boundaries of what they can and can’t do in this family, without wanting too come down too hard on their freedom. RT2: I was wondering how this pulling together process is affected by the fact that John had to do a lot of the decision making and parenting on his own for a number of years. Does it feel like a welcome relief to share things with Jean, or does the extra negotiating make it harder? RT3: I suppose that would depend on what are the family’s ideas about sharing out roles. I mean I was wondering whether they see the role of a stepparent as being any different from that of a parent in their family. RT1: Yes sometimes the roles can be quite different, each one having its pros and cons. Sometimes a stepparent can bring a fresh perspective on things, take a step back and look at things in a different way, like Jean felt she often did. A parent might enjoy a special relationship of understanding because they have been closer to the child for longer. It may be that these differences could be used to complement each other. RT3: I was thinking these things might be influenced a lot by gender, because Jean was saying she and Jodie have developed a closer relationship, partly because they were both women, and there were different expectations of the things Jean might be able to do as a step-mum. RT2: It feels like these things take time to negotiate though, and I wonder if this period of negotiation is what the family are still struggling with, because it might take longer when the children are teenagers, and have plenty of ideas themselves about how things should be. RT1: I wondered what ideas the family had of how to take this negotiation further, if it is something they feel might be worthwhile pursuing. Is it something they would like to discuss here, with us, or do they feel the negotiation will just evolve naturally? Th: Perhaps we can leave it there then, and I will take your ideas up with the family.
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4.5 Child Centred Interventions It will be important for therapists to bear in mind the needs of children within therapy session. Interventions will need to be tailored to fit their development level, both cognitively and emotionally. Particularly:
The process and implicit rules of therapy may be particularly confusing and anxiety provoking for children. Engagement should therefore focus on aspects of the world which the child is familiar or is likely to enjoy. Therapists should use a friendly manner, and try not to raise issues which are likely to provoke anxiety. It may also be necessary for therapists to clearly and explicitly explain parts of the therapeutic process which children may find confusing.
Questions will need to be adapted so that children can understand the meaning of questions and the form of answers that are required. This may require therapist’s to give concrete examples or use names of individuals to whom they are referring. This is particularly relevant for circular questions which require respondents to take another’s perspective. Section 4.2
Children are likely to use multiple channels for communication. It is important for therapists not to rely solely on verbal channels in communicating with children. Drawings, play, and puppetry may all be helpful in enabling children to communicate their ideas, and therapists should be comfortable in using these methods with children.
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5. Therapeutic Setting 5.1 Convening Sessions In setting up the initial therapy session, therapists should begin by discussing the referral information within the therapy team. In deciding whom to invite to the first session attention should be paid to the following factors:
Who is living in the household? Who else is mentioned as important members of the family system? Recent family life events, that may affect attendance e.g. childbirth / separation. Is further information required from referrers before therapy can commence? What professional systems are involved with the family? In relation to: i. The presenting issues. ii. Other issues, such as child protection.
Would it be helpful to initiate a professional / network meeting prior to the therapy commencing?
Therapists should first write to the family, using the letter template provided. Appendix I. A follow up phone call should then be made one week before the initial session to discuss the therapy. As it is likely that the therapist will only speak to one member of the family during this phonecall, therapists should ask whoever they speak to, to convey the message to the rest of the family. The topics to be covered in the phone call are: Team working Attendance issues, who will be coming, how to get there, and ambivalence about attending. Therapist’s interest in hearing everyone’s ideas Video recording Confidentiality 5.2 Team The team within which you are working should comply with the following guidelines: Include at least two qualified family therapists (eligible for UKCP registration) One of the qualified therapists should meet with the family whilst the other forms part of the observing team. Team members should have read and incorporated the guiding principles into their thinking. Section 2 Teams should include therapist and family activities in their observations. Teams should have at least one method for observing the therapist, e.g. one way mirror, in room observation Teams should have at least one method of communication between team and therapist, e.g. telephone, earbug, interruptions. 5.3 Video There should be capacity to video therapy sessions and permission to video therapeutic work should be sought from the family in a manner which clearly discusses the video permission they are granting. Section 6.1 - Permission should be confirmed by using the form provided. Appendix II. 5.4
Pre-therapy preparation
In preparing for the first session the therapist and the team should meet for at least 15 minutes before the session begins and address the following issues: Construct a genogram from referral information Genogram example Summarise the main themes from the referral Consider the recent life events of the family Consider difficulties which may arise around engagement and how to address these Consider broader system issues, and define who is in the network
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Brainstorm themes/hypotheses/formulations which may be relevant to the family
Genograms Genograms are a means to visually conceptualise the family and wider system, in terms of its members and relationships. They should include the following information: All members of the family system, including adopted/fostered members Delineation of the household All members of the wider system Dates of birth Deaths, with dates Partnerships and marriages, with dates Separations and divorces, with dates Pregnancies, miscarriages, and terminations, with dates Occupations / Schooling Any information that is missing from the referral information should be noted and enquired about during the initial session of therapy. Tobias m : 1952 dob: 12.4.27 died : 1967 heart attack
m: 1977 d: 1988
54 Leonard dob: ?
Marcia
Paul
66
71
dob: 20.5.32
44
43
38
Carmel
Leon
Brian
dob: 3.6.54
28
dob: 30.7.55 dob: 13.8.60 Jean dob: ? Painter nurse
26
31
Joan
Charles
dob: ? nurse
dob: ?
due : Feb 1999
18 Tobias dob: 10.5.80 bank worker
16
14
Jacob
Rachelle
dob: 19.1.82
14 Monica
dob: 12.2.84
St James Grammer School
5.5 Pre & Post Session Preparation The therapist and therapy team should allow 15 minutes before and after each session to prepare for their meeting with the family and review the progress of therapy. Issues to be addressed in these discussions should include: Pre-Session Summary of the main themes from previous session Information which requires clarification from previous session Between session contact the therapist has had with the family/wider system The current formulation/themes/hypothesis of the issues with which the family are bringing Ways forward for the current session which are being considered Any team – therapist issues which need to be addressed Any family – family/team issues which need to be addressed
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Post-session Review of main interventions and family’s response Ideas for future sessions, themes/issues to follow up, E.g. narrative prompts, unexplored areas, facts to check Feedback to therapist of team observations Therapist’s reflections on issues evoked for them by the session Review of important information shared, e.g. life events, elements of genogram 5.6 Correspondence Letters should be used throughout therapy to maintain contact with the family system and the wider network, as illustrated in this manual. Appendices I, III, IV, V. Throughout this contact, the team’s writing of the letters should always consider the guiding principles outlined in Section 2. Particularly important are issues of connecting with the whole system and not locating pathology within individuals. Particular attention to the language used will be important so that correspondence can be both easily understood, and reflect the contributions of the family to therapy. 5.7 Case notes All written records should be non-pejorative, legible, dated, signed, with no abbreviations. Alterations and Corrections should be clearly marked and signed. Case notes should include: Family information sheet Genogram Referral information/letter All other written communications to and from the centre Record of attendance Sessions notes Notes on telephone contacts to and from the centre 5.8 Session notes The therapy team should make session notes for each meeting between the therapist and family/wider system. In this way case notes form an observational record of the process of therapy. Session notes should include : Date and number of session Who attended therapy Therapist/Team member names Main themes of the session – including key language used by family Team observations – clearly labelled as impressions Record of interventions Key points/ideas/decisions to follow up in later sessions Team members should record session notes on the record form provided. Appendix VI
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6. Initial sessions Initial sessions of therapy consist of the first and second session of therapy. If a family seems well engaged, and if all of the goals for initial sessions have been covered during the first session, therapists may proceed to the goals for middle session. Section 7. If this is not the case therapists’ should continue to focus on the goals for initial session for a second session. Goals during initial session 1. 2. 3. 4.
Outline Therapy Boundaries & Structure Engage and Involve all family members Gather and Clarify Information Establish Goals and Objectives of Therapy
6.1. Outline Therapy Boundaries & Structure During the initial stages of therapy it is important for the therapist to set the boundaries of therapy by sharing some information with the family / professional system which informs them about the process of therapy, and orientates them to the first meeting. This information is most easily shared by simple statements made by the therapist, these should include: •
Introductions The therapist should introduce himself or herself as a team member and explain the role and context within which they work (the team and the centre).
•
Team working The therapist should explain that they work as part of a team, and that the team’s role is to generate ideas and help the therapist understand the family / system. The therapist should explain how many team members there are, and the professional background of the team members. The technical equipment used should be explained including the use of the one way screen / phone / earbug.
•
Video The therapist should explain that family sessions are usually videod, but that the cameras are NOT yet switched on. The purpose of the filming (research / review) should be explicitly stated, as should the storage of videotapes, and who has access to the tapes. The choice of whether to proceed with video should then be given, and the forms completed at the end of the meeting, giving the family a chance to decide then that the video can be erased. �Appendix II
•
Confidentiality The confidentiality of the videotapes and any information discussed in the session should be outlined. Specific statements about the boundaries of confidentiality should be made in relation to other systems, and with regard to child protection issues.
•
Structure of the session Information should be given on the length of the meeting, the breaks, and the use of team feedback through messages or reflecting teams. Explain that during the break, videoing will stop and the screen will be covered.
•
Structure of therapy Explain that if the family/team decide to meet again, that the meetings will be approximately every 4 weeks, on the same day, and the same place. Explain that the length of therapy will be decided together by the family / team in accordance with their needs and wishes.
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•
Questions Time should then be spent giving the family an opportunity to ask questions and meet the team. Agreement to proceed with videoing should be confirmed, and the family informed that the video will now be switched on.
6.2 Engage and Involve all family members
Supportive environment: Initially it is very important for the therapist to provide a warm, supportive and empathic environment, to increase trust and rapport and to build the therapeutic relationship. The therapist must work to help the family feel understood, accepted, comfortable and less anxious. This may include making the room comfortable and safe for younger children, and making it clear they are free to play/draw during the session.
Hear from everyone: Therapists should try to hear from all members of the system/family, initially connecting with them all at an individual level, and assessing the level of contribution they feel they are able to make to the discussion, from either verbal or non-verbal cues. The therapist should try to make sure that everyone in the system is able to contribute to the discussion if they wish.
Neutrality: The therapist is trying not only to hear everyone’s views but also to establish their interest in different perspectives that may be held within the system. At this point unless serious concerns arise regarding safety/confidentiality the therapist should remain neutral to the difficulties and issues that the family are presenting and their views about them.
6.3 Gather and Clarify Information Information should be gathered by the therapist to orientate them to the system and enable them to hear more about the issues the family is bringing to therapy. Information should be obtained on the following topics: •
The Context of therapy: decision to come to therapy, relationship with referrer, previous experiences of therapy, concerns or dilemmas, and their expectations of what would be a successful therapy outcome.
•
The System: Gathering information about the system and its relationship to other systems will be important in beginning to develop a broader picture of the family composition, relationships, history, and family patterns. Information should therefore not only be factual, in relation to who is in the system, how old are they etc., but also the relationships and roles they have developed within the system. Information concerning the system should be collated and added to the genogram generated in pretherapy preparation. �Section 5.4
•
The Presenting difficulties or issues: If the family are introducing information about the difficulties it will be important to follow this up, and open up a wider dialogue about the difficulties, hearing everyone’s perspective. Attention should be paid at this early stage to tracking the behaviour patterns that are defined as difficult, though some exploration of explanations and beliefs that have developed around the difficulties may be appropriate.
•
Solutions and Successes to date: It is important to gain some awareness of the actions the family has taken to try and address the difficulties, and their evaluation of the effectiveness of these measures. If the family are finding it difficult to generate concrete examples of things they have tried, hypothetical ideas for future solutions may bring ideas forward for discussion.
Attention should be paid to collecting information in a circular manner. Although it will be appropriate to ask linear questions in collecting information, especially at this early stage of therapy, circularity can be maintained by linking multiple linear questions between family members in a circular way. 6.4 Establish Goals and Objectives of Therapy The therapist should consider with the system what are their goals and objectives for therapy. What are the family hoping to get from the meeting today and the therapy in broader terms, and what are their different views about this and how might this impact on the therapy?
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The establishment of goals should be achieved in a way which expresses the Possibility of Change, and should convey the expectation that change is possible, and likely to occur, that the therapy team may be able to work with the family towards this. This intention is to build the family’s confidence in their ability to make changes. Initial Session Checklist for Therapists Now you have finished the initial session/s of therapy: � Do you know who is in the family? � Have you outlined the way you work and the setting? � Have you introduced the therapy team to the family? � Have you discussed issues of confidentiality? � Have you given the family a chance to ask questions about the therapeutic process? � Have you begun to engage all members of the family? � Do you know the important people in the wider system/network? � Do you have a clear idea of the difficulties/issues with which the family are struggling? � Have you heard views of the difficulties from each family member? � Do you have an idea of the solutions and strategies that the family have tried so far? � Do you have an idea about the family’s strengths? � Do you have an idea about what the family would like to change or be different? � Have you remembered to obtain written video permission? � Have you written to the referrer to inform them of the appointment? Appendix III
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7. Middle Sessions Goals during middle sessions
1. 2. 3. 4. 5.
Develop and Monitor Engagement Gather Information and Focus Discussion Identify & Explore Beliefs Work towards change at the level of beliefs and behaviours Return to Objectives and Goals of Therapy
7.1 Develop engagement The therapist should pay particular attention to developing a co-constructed therapeutic relationship. In addition to attending to the three aspects of engagement from the initial meeting (supportive environment/hearing from everyone/neutrality), attention should be paid to: Creating and offering choices about the process of therapy Resolving issues in the family-therapist-team system as they arise. This will require therapists to allow sufficient time for team discussions pre and post sessions (Section 5.5), and time within sessions to discuss the process of therapy with families and any concerns or questions they have in relation to this. 7.2 Gather Information & Focus Discussion Information is still gathered by the therapist, but more of an emphasis should be paid to focusing this discussion, so that issues and areas for discussion from the initial broad discussions may be looked at in greater detail or from different perspectives. The therapist plays a role in developing this discussion to develop themes and keep the discussion focused. Information may often focus on the following topics: • The presenting difficulties or issues: The therapist will still be gathering information about the difficulties and issues presented. They will look more closely at the consequences/effects of behaviours. They should be tracking behavioural patterns, and giving feedback to the family about the behavioural or emotional interactions and sequences which are discussed or observed. Therapists’ should be collecting this information in a manner that enables circular descriptions of behaviour to develop. • The family and wider system: The therapist will still gather information about the family and wider system as is necessary to understand the information and stories being presented by the family. The gathering of information about the family should have reduced considerably from the initial sessions. As the therapist becomes more familiar with who is in the family and their roles, the focus of information should turn more to relationships. • Solutions & Successes: The focus on the successes and solutions available to the family should be steadily increasing throughout therapy. 7.3 Identify & Explore Beliefs The therapist should identify and explore the family’s thoughts, beliefs, myths or attitudes, which may be contributing to their dilemmas and difficulties. The therapist should be beginning to develop a picture of the ideas and beliefs that inform and influence behaviour, as they are gathering a circular description of the difficulties with which the family are struggling. Circular questions which build up circular descriptions of behaviour can also be used to explore the beliefs and assumptions which lie behind those behaviours.
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Example: Father and stepmother in the family are talking about their parents’ beliefs about childcare, in relation to being offered numerous solutions from grandparents and friends about how to manage the teenage years. The therapist is trying to explore ideas about childcare, where these have developed from, and how they might develop in the future. Fa: Well my mother would have a lot to say about that. I mean if we were ever like that there was a firm hand. We would have never have got away with it. Th: And where do you think your ideas and values about how to manage the children come from, your own parents? Fa: Well, not really so much from my parents, I mean I would disagree with a lot of their ideas about how to do things. I think really I have got more of my guides from the church, that’s what has really shaped me. Th: And when was it you started to take on the ideas of the church. Fa: Well I suppose in my late teens, early twenties really, but I have always been interested. Jane (stepmother) has been going since a child and I would say your family were more strongly Christian than mine were, wouldn’t you? Mo: Yes, I have always gone to church. Th: What are the values from the church that have influenced you as parents? Mo: Well really a sense of sharing, we feel it’s important for us both to take some interest in the children, and show them we care, not just one or other of us. But, I don’t know whether we always manage it. Th: (to the teenage children) When you two are parents where do you think your values will come from? Son: Well neither of them, well… I suppose I am a bit like dad, maybe I’d be a bit like him. Th: (To son) And if you were a parent, in their situation as parents now, what might you advise them to do?
The exploration of family beliefs should be used by the therapist to look at a range of family activities, and not just the presenting difficulties. Therapists should explore the family’s beliefs in relation to:
The presenting difficulties. E.g. What ideas has your wife come up with to explain the behaviour John is showing? How do you understand the idea that James is less concerned about the behaviour than Jill?
Relationships within the family and with the wider system. E.g. Who feels it is most important to keep liasing with the school over this issue? What would your church say about how families cope with loss and bereavement?
Solutions that have been tried or hypothesised. E.g. What gave you the confidence to keep going with this new idea? What gave you the idea to try and tackle things in this manner?
Successes in all areas of family life and relationships to the wider system. E.g. Would that be judged as a success in your family? If John’s grandparents were here would they see that as a success, or would they have different ideas about success?
Therapy process, beliefs about therapy E.g. What led to your decision not to bring the children to today’s meeting? In what ways do you think Jill was disappointed with the therapy she went to last year?
Family behaviour during therapy. E.g. Jill is looking distressed, what do you think was so upsetting for her in talking
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about the difficulties you are experiencing? How do you understand John’s anger with the way that things have gone in today’s meeting? 7.4 Work towards change at the level of beliefs and behaviours Challenge existing patterns and assumptions: To move with the family to a position where they are able to query their own beliefs, perceptions and feelings. The therapist should actively query the family’s existing beliefs, assumptions or behaviours. The use of circular questioning, alternative perspective and possible futures questioning may be particularly helpful in achieving this.
Example: A 12-year-old child (John) is discussing how he feels to blame when things in the family go wrong, or there are arguments between he and his mother. The therapist begins by clarifying what are the child’s assumptions, then begins to challenge some of the linear aspects of them. John: Well I know it must be me, cause I am the one who always gets shouted at. Th: So do you sometimes feel you are to blame for things that happen at home? John: Well mainly. Th: Who would be able to convince you otherwise? John: Well sometimes Nan says things are not my fault, and that me and mum should listen more to each other, but, I figure it must be me or mum who is at fault. Th: Does it have to be either your mum to blame or you to blame? John: Well I don’t know, we are all right together sometimes. Th: How would your Nan explain the times when you and your mum do get on well together? John: Well she says we are alright when we stop and listen, sometimes we can just bite off each other’s heads you see, over nothing, when no-one has really done anything wrong.
Provide distance between the family and the problem:
Providing distance to try and free the family from the pressure of the difficulties, so that they are more able to consider and reflect upon them. Alternative perspective circular questions and those aimed at looking at possible futures can often be helpful in achieving this.
Example: The therapist is talking alone to a mother who has been attending therapy with her children. Since the separation from her partner she has been finding coping with the demands of the childcare increasingly arduous, and at times has felt very low about her ability to carry on and cope. The therapist is trying to work towards creating some distance between the mother and the situation in which she finds herself, to allow a space for reflection on the position she is in. Mary: Sometimes I feel so inadequate as a mother, I find myself constantly doubting my own judgement. Th: If we met with a group of single parents, do you think that would be a concern for most of them? Would they say making parental decisions alone is very demanding because they may not have immediate confirmation from another adult? Mary: Well maybe, but it is so hard because though there is not another adult there, the children are quick enough to say, other mums don’t do that, or so and so’s mum would let them do this or that. Th: When your children grow up, do you think they will more fully appreciate the job you do, and your determination to do your best by them?
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Mary: Well I hope so, I think sometimes they know now how hard things are for me on my own, how much more running around I have to do, and sometimes how exhausted I am. Th: When they become parents of their own children, do you think they will see how hard you have been trying to be both mum and dad at times?
Externalize
One specific way of providing distance between the family and the difficulties, which is particularly useful if the difficulties are seen to reside within one family member is to externalise the problem. That is to give the problem an external, objective reality outside of the person. This can be useful in mobilising the family’s resources to unite in working towards solutions and new ways of thinking which challenge the difficulties.
Example: The therapist is talking to a 10-year-old boy (Max) during the course of a family meeting. Max has been describing how bad tempered he can be, especially at school. Family members have been agreeing that Max is bad tempered. The therapist is working to externalise the temper from Max, in order that he and his family find ways they can have an influence on the tempers. Th: Can we give this bad temper a name? Max: Well, it’s a sort of me at my angriest, a mad max I suppose. Th: When mad max is around, what effect does he have on your friendships at school? Max: Well, that when it can be at its worst, mad max can get me to be very argumentative, my friends stay well away from me. Th: So when mad max is around they stay away. What happens when mad max isn’t there? Max: Well I tend to play football with my mates.
Reframe:
Reframe some of the constraining ideas presented by the family. Relabelling in a positive way, ideas and descriptions given by family members, in a manner which is consistent with their realities. Circular questions are often most helpful in opening up reframes with the family.
Example A father is defining himself and his parenting behaviour as the ‘problem’ in relation to his children’s teenage struggles. The therapist works towards redefining the descriptions of behaviour as less problematic and offering some positives for the family. Cl: I think I’m basically just too inconsistent, it depends what mood I am in, or how busy I am, as to what answer the kids will get from me. Th: I am just wondering, this inconsistency, who is it a problem for? Cl: Well them, I think. They don’t know where they stand half the time. Th: Does it leave people not knowing where they stand or does it leave people having to make up their own minds? Cl: Well both, I’ve never really thought about it like that, but I feel like I don’t always think before I react. Th: Tell me Jane, what are some of the helpful things about your dad just reacting sometimes?
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Open up new stories/explanations:
Either by facilitating the family’s evolution of new ideas and narratives, or by the introduction of these ideas by the therapist. All family members will have stories about their lives, the lives of other family members, and the life of the family. They will prioritise certain information from the world around them to build these stories and neglect other aspects. Exploration of neglected information may open up the development of stories which are more helpful to the family in coping with their concerns. Information which is neglected often concerns: Successes Solutions Exceptions Alternative views from the network Other strengths The therapist should pay particular attention to enquiring about this information as therapy progresses, using circular questions so that the information is provided in a non-threatening manner. Often circular questions, which are aimed at offering alternative perspectives, can be helpful to this aim. As information is likely to remain neglected by the family even if introduced into the therapeutic conversation, it can often be helpful to emphasise neglected information by therapist statements and reflecting team messages.
Example: Mother: Cindy has always wanted to be a nurse. She entered nurse training but as usual she made a mess of it. She always does things the hard way. She continued to dream of going away to college, and get on in some way even after she had failed her exams. She is now doing volunteer auxiliary nursing. Th: She has continued to work as an auxiliary nurse, she really sounds determined. It seems impressive that she has found another way to fulfil her ambition, and not let herself get discouraged. Where does she get that determination from?
Elicit Solutions:
It will be helpful to gather information from the family about solutions for the difficulties that they have tried or would consider useful. Ideas generated by them are usually most helpful and linear questions are often used to develop an overview of solutions that the family have tried or thought of. If the family are finding it difficult to generate successes circular future orientated questions – such as the miracle question can be helpful. However at times it may be useful for the therapist or therapy team to offer ideas to begin a process whereby the family can generate solutions. If this is necessary ideas should be tentative and flexible enough to allow the family to disregard them or build upon them.
Example: The therapist is talking to a mother and her three children. They are having difficulties getting along together, which is intensified by the cramped living accommodation, and their feelings that they don’t have space for themselves. Th: So it seems important for you to be able to keep things private, to have space that is your very own. What ideas have you come up with to achieve this? Mo: Well we tried letting the children lock their rooms, so that they wouldn’t be in and out of each other’s rooms, arguing about stuff. But it’s just seemed to cause more arguments, they would just stand outside each other’s doors screaming to be let in. Th: So what else did you try then? Mo: Well we have tried just about everything, you name it we have tried it. Th: Jane, what does your mum mean? Tell me a bit more about all the things your family have tried.
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Jane: Well when the keys got taken off us, I said Jack and Jodie had to knock on my door, but they never did, especially him. So mum said we would have to play down stairs all the time, which didn’t last long, because when I had a friend round I wanted to go upstairs. Th: So Jack, your sister says you have all being trying hard with ideas about this, can you tell me any other things that have been tried? Jack: Nothing else. Th: Well can you think of other things you think might help which you haven’t tried yet? Jack: No, nothing seems to work. Th: Imagine in a month’s time Jane and Jodie had stopped coming into your room, what would have had to happened to make that possible? Jack: Well mum might have really told them off when they did it, and said no TV and stuff like that. Th: Jodie do you think that would stop Jack coming into your room if your mum said that to him? Jodie: No, he would do it anyway. Th: What do you think might help Jack to stop coming in? Jodie: No computer.
Amplify change:
In order to maximise the change or potential change that is occurring throughout the course of therapy it will be important for the therapist to focus on statements the family present about progress. Initially these aspects may be minimal, or presented in a manner by the family which denies the magnitude of the effort or progress they have made. The therapist should focus on descriptions of actions where the family could be seen to have initiated or implemented change, in a manner which is positive but sensitive to the family’s level of confidence that change has occurred.
Example: A 10-year old boy (Jake) is talking about a time when he and he had been pleased about his behaviour, against a context of difficulties in relationships and communication with his father, as well as difficulties at school. The therapist explores the event in more detail to emphasise the success and implications of this for their relationship. Jake: Well last Thursday we went to the park, and I went on a school trip, and we got to go on a fair ride, and the teacher said I had been really good. Th: That sounds like a really nice time, does your mum know about this? Jake: Yeah, I told her what the teacher had said. Th: How did your mum react to the good news? Jake: She was pleased I think. Th: How did you know? How could you tell your mum was pleased? Jake: She looked quite happy, and she said we could go to McDonalds on the way home. Th: (to mother) So you were able to show Jake how pleased you were, how did you feel he responded to that? Fa: I was quite surprised actually, we went to McDonalds and he didn’t play up at all, and he told me about the day, which is a bit of a first for him. Th: So you noticed you were able to talk more together, what made that possible? Fa: Well I don’t know, really. Th: Did you notice you were more relaxed at all? Fa: Well I suppose that did help, we had a bit of time together because we were out just the two of us, and I wasn’t wound up so much, cause I was really pleased that he had behaved himself all day? Th: What would make it possible for you to both find other times in the week when you could have a bit more time just the two of you, to feel more relaxed and talk.
Enhance mastery:
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To encourage the family to gain a sense of mastery or control over their situation, their thoughts, feelings and behaviours. This should enable the family members to take responsibility for their own roles and actions, and for the process of change. In addition should enable family members to gain an awareness of the actions and motivations of other people in their family in achieving change.
Example: A mother and her two children aged 5 and 7 years are attending a late middle session of therapy. The parents separated 3 years ago, and the mother has been finding managing the children’s behaviour difficult since this time. The therapist and family have been working together through the therapy to identify the things that the mother is doing well in relation to managing the children’s behaviour and managing her own low feelings. The therapist is commenting on this process and highlighting the mother’s own stories of competence which are often lost. Mo: Well I feel like things have been going quite well with the kids, they have been behaving really well most times, but I don’t know sometimes I still feel low, I wonder whether I am doing ok. What do you think? Th: We would predict many of the things you have been telling me about today, about things being up and down at this stage. I hesitate to advise a family who have come up with such good ideas and solutions on their own. Especially when most of them seem to be having the desired effect. What have you been thinking of trying most recently? Mo: Well I’m not sure sometimes I feel it’s right to take a sympathetic approach to the kids, then other times I come down on them hard, you know, if they are playing up. Th: If Josie (mother’s friend) were looking in on how you were managing them now, would she say you are combining these two approaches, or are you sticking with one or the other? Mo: Well she’d see a mix of the both I think, I mean I try and judge each situation as it comes. Th: So do you feel you are becoming more confident in trusting your judgement about what is right for the kids and when? Mo: Well a bit yes, I mean they don’t pull the wool over my eyes, I know when they are just playing up or when they are really upset. Th: So when did you decide to be a bit more flexible about how you dealt with the situations at home?
Introduce therapist/team ideas:
May include the therapist sharing their ideas and hypothesis about the family, individual, or difficulties, for a variety of reasons. Including:
Normalise difficulties Move the family to new ideas Connect family’s ideas Suggest ways to organise the discussion, e.g. Enactments. Example:
A mother, her social worker and the therapist are having a session. The mother begins to discuss her experiences of violence from her ex-partner when she was first married, in her early twenties. As the mother is taking a rather critical stance towards her own actions at that time, the therapist normalises her reactions to the violence, to try to begin to open up less critical stories and reframe the mother’s actions at the time as understandable rather then ‘weak’. Mo: I suppose I should have been stronger, and not let him trample all over me. My mum used to say just get out, leave him, and I did for a while, I did try, but then I weakened and let him back even though I thought why I am I doing this? What about the kids? I really should have tried to be stronger.
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Th: Was your mum the only person with whom you shared this? Mo: Well I tried to talk to my friend but I felt a bit bad, because all the same stuff had happened to her, and I just told her to leave and lost patience with her, and then I ended up being just as weak as she was. Th: From talking to other women who have lived with violence like you have, I often hear a similar story that they feel they should leave, but it is easier said than done when you are living with that fear on a day to day basis. Mo: That was it really, the fear, it kept me weak, and I loved him. Th: Women tell me they hold onto a hope that if only they did a bit better, were a bit stronger, their partner will change, so they keep trying over and over again. Did that happen for you? Mo: Yes, I took him back more than once you see, lots, but then I thought no more, not with the kids seeing things and all that. Th: What gave you the strength to put the kids first, and keep sticking to it?
7.5 Return to Objectives and Goals of Therapy The therapist should return to the issues of goals for therapy as therapy progresses: i. ii. iii.
If goals seemed unclear during the initial stages of therapy, it may take some time and thought with the family for them to consider the areas they want to change in therapy, or to find priorities for change. If goals are achieved, so that goals can be renegotiated, perhaps for change at a wider system level, or a decision to move towards the end of therapy is made If goals change due to changing circumstances for the family.
Example: Things are beginning to improve for a family whose initial concerns were the suicide attempt made by their daughter. She is no longer suicidal and seems to be getting happier at home and at school. The therapist discusses with the family whether they are happy with this progress, and whether they are left with other issues they would like to bring to therapy. Fa: I mean I think we are all lot more relaxed about Janice now, she was in her room for hours at the weekend, and I realised at the end of the day that I hadn’t gone and checked on her once, and I figured that was because I was beginning to trust her again, I mean I didn’t have to watch her every 5 minutes, or worry what she was up to. Th: So it seems like all of you are feeling that your concerns that Janice will harm herself are less now, and Janice you said you felt a bit happier at school. Now these changes are taking place, has it left you with different ideas about what it could be helpful for us to discuss here? Janice: Nothing much else to say. Th: John do you think there are things which Janice might appreciate us talking about here? John: Well I know she doesn’t like talking about it, and I think that’s half the trouble, but I think maybe we need to think about how to help Janice cope with all the stuff that goes on at school, all the bullying. Th: Janice, is that one of the most difficult things for you to talk about? Janice: Yes. Th: Would it be helpful to think with you and your family how we could make talking about it easier? Janice: I’m not sure, there is nothing they can do anyway. Fa: Me and your mum think if you could talk a bit though, you would like have a shoulder to cry on and not feel alone. Th: Do you feel you mum and dad might be able to help support you Janice? Janice: Yes I suppose so, I did talk to mum once and I felt better. Th: Would that be something we could try to develop here. Janice: Well I will give it a go.
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Middle Sessions Checklist for Therapists Now you are nearing the end of the middle sessions of therapy: � Have you continued to engage the family in the work together? � Have you addressed problems in working together as they have arisen? � Have you developed a circular description of the interactions and difficulties with which the family are struggling? � Are you developing a clear idea about the strengths and resources the family are drawing upon? � Are you working with the family to generate new solutions for the issues they are bringing? � Have you begun to explore the family’s beliefs and ideas about the interactions and relationships in their family? � Has there begun to be a shift in the interactions in which the family are engaged? � Have you challenged the family’s beliefs about the issues that they are discussing? � Have you worked with the family to open up new stories/explanations about the difficulties they are experiencing? � Have you worked to reframe the difficulties or struggles that the family are experiencing? � Have you introduced distance between the family and the difficulties or tried to externalise the difficulties? � Have you tried to amplify the successes and change that the family achieved? � Are you working with the family to try and increase the sense of mastery and control they feel they have over the difficulties? � Have you reconsidered with the family if they are achieving change in the way they had hoped? � Have you written to the referrer to inform them of the progress of therapy? Appendix IV.
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8. End Sessions Goals during ending sessions 1. 2. 3. 4. 5.
Gather Information and Focus Discussion Continue to work towards change at the level of behaviours and beliefs Develop family understanding about behaviours and beliefs Secure Collaborative Decision re: Ending Review the process of therapy
8.1 Gather Information & Focus Discussion Information gathering and focusing the information brought by the family to sessions is still important towards the end of therapy, though the focus of the information is likely to be considerably different. •
The Presenting difficulties or issues:
There will still be a lot of information shared about the difficulties with which the family are struggling, though the focus will be on changes that have arisen concerning these issues over the course of therapy. •
Solutions and Successes to date:
There should be a considerable amount of discussion about the solutions that the family are now implementing in relation to the difficulties, as well as the successes they feel they have achieved so far, and those they are looking forward to in the future. If the family are slipping into focusing on the difficulties, it will be important to enquire further about the successes about which the therapist has heard over the course of therapy, which the family are currently neglecting. •
The System / Wider system:
There should be a considerable decrease in the amount of information shared about the system and wider system. Of the information that is shared it is likely to be in relation to how the difficulties are showing/decreasing in other contexts. Also supports in the wider network which may be drawn upon once therapy has concluded are often explored. 8.2 Continue to work towards change at the level of behaviours and beliefs As in middle sessions the therapist and family are continuing to work towards change at the levels of belief and behaviour. The methods they use can incorporate any of those highlighted in the middle session. See section 7.4. However it is more common in end sessions for the focus to be on the following methods:
Amplifying change: In order to maximise the change or potential change that is occurring throughout the course of therapy it will be important for the therapist to focus on statements the family present about progress. Initially these aspects may be minimal, or presented in a manner by the family which denies the magnitude of the effort or progress they have made. The therapist should focus on descriptions of actions where the family could be seen to have initiated or implemented change, in a manner, which is positive, but sensitive to the family’s level of confidence that change has occurred.
Enhancing mastery: To encourage the family to gain a sense of mastery or control over their situation, their thoughts, feelings and behaviours. This is to enable the family members to take responsibility for their own roles and actions, and for the process of change. In addition should enable family members to gain an awareness of the actions and motivations of other people in their family in achieving change.
Challenging existing patterns and assumptions: To move with the family to a position where they are able to query their own beliefs, perceptions and feelings. The therapist should actively query the family’s existing beliefs, assumptions or behaviours. The use of circular questioning, alternative perspective, and possible futures questioning may be particularly helpful in achieving this.
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Reframing: Reframe some of the constraining ideas presented by the family. Relabelling in a positive way, ideas and descriptions given by family members, in a manner which is consistent with their realities. Circular questions are often most helpful in opening up reframes with the family.
Developing new stories and explanations: Either by facilitating the family’s generation of new ideas and narratives, or the introduction of these ideas by the therapist. All family members will have stories about their lives, the lives of other family members, and the life of the family. They will prioritise certain information from the world around them to build these stories and neglect other aspects. Exploration of neglected information may open up the development of stories to become stories that are more helpful to the family in coping with their concerns. Information which is often neglected often concerns: Successes & Solutions Strengths Exceptions Alternative views from the network
8.3
Develop family understanding about behaviours and beliefs
As therapy ends it will be important for the therapist to work with the family to develop and encourage their understanding of the process of the development of difficulties. This may be helpful in equipping the family with the ability to recognise the development of such processes in the future. Particular attention should be paid to: Underlying family interactional patterns. Motivations for assumptions, behaviours and feelings. Understanding of a family member’s reactions to other’s behaviours. 8.4
Collaborative ending decision
The timing of ending is not always obvious and in aiming to make the ending process a collaborative process the therapist and therapy team should be alert to a number of signals in sessions which may indicate that therapy may soon draw to a close. These include:
Positive feedback from the family: the family situation or the issues they presented are reported as improved or improving. The family report having made changes in other areas of their lives.
Negative feedback from the therapy: The family report dissatisfaction about the therapy, or the progress they are making. This is often done through expressing the views of a family member absent from therapy.
Therapist notices changes: Missed sessions by the family. Changes in the level of engagement in therapy. Therapist notices positive changes in the way the family are interacting during sessions, for example they are beginning to use new narratives, or are beginning to comment in a different way on their relationships and the issues with which they are struggling. The relationship to therapy may change, with the family becoming more confident in their own abilities, resources and solutions, and attributing change to this.
If it seems that ending therapy is indicated it is important for the therapist to hear from everyone their thoughts and feelings about ending therapy and make this a collaborative decision. To do this the therapist and therapy team must share their thoughts about ending with each other and the family. The team should consider the following issues and then gather the family’s views on these.
Whether the family might feel it was appropriate to end therapy, do they feel they have achieved what they set out to achieve?
How might the family prefer to end therapy, would they like a follow up appointment or would they like to re-contact the team if necessary?
Might the family feel it would be important to engineer systems of support, before therapy ends?
With whom should the team share information about the therapy and what has been achieved, e.g. referrer, school.
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A useful and engaging way of saying goodbye to the family.
Once this information has been shared decisions should be reached about: When therapy will end. What follow up arrangements will be made. What the family might do if difficulties should arise again. Who will be contacted post therapy. 8.5 Review the process of therapy It will be helpful for the therapist to invite the family to review the process of therapy. This may be useful for the team and family in relation to prevention of future difficulties, and to empower the family in any future contact with therapeutic services. Issues that should be considered include: What has been gained/lost for the family through therapy? Any misunderstandings not addressed during therapy should be clarified and addressed. Reasons for therapist’s behaviours and procedures used. What might the family do differently if future difficulties arise? End Sessions Checklist for Therapists End Sessions Checklist for Therapists Before you end therapy check: � Do the family have an understanding of the issues which they are happy with? � Are the family happy with the ways of interacting that they are currently developing? � Have you continued to amplify change, enhance mastery, challenge existing patterns and assumptions, reframe concerns and difficulties, and develop new stories and explanations of difficulties? � Have you discussed ending therapy with the family, and listened to their wishes about ending? � Have you reviewed with the family the goals outlined in the initial and middle stages of therapy? � Have you considered contingency plans for the family when future difficulties arise? � Have you reviewed with the family what was useful and not useful about therapy? � Have you discussed how to re-engage with therapy if required? � Have you written a closing summary of the work to the referrer? Appendix V
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9. Indirect Work There are many areas of systemic work, which although they do not directly involve the presence of the family, are essential in supporting the ongoing work with the family. Directions for conducting this nondirect work are therefore outlined below. Therapists are reminded that the guiding principles outlined at the beginning of this manual will also be applicable to the non-direct work outlined in this section. 9.1 Child Protection Therapists should abide by the local child protection procedures outlined by their area. Wherever possible the local procedures should be carried out using the systemic principles described in section 2. It may be necessary to move from the domain of therapy to the domain of protection but the manner in which this is achieved should retain a systemic focus, and not preclude the possibility of moving back into the domain of therapy at a later stage. Therapists should inform the family that they are now not talking with them in their therapeutic role as they have serious concerns about the safety of a family member. Particular attention should be paid to bearing the needs of the system in mind whilst still prioritising the needs of the child for protection, the language and narratives about abuse and protection, and the co-construction of the relationship. If at all possible, without placing the child at further risk, therapists should discuss the child protection issues with the family, and keep them informed of any protective procedures that the therapist is to instigate. 9.2 Clarifying therapy with referrer present In situations where referrals are vague, complex, or involve a network of professionals, it may be necessary to clarify the nature and boundaries of the referral over the telephone, or in person. This ideally should be done with the referrer and family at a pre-therapy meeting, where the multiple views about therapy, its utility and limits, can be shared between all members of the system. However in referrals where there may be tensions in the referring relationship, or issues of advocacy may limit the family’s ability to communicate their ideas and wishes, separate contacts should be used to clarify therapy, before therapy commences.
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9.3 Identifying the network and clarifying relationships It is important for the therapy team to identify the components of the family’s network from the referral information given and during the assessment process. This includes professional and extended family contact, as well as other relationships, friendships and occupational aspects of the family’s life. This should be done for current relationships as well as important contacts in the family’s history. Important life events such as illnesses, hospitalisations, and periods of separation can be built into this picture. This information should be used in relation to the therapeutic goals and in relation to contact with the wider system that the therapy team and family participates in during therapy. If the family are participating in any other therapeutic activity during the time they are attending family therapy, for example individual or couple therapy, the boundaries of the work should be clarified in relation to the current goals for family therapy. In addition, in identifying the network and clarifying relationships, the boundaries of confidentiality and the family’s wishes concerning this should be discussed and clearly stated to all members of the network. 9.4 Assessing risk At times during therapy it will be necessary to consider the risk which one or more member of the family poses in relation to their own well being or the well being of a family member. The risk may be in relation to a number of issues, for example, child protection, domestic violence, or suicide attempts. Therapists should bring their concerns into the discussion with the family to hear their own views of the risks. It is important that the therapist’s and family’s concerns are identified, in a manner which opens up communication and leads to the establishment of contingency plans to monitor or prevent further risks. In relation to suicidal ideation it may be necessary for the therapist to move outside the domain of therapy and complete a full psychiatric risk assessment, or refer to someone able to complete this. Again this should be a process in which the family are actively involved and therapists should inform the family that they are now not talking with them in their therapeutic role as they have serious concerns about the risks to a family member.
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10. Proscribed Practices The proscribed practices described below are things that would not be included in a routine therapy session. It may be that on one or two occasions it is appropriate to use one of these approaches, however they must be used within a systemic framework, that is, using the guiding principles outlined at the start of this manual. Team members should monitor sessions for proscribed interventions, and record these, together with any justification, in session notes? Section 5.8 10.1 Advice As a systemic therapist you would not usually offer direct advice to the family about their interactions or the difficulties they are experiencing. If the family ask for advice about a particular issue with which they are struggling or the therapist feels advice may be appropriate in helping the family work towards their goals, advice may be offered in a non-directive or reflexive manner. Options should be presented as choices about which the family can make their own decisions. 10.2 Interpretation Psychodynamic interpretations about the meaning of symptoms or interactions in relation to individual or trauma would not be usual for systemic therapists. Rather, meanings are explored in relational and interactional terms between members of the system. 10.3 Un-transparent/Closed Practice Therapists should not remain closed about their working practices, ways of thinking and understanding the difficulties with which the family are struggling. They should try to remain transparent by explaining their practices at the beginning of therapy, and during therapy as appropriate. 10.4 Therapist monologues In the co-created process of therapy therapists should not find themselves lecturing or using long monologues in their interactions with the family. The process should be more like a sharing of ideas between therapist and family, and between family members. 10.5 Consistently siding with one person In taking a neutral stance therapists should not find themselves consistently siding with one person in the family. It may be necessary at times, for ethical or therapeutic reasons, to align oneself with a member of the family, but if therapy is to continue, this should not be a constant state. 10.6 Working in the transference Therapists should be paying attention to the relational and engagement issues between themselves and the family with which they are working but they should not use the relational aspects between themselves and the family as the tool of therapy, that is work within the transference. 10.7 Inattention to use of language Therapists should not be inattentive to the use of language used by the family. They should pay attention to the both the words and phrases used, and the meanings attributed to these. 10.8 Reflections Therapist’s simple reflections of the points or phrases that are used by the family should be kept to a minimum. Reflections may be used to enhance engagement and to develop the family’s sense of being listened to and understood, but when used, reflections should be followed by questions, and increased curiosity about the issues presented. 10.9 Polarised position Therapists should avoid taking a position which is polarised from that of the family, or a position which is likely to escalate to a polarised position. Therapists should be thinking about how to take a position which connects to the ideas of the family, whilst still questioning those ideas, and allowing them to remain curious.
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The therapeutic team can enable the therapist to achieve this by presenting the multiple perspectives from which the family situation can be understood. 10.11 Sticking in one time frame Therapists should not stick in one time frame, but move the focus of their questions and discussion between the past, present and future. 10.12 Agreeing / not challenging ideas Therapists should not be in a continual state of agreement with the family’s ideas. They should remain curious and challenging about the nature and content of these ideas, in order to introduce new unexplored possibilities and ideas. 10.13 Ignoring information that contradicts hypothesis Therapists should not ignore, or minimise information presented by the family which contradicts their own ideas and hypotheses, rather they should take this information seriously and use it to modify and expand their working ideas. 10.14 Dismissing ideas The ideas presented by the family about the difficulties with which they are struggling, or the process of therapy itself should not be dismissed by the therapist. 10.15 Inappropriate affect The therapist’s affect should match that of the family, and would be considered inappropriate if it remained dissimilar from family for an extended period of time. One example might be if the family were feeling optimistic about change and the progress they were making, and the therapist remained pessimistic. There may be times, when a mismatch of affect is used transiently, in order for the therapists to take a position in relation to the family as a way of questioning or challenging their ideas. 10.16 Ignoring family affect Therapists should pay attention to the affect that the family is showing in the session, and not ignore strong expressions of affect during the sessions. This may be particularly relevant when a member of the family shows distress during the meeting, either by sad or angry behaviour. 10.17 Ignoring difference Therapists should not ignore issues of difference between themselves and the family or within the family. These may be differences in views, beliefs, gender, abilities, class or race, and should be raised by the therapist in a sensitive and open manner for further exploration.
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APPENDIXES Appendix 1: Sample Appointment Letter Appointment letters should include:
Referral source and name of referrer Invitation to the whole family Reasons why all the household should attend Date, time and place Confirmation request Brief explanation of teamwork Main therapists name
Dear Mr & Mrs Smith & Jodie and Jonathan, We have heard from your GP, Dr. Jones, that it might be worthwhile exploring whether family therapy could be of help to you all. We would therefore like to offer you an appointment to come along and meet us at our Family Therapy and Research Centre on Wednesday 13th July at 4.30pm. This first session would be to discuss the issues that concern you and to decide whether family therapy might be useful. We find it helpful to meet all members of the family or household so that we can learn how things are from everyone's point of view. We hope to see as many of you as possible for this first appointment. We work as a team in order to generate more ideas which we hope to share with you. There are about 5 people in the team, but the person who will be talking with you most directly is Dr. Peter Stratton. Enclosed is a map giving directions to the clinic, which is situated in the Department of Psychology at Leeds University. Please let us know whether or not you can attend, as soon as possible by telephoning our secretary on the above number. It is important that you give us this information as we have a waiting list for appointments. Yours sincerely,
Dr Peter Stratton Family Therapist On behalf of Leeds Family Therapy Team
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Appendix II: Sample Video Consent Form
Consent Form for the Use of Video Tape We give consent for the use of these video recordings for the following purposes: 1. To help the team deliver a more effective service to our family. For the purposes of supervision and in order to plan future therapy sessions. Confidentiality will always be maintained. Viewing will be confined to the regular members of your family therapy team. 2. For teaching & research, in order to develop our service through training other therapists, and improving the service for families through research. Such tapes are only shown to audiences of professional clinicians and researchers who are warned about the importance of confidentiality. Please delete as appropriate.
Signed: ………………………………………………………………………… …………………………………………………………………………………. Dated: …………………………………………………………………………. You
are
entitled
to
change
your
mind
about
the
consent
given
above
at
any
time.
All video material is stored in locked cabinets and every effort will be made to ensure confidentiality. No video material will be identified using your family’s name. Signed: ………………………………………………………………………… …………………………………………………………………………………. All Family Members Dated: …………………………………………………………………………. Member of Family Therapy Team
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Appendix III: Sample Referrer letter This letter is to be sent to the referrers when first appointment sent out. It should include:
Referral date Referral reason Family name & address Date of appointment Proposed future contact Contact person
Dear Dr. Jones Re:
Smith Family 11 James Avenue, Leeds, LS2
Further to your referral of the Smith family, for help concerning bereavement issues, in March 1998, we have offered them an appointment at the Leeds Family Therapy and Research Centre on Wednesday 13th July at 4.30pm. We will keep you informed of their progress should they go ahead with family therapy. If in the meantime you have any further issues regarding this family please contact Dr. Peter Stratton. Yours sincerely
Dr Peter Stratton Family Therapist On behalf of Leeds Family Therapy Team
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Appendix IV: Post-assessment letter A letter should be sent to the referrer once an assessment is completed or when the initial goals of therapy are clarified with the family. This letter should include:
Number of assessment sessions attended Who attended Brief family composition Referrers concerns Family’s concerns Systemic Formulation/Understanding
Difficulties Agreed Goals for Therapy Agreed liaison with other systems
of
Dear Dr. Jones Re:
Smith Family - 11 James Avenue, Leeds, LS2
I have now seen the Smith family on 2 occasions following your referral for help with bereavement issues following the death of the eldest child in the family, Julie. Mr & Mrs Smith attended alone for the first meeting, as they were concerned to give us a picture of the difficulties without upsetting the children. This was followed up with a meeting with the whole family. As you know the family consist of Mr & Mrs Smith, and their 2 children Jodie (6 years) & John (9 years), both of whom are attending Jacob School. The eldest child of the family, Julie, died in a car crash in September 1997. Mr & Mrs Smith outlined to us their concerns that their children were expressing no grief relating to the death of their elder sister Julie. They were concerned about how the loss was affecting them in both their achievement and behaviour at school, and expressed a wish that they were more able to talk about the issue as a family. The children were quite cautious about discussing this issue initially, and expressed a desire not to upset their parents further by talking about Julie’s death. It seemed that although this was a topic all the family felt would be helpful to discuss more openly, no one dared to begin the conversation, as they were concerned not to bring further distress to members of their family. The children had carried this silence to school, and would not talk to any of Julie’s old friends about her, yet consistently showed distress through their behaviour and lack of concentration. It was therefore decided to try and begin to talk about Julie’s death and the impact this had had on the whole family in our meetings. The children very much wanted this to be at their pace, and we have been thinking with them about ways to help the process of talking easier. We also plan to make links with Jacob school, to discuss how the children might show their distress in different ways at school. I will contact you again once therapy has ended to discuss the utility of these interventions for the family. Yours sincerely, Dr Peter Stratton Family Therapist On behalf of The Leeds Family Therapy Team
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Appendix V: Closing letter to referrer A letter should be sent to the referrer after therapy has ended and should include:
Reasons and date of original referral. Number of meetings held Who attended the meetings The family’s concerns Systemic Formulation/Understanding of Difficulties Themes covered in meetings Utility of therapy for the family Evaluation of current state Future plans Copies to other agencies involved, with family’s permission
Dear Dr Jones Re: Smith family - 11 James Avenue, Leeds, LS2. You will remember you referred the Smith family for family therapy in March 1998, for help with bereavement issues. The family attended for 5 appointments. We saw them last in November 1998 and a further appointment for December was cancelled. All members of the family attended meetings following an initial meeting with Mr & Mrs Smith alone. The parents outlined to us their concerns that their 2 children Jodie (6years) & John (9years), were expressing no grief relating to the death of their elder sister Julie, who died in a car crash in September 1997. Mr & Mrs Smith were concerned about how the loss was affecting them in both their achievement and behaviour at school, and expressed a wish that they were more able to talk about the issue as a family. Our 5 meetings were spent looking at the effect Julie’s death had had on both the parents and the children, and the stories they had developed for understanding what had happened. At the family’s request we also invited the Headmistress of the children’s school, Mrs Small, to look at ways the children could express their grief about Julie’s death within the school setting. In addition we thought about ways they might be supported to develop their concentration, when distracted or upset at school. The family used all of the meetings to their fullest, and communication concerning the bereavement improved very rapidly. The children also reported feeling happier at school. We had planned to continue, but the family phoned and left a message to say they felt things had improved at home and at school and they would contact us again if the need arose. We left it with them that we would be very happy to see them again if requested. Yours sincerely Dr Peter Stratton Family Therapist On behalf of The Leeds Family Therapy Team c.c. Mrs Small, Headmistress, Jacob School
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Appendix VI : Session Notes Record Form SYSTEMIC FAMILY THERPY MANUAL SESSION NOTES Record Sheet Date of Session
Session
Number
Who attended therapy?
Therapist name Team member names Main themes of the session
Include key language used by family
Main themes continued
Team observations
Clearly labelled as impressions
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Interventions
Key points/ideas/decisions to follow up in later sessions 1.
2.
3.
Proscribed Practices included in session
Justification
1. 2. 3.
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Appendix VII – Diagonistic Interview Outline MULTIPLE FAMILY GROUP THERAPY DIAGNOSTIC INTERVIEW OUTLINE ©1993 by Lewis N. Foster
I. Generally: A. Work toward an active interpretation of content, but focus on process, and have fun; B. Be as unbiased as possible in your observation of the families, don't be judgmental; C. Establish the therapists' control --- a therapist must be in control because dysfunctional families are not in control. The families will feel secure that the therapist can handle, and not be shocked by, what happens in the multiple family group therapy session. D. Where in the family life-cycle are the families, and at what stage of development are the family members? II. Methods (see the Evaluation and Session Guide form): A. Take the time to make the families as comfortable as possible. Treat them as though they are in your living room. B. Select out the important family themes. A theme(s) will emerge very early in the session. Help the families to stick with the theme(s) instead of wandering. It is more gainful for both the families and the therapist. C. Once a theme is selected it should be discussed by each family member. Encourage interaction between the families regarding the theme, taking the theme back to the therapist for clarification if the discussion becomes punitive in nature. D. Try to delineate areas of consensus among family members on problem issues. Point out commonalities between families. E. Summarize and reframe as needed. F. Contract with the families for three sessions. It will be easier to get the families to agree to three sessions than eight or ten, for example. Know that around the third or forth session each family will come to the group in crisis. This will help you keep the family in treatment for another three sessions. Begin to think about what the crisis may be about. G. Establish as definitely as possible the conditions for treatment. Clarify the therapist's expectations (for example, who is expected to attend) and maintain an orientation to the presenting problem(s). H. Some education on Enhancing Intimacy, Managing Conflict, Parenting, Dependency, or other issues may be needed.
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III. Assessment (see Assessing The Family Dance) is an on going process from session to session and is done in the Multiple Family Therapy Group: A. Investigate the internal organization of the families (their family dance). 1. What kind of support do they give each other and how do they communicate intimacy? 2. What kind of satisfaction of needs do they supply for each other? 3. What are the patterns of communication? 4. What are the lines of authority and who is the functioning head of the individual families? 5. How do the families share pleasures and problems? 6. What are the sex identities and sex roles in the families? 7. What are the parent-child interactions about? 8. What are the alliances between family members? 9. What is the value system of the families? 10. What are the struggles and goals? 11. Who becomes a leader in the group? B. The external organization of patterns of interaction of the families (their connection with society). 1. What are the contacts with the outside? a. social network b. kin network c. church 2. What is their position in their sub-cultural system? a. economic b. race c. kinship d. social C. Conflicts, Conflict Styles, and Themes. 1. What are the sources of conflict? 2. What are the resources and available coping mechanisms mobilized to deal with conflicts? Ways of coping can include the following: a. Intensification of some dyadic relationships. b. The mobilization of some outside or external support such as peers, neighbors, the paramour, or other "sympathetic ears." c. Change of environment for one or more family members. d. Re-peopling, or an increase or decrease in family participants as occurs with marriage, birth, death, divorce, extended family moving in, pets, etc. e. Reorganization of roles. f. Emotional divorce or distancing, (this includes the "pseudomutual" relationship which is emotional distancing with accompanying complete denial of that distancing. Pseudomutual couples operate as if
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they are in complete agreement. There exists a pretense of lack of conflict in the midst of much difficulty with accompanying fear and/or incapacity to come close. Pseudomutuality may break up via the paramour). g. Compromise. h. Scapegoating. i. Healing, or an escape to health (healing is often seen in conjunction with scapegoating). 3. What are the pathogenic features used to deal with conflicts? D. Affect, Mood and Family Processes. 1. What are the affects (feelings and emotions conveyed by means of facial expressions) and moods of the families? 2. How do the families carry out affect and mood? E. Family Systems and Subsystems. 1. Marital Relationships a. The positives and negatives of the couples' sexual and emotional life. b. The perception of each other and of each other's role (this is also known as delineation, or the perception that a person has of his mate as seen through the behavior that both exchange and how each fits into the frame of the other's future needs). c. The stability of the marital relationships. d. The ways in which each spouse is separate and autonomous from each other, her/his family of origin, and others in the group. e. The role of adaptation of each partner. 2. Parenting Relationships a. How the parents cope with their children's social maturation outside the home and in the MFT group. b. Are there clear lines structurally between the parenting and marital relationships? c. Is there functional parental authority? d. At what developmental stages are the children? 3. Sibling Relationships a. The way the siblings organize themselves to educate the parents. b. The support they give each other in the process of each sibling's maturation or striving for independence. 4. Extended Family Relationships a. Have the parents successfully left home? b. Are grandparents actively involved in the parenting of the children? c. How involved are other extended family members?
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BASIC FAMILY THERAPY TECHNIQUES IN ALPHABETICAL ORDER
ACCOMMODATION The therapist makes personal adjustments in order to achieve a therapeutic alliance. Accommodating is: adapting to a family's communication style. – (Also see: “joining”)
ADVICE & INFORMATION These are derived from experience and knowledge of the family in therapy. They are used to calm down anxious members of families or reassure these individuals and families about certain actions.
AFFECTIVE CONFRONTATION Affective Confrontation of Rigid Patterns and Roles is used to interrupt rigid patterns. The goals may be a/ to raise clients' awareness when they do not know how they are contributing to the problem. b/ to raise a taboo subject that the client and others have been avoiding, or c/ to increase motivation to make changes when there is cognitivie awareness but no change in action.
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Examples: "When did you divorce your husband and marry your son?" "You are aware that you have abandoned the family to advance your career?" "What do you think would be more detrimental for your daughter: missing dance practice once a week for a few months or having her parents divorce? Do you want to ask your child what her preference is?"
ASKING PERMISSION Narrative therapists use permission questions to emphasize the democratic nature of the therapeutic relationship and to encourage clients to maintain a clear, strong sense of agency when talking with the therapist. Asking permission to ask a question goes against the prevailing assumption that therapists can ask any question they want tot gather information they purportedly need to help the client. Many clients feel compelled to answer these questions, even if they are not comfortable doings so. Narrative therapists show their sensitivity by asking permission before asking questions that are generally taboo or concern difficult objects. Example: "Would it be okay if I ask you some questions about your sex life?" In addition, throughout the interview, the therapist may ask for client input and permission to continue with a particular topic or line of questioning.
BEGINNER’S MIND "In the beginner's mind there are many possibilities, in the expert's mind there are few" Position of curiosity. Viewing experiences as though for the first time. A beginner's mind is very open, very alert. It is not filled with ideas and notions, truths and dogmas. It is receptive.
BOUNDARY FORMATION Part of the therapeutic task is to help the family define, or change the boundaries within the family. The therapist also helps the family to either strengthen or loosen boundaries, depending upon the family’s situation. Boundary making is a special case of enactment, in which the therapist defines areas of interaction that he rules open to certain members but closed to others. When Minuchin prevents the husband from “helping” his wife to discipline the girls, he is indicating that such specific transaction is for the mother and daughters to negotiate, and that father has nothing to do at this point; this specific way of making boundaries is also called blocking. Other instances of boundary making consist of prescriptions of physical movements: a son is asked to leave his chair (in between his parents) and go to another chair on the opposite side of the room, so that he is not “caught in the middle”; a grandmother is brought next to the therapist and far from her daughter and granddaughters who have been requested to talk; the therapist himself stands up and uses his body to interrupt visual contact between father and son, and so forth. Boundary making is a restructuring manoeuvre because it changes the rules of the game. Detouring mechanisms and other conflict avoidance patterns are disrupted by this intervention; underutilized skills are allowed and even forced to manifest themselves. The mother of the 5 year old is put in the position of accomplishing something without her husband’s help; husband and wife can and must face each other without their son acting as a buffer; mother and daughter continue talking because grandma’s intervention, which usually puts a period to their transactions, is now being blocked; father and son can not distract one another through eye contact. As powerful as the creation of specific events in the session may be, their impact depends to a large extent on how the therapist punctuates those events for the family. (Jorge Colapinto – Structural Family Therapy)
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ADDING COGNITIVE CONSTRUCTIONS 1.Advice & Information are derived from experience and knowledge of the family in therapy. They are used to calm down anxious members of families or reassure these individuals and families about certain actions. 2. Pragmatic fictions are formal expressions of opinion to help families and their members change. 3. Paradox is an apparently sound argument leading to a contradiction. It is used to motivate family members to search or alternatives. Family members may defy the therapists and become better or they may explore reasons why their behaviours are as they are and make changes in the ways members interact.
COMMUNICATION TECHNIQUES 1. MATCHING THE CLIENT’S LANGUAGE Example: Use the exact words the client uses to describe the problem in asking questions about what they have done before, when it is not so serious a problem, etc. Also, attend to client’s metaphors and utilize them also to extend observations, learn about their interests or hobbies to use metaphors that involve them. 2. MATCHING SENSORY MODALITIES Use words pertaining to “seeing” or “hearing” how things are and use words in the same vein. 3. CHANNELING THE CLIENT’S LANGUAGE Channel away from jargon into action descriptions used in every day language. This has the effect of depathologizing or normalizing clients’ situations. Gradually change your terminology to less serious, more positive words. (Example: Use the words “transitional period” as this give the client the opportunity to take solace in hearing that a problem is temporary, helps shape their expectations for the future). 4. USE OF VERB FORMS Create a reality where the problem is in the past and possibilities exist for the present and in the future. “When you had this problem before, you used to . . you were having difficulty . . how did the old you . . .” - Help clients make distinctions that are helpful (feeling like or thinking about . . . rather than doing it). 5. GIVE CLOSE EXAMINATION TO THEIR LANGUAGE AND YOURS. A.
Vague statements
B.
Unspecified verbs :
“He ruined the relationship” (how, what way?). “I am scared” (of what)
C.
Specify comparison:
“He is lazy” (compared to whom)
D.
Empty nouns:
respect, love, anger, depression
E.
Generalization:
all, none, always, never
F.
Cannot/will not vs. doesn’t /did not
G.
Characterizations
lazy, aggressive
H.
Challenge claims:
“How do you know you feel depressed”
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COMMUNICATION SKILL-BUILDING TECHNIQUES More often than not, it's a family's communication patterns and styles that lead to conflict and division. Communication patterns and processes are often major factors in preventing healthy family functioning. Faulty communication methods and systems are readily observed within one or two family sessions. A variety of techniques can be implemented to focus directly on communication skill building between a couple or between family members. Communication techniques are used to build skills that allow for effective communication between family members.Listening techniques including restatement of content, reflection of feelings, taking turns expressing feelings, and nonjudgmental brainstorming are some of the methods utilized in communication skill building. 1. REFLECTING involves having a member express her feelings and concerns, then having another member repeat back what he heard that person say. 2. REPEATING techniques involves having a member state how he feels, while another member repeats back what was said. Repeating and reflecting techniques allow members to better understand where the other is coming from and why she feels as she does. 3. FAIR FIGHTING TECHNIQUES focus on attentive listening and expressing feelings and concerns in a nonthreatening manner.
CONCLUSION The techniques suggested here are examples from those that family therapists practice. Counsellors will customize them according to presenting problems. With the focus on healthy family functioning, therapists cannot allow themselves to be limited to a prescribed operational procedure, a rigid set of techniques or set of hypotheses. Therefore, creative judgment and personalization of application are encouraged.
CONFIRMATION OF A FAMILY MEMBER: Using an affective word to reflect an expressed or unexpressed feeling of that family member. The therapist can join families from different positions of proximity. In the close position of proximity, he can affiliate with family members, perhaps even entering into coalition with some members against others. Probably the most useful tool of affiliation is confirmation. The therapist validates the reality of the family member(s) he joins. He searches out positives and makes a point of recognizing and awarding hem.
DEFRAMING Deframing is a strategy that works hand-in-hand with normalization. Like normalization, deframing is useful in many areas of therapy, but it can be particularly effective with involuntary clients. Deframing is defined as a strategy that introduces uncertainty into the client’s present and past view of things which have not been shown to be useful (O’Hanlon & Beadle, 1997 p. 35). Generally speaking, deframing focuses on the process of deconstructing past or present embedded, nonfunctional beliefs. It begins that process by introducing uncertainty into the therapeutic conversation. The therapist functions from a position of influence. What a therapist says or does not say in the course of a therapeutic interview influences the client. What is emphasized or ignored also makes a difference. Wording, phrasing, interrupting, or remaining silent: all influence what the client is feeling and thinking in the therapeutic relationship.
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In fact, for any given client statement, the therapist has the choice to take that statement in many directions. These choices usually involve—in some way—reifying the problem (i.e., lending credence to the fact that there is a problem). Deframing is another option. It works in the opposite direction of reification, and it effectively challenges the existence—or at least the power—of the problem (O’Hanlon & Weiner-Davis, 1989, pp. 52–53). Because postmodernist therapy views the congruent therapist a forming a system with the client, the therapeutic unity that evolves in that process represents a co-creative effort at finding a solution or dissolution to the problem. And so, it becomes clear that deframing—introducing uncertainty and doubt into the client’s cosmos—can be a powerful tool for influencing the client when dealing with a client’s dysfunctional, useless embedded beliefs. Examples of Deframing Questions -
How do you know that to be so? What makes you say that? How is that so? Where did you get that idea? On what basis have you reached that conclusion? What do you think is the origin of that belief? What is the foundation on which you rest your case? Did you ever have any doubts about those thoughts? Are you sure that’s accurate? What makes you so sure? What are the benefits in believing that? What influenced you to think along those lines? Why would you want to stick with that belief?
Example of a Deframing Sequence Therapist: How do you know that having a baby now will make you feel better? Client: It’ll be part of me. It’ll be something I can call my own. T: How is it important for you, right now, to have something you can call your own? C: It’s normal. That’s for sure. T: And what makes you say that? C: It’s all around me. T: What’s all around you? C: Kids. T: I’m sorry. I don’t understand. What does that mean? C: You know. Kids! My mother had 10. Lots of my girlfriends already have one or two. T: And how old are your friends? C: Sixteen. T: How is it that they had children at 16? C: Well, there’s no sense going to school if you’re failing semester after semester. T: So, they were failing all along? C: Yes. They were. T: I understand you’re still attending school. How are you doing in school? C: Barely hanging in there. T: Barely? How’s that? C: I’m passing, but barely passing. T: What are some things that passing could mean to you?
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C: I don’t know. I guess a lot of things: bad and good. T: Could you describe for me some of the good things? Deframing can be especially useful in the preceding example because it avoids a possible confrontation with a person who is firmly entrenched in an opposing belief system. It also avoids a certain kind of preachiness that can easily deteriorate the immediate relationship with the client. Deframing, as a deconstructive tool, effectively calls into question the validity of a client’s beliefs and motivations. In most cases, employing logic, for instance, a direct common-sense approach exhorting the teenager to stay in school and not have children, could easily prove to be ineffectual. Dealing with beliefs or belief systems head-on, in this case with an adolescent mindset, not always grounded in long-range perspectives, is usually doomed to failure. Deframing, instead, seems to offer a greater opportunity for success at penetrating a deeply embedded belief by inserting doubt into the client’s mindset. Deframing is achieved by calling into doubt the client’s beliefs or belief system. Another strategy related to deframing deals with the entire area of what a client may have intended but was not subsequently realized, or was manifested in strange and not easily recognizable ways. Positive connotation, a strategy that is easily overlooked, calls into play the whole area of client intentions, which can yield valuable information.
DETRIANGULATION The process by which an individual removes himself or herself from the motional field of two others. (triangulation is: Detouring conflict between two people by involving a third person, stabilizing the relationship between the original pair.)
DIAGNOSING Diagnosing is done early in the therapeutic process. The goal is to describe the systematic interrelationships of all family members to see what needs to be changed or modified for the family to improve. By diagnosing interactions, therapists become proactive, instead of reactive.
DIFFERENTIATION OF SELF Psychological separation of intellect and emotions and independence of self from others; opposite of fusion. (Fusion is a blurring of psychological boundaries between self and others and a contamination of emotional and intellectual functioning; opposite of differentiation.)
DISEQUILIBRIUM TECHNIQUES The following techniques are used to create a different perception of reality. 1. REFRAMING: The technique of reframing is a process in which a perception is changed by explaining a situation in terms of a different context. For example, the therapist can reframe a disruptive behaviour as being naughty instead of incorrigible allowing family members to modify their attitudes toward the individual and even help him or her makes changes. Reframing is putting the presenting problem in a perspective that is both different from what the family brings and more workable. Typically this involves changing the definition of the original complaint, from a problem of one to a problem of many. In a consultation (Minuchin, 1980) with the family of a 5-year-old girl who is described by her parents as “uncontrollable,” Salvador Minuchin waits silently for a couple of minutes as the girl circles noisily around the room and the mother tries to persuade her to behave, and then he asks the mother: “Is this how you two run your lives together?” If the consultant had asked something like “Is this the way she behaves usually?” he would be confirming the family’s definition of the problem as “located” in the child; by making it a matter of two persons, the consultant is beginning to reframe the problem within a structural perspective.
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ln the quoted example the consultant is feeding into the system his own reading of an ongoing transaction. Sometimes a structural family therapist uses information provided by the family as the building materials for his frame. Minutes later in the same session, the mother comments: “But we try to make her do it,” and the father replies “I make her do it.” Minuchin highlights then this brief interchange by commenting on the differences that the family is presenting: mother can not make her do it, father can. The initial “reality” described just in terms of the girl’s “uncontrollability” begins to be replaced by a more complex version inv9lving an ineffective mother, an undisciplined child, and maybe an authoritarian father. The consultant is reframing in terms of complementarity, a typical variety of the reframing technique, in which any given individual’s behavior is presented as contingent on somebody else’s behavior. The daughter’s uncontrollability is related to her mother’s ineffectiveness which is maintained by father’s taking over— which, on the other hand, is triggered by mother’s ineffectiveness in controlling the daughter. Another example of reframing through complementarity is the question “Who makes you feel depressed?” addressed to a man who claims to be “the” problem in the family because of his depression. As with all other techniques employed in structural family therapy, reframing is based on an underlying attitude on the part of the therapist. He needs to be actively looking for structural patterns if he is going to find them and use them in his own communications with the family. Whether he will read the 5-year-old’s misbehavior as a function of her own “uncontrollability” or of a complementary pattern, depends on his perspective. Also, his field of observation is so vast that he can not help but be selective in his perception; whether he picks up that “I make her do it” or lets it pass by, unnoticed amidst the flow of communication, depends on whether his selective attention is focused on structure or not. As with joining, as with unbalancing, reframing requires from the therapist a “set” without which the technique can not be mastered. The reframing attitude guides the structural family therapist in his search of structural embeddings for “individual” problems. In one case involving a young drug addict, the therapist took advantage of the sister’s casual reference to the handling of money to focus on the family’s generosity toward the patient and the infantile position in which he was being kept. In another case, involving a depressed adolescent who invariably arrived late at his day treatment program, the therapist’s reframing interventions led to the unveiling of a pattern of overinvolvement between mother and son: she was actually substituting for his alarm-clock. In an attempt to help him she instead was preventing him from developing a sense of responsibility. The intended effect of reframing is to render the situation more workable. Once the problem is redefined in terms of complementarity -for instance, the participation of every family member in the therapeutic effort acquires a special meaning for them. When they are described as mutually contributing to each other’s failures, they are also given the key to the solution. Complementarity is not necessarily pathological; it is a fact of life, and it can adopt the form of family members helping each other to change. Within such a frame, the therapist can request from the family members the enactment of alternative transactions. 2. ENACTMENT: Enactment is the actualization of transactional patterns under the control of the therapist. This technique allows the therapist to observe how family members mutually regulate their behaviors, and to determine the place of the problem behavior within the sequence of transactions. Enactment is also the vehicle through which the therapist introduces disruption in the existent patterns, probing the system’s ability to accommodate to different rules and ultimately forcing the experimentation of alternative, more functional rules. Change is expected to occur as a result of dealing with the problems, rather than talking about them. In the case of the uncontrollable girl, the consultant, after having reframed the problem to include mother’s ineffectiveness and father’s hinted authoritarianism, sets up an enactment that will challenge that “reality” and test the family’s possibilities of operating according to a different set of assumptions. He asks the mother whether she feels comfortable with the situation as it is—the grown ups trying to talk while the two little girls run in circles screaming and demanding everybody’s attention. When mother replies that she feels tense, the therapist invites her to organize the situation in a way that will feel more comfortable, and finishes his request with a “Make it happen” that will be the motto for the following sequence. The purpose of this enactment is multileveled. At the higher, more ambitious level, the therapist wants to facilitate an experience of success for the mother, and the experience of a successful mother for the rest of the
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family. But even if mother should fail to “make it happen” the enactment will at least fulfill a lower-level goal: it will provide the therapist with an understanding of the dysfunctional pattern and of the more accessible routes to its correction. In our specific example, the mother begins to voice orders in quick succession, overlapping her own commands and hence handicapping her own chances of being obeyed. The children seem deaf to what she has to say, moving around the room and only sporadically doing what they are being asked to do. The consultant takes special care to highlight those mini-successes, but at the same time he keeps reminding the mother that she wanted something done and “It is not happening—make it happen.” When father, following the family rule, attempts to add his authority to mother’s, the consultant blocks his intervention. The goal of the enactment is to see that mother “makes it happen” by herself; for the same reason, the consultant ignores mother’s innumerable violations to practically every principle of effective parenting. To correct her, to teach her how to do it would defeat the purpose of the enactment. The consultant keeps the enactment going on until the mother eventually succeeds in organizing the girls to play by themselves in a corner of the room, and then the adults can resume their talk. The experience can later be used as a lever in challenging the family’s definition of their reality. If mother had not succeeded, the consultant would have had to follow a different course—typically one that would take her failure as a starting point for another reframing. Sometimes the structural family therapist organizes an enactment with the purpose of helping people to fail. A classical example is provided by the parents of an anorectic patient who undermine each other in their competing efforts to feed her. In this situation the therapist may want to have the parents take turns in implementing their respective tactics and styles, with the agenda that they should both fail and then be reunited in their common defeat and anger toward their daughter—now seen as strong and rebellious rather than weak and hopeless. Whether it is aimed at success or at failure, enactment is always intended to provide a different experience of reality. The family members’ explanations for their own and each other’s behaviors, their notions about their respective positions and functions within the family, their ideas about what their problems are and how they can contribute to a solution, their mutual attitudes are typically brought in-to question by these transactional microexperiences orchestrated by the therapist. Enactments may be dramatic, as in an anorectic’s lunch (Rosman, Minuchin & Liebman, 1977, pp. 166—169), or they can be almost unnoticeably launched by the therapist with a simple “Talk to your son about your concerns, I don’t know that he understands your position.” If this request is addressed to a father that tends to talk to his son through his wife, and if mother is kept out of the transaction by the therapist, the structural effects on behavior and perception may be powerful, even if the ensuing conversation turns out to be dull. The real power of enactment does not reside in the emotionality of the situation but rather in the very fact that family members are being directed to behave differently in relation to each other. By prescribing and monitoring transactions the therapist assumes control of a crucial area—the rules that regulate who should interact with whom, about what, when and for how long. 3. BOUNDARY MAKING Boundary making is a special case of enactment, in which the therapist defines areas of interaction that he rules open to certain members but closed to others. When Minuchin prevents the husband from “helping” his wife to discipline the girls, he is indicating that such specific transaction is for the mother and daughters to negotiate, and that father has nothing to do at this point; this specific way of making boundaries is also called blocking. Other instances of boundary making consist of prescriptions of physical movements: a son is asked to leave his chair (in between his parents) and go to another chair on the opposite side of the room, so that he is not “caught in the middle”; a grandmother is brought next to the therapist and far from her daughter and granddaughters who have been requested to talk; the therapist himself stands up and uses his body to interrupt visual contact between father and son, and so forth. Boundary making is a restructuring manoeuvre because it changes the rules of the game. Detouring mechanisms and other conflict avoidance patterns are disrupted by this intervention; underutilized skills are allowed and even forced to manifest themselves. The mother of the 5 year old is put in the position of accomplishing something without her husband’s help; husband and wife can and must face each other without their son acting
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as a buffer; mother and daughter continue talking because grandma’s intervention, which usually puts a period to their transactions, is now being blocked; father and son can not distract one another through eye contact. As powerful as the creation of specific events in the session may be, their impact depends to a large extent on how the therapist punctuates those events for the family. 4. PUNCTUATION: Punctuation is “the selective description of a transaction in accordance with a therapist’s goals”. Therefore it is verbalizing appropriate behaviour when it happens. Punctuation is a universal characteristic of human interaction. No transactional event can be described in the same terms by different participants, because their perspectives and emotional involvements are different. A husband will say that he needs to lock himself in the studio to escape his wife’s nagging; she will say that she can not help protesting about his aloofness. They are linked by the same pattern, but when describing it they begin and finish their sentences at different points and with different emphases. The therapist can put this universal to work for the purposes of therapeutic change. In structural family therapy punctuation is the selective description of a transaction in accordance with the therapist’s goals. In our example of enactment, the consultant organized a situation in which the mother was finally successful, but it was the consultant himself who made the success “final.” Everybody—the mother included—expected at that point that the relative peace achieved would not last, but the consultant hastened to put a period by declaring the mother successful and moving to a different subject before the girls could misbehave again. If he had not done so, if he had kept the situation open, the usual pattern in which the girls demanded mother’s attention and mother became incompetent would have repeated itself and the entire experience would have been labeled a failure. Because of the facts of punctuation, the difference between success and failure may be no more than 45 seconds and an alert therapist. Later in the same session the consultant asked the parents to talk without allowing interruptions from their daughter. The specific prescription was that father should make sure that his wife paid attention only to him and not to the girl. Given this context for the enactment, whenever mother was distracted by the girl the therapist could blame father for the failure—a different punctuation from what would have resulted if the consultant had just asked mother to avoid being distracted. A variety of punctuation is intensity, a technique that consists of emphasizing the importance of a given event in the session or a given message from the therapist, with the purpose of focusing the family’s attention and energy on a designated area. Usually the therapist magnifies something that the family ignores or takes for granted, as another way of challenging the reality of the system. Intensity is achieved sometimes through repetition: one therapist put the same question about 80 times to a patient who had decided to move out of his parents’ home and did not do so: “Why didn’t you move?” Other times the therapist creates intensity through emotionally charged interventions (“It is important that you all listen, because your sister can die”), or confrontation (“What your father did just now is very disrespectful”). In a general sense, the structural family therapist is always monitoring the intensity of the therapeutic process, so that the level of stress imposed on the system does not become either unbearable or too comfortable. 4. UNBALANCING: This is a procedure wherein the therapist supports an individual or subsystem against the rest of the family. When this technique is used to support an underdog in the family system, a chance for change within the total hierarchical relationship is fostered. Unbalancing is a term that could be used to encompass most of the therapist’s activity since the basic strategy that permeates structural family therapy is to create disequilibrium. In a more restricted sense, however, unbalancing is the technique where the weight of the therapist’s authority is used to break a stalemate by supporting one of the terms in a conflict. Toward the end of the consultation with the family of the “uncontrollable” girl, Minuchin and the couple discuss the wife’s idea that her husband is too harsh on the girls:
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Minuchin. Why does she think that you are such a tough person? Because I think she feels that you are very tough, and she needs to be flexible because you are so rigid. I don’t see you at all as rigid, I see you actually quite flexible. How is that your wife feels that you are rigid, and not understanding? Husband:
I don’t .know, a lot of times I lose my temper I guess, right? That’s probably why.
Wife: Yeah. Minuchin: So what? So does she. I have seen you playing with your daughter here and I think you are soft and flexible, and that you were playing in a rather nice and accepting way. You were not authoritarian, you had initiative, your play engaged her. . . . That is what I saw. So why is that she sees you only as rigid and authoritarian, and she needs to defend the little girls from your (punches father’s knee)? I don’t see you that way at all. Husband: I don’t know, like I say, the only thing I can think of, really, is because I lose my temper with them. Wife: Yes, he does have a short fuse. Minuchin: So what? So do you. Wife: No, I don’t. Minuchin: Oh you don’t. Okay, but that doesn’t mean that you are authoritarian, and that doesn’t mean that you are not understanding. Your play with your daughter here was full with warmth and you entered very nicely, and as a matter of fact she enjoyed the way in which you entered to play. So, some way or other your wife has a strange image of you and your ability to understand and be flexible. Can you talk with her, how is that she sees that she needs to be supportive and defending of your daughter? I think she is protecting the girls from your short fuse, or something like that. Talk with her about that, because I think she is wrong. Wife: That’s basically what it is, I’m afraid of you really losing your temper on them, because I know how bad it is, and they are little, and if you really hit them with a temper you could really hurt them; and I don’t want that, so that’s why I go the other way, to show them that everybody in the house doesn’t have that short fuse. Husband. Yes, but I think when you do that, that just makes it a little worse because that makes her think that she has somebody backing her, you know what I mean? Minuchin (shakes husband’s hand): This is very clever, and this is absolutely correct, and I think that you should say it again because your wife does not understand that point. In this sequence the consultant unbalances the couple through his support of the husband. His focus organizes him to disregard the wife’s reasons, which may seem unfair at first sight. But it is in the nature of unbalancing to be unfair. The therapist unbalances when he needs to punctuate reality in terms of right and wrong, victim and villain, actor and reactor, in spite of his knowing that all the comings and goings in the family are regulated by homeostasis, and that each person obliges with his and her own contribution; because the therapist also knows that an equitable distribution of guilt’s and errors would only confirm the existing equilibrium and neutralize change potentialities. While unbalancing is admittedly and necessarily unfair, it is not arbitrary. Diagnostic considerations dictate the direction of the unbalancing. In the case of our example, the consultant chooses to support the husband rather than the wife because in so doing he is challenging a myth that both spouses share: initially the husband agrees to his wife’s depiction of him, and it is only through the intensity of the consultant’s message that he begins to challenge it. At different points in the same session, the consultant supports the wife as a competent mother and questions the idea of her unremitting inefficiency— again, a myth defended not only by her husband but by herself as well. In the last analysis unbalancing—like the entire structural approach—is a challenge to the system rather than an attack on any member..
LESSONS IN EFFECTIVE COMMUNICATION If each member of the family is interdependent on other members of the family it stands to reason that dysfunction with one will affect the whole. Effective communication is an important lessons that family systems psychologist incorporate into group and individual family therapy sessions. To create an effective solution to
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any dysfunction or problem in the group dynamic requires effective communication so that all members of the group or family are in touch with each other. For example, the mother who commits to more and more tasks in order to compensate for her family's overextending commitments may stretch herself to the limits because she lacks the ability to communicate how stretched thin she is. Instead, she promises to do more and more, exerting increasing emotional and mental stress upon herself when she cannot meet all the commitments she is making. This leads to disappointment and disagreement in the family. When other members of the family express their disappointment, this impacts her already damaged sense of self-worth leading to a vicious cycle that may result in depression, generalized anxiety disorder, substance abuse and more. In every way, however, the family is not happy. Therapists teach effective communication skills and the importance for mom to let the family know she is overextended and that she either needs help or they need to rearrange priorities in order to break out of the circular causality of this family's problems. Effective communication allows a family to dialogue on their problems, concerns and feelings without lashing out or feeling obligated to resolve the problems being shared. A large portion of effective communication resides in active listening, a skill that must be learned.
EMOTIONAL CUT-OFF Bowen's term for flight from an unresolved emotional attachment Examples of emotional cut-off
A man refuses to speak to his sister for 15 years. The reason? At the time of their mother's death, he was left alone to care for her as she died. Then, to add insult to injury, her sister questioned his family loyalty.
After years of criticism and rejection, a wife decides not to speak to her in-laws anymore, a decision that causes chronic problems in her marriage.
The child of a close-knit family moves across the country and only communicates with the family through greeting cards on holidays.
Emotional cut-off is a process in which one or both parties in a relationship effectively terminate that relationship in response to uncomfortable feelings between them. It's not uncommon within families. To understand emotional cut-off it is necessary to understand the concept of emotional fusion. Fusion has to do with the degree of emotional reactivity that exists between people. If our reactivity to each other is so powerful that I cannot define and hold my own position as a self in our relationship, I might feel I need to "cut-off" in order to feel functionally independent. If my feelings in reaction to you are intense and unpleasant enough, I may "cut-off" from you rather than dealing with my own strong feelings. Once I am "cut-off" from you, I no longer feel I have to deal with our relationship. It relieves my anxiety. The problem with emotional cut-off is that it is a short-term solution, which creates a long-term problem. People grow, emotionally, through working out relationship hassles. In the process, they achieve "differentiation," the polar opposite of fusion. First, I can tell the difference between me and you. I don't have to react blindly to things you do or say. I am myself and don't mind saying so. Second, I can differentiate my emotions from my reason. I can choose my responses rather than reacting automatically (blindly). This is maturity: differentiating self from other; differentiating emotion from reason.
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Article Source: http://EzineArticles.com/?expert=Hugh_Leavell Emotional cut off can have the illusion of appearing like differentiation. They are similar in that a person is realizing that their thoughts and feelings are different from their families. However, the difference is that people who are emotionally cut off are no longer connected. The classic example of emotional cut off is the family member who moves to another state or country just to “get away from his crazy relatives.” While this may seem on the surface like maturity, is actually not as mature as being able to maintain that same sense of separateness while remaining in contact with one’s family. The truly differentiated person is not so threatened that they need to travel hundreds of miles away and change their phone number in order to maintain their separateness. They are able to be around those who think and feel differently, while not being negatively affected. I believe that emotional cut off is sometimes a precursor to differentiation. Sometimes it is easier to be comfortable “at home” after going away and having and “away home” experience. (Brent Henrikson)
THE EMPTY CHAIR The empty chair technique, most often utilized by Gestalt therapists (Perls, Hefferline, & Goodman, 1985), has been adapted to family therapy. In one scenario, a partner may express his or her feelings to a spouse (empty chair), then play the role of the spouse and carry on a dialogue. Expressions to absent family, parents, and children can be arranged through utilizing this technique.
ENACTMENT The process of enactment consists of families bringing problematic behavioural sequences into treatment by showing them to the therapist a demonstrative transaction. This method is to help family members to gain control over behaviours they insist are beyond their control. The result is that family members experience their own transactions with heightened awareness. In examining their roles, members often adapt new, more functional ways of acting.
FAMILY CHOREOGRAPHY In family choreography, arrangements go beyond initial sculpting; family members are asked to position themselves as to how they see the family and then to show how they would like the family situation to be. Family members may be asked to re-enact a family scene and possibly re-sculpt it to a preferred scenario. This technique can help a stuck family and create a lively situation.
FAMILY CONTRACT The family contract is a therapeutic tool that allows families to negotiate terms and come to an agreement on how they want to handle future family problems and to commit to positive change. A family contract, for example, may detail that a child who copes with an eating disorder commits to talking about her feelings on weight, eating and social perception. Her parents will then commit to listening and not dismissing her feelings. All parties commit to working together to build self-esteem and a healthy lifestyle. Family contracts are a positive tool in the arsenal of a family systems psychologist because they are facilitated agreement that a family makes to avoid future dysfunction. The family contract also helps family members recognize when problems are occurring, particularly if elements of the contract are not being upheld. Effective family therapy techniques treat the entire family as an emotional unit of which each family member is a part of and acknowledges that what affects one member of the family affects the whole family. By treating the whole family as a unit, the family also becomes a part of the solution.
FAMILY COUNCIL MEETINGS Family council meetings are organized to provide specific times for the family to meet and share with one another. The therapist might prescribe council meetings as homework, in which case a time is set and rules are outlined. The council should encompass the entire family, and any absent members would have to abide by
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decisions. The agenda may include any concerns of the family. Attacking others during this time is not acceptable. Family council meetings help provide structure for the family, encourage full family participation, and facilitate communication.
FAMILY FLOOR PLAN The family floor plan technique has several variations. Parents might be asked to draw the family floor plan for the family of origin. Information across generations is therefore gathered in a nonthreatening manner. Points of discussion bring out meaningful issues related to one's past. Another adaptation of this technique is to have members draw the floor plan for their nuclear family. The importance of space and territory is often inferred as a result of the family floor plan. Levels of comfort between family members, space accommodations, and rules are often revealed. Indications of differentiation, operating family triangles, and subsystems often become evident. Used early in therapy, this technique can serve as an excellent diagnostic tool (Coppersmith, 1980).
FAMILY LIFE CYCLE Stages of family life from separation from one's parents to marriage, laving children, growing older, retirement, and, finally, death. Jjust like an individual, a family has developmental tasks and key (second-order) transitions like leaving home, joining of families through marriage, families with young children (the key milestone, and one that initiates vertical realignment), families with adolescents, launching children and moving on, families in later life. Key question: "How well did the family do on its last assignment?" Horizontal stressors are those involving these transitional assignments; vertical stressors are transmitted mainly via multigenerational triangling. Symptoms tend to occur when horizontal and vertical stressors intersect. Divorce adds extra developmental steps for all involved families. Carter and Mcgoldrick elaborated the family life cycle a. Leaving home b. Joining of families through marriage c. Families with young children d. Adolescence e. Launching children and moving on f. Families in later life
FAMILY PHOTOS The family photos technique has the potential to provide a wealth of information about past and present functioning. One use of family photos is to go through the family album together. Verbal and nonverbal responses to pictures and events are often quite revealing. Adaptations of this method include asking members to bring in significant family photos and discuss reasons for bringing them, and locating pictures that represent past generations. Through discussion of photos, the therapist often more clearly sees family relationships, rituals, structure, roles, and communication patterns.
FAMILY SCULPTING Developed by Duhl, Kantor, and Duhl (1973), family sculpting provides for recreation of the family system, representing family members relationships to one another at a specific period of time. The family therapist can use sculpting at any time in therapy by asking family members to physically arrange the family. Adolescents often make good family sculptors as they are provided with a chance to nonverbally communicate thoughts and feelings about the family. Family sculpting is a sound diagnostic tool and provides the opportunity for future therapeutic interventions.
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An activity in which family members place themselves in postures symbolic of the family dynamics. Satir placed people in position herself to activate right-brain experiencing.
FAMILY SYSTEM STRATEGIES A family operates like a system in that each member's role contributes to the patterns of behaviour that make the system what it is. Certain therapy techniques are designed to reveal the patterns that make a family function the way it does. The tracking technique is a recording process where the therapist keeps notes on how situations develop within the family system. Interventions used to address family problems can be designed based on the patterns uncovered by this technique. Family sculpting is another technique that's used to realign relationship patterns within the group. Members are asked to physically arrange where they want each member to be in relation to the others. This technique provides insight into relationship conflicts within the family.
THE GENOGRAM One of the best ways to begin therapy and to gain understanding of how the emotional system operates in your family system is to put together your family genogram. Studying your own patterns of behaviour, and how they relate to those of your multigenerational family, reveals new and more effective options for solving problems and for changing your response to the automatic role you are expected to play. The genogram, a technique often used early in family therapy, provides a graphic picture of the family history. The genogram reveals the family's basic structure and demographics. (McGoldrick & Gerson, 1985). Through symbols, it offers a picture of three generations. Names, dates of marriage, divorce, death, and other relevant facts are included in the genogram. It provides an enormous amount of data and insight for the therapist and family members early in therapy. As an informational and diagnostic tool, the genogram is developed by the therapist in conjunction with the family.
GOAL SETTING Start small — “What will be the first sign that things are moving in the right direction?” Goals must be concrete.
ICEBREAKER COMPLIMENT OR POSITIVE STATEMENT Generally speaking, when therapy begins with an involuntary client, one tool that is worth employing as a matter of course involves the use of an icebreaker compliment or positive statement. The creative use of an appropriate remark in the form of a compliment or some kind of positive statement to the client can go a long way in easing tension in the client. It is considered creative when it requires the counselor to immediately incorporate incidental elements in an appropriate and credible context for a compliment directed at the client; or, it may simply state something positive to set the tone. The contexts for the compliment or the positive statement may include: • Relating situational factors, such as the client’s attendance or promptness for that day or the client’s care and persistence in filling out the required office forms • Thanking the client for coming to the session despite environmental factors such as the weather (good or bad) and any other reasonably credible conditions relating to the client. The icebreaker compliment or positive statement is deemed pre-emptive because the counselor delivers it at the very beginning of the first session. It is poised and intended to make the client feel relaxed and welcomed. Examples of Icebreaker Compliments or Positive Statements -
I’d like to thank you for getting here so promptly today. I do appreciate that very much. I’d like to thank you for taking the time to come in today. I’d like to thank you for filling out all those forms. I’d like to thank you for answering all those questions on the forms you filled out. I’d like to thank you for coming in and giving me the time to go over some things with you. I’d like to thank you for coming on time today on such a gloomy (or gorgeous) day.
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IDENTIFICATION Family therapy techniques are used with individuals and families to address the issues that effect the health of the family system. The techniques used will depend on what issues are causing the most problems for a family and on how well the family has learned to handle these issues. Strategic techniques are designed for specific purposes within the treatment process. Background information, family structuring and communication patterns are some of the areas addressed through these methods.
INFORMATION-GATHERING TECHNIQUES At the start of therapy, information regarding the family's background and relationship dynamics is needed to identify potential issues and problems. 1. The Genogram The genogam is a technique used to create a family history, or geneology. Both the family and therapist work to create this diagram. 2. Family Photos Having family members bring in meaningful family photos is also a technique used to gather information as to how each member perceives the others. 3. Family Floorplan One other technique involves having family members draw up floor plans of their home. This exercise provides information on territorial issues, rules, and comfort zones between different members.
INTENSITY Intensity is the structural method of changing maladaptive transactions by using strong affect, repeated intervention, or prolonged pressure. Intensity works best if done in a direct, unapologetic manner that is goal specific.
INTERVENTION TECHNIQUES Intervention techniques are directives given by the therapist to guide a family's interactions towards more productive outcomes. Reframing is a method used to recast a particular conflict or situation in a less threatening light. A father who constantly pressures his son regarding his grades may be seen as a threatening figure by the son. Reframing this conflict would involve focusing on the father's concern for his son's future and helping the son to "hear" his father's concern instead of constant demands for improvement. Another technique has the therapist placing a particular conflict or situation under the family's control. What this means is, instead of a problem controlling how the family acts, the family controls how the problem is handled. This requires the therapist to give specific directives as to how long members are to discuss the problem, who they discuss it with, and how long these discussions should last. As members carry out these directives, they begin to develop a sense of control over the problem, which helps them to better deal with it effectively.
INVOLUNTARY CLIENT SHEMA Citing original work done by Insoo Kim Berg (1990) together with Eve Lipchik regarding initial approaches in dealing with involuntary clients, Walter and Peller present a useful involuntary client schema that reflects and encapsulates the joint efforts of all four counselors. Their collective work centers on the employment of a specific sequence of questions aimed at overtly clarifying the relationship between the counselor and the involuntary client (or patient) at the outset of the first session (Walter and Peller, 1992, pp. 247–253). The purpose of this schema is to effect a transformation of the mindset of an involuntary client into that of a voluntary client in the sense that the then-converted voluntary client may care to propose a goal which can become the focus of therapy.
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Before proceeding with the illustration of the schema, a few conditions warrant consideration. If the therapist does not succeed in negotiating this new mindset with the use of the schema, and if the involuntary client chooses to remain the same (i.e., not establish a goal), and if the series of appointments must be continued because of contractual arrangements (e.g., by the courts or by other agencies), then all the possible consequences (the resulting constraints) will be explained to the client. One possible consequence may involve the fact that future therapy sessions may be terminated by the therapist despite the existence of a contractual agreement with outside agencies (courts). This factor often compels clients to rethink their position. Even if the client is resistant to change and does not admit to the existence of a problem, there is hope that during the session the client could have a change of heart and may want to discuss the problem and establish a related goal. The schema shown below illustrates the basic approach to changing the mindset of clients from an involuntary to a voluntary status. Those questions posed by the therapist make reference to the person or agent who initiated the request (or order) to have the client attend therapy. The initiator may be a spouse, a parent, or a court judge. Walter and Peller’s schema is carried out with involuntary clients in the following manner. Our work with them follows this schema: - Whose idea is it that you come here? - What makes think you should come here? - What does want you to be doing differently? - Is this something you want? (Goal frame) If yes, proceed as with a voluntary client. If no, ask: Is there something you would like out of coming here? (Goal frame) - If yes, proceed as with a voluntary client. - If no, explore the consequences of not coming to sessions. Source: Walter, J. L., and Peller, J. E. (1992). Becoming solution-focused in brief therapy, 247. New York: Routledge. Carpetto and Peller suggest asking the client again “what the referring person expects out of the client coming in for therapy.” If that is not clear, it should be clarified by seeking the specifics. Again, if the client still insists on not abiding by the referring person’s goal, two options remain for the therapist: “say goodbye” to the client or “state conditions for further sessions if continued sessions are required by the court or agency policy” . In a nutshell, this is a flexible and effective general approach that will usually expedite the process of therapy. Like all strategies, there is no guarantee that it will work in all cases. Nonetheless, it is a highly recommended strategy because of the following considerations. • It allows clients to think seriously about the decision to accommodate or not to accommodate the referring person’s goal. • It allows clients to consider what they want to get out of coming to therapy. • It is particularly advisable as an initial approach because regardless of the outcome the client knows the options from the outset. • There are no hidden agendas, and a sense of collusion between the therapist and outside agencies or family initiators is completely avoided. • The process can help to pre-empt many unexpected problems from becoming greater problems. Even if the sessions become difficult, the relationship between therapist and client at least had been clarified and the options were plainly spelled out. By contrast, therapists who attempt to treat involuntary clients as voluntary clients (i.e., like any other client) in the initial session without the use of the schema (as presented by Walter and Peller or by a similar pre-emptive strategy) will most likely find their difficulties intensified in conducting therapy. If such is the case, then the therapist-client relationship in the initial and in forthcoming sessions may prove to be frustrating.
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After this initial strategy is employed with the involuntary client, the client may choose to become a voluntary client. If that is the case, then any number of approaches, including those suggested in the prior chapter, are readily available to begin the process of therapy, which would also include discussing the problem and establishing a goal.
JOINING This is the process of coupling that occurs between the therapist and the family, leading to the development of therapeutic system. In this process the therapist allies with family members by expressing interest in understanding them as individuals and working with and for them. In joining, the therapist becomes accepted as such by the family, and remains in that position for the duration of treatment; although the joining process is more evident during the initial phase of therapy, the maintenance of a working relationship to the family is one of the constant features in the therapist’s job. Joining is considered one of the most important prerequisites to restructuring. It is a contextual process that is continuous. Much of the success in joining depends on the therapist’s ability to listen, his capacity for empathy, his genuine interest in his client? dramas, his sensitivity to feedback. But this does not exclude a need for technique in joining. The therapist’s empathy, for instance, needs to be disciplined so that it does not hinder his ability to keep a certain distance and to operate in the direction of change. Contrary to a rather common misunderstanding, joining is not just the process of being accepted by the family; it is being accepted as a therapist, with a quota of leadership. Sometimes a trainee is described as “good at joining, but not at pushing for change”; in these cases, what in fact happens is that the trainee is not joining well. He is accepted by the family, yes, but at the expense of relinquishing his role and being swallowed by the homeostatic rules of the system. Excessive accommodation is not good joining. There are five ways of joining in structural family therapy.
1. Tracking: In tracking, the therapist follows the content of the family that is the facts. Getting information through using open-ended questions. Tracking is best exemplified when the therapist gives a family feedback on what he or she has observed or heard. According to Minuchin, tracking is where the therapist, “follows the content of the family’s communications and behaviour and encourages them to continue… In its simplist form it means to ask clarifying questions, to make approving comments, or to elicit amplification of a point.” (Minuchin (1974). With maintenance the therapist’s message seems to be, “I see you, I support you in this, I validate you and don’t judge”, in tracking the therapist’s message seems to be, “let me see if I am understanding correctly…can you help me by clarifying that last thing you said”. Tracking lets the therpist check with the family that she is understanding correctly, and at the same time she is allowing the family members to make clearer and more explicit the implicit feelings and thoughts of the members. Tracking reminds me of Roger’s idea of accurate empathy.
2. Mimesis: The therapist becomes like the family in the manner or content of their communications. According to Minuchin, “A therapist uses mimesis to accommodate to a family’s style and affective [feeling range]. He adopts the family’s tempo of communication slowing his pace, for example, in a family that is accustomed to long pauses and slow responses. In a jovial family he becomes jovial and expansive. In a family with a restrictive style, his communication becomes sparse.” (Minuchin (1974)) The task with mimesis is to join the family, to be engage in mutual acceptance with them. To be taking into the confidences of a family in difficulty (or any family for that matter) and be of help requires a lot of trust. Minuchin mentions that mimesis can happen without the awareness of the therapist as she endeavours to “tune into” her client family. When I read about mimesis I thought of the concept of building rapport as outlined in NLP.
3. Confirmation of a family member: Using an affective word to reflect an expressed or unexpressed feeling of that family member.
4. Accommodation:
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The therapist makes personal adjustments in order to achieve a therapeutic alliance. Joining and accommodation are two ways of describing the same process. Joining is used when emphasizing actions of the therapist aimed directly at relating to family members or the familysystem. Accommodation is used when the emphasis is on the therapist’s adjustment . . . in order to achieve joining. To join a family system, the therapist must accept the family’s organization and style and blend with them. (Minuchin, 1974, p.123) Diagnosis in family therapy is achieved through the interactional process of joining. (Minuchin, 1974, p. 130). Families like therapists accommodate to the other. A therapist “brings an idiosyncratic style of contacting, and a theoretical set. The family will have to accommodate to this package, in some fashion or another, and the therapist will have to accommodate to them. (Minuchin & Fishman, 1981) In family therapy, a diagnosis is the working hypothesis that the therapist evolves from his experiences and observations upon joining the family. This type of assessment, with its interpersonal focus, differs radically from the process usually called diagnosis in psychiatric terminology. A psychiatric diagnosis involves gathering data from or about the patient and assigning a label to the complex of information gathered. A family diagnosis, however, involves the therapist’s accommodation to the family to form a therapeutic system, followed by his assessment of his experiences of the family’s interaction in the present. (Minuchin, 1974, p. 129)
5. Maintenance Maintenance is one of the techniques used in joining. The therapist lets himself be organized by the basic rules that regulate the transactional process in the specific family system. If a four-generation family presents a rigid hierarchical structure, the therapist may find it advisable to approach the great-grandmother first and then to proceed downward. In so doing, the therapist may be resisting his first empathic wish—perhaps to rescue the identified patient from verbal abuse—but by respecting the rules of the system he will stand a better chance to generate a therapeutic impact. However, in order to avoid total surrender the therapist needs to perform his maintenance operations in a way that does not leave him powerless; he does not want to follow the family rule that Kathy should be verbally abused whenever somebody remembers one of her misdoings. As with any other joining technique, maintenance entails an element of challenge to the system. The therapist can for instance approach the great-grandmother respectfully but he will say: “I am very concerned because I see all of you struggling to help, but you are not being helpful to each other.” While the rule “great-grandma first” is being respected at one level, at a different level the therapist is positioning himself one up in relation to the entire system, including grandmother. He is joining the rules to his own advantage. While maintenance concentrates on process, the technique of tracking consists of an accommodation of the therapist to the content of speech. In tracking, the therapist follows the subjects offered by family members like a needle follows the record groove. This not only enables him to join the family culture, but also to become acquainted with idiosyncratic idioms and metaphors that he will later use to endow his directive statements with additional power—by phrasing them in ways that have a special meaning for the family or for specific members. At times the therapist will find it necessary to establish a closer relation with a certain member, usually one that positions himself or is positioned by the family in the periphery of the system. This may be done through verbal interventions or through mimesis, a nonverbal response where the therapist adopts the other person’s mood, tone of voice or posture, or imitates his or her behaviour -crosses his legs, takes his jacket off, lights a cigarette. In most of the occasions the therapist is not aware of the mimetic gesture itself but only of his disposition to get closer to the mimicked member. In other cases however, mimesis is consciously used as a technique: for instance, the therapist wants to join the system via the children and accordingly decides to sit on the floor with them and suck his thumb.
NORMALIZATION Normalization is generally defined as a therapist’s use of indirect or direct statements that refer to client problems not necessarily viewed “as pathological manifestations but as ordinary difficulties of life” (O’Hanlon & Weiner-Davis, 1989, p. 93). The goal of this strategy is to pre-emptively depathologize client problems and
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the client’s view of the problems. However, normalization does not mean that criminal acts are honored, approved, or condoned as being normal. Rather, normalization attempts to reframe client problem situations as being understood as human. The normalization statement also contains the counselor’s implicit acceptance of the client. It recalls Rogers’s sense of respect for the client and the client situation. In conducting psychotherapy with people who have committed criminal acts, normalization occurs when the therapist accepts the ease with which vulnerable people can fall into criminal patterns. It does not mean acceptance of the crimes. Examples of Indirect Normalizing Statements When therapists normalize the difficulties clients bring to therapy, clients seem relieved. Imagine the calming effect when the “expert” appears unruffled by your description of the problem. This reaction influences clients to think that perhaps things aren’t as bad as they had thought. This is an area where it is perhaps best to communicate indirectly, by what is not said, by what one remains unruffled about. The most common way we normalize during the session is to say things such as, “Naturally,” “Of course,” “Welcome to the club,” “So what else is new?” and, “That sounds familiar,” when people are reporting things they think are unusual or pathological. (p. 94) More complicated than the indirect normalization and its typically implicit suggestion of understanding the client situation, normalization can also take the form of a direct statement that may also be expressed as a compliment. Direct normalization usually depends on incorporating material (content) that the client has just related. The direct statement requires more work and creativity on behalf of the therapist. It also has a larger overview, and it can be particularly effective and uplifting to the client when the therapist manages to find the right wording and metaphors to deflate the emotional overlay of pathological fears the client may be experiencing. In reality, normalization is a special form of reframe. Normalization, in effect, emphasizes human qualities such as one’s vulnerability in experiencing problems in living (O’Hanlon & Beadle, 1997, p. 40). The reality of the human condition involves experiencing reactions to those life events and situations that are unforeseen or are simply normal transitions in the life cycle. To all losses, to all adjustments and changes, there characteristically ensue conditions that are sometimes difficult and unmanageable. Unfortunately, self-blaming, low self-worth, and poor support systems exacerbate these conditions. However, normalization may often become a first step in lessening the impact of these negative reactions. Normalization can offer recognition (a compliment) of the client’s efforts or persistence in coping with the problem (O’Hanlon & Weiner-Davis, 1989, pp. 99–100). Examples of Direct Normalizing Statements • When the two of you tell me that you’re earning just above minimum wage and are working full-time and raising five kids, I can’t help but admire your efforts at stretching the dollar so well. • Given the fact that you lost everything you owned in the fire last year, I’m moved by your determination to wait it out and do with what little you have right now until you receive the insurance money to rebuild. Another Example of a Direct Normalizing Statement Client: We’re having a rough time being a blended family. The kids resent him as my new husband. Therapist: Maybe you expected there to be instant intimacy or closeness, or you hoped things would gel more quickly. Most people find they have “lumpy” families for quite a while before they get blended (O’Hanlon & Beadle, 1997, p. 40). More Examples of Direct Normalizing Statements Client: Since the divorce, the kids have been absolutely rebelling against everything and everybody. And that includes me! I feel as if I’m the captain, and the crew is out to get me.
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Therapist: That’s often the case with teenagers when major life changes occur to them. It may mean sitting down and plotting a new course with them. Client: I really can’t see the sense of doing this anger management thing for the courts when I’ve been this way all of my life. That’s my personality. That’s me! Ever since I can remember I’ve been this way. Therapist: The fact that you can talk about that experience with such feeling and determination and that you’ve been angry all of your life is the first step on the journey. Welcome to the program. Normalizing client statements involves the therapist’s respecting and accepting the client and the client situation and acknowledging the client’s humanity and the client’s struggles and frailties. In agreement with Maslow’s philosophy, normalization focuses more on the acceptance of and empathy for human struggles and less on pathology. While normalization downplays the pathological implications of the human situation, there is a corresponding reframing that focuses on acknowledging the individual’s efforts and struggles in dealing with human challenges. Again, normalization is a special kind of reframe, and as with all reframes, it is an attempt to accommodate the client and hopefully join the client sooner.
OBSERVATION Family units establish equilibriums to protect the family unit, but that equilibrium can cause an imbalance for individual parts of the family. A clinical psychologist is trained to observed the family dynamic and monitor both verbal and non-verbal cues. During the assessment phase and initial interviews, the family systems psychologist will monitor how the parents interact with each other and how their children react to them. He or she will compare his or her observations with testing data offered in both subjective and objective forms. The subjective test data is gathered during the interview while the objective test data is gathered via clinical tests that family members are requested to fill out and return to the psychologist. Observation is an effective family therapy technique because it offers the psychologist the first real window into the family dynamic. Family therapy may be recommended for any number of causes, but for the psychologist to make a fair and accurate assessment, he or she must get a base measurement of the family's interactions, emotional balance and initial dysfunction. During observation, for example, it may be revealed that a mother's depression and need for anti-anxiety medication is due in part to her husband's unemployment and the economic pressure she is overcompensating to fulfill. To create an effective treatment plan for the family, the therapist needs as much data as possible.
POSITIVE CONNOTATION Positive connotation, a term derived from the Milan School, is an approach combining reframing and joining efforts whereby the therapist—after examining the family interactional patterns—ascribes worthy motives and noble intentions to what otherwise might be considered only symptomatic behavior. In contrast to deframing, which actively seeks to deconstruct useless beliefs, positive connotation seeks to reconstruct new possibilities based on prior good intentions that were not realized. In essence, positive connotation deflates the symptomatic dimensions of a problem while focusing on the potential stabilizing prospects of positive intentions, which are sought because they demonstrate a more positive evaluation of family behavior. This tact serves as a means to enter the family trust at the intentions level, uncharted territory where feuding or alienated family members rarely travel. Thus exploring the intentions of family members can make the process of therapy more responsive and effective (Simon, Stierlin, & Wynne, 1985). Example of Positive Connotation in Referring to a Specific Family Member An 8-year-old boy stopped doing well in school after the death of his grandfather. He also started talking and acting like a caricature of a little old man. The boy insisted that his grandfather was following him when he took walks with his father. The therapist stated to the boy, “I understand that you considered your grandfather to be the central pillar of your family. Without your grandfather’s presence, you are afraid something would change, so you thought of assuming his role, perhaps because you’re afraid the balance in the family would change” (Sauber et al., 1993, p. 303).
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In the preceding example, it is important to note that the symptomatic behavior (i.e., doing poorly in school) is not what is connoted as positive. What is key to understanding positive connotation is the ascribed intent underlying the behavior that is connoted as positive, in that the child’s desire to perpetuate a sense of family stability is personified in the figure of the grandfather. Positive connotation, in effect, deframes the strength and power of the symptomatic behavior by ascribing good intentions as being present behind symptomatic behaviors. Once the deframing is accepted, the therapist may proceed to process, for instance, how the other family members present in the session feel about this perspective, the positive connotation. Example of a Brief Amplification of a Positive Connotation
Father: At first, the new interpretation struck me as far-fetched: seeing the acting out and doing poorly in school as connected to his desire to see the family remain in balance. I think I could stretch a little and see it as some way fitting into the situation facing the family. Therapist: How would all of you see it fit? Mother: Well, I can see it fit very easily. My father-in-law is missed a lot by just about everybody. He was well-liked and loved. And, I guess kids can be pretty complex creatures despite their age. I could see how his acting and pretending to be his grandfather means he misses him a lot and misses all the things he stood for. T: What could be done? F: I guess we can talk about my father, include him more in our conversation. T: What are the kinds of things you’ll be saying? M: We could say how much we miss him. We can talk about what he might have said or done about things that come up in our lives. F: We could visit the gravesite more often, bring flowers, and things like that.
For family members troubled by certain familial situations, positive connotation can often act as a catalyst, helping family members to generate new ideas and new ways to handle problems. Positive connotation has the capacity to do this because it can call into question — as deframing does — uncertain beliefs and perspectives, but it can also serve to remove the negatively charged emotional overlay of symptomatic behaviors. It makes this possible by introducing (within reasonable credibility) the possibility of good intentions on behalf of a client and his or her intentions. If deframing or positive connotation does not produce some practicable results, then other strategies can be utilized. One such strategy is coping questions.
PARADOXICAL INJUNCTIONS A paradox is an apparently sound argument which leads to a contradiction. It is used to motivate family members to search or alternatives. Family members may defy the therapists and become better or they may explore reasons why their behaviours are as they are and make changes in the ways members interact.
PRAGMATIC FICTIONS Formal expressions of opinion to help families and their members change.
PRESCRIBING INDECISION The stress level of couples and families often is exacerbated by a faulty decision-making process. Decisions not made in these cases become problematic in themselves. When straightforward interventions fail, paradoxical interventions often can produce change or relieve symptoms of stress. Such is the case with prescribing indecision. The indecisive behaviour is reframed as an example of caring or taking appropriate time on important matters affecting the family. A directive is given to not rush into anything or make hasty decisions. The couple is to follow this directive to the letter.
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PROBLEM TRACKING Problem tracking involves tracing past behavioral transactions for the express purpose of noting probleminteraction sequences; however, problem tracking is not an end in itself. The use of problem-tracking interactions goes back to the Mental Research Institute (Watzlawick, Weakland, & Fisch, 1974, pp. 110–115). Postmodern therapy has since adopted the problem-tracking interaction strategy when it becomes necessary to explore past interactive sequences. This strategy is often called into service when clients have difficulty responding openly to basic questions or struggle to piece together the results of prior interviewing sequences. Backtracking to past interactive behaviors that are related to the problem-maintaining patterns can offer notable results. Problem tracking can often serve as a basis for returning to a present or future context for creating solutions or dissolutions.
PROBLEM SOLVING TECHNIQUES Problem solving is an effective therapy technique not because it teaches the family how to resolve the issue that brought them to see the family systems psychologist, but it teaches them how to identify, develop plans and create resolutions for future problems. Problem solving may seem like a common sense resolution, but it requires a willingness on the parts of all parties to contribute to the solution. Problem solving is a family therapy technique that requires effective communication and often comes later in therapy sessions as the therapist challenges family members to role-play situations previously deemed irresolvable. Family members may also be required to play the part of other family members, parents playing the part of the children or dad taking on the role of mom to a child's dad and a mom's child. By actively role playing other members of the family, each member is required to see that person's point of view. This leads to learning how to disagree in positive and respectful manner and to not allow those disagreements to impede problem solving efforts. 1. Dissolve the idea that there is a problem: Help people see their situations in new ways. 2. Negotiate a solvable problem: Reduce the size of the problem in the client’s eyes. (Get specific about the problem; focus on when it is not so serious a problem). 3. Frame towards the idea that clients have all the abilities and resources to solve the problem: Create an atmosphere that facilitates the realization of strengths and abilities.
PROBLEM DISSOLUTION The point in the course of therapy when the client readily admits that the problem no longer exists and it becomes apparent that the problem has been dissolved. This positive scenario is usually brought about by the deconstructive efforts of deframing, whose thrust progressively eliminates the original impact of the problem to the point where the problem evolves into a non-issue. This kind of outcome can and does occur with regular frequency among postmodernist therapists, because their strategies and perspectives downplay pathology and emphasize wellness.
PUNCTUATION Punctuation is “the selective description of a transaction in accordance with a therapist’s goals”. Therefore it is verbalizing appropriate behaviour when it happens. Punctuation: thinking that you cause what I say.
PUTTING CLIENT IN CONTROL OF THE SYMPTOM This technique, widely used by strategic family therapists, attempts to place control in the hands of the individual or system. The therapist may recommend, for example, the continuation of a symptom such as anxiety or worry. Specific directives are given as to when, where, and with whom, and for what amount of time
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one should do these things. As the client follows this paradoxical directive, a sense of control over the symptom often develops, resulting in subsequent change.
QUESTIONS 1. THE MIRACLE QUESTION: Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different? This type of question seems to make a problem-free future more real and therefore more likely to occur. The therapist gives guidelines and information to help the client go directly to a more satisfactory future. 2. FAST-FORWARDING QUESTIONS can be used when clients can’t identify exceptions or past solutions. Clients are asked to envision a future without the problem and describe what that looks like. (The miracle question or a magic wand question). => “What will not would be different?” 3. THE EXCEPTION QUESTION: Asks the client to focus on times when problem does not occur or has not occurred when they expected it would. They may discover solutions they had forgotten or not noticed. The therapist might find clues on which to build future solutions. Example: “What is different about those times when things are working?” 4. STRATEGIC BASIC QUESTIONS: For a strategic therapist two questions are basic: How is the symptom “helping” the family to maintain a balance or overcome a crisis? How can the symptom be replaced by a more effective solution of the problem? 5. PROVOCATIVE QUESTIONS: The therapist attempts to recreate typical family interactions and conversation through provocative questioning techniques so that the problems can be presented and addressed accordingly. It also give family members a chance to see how their interactions and responses can contribute to a dysfunctional situation. 6. SCALING QUESTIONS AND PERCENTAGE QUESTIONS Scaling questions are tools that are used to identify useful differences for the client and may help to establish goals as well. The poles of a scale can be defined in a bespoke way each time the question is asked, but typically range from "the worst the problem has ever been" (zero or one) to "the best things could ever possibly be" (ten). The client is asked to rate their current position on the scale, and questions are then used to help the client identify resources (e.g. "what's stopping you from slipping one point lower down the scale?"), exceptions (e.g. "on a day when you are one point higher on the scale, what would tell you that it was a 'one point higher' day?") and to describe a preferred future (e.g. "where on the scale would be good enough? What would a day at that point on the scale look like?") A strategy using simple mathematical values in a relative way, typically from one to ten, where a client ascribes a mathematical value to describe the level of intensity regarding an affect, a behaviour, a thought, or any other related query. For instance, a therapist may ask, “On a range from one to ten, how painful was it for you at the beginning of this session? With one being very painful and ten being no pain whatsoever.” If the client answers, “one” to that question, the response implies that coming to therapy must have been a rather painful time for the client. Scaling questions can also serve as a negotiating tool in which questions are posed in the form of embedded commands. percentage questions: Like scaling questions, may be employed as tools for both gathering information and for negotiating conditions for change by posing questions as embedded commands. These include burrowing out double descriptions from the mass of information in the problem situation, measuring progress once a trajectory
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of progress has been established, negotiating new growth along that trajectory, and goal-setting. The negotiating process expands the possibilities toward building solutions or dissolving the problems. 7. EXCEPTION SEEKING QUESTIONS Proponents of SFBT insist that there are always times when the problem is less severe or absent for the client. The counsellor seeks to encourage the client to describe what different circumstances exist in that case, or what the client did differently. The goal is for the client to repeat what has worked in the past, and to help them gain confidence in making improvements for the future. 8. COPING QUESTIONS Coping questions are designed to elicit information about client resources that will have gone unnoticed by them. Even the most hopeless story has within it examples of coping that can be drawn out: "I can see that things have been really difficult for you, yet I am struck by the fact that, even so, you manage to get up each morning and do everything necessary to get the kids off to school. How do you do that?" Genuine curiosity and admiration can help to highlight strengths without appearing to contradict the clients view of reality. The initial summary "I can see that things have been really difficult for you" is for them true and validates their story. The second part "you manage to get up each morning etc.", is also a truism, but one that counters the problem focused narrative. Undeniably, they cope and coping questions start to gently and supportively challenge the problem-focused narrative. coping questions are A strategy to explore what has occurred that is responsible for not making things get worse; in other words, how family members have coped with the problem situation so that, at the very least, things are the same and not worse. In explaining how things haven’t gotten worse, the clients usually allude to something being done correctly, even if minimally. It is that kind of minor breakthrough that often allows the therapist to expand upon the positive event that has actualized in the problem situation. Potentially, that breakthrough can be a gateway to more positive developments, thus moving the therapeutic conversation forward in search of more solutions toward resolving the problem or toward dissolving the problem. The strategy of coping questions could be employed in many areas of therapy, but it is particularly useful as a tool with difficult clients. Often clients adamantly decline invitations to speak about the times in the past when exceptions to their problem existed (i.e., periods of time when the problem was not present). They also can be vehemently opposed to any therapeutic plan of action, which can be frustrating for the therapist. One possible source for motivating the client to move forward in the therapeutic conversation is the introduction and use of coping sequences. They are introduced by coping sequence questions. Example of the Use of Introductory Coping Questions With families that . . . do not respond well . . . I shift gears and mirror their pessimistic stance by asking them: “How come things aren’t worse?”; “What are you and others doing to keep this situation from getting worse?” Once the parents respond with some specific exceptions, I shift gears again and amplify these problem-solving strategies and ask: “Howdid you come up with that idea!?”; “How did you do that!?”; “What will you have to continue to do to get that to happen more often?” (Selekman, 1993, pp. 65–66) The employment of a coping sequence involves exploring the problem at its present level of intensity and why the problem has remained at that particular level. In short, why hasn’t it gotten any worse? In explaining how it hasn’t gotten worse, the client usually alludes to something having been done right—even if minimally. It is that kind of minor breakthrough that now allows the therapist to expand on the positive action that is actualized in the problem situation. Potentially, that breakthrough can be a gateway to more positive developments, thus moving the therapeutic conversation forward in search of more solutions toward resolving the problem or toward dissolving the problem. Example of a Coping Sequence Therapist: What brings you here today?
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Client: Literally, my husband. He’s waiting outside. He’s been insisting I see a therapist. T: How is it that he wants you to seek counseling? C: Because he says I’m pretty much impossible to live with. T: What is the specific nature of the situation that brought you here? C: There’s no more communication. We barely speak the way we used to. Sex has become a sprint; there’s no intimacy. We both have difficult jobs with long hours, and barely enough time to do anything. T: How many years have you been married? C: Five years. No kids. It’s just the two of us. T: When did the situation start? C: I see it as starting a year ago. T: How long would he say the situation between the two of you has been going on? C: That’s just it. He doesn’t realize there’s a problem with him. Everything is okay by him. Work, work, and save money. That’s it in a nutshell. He started on that kick a year ago. Since then, we’ve done nothing else but that. But he thinks there’s something wrong with me. That’s why he forced me to be here today. He’s got me thinking that I’m going crazy. T: I’m just very curious as to how come things haven’t gotten any worse? C: He’s a good provider. He doesn’t run around. He has no vices, and he does love me. T: So what else is there that has prevented things from getting any worse? C: Well, we love our home. It’s in a gorgeous neighborhood. Our house should be paid off in about five more years. T: What else have you been doing so that things aren’t getting worse? C: Well, two weeks ago, I got him to see a play downtown? T: How important was that for you? C: Very! It was the first time in ages that we actually spent money to see a play. T: How did you get him to do that? C: One evening, when he seemed cheerful, I just sat down with him. I said I really wanted to see this play with him and he agreed. I was shocked. It seemed so easy. T: So, it seems like something positive has already begun. How did you get that to happen? C: Well, I told him how important it was for me. It was a play we had seen together when we were dating, and I remembered that it was one of the few musicals he enjoyed. He normally hates musicals. T: Sounds great. So what other changes do you think you might havestarted and not have realized until our conversation today? In the preceding example, the coping sequence questions did their job well. They accounted for the creation of a new therapeutic context that in turn offered the possibility of a significant shift in direction in which other forgotten or discarded solutions could come to the fore. In addition, other positive conditions could also be pursued. Once coping questions arrive at the level of recognizing patterned improvements, these patterns serve to confute the client’s initially negative script, and the therapist could develop different strategies toward solution to the client problem or toward dissolution of the problem. As with all strategies, there are no guarantees, and coping sequences are no exception to that rule. When coping sequences do not achieve success, a follow-up strategy of pessimistic questions may help bring the session forward. 9. OPEN QUESTIONS The therapist uses open-ended questions to get information. An open-ended question cannot be answered with a simple "yes" or "no", or with a specific piece of information, and gives the person answering the question scope to give the information that seems to them to be appropriate. Open-ended questions are sometimes phrased as a statement which requires a response.
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Examples of open-ended questions:
Tell me about your relationship with your husband. How do you see your future? Tell me about the children in this photograph. What is the purpose of this rule? Why did you choose that answer?
10. PROCESS QUESTIONS. The most common Bowen technique consists of asking process questions that are designed to get clients to think about the role they play in relating with members of their family. Bowen's style tended to be controlled, somewhat detached, and cerebral. In working with a couple, for example, he expected each partner to talk to him rather than to talk directly to each other in the session. His calm style of questioning was aimed at helping each partner think about particular issues that are problematic with their family of origin. One goal is to resolve the fusion that may exist between the partners and to maximize each person's self-differentiation both from the family of origin and the nuclear family system. A Bowen therapist is more concerned with managing his or her own neutrality than with having the "right" question at the right time. Still, questions that emphasize personal choice are very important. They calm emotional response and invite a rational consideration of alternatives. Examples of process questions: A therapist attempting to help a woman who has been divorced by her husband may ask:
"Do you want to continue to react to him in ways that keep the conflict going, or would you rather feel more in charge of your life?"
"What other ways could you consider responding if the present way isn't very satisfying to you and is not changing him?"
"Given what has happened recently, how do you want to react when you're with your children and the subject of their father comes up?"
Notice that these process questions are asked of the person as part of a relational unit. This type of questioning is called circular, or is said to have circularity, because the focus of change is in relation to others who are recognized as having an effect on the person's functioning. 11. LINEAR QUESTIONS Direct linear questions can often be useful in gathering information from the system and clarifying information given, especially at the beginning of therapy. Linear questions can be built up in a circular manner around the family by asking different family members the same/similar linear questions. Examples of linear questions:
How old are you? Where do you go to school? What do you do if you are upset? What do you do after that?
12. CIRCULAR QUESTIONS Circular questions are aimed at looking at difference and therefore are a way of introducing new information into the system. They are effective at illuminating the interconnectedness of the family sub-systems and ideas. A variety of circular questions may be used by the therapist as outlined in Table 2. These may be more or less appropriate as therapy progresses.
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The use of particular types of circular questioning at different stages of the therapy will be highlighted throughout the manual. The time scale of circular questions often changes fluidly between the past, present, future. Examples of circular questions: About another’s state / behaviour / beliefs What do you think John is feeling? What do you think John is feeling when he shouts at you? What ideas do you think John might have about that? Offering alternative perspectives What does John think of your school performance? If I asked a teacher what would they say about it? About relationships direct : indirect :
Do the girls really dislike each other? How do the children react when they see you arguing?
Circular Definitions When you and John raise your voices and Jill starts crying what does John do then? Hypothetical and future-oriented questions What will you think in 5 years time? If you were to believe that attending to lifestyle changes would make a difference to your cardiac condition, would that make you feel more inclined to quit smoking? When you think about your health 5 years from now, what is your greatest concern? Miracle question: Imagine you woke up tomorrow morning and all the difficulties you were experiencing currently had disappeared, how would things be different? What effect would that have upon your relationship with x? Ranking or Scaling Questions, also named “difference questions”: Who is most likely to get upset when father is away, and who next is most upset? Was there more communication between you before or after the heart attack last year? On a scale of one to ten, how close do you think James and Sue feel when they argue? Who worries the most about the angina attacks, your husband or yourself? Behavioural effect questions: When your husband tells you to stop working and rest during your angina attacks, what do you do? When your husband shows that he is worried about you, what does that say to you and what effect does that have on your own behaviour? Triadic questions If your daughter were here, what would she tell me about how the heart disease has affected your relationship as a couple? What would your husband say the physician's greatest concern about your health is at this time? 13. MONADIC, DIADIADIC AND TRIADIC QUESTIONS Direct questions asked by a therapist to a client are called monadic questions. Monadic denotes the number one (i.e., the client). “What is it like to be in jail?” is a monadic question.
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A therapist may also ask a client speculative questions such as what another person might think about the client and client situation. Those questions are called dyadic because dyad refers to the number two: the client and someone else. If no headway is made with the use of monadic questions, a dyadic question will often serve as a strategic manoeuvre to allow the client more psychological space to answer. The dyadic question, “What do you think your wife felt about your being in jail?” involves two people: the client and his wife. In this case, the client will probably be more apt to answer. Similarly, a triadic question merely adds a third person to the dyad. The triadic question, “What do you think your mother thought about your wife’s view of your being in jail?” involves three people. Dyadic and triadic questions are clever means of making dialogue possible between therapists and reluctant clients. When involuntary clients hesitate to talk about themselves, the therapists may find dyadic and triadic questioning particularly helpful in gathering data. Strategically, these questions often further distance the client from the painful immediacy of the situation by “letting someone else” describe it. The crucial importance of a dyadic or triadic question lies in the oblique manner a therapist is able to phrase questions. It serves as an indirect route to access client data. While there are no guarantees that clients will respond favourably to dyadic or triadic questions, clients who do not care to answer questions about themselves are more likely to answer questions that are posed from an oblique perspective. These questions act as a bypass or a detour, cleverly couched and positioned as if the answers are coming from the thoughts and feelings of other people. The client’s voicing of what others might believe and what others might be saying or thinking paradoxically allows the therapist access into the client’s world. In effect, dyadic and triadic questions permit the clients, on the one hand, to hide and partially protect themselves and, on the other, to reveal the nature and quality of their interactive relationships. Examples of Dyadic Questions How does your wife feel about your drinking problem? What do you think are your husband’s feelings about the affair you had? How does your mother feel about your getting stopped for a DUI? What does your father think about your being asked to leave college? What would your favorite hero think about your actions? Examples of Triadic Questions What does your mother think about the way your wife feels about your drinking problem? What would your mother think about your husband’s feelings about your affair? What does your father think about your mother’s feelings about your getting stopped for a DUI? How does your mother feel about your father’s thoughts about your being asked to leave college? What would your father feel about your favorite hero’s thoughts about your actions? When a client is responsive to dyadic or triadic questions, the therapist will usually ask more related questions. In this instance, the questions could take the form of an amplification that would yield more in-depth information. Here the therapist is definitely offered an opportunity to explore and learn about the client’s cosmos. Example of a Dyadic Question Followed by Amplification Therapist: What does your father think about your being asked to leave college? Client: He’s pissed, he’s real pissed at me. T: How did he show that?
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C: He said that if I didn’t go to therapy, he’d take the car away from me. And the car is under his name. I’m not 18 yet. I won’t be for another seven months. I started college a year early. I was in a special program in high school. T: Wow, so you’re a year ahead of most high school students your age. Could you tell me how you achieved that?
The client in the above scenario had initially been reluctant to talk about himself when the therapist employed monadic questions, but when asked a dyadic question, he responded with little hesitation. Generally speaking, reluctant clients are more apt to answer dyadic questions because they are probably perceived as less troublesome. Surely there are many operative reasons why clients find them easier to respond to, and those reasons vary from person to person. As is often the case, the client most likely found little difficulty acting as “spokesman” for his father’s “thoughts and feelings.” When dyadic and triadic questions fail to achieve success with involuntary clients, another strategy, “normalization”, should be considered.
14.
PESSIMISCTIC QUESTIONS
A strategy wherein the therapist joins the pessimism of the client and creates a new context from which the therapist can launch questions of a different kind that might prove to be more effective than the prior coping questions. Strategically, pessimistic sequence questions can often evoke client response because pessimistic questions gain their strength by yielding to an anticipatory sense of worsening client scenarios. The therapist’s joining clients in their worsening situation helps to create a reverse psychology scenario where the therapist—now one of them, so to speak—suggests pre-emptively a kind of hopelessness that ironically the client might best handle with a positive activity. The strategy of pessimistic questions involves the therapist’s joining the pessimism of the client(s). As a tactic, it allows the therapist to launch questions of a different nature, which might prove to be effective almost immediately in some cases. Strategically, pessimistic questions can be effective in evoking client responses because these questions gain their strength by yielding to an anticipatory sense of worsening client scenarios. In effect, the therapist’s act of joining clients in their worsening situation helps to create a reverse psychology scenario where the therapist—now being one of them, so to speak—is suggesting pre-emptively a kind of hopelessness that, ironically, the client might best handle with some kind of positive activity. Example of the Use of Introductory Pessimistic Questions Often this line of questioning will enable family members to generate some useful problem solving and coping strategies to better manage their difficult situation. Typical examples of pessimistic questions are as follows: “What do you think will happen if things don’t get better?”; “And then what?”; “Who will suffer the most?”; “Who will feel the worst?”; “What do you suppose is the smallest thing you could do that might make a slight difference?”; “And what could other family members do?”; “How could you get that to happen a little bit now?” (Selekman, 1993, p. 72) Example of a Pessimistic Question Sequence
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Therapist: You seem to be telling me that at home things went from bad to worse. If things don’t get better now, what do you think will happen? Client: She’ll pick up and leave. (pause). T: And then what? C: It’ll be a real mess then, because she knows I love her. We both had a drug habit, but now she’s clean, but I’m not. (pause). T: Who will suffer the most if she leaves? C: I will. T: In what way? C: I don’t want her to leave. I love her too much for her to leave. It’s a cruel world out there. I like her a lot, and she knows that. We had plans to get married. I want her to be my wife. I’m not looking for other women. T: And so, what do you suppose is the smallest thing you can do to make things just a little bit better, however slight? C: I’d say I’d have to go cold turkey. T: What makes you say that? C: Because that’s how she did it. T: And? C: She’ll expect me to do the same thing. T: Do you know that for sure? C: She told me so. T: How did she go cold turkey? C: Willpower. She’s a pretty strong person. T: What do you suppose could be done in your situation? C: I guess I’d have to ask her for help. T: In what way? C: I don’t know. Maybe I can ask her for some ideas. T: What made you think of asking her for some ideas? C: I don’t know . . . just an idea I had. T: It’s not just an idea. It’s a great idea. What made you think of that? C: Well, she’s resourceful. T: In what ways do you think she’ll be resourceful when you ask her? C: Maybe she’ll come up with ways that’ll help me cope with going cold turkey. T: I bet you know some of those things already. C: Yeah, I noticed some of the things she did. T: Could you mention some of them? The main objective of pessimistic sequences is to assist the individual client, a couple, a family, or anyone in a relationship to come up with new ideas or to recall successful strategies (exceptions) from their respective pasts. Once new ideas or tried-and-tested exceptions from the past are accessed and amplified, they in turn help to generate not only coping skills in the present but also major creative ways to solve problems. That is the essence of pessimistic sequences. Clients may be so entrenched in their problems that pessimistic sequences and coping sequences have little or no affect on them. In this case, the strategy of problem-tracking sequences can be tried. Problem tracking can be used as a new introductory strategy that serves to discover new contexts by starting at the rock bottom of fundamentals, namely, the interactive patterns (the behaviors) that maintain the problem situation (Selekman, 1993, pp. 76–77). 15. PROBLEM TRACKING QUESTIONS
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Tracing past behavioral interactions for the express purpose of noting problem interaction sequences; however, problem tracking is not necessarily an end in itself. This strategy is often called into service when clients have difficulty responding openly to basic questions or when they struggle to piece together the results of prior interviewing sequences. Backtracking to past interactive behaviors relative to problem-maintaining patterns can offer notable results. It can often serve as a basis for returning to a present or future context for creating solutions. Examples of Problem-Tracking Questions “If you were to show me a videotape of how things look when your brother comes home drunk, who confronts him first [asking a sibling of the identified client], your mother or your father?”; “After your mother confronts him, what does your brother do?”; “How does your brother respond?”; “Then what happens?”; “What happens after that?” Ideally the brief therapist will secure a detailed picture from the family members regarding the specific family patterns that have maintained the presenting problem. (Selekman, 1993, pp. 76–77) In the next example, a consultant was asked for a one-time consultation in an ongoing treatment with a family that suffered from an unyielding problem concerning the children’s “unmanageable, disruptive behavior.” The heart of the consultation interview consisted of about 10 questions, which have been condensed into the following outline. Example of a Problem-Tracking Sequence Therapist: The children are both equally disruptive, or is one more disruptive than the other? Client: Both equally. T: Disruptive outside the house mostly, or inside, or both? C: Only in the house. T: I see. At any particular time or circumstance? C: During dinner. T: So, what happens? C: Well . . . [Goes on to explain details of escalating disruption.] T: And then who tries to stop this? C: Mother. T: What does she do? C: [Goes on to explain mother’s failing attempts at control.] T: And while this is going on between mom and the kids, what is father doing? C: At first father doesn’t do anything, but then when it gets loud enough he yells from the bedroom and then things settle down. T: Excuse me, father is not at table? C: No, father is bedridden. T: Why is that? C: He has cancer. T: I see. For how long has he been bedridden? C: Two months. T: For how long has this disruption been a problem? C: Two months. (Real, 1990, p. 265)
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When affect and cognition are difficult to ascertain, problem tracking becomes a key strategy. This helps explain the key role that problem tracking plays especially when dealing with reluctant clients or with clients who present many difficulties. Problem Tracking and its Pivotal Position. In general, when therapeutic strategies do not seem to be working effectively, the strategic use of problem tracking may jump-start the therapeutic process. It may bring to light the problem-maintaining sequences of familial interactions (i.e., negative or unwanted behaviors that perpetuate themselves). However, once those unwanted interactive behaviors are examined in the therapeutic process, the palpable knowledge of their existence may often become the basis for the generation of new kinds of questions that may lead to the successful resolution of the client problem. Because problem-tracking sequences are often able to overcome client reluctance to engage in dialogue, they acquire pivotal positions from which many other therapeutic strategies may be launched in the resolution of problems. Integrative Options Once problem tracking has proved to be successful in disarming client reluctance or client resistance (when prior strategies weren’t able to do so), this becomes an opportunity to revisit and utilize prior strategies. While problem tracking is useful by itself (examination of behavioral interactions), it acquires more worth by being a conduit to other strategies and allowing them to perform their functions. Once problem tracking has performed its job, the therapist—in an integrative format—may return any number of strategies. When the problem-tracking strategy overcomes a roadblock in the process of interviewing, many strategies become available. The therapist has immediate access to a host of strategies, such as the ones discussed in prior chapters (for instance, utilization, dyadic/triadic, normalization, deframing, coping, and pessimistic sequences). In addition, therapists may also employ other prominent strategies such as those listed below. • Exception-oriented questions • Miracle question sequence • Problem dissolution. The problem dissolution strategy seems to be underutilized, yet it constitutes one of the typically important postmodernist strategies.
16. CONVERSATIONAL QUESTIONS In a sense, a deep return to eliciting basics, and a major resourceful strategy when clients are reluctant to discuss their affect, behavior, and cognition. It has been found to be particularly useful with “highly entrenched and traumatized families” and in cases where there are “family secrets.” It embodies a special tripartite therapeutic focus on employing a not-knowing attitude, a unique therapeutic focus on posing questions based on a profoundly elemental sense of curiosity, and a healthy introduction of uncertainty. if the therapist has not had success with problem tracking sequences, circular questioning, or externalization of the problem, then the therapist may proceed with conversational questions. When clients are reluctant to discuss affect, cognition, and especially behavior (problem tracking), conversational questions can become a major strategy. This option has been found to be particularly useful, for instance, with “highly entrenched and traumatized families” and in cases where there are “family secrets” (Selekman, 1993, pp. 77–79). Conversational questions allow the use of dialogical choices that usually involve returning to eliciting basics, with a postmodernist twist. The questions embody a special therapeutic focus that employs a not-knowing attitude and, similarly, a unique therapeutic focus on posing questions. The strategy is based on a profoundly elemental sense of curiosity as professed by Anderson and Goolishian in the espousal of their conversational approaches that emphasize a high collaborative relationship with the client.
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The therapist thereby establishes an open-ended agenda that requires starting from a new beginning. The process is akin to starting at the origin of the client reason for being there and a host of general questions that encourage clients to talk, dialogue, and interact verbally in the session. Nothing is taken for granted. Clients are encouraged to speak freely about their situation, what brought them there, and virtually anything else that is on their minds that seems important at the moment. Despite whatever feelings of discomfort clients may experience on this therapeutic turf, conversational questions as a strategy help create the new conditions for a fresh start. Conversational questions maintain effectiveness not only because of the engaging attitude of the therapist, but also because of the quality and substance of well-chosen questions. Clients might be asked about what kinds of questions they felt the therapist should have or could have previously asked in the session (but didn’t); or about what kinds of things prior therapists did that could have been done differently or better; or what they did that was totally useless and ineffectual. In all, this strategy constitutes an elemental therapeutic process of entering and expanding the areas of the unsaid or the not-yet-said (Anderson & Goolishian, 1988, p. 381). This unique process of questioning might be compared to a metaphoric rite of passage. Once therapists are offered privileged access into this once uncharted and inviolable precinct, they may find that it contains a painful family secret, a dilemma that seems uniquely impenetrable to clients, or simply a difficult situation that appears to be not easily discussed at the moment. The following six conversational questions are examples taken from Selekman’s work. They offer a rich flavor of the kinds of questions that therapists can ask to insure the certainty of this new openness with its unquestionably “non-agenda” agenda condition. From an integrative perspective, it is an all-out approach at loosening up and breaking through familial barriers and through the mountainous accumulation of family members’ failed attempts at dealing with their issues in order to reach family members who now may feel all the more stymied in the throes of therapy. Examples of Conversational Questions
You have seen many therapists. What do you suppose they overlooked or missed with you? If I were to work with another family just like you, what advice would you give me to help that family out? Who had the idea in the family to go for therapy? If there were one question you were hoping I would ask, what would that be? If there were one issue in this family that has not been talked about yet, what would that be? Who in the family will have the most difficult time taking about this issue? (Selekman, 1993, p.78) Who probably had the most difficult time coming here today? What is one major thing holding everyone back? What is one major reason for not talking together as a family? What are some things I should be asking about you? If you’ve been to other therapists, what are some of the things you didn’t like about the questions they asked or how they asked the questions? What do you think are some needs that we should discuss first, before moving forward? What did you like or dislike about your prior therapists? What people in the family could change things if they had the power? What people do you trust the most? Why is that so? What is one small thing that could be changed to help get us started today?
In sum, the use of conversational questions may be a major tool when a client or an entire family is reluctant to speak openly or when the therapeutic dialogue comes to a grinding halt. It is the therapist’s hope that conversational questions such as the ones above will create the new and necessary conditions for a more
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expanded focus and a continuance of the therapeutic conversation. Whenever breakthroughs occur in this manner, it means that situational issues, family stories, family problems, and family secrets become acceptable topics. This increases the possibility of bringing about therapeutic conversations. 17. FRAMING QUESTIONS Questions asked can elicit information about strengths, abilities, and resources. Perceptions of problems then change significantly in this context. 18. DEFRAMING QUESTIONS Deframing effectively challenges the existence—or at least the power—of the problem (O’Hanlon & WeinerDavis, 1989, pp. 52–53). By introducing uncertainty and doubt into the client’s cosmos. It can be a powerful tool for influencing the client when dealing with a client’s dysfunctional, useless embedded beliefs. Examples of Deframing Questions -
How do you know that to be so? What makes you say that? How is that so? Where did you get that idea? On what basis have you reached that conclusion? What do you think is the origin of that belief? What is the foundation on which you rest your case? Did you ever have any doubts about those thoughts? Are you sure that’s accurate? What makes you so sure? What are the benefits in believing that? What influenced you to think along those lines? Why would you want to stick with that belief?
REFRAMING Most family therapists use reframing as a method to both join with the family and offer a different perspective on presenting problems. Specifically, reframing involves taking something out of its logical class and placing it in another category (Sherman & Fredman, 1986). For example, a mother's repeated questioning of her daughter's behaviour after a date can be seen as genuine caring and concern rather than that of a nontrusting parent. Through reframing, a negative often can be reframed into a positive. The technique of reframing is a process in which a perception is changed by explaining a situation in terms of a different context. For example, the therapist can reframe a disruptive behaviour as being naughty instead of incorrigible allowing family members to modify their attitudes toward the individual and even help him or her makes changes.
REFRAMING PROBLEM DEFINITIONS Solution Oriented therapists offer new, more workable problem definitions that are within the power of the client and therapist to solve. They usually help the client reframe the problem definition to a more positive one or listen for a hint of something in the client’s complaint that can be solved. This co-creates the experience that the problem is solvable and the client has some ability to solve it.
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RESTRUCTURING The procedure of restructuring is at the heart of the structural approach. The goal is to make the family more functional by altering the existing hierarchy and interaction patterns so that problems are not maintained. It is accomplished through the use of enactment, unbalancing, and boundary formation.
SHAPING COMPETENCE The family therapists help families and individuals in becoming more functional by highlighting positive behaviours.
USE OF SILENCE A strategy that is generally used only after most other strategies have failed for one reason or another. Silence can also be an effective tool at the beginning of a session, if the conditions warrant it. Pre-emptive tactics, such as the involuntary client schema developed by Walter and Peller, are designed to encourage the client to communicate openly, thereby avoiding the therapist’s use of silence. If the use of silence becomes necessary, the therapist should inform the client of the reason and should make it clear that the client is welcome to speak and begin a conversation. The use of silence should not be confused with a pause in the interview process, which is intended to be momentary. The pause serves to give the client time and psychological space to think especially if the therapist’s question involves something painful. Silence, instead, is a strategy that brings the therapist’s questions to a grinding halt. Silence may also be an effective tool at the beginning of the session if conditions warrant it. For instance, if an involuntary client is totally nonresponsive and does not care to communicate at all, then employing silence as a strategy at the beginning of the hour is understandable, though not usually the case. In dealing with the involuntary client, early options should be presented that include the use of an interviewing schema, such as the one discussed earlier by Walter and Peller, or any other pre-emptive tactic geared to involuntary clients. When all attempts yield little or nothing and the therapist surmises that the client is maintaining a silence even after being made aware of the consequences of not having future sessions, it may be time for the therapist to introduce silence into the interview. Before embarking on extended periods of silence, the therapist should inform the client that, for the time being, silence will prevail only because there has been no real communication, but if the client cares to speak and begin a conversation, that will be welcomed. Once the strategy of silence is implemented, a staring contest will usually ensue. Three Examples of Preparatory Statements Prior to the Use of Silence Example 1 Therapist: So far we’ve spent about 30 minutes together, and you’ve said very little. We’ve already discussed the consequences of your not coming to future sessions. Your parole officer or the court may decide to change your status. I’ll remain quiet for a while, and whenever you feel you’d like to say something to get things going, I’ll welcome your remarks. Example 2 Therapist: So far we’ve spent about 20 minutes together, and you’ve said very little. We’ve already discussed the consequences of your not coming to future sessions. Your spouse may decide to take action that may not please you. I’ll remain quiet for a while, and whenever you feel you’d like to say something to get things moving along, I’ll welcome your remarks.
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Example #3 Therapist: So far we’ve spent about 15 minutes together, and you’ve said very little. We’ve already discussed the consequences of your not coming to future sessions. Your parents may decide to take action that may not please you. I’ll remain silent for a while, and whenever you feel like saying something to get things moving along, I’ll welcome your remarks. Silence can function as a tool to negotiate a new beginning for the client-counselor relationship. By contrast, this chapter, as a whole, invites the beginning counselor to examine a substantially rich foundation of versatile strategies and to utilize them in an effective integrative manner in interviewing involuntary clients. The involuntary client schema, a key protocol to be used at the beginning of the first session with involuntary clients, was specifically designed to minimize possible roadblocks at the outset of the therapeutic process. While accessing and utilizing effective integrative strategies, it is important to remember that the counselor’s posture (attitude) is a major ingredient in establishing and maintaining a collaborative relationship with the involuntary client. Being able to enter the client cosmos and empathically understand the specifics of the client’s frame of reference, especially client rationales and purported defenses, is one of the major keys to success. The following extract corroborates what many postmodernist proponents have said all along. The biggest lesson of my 25 years in this work is that when you align with the client’s defenses, you have essentially removed the need for them. And it is only when the clients’ defenses soften—whether they are courtmandated clients or self-referred—that they are able to take the first steps toward looking at themselves, connecting with others and ultimately taking responsibility for their lives. (Borash, 2002, p. 22)
SPECIAL DAYS, MINI-VACATIONS, SPECIAL OUTINGS Couples and families that are stuck frequently exhibit predictable behaviour cycles. Boredom is present, and family members take little time with each other. In such cases, family members feel unappreciated and taken for granted. "Caring Days" can be set aside when couples are asked to show caring for each other. Specific times for caring can be arranged with certain actions in mind (Stuart, 1980).
WORKING WITH SPONTANEOUS INTERACTION In addition to enactment, structural family therapists concentrate on spontaneous behaviours in sessions. It occurs whenever families display behaviours in sessions that are disruptive or dysfunctional, such as members yelling at one another or parents withdrawing from their children. The focus is on process not content. It is important that therapists help families recognize patterns of interaction and what changes they might make to bring about modification.
STRATEGIC ALLIANCES This technique, often used by strategic family therapists, involves meeting with one member of the family as a supportive means of helping that person change. Individual change is expected to affect the entire family system. The individual is often asked to behave or respond in a different manner. This technique attempts to disrupt a circular system or behaviour pattern.
TRACKING The tracking technique is a recording process where the therapist keeps notes on how situations develop within the family system. Interventions used to address family problems can be designed based on the patterns uncovered by this technique Most family therapists use tracking. Structural family therapists (Minuchin & Fishman, 1981) see tracking as an essential part of the therapist's joining process with the family. During the tracking process the therapist listens intently to family stories and carefully records events and their sequence. Through tracking, the family therapist
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is able to identify the sequence of events operating in a system to keep it the way it is. What happens between point A and point B or C to create D can be helpful when designing interventions. In tracking, the therapist follows the content of the family that is the facts. Getting information through using open-ended questions. Tracking is best exemplified when the therapist gives a family feedback on what he or she has observed or heard.
UNBALANCING This is a procedure wherein the therapist supports an individual or subsystem against the rest of the family. When this technique is used to support an underdog in the family system, a chance for change within the total hierarchical relationship is fostered.
INTRODUCING UNCERTAINTY The therapist can introduce some uncertainty into the problem definition by asking “What gives you the impression that things seem difficult to handle?” Or he/she can imply that there are days when the problem is nonexistent by asking “What is different about the days when things seem manageable?”
UTILIZATION STRATEGY The utilization strategy, one of the most powerful Ericksonian strategies, is based on a simple concept. It involves the therapist learning from the outset as many of the specific strengths and resources the client possesses. This usually means asking clients questions that will evoke positive data. The therapist could then process and integrate those data expeditiously in the early process and possibly accelerate the course of therapy. Utilization may also include thoroughly exploring certain particulars of the client’s intake form, looking for relevant particulars that, when incorporated in the process, could offer a possible winning combination in an attempt to effectively enter a reluctant client’s cosmos. These particulars involve aspects of the client’s life experience, attitudes, overall strengths and talents such as in the following: • Work history in a particularly interesting or difficult job • Interesting profession • Challenging work experiences • Hobbies • Talents • Interests • Sense of humor • Desire for change • Positive attitudes • Use of language • Beliefs • Intentions • Narrative abilities • General experiences. Because Erickson pragmatically concluded from his studies that patients know (consciously and otherwise) their strengths and resources best, he believed that it was natural for the therapist to utilize those strengths and resources as early as possible, including those in the client’s “environmental” areas such as familial and community relationships. In the therapeutic session, Erickson focused on utilizing patient strengths and resources as a matter of course, not as remote theoretical options. Utilization has the immediate advantage of not having to search elsewhere, especially in time-consuming excavational protocols.
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Example of Utilization Strategy Therapist: I understand that you do artwork. Is that right? Client: Yes. I do portraits at home and also commercial stuff. T: Could you tell me about when you first started? C: I always drew and doodled as a kid. Then, as a teenager, I discovered I could paint and get paid for it too. So, it’s been about 20 years since I’ve been painting privately and working as a commercial artist. T: What does your wife think about this talent that you possess? C: She’s my biggest fan and, of course, my biggest critic. T: How is she your biggest fan? C: She supported and encouraged me in some of the lean years when my stuff wasn’t selling and when things were slow and the commercial world gave me the pink slip. She was there whenever things got bad or I began to doubt myself. T: I’m just curious about something. How fast does your wife pick up on things in general? C: I’d say pretty fast, but it all depends on what you’re talking about. T: Does she pick up on how things are going in your life? C: Yes. She’s pretty good at that. Yes, she is. T: Do you have any examples as to when she definitely picked up on something, and it proved to be beneficial to the two of you? C: I was forced to stop work some years ago, and she picked up that I was prone to depression when things got too stressful for me. T: How did she help you then? C: Well, at first, I fought her tooth and nail. (pause). T: And, what else? C: I guess I was stubborn. T: How’s that? C: I thought that depression just couldn’t happen to me, and so I fought all the way. T: In what sense, all the way? C: Denial. I denied all the way to the hospital. Things had gotten so bad that I started to drink. That was something I didn’t usually do. I went into a stupor a couple of times, and the last time I did, she got frightened and drove me to the emergency room. (pause). T: What sense do you make of that event in your life? C: She was right on the money. T: How did it turn out? C: I was only in the hospital for a few days. I was diagnosed with depression. Then I was discharged. While I was there, they ran tests. They discovered that I also had a liver disease that I never knew about. If I had continued drinking, I would have been dead a long time ago. T: Have you had it checked out by your doctor since then? C: Several times. My liver is doing fine. T: That sounds like great news. I imagine you must be happy about that. C: Yes, I am. T: I understand your wife has some other concerns about you right now. Would you like to talk about them? Before the preceding dialogue took place, the therapist had perused the client’s paperwork (intake). As in most
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intake forms, client attitudinal responses to intake questions vary. The answers to specific questions can often be left blank, barely stated or understated, or sometimes even overstated. It is the therapist’s responsibility to read and perhaps utilize any information that may offer the key to unlocking the door to the client’s world. Prior to the therapy session in the preceding example, the therapist gleaned from the intake form some items that could possibly offer easier access to the client’s cosmos. From these items, the therapist learned that: • The client had identified himself as a commercial artist. • He presented depression as the problem. • He had prior psychiatric care. • He had been requested by his wife to attend therapy. • He was married for 15 years. The therapist mingled these important factors and hypothesized that they could prove to be useful as a means to enter the client’s cosmos as naturally as possible. The therapist attempted this by initially utilizing the client’s talents as they might present an opportunity to both empower the client and join the client from the outset. Once the session had begun, the therapist quickly utilized the apparent strengths possessed by both the client’s wife and himself. These became the context and prelude to discussing the presenting problem. This example illustrates how utilizing client information in the form of strengths and resources could effect a jump-start in the initial interview of a client who is requested or ordered by the spouse to attend therapy. However, as with any therapeutic attempts at entering the client’s world, they may fail to achieve the desired results, and the therapist must move on to alternative strategies. When such is the case, dyadic and triadic questions may be helpful.
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Summary of Family Therapy Theories & Techniques Theoretical Model
Adlerian Family Therapy
Attachment Theory
Theorists
Summary
Techniques
Alfred Adler
Also known as "Individual Psychology”. Sees the person as a whole. Ideas include compensation for feelings of inferiority Psychoanalysis, Typical leading to striving for significance toward a Day, Reorienting, Refictional final goal with a private logic. Birth educating order and mistaken goals are explored to examine mistaken motivations of children and adults in the family constellation.
John Bowlby, Mary Ainsworth
Individuals are shaped by their experiences with caregivers in the first three years of life. Used as a foundation for Object Psychoanalysis, Play Relations Theory. The Strange Situation Therapy experiment with infants involves a systematic process of leaving a child alone in a room in order to assess the quality of their parental bond.
Also known as “Intergenerational Family Therapy” (although there are also other schools of intergenerational family therapy). Murray Bowen, Betty Family members are driven to achieve a Carter, Philip Guerin, balance of internal and external Detriangulation, Michael Kerr, Thomas Bowenian Family differentiation, causing anxiety, Nonanxious Presence, Fogarty, Monica Systems triangulation, and emotional cut-off. Genograms, Coaching McGoldrick, Edwin Families are affected by nuclear family Friedman, Daniel emotional processes, sibling positions and Papero multigenerational transmission patterns resulting in an undifferentiated family ego mass. Problems are the result of operant Therapeutic Contracts, conditioning that reinforces negative Modelling, Systematic Cognitive behaviours within the family’s interpersonal John Gottman, Albert Desensitization, Behavioral Family social exchanges that extinguish desired Ellis, Albert Bandura Shaping, Charting, Therapy behaviour and promote incentives toward Examining Irrational unwanted behaviours. This can lead to Beliefs irrational beliefs and a faulty family schema. Individuals form meanings about their experiences within the context of social relationship on a personal and organizational Dialogical Harry Goolishian, level. Collaborative therapists help families Conversation, Not Collaborative Harlene Anderson, reorganize and dis-solve their perceived Knowing, Curiosity, Language Systems Tom Andersen, Lynn problems through a transparent dialogue Being Public, Reflecting Hoffman, Peggy Penn about inner thoughts with a “not-knowing” Teams stance intended to illicit new meaning through conversation. Collaborative therapy is an approach that avoids a particular
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theoretical perspective in favour of a clientcentred philosophical process. All people are born into a primary survival triad between themselves and their parents where they adopt survival stances to protect their self-worth from threats communicated Virginia Satir, John by words and behaviours of their family Communications Banmen, Jane Gerber, members. Experiential therapists are Approaches Maria Gomori interested in altering the overt and covert messages between family members that affect their body, mind and feelings in order to promote congruence and to validate each person’s inherent self-worth.
Equality, Modeling Communication, Family Life Chronology, Family Sculpting, Metaphors, Family Reconstruction
Families are built upon an unconscious network of implicit loyalties between parents and children that can be damaged when these “relational ethics” of fairness, trust, entitlement, mutuality and merit are breached.
Rebalancing, Family Negotiations, Validation, Filial Debt Repayment
Couples and families can develop rigid patterns of interaction based on powerful emotional experiences that hinder emotional engagement and trust. Treatment aims to enhance empathic capabilities of family members by exploring deep-seated habits and modifying emotional cues.
Reflecting, Validation, Heightening, Reframing, Restructuring
Carl Whitaker, David Kieth, Laura Roberto, Walter Kempler, John Warkentin, Thomas Malone, August Napier
Stemming from Gestalt foundations, change and growth occurs through an existential encounter with a therapist who is intentionally “real” and authentic with clients without pretence, often in a playful and sometimes absurd way as a means to foster flexibility in the family and promote individuation.
Battling, Constructive Anxiety, Redefining Symptoms, Affective Confrontation, CoTherapy, Humour
Feminist Family Therapy
Sandra Bern,
Complications from social and political disparity between genders are identified as underlying causes of conflict within a family Demystifying, system. Therapists are encouraged to be aware of these influences in order to avoid Modelling, Equality, perpetuating hidden oppression, biases and Personal Accountability cultural stereotypes and to model an egalitarian perspective of healthy family relationships.
Milan Systemic Family Therapy
A practical attempt by the “Milan Group” to establish therapeutic techniques based on Luigi Boscolo, Gregory Bateson’s cybernetics that disrupts Hypothesizing, Circular Gianfranco Cecchin, unseen systemic patterns of control and Questioning, Neutrality, Mara Selvini Palazzoli, games between family members by Counter paradox Giuliana Prata challenging erroneous family beliefs and reworking the family’s linguistic assumptions.
Contextual Therapy
Ivan BöszörményiNagy
Emotion-Focused Sue Johnson, Les Therapy Greenberg
Experiential Family Therapy
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Medical Family Therapy
MRI Brief Therapy
Families facing the challenges of major illness experience a unique set of biological, George Engel, Susan psychological and social difficulties that McDaniel, Jeri require a specialized skills of a therapist Hepworth & William who understands the complexities of the Doherty medical system, as well as the full spectrum of mental health theories and techniques.
Gregory Bateson, Milton Erickson, Heinz von Foerster
Grief Work, Family Meetings, Consultations, Collaborative Approaches
Established by the Mental Research Institute (MRI) as a synthesis of ideas from multiple Reframing, Prescribing theorists in order to interrupt misguided the Symptom, attempts by families to create first and Relabeling, Restraining second order change by persisting with (Going Slow), Bellac “more of the same,” mixed signals from Ploy unclear meta communication and paradoxical double-bind messages.
People use stories to make sense of their experience and to establish their identity as a social and political constructs based on local Deconstruction, Michael White, David knowledge. Narrative therapists avoid Externalizing Problems, Narrative Therapy Epston Mapping, Asking marginalizing their clients by positioning Permission themselves as a co-editor of their reality with the idea that “the person is not the problem, but the problem is the problem.”
Object Relations Therapy
Psychoanalytic Family Therapy
Individuals choose relationships that attempt De-triangulation, CoHazan & Shaver, to heal insecure attachments from Therapy, David Scharff & Jill childhood. Negative patterns established by Psychoanalysis, Holding Scharff, James Framo, their parents (object) are projected onto their Environment partners.
Nathan Ackerman
Kim Insoo Berg, Steve de Shazer, William Solution Focused O'Hanlon, Michelle Therapy Weiner-Davis, Paul Watzlawick
Strategic Therapy
Jay Haley, Cloe Madanes
Salvador Minuchin, Harry Aponte, Charles Structural Therapy Fishman, Braulio Montalvo
By applying the strategies of Freudian psychoanalysis to the family system Psychoanalysis, therapists can gain insight into the Authenticity, Joining, interlocking psychopathologies of the family Confrontation members and seek to improve complementarity The inevitable onset of constant change leads to negative interpretations of the past and language that shapes the meaning of an individual’s situation, diminishing their hope and causing them to overlook their own strengths and resources.
Future Focus, Beginner’s Mind, Miracle Question, Goal Setting, Scaling
Directives, Paradoxical Symptoms of dysfunction are purposeful in Injunctions, Positioning, maintaining homeostasis in the family Metaphoric Tasks, hierarchy as it transitions through various Restraining (Going stages in the family life cycle. Slow) Family problems arise from maladaptive Joining, Family boundaries and subsystems that are created Mapping, within the overall family system of rules and Hypothesizing, Rerituals that governs their interactions. enactments, Reframing,
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Unbalancing
Family Therapy Survey Nichols and Schwartz (1998)
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I. The Foundations of Family Therapy - Outline by David Peers A. The myth of the hero 1. The individual is unique and autonomous 2. Breaking free from childhood 3. The myth of rising above the human condition and individuation 4. Individuals are sustained by interpersonal relationships 5. Families are both withholding and uplifting - sometimes at the same time B. Psychotherapeutic sanctuary 1. Therapy in isolation or in groups? 2. Freud and Rogers emphasized private patient/therapist relations 3. Freud: real family who needs it? The use of transference - the therapist as parent 4. Rogers: exploration of self and self - actualization. The need for approval 5. Rogers: support, unconditional positive regard, and the art of listening C. Family vs. Individual therapy 1. Both are approaches to treatment and understandings of human behavior 2. Individual therapy a. Concentrated focus b. Internalization of personal dynamics 3. Family therapy a. External focus b. Changing organizations - change on the entire family, systemic 4. Are we separate entities or embedded in a network of relationships? D. Psychology and social context 1. Family therapy flourishes because of success and recognition of interconnectedness 2. Is psychotherapy intrapsychic or interpersonal? Perhaps both or neither? 3. Family therapy as an orientation rather than a technique 4. Uncovering family influences 5. Individuals within a system
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E. The power of family therapy 1. Evolution from 1950’s to today 2.1975 - 1985 as golden age - shared optimism and common purpose 3. Problems may originate from interaction so change focuses on interactions 4. Questions: a. Constructivist notions? b. Narrative therapy? c. Integrative techniques? d. Social issues? F. Contemporary cultural influences 1. Managed health care a. Crisis intervention versus ongoing personal exploration? b. Confidentiality?. Prejudicial employers? 2. Postmodern scepticism a. Integrated schools of thought b. Approaches to clients or clients to approaches? G. Thinking in lines vs. Thinking in circles 1. Cause and effect perspectives - unilateral influence 2. Circles of thought as empowering 3. Transforming interactions 4. Major advantage of family therapy: works directly on unhappy relationships 5. The difficulty of change 6. Personal participation in problems 7. Circular problems - the cause is the result and the result the cause 8. Learning life’s painful lessons and understanding the family’s story
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II. The Evolution Of Family Therapy - Outline by Lori Rice A. The undeclared war 1. 1950’s - - change in one person changes the system 2. Brown research with schizophrenic patients returning home (1959) 3. Current psychiatric hospital therapy and possible family segregation B. Small group dynamics 1. William Mcdougall - group mind 2. Lewin - group is more than the sum of its parts - - group discussions superior to individual instruction for changing ideas/behavior 3. Bion (1948) fight - flight, dependency, and pairing 4. Process/content in group dynamics 5. Role theories 6. Similarities between group and family therapies C. Child guidance movement 1. Scholars publishing more than clinicians 2. Movement assumption: Emotional problems begin in childhood, therefore treat the child 3. Shift to include families in treatment, but typically blame parents for child’s problems Fromm - Reichmann’s schizophrenogenic mother D. The influence of social work 1. Family casework - families must be considered as units 2. Social workers among most influential in family therapy E. Research on family dynamics and the etiology of schizophrenia 1. Gregory Bateson a. Researched communication among animals b. Functions of communication: report and command, metacommunication c. Bateson joined by others to investigate conflicts between messages and qualifying messages d. Double bind 2. Theodore Lidz 3. Lyman Wynne - rubber fences, pseudomutuality, and pseudohostility 4. Role theorists marriage counseling
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III. Early Models And Basic Techniques - Outline by Sarah Sifers: Group Process And Communications Analysis A. Family therapy has a history of being condescending B. Sketches of leading figures 1. Group family therapy (group) - Bell, Dreikurs, Midelfort, Foulkes, Skynner 2. Communications family therapy (communication) - Jackson, Haley, Bateson, Satir C. Theoretical formulations - group 1. Group/family leaders 2. Family defense mechanisms 3. Subgroups 4. Field theory (Lewin) - conflict is an ‘inevitable part of group life 5.Role theory - every group has roles that have "rules" for conduct (intra - and inter - role conflict, fit between personality and role) D. Theoretical formulations - communications 1. Black box - disregards individual complexity to focus on input and output (communication) 2. Circular causal (disregard past) 3. Syntax - - ways words are put together to make sentences 4. Semantics - clarity, private or shared communication systems, concordance versus confusion 5. Pragmatics - behavioral effects of communication 6. People are always communicating 7. Re ort - (content) conveys information 8. Command - statement about the definition of the relationship 9. Family rules - description of regular interactions 10. Family homeostasis - acceptable behavioral balance within the family 11. Complementary relationships - based on differences that fit together 12. Symmetrical relationships - based on equality and mirroring of behavior 13. Communication punctuation - organizes behavioral events and reflects observer bias 14. Negative feedback loop - perpetuates problems by maintaining status quo 15. Positive feedback loop - alters the system to accommodate novel input
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E. Normal family development 1. Group a. Instrumental and expressive leaders b. Three phases of group development: inclusion, control, affection c. Cohesiveness d. Need compatibility 2. Communications a. Feedback loops b. Normal families become unbalanced during transitions in family life cycle F. Development of behavior disorders 1. Group - symptoms as products of disturbed and disturbing group processes - if needs continue to go unmet, symptoms may be perpetuated into a role and group organizes around a "sick" member 2. Communications - "identified patient" as a role with counter roles and complimentary roles that maintain the system - - - caused by pathological communication such as paradoxical injunctions/ double binds G. Goals of therapy 1. Group - individuation of group members, personal growth, and improved relationships 2. Communications - change/prevent maladaptive interactions viii. H. Conditions for behavior change 1. Group - help family members talk to each other, concentrating more on process than content, then explore those feelings 2. Communications - making covert messages behind symptoms overt. Therapist may manipulate the family be prescribing the symptom or therapeutic double binds, introducing positive feedback loops I. Techniques of group family therapy 1. Therapist as process leader 2. Stages - child - centered, parent - centered, family - centered 3. Types of therapy - multiple group therapy, multiple impact therapy, network therapy 4. Resistance - anything that interfered with balanced self - expression J. Techniques of communications family therapy 1. Structured family interview (5 tasks) 2. Teaching rules of clear communication - (using "I", stating facts, talking to - not about) 3. Used family’s moment to circumvent resistance 4. Therapist as referee and reframer, making implicit rules explicit and using therapeutic paradox
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K. Lessons from early models 1. Group - group dynamics, roles, process/content distinction, free and open discussion, reflective interpretations, connective interpretations, reconstructive interpretations, normative interpretations, networking, confronting, caveat - families aren’t egalitarian 2. Communications - double bind, meta communication, homeostasis, rules, feedback loops, cybernetics, altering patterns of communication, paradoxical directives, symptoms - focused, focus on marital pair L. System’s anxiety 1. Therapists viewed family as being to blame for a "victim’s" illness and were, therefore, the enemy 2. Cybernetics and general systems theory helped clinicians understand families, but tend to dismiss selfhood as an illusion M. Stages of family therapy 1. Initial call - keep it short 2. First interview - build alliance and hypothesize 3. Early phase of treatment - refining hypothesis and beginning to work on problems 4. Middle phase of treatment - family begins to take more active role 5. Termination - review and consolidate N. Family assessment 1. Presenting problem 2. Understanding referral route 3. Identifying systemic context (interpersonal context of presenting concern) 4. Stages of life cycle 5. Family structure 6. Communication 7. Drug and alcohol abuse 8. Domestic violence and sexual abuse 9. Extramarital involvement (not just sexual affairs) 10. Gender (roles, expectations, and society) 11. Cultural factors (including mainstream) 12. Ethical dimension (therapist and family’s ethics) O. Working with managed care - it’s necessary, so cooperate
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IV. The Fundamental Concepts Of Family Therapy - Outline by Anabella Pavon A. Conceptual influences on the evolution of family therapy 1. Opening thoughts a. Systems theory i. Consensus among family therapists about systems theory - most influential in development ii. Consensus among family therapists about systems theory - don’t really know how to explain it iii. Systems theory - abstract concept; way of thinking rather than established doctrine b. Many influences on family therapy i. Biology v. Community mental health ii. Physiology vi. Anthropology iii. Cybernetics vii. Social work iv. Psychosomatic medicine 2. Functionalism a. Reaction to evolutionary method of removing from context b. Anthropology - Malinowski and Brown - need to study in context c. Functionalist premise - "...the adaptive value of any activity can be found if the behavior is viewed in the context of the environment" (pg. 110) d. Evolutionary theory and psychoanalysis e. Bateson f. Functionalist influence on family therapy i. Deviant behaviors may be functional - (scapegoats) ii. Brass tacks - families are organisms adapting to environment in context problems with family show problems with adjustment to environment iii. Problem - "us against them" 3. General systems theory - Bertalanffy - a misinterpretation a. All systems are subsystems b. What did family therapy forget? Larger systems c. Is it important for family therapists to consider values? 4. Cybernetics of families a. Weiner’s idea of self - correcting systems b. Feedback loop i. Negative feedback loop - reduces deviation or change ii. Positive feedback loop - amplifies deviation or change c. Cybernetics applications to families: family rules, neg. Feedback, sequences of interactions, positive feedback loops when neg. Feedback loops don’t work d. Meta communicating - communicating about communicating e. Bateson - introduced concept to family therapy - movement from linear circular causality f. Split - Haley control and power vs. Bateson
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5. From cybernetics to structure a. Haley - coalitions b. Structural concept of families - subsystems with boundaries c. Basic premise - chance structural context, change individual d. Minuchin - cartographer of family structure 6. Satir’s humanizing effect - look at nurturance instead of control 7. Bowen and differentiation of self a. Undifferentiated family ego mass b. Differentiation of self c. Multigenerational transmission process 8. Family life cycle B. Enduring concepts and methods 1. Interconnectedness 2. Sequences of interaction a. Triangles b. Circular sequences c. Indirect communication 3. Family structure 4. Function of the symptom 5. Circumventing resistance 6. The non pathological view of people 7. Family of origin 8. Focussing on solutions 9. Changing a family’s narrative 10. The influence of culture
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V. Bowen Family Systems Therapy - Outline by Jared Warren A. Sketches of leading figures 1. Murray Bowen 2. Philip Guerin 3. Thomas Fogarty 4. Betty Carter 5. Monica McGoldrick 6 Edwin Friedman 7. Michael Kerr 8. James Framo B. Theoretical formulations 1. Differentiation of self 2. Triangles 3. Nuclear family emotional process 4. Family projection process 5. Multigenerational transmission process 6. Sibling position 7. Emotional cut-off 8. Societal emotional process C. Normal family development 1. All families lie on continuum from emotional fusion to differentiation 2. Optimal family development: good differentiation, low anxiety, parents in good emotional contact with families of origin 3. Fogarty elaborates 12 characteristics of well - adjusted families in "systems concepts and the dimensions of self’ (1976) 4. Hallmark of well adjusted person is rational objectivity and individuality 5. Carter and mcgoldrick elaborated the family life cycle a. Leaving home b. Joining of families through marriage c. Families with young children d. Adolescence e. Launching children and moving on f. Families in later life 6. First - order change vs. Second - order change
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D. Development of behaviour disorders 1. Symptoms develop when level of anxiety exceeds system’s ability to cope 2. Most vulnerable individual is most likely to develop symptoms 3. Bowen’s primary approach: calm down the parents and coach them to deal more effectively with the problem 4. Guerin and fogarty put more emphasis on relationship with symptomatic child and nuclear family triangles 5. According to bowen, behavior disorders result from emotional fusion transmitted from one generation to the next E. Goals of therapy 1. Keys to therapy: process and structure 2. Primary goals: decrease anxiety and increase differentiation of self 3. Creation of new triangle in therapy between husband, wife, and emotionally neutral therapist 4. Goals for extended family: developing one - to - one relationships and avoiding triangles 5. Approaches of Guerin and McGoldrick F. Conditions for behavior change 1. Therapists must avoid taking sides and promoting triangulation, and avoid being reactive to inevitable emotionality in families 2. Change requires awareness of entire family 3. Development of personal relationship with everyone in family G. Techniques 1. Bowenian therapy with couples a. Use of displacement b. Therapist concentrates on process of couple’s interactions c. Use of the "i - position" d. Didactic teaching 2. Bowenian therapy with one person a. Goal of differentiation b. Genograms c. Identifying triangles, reentry into family of origin H. Evaluating therapy theory and results 1. Major shortcoming: can neglect importance of working directly with nuclear family 2. Evaluation has relied more on clinical reports than empirical data I. Summary - Seven prominent techniques 1. Genogram 2. The therapy triangle 3. Relationship experiments 4. Coaching 5. The "I-position" 6. Multiple family therapy 7. Displacement stories
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VI. Experiential Family Therapy Outline by Sarah Sifers A. Leading figures and background 1. Emerged in the 1960s from humanistic psychology and drew heavily from gestalt therapy and encounter groups (it is not very popular today) 2. Carl Whitaker 3. Virginia Satir (yes, the same one from communications family therapy) 4. Walter Kempler 5. Bunny and Fred Duhl 6. David Kantor 7. Current figures: Leslie Greenberg and Susan Johnson B. Theoretical formulations 1. Commitment to freedom, individuality, personal awareness, individuals’ goals and values, self - expression, and personal fulfilment, but largely a-theoretical 2. There is a wide variety of perspectives that a rather loosely connected under the heading of experiential family therapy C. Normal family development a. Continuous growth and change and flexibility b. Nurtures and supports individual growth and experience (which leads to increased growth in the family) open (say anything) and constructive problem solving c. Natural and spontaneous; freedom, privacy, and togetherness D. Development of behavior disorders 1. Family and societal pressures prevent naturally occurring self - actualization 2. Denial of impulses and suppression of feelings (emotional deadness) 3. Seeking security and stability (rigid) rather than satisfaction 4. Loyalty to family stressed over loyalty to self 5. Mystification - smothering emotion and desire 6. Marriages consist of two people trying to work out conflicts that arise from each trying to reconstruct his or her family of origin and their differences frighten them causing them to cling closer together 7. Includes "normal" difficulties such as infidelity or "quiet desperation" and "invisible" (culturally accepted) symptoms such as overwork and smoking 8. Intra-psychic defences that lead to interpersonal problems 9. Getting stuck during a life transition or change 10. Lack of warmth >>> avoidance >>> preoccupation with outside activities 11. "wrong" communication: blaming, placating, being irrelevant, and being super reasonable
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E. Goals of therapy 1. Find fulfilling roles for self that don’t override concern for the needs of the family as a whole (personal growth and family integration) 2. Increased self - awareness and expression that facilitates open family communication (you can’t communicate what you’re not aware of) 3. Growth, personal integrity, freedom of choice, less dependence, "expanded experience," increased sense of competence, self - esteem, and well - being 4. Openly acknowledge support, and make use of individual differences 5. Being spontaneous, "crazy" F. Conditions for behavior change 1. Evocative measures (resulting in anger, anxiety, etc.) To create therapeutic change by opening people up or discover hidden emotions 2. Therapist must be warm and supportive, become a family member, be a "real person" 3. Therapist teaches by example how to be open, honest, and spontaneous 4. Including as many family members as possible (3 generations and kids) 5. Therapist needs to be mature, experienced, and have a satisfying family life G. techniques 1. Clarifying communication (often through directives) 2. Focus on solutions rather than past grievances and point out positives 3. Support all family members’ self - esteem 4. Asking questions about emotions that are not expressed clearly (ind. Nonverbal cues) 5. Use of touch 6. Use of co - therapists to manage counter - transference 7. Very little formal assessment or history taking 8. Specific techniques: family sculpture, family puppet interviews, family art therapy, conjoint family drawings, gestalt therapy techniques, symbolic drawing of family life space, role playing, there - and then techniques, "psychotherapy of the absurd" 9. Interrupting family dialogues to work with individuals H. Evaluation 1. No empirical studies, but some anecdotal support 2. Family therapists would benefit from being more honest and open with clients 3. Shifting the focus to an individual is a way to stop family bickering
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VII. Psychoanalytic Family Therapy Outline by Anabella Pavon A. Introduction 1. Many early family therapists have their roots in psychoanalytic training 2. Several psychodynamic therapists completely turned away from looking at the individual 3. 80s - family therapists looked at the individual again 4. Paradox: psychoanalysis is for the individual, family therapy the family. How can there be Psychoanalytic family therapy? B. Sketches of leading figures 1. Four groups of contributors to psychoanalytic family therapy - forerunners, psychoanalytically trained pioneers, psychoanalytic ideas and thoughts when the field turned from psychoanalytic ideas, and contemporary psychoanalytic family therapists 2. Adelaide Johnson - superego lacunae - gaps in personal morality passes on by parents 3. Erik Erikson - sociology and ego psychology 4. Wait ... There’s more - Erich Fromm predecessor of Bowen, Sullivan, Wynne, Lidz, Acherman - strongest tie to psychoanalytic theory 5. Nathan Acherman - the psychodynamics of family life (1958) - first book dealing strictly with diagnosis and treatment of families 6. Ivan Boszormenyi - Nagy - center of family therapy at the eastern Pennsylvania Psychiatric Institute. 7. Dicks - worked with couples in England 8. John Bowlby C. Theoretical formulations 1. "Practical essence of psychoanalytic theory is being able to recognized and interpret Unconscious impulses and defenses against them .... 2. Freudian drive psychology - sexual and aggression 3. Self psychology - people want to be appreciated 4. Object relations theory - bridge between psychoanalysis and family therapy - relate to people in the present partially based on expectations we develop in early relationships D. Normal family development 1. Healthy psychological development based on good early environment - parents - good object relations 2. Lots of talk about the mother and early mother/child attachment 3. Separation/individuation - provision of reliable support from mother is necessary 4. Parents need to be empathetic and model idealization 5. Ivan Boszormenyi - Nagy - contextual therapy - concerned with the ethics of families "loyalty and trust provide the glue that holds families together"
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E. Development of behavior disorders 1. Where non - psychoanalytic family therapist look at problems in interactions between people while psychoanalytic therapists look at problems in the actual people in the family 2. Symptoms come from attempting to cope with unconscious conflicts and the Anxiety that signals the emergence of repressed impulses" 3. Some problems can occur with parents not accepting children’s separation 4. Kohut - mirroring and idealization - when these needs aren’t met from parents, go on to be showy and seek admiration 5. Fixation and regression in families - after marriage, people can go back to behaviors seen when they were younger 6. Nnagy - symptoms occur when trust breaks down in relationships - individuals feel the effects 7. Kernberg - blurred boundaries occur when connections are formed with family members F. Goals of therapy 1. " . . . Free family members of unconscious restrictions so that they’ll be able to interact with one another as whole, healthy persons on the basis of current realities rather than Unconscious images of the past." 2. Therapy focuses on supporting defenses and helping communication instead of analysis of defenses and finding repressed needs and impulses G. Conditions for behavior change 1. Insight is necessary - in family therapy expand that insight knowing that psychological life goes beyond conscious experiences. Want family members to understand and accept repressed parts of personalities. Need to work through those things. 2. Important for the therapist to establish a sense of security H. Techniques 1. Four basic techniques - listening, empathy, interpretation, and keep analytic neutrality 2. Don’t focus on reassuring or advise or confronting, silence is important. If they do intervene it’s to provide empathic understanding to help member of the family open up. Analysts also clarify things that appear to be hidden or need clarification 3. Mostly used with couples. 4. Therapists focus on the feelings associated with problems, not the causality to begin questioning about what’s at the root of the problem 5. Explore in four areas with couples: internal experience, history of the experience, how partner can trigger the experience, and how the context of session and therapist’s input might contribute to the situation 6. "Family dynamics are more than the additive sum of individual dynamics" (p. 228) 7. Therapist has to have a hypothesis
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VIII. Structure Family Therapy — Outline by Patty Salehpur A. Assumptions 1. Family are individuals who effect each other in powerful but unpredicatable ways 2. The consistent repetitive organized and predictable patterns of family behavior are important 3. The emotional boundaries and coalitions are important B. Salvador Minuchin 1. Always concerned with social issues 2. Developed a theory of family structure and guidelines to organize therapeutic techniques 3. 1970 headed Philadelphia Child Guidance Clinic where family therapists have been trained in structural family therapy ever since 4. Born in Argentina , served in the Israel army as a physician, in the USA trained in child psychiatry and psychoanalysis with Nathan Ackerman, worked in Israel with displaced children, also worked in the USA with Don Jackson with middle class families. 5. Fist generation of family structural therapists: Braulio Montalvo, Jay Haley, Bernie Rosman, Harry Aponte, Carter Umbarger, Marianne Fishman, Cloe Madanes, and Stephen Greenstein. C. Theoretical formulations - three essential constructs 1. Structure — the organized pattern in which family members interact, predictable sequences of family interaction, patterns of interaction. Structure involves a series of covert rules. There are universal and idiosyncratic constraints. Families may not be able to tell you the family structure, but they will show it to you in their interactions. 2. Subsystems — Families are differentiated into subsystems of members who join together to perform various functions. Each person is a member of one or more subsystems in the family. Some groupings are obvious and based on such factors as generation, gender, age or common interests. Other coalitions may be subtle. Every member may play many roles in various subgroups. 3. Boundaries are invisible barriers that regulate the amount and nature of contact with members. They range from rigid to diffuse, clear to unclear, disengaged to enmeshed D. Normal family development 1. Marriage begins with accommodation and boundary making 2. Couples are influenced by the structure of their families of origin 3. Couples also form boundaries with their families of origin 4. The advent of children requires that the structure of the family change E. The development of behavior disorders 1. Family dysfunction results from stress and failure to realign the structure to cope with it. 2. Disengaged families have rigid boundaries and excessive emotional distance. They fail to mobilize to deal with the stress. 3. Enmeshed families have diffuse boundaries and family members overreact emotionally and become intrusively involved with one another. These actions hinder mature actions to resolve stress. 4. Subsystems in the family may be disengaged or enmeshed. 5. Power hierarchies may develop which may be weak and ineffective or rigid and arbitrary. 6. Conflict avoidance prevents effective problem solving. 7. Generational coalitions may also prevent effective problem solving. 8. Family structure may fail to adjust to family developmental processes.
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9. A major change in family composition demands structural adaptation. 10. Symptoms in one family member may reflect dysfunctional structural relationships or simply individual problems. F. Goals of therapy 1. Changing family structure - altering boundaries and realigning subsystems 2. Symptomatic change - growth of the individual while preserving the mutual support of the family 3. Short-range goals may be developed to alleviate symptoms especially in life threatening disorders such as anorexia nervosa, but for long-lasting effective functioning the structure must change. Behavioral techniques fit into these short-term strategies. G. Techniques — join, map, transform structure 1. Joining and accommodating, then taking a position of leadership a. Listen to "I" statements 2. Enactment for understanding and change 3. Working with interaction and mapping the underlying structure a. Looking at the power hierarchies b. Using enactment to understand and clarify c. Looking at the boundary structures 4. Diagnosing a. individual vs. subgroup b. structural diagnosis 5. Highlighting and modifying interpersonal interactions is essential a. Control intensity by the regulation of affect, repetition and duration b. Don’t dilute the intensity through overqualifying, apologizing or rambling c. Shape competence, e.g. "It’s too noisy in here. Would you quiet the kids." 6. Boundary making and boundary strengthening a. Seating b. Seeing subgroups or individuals to foster boundaries and indivduation c. Clarify circular causation 7. Unbalancing may be necessary a. Taking sides b. Challenging c. Directives 8. Challenging the family’s assumptions may be necessary a. Teaching may be necessary b. Pragmatic fictions c. Paradoxes d. Therapist sometimes must challenge the way family members perceive reality, changing the way family member relate to each other offers alternative views of reality. 9. Therapists must create techniques to fit each unique family
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