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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

 

Family Therapy History, Theory, and Practice, 6th Edition Gladding – Test Bank

 

 

Sample  Questions

 

Chapter 1

The History of Family Therapy: Evolution and Revolution

 

Chapter Overview

 

Family Therapy Through the Decades

 

  • Prior to the development of marriage and family therapy as a profession, older family members assisted younger members and adult family members cared for the very young and the very old
  • Before 1940
  • focus in the United States was on the individual
  • society utilized clergy, lawyers, and doctors for advice and counsel
  • prevailing individual theories were psychoanalysis and behaviorism
  • Catalysts for the growth of family therapy
  • courses in family life education became popular
  • establishment of marriage and family training programs (e.g., Marriage Council of Philadelphia in 1932)
  • founding of the National Council on Family Relations in 1938 and the journal Marriage and Family Living in 1939
  • county home extension agents educated and promoted understanding family dynamics
  • Family therapy: 1940 to 1949
  • establishment of the American Association of Marriage Counselors in 1942
  • first account of concurrent marital counseling published in 1948 by Bela Mittleman
  • research on families with a schizophrenic member by Theodore Litz
  • National Mental Health Act of 1946 funded research on prevention, diagnosis, and treatment of mental health disorders
  • Family therapy: 1950 to 1959
  • individual leaders dominated the profession
  • Nathan Ackerman used a psychoanalytical approach to understand and treat families
  • Gregory Bateson studied communication patterns in families with a schizophrenic member and developed the double bind theory
  • double bind theory – two seemingly contradictory messages may exist simultaneously and lead to confusion
  • Mental Research Institute was created by Don Jackson in Palo Alto, CA
  • changed problem conceptualization from a pathology oriented individual perspective to a more relationship based orientation
  • brief therapy developed at MRI as one of the first new approaches to family therapy
  • Carl Whitaker pushed the conventional envelope by seeing spouses and children in therapy
  • set up the first family therapy conference at Sea Island, GA
  • Murray Bowen studied families with schizophrenic members
  • held therapy sessions with all family members present
  • pioneered theoretical thinking on the influence of previous generations on the mental health of families
  • Ivan Boszormenyi-Nagy developed contextual therapy focusing on the healing of human relationships through trust and commitment
  • Family therapy: 1960 to 1969
  • An era of rapid growth in family therapy
  • Increase in training centers and academic programs in family therapy
  • Jay Haley, expanding on the work of Milton Erikson, developed strategic family therapy
  • emphasis on the therapist gaining and maintaining power during treatment
  • strategic therapy uses directives to assist clients to go beyond gaining insight
  • edited Family Process from 1961 to 1969, providing a means for to keep professions linked and informed
  • Haley joined with Salvador Minuchin at the Philadelphia Child Guidance Clinic in the late 1960’s
  • Salvador Minuchin developed structural family therapy, based on his work with the Wiltwyck School for Boys
  • utilized minority community members as paraprofessionals to better relate to urban blacks and Hispanics
  • Virginia Satir was the only woman among the family therapy pioneers
  • started seeing family members as a group in the 1950’s
  • utilized touch and nurtured her clients, emphasizing self-esteem, compassion, and affective congruence
  • published Conjoint Family Therapy in 1964 which stressed the importance of seeing distressed couples together at the same time
  • Virginia Satir was an influential, charismatic leader
  • Carl Whitaker pioneered unconventional, spontaneous, sometimes outrageous appearing approaches, designed to help families achieve freedom and growth
  • Family Process co-founded in 1961 by Don Jackson and Nathan Ackerman
  • Nathan Ackerman published Treating the Troubled Family in 1966, advocating closer therapist involvement with families during treatment, being confrontive, and making covert issues overt
  • John Bell developed a family group therapy model, advocated that children 9 years and older should participate in family therapy, and offered one of the first graduate family therapy courses in the United States
  • Murray Bowen discovered that emotional reactivity in many families created undifferentiated family ego mass (i.e., family members have difficulty maintaining their individual identities and actions)
  • Systems theory developed by Ludwig Von Bertalanffy in 1968
  • a way of looking at all parts of an organism simultaneously
  • a set of elements standing in interaction with one another
  • each element of a system is affected by what happens to any other element
  • the whole is greater than the sum of its parts
  • became the basis for most family therapy
  • less reliance on linear causality (direct cause and effect)
  • increased emphasis on circular causality (events are related through a series of repeating cycles or loops)
  • family therapists seen as a specialists within the field
  • first license regulating family therapists granted in California in 1963
  • Institutes and training centers
    • Mental Research Institute continues its work in training and research
    • Family Therapy Institute of New York established with Nathan Ackerman as director
    • Philadelphia Child Guidance Clinic developed innovative supervision techniques such as the ‘bug in the ear”
    • Family Therapy Institute of Philadelphia founded in 1964, merging the Eastern Pennsylvania Psychiatric Institute and the Family Institute of Philadelphia
    • Boston Family Institute founded by Fred Duhl and David Kantor, focusing on expressive and dramatic interventions and originating the family sculpting technique
    • Institute for Family Studies in Milan, Italy formed in 1967
    • an MRI based model that developed many innovative short term approaches
  • Family therapy: 1970 to 1979
    • rapid growth in AAMFT based partly on recognition as an accrediting body for marriage and family training programs
    • The American Association of Marriage and Family Counselors (AAMFC) changed its name to the American Association for Marriage and Family Therapy (AAMFT) in 1977
    • Journal of Marital and Family Therapy founded by AAMFT in 1974
    • American Family Therapy Academy (AFTA) founded in 1977 to address clinical, research, and teaching issues
    • AAMFT and AFTA agreed on distinct roles within the profession
    • AFTA concentrated on the exchange of ideas among advanced professionals
    • AAMFT focused on accreditation of training programs
    • family therapy continued to growth and become more refined outside of psychoanalytical traditions
    • Nathan Ackerman died in 1971
    • the approaches of Carl Whitaker (experiential family therapy), Salvador Minuchin (structural family therapy), and Jay Haley (strategic family therapy) gained in popularity and influence
    • Families and Family Therapy published in 1974 by Minuchin, serving as a practical training guide for structural family therapy
    • Psychosomatic Families: Anorexia Nervosa in Context published by Minuchin and associates in 1978, highlighting the power of the structural family therapy approach in working with this disorder
  • Influence of foreign therapies and therapists
  • family therapy grew rapidly in Europe, particularly in Milan, Italy
  • Milan associates
  • developed circular questioning (asking questions that highlight differences among family members)
  • developed triadic questioning (asking a third member how two other members of the family relate)
  • emphasis on developing hypotheses about the family before treatment begins
  • utilized outside of session homework assignments that were often difficult and ritualistic
  • D. Laing, a British professional, created the term mystification to describe how some families mask interactions between family members by giving contradictory or confusing explanations
  • Robin Skynner, from Great Britain, developed a brief psychoanalytic family therapy which complemented the earlier work of Nathan Ackerman and Ivan Boszormenyi-Nagy
  • Feminist theory and family therapy
  • feminists began to question whether or not some concepts of family therapy were oppressive to women
  • A Feminist Approach to Family Therapy was published in Family Process by Rachel Hare-Mustin in 1978
  • belief that sexism limits the psychological well-being of women and men and must not be tolerated
  • Family therapy: 1980 to 1989
  • marked by the retirement or death of many family therapy founders and leaders and the emergence of new leaders
  • increase numbers of women leaders who created new theories which challenged older ones
  • Women’s Project in Family Therapy in 1988 focused on gender free approaches to family therapy
  • increased numbers of individuals and associations devoted to family therapy, including the International Association for Marriage and Family Counseling (IAMFC) of the American Counseling Association and Division 43 (Family Psychology) of the American Psychological Association
  • increased levels of research in family therapy to provide evidence of the effectiveness of family therapy
  • increased numbers of publication in the family therapy field, including the Family Therapy Networker
  • Creation of multisystemic therapy, an intensive family- and community-based approach for working with juvenile offenders
  • recognition of family therapy as one of four core mental health providers eligible for federal training grants
  • Family therapy: 1990 to 1999
    • family therapy became a more worldwide phenomenon, with associations, research, and training institutes established across the globe
    • new theories were developed or refined
    • feminist family therapy examined gender sensitive issues in therapy rather than masculine or feminine issues, per se
    • the reflecting team approach of Tom Anderson used clinical observers to discuss their impressions with the therapist and the family, thus becoming a part of the therapeutic team
    • the therapeutic conversations model of Harlene Anderson and Harry Goolishian used a postmodern approach in which the therapist relates to the family in a more collaborative, egalitarian partnership
    • the psychoeducational model of Carol Anderson emphasized teaching family members about multiple aspects of mental illness, focusing on boundaries, hierarchy, and the integrity of subsystems
    • the internal family systems model of Richard Schwartz looks at both individual intrapsychic dynamics and family systems
    • social constructionism based models were radically different than systems based models in that they are based on the belief that our experiences are a function of how we think about them rather than objective truths
    • Basic Family Therapy Skills Project was established in 1987 to determine the essential skills needed for mastery of structural, strategic, brief, and transgenerational family therapy approaches
    • increased awareness and focus on the influence of the therapist on the therapy (second-order cybernetics)
    • increased importance of the family ontology or ‘world view’ stressing circularity and autonomy of systems
    • change in training emphasis from producing narrowly focused, theory bound clinicians to a focus on how to work with specific populations or types of families
  • Family therapy: 2000 to 2009
  • family therapy has spread to Europe, Asia, Africa, Australia and South America
  • International Family Therapy Association founded in 1987
  • professional associations continue to grow, providing services, educational opportunities, and publications
  • licensure has grown to all 50 states
  • marriage and family therapists recognized as one of five core mental health providers (along with psychiatrists, psychologists, social workers, and psychiatric nurses)
  • Accreditation of family therapists
  • two associations accredit marriage and family training programs
  • Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)
  • Council for Accreditation of Counseling and Related Educational Programs (CACREP)
  • Developing culturally effective family-based research
  • increased research on the effectiveness of family therapy with different cultural groups
  • continued development of marriage and family therapy in regard to new narratives and approaches to working with couples and families
  • health care reform
  • Family therapy: 2010 to the present
  • Social conditions continue to change, requiring marriage and family therapists to formulate new and more socially relevant ways to work with couples and families
  • Professional associations such as the AAMFT and the IAMFC rely heavily on technology to disseminate information
  • Online therapy is becoming more popular and prominent
  • The AAMFT and IAMFC updated their respective codes of ethics in 2012 to keep pace with the times
  • The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was published in 2013 and continues to pose challenges for family therapists’ treatment of couples and families and reimbursement for their work
  • The Supreme Court of the United States rendered two important decisions in 2013 with ramifications for marriage and family therapists, one related to the legal definition of “spouse,” and, a second lifted the ban on same-sex marriage in California

 

 

Key Terms

 

Basic Family Therapy Skills Project   a project that began in 1987 which focuses on determining, defining, and testing the skills essential for beginning family therapists to master for effective therapy practice.

 

brief therapy   an approach to working with families that has to do more with the clarity about what needs to be changed rather than time. A central principle of brief therapy is that one evaluates which solutions have so far been attempted and then tries new and different solutions to the family’s problem, often the opposite of what has already been attempted.

 

circular questioning   a Milan technique of asking questions that focus attention on family connections and highlight differences among family members. Every question is framed so that it addresses differences in perception about events or relationships by various family members.

 

dual therapy   the name for conjoint couple therapy devised by Carl Whitaker.

 

family life education   the study of family life including developmental and situational factors that affect or change the life of families.

 

internal family systems   model of Richard Schwartz which considers both individual intrapsychic dynamics and family systems.

 

interpersonal   pertaining to matters or relationships between two or more persons.

 

intrapersonal   thoughts, feelings, and processes within a person.

 

mystification   the actions taken by some families to mask what is going on between family members, usually in the form of giving conflicting and contradictory explanations of events.

 

National Mental Health Act of 1946   legislation that authorized funds for research, demonstration, training, and assistance to states in order to find the most effective methods of prevention, diagnosis, and treatment of mental health disorders.

 

new epistemology   the idea that the general systems approach of Bateson, sometimes referred to as cybernetics, must be incorporated in its truest sense into family therapy with an emphasis on “second-order cybernetics” (i.e., the cybernetics of cybernetics). Basically, such a view stresses the impact of the family therapist’s inclusion and participation in family systems.

 

ontology   a view or perception of the world.

 

psychoeducation   a strategy that involves educational methods such as reading books, attending workshops, listening to audiovisual material and interactive discussions.

 

reflecting team approach   an approach where clinical observers of a therapeutic session come out from behind a one-way mirror observing room to discuss with the therapist and client couple/family their impressions.

 

schism   the division of the family into two antagonistic and competing groups.

 

second-order cybernetics   the cybernetics of cybernetics, which stresses the impact of the family therapist’s inclusion and participation in family systems.

 

skew (marital skew)   a dysfunctional marriage in which one partner dominates the other.

 

social constructionism   a philosophy that states experiences are a function of how one thinks about them and the language one uses within a specific culture. From this perspecitve all knowledge is time- and culture-bound. It challenges the idea that there is objective knowledge and absolute truth. Narrative and solution-focused therapy are based on social constructionism. system  a set of elements standing in interaction. Each element in the system is affected by whatever happens to any other element. Thus, the system is only as strong as its weakest part. Likewise, the system is greater than the sum of its parts.

 

systems theory   a theory, sometimes known as general systems theory, that focuses on the interconnectedness of elements within all living organisms, including the family. It is based on the work of Ludwig von Bertalanffy.

 

therapeutic conversations model   a postmodern approach where the family therapist relates to the couple or family in a more egaliarian partnership

 

undifferentiated family ego mass   according to Bowen, an emotional “stuck togetherness,” or fusion, within a family.

 

 

 

 

Classroom Discussion

 

  1. Freud and others believed that the family is often the source of difficulties and as a result, the patient should be treated separately from the family to avoid contamination. Family therapy, on the other hand involves family members in the treatment process and brings the action into the room rather than just talking about problems.  If you were a member of a professional panel discussion of individual and family therapies, what rationale would you give for the value of family therapy?

 

  1. Client satisfaction rates are claimed to be as high as 97% for marriage and family therapy clients. What do you think accounts for this high rate of satisfaction?

 

  1. Like families themselves, the field of family therapy has changed markedly over the past few decades. Early approaches emphasized giving directives and therapists being “in charge” during treatment.  In the 1990’s, social constructivist models emphasized individual rather than absolute truths, and a more egalitarian therapist-client relationship.  Discuss the merits of the ‘therapist as leader’ versus the ‘therapist as collaborator’ and explain how can these two very different approaches might peacefully co-exist.

 

 

Multiple Choice Questions

 

  1. Family therapists believe most life difficulties stem from:
  2. individual problems
  3. family problems
  4. societal problems
  5. intrapersonal problems

 

  1. Family therapy is particularly effective with:
  2. adult obesity
  3. insomnia
  4. couple distress
  5. A and C

 

  1. Before 1940, mental health treatment focused on:
  2. families
  3. groups
  4. individuals
  5. interpersonal issues

 

  1. The systems theory developed by Ludwig Von Bertanlanffy had less reliance on _____ and more emphasis on _____.
  2. family therapists; paraprofessionals
  3. circular causality; linear causality
  4. individual parts; societal influence
  5. linear causality; circular causality

 

  1. The only woman pioneer in the early days of family therapy was:
  2. Monica McGoldrick
  3. Evelyn Duvall
  4. Virginia Satir
  5. Rachel Hare-Mustin

 

 

 

  1. A type of questioning developed by the Milan Associates, emphasized asking questions that highlighted differences among family members. This type of questioning is called:
  2. linear questioning
  3. triadic questioning
  4. open ended questioning
  5. circular questioning

 

  1. The following family therapy pioneer utilized touch and nurturing of family members, emphasizing self-esteem, compassion, and affective congruence:
  2. Ludwig Von Bertalanffy
  3. Virginia Satir
  4. Carl Whitaker
  5. all of the above

 

  1. There are currently two associations accrediting marriage and family therapy training programs:
  2. APA; AAMFT
  3. CACREP; AAMFT
  4. AFTA; AAMFT
  5. AAMFT; ACME

 

  1. Family therapy focuses on the _____ rather than the _____, which creates new and unique ways of resolving problems.
  2. intrapersonal; interpersonal
  3. physical; emotional
  4. individual; system
  5. interpersonal; intrapersonal

 

  1. Family therapy tends to be _____ than individual counseling.
  2. longer
  3. briefer
  4. about the same
  5. faster

 

 

True/False Questions

 

  1. In the 1970s, feminists began to question whether or not some concepts of family therapy were oppressive to women.

 

True ___    False ___

 

  1. The purpose of mystification is to simultaneously send two seemingly contradictory messages, leading to confusion.

 

True ___    False ___

 

  1. The first family therapy license was granted in Michigan in 1963.

 

True ___    False ___

 

  1. John Bell was known for his unconventional, spontaneous, sometimes outrageous appearing approaches, designed to help families achieve freedom and growth.

 

True ___    False ___

 

  1. The most popular family therapy approaches in the 1970’s were experiential family therapy, structural family therapy, and strategic family therapy.

 

True ___    False ___

 

  1. The Supreme Court of the United States ruled in 2013 that Section 3 of the Defense of Marriage Act (DOMA) was unconstitutional under the Due Process Clause of the Fifth Amendment.

 

True ___    False ___

 

 

Chapter 2

The Theoretical Context of Family Therapy

 

Chapter Overview

 

Historical Perspective

 

  • Families have played an important part throughout history in the lives of peoples and nations
  • Families provide deep emotional experiences such as love, devotion, attachment, belonging, fun, and joy
  • A family also can be a therapeutic environment for its members by listening, sympathizing, assisting, and reassuring each other
  • Over time, families have been shaped by social, cultural, economic, and governmental changes

Family Definitions

 

  • Families are systems in which the members interact with one another
  • Family members influence each other and, in turn, are influenced by each other
  • Because of this mutual interaction, a family is greater than the sum of its parts
  • The interrelatedness of the family is known as cybernetics
  • Definitions of what a family is and how it is structured vary across cultures and are constantly changing and evolving
  • Families are both universal and unique, each family having its own set of rules, sequences, subsystems, feedback loops, hierarchy, and organization
  • Common family types in American society include nuclear, single parent, and blended, with variations of these three family forms described as dual career, child free, special needs children, gay/lesbian, aging, multigenerational, grandparent headed, and military
  • The family one grew up in is known as one’s family-of-origin

 

Individual and Family Development

 

  • It is useful to study families from a developmental perspective, (i.e., the predictable changes that occur in individuals and families over time)
  • The ‘life course’ refers to different time dimensions such as individual time (the time from birth to death), social time (important social events such as marriage, parenthood, and retirement), and historical time (the era and culture in which one lives)
  • The term ‘life cycle’ is used to describe the continuous development of people over time
  • Individuals and families experience predictable events and developmental crises (changes) which are often sequential
  • Life cycle stages require some level of success at each stage before proceeding to the next stage. There are times of predictable developmental crises (times of turmoil and opportunity) in each stage.
  • Erik Erikson, a pioneer in the area of human growth and development, described human life in terms of stages or sequential developmental occurrences. He developed an influential eight stage model of individual development.  The first five stages focus on individual skill and identity development, the last three are more interpersonally based
  • Evelyn Duvall first proposed a family life cycle model based on the intact, middle class nuclear family in 1956. This model has lost influence due to the decrease in number and percentage of nuclear families in the United States
  • In 1999, Carter and McGoldrick proposed a six-stage family life cycle model of the intact middle class nuclear family that begins with the unattached adult and continues through retirement
  • Each stage in this model requires key adjustments, tasks, and changes for the individuals to survive and thrive. There is often intergenerational ambivalence in families as children, especially young adults, move to more independence and yet need assistance

Stage 1  Single Young Adults: Leaving Home

 

  • the numbers of single young adults is increasing
  • traditional family oriented activities are being reshaped to accommodate singles
  • a major task of single young adults is to disconnect and reconnect with one’s family on a different level and to develop a strong identity – a “solid self”
  • cohabitation (living together without being married) is increasing with positive, negative and neutral aspects to it
  • singlehood is a viable alternative to marriage; more accepted now than in the past
  • singles are the second happiest group (married couples being the happiest)
  • society continues to promote marriage, creating internal and external pressures on singles to marry
  • singles must establish social networks, find meaning in work or avocations, and live a balanced life to be physically and psychologically healthy
  • singles typically seek family therapy due to a weak sense of self, inability to separate from their family of origin, and a lack of social skills to establish significant relationships with others

Stage 2  The New Couple: Joining of Families Through Marriage

 

  • new couple relationships begin with courtship, in which individuals test their compatibility and tend to idealize the relationship
  • individuals tend to be most comfortable with others at the same or similar developmental level (e.g., secure men tend to be involved with secure women; anxious women may be attracted to less committed and more disengaged men)
  • the new couple stage is a period of adjustment and accommodation and requires time, energy, good will, and the ability to compromise
  • this stage can be quite satisfying for those who are able to resolve differences successfully – they maintain a high level of idealistic distortion about their marriage and spouse,
  • this stage can result in divorce for those unable to make the necessary adjustments
  • new couples typically seek family therapy due to the inability to adjust to living as a couple instead of individually, difficulty with relatives (in laws and/or family of origin), inability to develop effective communication and problem solving skills, and differences over whether and when to have children

Stage 3  Families with Young Children

 

  • this stage is characterized by dramatic changes in lifestyle which stress a couple’s lifestyle and marital relationship,
  • this stage create new parenting/maternal demands and unbalances the patterns and interactions previously developed – at least temporarily
  • although marital satisfaction tends to decrease in this stage, strong marital bonds can mediate the stresses associated with children and work issues
  • families with young children typically seek family therapy due to inability to reorganize and restructure following the arrival of children as well as differences over how to raise and discipline children

 

Stage 4  Families with Adolescents

 

  • this stage is one of the most active and exciting yet it can be very stressful and demanding for many families
  • couples may be caring for aging parents in addition to adolescent family members they are often squeezed psychologically and physically — sometimes referred to as the ‘sandwich generation’
  • stressors may include difficulty in setting limits, redefining relationships, and caring and supporting one another; decreasing parental influence and increasing peer influence; generational and gender differences; and maintaining open communication
  • when adolescents develop ‘planful competence’ they come to have a realistic understanding of their intellectual, social, and personal responses in their relationships with others
  • families with adolescents typically seek family therapy due to parent-adolescent conflict, developmental and psychological stress of marital partners who see their dreams ‘slipping away,’ and the stresses involved with caring for multiple generations of family members as well as for themselves

Stage 5  Launching Children and Moving On

 

  • the ’empty nest’ describes parents whose children have left home for college, marriage, careers, etc.
  • this can be a positive time for couples, (e.g., some rediscovering the couple relationship and enjoying new freedoms from responsibility)
  • this can be a negative time for couples, especially those who have defined themselves primarily as parents and have been heavily focused on their children.
  • children who leave and then return (‘boomerang children’) can create tension among family members
  • families in the launching and moving on stage typically seek family therapy due to a sense of loss of self, the marriage or the child who has left; conflict with the child who is not independent enough; or frustration/anger over the marriage and/or career ambitions

Stage 6  Families in Later Life

 

  • within this stage are three groups: the young old (65-74), the old (75-84), and the oldest old (85 and after)
  • characterized by decline in finances, health, loss of spouse, chronic illness, depression, and helplessness
  • positive aspects of this stage include interacting with grandchildren, doing what one wants and setting one’s own pace, and reflecting on important life activities
  • families in later life typically seek family therapy due to a lack of meaning or enjoyment in life, concern over the aging process, the lack of quality relationships with family members (for example, children, in-laws, grandchildren)

Unifying Individual and Family Life Cycles

 

  • Although outwardly the individual life cycle stages do not appear to have much in common with family life cycle stage, they do share some commonalities
  • Both share an emphasis on growth and development
  • Growth is seen as a conscious process that involves a fair amount of risk and courage
  • Both can be viewed from a systemic theory perspective, which emphasizes the interrelatedness of the entire unit, that a family is greater than just the sum of its parts, and that families have organization, rules, and repetitive patterns
  • The concept of ‘circular causality’ is based on the idea that family member’s actions influence others and are in turn influenced by others. This differs from ‘linear causality’ in which actions move in one direction only, with each action causing another
  • in linear causality, a mother may be seen as the cause of a child’s problem
  • in circular causality, the parent and child interact in a way that results in the problem repeating and intensifying (e.g., the more a parent protects a shy child, the more shy the child becomes, which results in more protection and more shyness, etc.)
  • Life cycle models are complementary in the development and ‘readiness’ of persons; they tend to strengthen and prepare people for challenges and work
  • Life cycle models are competitive in that the needs of individuals often are in competition with the needs of the family and can create tension

 

 

Implications of Life Cycles and Family Therapy

 

  • The ‘fit’ between the therapist and the family can influence the outcome of therapy
  • therapists bringing unresolved issues into their clinical work can create problems
  • therapists may not have experienced the family’s developmental stage, may be currently experiencing the same stage as the family, or may already have been through the family’s stage – all of these situations can cause problems
  • race, gender, ethnicity, class, sibling position, and sexual orientation of the therapist can positively or negatively influence the ‘fit’ and outcome of therapy.
  • therapists can improve the ‘fit’ or match with families by increasing their sensitivity to particular families, obtaining peer or clinical supervision to overcome deficiencies, or receiving continuing education to increase knowledge and skills
    • Therapists must be sensitive to cultural differences which require adjustments to life cycle models
    • Illness in a family member, either temporary or permanent, disrupts life cycles and can wear down a family’s ability to handle the situation or can provide opportunities for growth and cohesion
    • Therapists can assess the family’s present and prior functioning and assist them to better understand the illness, resolve developmental disruptions, and develop more effective coping methods
    • Special-needs children, i.e., those with disabilities, may affect parents/family positively or negatively; regardless expected life cycle of family is affected and therapist must take this matter into consideration
    • Poverty and professionalism are economic and social factors that influence families in different ways, with poor families having fewer resources and struggling more with unexpected life events as compared with more affluent professional families

 

 

Key Terms

 

boomerang children   adult children who, after being out on their own for awhile, return to live with their parents because of financial problems, unemployment, or an inability or reluctance to grow up

 

circular causality   the idea that actions are part of a causal chain, each influencing and being influenced by the other.

 

cohabitation effect   the phenomenon of lower marital quality, more negative communication, less dedication, and higher rates of divorce for couples who cohabitated before marriage

 

courage   the ability to take calculated risks without knowing the exact consequences

 

cybernetics   a type of systemic interrelatedness governed by rules, sequences, and feedback. The term was introduced as a concept to family therapy by Gregory Bateson. See also new epistemology.

 

development   predictable physical, mental, and social changes over life that occur in relationship to the environment.

 

empty nest  a term that describes couples who have launched their children and are without childrearing responsibilities.

 

family of origin   the family a person was born or adopted into.

 

homeostasis   the tendency to resist change and keep things as they are, in a state of equilibrium.

 

idealistic distortion  viewing one’s marriage and spouse to be better than they actually are

 

linear causality   the concept of cause and effect—that is, forces being seen as moving in one direction, with each action causing another. Linear causality can be seen in, for example, the firing of a gun.

 

negative feedback loops   behaviors that reduce deviation within a system and bring the system back to its former, homeostatic state.

 

organism   a form of life composed of mutually dependent parts and processes standing in mutual interaction.

 

planful competence   when adolescents have a reasonably realistic understanding of their intellectual abilities, social skills, and personal emotional responses in interrelationship with others.

 

positive feedback loops   behaviors that amplify deviation within a system and take the system further away from

homeostasis.

 

sandwich generation   couples who have adolescents and their aging parents to take care of and are squeezed psychologically and physically.

 

senescence  a gradual physical decline of individuals related to age. This decline begins after overall growth stops and varies greatly from individual to individual.

 

singlehood  being single

 

solid self  a Bowenian term for developing a sense of one’s own identity where beliefs and convictions are not simply adaptive to others.

 

subsystems   smaller units of the system as a whole, usually composed of members in a family who because of age or function are logically grouped together, such as parents. They exist to carry out various family tasks.

 

systems theory   a theory, sometimes known as general systems theory, that focuses on the interconnectedness of elements within all living organisms, including the family. It is based on the work of Ludwig von Bertalanffy.

 

 

Classroom Discussion

 

  1. Discuss the pros and cons of the life cycle perspective in assessing and treating couples and families.

 

  1. Pick a particular life cycle stage, discuss what tasks and challenges you may have encountered and what you and your family may have done to work through them.

 

  1. It is believed that the ‘fit’ between the therapist and the family can influence the outcome of therapy. What are some of the issues that may cause difficulty in this area?  What factors may be assets in this area?

 

 

Multiple Choice Questions

 

  1. Families may respond to change by using negative feedback loops, which are loops that:
  2. promote a return to the status quo
  3. promote change
  4. promote appreciation for each other
  5. accommodate to new situations and challenges

 

  1. Families may respond to change by using positive feedback loops, which are loops that:
  2. promote a return to the status quo
  3. promote change
  4. promote appreciation for each other
  5. accommodate to new situations and challenges

 

  1. The family life cycle is useful in studying families from a(n) _____ perspective.
    psychopathological
  2. hierarchical
  3. developmental
  4. empathic

 

  1. The three time dimensions referred to as the ‘life course’ are:
  2. historical, evolutionary, predictable
  3. developmental, historical, cultural
  4. individual, social, historical
  5. horizontal, vertical, transitional

 

  1. Erik Erikson, a pioneer in the area of human growth and development, developed an eight stage model of individual development. The first five stages focus on individual skill and identity development.  The last three stages focus on:
  2. interpersonal development
  3. cybernetics
  4. idealistic distortion
  5. hierarchical structure

 

  1. Family subsystems include all the following except:
  2. parents
  3. siblings
  4. boys/men
  5. spouses

 

  1. A key task of Stage 1, Leaving Home, of Carter and McGoldrick’s life cycle model is:
  2. separation from the family of origin
  3. developing effective communication skills
  4. developing skills in limit setting
  5. developing the ability to compromise

 

  1. In Stage 5, Launching Children and Moving On, families typically seek family therapy due to:
  2. the stresses involved with caring for multiple generations
  3. a lack of social skills to establish significant relationships with others
  4. frustration/anger over the marriage and/or career ambitions
  5. lack of meaning or enjoyment in life

 

  1. During the New Couple stage, a major task for the couple is:
  2. developing effective communication and problem solving skills
  3. developing independence
  4. developing effective social skills
  5. all of the above

 

  1. Circular causality differs from linear causality. In linear causality, _____.
  2. each family member’s actions influence others
  3. family member’s actions move in one direction only
  4. family member’s actions are complementary
  5. family member’s actions are interrelated

 

  1. A relatively recent development is couples who have adolescents and their aging parents to take care of and who feel they are squeezed psychologically and physically. This development is called:
  2. planful competence
  3. empty nest
  4. circular causality
  5. sandwich generation
  6. Although at first they seem very different, the individual and family life cycle models share an emphasis on:
  7. interpersonal development
  8. intrapsychic development
  9. pathological development
  10. growth and development

 

 

True/False Questions

 

  1. Definitions of what a family is have remained pretty much the same over generations and across cultures.

 

True ___    False ___

 

  1. An inability to work through interpersonal issues, such as developing adequate or optimal communication patterns, is one of many issues that may prompt new couples to seek family therapy.

 

True ___    False ___

 

  1. Life cycle stages are independent of one another and do not require some level of success before proceeding to the next step.

 

True ___    False ___

 

  1. “The more a parent protects a shy child, the shyer the child becomes.” This fact is an example of the concept of ‘circular causality.”

 

True ___    False ___

 

  1. In general, singles are the second happiest demographic group (married couples being the happiest).

 

True ___    False ___

 

 

Chapter 3

Types and Functionality of Families

 

Chapter Overview

 

The Family System and Health

 

  • Time changes perspectives on the family; what was considered healthy at one time may no longer be seen the same way later
  • Traditional families were very patriarchal with men being the breadwinners and rule makers and women staying at home to be the bread makers and caregivers
  • In modern times, roles have changed and so have family forms with nontraditional families outnumbering traditional nuclear families
  • The most prevalent family forms are the nuclear family, the single-parent family, and the blended family
  • Among some of the variations on the nuclear, single-parent, and blended families are the dual-career family, child-free family, special-needs-child/children family, gay/lesbian family, aging family, multigenerational family, grandparent-headed family, and military family
  • Family health fluctuates over the lifespan as families respond to changes or destabilizing events
  • Healthy families make adjustments to accommodate to new situations and challenges
  • Based on systems theory, change in any part of a family affect all the other parts of the family
  • Depending on the situation, families may respond to change by using negative feedback loops (loops that promote a return to the status quo) or positive feedback loops (loops that promote change)
  • Healthy families strive for a balance between change and stability; too much stability inhibits growth and produces stagnation, too much change results in chaos

 

Qualities of Healthy Families

 

  • Healthy families encourage positive relationships among family members and insure a good give-and-take balance between individual and family needs
  • Healthy families do not always produce healthy individuals and healthy individuals may not always come from healthy families
  • Successful families are balanced in many ways and do not operate from extreme positions of cognition or emotion
  • Healthy families have a strong and healthy marital unit characterized by promotion of individual growth and mutual support and sacrifice
  • Characteristics of Healthy Families
  • commitment to the family and its members (e.g., devotion to individual and family growth, family loyalty)
  • appreciation for each other (e.g., verbal and physical expression, mutual love, respect, and compliments)
  • willingness to spend time together (e.g., qualitative and quantitative time, positive time, sharing, builds cohesion)
  • effective communication patterns (e.g., clear and congruent messages sent and received, wide range of communication, conflict resolution through discussion, positive tone)
  • high degree of religious/spiritual orientation (e.g., helpful in coping, resiliency, finding meaning, and providing a moral foundation, increases marital satisfaction)
  • ability to deal with crises in a positive manner (e.g., dealing with events and nonevents with appropriate coping strategies, negotiation, humor, respect, and support)
  • encouragement of individuals (e.g., strengthens weak members, most crucial in life cycle transitions)
  • clear roles (e.g., clear, appropriate, suitable allocated, mutually agreed upon, integrated, enacted, interchangeable and flexible)
  • growth-producing structure and development patterns (e.g., absence of intergenerational coalitions and conflictual triangles, clear boundaries, balance of stability and change)

 

Family Life Stressors

 

  • Stress is a normal part of family life
  • Vertical stressors are historical and come from previous family history and experience, for example, family attitudes, expectations, secrets, and legacies
  • Horizontal stressors are related to current events, are developmental and continually unfolding, and may be predictable or unpredictable
  • Expected life stressors may be developmental (life cycle related), situational (interpersonal), or historical (related to family life history)
  • Common stressors that are developmental and situational include:
  • economics and finances
  • children’s behaviors
  • insufficient couple time
  • communicating with children
  • insufficient personal time
  • insufficient family play time
  • Unexpected life stressors include events which occur “off schedule” or not at all. Family adaptability may be related to environment fit (e.g., economic and support factors)
  • Common unexpected life stressors include
  • happenstance or random, chance life changes
  • physical/psychological trauma
  • success and failure
  • gaining or losing a family member

Family Structure and Functionality

 

  • Family structure influences the ability to handle stressors
  • Three common family structures:
    • symmetrical/complementary
    • symmetrical interaction is based on similarity of behavior, i.e., either partner might do the work; it can result in completion between spouses
    • complementary interaction is defined more rigidly and maximizes differences in family roles, for example, traditional gender roles
    • parallel relationships are a combination of symmetrical and complementary interaction as appropriate and can produce optimum family and couple functioning
    • centripetal/centrifugal
  • centripetal families focus on family closeness, get their needs met primarily through the family, and may produce children who are at their worse family dependent, antisocial, irresponsible, and egocentric
  • centrifugal families are more disengaged, get their needs met primarily outside of the family, and may produce children who at their worse become socially isolated, disorganized, or withdrawn
  • extremes of either style are like to result in poor family functioning
  • at different times both styles are appropriate, e.g., centripetal structure at the birth of a baby; centrifugal structure at the launching of children
  • cohesion/adaptability
    • cohesion, or emotional bonding, can be measured on four levels from low to high: (1) disengaged, (2) separated, (3) connected, (4) enmeshed
    • adaptability, or the ability to be flexible and change, can be measured on four levels from low to high: (1) rigid, (2) structured, (3) flexible, (4) chaotic
    • the relationship between cohesion and adaptability is curvilinear
    • dysfunctional families tend to be either very high or very low on these dimensions, while healthy families tend to be more balanced
    • life cycle stage and culture influence these two dimensions and must be considered in assessing families

Coping Strategies in Families

 

  • In coping with stress, useful family characteristics include the following:
  • ability to identify the stressor
  • ability to view the situation as a family problem, rather than a problem of one member
  • solution-oriented approach rather than blame-oriented
  • tolerance for other family members
  • clear expression of commitment to and affection for other family members
  • open and clear communication among members
  • evidence of high family cohesion
  • evidence of considerable role flexibility
  • appropriate utilization of resources inside and outside the family
  • lack of physical violence
  • lack of substance abuse

 

  • Other effective coping strategies include:
  • recognizing that stress may be positive and lead to change
  • realizing that stress is usually temporary
  • focusing on working together to find solutions
  • realizing that stress is a normal part of life
  • changing the rules to deal with stress and celebrating victories over events that led to stress

 

  • ABCX Model (also referred to as the “check mark diagram”) of adjustment to a crisis
  • “A” is the stressor event
  • “B” is the resources available at the family’s disposal
  • “C” is the meaning or significance of the event for the family
  • “X” is the combined effect of these factors (i.e., the crisis itself)
  • in this model, the same event may be handled differently by different families

 

  • Double ABCX Model of adjustment to a crisis
  • expands on the ABCX Model by focusing on family interactions between situations and on family resolutions over time.
  • incorporates the ‘pile up of demands’ as a variable in how families are able to respond to stressors

 

  • An inability to adjust to change can result in families trying the same solutions over and over, thus intensifying nonproductive behaviors and exacerbating the symptomatic behavior

 

  • There are two levels of change:
  • first-order change is characterized by superficial or incremental change
  • second-order change results in the introduction of new rules and behaviors into existing behavioral patterns; it is metachange

 

Implications of Health in Working with Families

 

  • Studying healthy families is a complex process
  • Research on healthy families benefits family therapists in the following ways
  • appreciation for the multidimensionality of families and the mutual influence of family members
  • identifies areas of health and strength in all families, not just pathology
  • highlights the developmental nature of both health and pathology in families
  • increased awareness that healthy families have deficits and dysfunctional families have strengths
  • awareness of potential stressors helps family therapists prepare families through education

 

 

Key Terms

 

ABCX Model of a crisis   in this model “A” represents the stressor event that happens to the family, “B” represents the resources at the family’s disposal, and “C” represents the meaning or interpretation the family attaches to the experience. “X” is the combined effect of these factors (i.e., the crisis itself). This model highlights that the same type of event may be handled differently by different families.

 

boundaries   the physical and psychological factors that separate people from one another and organize them.

 

centrifugal   literally, directed away from a center. It describes how people move away from their family (i.e., family disengagement).

 

centripetal   literally, directed toward a center. It describes a tendency to move toward family closeness.

 

check mark diagram   in the ABCX model of a crisis, the process that a family goes through in adjusting to situations, i. e., it initially tumbles down like the slope of a check mark and then after reaching bottom reestablishes itself like the upslope of a checkmark from anywhere below, the same, or above where it was in the beginning.

 

complementary relationship   relationships based on family member roles or characteristics that are specifically different from each other (e.g., dominant versus submissive, logical versus emotional). If a member fails to fulfill his or her role, such as be a decision maker or a nurturer, other members of the family are adversely affected.

 

conflictual triangles   two individuals, such as a mother and father arguing over and interacting with another, such as a rebellious son, instead of attending to their relationship.

 

developmental stressors   stressful events that are predictable and sequential, such as aging.

 

DINK   an acronym meaning dual income, no kids.

 

Double ABCX model   a model for dealing with crises that  builds on the ABCX model but focuses on family resolutions over time rather than in regard to a single happening.

 

dual-career families   those families in which both marital partners are engaged in work that is developmental in sequence and to which they have a high commitment.

 

family adaptability   the ability of a family to be flexible and change.

 

family cohesion   emotional bonding within a family.

 

family development and environmental fit   a concept that states that some environments are conducive to helping families develop and resolve crises, and others are not.

 

first-order change   the process whereby a family that is unable to adjust to new circumstances often repetitiously tries the same solutions or intensifies nonproductive behaviors, thus assuring that the basic organization of the family does not change.

 

happenstance   an unpredictable event, a chance circumstance.

 

health   an interactive process associated with positive relationships and outcomes.

 

horizontal stressors   stressful events related to the present, some of which are developmental, such as life cycle transitions, and others of which are unpredictable, such as accidents.

 

intergenerational coalitions   members from different generations, such as a mother and daughter, colluding as a team.

 

life cycle transitions   predictable movement from one stage of life to another, such as going from being married to being married with children.

 

metachange   a changing of rules sometimes referred to as a change of change.

 

nonevent   the nonmaterialization of an expected occurrence (e.g., the failure of a couple to have children).

 

parallel relationships   relationships in which both complementary and symmetrical exchanges occur as appropriate.

 

postgender relationship   a symmetrical relationship where each partner is versatile and tries to become competent in doing necessary or needed tasks, e.g., either a man or a woman can work outside the home or take care of children.

 

Resiliency Model of Family Stress, Adjustment, and Adaptation   a model of family adjustment that proposes that a family’s capability to meet demands is dynamic and interactional

 

roles   prescribed and repetitive behaviors involving a set of reciprocal activities with other family members or significant others; behaviors family members expect from each other and themselves.

 

second-order change   a qualitatively different way of doing something; a basic change in function and/or structure.

 

situational stressors   stressful events that are unpredictable, such as interpersonal relationships that are emotional.

 

spillover  the extent to which participation in one domain, e.g., work, affects participation in another domain, e.g., the family.

 

symmetrical relationship   a relationship in which each partner tries to gain competence in doing necessary or needed tasks. Members within these units are versatile. For example, either a man or a woman can work outside the home or care for children.

 

vertical stressors   events dealing with family patterns, myths, secrets, and legacies. These are stressors that are historical and that families inherit from previous generations.

 

 

 

Classroom Discussion

 

  1. Just as the world changes constantly, so do families. What do you consider some healthy characteristics of today’s family?  What are some unhealthy characteristics?

 

  1. In modern times, nontraditional families outnumber traditional families. What are some nontraditional family types?  What special difficulties might they face in today’s culture?

 

  1. When families are unable to adjust to change, they often try the same solutions over and over again without success. What are some examples from your own family, pop culture, movies, television shows, or books that illustrate how this can happen?  What might they do differently that might help them become healthier families?

 

 

Multiple Choice Questions

 

  1. Studies reveal that healthy and functional families in virtually all cultures are able to:
  2. adapt to change
  3. set appropriate boundaries
  4. express confidence in themselves and their children
  5. all of the above

 

  1. Members of healthy families often use humor, soothing comments, or changes of subject to steer difficult family conversations in positive directions. This process of redirecting difficult conversations is known as:
  2. redirection
  3. repair
  4. relating
  5. re-authoring

 

  1. Horizontal stressors are:
  2. related to historical events
  3. related to current events
  4. related to previous family history
  5. both A and C

 

  1. Symmetrical interaction is based on:
  2. rigidity and maximizing differences
  3. family closeness and getting needs met inside the family
  4. disengagement
  5. similarity of behavior and competition

 

  1. Cohesion, or emotional bonding, can be measured on four levels from low to high:
  2. disengaged, separated, connected, enmeshed
  3. separated, disengaged, enmeshed, connected
  4. enmeshed, connected, separated, disengaged
  5. connected, enmeshed, disengaged, separated

 

  1. In the ABCX Model, the “C” is:
  2. the crisis or stressor event
  3. the combined effect of all factors
  4. the resources available at the family’s disposal
  5. the meaning or significance of the event for the family

 

 

 

 

  1. There are two levels of change, first-order and second-order. First-order change is characterized by:
  2. trying the same behavior over and over
  3. nonevents
  4. superficial change
  5. life cycle transitions

 

  1. Centrifugal families are more _____ than centripetal families.
  2. healthy
  3. disengaged
  4. enmeshed
  5. none of the above

 

  1. The Double ABCX Model differs from the ABCX Model in some significant ways, including:
  2. awareness of potential stressors
  3. focus on family interactions over time
  4. incorporation of metachange factors
  5. focus on parallel relationships

 

  1. Useful family characteristics for coping with stress include all the following except:
  2. lack of physical violence
  3. identification of the family member who caused the problem
  4. solution oriented rather than blame oriented
  5. open and clear communication

 

 

True/False Questions

 

  1. The three least prevalent types of families in American culture are nuclear, single parent, and blended.

 

True ___    False ___

 

 

  1. A high degree of religious/spiritual orientation is a characteristic of healthy families.

 

True ___    False ___

 

  1. Although healthy families do not always produce healthy individuals, being in a healthy family environment is an advantage.

 

True ___    False ___

 

  1. Vertical stressors are related to current events, are developmental and continually unfolding.

 

True ___    False ___

 

  1. Research on families is important because it helps identify healthy family characteristics, not just pathology

 

True ___    False ___

 

  1. All healthy families have deficits and all dysfunctional families have strengths.

 

True ___    False ___

 

 

 

Chapter 4

Working with Single-Parent and Blended Families

 

Chapter Overview

 

  • Single-parent and blended families are common family types in the US
  • Single-parent families may over time become blended families because of remarriage
  • Single-parent families and blended families face some similar issues, including adjustment to new roles and new rules, establishment and maintenance of healthy boundaries, and adaptation to changes in daily routines

 

Single-Parent Families

 

  • Single-parent families are headed by a mother or father, a sole parent, responsible for taking care of herself or himself and a child or children (Walsh, 1991)
  • Single-parent families are created as a result of
  • divorce
  • death
  • abandonment,
  • unwed pregnancy
  • adoption
  • temporary circumstances (e.g., military deployment)
  • Historically single-parent families were created by death or desertion of a spouse
  • In the 1950s, families created by divorce started to exceed those created by death
  • In the 1970s, the decision of many unmarried women to bear and raise children by themselves increased
  • In 2010, there were approximately 11.7 million single parents living with their children (29.5% of US households with children)

Types of Single-Parent Families

 

  • Single parenthood as a result of divorce
  • two subunits are formed (except in some cases of joint custody)
    • custodial parent, with whom the child resides and his or her interactions with the ex-spouse and child(ren)
      • stressors include rebuilding financial resources and social networks
      • benefits include a renewed sense of confidence in oneself
    • noncustodial parent, and his or her relationships with the ex-spouse and child(ren)
      • stressors include finding ways to stay involved with one’s children as a parent
      • rebuilding of social networks
      • benefits include devising creative problem-solving methods
      • gaining renewed self-confidence
    • both parents have the same rights, unless a court order specifies differently
    • Single parenthood as a result of death
    • reestablishing one’s life and restructuring of the family are major tasks
    • three stages
      • mourning stage – helps with release of positive and negative feelings and emotions; “death ends a life, not a relationship”
      • readjustment stage – learning to do new tasks, dropping old tasks, reassigning duties to other family members
      • renewal and accomplishment stage – focus on finding and engaging in new growth opportunities
    • Single parenthood by choice
    • characterized by choice and intentionality
    • actions include
      • conceiving a child out of wedlock
      • carrying a child to term after accidentally becoming pregnant out of wedlock
      • adopting a child as a single adult
    • parent has time to prepare before the child arrives
    • clear from the beginning that there will usually be no outside support
    • Single parenthood as a result of temporary circumstances
    • change that is usually the result of uncontrollable circumstances (e.g., job change, deployment in the military)
    • usually involves one parent making an immediate move while the other parent remains behind
    • suddenness and seriousness of the change increases stress levels

Dynamics Associated with the Formation of Single-Parent Families

 

  • Dynamics of single-parent families formed through divorce
  • top three reasons for divorce are social, personal, and relationship issues
  • social issues
    • new technologies
    • more alternatives
    • less stability
    • greater opportunities for frustration, fulfillment, and alienation
    • changing of women’s roles
    • weakening of alliance of men and their work
    • increased acceptance of options, transitions, and a new openness to mores and laws
    • divorce is more acceptable today
  • personal issues
    • people marry at different levels of psychological maturity
    • people marry with different expectations
    • personality conflicts may doom marriages
    • some marriages may be best served when the relationship is dissolved
  • interpersonal issues
    • marriages dissolve when couples perceive the costs as exceeding the benefits
    • couples frequently do not seek help or seek it too late
  • common issues following divorce or separation
    • resolution of the loss of the marriage
    • acceptance of new roles and responsibilities
    • renegotiation and redefinement of relationships with family and friends
    • establishment of a satisfactory arrangement with one’s ex-spouse
    • significant decrease in income
    • society as a whole still subtly disapproves and stigmatizes those who divorce
  • Dynamics of single-parent families formed through death
  • death is a shock even when expected, important to appropriately grieve
  • family members should talk to one another and with others
  • releasing feelings assists family members to see the deceased person as mortal instead of ‘superhuman’
  • Dynamics of single-parent families formed through choice
    • a large and rapidly growing segment of the population
    • cuts across racial, social, and economic divisions
    • three major factors influencing this trend
    • historical tradition
    • in maternally oriented subcultures, many children have been raised by single parent mothers and are inclined to avoid marriage and follow the same patterns they grew up in
    • racism, ignorance, and socioeconomic crises contribute to this pattern
    • such patterns or cycles can be difficult to break
    • change and acceptance by society
    • stigmas and taboos have been broken down
    • traditional norms and patterns have eroded
    • choice
    • includes women who are well educated and older
    • dramatization in books, movies, and television
    • it is more socially acceptable for single women to adopt babies
    • women who adopt can pick the time when they wish to become a parent
    • women who adopt tend to be affluent, not encumbered by a marital relationship, and can provide more nurturance and time to the child(ren)
  • Dynamics of single-parent families formed through temporary circumstances
    • the parent left in charge may be overloaded with extra duties and responsibilities with no additional resources
    • the parent must prioritize tasks and decide what can be postponed and/or dropped
    • can be a period of disorganization and stress
    • the time period for functioning in this way is time-limited

Strengths and  Challenges Connected with Single-Parent Families

 

  • Strengths of single-parent families
    • tendency to be more democratic than most family types
    • informal style of relating
    • the needs of all parties are usually considered in decision making
    • limited resources may result in role flexibility in household tasks regarding which members perform which tasks
    • children often learn how to take responsibility for their actions at an early age
    • children learn essential skills, such as find a bargain or saving money, faster than most children
    • increase in creativity in locating and utilizing needed materials for their overall well-being
    • survival skills are developed through being frugal as well as innovative
  • Challenges of single-parent families
  • defining and refining boundaries and roles
    • problem areas include boundary disputes between former spouses, absent spouses, and between children and their custodial parent or joint custody parents
    • boundary issues with former spouses may focus on everything from visitation to sexuality
  • democratic nature of single-parent families may blur parent and child roles, resulting in chaotic and confusing interactions
    • children more than twice as likely to have emotional and behavior problems than children in intact families
    • role flexibility may add stress and work resulting in fatigue and burnout
  • academic difficulties are common for the first 18 months after a divorce
    • children of divorced parents are less educated than others their age and are less likely to graduate from high school than those from intact families
    • the academic gap between children in single-parent families of divorce and those in two-parent families may be linked to the additional resources that are often available to children in two-parent families
    • difficulty establishing a clear and strong identity and relating to the opposite gender
    • children of divorce leave home earlier than others
    • children of divorce are far more likely to cohabit before they marry
    • children of divorce more likely to divorce
    • children of divorce may not experience life to the fullest
    • children of divorce may come to resent growing up so fast and may consciously or unconsciously display less maturity
  • single-parent families are financially less well off than other family forms
  • six times more likely to be poor than are nuclear families
  • frequently lack child support
  • 50% of children living in single parent families live below the poverty line
  • emotional issues
  • common emotions are helplessness, hopelessness, frustration, despair, guilt, depression, and ambivalence
  • unresolved issues with a significant other
  • lack of ready access to the needed person
  • over time, feelings may increase and stress intensify
  • unresolved emotions keep the person ‘hooked’ emotionally to historical times and situations
  • usually takes 2 or more years for a single parent family to resolve their emotions and to form into a functional unit

 

Approaches for Working with Single-Parent Families

 

  • Preventative approaches
    • premarital counseling results in couples who are more likely to seek marriage therapy more often, had lower levels of stress, and benefited more from marriage therapy than couple without premarital counseling
    • programs that help a spouse after a traumatic separation may be extremely beneficial

 

Educational and Behavioral Approaches for Treating Single-Parent Families

 

  • Various educational and behavioral strategies can help strengthen aspects of single-parent families
    • helping family members communicate clearly and frequently
    • weekly family conference to talk about concerns, resolve problems and plan for the future
    • linking family members to needed sources of social support (e.g., Parents Without Partners)
    • assisting families with resolving financial matters so they can best utilize their resources
    • educational methods such as reading books and newsletters

 

Role of the Therapist

 

  • Therapist must realize single-parent families, as with all families, are socially, psychologically, and economically unique
  • Biases and personal prejudices about single-parent families
    • therapists must examine and set aside their own biases and personal prejudices about single-parent families
    • therapists must resolve their own personal problems (e.g., a divorce) that might involve the issue of a single-parent family
    • family therapists must deal directly with people, hierarchies, and circumstances of these families, not myths and stereotypes
    • family therapists must assist single-parent families in giving up negative stereotypes of themselves
  • Emotional volatility
    • assist clients to distinguish between emotional divorce issues and legal divorce issues
    • assist clients to set aside emotional issues at times in order to make mature and reasonable legal decisions
  • Accessing inner resources
    • assist families to tap into their inner resources and strengths
    • encourage families to utilize support groups

 

Process and Outcome

 

  • Single-parent families benefit from family therapy in four major ways
  • more confidence and competence in themselves. Family members:
  • rely more on themselves and extended networks of family and friends
  • function better with greater efficiency
  • have better knowledge of agencies or support networks
  • experience fewer behavior problems and less stress
  • increase their relationship skills, especially between parents and children
  • clear and functional boundaries
  • new hierarchies, free of intergenerational enmeshment
  • parentified child’s role is no longer necessary and can be given up
  • interactions between the new single parent family and others
  • ability to make informed decisions about remarriage
  • ability to examine the pros and cons of remarriage options
  • single parents can make better decisions
  • children can work through their feelings before instead of after the marriage
  • utilization of resources
  • more use of community resources
  • better use of their own resources
  • financial and personal management improvement
  • reduction of negative feelings from past experiences

 

Blended Families

 

  • Terms for blended families include
  • stepfamilies
  • reconstituted families
  • recoupled families
  • merged families
  • patched families
  • remarried families
  • Blended families consist of two adults and step-, adoptive, or foster children
  • Blended families have become a norm in American society
  • High divorce rates (approx. 50%) have contributed to a large remarriage trend because 3 out or 4 divorced people eventually remarry

Forming Blended Families

 

  • Most commonly formed when a person whose previous marriage has ended in death, divorce, or abandonment marries a previously married person or someone who has never married
  • Common concerns of blended families
  • establishing a blended family is a complex process
  • complex kinship networks
  • ill-defined goals
  • new patterns of interaction
  • Carter & McGoldrick 3 stage model with developmental issues
  • Dealing with the death of a parent
  • before the twentieth century
  • one of every two adults died before age 50
  • less than a third of all marriages lasted more than ten years
  • 50% of children lost a parent before reaching maturity
  • blending of families and use of kinship networks were common responses
  • death was ‘real’ and rituals helped with mourning and moving on with life
  • currently
  • death is covered up or denied in many families
  • death occurs in hospitals away from family members
  • funeral services may have closed caskets
  • those who have died are described in vague terms (e.g., departed, passed on)
  • result may be incomplete grief
  • in blended families, family members may have difficulty accepting a new member who is seen as ‘replacing’ a deceased family member
  • no established guidelines for couples and their offspring to follow in coming together
  • Dealing with the divorce of a couple
  • common reasons include affairs and conflicting role expectations
  • predictors include a husband’s unwillingness to be influenced by his wife and a wife who starts quarrels ‘harshly’ and with hostility
  • two thirds of divorces occur in the first ten years of marriage
  • most vulnerable times for divorce are during the first seven years and after 16 to 24 years of marriage
  • the birth of a child can also produce distress and disruptions
  • most people who divorce eventually remarry
  • ethnic groups experience the consequences of divorce differently
  • African-Americans couples are more likely to separate and stay separated longer before obtaining a divorce and less likely to remarry once separated
  • a greater percentage of African-American children (75%) will experience divorce than will European-American children (40%)
  • contact between nonresidential parents and their children declines over the years
  • boys are negatively impacted without contact with non-residential fathers, becoming less competent and having more behavioral problems than children in other types of family arrangements

 

Dynamics Associated With Blended Families

 

  • “Blended families are born out of loss and hope”
  • Blended family members often carry a positive fantasy with them about what family life can be like
  • Before a remarriage can develop, prior experiences with a former family must be resolved
  • Without mourning and resolving prior issues, it is difficult to emotionally join a new family
  • Structural characteristics of blended families include
  • a biological parent elsewhere
  • a relationship in the family between an adult (parent) and at least one child that predates the present family structure
  • at least one child who is a member of more than one household
  • a parent who is not legally related to at least one child
  • a couple that begins other than simply as a dyad
  • a complex extended family network
  • The structure of most blended initially is a weak couple subsystem, a tightly bonded parent-child alliance, and potential ‘interference’
  • Blended families are binuclear, that is, two interrelated family households that comprise one family system
  • Blended families have quasi kin who are part of an extended kin network of blended spouses’ families

 

Issues within Blended Families

 

  • Prominent issues center around
  • resolving the past
  • alleviating fears and concerns about stepfamily life
  • establishing or reestablishing trust
  • fostering a realistic attitude
  • becoming emotionally/psychologically attached to others
  • Finding time to establish the couple relationship
  • younger children (below the age of 9) bond more easily with stepparents but are more physically demanding on parents than older children
  • adolescent identity development issues may complicate the bonding process
  • Romantic and negative feelings must be sorted out in a timely and appropriate way
  • partners may not have thought through feelings they bring into the relationship until after it is formed
  • expectations may not be realized
  • unresolved mourning issues may not be adaptable or open to changes
  • Integrating new members into a cohesive family unit
  • stepfamilies are less cohesive, more problematic, and more stressful than first marriage families
  • stepparent/child and sibling relationships are less warm and intimate than first marriage families
  • interpersonal connectedness and rapport requires much work
  • stepfather/stepdaughter interactions, especially with preadolescent children, can be especially troublesome
  • 2 to 5 years may be needed to form in-depth relationships with stepchildren and to establish the primary parent role
  • Visher and Visher have identified eight tasks for stepfamily identity development

 

Strengths and Challenges of Blended Families

 

  • Strengths of blended families
  • life experience
  • common interests or opportunities unavailable in the original family of origin
  • survival of critical incidents from which they have learned about themselves and others
  • assists in understanding environments in different and potentially healthy ways
  • can increase empathy and influence individual and family resilience
  • kin and quasi-kin networks
  • help reduce couple and family isolation and frustration
  • may provide moral support, guidance, or physical comfort
  • creativity and innovativeness
  • blended family members can offer new ideas, perceptions, and possibilities for resolution of issues
  • appreciation and respect for differences
  • ability to appreciate and respect differences in people and ways of living
  • mothering and fathering can take many different forms
  • new habits from stepsiblings may be helpful
  • making the most of situations
  • coping successfully with difficult situations strengthens blended families
  • insights gained can be taught to other families
  • Challenges of blended families
  • loss of an important member
  • non-custodial parents may be physically absent but retain a strong impact on the remaining family members
  • all members of the family may be affected by one individual’s unresolved personal issues related to loss
  • establishment of a hierarchy
  • children can lose status regarding their ordinal position in the family
  • loss of place and power are exacerbated if the children involved don’t like their new stepsiblings or stepparent
  • until relationship issues are worked out, families may be vulnerable to disruption and volatile emotional and/or physical outbreaks
  • boundary difficulties
    • the structure of a blended family is less clear than biological families
    • boundary ambiguity may result in loyalty conflicts and feelings of guilt about belonging to two households
    • boundary issues include
    • membership (Who are the real members of the family?)
    • space (What space is mine? Where do I really belong?)
    • authority (Who is really in charge? Of discipline?  Of money?  Of decisions?  )
    • time (Who gets how much of my time and how much do I get of theirs?)
    • boundary problems can create chaos and members are unsure of who and what is involved in making their lives adaptable
    • boundary issues are best dealt with in straightforward fashion, including sexuality issues between unrelated siblings or parents and siblings
    • boundary issues can and should be discussed and negotiated by family members
  • resolving feelings
  • feelings and emotions need to be resolved but are often suppressed, denied, or projected onto others
  • economic problems
    • as a group, blended families are less affluent than all other family types except single parent families
    • lack of money adds stress to the family
    • unique expenses of child support and/or the cost of maintaining two residences add to financial difficulty
    • blending finances can be difficult but are best achieved through:
    • re-evaluating insurance needs
    • updating financial documents
    • creating and sticking to a budget
    • rethinking asset allocations
    • developing a will or a living will

 

Approaches for Working with Blended Families

 

  • Guidance in retaining old loyalties
  • blended family members need not give up old loyalties in order to form new ties
  • families benefit from learning to be inclusive rather than exclusive
  • therapists may assess how the family is operating and challenge the family to participate in cooperative interactive events
  • Focus on parental involvement
  • stepparents need to balance their involvement so there is a balance among all family members
  • stepparents should spend time before and after their wedding discussing the impact of past relationships on new relationships
  • family therapists can help stepparents overcome unresolved issues and learn to contribute to the well-being of all family members.
  • Provide education
    • education can help blended families understand differences between blended family and non-blend family systems and provide guidelines for handling typical situations
    • books and pamphlets can be effective for all ages
  • Assist in the creation of family traditions and rituals
  • help families develop new traditions and rituals
  • rituals may be beneficial to:
  • the forming of relationships
  • the resolution of ambiguous boundaries
  • the healing of loss
  • the settling of hierarchy and power struggles
  • the creating of beliefs
  • the beginnings of changes

Role of the Therapist

 

  • Therapists must be active, flexible and resourceful in the use of different therapeutic modalities, i.e., wear many hats
  • Decrease confusion, fear, and depression of children who are the focal points of child custody, visitation, or child support disputes
  • Be well informed about legal processes as well as psychological ones
  • Knowledge of family jurisprudence can help all family members make better decisions
  • Work with family members to arrange predictable and mutually satisfactory arrangements between former parents and their child or children
  • Help stepparents work together to be effective parents
  • Encourage family members to relinquish personal myths they have carried into the new family relationship
  • Help family members learn effective communication skills
  • Provide information about structured programs and reading lists for both adults and children
  • Provide a forum within the therapeutic setting for mourning the loss of the previous relationships and developing new relationships in the reconstituted family

Process and Outcome

 

If therapist is successful, families gain the following:

  • Better understanding of themselves as systems and subsystems
  • Support for the new parent and sibling subunits, stressing the importance of learning to work, play, and make mistakes together
  • Development of age and stage appropriate cohesion
  • Parents present a unified front regarding acceptable and unacceptable behaviors
  • Increase tolerance for one another and family life events
  • Decreased projection and distortions
  • Eliminating the romanticizing or idealizing of those who are now outside the formal structure of the family
  • Members find their place in the new family
  • Family environment becomes cohesive, safe, and open to novel ideas
  • Fostering of new traditions, celebrations, and rituals
  • Development of a healthy self-concept of themselves as a family
  • Development of internal strength to deal with external pressures and stereotypes

 

Key Terms

 

custodial parent   a parent who has primary physical custody of a child.

 

joint custody   an arrangement where both divorced parents assume equal custody of their children.

 

noncustodial parent   a parent who does not have primary physical custody of a child but who has the same rights as a custodial parent unless there is a court order expressively stating otherwise.

 

parentified child   a child who is given privileges and responsibilities that exceed what would be considered developmentally consistent with his or her age. Such a child is often forced to give up childhood and act like a parent, even though lacking the knowledge and skills to do so.

 

Parents Without Partners   a national organization that helps single parents and their children deal with the realities of single-parent family life in educational and experiential ways.

 

premarital counseling   working with a couple to enhance their relationship before they get married.

 

quasi kin   a formerly married person’s ex-spouse, the ex-spouse’s new husband or wife, and his or her blood kin.

 

 

Classroom Discussion

 

  1. Marriage and divorce are ‘hot button’ issues for many clients and family therapists alike. What are your personal values and beliefs about marriage and divorce and how might they impact your work with clients?

 

  1. An increasingly popular trend is single parenthood by choice, often through adoption or conceiving a child out of wedlock. What are your thoughts about the propriety, advisability, advantages, and risks of this type of single-parent family?

 

  1. It is said that “blended families are born out of loss and hope.” Explain what is meant by this statement.

 

  1. Family therapists who work with blended families are well advised to be knowledgeable about legal processes as well as family processes. What are some of the legal processes with which you should be familiar?

 

  1. An important element in the establishment of a healthy blended family unit is the creation of new traditions, celebrations, and rituals. Compare with a partner some of the traditions from each of your families of origin (e.g., holidays, birthdays, family vacations, etc.) and create some new ones that respect and honor your past but represent something for the present and future.

 

 

Multiple Choice Questions

 

  1. In the _____, families created by divorce began to exceed those created by death.
  2. 1940s
  3. 1950s
  4. 1960s
  5. 1970s

 

  1. A large and rapidly growing segment of the population is
  2. single-parent families formed through divorce
  3. single-parent families formed through death
  4. single-parent families formed through abandonment
  5. single-parent families formed through choice

 

  1. Healthy adjustment of children is strongly correlated with
  2. pre-divorce/death levels of family functioning
  3. mental and emotional anguish
  4. taking sides
  5. premarital counseling

 

  1. Single-parent families tend to be more _____ than most family types.
  2. autocratic
  3. democratic
  4. rigid
  5. formal

 

  1. Which of the following is not a recommended educational or behavioral strategy that can help strengthen aspects of single-parent families?
  2. helping family members maintain negative communication patterns
  3. encouraging weekly family conferences to talk about concerns, resolve problems and plan for the

future

  1. linking family members to needed sources of social support (e.g., Parents Without Partners)
  2. suggesting educational methods such as reading books and newsletters

 

  1. Children of divorce are _____ to divorce than others.
  2. less likely
  3. more likely
  4. six times more likely
  5. six times less likely

 

  1. To help kids through the divorce process, it can be helpful to:
  2. define and refine clear boundaries and roles
  3. have diffuse boundaries and roles
  4. have a more formal style of relating
  5. have both parents tell the children about the divorce and let the children decide who’s right and who’s wrong

 

 

 

 

  1. A major challenge for children in blended families is:
  2. identifying common interests among new step siblings
  3. establishing a new identity
  4. losing one’s ordinal position from a previous family experience
  5. creativity and innovativeness

 

  1. Establishing a blended family
  2. is a complex process
  3. is a relatively short process (i.e., 1 to 2 years)
  4. is easier than establishing a family in a first marriage
  5. should be based on established guidelines to follow in coming together

 

  1. The structure of most blended families initially includes
  2. clear romantic and negative feelings
  3. a weak couple subsystem
  4. a unified parental subsystem
  5. clear boundaries

 

  1. A formerly married person’s ex-spouse, the ex-spouse’s new husband or wife, and his or her blood kin are called ______.
  2. kin once removed
  3. new kin
  4. new relatives
  5. quasi kin

 

  1. In working with blended families, therapists should
  2. be passive
  3. be active
  4. be legal advisors
  5. be predictable

 

  1. An important step in developing new relationships in blended families is
  2. giving up old loyalties to make space for new ties
  3. setting up closed systems to maximize internal family strengths
  4. encouraging projection
  5. mourning the loss of previous relationships

 

  1. _____ can help blended families understand the differences between blended family and non-blended family systems and provide guidelines for handling typical situations.
  2. education
  3. choreography
  4. genograms
  5. projection

 

  1. Questions such as “Who are the real members of my family?” “What space is mine?” or “Where do I really belong?” are examples of what kind of challenges in blended families?
  2. economic problems
  3. resolution of feelings
  4. boundary difficulties
  5. establishment of a hierarchy

 

 

 

 

 

 

True/False Questions

 

  1. Parentification of children can occur if families are enmeshed or do not successfully adjust to the new hierarchy following a family break-up.

 

True ___    False ___

 

  1. Bibliotherapy is a helpful means of working with single-parent families.

 

True ___    False ___

 

  1. Families that experience the temporary absence of a parent due to military deployment or other temporary circumstances are not considered to be “single-parent families.”

 

True ___    False ___

 

  1. Families that are created as a result of the death of a parent may experience three developmental stages: mourning, readujstment, and renewal and accomplishment.

 

True ___    False ___

 

  1. Noncustodial parents do not have the same legal, parental rights as custodial parents.

 

True ___    False ___

 

  1. Most people who divorce eventually remarry.

 

True ___    False ___

 

  1. In blended families, there are no accepted social roles for stepparents.

 

True ___    False ___

 

  1. Working with families to arrange predictable and mutually satisfactory visitation arrangements is not an appropriate role for a family therapist.

 

True ___    False ___

 

  1. In most blended families, family members have a realistic attitude concerning how to establish cohesion and trust among new family members.

 

True ___    False ___

 

  1. Two thirds of marriages end in divorce within the first 10 years of marriage.

 

True ___    False ___

 

Chapter 5

Working with Culturally Diverse Families

 

Chapter Overview

 

  • Multiculturalism is a term used to refer to the cultural groups within a region or nation and their needs
  • Although American society has been diverse since its beginnings, little focus was placed on multiculturalism until the 1970s and 1980s
  • assumption that conceptual, theoretical, and methodological frameworks already developed would be appropriate for everyone, regardless of color or background
  • until the 1980s, the non-white population was relatively small in the United States
  • today, non-white racial and ethnic groups are growing rapidly and intercultural couples are becoming more common
  • 1 in 15 marriages in the United States in 2005 were mixed race or ethnicity, a 65% increase from 1990
  • Interethnic, interfaith, and interracial couples experience challenges both inside and outside the couple and family
  • Family therapists must be open to diversity and culturally competent to be effective
  • Cultural competency is sensitivity to factors such as race, gender, ethnicity, socioeconomic status, and sexual orientation and the ability to respond appropriately in a therapeutic manner to persons with a different cultural background than their own
  • Therapists who are not culturally competent risk undervaluing, misunderstanding, and/or pathologizing client behaviors
  • Although cultural groups share similarities, stereotyping groups according to cultures should be avoided; within group differences are greater than outside differences in cultures

 

What is Culture?

 

  • Culture is the customary beliefs, social forms, and material traits of a racial, religious, or social group
  • culture include diverse groups of people who may differ in regard to race, religion, or social status but who identify themselves collectively in a certain way
  • cultures operate on many levels, inclusive or exclusive, specific or general
  • cultural values define behaviors and therefore establish norms for attitudes and behaviors within families
  • Ethnic groups are large groups of people classed according to common racial, national, tribal, linguistic, or cultural origin or background
  • ethnicity influences the kinds of messages that people learn, such as patterns for intimacy
  • ethnic family customs influence a group’s “fit” within an overall culture

 

Dynamics Associated with Culturally Diverse Families

 

  • The ways in which families from different cultural backgrounds view and respond to life events differs from other families
  • Jewish families often marry within the group, encourage children, value education, and use guilt to shape behavior
  • Italian families place importance on expressiveness, personal connectedness, enjoyment of food and good times, and traditional sex roles
  • certain events in the family life cycle represent greater crises for one culture than another
  • Irish families view death as the most significant life cycle transition and will go to great lengths to not miss a wake or a funeral
  • Puerto Rican families stress interdependence in their culture and therefore experience death as an especially profound threat to the family’s future and often experience extreme anxiety

 

  • Culturally diverse families often experience overt as well as covert criticisms of their patterns of family interaction that may not be universally accepted
  • women who are treated as inferior by certain families may be taken to task by others
  • majority culture may ignore or disdain important civic or religious holidays in particular cultural groups
  • Physical appearance (e.g., skin color, physical features, dress) may lead to subtle and blatant prejudice and discrimination
  • minority culture families are faced with the task of nurturing and protecting each other in ways unknown to majority culture families
  • Access to mental health services may be difficult for minority culture families, i.e., institutional barriers
  • location, formality, advertising of services, clinic operation hours, language used, and lack of culturally diverse practitioners may limit access and utilization of services by culturally diverse families
  • Economic factors such as exclusion from certain jobs and limited employment opportunities result in many culturally diverse families living in poverty

 

Issues within Culturally Diverse Families

 

  • Family therapists may be at an initial disadvantage in working with culturally diverse families because the field of marriage and family therapy reflects a dominant European American bias
  • Sensitivity, experience, acceptance, ingenuity, specificity, and intervention are factors that often determine successful treatment
  • Sensitivity
  • sensitivity and respect for beliefs and the worldview of the client/family is crucial
  • ‘culturally encapsulated counselors’ tend to treat everyone the same and make mistakes in so doing for they miss diversity
  • Experience
  • family therapists can benefit from having life experiences that include cultural diversity
  • cultural backgrounds of culturally diverse families are often influenced by a family’s experience with the larger society
  • Acceptance
  • therapists who cannot openly accept culturally diverse families may exhibit overt or covert prejudice that negatively impacts the therapeutic process
  • social, behavioral, and economic differences need to be examined to determine whether the therapist and family are a good match
  • Ho (1987) has developed a model for examining therapist’s values
  • Ingenuity
  • effective family therapists utilize natural help-giving networks that exist in most cultural settings
  • therapists act as consultants to agencies and persons who can best work with certain families
  • some cultures may respond best to subtlety and indirectness on the part of the family therapist rather than direct confrontation and interpretation
  • Specificity
  • because each family is unique, family therapists must assess the strengths and weaknesses of each family and design and implement specific procedures for each
  • therapy models should be selected and/or modified to address the needs of specific families
  • Intervention
  • therapists serve as systematic change agents by intervening on behalf of families in unhealthy and intolerant systems
  • some systems involve ‘passive insensitivity to diversity’ (i.e., the plight of people outside one’s culture is simply ignored) while others involve ‘active and intentional insensitivity to diversity’ (i.e., fostering active discrimination that is easier to identify)
  • advocating for culturally diverse families requires courage, persistence, and time

 

Approaches for Working with Culturally Diverse Families

 

  • Culturally diverse families have some commonalities, including the importance of extended family and kinship ties
  • There are a number of culturally diverse families including the invisible family form Gay/Lesbian (found in most cultures) and six culturally diverse family groups: African Americans, Asian Americans, Hispanic/Latino Americans, Native Americans, Arab Americans, and European Americans

Gay and Lesbian Families

 

  • 1 out of every 10 cases in marriage and family therapy in the United States involves lesbians or gays
  • gay and lesbian couples are more likely to seek professional mental health services than heterosexual

couples

  • gay and lesbian couples are intergenerational
  • gay and lesbian life cycle issues are crucial to understand if these families are to be understood
  • there is much within group variation among gay and lesbian families
  • gay and lesbian families have mixed levels of satisfaction in their relationships
  • many gay and lesbian couples and families suffer from a lack of affirming role models
  • gay and lesbian couples and families face discrimination from society in general
  • Working with gay and lesbian families
  • therapists need to begin by examining their own values and feelings regarding this population
  • therapists need to be aware of internal and external issues associated with being a gay or lesbian couple or family, including cultural and societal homophobia and local, state, and national laws affecting gays and lesbians
  • extended families may need to be involved in treatment due to the difficulty many families have in accepting the lifestyle and sexual orientation of their kin
  • treatment planning can be complex due to the variety of gay and lesbian lifestyles and subcultures
  • a challenge is assisting families to relate positively to themselves, their partners, and society
  • commitment ambiguity can occur where one partner is not sure about his or her place in the relationship

African American Families

 

  • African Americans are currently the second largest minority group in the United States — approximately 40 million, 13% of population
  • because of continuous racism, poverty, and discrimination, the family unit has been an essential institution

for survival

  • families are known to be ‘strong’ in the areas of kinship bonds
  • religious orientation and spirituality are strengths
  • cooperation, strong motivation to achieve, caring parenting, and work orientation are positive characteristics of African Americans
  • African Americans are adaptable in their family roles, meaning they are less likely to stereotype each other into roles based on gender
  • male-female relationships tend to be more problematic, conflictual, and destructive
  • mistrust, insecurity, unemployment, socialization, and rage (conscious and unconscious legacies of slavery and a changing society) influence African American roles
  • despite a belief in the institution of marriage, fewer African Americans marry today than at any time in history
  • out of wedlock births account for almost three of four African American births
  • since the 1970s, African Americans have had increasing opportunities for financial and social upward mobility, employment and education, and housing and social options
  • African Americans who remain in poverty tend to be poorer and less educated, and to have less opportunity to advance
  • unemployment has risen for African Americans because of the elimination of many working-class jobs
  • single parenting, high unemployment, and living in or near the poverty level has resulted in a loosening of family ties
  • Working with African American families
  • although utilization rates for individual therapy are high, they are low for family therapy
  • traditionally, African American families have relied upon extended family networks
  • men, in particular, have been reluctant to share intimate thoughts and feelings because of socialization patterns that have taught them not to share pain and frustration
  • trust issues must be resolved between non African American family therapists and African American families
  • it is helpful to frame family therapy as a form of social support that African Americans can benefit from
  • psychoeducation, especially with single parent African American women, can be effective
  • clear understanding of multigenerational family systems in African American communities, especially the importance of respect for elderly family members, is crucial for therapists to                understand
  • therapists must assure families that they can learn how to handle many of their own problems, increase their confidence and competence levels
  • social and institutional issues may need to be challenged when they act as barriers to improvement and African American families must learn to advocate on their own behalf
  • presentation of positive role models to African Americans can also make a difference

 

Asian American Families

 

  • Asian Americans trace their cultural heritage to countries such as China, Japan, Vietnam, Cambodia, India, Korea, the Philippines, and the Pacific islands
  • as many as 32 different Asian ethnic groups have been identified in the U.S.
  • shared cultural values include
  • respect and reverence for the elderly
  • extended family support
  • family loyalty
  • high value on education
  • strong emphasis on self-discipline, order, social etiquette, and hierarchy
  • Confucian philosophies and ethics heavily influence some Asian American families
  • specific and proper relationships and roles including father/son, husband/wife, elder/younger siblings
  • feelings of obligation and shame are prevalent (e.g., if a family member behaves improperly, the whole family loses face)
  • Buddhist values are also prevalent and stress
  • harmonious living
  • compassion
  • respect for life
  • moderation of behavior
  • self-discipline
  • patience
  • modesty
  • friendliness
  • geographically and emotionally, families are moving further apart
  • substance abuse is increasing among some Asian American populations
  • weakening of the patriarchic family system with less complete obedience from children and more democratic family decision making is on the rise
  • Working with Asian American Families
  • levels of acculturation must be assessed
  • first-generation families may need assistance in interrelating to other families and societal institutions; problems of social isolation, adjustment difficulties, and language barriers may also be prevalent
  • role of the therapist with first-generation families may be primarily educational and avocational rather than remedial
  • established families may need help in resolving intrafamily difficulties such as intergenerational conflicts, role confusion, and couple relationships
  • an acculturation gap (i.e., different rates of acculturation) between immigrant parents and U.S. raised children often result in misunderstandings, miscommunications, and conflict
  • because most Asian American families are reluctant to initiate family therapy, therapists can be most effective by doing the following:
  • orient them and educate them to the value of therapy
  • establish rapport quickly through the use of compassion and self-disclosure
  • emphasize specific techniques families can use to improve relationships and resolve problems
  • racism may disrupt internal family dynamics as well as outside relationships
  • therapists can assist by addressing societal changes and assessing family skills and values for dealing with prejudice and discrimination
  • therapists must create a safe and nurturing environment where family members are respected and, without fear, explore relevant problems and concerns
  • general guidelines for working with Asian American families
  • assess support available to the family
  • assess past history of immigration,
  • establish professional credibility
  • be problem focused/present focused
  • be directive in guiding the therapy process
  • provide positive reframes that encourage the family

Hispanic/Latino American Families

 

  • Hispanic or Latino refers to people who were born in any of the Spanish-speaking countries of the Americas (Latin America), Puerto Rico, or from the U.S. who trace their ancestry to either Latin America or to Hispanic people from U.S. territories that were once Spanish or Mexican
  • Hispanic/Latino population is the nation’s largest minority and is growing rapidly
  • Most Hispanic/Latino American families trace their ancestry to Mexico, Cuba, or Puerto Rico
  • Most wish to be in the mainstream of society in the United States
  • Family oriented and child centered
  • Parents tend to take ‘complementary’ roles in disciplining (i.e., fathers) and nurturing (i.e., mothers) of their children
  • Challenges for Hispanic/Latino families
  • higher unemployment rate than non-Hispanic/Latinos
  • live below the poverty line at twice the rate of non-Hispanic/Latinos
  • lag behind non-Hispanic/Latinos in earning high school diplomas and college degrees
  • Strengths and assets of Hispanic/Latino families
  • collectivistic culture which views accomplishments as being dependent on the outcomes of others
  • cultural values of
  • dignidad (dignity)
  • orgullo (pride and self-reliance)
  • confianza (trust and intimacy)
  • respecto (respect)
  • simpatia (smooth, pleasant relationships)
  • personalismo (individualized self-worth)
  • machismo (male self-respect and responsibility)
  • Working with Hispanic/Latino families
  • family plays a central part in Hispanic/Latino culture
  • therapists need to develop a basic knowledge about cultural traditions (e.g., traditional rituals, religious festivities, Quinceanos, engagements, weddings, and funerals)
  • Hispanic/Latino individuals prefer to get to know someone as a person rather than assessing others based on external factors (e.g., occupation, socioeconomic status)
  • Hispanic/Latinos tend to be physically expressive (e.g., gesturing while they talk)
  • specific therapeutic considerations
  • stress related to economic and working conditions can contribute to intrafamily difficulties; therapists can advocate and be a resource in this area
  • assess for different levels of acculturation and how the pressure to acculturate may contribute to family turmoil, especially as it relates to family loyalty
  • language factors, especially bilingualism, must be explored
  • outside resources, such as the Catholic church, may be helpful in providing social, economic, and emotional support
  • therapist must reinforce the father as being the central figure of the family
  • therapist must initially accept the role of women as self-sacrificing and victims of other family members and redirect this behavior to assist in getting others to therapy
  • Hispanic/Latinos expect therapy to be brief, reflecting their experience with physicians

American Indians (AI) and Alaska Natives (AN) Families

 

  • Extremely diverse group belonging to 557 federally recognized and several hundred state-recognized nations
  • Culture is built around
    • harmony
    • acceptance
    • cooperation
    • sharing
    • respect for nature and family, including extended family
  • Break up or dysfunctionality of the family and extended family is a major problem in most AI/AN cultures
    • historically, between 25% and 55% of all AI children have been separated from their families of origin and placed in non-AI foster homes, adoption homes, boarding homes, or other institutions
    • family breakups have resulted in identity confusion and trauma about relationships to others
  • More AI/AN families now living in urban areas than on reservations
    • cultural connectedness is important to AI/AN families
    • urban life is stressful and contributes to poor mental health
    • isolation from their roots presents multiple difficulties in terms of functionality
  • Substance abuse, particularly alcoholism, is a major problem for AI/AN families
    • in some family groups, drinking is encouraged as a form of socialization
    • alcohol related problems include suicide, higher death and disorder rates, cirrhosis of the liver, and fetal alcohol syndrome
  • Working with AI/AN families
    • outsiders do not gain entrance into the family easily
    • indirect forms of questioning and open-ended questions work best
    • therapists should know and utilize sacred symbols that can be used metaphorically as models for relationships
    • admission by therapists that they may make mistakes in treatment because of cultural ignorance is helpful in establishing rapport
    • home-based therapy works well by offering essential services to families who would not otherwise receive them
    • many AI/AN languages have a visual emphasis (e.g., the verb ‘to learn’ is a combination of the verbs ‘to see’ and ‘to remember’)
    • concrete and active behavior, rather than insight is stressed in AI/AN healing
    • therapeutic approaches that are directive but open ended are effective

Arab American Families

 

  • Over three quarters of the Arab American population are immigrants
  • Arab Americans mostly come from Asia, Africa, and the Middle East
  • Arab Americans are the largest cohort of Muslims in the United States
  • Arab culture is high context rather than low context as found in North American society
  • emphasis on social stability and collectivity
  • slower pace of social change
  • Family is the most significant element in most Arab American subcultures
    • family connections are the source of influence, power, position, and security
    • patriarchal family structure; husbands are the undisputed head of the household
    • husbands are subordinate to their own fathers who in turn, defer to the head of the clan
  • Working with Arab American Families
    • sharp delineation of gender roles
    • patriarchal authority patterns
    • conservative sexual standards
    • emphasis on self-sacrifice for the greater good of the family
    • emphasis on honor and shame (i.e., outside help is sought only as a last resort)
    • negative fallout, tension, and distrust from September 11, 2001
    • clinical recommendations for therapists
  • be aware of the unique cultural context
  • be sensitive to issues of family leadership and authority
  • be aware of the strong influence of the family in decision making
  • be sensitive to the large role of culture
  • be aware strengths-based approaches are most effective
  • be active and balanced so as not to be seen as a rescuer or a threat
    • initial interventions should focus on exploring identity, blending Arab and American identities, and replacing either/or decision making
    • genograms can be helpful to assess couple/family strengths, both past and present
    • although difficult, focusing on couple dynamics can help each spouse find needed support
    • helping Arab Americans access religious and other groups can provide support and a sense of community

European Americans

 

  • As a group European Americans are sometimes referred to under the category of “White” due to their skin color
  • White skin is assumed to grant an individual membership into a privileged group
  • Most people equate White with White Anglo-Saxon Protestant (WASP) ideals
  • As with other groups, European Americans are a diverse group, coming originally from countries such as Italy, France, Germany, Ireland, Sweden, Hungary, Ireland, and Greece
  • some groups of European Americans (e.g., Italians, Slavics, and Irish immigrant groups) have experienced racist treatment from other European American groups
  • WASP values such as rugged individualism, mastery over nature, competitiveness, and Christianity, are not representative of all European Americans
  • similarities between European American groups and other groups exist, such as being middle-class; many differences too
  • Working with European Americans
  • no one approach fits best
  • different approaches may work best for select cultural groups

Guidelines for Selecting Treatment Approaches in Working with Culturally Diverse Families

 

  • Two main approaches
  • culture-specific model
  • emphasis on values, beliefs, and orientation of different ethnic cultural groups
  • basis for most counselor education multicultural courses
  • focus on memorizing variations among groups may result in information overload and emphasizing stereotyping rather than uniqueness among groups
  • universal perspective model
  • a generalist approach
  • assumption that developed counseling models can be successfully adapted to different cultural groups
  • focuses on identifying similarities in human processes, regardless of ethnicity or cultural background
  • may be too general to be of any real use to therapists

 

  • General guidelines in selecting interventions
  • assess whether the family’s difficulties are internal or external
  • for internal problems, standard approaches may be employed
  • for external problems, culture specific approaches may be best
  • determine the family’s degree of acculturation
  • “Americanized” families may respond to a broader range of interventions than families of new immigrants or only second generation
  • explore the family’s knowledge of family therapy and their commitment to problem resolution
  • for families with little knowledge of mental health services or with time pressures, educational and/or direct, brief-theory driven approaches are recommended
  • for other families, culture specific approaches are recommended
  • identify what the family has tried before and what they prefer
  • preference is an important element for establishing rapport and treatment effectiveness

 

  • Role of the therapist
    • intellectual and emotional exploration of biases and values is essential
      • some majority culture therapists may minimize the impact of societal or cultural expectations on minority families
    • culturally skilled family therapists have the following characteristics
    • aware and sensitive to their own cultural heritage and to valuing and respecting differences
    • comfortable with differences between themselves and their clients
    • sensitive to circumstances that may indicate the need to refer a family to another therapist (e.g., personal biases)
    • knowledgeable of personal racist attitudes, beliefs, and feelings
    • family therapists blend different styles of family therapy with the unique cultural or ethnic values of the family
    • family therapists should remain concurrently culturally sensitive and open to themselves and the family
    • provide support, when and where appropriate, for the expression of thoughts and emotions
    • assist families to acknowledge and celebrate their heritage and marker events, especially those associated with specific life cycle stages
    • assist families to be aware of, accept, and adjust to family life stages
    • four major investments therapists must make (ESCAPE)
    • E – engagement with families and process
    • S-C – sensitivity to culture
    • A-P – awareness of family potential
    • E – knowledge of the environment

 

Key Terms

 

acceptance   the therapist’s personal and professional comfortableness with a family.

 

acculturation   the modification of a culture as a result of coming into contact with another culture. In many instances, minority cultures incorporate many traditions and mores of majority cultures in attempts to “fit in.”

 

acculturation gap   different rates of acculturation between immigrant parents and U.S.-raised children that complicates the normal generation gap. The results of this gap may result in greater misunderstandings, miscommunications, and eventual conflicts among family members than would otherwise happen.

 

commitment ambiguity   a situation usually in gay and lesbian couple relationships where one partner is not sure about his or her place in the affiliation.

 

culturally encapsulated counselors   professional therapists who treat everyone the same and, in so doing, ignore important differences.

 

culture   the customary beliefs, social forms, and material traits of a racial, religious, or social group.

 

cultural competency   sensitivity to such factors as race, gender, ethnicity, socioeconomic status, and sexual orientation as well as the ability to respond appropriately in a therapeutic manner to persons whose cultural background differs one’s own.

 

culture-specific model of multicultural counseling   a model of counseling that emphasizes the values, beliefs, and orientation of different ethnic cultural groups

 

ESCAPE   an acronym that stands for four major investments therapists must make: (1) engagement with families and process, (2) sensitivity to culture, (3) awareness of families’ potentials, and (4) knowledge of the environment.

 

Hispanic or Latino   a person born in any of the Spanish-speaking countries of the Americas (Latin America), Puerto Rico, or the United States who traces his or her ancestry to either Latin America or to Hispanic people from U.S. territories that were once Spanish or Mexican.

 

home-based therapy   a method of treatment that requires family therapists to spend time with families before attempting to help them.

 

institutional barrier   any hardship that minority populations must endure to receive mental health services, such as the inconvenient location of a clinic, the use of a language not spoken by one’s family, and the lack of diversified practitioners.

 

intercultural couple   individuals who elect to marry outside of their culture

 

multicultural   a term used to refer to the cultural groups within a region or nation.

 

racism   discrimination or prejudice based on race.

 

systematic change agent   the role a therapist takes when he or she tries to intervene on behalf of families in unhealthy and intolerant systems.

 

universal perspective model of multicultural counseling   a model of counseling that assumes that counseling approaches already developed can be applied with minor changes to different cultural groups. Thus, cultural differences are recognized from a family systems perspective.

 

WASPs   white anglo-saxon protestants, often the group associated with the term “White.”

 

White   a term that is sometimes generalized and used to describe any person with white skin who has European ancestory.

 

worldview   the dominant perception or view of a specific group.

 

 

 

 

 

 

 

Classroom Discussion

 

  1. The two main approaches used in working with culturally diverse families, the culture-specific model and the universal perspective model. Both approaches have strengths and weaknesses.  Debate the merits of each and try and identify a ‘hybrid’ that might have greater utility and usefulness in working with culturally diverse families.

 

  1. The Hispanic/Latino population is the nation’s largest growing minority. Hispanic/Latino individuals prefer to get to know someone as a person rather than assessing others based on external factors (e.g., occupation, socioeconomic status).  What are some strategies and/or things you would do or say to develop a trusting relationship with a Hispanic/Latino family that respects this cultural preference?

 

  1. Following the events of September 11, 2001, Arab Americans have suffered negative fallout, tension, distrust, and both overt and covert discrimination. In addition, Arab American culture is very different in many ways from North American culture.  What are your biases, values, and beliefs about Arab Americans and working with Arab American families?  How would/could you address any issues which might limit your effectiveness with this population?

 

 

Multiple Choice Questions

 

  1. Multiculturalism is
  2. a term used to refer to the cultural groups within a region or nation
  3. a family, tribe, people, or nation belonging to the same stock
  4. the customary beliefs, social forms, and material traits of a racial, religious, or social group
  5. the dominant perception or view of a specific group

 

  1. Culture is
  2. a term used to refer to the cultural groups within a region or nation
  3. a family, tribe, people, or nation belonging to the same stock
  4. the customary beliefs, social forms, and material traits of a racial, religious, or social group
  5. the dominant perception or view of a specific group

 

  1. Ethnicity is
  2. a term used to refer to the cultural groups within a region or nation
  3. a family, tribe, people, or nation belonging to the same stock
  4. the customary beliefs, social forms, and material traits of a racial, religious, or social group
  5. the dominant perception or view of a specific group

 

  1. _____ is a term used to describe some counselor’s tendency to treat everyone the same and make mistakes in so doing.
  2. systematic change agent
  3. WASP
  4. culturally encapsulated
  5. culturally diverse

 

  1. In treating gay and lesbian couples and families, it is important to be aware of
  2. internal and external issues
  3. extended family involvement
  4. local, state, and national laws
  5. all of the above

 

 

 

 

  1. In African American families, _____ has been an essential element for survival.
  2. an emphasis on social stability and collectivity
  3. a collectivistic culture
  4. a strong emphasis on self-discipline, order, social etiquette, and hierarchy
  5. the family

 

 

  1. Although utilization rates for individual therapy are _____ among African Americans, they are _____ for family therapy.
  2. high, low
  3. low, high
  4. about the same for each

 

  1. For African American families, _____ approaches may offer the greatest benefit.
  2. problem focused and multigenerational
  3. brief therapy
  4. structural family therapy combined with traditional healing modalities
  5. strengths based

 

  1. _____ families place a high value on education.
  2. African American
  3. Asian American
  4. Hispanic/Latino
  5. American Indians/Alaska Natives

 

  1. Some cultural groups, such as Hispanic/Latino and American Indians/Alaska Natives, place a strong emphasis on _____, which refers to viewing accomplishments as being dependent on the outcomes of others.
  2. rugged individualism
  3. machismo
  4. family leadership and authority
  5. collectivism

 

  1. Which cultural group prefers to get to know someone as a person rather than assessing others based on external factors?
  2. African American
  3. Asian American
  4. Hispanic/Latino
  5. American Indians/Alaska Natives

 

  1. Which cultural group tends to be physically expressive (e.g., gesturing while they talk)?
  2. African American
  3. Asian American
  4. Hispanic/Latino
  5. American Indians/Alaska Natives

 

  1. Which cultural group tends to have a visual emphasis in their languages (e.g., the verb ‘to learn’ is a combination of the verbs ‘to see’ and ‘to remember’)?
  2. African American
  3. Asian American
  4. Hispanic/Latino
  5. American Indians/Alaska Natives

 

 

 

 

 

  1. Indirect forms of questioning and open-ended questions work best with which cultural group?
  2. African American
  3. Asian American
  4. Hispanic/Latino
  5. American Indians/Alaska Natives

 

  1. In which cultural group is the father the undisputed head of the household?
  2. African American
  3. Asian American
  4. Hispanic/Latino
  5. Arab American

 

  1. Which of the following cultural groups is high context, rather than low context as found in most North American society?
  2. African American
  3. Asian American
  4. Hispanic/Latino
  5. Arab American

 

  1. Strengths based approaches are most effective with which cultural group?
  2. African American
  3. Asian American
  4. Hispanic/Latino
  5. D. Arab American

 

  1. “WASP” values, often equated with “White” ideals, include all the following except:
  2. rugged individualism
  3. emphasis on honor and shame
  4. mastery over nature
  5. competitiveness

 

  1. The model used in most counselor education multicultural courses is
  2. intercultural model
  3. universal perspective model
  4. culture-specific model
  5. ESCAPE

 

  1. In all forms of family therapy with culturally diverse families, it is essential for family therapists to:

 

  1. memorize variations among cultural groups
  2. utilize standard approaches
  3. make assumptions in order to generalize treatment among cultural groups
  4. explore personal biases and values

 

 

True/False Questions

 

  1. Although American society has been diverse since its beginnings, little focus was placed on multiculturalism until the 1970s and 1980s.

 

True ___    False ___

 

  1. Sensitivity, experience, acceptance, ingenuity, specificity, and intervention are appropriate treatment goals for most culturally diverse families.

 

True ___    False ___

  1. Family therapists may be at an initial disadvantage in working with culturally diverse groups because the field of marriage and family therapy reflects a predominant European American bias.

 

True ___    False ___

 

  1. A strong belief in the institution of marriage has resulted in more African Americans marrying today than at any time in history.

 

True ___    False ___

 

  1. Assessing for levels of acculturation is important in working with culturally diverse families.

 

True ___    False ___

 

Chapter 6

Ethical, Legal, and Professional Issues in Family Therapy

 

Chapter Overview

 

  • In family therapy, there is a link between selecting treatment approaches and professional issues, such as ethical and legal factors
  • Knowledge of ethical, legal, and professional issues can prevent clinical or personal actions that result in harm to families
  • For family therapists to stay healthy, they must abide by ethical codes and legal statutes and practice according to the highest standards possible

 

Overview of Ethics in Family Therapy

 

  • Ethics are moral principles from which individuals and social groups, such as families, determine rules for right conduct
  • Relationship ethics refer to ethics in a family that are based on the principles of equitability and caring.
  • equitability – everyone is entitled to have his or her interests and welfare considered in a way that is fair from a multilateral perspective
  • caring – moral development and principles are centered in the social context of relationships and interdependency
  • Early family therapy models stressed neutrality, rarely discussed ethical principles with clients, and believed theory and practice were ‘value free’
  • Modern practitioners understand that all therapeutic decisions are related to values and cannot be ethically neutral
  • Family therapists may face more ethical conflicts than other types of therapists due to the complexity of relationships and of meeting the needs of multiple individuals within the system

Ethics and Values

 

  • Values are a ranking of an ordered set of choices from the most to the least preferable
  • Values have four domains
  • personal
  • family
  • political/social
  • ultimate
  • Effective family therapists closely examine their own values first
  • ethical genograms help determine how one’s family of origin made tough ethical decisions
  • examine the values of client families from a systemic view (i.e., how family members’ values affect the family as a whole) and negotiate with the family if values are far apart
  • explore values associated with theories, processes, and outcomes selected
  • using therapy as a means to promote personal values is unethical
  • denying the role of values in selecting treatment approaches and outcomes can lead to clinical errors and possible harm to clients

 

How Do Values Influence Ethical Practice?

 

  • All ethical decision making has, as its core, the values, beliefs, and preferences of individuals and groups
  • “All values that deal with social rights and obligations inevitably surface in ethical decisions” (Doherty & Boss, 1991, p. 610)
  • Action-oriented research focuses on finding solutions to problems such as abuse
  • Family therapists are ethically bound to be honest and open with client families, clearly informing them of biases and values that impact clinical practices and outcomes

Guidelines for Making Ethical Decisions

 

  • Family therapists must be aware of professional guidelines for making ethical decisions
  • Five primary models and resources
  1. Codes of ethics – guidelines developed by professional associations (e.g., AAMFT, IAMFC) to address issues confronting family therapists including:
  • confidentiality
  • responsibility to clients
  • professional competence
  • integrity
  • assessment
  • financial arrangements
  • research and publications
  • supervision
  • public statements
  • common ethical concerns include
  • treating the entire family
  • being current on new family therapy developments
  • seeing one family member with the others present
  • sharing values with clients
  • few specific behavioral guidelines on what to do and how
  • dual or multiple relationships can be problematic
  • determining the best course of action from simply reading the code of ethics may be difficult for both beginning and experienced family therapists
  1. Educational resources
  • case histories relating to ethical dilemmas
  • User’s Guide to the AAMFT Code of Ethics (AAMFT, 2001)
  • The Family Journal
  • ethical decision making process involves the following steps
  • generate a continuum of alternative actions for the good of the family and to meet professional responsibilities
  • evaluate and weigh the consequences of each
  • make a tentative decision and consult with colleagues/supervisors
  • implement the decision
  • document the process
  1. Professional consultation
    • consultation is the use of experts in an area to enhance one’s own knowledge and abilities
  • internal consultation – talking with an expert where one works about an ethical matter
  • outside consultation – conversations with a professional outside one’s agency or setting
  • process consultation – conferring with an expert about the ethics or methods one is using with a family
  • outcome consultation – focuses on the ethics of what the therapist and/or family hopes to accomplish
  • formal consultation – input received from an expert through an appointment or structured meeting
  • informal consultation – talking with an expert in the hallways at a professional therapy conference or some less structured way of interacting
  1. Interaction with colleagues and supervisors
  • provides opportunities for sharing of expertise and wisdom
  • colleagues may be more accessible than consultants/ed. materials
  • cost is inexpensive or free
  • direct supervision by noncolleagues is effective and recommended
  • family therapy supervision is different from individual therapy supervision
  • focus on interpersonal as well as intrapersonal issues
  • videotapes used to critique work
  • one-way mirrors for live observation and/or supervision
  • bug-in-the-ear supervision allows live communication with the therapist during sessions
  1. Meta-ethical principles
  • high level principles that guide ethical decision making
  • autonomy – the right of individuals to make decisions and choices
  • nonmaleficence – the avoidance of doing possible harm to a client through one’s actions
  • beneficence­ – doing good and promoting the welfare of the client
  • fidelity – being trustworthy, loyal, and keeping one’s promises
  • justice – treating people equally

Common Ethical Concerns

 

  • Confidentiality is the ethical and legal duty to fulfill a contract or promise to clients that the information revealed during therapy will be protected from unauthorized disclosure
    • Confidentiality issues should be conveyed to all family members in a written professional self-disclosure statement
  • Confidentiality has limitations, including:
  • if clients may inflict harm on themselves or others
  • when the mental or physical health of a client(s) is called into question
  • when child or elder abuse or neglect is suspected
  • when clients give the therapist written permission to share information (e.g., with another professional)
  • privileged communication is a client’s legal right that confidences originating in a therapeutic relationship will be safeguarded
  • avoid talking about cases in public
  • cell phones, e-mails, and faxes may not be secure
  • office personnel must understand and abide by confidentiality requirements
  • client information stored on computers should be password protected
  • computers should be oriented so that unauthorized persons cannot view the screen
  • client notes and records must be kept securely locked
  • Gender issues
  • gender of therapist and family members influence what issues are addressed in treatment
  • gender sensitive issues may include
    • the balance of power between a husband and wife both financially and physically
    • the rules and roles played by members of different genders and how these are rewarded
    • what a shift in a family’s way of operating will mean to the functionality of the family as a while
  • avoid implementing changes in gender-prescribed behaviors solely based on therapist values or beliefs
  • failure to address emotional abuse or intimidation that is lethal to the life and functioning of the family is irresponsible
  • Sex between a therapist and a family member
  • sexual relations between a therapist and client are forbidden in the code of ethics of all family therapy associations
  • if sexual behavior between a therapist and client is discovered, the person receiving the news should confront the accused professional with the evidence and file a written report to the appropriate association ethics and/or licensure/certification board
  • ethics and licensure boards have the authority to investigate, receive testimony, make a decision, and determine appropriate consequences
  • Theoretical techniques
  • some theoretical approaches are controversial and should be used with discretion
  • conscious deceit
  • paradox
  • neutrality when violence is occurring
  • Multicultural therapy issues
  • multicultural competence is necessary to insure therapists do not impose their values on families
  • three potentially serious ethical errors in working with minority culture families
  1. overemphasize similarities
  2. overemphasize differences
  3. make assumptions that either similarities or difference must be emphasized
  • ‘culturally relevant perspective’ identifies what is culturally significant from the family’s perspective rather than from a prescribed cultural perspective that may not be relevant to a family
  • Use of the Internet for online therapy
  • useful to communicate with clients locally and around the world
  • clients can email questions to a counselor and receive an email response within 24 to 72 hours for a predetermined fee
  • hearing impaired clients or clients in remote areas can benefit from Internet based counseling
  • introverted clients may benefit from web based counseling
  • communication with families or family members in between sessions for guidance, to lower anxiety, or clarify issues
  • ethical issues include:
  • security issues
  • possible breaches of confidentiality
  • inability of therapists to either protect clients or warn others of potential danger
  • inability of therapists to read nonverbal responses and clues
  • potential for client misunderstanding of written communications
  • client vulnerability due to incompetent therapists
  • few existing guidelines for ethical practice (exception is Shaw & Shaw’s Ethical Intent Checklist to evaluate online counseling websites)

Addressing Unethical Behavior

 

  • When unethical behavior is observed, the behavior should first be discussed directly with the person observed to have acted unethically
  • If the problem is not resolved at this level, the family therapist should be reported to the appropriate national association (e.g., AAMFT, IAMFC) or licensure/certification board regulating the practice of family therapy
  • If allegations about a family therapist are made through a client, options include:
  • check with an attorney or ethics case manager
  • encourage your client to file an ethics complaint with her or his professional association or licensure/certification board
  • file a complaint yourself
  • do nothing, if your professional code does not require you to report
  • In addressing ethical violations, it can be traumatic for a client to come forward against a therapist

Legal Issues in Family Therapy

 

  • Ethical issues often overlap with legal issues
  • Important legal terms
  • legal – law or the state of being lawful
  • law – a body of rules recognized by a state or community as binding on its members
  • liability – an obligation and responsibility one person has to another
  • civil liability – results from lawsuit by a client against a therapist for professional malpractice (negligence) or gross negligence
  • criminal liability – results from the commission of a crime by the therapist, such as failing to report child abuse, engaging in sexual relations with a client, or insurance fraud
  • administrative liability – results when the therapist’s license to practice is threatened by an investigation from a board which has the power to suspend or revoke the license
  • Differences between legal and therapeutic systems
  • legal systems are concerned with gathering evidence based on facts
  • therapy is more interested in processes and making changes
  • attorneys spend more time gathering information and concentrating on content than therapists do
  • legal systems rely on adversity
  • therapeutic systems rely on cooperation
  • attorneys focus on ‘winning’ cases for their clients, often discrediting or disproving evidence that contradicts their cases
  • family therapists affirm family members and work towards equitable resolution of family issues
  • in the legal system, each family member is represented by a different legal counselor
  • family therapists work with the whole family to resolve internal disputes
  • attorneys work with individuals
  • AAMFT provides its members one free consultation per quarter with legal counsel to discuss legal and ethical practice issues
  • Types of law
  • common law – law that is derived from tradition and usage; accepting customs passed down from antiquity such as English law
  • statutory law – laws passed by legislative bodies and signed by an authorized source; only valid in the jurisdiction in which they are passed
  • administrative (regulatory) law – specialized regulations passed by authorized government agencies that pertain to certain specialty areas
  • case law (court decisions) – law that is decided by decisions of courts at all levels from state to federal
  • civil law – acts offensive to individuals; most applicable to family therapists
  • criminal law – acts offensive to society in general
    family therapists must be aware of their duties and responsibilities in all areas of law and ethics

Legal Situations That Involve Family Therapists

 

  • Family therapist may encounter a number of legal situations, for example, dealing with minors, mature minors, age of consent, emancipation, common law marriage, durable power of attorney, and custody issues

 

  • Persons younger than the age of 18 years, who ordinarily cannot enter into binding legal contracts. Mature minors. Persons 16 years or older but younger than the age of 18 years who have demonstrated the ability and capacity to manage their affairs and to live wholly or partially independent of their parents or guardians.
  • Age of consent. The age at or above which a person is considered to have the legal capacity to consent to sexual activity.
  • Emancipated minors. Persons who are usually at least 16 years old and are considered adults for several purposes, including the ability to enter into a contract, rent an apartment, and consent to medical care. Emancipated minors include those who are self-supporting and not living at home, married, pregnant or a parent, in the military, and who have been declared emancipated by a court.
  • Common-law marriages. Sometimes called de facto marriages or informal marriages, these are arrangements by which couples are considered legally married without a having undergone a ceremony or a received a license.
  • Common law marriages receive the same legal treatment as other types of marriages, including the fact that the couple must go through a divorce to legally end the marriage.
  • Durable power of attorney. An authorization to act on someone else’s behalf in a legal or business matter
  • Custody. A legal term describing the relationship between a parent and a child, including the parent’s duty to care for the child and make decisions regarding the welfare of the child.

 

  • Therapists may be called on to participate in some legal and legally related situations as expert witnesses, child custody evaluators, reporters of abuse, and court-ordered witnesses.

 

  • Expert witness
  • family therapists may be asked to testify in court about probable causes and recommendations in regard to family members
  • essential for therapist to remain objective, establish credibility, speak from authority, and be specific
  • courts are adversarial, with one side seeking to affirm the testimony of the expert witness and the other side working to discredit the expert witness’s testimony
  • Child custody evaluator
  • family therapists may be asked to determine what is in the best interest of a child when making child custody arrangements
  • child custody evaluators represent the child and the court, not the parents
  • duties may include home visits, testing, and conversations with the child
  • requires a background and experience in child development, family systems, parenting skills, psychometrics, counseling, and witness testimony
  • Reporter of abuse
  • when reporting abuse, family therapists are breaking confidentiality
  • abuse reporting is mandated in all states
  • Child Abuse Prevention and Treatment Act of 1974 established mandated reporting for the greater good of society
  • it is recommended that family therapists advise the family when they are obligated to report abuse and to explain the reporting process
  • Court-ordered witness
  • family therapists may be asked to testify in court on behalf of or against a family or family member
  • if subpoenaed, it is recommended that family therapists immediately seek the advice of an attorney to avoid pressures to take sides and to avoid penalty or perjury situations

Issues of Law in Family Therapy

 

  • Malpractice – failure to fulfill the requisite standard of care because of ‘omission’ (what should have been done, but was not done) or ‘commission’ (doing something that should not have been done)
  • negligence must be proven for a malpractice suit to be brought forward
  • common malpractice issues include:
  • advertising – most states place legal limits on practice titles and only professionals who have met specified criteria may call themselves ‘licensed marriage and family therapists’
  • record keeping – clinical records must be accurate, kept secure, and maintained for a specified length of time
  • “in camera review” of clinical records is when an impartial party, usually a judge, reviews records and releases on pertinent parts of the clinical record
  • liability insurance is essential to protect therapists financially from legal claims that they have mishandled family needs or members

 

  • Managed care and the process of therapy
    • third party reimbursement for private practitioners have changed from the traditional ‘fee for service’ health care system to a ‘managed care’ health care system
    • managed care systems were created to address a perception of overutilization of benefits and little accountability within the health care industry
    • managed care has resulted in changes for private practitioners
  • the number of practitioners available to see families
  • the length of treatment authorized
  • the types of treatment received
  • compensation rates
    • in managed care systems, limits are placed on the amount and type of services provided by close monitoring of services and changing the nature of approved services
  • utilization review requires practitioners to submit written justification for treatment and comprehensive treatment plans that are submit to review and approval
  • services not previously authorized or approved are not reimbursed
  • capitated contracts, an emerging managed care method, are service contracts in which practitioners (called providers) agree to provide treatment for a population for a per person per year fee
  • due to a high demand to minimize the number of sessions available for reimbursement, brief therapy, solution-focused, narrative, and strategic family therapy approaches have become common
  • providers must be skilled in drafting treatment plans, following them, and providing evidence of treatment effectiveness
  • care pathway guidelines have been developed that provide timelines and guidelines which address the decision making process, clinical services offered, and the potential interactions among multidisciplinary health care professions

Professional Identification as a Family Therapist

 

  • Who are marriage and family therapists?
  • AAMFT research on MFTs in the United States in 2004
  • over 50,000 licensed MFTs
  • 30,000 MFT trainees working toward licensure or completing coursework
  • two-thirds have masters degrees, one-third doctorates
  • half of the professionals work exclusively in private practice
  • one quarter work in institutional or organizational settings
  • one quarter work in both
  • two thirds work full time; 21% work part time
  • most clients are seen during normal business hours
  • 73% also see clients in the evenings
  • one third see clients on weekends
  • mean salary in 2004 was $46,573, compared to the overall mean of $43,000 for the general population
  • income varies greatly due to the diversity of settings, and other factors such as age and experience
  • mean age is 54
  • 60% of licensed MFTs are women
  • 91% are white
  • Who seeks marriage and family therapy?
  • majority are women
  • ethnic distribution closely resembles the general population
  • 80% white
  • 9% black
  • 10% Hispanic
  • 4% Asian
  • 1% Native American
  • 10% other
  • children are overrepresented in MFT caseloads
  • average session length is 59 minutes
  • two thirds of clients were in therapy for less than one year
  • treatment approaches
  • 33% use cognitive-behavioral approaches
  • 10% use multi-systemic approaches
  • 6% use psychodynamic approaches
  • 5% use Bowen family therapy
  • 5% use solution-focused therapy
  • most common presenting problems
  • mood disorders
  • couple relationship problems
  • family relationship problems
  • anxiety disorders
  • adjustment disorders

 

  • Organizations associated with family therapy
    • professional associations
  • establish standards for the profession, including ethical codes
  • provide a means for address grievances involving practitioners or the profession in general
  • provide a means for practitioners to communicate with one another through conferences and publications
  • provide opportunities for continuing education to keep practitioners abreast of current practices and issues
    • American Association for Marriage and Family Therapy
  • oldest and largest (23,000 members)
  • established in 1942
  • focus on accrediting educational programs (COAMFTE)
  • focus on advocating for MFT licensure at the state level
  • publishes professional literature and videotapes
  • Journal of Marital and Family Therapy
  • Family Therapy News
  • lobbies for MFTs, including recognition of MFTs as ‘core’ mental health providers
  • American Family Therapy Association
  • founded by Murray Bowen in 1977
  • 1,000 members
  • objectives are
  • advancing systemic theories and therapies
  • promoting research and professional education
  • disseminating information about family therapy
  • fostering the cooperation of all professionals concerned with the needs of families
  • promoting the science and practice of family therapy
  • membership categories include
  • charter
  • clinical-teacher
  • research
  • distinguished
  • foreign
  • annual conference to share ideas and develop common interests
  • Division 43 of the American Psychological Association: Family Psychology
  • established to enable psychologists who worked with families to maintain their identity as psychologists
  • concerned with the science, practice, public interest, and education of psychologists who work with families
  • annual conference
  • The Family Psychologist
  • Journal of Family Psychology
  • according to L’Abate (1992), family psychologists differ from family therapists in three areas
  1. family psychology is interested in the whole functionality-dysfunctionality continuum, while family therapy is mainly concerned with dysfunctionality
  2. family psychology focuses reductionistically on the relationship of the individual within the family, while family therapy focuses holistically on the family as a whole unit or system
  3. family psychology stresses objective evaluation and primary and secondary prevention approaches, while family therapy stresses the subjective understanding of the family and sees therapy as one type of tertiary prevention
  • not everyone agrees with L’Abate and there continues to be debate on the identify of family psychology

 

  • International Association of Marriage and Family Counselors
  • a division of the American Counseling Association
  • regional and national conferences
  • established national training standards (CACREP)
  • The Family Journal: Counseling and Therapy for Couples and Families
  • IAMFC Newsletter
  • produces training videotapes and publishes books
  • established standard to credential MFTs
  • National Council on Family Relations
  • established in 1939
  • the oldest professional association dedicated to working with families
  • focus on education
  • focus on disseminating information on family history, family forms and functions, and family life in a variety of settings
  • Journal of Marriage and the Family
  • Journal of Family Theory and Review
  • Family Relations: Interdisciplinary Journal of Applied Family Studies
  • annual conference
  • Education of family therapists
  • professional identity is linked to one’s education
  • educational programs and processes are regulated by accreditation bodies
  • Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)
  • Council on Accreditation of Counseling and Related Educational Programs (CACREP)
  • issues in the education programs in family therapy
  • professional ‘in-fighting’ for recognition among accreditation boards and professional groups
  • some professional groups refuse to recognize other similar groups
  • current programs tend to ignore controversial issues or issues that are hard to teach (e.g., divorce, substance abuse, homelessness, teen pregnancies, extramarital affairs, impact of HIV/AIDS on family life)
  • Issues in professional identification
  • practitioners have many choices for professional organizations and alignment
  • each professional association has unique aspects or foci
  • friction continues to exist among associations dedicated to family therapy

 

 

Key Terms

 

action-oriented research   research that focuses on finding solutions to a problem, such as spouse abuse.

 

administrative (regulatory) law   specialized regulations that pertain to certain specialty areas that are passed by authorized government agencies, for example, laws governing the use of federal land.

 

American Association for Marriage and Family Therapy (AAMFT)   the oldest and largest (23,000 members) professional family therapy organization in the world and dedicated to increasing understanding, research and education in the field of marriage and family therapy, and ensuring that the public’s needs are met by trained practitioners.

 

American Family Therapy Academy (AFTA)   a non-profit organization of “leading family therapy teachers, clinicians, program developers, researchers and social scientists, dedicated to advancing systemic thinking and practices for families in their ecological context.”

 

autonomy   in ethics, the right of individuals to make decisions and choices.

 

beneficience   the ethical principle of first do no harm to individuals and work in their best interest.

 

bug-in-the-ear supervision method   a supervision model where the therapist working with a family receives messages from a supervisor through a telephone hookup device.

 

camera review   where an impartial party, usually a judge, reviews a therapist’s records and releases only those portions that are relevant to the situation at hand in a court case.

 

caring   the idea that moral development and principles are centered in the social context of relationships and interdependency.

 

case law (court decisions)   the type of law decided by decisions of courts at all levels from state to federal.

 

child custody evaluator  a family therapist who acts on behalf of a court to determine what is in the best interest of a child in a custody arrangement.

 

civil law   that part of the law that pertains to acts offensive to individuals. Law involving family therapists pertains primarily to civil law—for example, divorce.

 

common law   law derived from tradition and usage.

 

consultation   the use of a neutral third party experts in an area to enhance one’s own knowledge and abilities in that area.

 

criminal law   that part of the law that deals with acts offensive to society in general.

 

Division 43 of the American Psychological Association (APA): Family Psychology   a division of the APA established to enable psychologists who worked with families to keep their identity as psychologists. The division’s mission is to expand both the study and the practice of family psychology, through education, research, and clinical practice.

 

dual (multiple) relationship   a relationship that is not built on mutuality and where a therapist assumes a second role, for example, being a friend, business associate, lover, and so on.

 

equitability   the proposition that everyone is entitled to have his or her welfare interests considered in a way that is fair from a multilateral perspective. Equitability is the basis for relationship ethics.

 

ethics   the moral principles from which individuals and social groups, such as families, determine rules for right conduct. Families and society are governed by relationship ethics.

 

family therapy supervision   a systemic type of supervision that includes a focus on interpersonal as well as intrapersonal issues.

 

fidelity   the ethical prinicple of being trustworthy and keeping one’s promises.

 

International Association of Marriage and Family Counselors (IAMFC)   a division within the American Counseling Association that promotes excellence in the practice of couples and family counseling by creating and disseminating publications and media products, providing a forum for exploration of family-related issues, involving a diverse group of dedicated professionals, and emphasizing collaborative efforts with other marriage and family counseling and therapy groups

 

justice the ethical principle of treating people equally.

 

law   a body of rules recognized by a state or community as binding on its members.

 

legal   the law or the state of being lawful.

 

liability   a legal term dealing with obligation and responsibility. A liability may be civil, e.g., dealing with professional malpractic such as negligence; criminal, e.g., dealing with the committing of a crime; or administrative, e.g., investigation from a licensure board.

 

liability insurance   insurance that protects therapists financially from legal claims that they have mishandled a clinical situation.

 

malpractice   the failure to fulfill the requisite standard of care either because of omission (what should have been done, but was not done) or commission (doing something that should not have been done). In either case, negligence must be proved.

 

National Council on Family Relations   the oldest professional association dedicated to working with families. It was established in 1939, and many of its members helped to create and support the AAMFT. Throughout its history, the NCFR has concentrated on education. Its membership is interdisciplinary and includes family life educators, sociologists, family researchers, and family therapists.

 

neutrality   literally value free; some family therapies pride themselves on operating around a neutrality framework. Critics of such a framework claim that all therapy has moral and political values. A neutrality stance has deep ethical implications.

 

nonmaleficence   the avoidance of doing possible harm to a client from clinical action.

 

privileged communication   a client’s legal right, guaranteed by statute, that confidences originating in a therapeutic relationship will be safeguarded.

 

professional self-disclosure statement   a statement given to the family by the therapist that outlines treatment conditions related to who will be involved, what will be discussed, the length and frequency of sessions, emergency numbers, information about confidentiality and exceptions to it, and fees.

 

records   remembrances in the form of written notes from sessions with couples and families. Records are important for treatment purposes and as a defense for the therapist if he or she is accused of wrongdoing.

 

relationship ethics   Boszormenyi-Nagy’s term for ethics in a family that are based on the principles of equitability and caring.

 

statutory law   that group of laws passed by legislative bodies, such as state and national legislatures, and signed by an authorized source, such as a governor or the president.

 

 

Classroom Discussion

 

  1. According to Fishman (1988), in family therapy, some therapists work from an individual therapeutic approach in the presence of the family, or they work with family members individually. This type of treatment raises a value and an ethical question because problems of the family in such an arrangement are not being viewed from their “context as a whole.”  Discuss the ethical issues involved in this type of treatment and why it is not considered an effective and/or ethical approach to family therapy practice.

 

  1. Codes of ethics are guidelines developed by professional organizations to address issues confronting marriage and family therapists. However, there are few specific behavioral guidelines on what to do and how.  As a result, determining the best course of action from simply reading the code of ethics may be difficult for both beginning and experienced family therapists.  How can codes of ethics best be used by practitioners to insure sound ethical practice and quality decision making?

 

  1. How does the considerable in-fighting among professional association groups impact the profession of marriage and family therapy? What would you suggest as strategies to reduce or eliminate this “turfism?”

 

Multiple Choice Questions

 

  1. Relationship ethics refer to ethics in a family that are based on the principles of:
  2. values and culture
  3. equitability and caring
  4. behavior and values
  5. mutuality and complementarity

 

  1. There are five primary models and resources for making ethical decisions. They include all the following except:
  2. educational resources
  3. professional consultation
  4. action-oriented research
  5. codes of ethics

 

  1. The ethical principle of _____ goes beyond the avoidance of doing possible harm to clients and includes doing good and promoting the welfare of the client.
  2. autonomy
  3. nonmaleficence
  4. beneficence
  5. fidelity

 

  1. The responsibility for maintaining confidentiality lies with
  2. the client
  3. the therapist
  4. both the client and the therapist
  5. none of the above

 

  1. Multicultural competence is necessary to insure therapists do not impose their values on families. One way to avoid serious ethical errors in working with minority culture families is the _____ perspective, which identifies what is culturally significant from the family’s perspective rather than from a prescribed cultural perspective that may not be relevant to a family.
  2. gender
  3. neutrality
  4. culturally relevant
  5. interactional

 

  1. When unethical behavior is observed, the behavior should first be
  2. discussed with the person observed to act unethically
  3. reported to the appropriate professional association
  4. reported to the appropriate licensure/certification board
  5. all of the above

 

  1. Marriage and family therapists may be called to provide testimony in court. One role in which family therapists are asked to testify about probable causes and recommendations in regard to family members is called:
  2. child custody evaluator
  3. expert witness
  4. court ordered witness
  5. court advocate

 

  1. Failure to fulfill the requisite standard of care when providing therapy services can result in
  2. an “in camera review”
  3. a malpractice suit
  4. nonmaleficence
  5. dual or multiple relationships
  6. Most marriage and family therapists in the United States practice
  7. full time
  8. part time
  9. some time
  10. seldom

 

  1. Most marriage and family therapy clients are
  2. men
  3. women
  4. childless couples
  5. deviant families

 

  1. Most marriage and family therapists have a
  2. bachelors degree
  3. masters degree
  4. doctoral degree
  5. medical degree

 

  1. The most widely used treatment approach by marriage and family therapists is:
  2. Bowen family therapy
  3. psychodynamic approaches
  4. cognitive-behavioral approaches
  5. solution-focused approaches

 

  1. The professional association that focuses on accrediting educational institutions and advocating for MFT licensure at the state level is:
  2. AAMFT
  3. AFTA
  4. IAMFC
  5. NCFR

 

  1. What are the two accrediting bodies for marriage and family training programs?
  2. COAMFTE and CACREP
  3. COAFTA and NCFR
  4. CORE and CACREP
  5. CAPA and COAMFTE

 

  1. _____ results from a lawsuit by a client against a therapist for professional malpractice (negligence) or gross negligence.
  2. criminal liability
  3. civil liability
  4. administrative liability
  5. no liability

 

 

True/False Questions

 

  1. Sexual relations between a therapist and a family member are never allowed.

 

True ___    False ___

 

  1. Internet counseling can be a useful therapeutic medium for many client types, especially for hearing impaired clients and clients in remote areas.

 

True ___    False ___

 

  1. In the legal system, attorneys affirm family members and work towards equitable resolution of family issues.

 

True ___    False ___

 

  1. Modern practitioners understand that all therapeutic decisions are related to values and therefore therapeutic practice must be ethically neutral.

 

True ___    False ___

 

  1. In the ethical decision making process, the first step is to consult with colleagues or an ethics case manager.

 

True ___    False ___

 

  1. Using experts in an area to enhance one’s own knowledge and abilities is known as consultation.

 

True ___    False ___

 

 

 

 

 

 

 

Chapter 7

The Process of Family Therapy

 

Chapter Overview

 

Common Factors in Therapy

 

  • Four common curative elements in psychotherapy
  • extratherapeutic factors
  • therapy relationship
  • expectancy, hope, and placebo factors
  • model and technique factors

 

The Personhood of Family Therapists

 

  • Personal characteristics of family therapists contribute to therapy success
  • Personal therapy can help resolve negative family of origin experiences
  • Major stressors for family therapists include
  • listening to client family’s problems
  • less time for one’s own family
  • unrealistic expectations for one’s own family
  • psychological distancing from one’s own family due to professional status
  • Enhancers for family therapists include
  • increased ability to solve one’s own family problems
  • acceptance of personal responsibility of all family members in contributing to family dysfunction
  • greater appreciation of one’s own family
  • increased desire and ability to communicate effectively
  • Successful family therapists appear to have artistic qualities, (i.e., they are intuitive and feeling oriented)

Common Problems of Beginning Family Therapists

 

  • Due to inexperience, beginning family therapists often overemphasize and try and do too much, or they underemphasize and fail to make timely interventions that might help the family
  • Overemphasis
  • overemphasis on details
  • two primary components of family therapy are content (details and facts) and process (how information is dealt with in an interaction)
  • beginning therapists tend to focus more on content rather than process
  • content is essential but does not tell the whole story
  • process questions (how the family interacts) are often more revealing than content questions (what, where, and when)
  • redirection is a technique that asks the family to attend to the process and affective components of their interactions
  • overemphasis on making everyone happy
  • beginning therapists often are overly concerned that families leave their offices in a ‘happy’ state
  • based on a belief that competent therapists help families solve their problems
  • beginning family therapists may lack confidence and may be uncomfortable with confrontation and/or friction/disharmony
  • family discomfort is sometimes unavoidable and can be productive and motivate families to change old behaviors
  • overemphasis on verbal expression
  • verbal expressions to families can be very helpful but often are not remembered and may have limited impact over time
  • it is what the family and family therapist do, as well as what is said, that makes a difference
  • a variety of therapist tools must be used for maximum impact such as instructing, commenting, asking questions, modeling behavior, role plays, assigning homework outside of the session
  • both verbal and nonverbal expressions are necessary
  • overemphasis on coming to an early or too easy resolution
    • families often report feeling better after discussing their situation for a few sessions even though they have not actually changed it
    • quick and easy resolutions rarely succeed
    • family therapy is an ongoing process that will vary for each family and families must be advised regarding time frames and expectations
  • overemphasis on dealing with one member of the family
  • families tend to scapegoat one member as the cause of the family problem
  • family therapists must view the family as a system and the problem as lying within the family system
  • family therapists must see the family as the unit of treatment, rather than one member of the family
  • a systemic approach helps family members become more aware of their actions and how they personally contribute to both family health and family dysfunction
  • Underemphasis
  • underemphasis on establishing structure
  • for therapy to be successful, therapy sessions must be conducted differently than the way families normally conduct their family life
  • the battle for structure refers to the struggle by the therapist to establish effective rules for therapy
  • the therapist must win the battle for structure so that the family will have a different and more productive experience rather than running the therapy sessions in their own nonproductive ways
  • family therapists can inform families about the conditions under which therapy will occur by using a written professional disclosure statement or informed consent brochure
  • fees and payment schedules
  • theoretical orientations
  • treatment approaches
  • rules about appointments
  • how to contact the therapist
  • confidentiality and limits to confidentiality
  • therapist qualifications
  • risks of therapy
  • family therapists structure the room by arranging furniture
    • to make it easy for family interaction to take place
    • to allow for family members to move closer or farther away from each other as necessary during the session
  • underemphasis on showing care and concern
  • beginning therapists may treat families more like objects than persons, thus increasing the family’s anxiety about therapy
  • beginning family therapists may appear rigid and distant due to a lack of confidence and experience
  • effective family therapists are caring, open, sensitive, and show concern and empathy
  • SOLER is an acronym which describes effective interactive skills for therapists
  • S means facing the family squarely
  • O means adopting an open posture that is nondefensive
  • L means leaning forward to show interest
  • E means making good eye contact when appropriate
  • R means to relax and feel comfortable
  • effective family therapists make self-disclosures and use self-effacing humor when appropriate
  • underemphasis on engaging family members in the therapeutic process
  • systemic therapy requires joining with all members of the system
  • it is important to spend time with each person in the system
  • rapport and cooperation are increased by acknowledging each person’s importance to the family
  • underemphasis on letting the family work on its problems
    • effective family therapists help families become motivated to make changes
    • help families to win the battle for initiative (the family’s motivation to change) by increasing their hope and the possibilities for change
  • underemphasis on attending to nonverbal family dynamics
  • nonverbal cues, such as eye glances, hands folded across one’s body, seating arrangements give essential information about family dynamics
  • ignoring nonverbal family processes gives an incomplete picture of the family and can limit change if not addressed

Appropriate Process

 

  • Therapists who do not plan properly are likely to fail
  • Because family systems are complex, conceptualizing, planning, and implementing interventions also are complex
  • How to conduct family therapy should be based on one’s impression of the family, one’s theoretical position, and one’s clinical skills

Pre-session planning and tasks

 

  • Family therapy begins with the first contact with the family
  • The family member who initiates the contact may be the one most interested in change and most open to engaging in therapy
  • Initial contact is best made with the therapist rather than a receptionist so the therapist can answer questions directly, determine who should attend, and how sessions will be conducted
  • Essential data is collected during the initial contact
  • Ideally, the initial appointment should be scheduled within 48 hours of the contact
  • Intake information should be used to develop an initial hypothesis about the family dynamics, life cycle stage issues, ethnic/cultural background, and initial diagnosis of the family problem
  • A DSM diagnosis of an individual family member may be indicated but does not substitute for a diagnosis of relational problems from a systemic perspective
  • Family therapists investigate the possible linkages within the family such as what happened, why did it happen, what can be done about it and how?
  • Family therapists use diagnostic information to come up with a ‘case conceptualization,’ which is a way to comprehend more thoroughly what is happening with the family members as well as the family as a whole
  • Case conceptualization is part of the planning process which helps family therapists integrate theory with practice and come up with a treatment plan

Initial session(s)

 

  • The first few therapy sessions may be the most critical in terms of success
  • Most families withhold judgment about family therapy for a few sessions to give treatment a chance to work
  • Critical factors are a combination of structuring (e.g., teaching, directing) behaviors and supportive (e.g., warmth, caring) behaviors by the therapist
  • The unit of treatment (i.e., the couple, the family, inclusion of children) is dependent on the theoretical approach used and the comfort level of the therapist
  • Children are most often included when the therapist is comfortable with children, children are quiet, when the presenting problem is child focused, and with single parent families
  • Join the family: establishing rapport
  • the first step in the initial session(s) is establishing a sense of comfort and trust with the family, a process called ‘joining’
  • failure to join with everyone is a common reason for unsuccessful treatment outcomes
  • Inquire about members’ perceptions of the family
  • begin by finding out how each family member perceives the problem
  • family members organize their thoughts and behaviors around a ‘frame’ or perception/opinion which results in predictable patterns of interaction around the problem
  • knowing how family members frame the problem, person, or situation helps therapists to challenge the family to redefine their perceptions and develop new ways of responding
  • Observe family patterns
  • families have unique ‘personalities’ and characteristic ways of interacting, often referred to as the ‘family dance’
  • the following questions help family therapists determine how families function together
  • What is the outward appearance of the family?
  • What is the cognitive functioning in the family?
  • What repetitive, nonproductive sequences do you notice?
  • What is the basic feeling state in the family and who carries it?
  • What individual roles reinforce family resistances and what are the most prevalent family defenses?
  • What subsystems are operative in this family?
  • Who carries the power in the family?
  • How are the family members differentiated from each other and what are the subgroup boundaries?
  • What part of the family life cycle is the family experiencing and are the problem-solving methods stage appropriate?
  • What are the evaluator’s own reactions to the family?
  • Assess what needs to be done
  • assessment is usually done informally, through observation, although diagnostic instruments are sometimes used
  • the assessment process involves determining what can and what should change to improve family functioning
  • Engender hope for change and overcome resistance
  • help families see that things can get better
  • identifying family strengths and assets helps families recognize their potential for improvement
  • almost all families exhibit resistance to treatment in some way
  • controlling sessions
  • absent or silent members
  • refusal to talk with each other
  • hostility
  • failure to do homework
  • coming late to sessions
  • challenging therapist competence
  • denial
  • rationalizing
  • family therapists need to understand the nature of resistance and overcome it without alienating family members
  • depending on theoretical orientation and how resistance is being used by the family (e.g., fear, defiance), interventions may be chosen to overcome, avoid, or use resistance to produce change
  • creating boundaries for the family can increase safety and interaction
  • reframing can give a positive and different interpretation to the family’s resistance
  • family therapists also use the technique of paradox to give families permission to do what they were going to do anyway
  • regardless of approach, resistance must be addressed in order for treatment to move forward positively

 

  • Make a return appointment and give assignments
  • at the end of the initial session, the family therapist should take the initiative in offering to see the family again
  • if future sessions have been agreed to, the therapist may assign the family ‘homework’ or tasks to complete outside the session
  • homework helps families behave and feel differently and gives them practice time, intensifies the relationship between the therapist and family, and helps the therapist see how the family members relate to one another
  • homework assignments must be clear and clearly understood by the family
  • tasks should be practiced in session first if time allows
  • Record impressions of family session immediately
  • if not recorded immediately, impressions of families may become difficult to recall and may be distorted over time
  • clinical notes should be used to record both content and process oriented information
  • clinical notes can
  • be studied over time to better understand processes and trends
  • offer a place to reflect and be objective
  • serve as a reminder of what has already transpired, avoiding repetitiveness
  • a unique way of writing clinical notes is to write them in the form of a letter to the family about what occurred in the session

 

Middle phase of treatment

 

  • This is a ‘working’ stage in which family therapists push family members to make changes and breakthroughs
  • involve peripheral members
  • make sure all family members are involved in the process of therapy
  • invite the least involved member to be an observer of the family
  • using the technique of circular questioning, ask the least involved member to comment on the different interactions of other family members
  • use the power of the entire family to physically and verbally insist on participation by reluctant members
  • seek to connect family members
  • link individuals with common generational interests and concerns (e.g., siblings)
  • support coalitions formed for connection, closeness, and growth
  • break up inappropriate coalitions formed against other family members
  • establish contracts and promote quid pro quo relations
  • promote the benefits of relationship changes through contracts (e.g., in return for doing chores, special privileges are granted) or quid pro quo (something for something) in which family members benefit from their interactions together
  • emphasize some change within the family system
  • help families understand the change process by helping them see their current situation, options for change, consequences of changing or not changing, and the skills and commitment needed
  • emphasize that change is often slow and that ‘baby steps’ now can produce larger changes over time
  • small changes are less threatening to families and give them time to get used to behaving differently
  • reinforce family members for trying new behaviors
  • the most simple way is to use brief, verbal acknowledgments such as ‘good’ or ‘nice work’
  • a goal is for family members to learn to give each other reinforcement
  • stay active as a therapist
  • successful family therapists are mentally, verbally, and behaviorally active with their client families
  • few approaches to family therapy are passive
  • family therapists, as a rule, do not count on insight as a primary basis for change
  • family therapists are actively involved in creating change opportunities for families and do not wait for insight or spontaneous remission of symptoms
  • link family with appropriate outside systems
    • family therapy success can be enhanced through appropriate referral to outside agencies
    • do not wait until the end of therapy to make referrals
    • Boszormenyi-Nagy stresses that healing and growth for families take place best when the total context in which families operate is included in treatment
  • focus on process
    • focus on process instead of just content tends to produce change
    • changes occur over time
    • families tend to make the easiest changes first
    • family therapists must continuously engage the family in the change process
  • interject humor when appropriate
    • humor can help change family perceptions from seeing their situation as a tragedy which results in hopelessness and paralysis
    • using humor does not mean making fun of families but helping them have fun and gain a different perspective on their situation
    • Frank Pittman says “If we are fully imbedded in our comic perspective, then we can bear all the reality life has to offer.”
  • look for evidence of change in the family
    • closely observe the family for signs of both obvious and subtle changes
    • point out changes the family does not readily notice or acknowledge
    • discovery of changes may signal moving to the termination stage of therapy

 

Termination

 

  • although it can be at times difficult to pinpoint the exact time to end or change therapy, termination should be a planned for part of the therapy process
  • termination usually occurs for one of the following reasons
  • the course of treatment has come to a natural end and there has been improvement (i.e., the goals have been met)
  • the couple or family’s problem exceeds the skills/competency of the therapist
  • the couple or family are no longer benefiting from therapy
  • the therapist must leave their employment, temporarily or permanently
  • the client family can no longer afford treatment and no viable alternatives are available
  • the termination process involves four steps
    • orientation
    • summarization
    • discussion of long-term goals
    • follow-up and relapse prevention
  • termination can begin by reducing the frequency of sessions
  • a three session termination procedure
    • setting the date
    • next-to-the-last session
    • final farewell session
  • rituals and tasks can provide meaning to the termination process and provide a forum to celebrate changes
  • termination is often premature, with 40% to 60% of families dropping out before therapy is finished
  • regardless of when termination occurs in the therapeutic process, it should take into account progress made and skills that can be used later

 

An Example of Appropriate Process in Family Therapy

 

  • Initial Sessions
  • joining and establishing rapport with family are foci of treatment
  • family dynamics observed in regard to power, boundaries, coalitions, roles, rules, and patterns of communication
  • importance of typical day and early recollections also important
  • therapist engenders hope that change can take place
  • Middle Phase of Treatment
  • therapist concentrates on helping family members become more aware of their behaviors and to reorient, or become more motivated and want to try new behaviors
  • Areas of difficulty include:
    • changes in perceptions, beliefs, values, and goals
    • changes in the structure and organization of the family
    • changes in the skills and social behavior of family through teaching
    • changes in the way indirect and direct power are imployed
      • Termination
    • begun with mutual agreement
    • family members encouraged to project ahead and discuss how they might address future problems
    • follow-up treatment is scheduled

 

 

Key Terms

 

battle for initiative   the struggle to get a family to become motivated to make needed changes.

 

battle for structure   the struggle to establish the parameters under which family therapy is conducted.

 

boundaries   the physical and psychological factors that separate people from one another and organize them.

 

captitated contract   a managed care method of cutting costs in which providers agree to provide treatment for a per-person, per-year fee.

 

care pathway guidelines   instructions and directions in the managed care arena that delineate specific timelines in which diagnosis, interventions, decision-making processes, clinical services, and the potential interactions among multidisciplinary health care professionals should occur.

 

case conceptualization   a presession exercise where therapists ask themselves certain questions about couples or families they are going to see in order to form an initial impression of their future clients. This procedure helps them integrate theory with practice and come up with a treatment plan.

 

circular questioning   a Milan technique of asking questions that focus attention on family connections and highlight differences among family members. Every question is framed so that it addresses differences in perception about events or relationships by various family members.

 

content   the details and facts.

 

distancing   the isolated separateness of family members from each other, either physically or psychologically.

 

enmeshment   loss of autonomy due to overinvolvement of family members with each other, either physically or psychologically.

 

family dance   the verbal and nonverbal way a family displays its personality.

 

fee-for-service health care system   a system where clients pay for services, such as family therapy, either directly or indirectly through insurance, without being accountable to a third party for specific ways of making interventions.

 

homework   tasks clients are given to do outside of therapy session. Marital and family therapies that are noted for giving homework assignments are behavioral, cognitive-behavioral, psychodynamic, systemic, structural,and postmodern approaches.

 

informed consent brochure   a brochure that includes all the information in a self-disclosure statement about therapy as well as a place for clients to sign off that they understand the policies and procedures involved.

 

joining   the process of “coupling” that occurs between the therapist and the family, leading to the development of the therapeutic system. A therapist meets, greets, and forms a bond with family members during the first session in a rapid but relaxed and authentic way and makes the family comfortable through social exchange with each member.

 

managed health care   a wide range of techniques and structures that are connected with obtaining and paying for medical care, including therapy. The most common are preferred provider organizations (PPOs) and health maintenance organizations (HMOs).

 

paradox   a form of treatment in which therapists give families permission to do what they were going to do anyway, thereby lowering family resistance to therapy and increasing the likelihood of change.

 

process   how information is handled in a family or in therapy.

 

professional self-disclosure statement   a statement given to the family by the therapist that outlines treatment conditions related to who will be involved, what will be discussed, the length and frequency of sessions, emergency numbers, information about confidentiality and exceptions to it, and fees.

 

quid pro quo   literally, something for something.

 

redirection   where the therapist asks the couple or family to attend to the process of their relationship instead of the content of it.

 

reframing   a process in which a perception is changed by explaining a situation from a different context. Reframing is the art of attributing different meaning to behavior.

 

resistance   anything a family does to oppose or impair progress in family therapy.

 

scapegoat   a family member the family designates as the cause of its difficulties (i.e., the identified patient).

 

SOLAR   an acroym, each letter of which stands for the way professional skills may be shown. S stands for facing the couple or family squarely, either in a metaphorical or literal manner. The O is a reminder to adopt an open posture that is nondefensive. L indicates that the therapist should lean forward toward the client family to show interest. E represents appropriate eye contact. R stands for relaxation.

 

structuring  behavior   a general term in family therapy for describing the activity of a therapist in teaching and directing.

 

subsystems   smaller units of the system as a whole, usually composed of members in a family who because of age or function are logically grouped together, such as parents. They exist to carry out various family tasks.

 

supportive behavior   a general term in family therapy for describing the giving of warmth and care by a therapist.

 

triangulating   projecting interpersonal dyadic difficulties onto a third person or object (i.e., a scapegoat).

 

utilization review   the process in managed health care by which a therapist submits a written justification for treatment along with a comprehensive treatment plan to a utilization reviewer for approval.

 

 

Classroom Discussion

 

  1. Successful family therapists appear to have artistic qualities (i.e., they are intuitive and feeling oriented). Explain how having artistic qualities are advantageous and give some examples of how they might be effectively utilized in family therapy.

 

  1. It is widely believed that therapists who do not plan properly are likely to fail. How can therapists blend the need to be flexible, creative, and spontaneous with the structure and rigidity which can be a part of the planning process?

 

  1. Resistance is defined as anything a family does to oppose or impair progress in family therapy. Why is it so important that resistance be addressed in order for treatment to move forward positively?  What are some ways of addressing resistance?

 

 

Multiple Choice Questions

 

  1. Beginning family therapists often overemphasize and try and do too much. All the following are examples of overemphasis except:
  2. details
  3. verbal expression
  4. dealing with one member of the family
  5. establishing structure

 

  1. SOLER is an acronym which describes effective interactive skills for therapists. In this acronym, the “R” stands for:
  2. relax and feel comfortable
  3. establish roles
  4. reframe
  5. respect the family

 

  1. Critical factors in the success of the first few sessions are:
  2. verbal and nonverbal behaviors
  3. structuring and supportive behaviors
  4. assessment and data collection
  5. orientation and summarization

 

  1. In family therapy, establishing a sense of comfort and trust with the family is called:
  2. hypothesizing
  3. circular questioning
  4. joining
  5. engendering hope

 

  1. Almost all families exhibit resistance of some kind during treatment. Which of the following is/are not an example(s) of resistance:
  2. hostility
  3. failure to do homework
  4. silence
  5. none of the above

 

 

 

 

 

 

  1. Involving peripheral members and pushing family members to make changes and breakthroughs is a characteristic of which phase of treatment?
  2. initial
  3. middle
  4. termination
  5. none of the above

 

  1. Termination from treatment is often premature, with _____ of families dropping out before therapy is finished.
  2. 10% to 25%
  3. 20% to 40%
  4. 40% to 60%
  5. 60% to 65%

 

  1. Third party reimbursement for private practitioners has changed over time from a _____ health care system to a _____ health care system.
  2. managed care system; fee for service
  3. capitated; utilization review
  4. fee for service; managed care
  5. preferred provider organization (PPO); health maintenance organization (HMO)

 

  1. In managed care systems, submitting written justification for treatment and comprehensive treatment plans is called:
  2. utilization review
  3. capitation
  4. fee for service
  5. care pathway guidelines

 

  1. One way therapists can inform families about the conditions under which therapy will occur is by using a(n):
  2. treatment plan
  3. paradox
  4. clinical note
  5. written professional disclosure statement

 

 

True/False Questions

 

  1. A common problem of beginning family therapists is the tendency to try too hard to make everyone happy.

 

True ___    False ___

 

  1. While being a family therapist can be stressful, it may also give therapists a greater appreciation of their own families.

 

True ___    False ___

 

  1. Family therapy begins with the first session as opposed to the first few sessions.

 

True ___    False ___

 

  1. Reframing can be used to give a positive and different interpretation to the family’s resistance.

 

True ___    False ___

 

  1. A common problem of beginning family therapists is the tendency to ask more process questions than content questions.

 

True ___    False ___

 

 

 

 

Chapter 8

Couple and Marriage Therapy and Enrichment

 

Chapter Overview

 

  • Approximately 90% of people in the United States will couple and eventually marry at least once by age 45
  • Approximately 50% of all marriages fail
  • Only 3% of married couples seek marital therapy
  • More than 40% of psychotherapy clients cite marital distress as the reason for seeking services

 

Types of couple and marriage treatments

 

  • Couple and marriage therapy may overall be defined as a process by which a therapist works with two individuals who are in a primary and intimate relationship
  • couple therapy consists of a therapist working with two individuals as a pair to improve their relationship
  • marriage therapy consists of a therapist working with a couple that is legally married to help them improve their relationship
  • more complicated than couples therapy due to legal considerations
  • premarital counseling consists of a therapist working with a couple to enhance their relationship before they get married
  • viewed as preventive
  • focus is on communication skills, conflict resolution skills, finances, and parenting

 

Preventive approaches to working with couples

 

  • Universal prevention
  • focuses on preventing problems in the general population (e.g., a media campaign on family togetherness)
  • Selective prevention
  • focuses on making interventions with at-risk groups to prevent problems (e.g., parenting classes for parents whose children are having difficulty in school)
  • Indicated prevention
  • focuses on minimizing the harmful impact of serious problems in the early stages of their development (e.g., working with couples to prevent marital difficulties from resulting in abuse or physical harm to their children)

 

Major theorists in marriage preparation and couple enrichment

 

  • David and Vera Mace
  • husband and wife team, focused on marriage enrichment (i.e., strengthening marriages before they are in crisis)
  • first marriage enrichment retreat in 1962
  • founded the Association for Couples in Marriage Enrichment (ACME) in 1973
  • authored 33 books on marriage enrichment
  • John Gottman
  • Executive Director of the Relationship Institute in Seattle; professor emeritus at University of Washington
  • mathematical/measurement emphasis in therapy
  • conducts studies on newly married couples in his Family Research Lab (i.e., The Love Lab); measures heart rate and blood pressure when couple has conflict
  • has found successful relationships in marriage have a ratio of positive to negative interactions of 5 to 1
  • prolific writer – more than 20 books and almost 200 academic articles

Major theories for prevention

 

  • Marriage and Relationship Education
  • more cognitive than marriage enrichment (which is more experiential)
  • use or lectures, visual aids, books, handouts, and interactive discussions
  • goal is to help couples learn about how relationships work and the rationale behind the strategies for improvement
  • most premarital counseling programs include at least four topics: communication skills, conflict resolution skills, finances, and parenting
  • bibliotherapy is an important learning strategy
  • ‘Smart Marriage’ conferences are popular events for marriage education
  • Marriage enrichment
  • a proactive systematic effort to improve the functioning of marital couples
  • focus on married couples interacting with other married couples, learning from each other
  • involves self-help and couple-help
  • structured exercises
  • sharing information and experiences
  • confronting areas of conflict
  • giving and receiving feedback (e.g., communication, finances, problem solving, and having children)
  • Father Gabriel Calvo
  • founded Marriage Encounter Program in 1962
  • team couple leads husbands and wives during a weekend of exercises and sharing of emotions and thoughts
  • effective communication skills taught
  • David and Vera Mace
    • founded the ACME and its marriage enrichment programs
    • husband and wife team lead a structured weekend experience and also provides long term support
    • five stages in the ACME process
    • security and community building
    • developing an awareness of the couple’s relationship
    • developing knowledge and skills to help improve the relationship
    • planning for growth
    • celebrating and closure
  • Bernard G. Guerney, Jr.
    • Relationship Enhancement (RE)
    • skills building approach
    • empathic expression
    • discussion/negotiation
    • problem/conflict resolution
    • facilitation (partner coaching)
    • self-change
    • other change
    • generalization
    • maintenance
    • use of coaching, modeling, and positive reinforcement
    • useful with distressed and nondistressed couples
    • solid research base
  • David Olson
    • PREPARE/ENRICH inventories
    • PREPARE is used with engaged couples
    • ENRICH is used with married couples
    • identifies strengths and growth opportunity areas for couples
    • five areas of focus
    • communication
    • conflict resolution
    • family-of-origin issues
    • financial planning/budgeting
    • goal setting
    • strong supportive research
    • effective with African American as well as European American couples
  • Training in Marriage Enrichment (TIME) and Prevention and Relationship Enhancement Program (PREP)
  • TIME is for married couples and can be a weekend or 10-week long program
  • organized developmentally and sequentially
  • begins with accepting responsibility and ends with resolving an actual problem
  • PREP is a 12-week long program focusing on communication and problem solving skills and enhancing commitment to the relationship
  • research supports long lasting benefits from these programs
  • Other programs
  • Couples Communication Program (CC)
  • Great Start
  • SANCTUS
  • Practical Application of Intimate Relationship Skills (PAIRS)

 

Marriage and Couple Therapy

 

  • Research support for reducing conflict, increasing marital satisfaction
  • Conjoint therapy more effective than individual treatment
  • Major theorists
  • Susan Johnson
  • developed emotionally focused therapy (EFT) in the mid-1980s
  • an alternative to behaviorally focused approaches at the time

Therapeutic Approaches for Working with Couples

 

  • Psychoeducational approaches combined with marriage therapy can make marriages stronger
  • Crisis oriented approaches are less effective in the long term than approaches with developmental perspectives
  • Half of all couples treated eventually return to original levels of relationship discord
  • Primary reasons for seeking marital therapy
  • lack of communication
  • financial stress
  • disagreements over priorities
  • infidelity
  • All approaches focus on improving marital quality (how the relationship is functioning and how partners feel about and are influenced by the functioning)
  • Assessment is complex
  • “feelings expressed about marriage are greatly affected by the events of the moment and can change considerably over short periods of time . . . Additionally, individuals in distressed relationships sometimes do not report themselves distressed” (Lebow, 2005, p. 38)
  • Common factors among all approaches
  • establishment of a therapeutic alliance with the couple
  • goal oriented in deescalating negative reciprocity
  • building of positive interactions
  • monitoring treatment progress
  • successful termination

 

 

 

 

Behavioral Couple Therapy (BCT)

 

  • Premises of the theory
  • based on the exchange/negotiation model of adult intimacy
  • combines problem solving and communication skills with behavioral contracting
  • Treatment techniques
  • focuses on negotiating pleasant behaviors and teaching problem solving and communication skills
  • techniques include positive reinforcement, shaping, modeling
  • contingency contracts describe the terms for behaviors and reinforcers, one action being contingent on another
  • operant interpersonal approach based on the assumptions of exchange theory and quid pro quo that successful relationships are rewarding
  • ‘caring days’ is a creative technique in which couples act as if they care about their spouses, regardless of the other’s actions
  • ‘positive risk,’ is a unilateral action that is not dependent on another for success
  • Process and outcome
  • behavioral analysis to assess the marital distress
  • positive reciprocity to increase rewarding and valued behaviors
  • communication skills training to increase use of “I” statements, develop behavioral labels, and provide positive feedback
  • problem solving to develop conflict resolution and negotiation skills
  • Unique aspects of behavioral couple therapy
  • well researched
  • works best with young couples without a long history of marriage
  • more effective than individual treatment with alcoholics and, with this population, reduces social costs, domestic violence, and problems of the couple’s children
  • Comparison with other theories
  • a specific and precise skills-based approach
  • more linear than systemic
  • Offshoots of behavioral couple therapy
  • integrative behavioral couple therapy (IBCT)
    • promotes acceptance as well as change
    • helps identify areas of the relationship unlikely to change and coming to terms with those problems
    • reframing of hard emotions (e.g., hostility) to softer emotions (e.g., sadness)
    • results are less blaming and more soft emotions, increased empathy and emotional closeness, and long lasting change
  • cognitive-behavioral couple therapy (CBCT)
  • empirically supported, highly effective, short term in nature
  • used psychodynamic, cognitive, behavioral, and humanistic constructs
  • first introduced by Albert Ellis and his Rational Emotive Therapy (called Rational Emotive Behavior Therapy today)
  • ABC procedure (A is the event, B is the thought produced by the event, C is the emotion produced)
  • individuals and couples choose to think and feel in one of four ways:
  • positive
  • negative
  • neutral
  • mixed
  • forms of cognition that cause marital distress
  • selective perceptions about the events occurring in couple interactions
  • distorted attributions about causes of positive and negative relationship events
  • inaccurate expectations or predictions about events that may occur in the relationship
  • inappropriate or inaccurate assumptions or general beliefs about the characteristics of people and their intimate relationships
  • extreme or unrealistic standards to which individuals hold relationships and their members
  • other cognitive behavior methods include
  • cognitive distraction (thinking of something other than negative aspects)
  • self-control strategies (how to use rational coping statements)
  • relapse prevention (learning self-control strategies to prevent relapse)
  • psychoeducational methods (reading books, attending workshops, listening to audiovisual materials)

Emotionally Focused Therapy

 

  • A systemic approach based on integration of experiential and structural family therapy
  • Focus on dual perspectives of intrapsychic processes (processing of emotional experiences) and interpersonal processes (patterns and cycles of partner interactions)
  • Approach is rooted in attachment theory
  • secure attachment is related to higher self-esteem, internal locus of control, extroversion, openness to experience
  • insecure attachment often stems from family-of-origin issues and is expressed in the form of put-downs, belligerence, lecturing, stonewalling, and anger
  • Interventions include both experiential and structural techniques
  • Goal is to soften intense emotions to help build attachment and connectedness
  • Treatment techniques
  • focuses on disclosure of feelings
  • therapist may interrupt arguments and disagreements and reflect with each member as a means of defusing hostility
  • members explore the perceptions behind partners’ emotional responses and
  • catharsis is encouraged along with self-awareness
  • techniques from Gestalt and psychodrama approaches may also be used
  • Role of the therapist
  • provides a safe environment for release of both positive and negative emotions
  • encourages emotional expression while protecting the couple as individuals and partners
  • Process and outcome
  • three stage interaction process with nine steps
  • cycle deescalation (steps 1-4)
  • designed to uncover negative or hard feelings
  • restructuring interactional positions (steps 5-7)
  • explore intrapsychic processing of attachment related affect
  • work to create new interactive patterns
  • externalize the problem into a relationship problem rather than an individual problem
  • consolidation/integration (steps 8-9)
  • review accomplishments
  • reinforce secure bonding interactions
  • restructure interactions more positively
  • Unique aspects of Emotionally Focused Therapy
  • strong empirical base
  • process research oriented
  • timing of positive/negative interaction important change element
  • appropriate for couples from all backgrounds
  • wide application
  • post-traumatic stress disorder
  • moderately distressed couples
  • families with a bulimic child
  • couples suffering from trauma
  • couples with depression and chronic illnesses
  • older couples
  • gay couples
  • new focus on forgiveness and reconciliation, attachment injuries, and relationship traumas
  • 70% recovery rate for distressed couples
  • 90% overall recovery rate for all couples
  • Comparison with other theories
  • stronger emphasis on emotion and the concept of self than most theories
  • strong emphasis on empirical validation
  • demonstrates efficacy apart from its originators

 

Infidelity

 

  • Unfaithfulness in marriage
  • having an affair
  • extramarital relationships
  • cheating
  • sexual intercourse
  • oral sex
  • kissing
  • fondling
  • emotional connections that are beyond friendships
  • friendships
  • internet relationships
  • pornography use
  • Infidelity is common in American society
  • Approximately 25% of men and 10% of women have affairs sometime during marriage
  • Risk factors include
  • race (African Americans)
  • gender (males)
  • age (younger couples)
  • employment (working outside the home)
  • infrequent church attendance
  • low marital satisfaction
  • Approaches for treating infidelity
  • assess for cultural context as culture may define how a couple view unfaithfulness
  • infidelity is one of the most damaging problems couples face and one of the most difficult to treat
  • three recovery stages
  • an emotional roller coaster of emotions
  • a moratorium
  • trust building
  • stages may be sequential but the recovery process is uneven and includes regressive moments
  • Should the act of infidelity be revealed in therapy and how much should be told?
  • one model of therapy requires no disclosure and respects self-determinism; most prevalent outside the United States
  • second model of therapy requires the noninvolved spouse be made aware of the affair if it has not been previously disclosed before therapy begins; if an affair is kept secret, it cannot be treated
  • behavioral couple therapy is effective in cases of infidelity
  • cognitive-behavioral approaches can emphasize forgiveness and ‘letting go’ of resentment, bitterness, and the need for vengeance
  • therapist must instill hope to the couple that they can make it
  • it is common for many couples to separate and divorce rather than trying to continue their lives together

 

Divorce Therapy, Mediation, and Collaboration

 

Divorce Therapy

 

  • All marriages have some conflict
  • 25% of couples seeking divorce report seeking professional help
  • Those couples who do seek help wait an average of 6 years following onset of a serious problem before actually seeking help
  • Reasons for divorce are many, including marital stress and dissatisfaction, and physical assault
  • Therapists must assess whether or not their efforts will be toward salvaging a relationship or assisting with its dissolution
  • Three common ways of dissolving relationships are through divorce therapy, mediation, and collaboration
  • Divorce therapy helps couples separate from each other physically, psychologically, and/or legally
  • Goals include
  • accepting the end of the marriage
  • achieving a functional post divorce relationship with an ex-spouse
  • achieving a reasonable emotional adjustment and finding emotional support
  • coping with religious or spiritual angst
  • realizing the part one played in the dissolving of the marriage
  • helping the children from the marriage (if there are any) adjust to the loss
  • using the crisis of the divorce as opportunity to learn about oneself and to grow
  • negotiating a reasonably equitable legal settlement
  • developing healthy habits
  • Techniques
  • reading
  • reflecting
  • participation in structured exercises
  • listening for feelings
  • shifting “you” statements to “I” statements
  • setting aside specific time to discuss problem issues
  • learning to fully attend to one’s partner during conflict without interrupting
  • avoiding “dumping” of past unresolved issues or behaviors
  • refraining from physical actions and/or advice giving
  • postponing resolution, if needed, until the couple can reenergize and think through issues

 

Family Mediation

 

  • Process of helping couples and families settle disputes or dissolve their marriages in a nonadversarial way
  • A viable alternative to court action
  • Family/couple mediators are specially trained to function as impartial and neutral third parties to facilitate negotiation between disputing parties
  • Objective is to help the disputing parties make informed and mutually agreed upon decisions that resolve their differences in a practical and fair manner
  • Steps include
  • obtain a brief history
  • gather data about assets, incomes, liabilities, and goals
  • prioritize important issues
  • When compared to divorce proceedings, mediation is quicker, less costly, less hostile and stressful, and more productive
  • Part of the mediation process is teaching disputing parties how to bargain and come to a fair agreement
  • Mediation is conducted within external deadlines and concludes with a negotiated written contract
  • For more information
  • Academy of Family Mediators
  • Association of Family and Conciliation Courts
  • National Institute for Dispute Resolution
  • Society for Professionals in Dispute Resolution

 

 

Collaborative Divorce

 

  • An intervention model in which the divorcing couple and attorneys agree, by an explicit, written contract, to work toward a settlement without resorting to litigation.
  • Training collaborative attorneys support their respective clients in negotiating a settlement in a four-person meeting (two attorneys, two spouses)
  • If either party in the procedure decides to pursue litigation both collaborative attorneys are automatically terminated and each client hires new litigation attorneys
  • Other professional, including those in mental health (called “coaches”), meet with clients three or four times prior to and during the decision to divorce to help clients manage their feelings
  • Financial planners, CPAs, and appraisers may also be consulted during the collaborative divorce proceedings

 

 

Key Terms

 

behavioral analysis   a procedure used in behavioral couples therapy to measure couple distress. It is based on interviewing, self reports on questionnaires, and making behavioral observations.

 

caring days   part of a behavioral marital procedure in which one or both marital partners act as if they care about their spouse regardless of the other’s action(s). This technique embodies the idea of a “positive risk”—a unilateral action not dependent on another for success.

 

collaborative divorce an intervention model in which the divorcing couple and attorneys agree, by an explicit, written contract, to work toward a settlement without resorting to litigation

 

communications theory   an approach to working with families that focuses on clarifying verbal and nonverbal transactions among family members. Much communication theory work is incorporated in experiential and strategic family therapy.

 

contingency contracting   a procedure in which a specific, usually written, schedule or contract describes the terms for the trading or exchange of behaviors and reinforcers between two or more individuals. One action is contingent, or dependent, on another.

 

couple therapy   when a counselor works with two individuals to improve their relationship as a dyad. The couple may be married or unmarried, gay or straight, and have various levels of commitment to each other.

 

Couples Communication Program   a marriage enrichment program which is divided into entry and advanced programs where couples learn about themselves and their partners better in addition to mastering 11 interpersonal skills for effective talking, listening, conflict resolution, and anger management

 

Great Start   a program that utilizes PREPARE/ENRICH inventories and is designed for premarital and early marital relationships. It is a part of the Couples Communication Program.

 

incest   sexual relations between people who are closely related in a family, such as a parent/child or siblings, that is illegal or forbidden by custom.

 

indicated prevention   preventive efforts that focus on minimizing the harmful impact of serious problems in the early stages of their development, such as having a therapist work with a couple whose marriage is coming apart in order to prevent them from doing harm to one another or harm to their children.

 

infidelity   a myriad of activities outside of a couple relationship including: ‘having an affair,’ ‘extramarital relationships,’ ‘cheating,’ ‘sexual intercourse,’ ‘oral sex,’ ’kissing,’ ’fondling,’ ‘emotional connections that are beyond friendships,’ ’friendships,’ ‘internet relationships,’ ‘pornography use,’ and others.

 

marital quality   how a marriage relationship is functioning and how partners feel about and are influenced by such functioning.

 

marriage education   the use of didactic lectures, visual aids, books, handouts, and interactive discussions to help couples learn about the pitfalls and possibilities of marriage.

 

marriage enrichment   the concept that couples stay healthy or get healthier by actively participating in certain activities, usually in connection with other couples.

 

marriage therapy   when a therapy works with a couple that is legally married to help them improve their relationship.

 

Marriage Encounter Program   founded  in 1962, the essence of this approach is to have a “team couple” lead a group of husbands and wives during a weekend in exercise that  give them the opportunity to share their emotions and thoughts. In essence, couples are taught how to make effective communication a part of their everyday lives.

 

operant conditioning   a tenet of Skinner’s behavioral theory that people learn, through rewards and punishments, how to respond to their environments.

 

operant interpersonal approach   the term first used to describe Richard Stuart’s initiatives in behavioral couple therapy.

 

Practical Application of Intimate Relationship Skills (PAIRS)   a  marriage enrichment program developed by Lori Gordon that teaches attitudes, emotional understandings and behaviors that nurture and sustain healthy relationships

 

positive reinforcer   a material (e.g., food, money, or medals) or a social action (e.g., a smile or praise) that individuals are willing to work for.

 

positive risk   a unilateral action that is not dependent on another for success.

 

premarital counseling   working with a couple to enhance their relationship before they get married.

 

quid pro quo   literally, something for something.

 

SANCTUS   a theologically and psychologically based marriage enrichment program based on step-wise process that incorporates building a pattern of love and relationship with God, one’s self, and others

 

selective prevention   preventive efforts that focus on making interventions with at-risk groups in order to prevent problems such as conducting parenting classes for parents whose children are having difficulties in school.

 

shaping   the process of learning in small gradual steps; often referred to as successive approximation.

 

social exchange theory   an approach that stresses the rewards and costs of relationships in family life according to a behavioral economy.

 

social learning theory   a theory that stresses the importance of modeling and learning through observation as a primary way of acquiring new behaviors.

 

universal prevention   prevention efforts that focus on preventing the development of problems in the general population, such as a media campaign promoting family togetherness.

 

Classroom Discussion

 

  1. In cases of infidelity, should the act of infidelity be revealed in therapy and, if so, how much should be told?

 

One model of therapy requires no disclosure and respects self-determinism.  This model is most prevalent outside the United States.  A second model of therapy requires the noninvolved spouse be made aware of the affair if it has not been previously disclosed before therapy begins; if an affair is kept secret, it cannot be treated.

 

What are the pros and cons of each approach?  In what circumstances might each approach be recommended?  Contraindicated?

 

  1. Couple and marriage therapy approaches encompass both systemic and linear orientations. What are the advantages and disadvantages of each perspective in treating distressed couples?

 

  1. How do therapists go about deciding when marital therapy becomes divorce therapy? What other factors might go into such decisions (e.g., personal values, religion, theoretical orientation)?

 

 

Multiple Choice Questions

 

  1. In premarital counseling, the focus is on
  2. prevention
  3. enrichment
  4. generalization
  5. all of the above

 

  1. The overall goal of marriage enrichment, education, and enhancement programs is to
  2. settle disputes or dissolve marriage in nonadversarial ways
  3. improve the functioning and quality of marriages
  4. explore intrapsychi processing
  5. resolve family of origin issues

 

  1. There are three preventive approaches to working with couples. They are:
  2. primary, secondary, tertiary
  3. premarital, education, enrichment
  4. universal, selective, indicated
  5. premarital, psychoeducational, conflict resolution

 

  1. Crisis oriented couples approaches are _____ effective in the long term than approaches with developmental perspectives.
  2. more
  3. less

C         about the same

  1. there is no such comparison

 

  1. Which couples therapy approach focuses primarily on negotiating pleasant behaviors and teaching problem solving and communication skills?
  2. Behavioral Couple Therapy
  3. Emotionally Focused Therapy
  4. Cognitive-Behavioral Couple Therapy
  5. Integrative Behavioral Couple Therapy

 

 

  1. Which couples therapy approach focuses on the dual perspectives of intrapsychic processes and interpersonal processes?
  2. Behavioral Couple Therapy
  3. Emotionally Focused Therapy
  4. Cognitive-Behavioral Couple Therapy
  5. Integrative Behavioral Couple Therapy

 

  1. A procedure used in behavioral couple approaches in which one or both partners act as if they care about each other, regardless of the other’s actions, is called:
  2. behavioral analysis
  3. self-analysis
  4. gunnysacking or dumping
  5. caring days

 

  1. The process of helping families or couples settle disputes or dissolve their relationships in a nonadversarial way is called:
  2. marriage education
  3. marriage encounter
  4. relationship enhancement
  5. mediation

 

  1. Important goals of divorce therapy would include all the following except:
  2. to help build attachment and connectness
  3. coping with religious or spiritual angst
  4. accepting the end of the marriage
  5. negotiating a reasonably equitable legal settlement

 

  1. Mediation, when compared to divorce proceedings, is _____.
  2. quicker
  3. less costly
  4. less hostile
  5. all of the above

 

  1. Infidelity in American society is:
  2. rare
  3. increasing
  4. decreasing
  5. common

 

  1. Risk factors for infidelity are higher for
  2. European Americans; females
  3. African Americans; males
  4. older couples; working outside the home
  5. low marital satisfaction; frequent church attendance

 

  1. In treating cases of infidelity, three recovery stages have been identified.
  2. Stage 1 a moratorium

Stage 2 an emotional roller coaster of emotions

Stage 3 trust building

  1. Stage 1 an emotional roller coaster of emotions

Stage 2 trust building

Stage 3 a moratorium

  1. Stage 1 trust building

Stage 2 a moratorium

Stage 3 an emotional roller coaster of emotions

  1. Stage 1 an emotional roller coaster of emotions

Stage 2 a moratorium

Stage 3 trust building

 

  1. Effective treatments for infidelity include
  2. Multisystemic
  3. community reinforcement
  4. Behavioral and Cognitive-behavioral
  5. Bowen and Structural

 

  1. When treating cases of infidelity, it is important for therapists to assess for the _____ context, as this may define how a couple view unfaithfulness.
  2. historical
  3. cultural
  4. narrative
  5. self-determinism

 

 

True/False Questions

 

  1. Common topics for marriage encounter, enrichment, and education programs include communication skills and conflict resolution.

 

True ___    False ___

 

  1. Most couples treated do not return to original levels of relationship discord.

 

True ___    False ___

 

  1. The ideal time for premarital counseling is 4 to 12 weeks before the wedding date.

 

True ___    False ___

 

  1. A good example of a marriage education program is Smart Marriage.

 

True ___    False ___

 

  1. Because all marriages have some conflict, individual therapy is more effective than conjoint therapy

 

True ___    False ___

 

 

 

 

Chapter 9

Transgenerational Theories: Psychodynamic Family Theory
and Bowen Family Systems Theory

 

Chapter Overview

 

  • Both therapies began developing in the 1950s
  • Nathan Ackerman, founder of psychodynamic therapy
  • Murray Bowen, founder of Bowen family therapy
  • Similarities
  • based on psychoanalysis
  • belief that changes occur best in the context of family history and development
  • conscious and unconscious processes are the focus of interventions
  • “the past is active in the present”
  • initial life experiences are relevant
  • intrapersonal and interpersonal processes are intertwined
  • change is gradual and requires a long term investment of time and resources (20 – 40 sessions)

Psychodynamic Family Therapy

 

  • Major theorists
  • Nathan Ackerman
  • began with an interest in families and their influence on mental health and illness
  • treated whole families and conducted staff home visits at the Menninger Clinic
  • established the Family Institute in 1960 (later called the Ackerman Institute for the Family)
  • cofounder of Family Process, the first journal in family therapy
  • new concepts included
  • ‘tickling of defenses’ (i.e., provoking family members to open up and say what was on their mind)
  • complementarity
  • focus on strengths
  • interlocking pathology
  • Premises of the Theory
  • human nature is based on drives (e.g., sexuality and aggression)
  • mental conflict arises when children learn, and mislearn, that expressing basic impulses leads to punishment
  • conflict is signaled by unpleasant affect such as depression or anxiety
  • unconscious processes, called interlocking pathologies, take place among family members that keep them together
  • more recent focus is object relations theory
  • an object is something that is loved, usually a person
  • object relations means “relations between persons involved in ardent emotional attachments”
  • humans have a basic motivation to seek objects, starting at birth
  • children often internalize (interject) good and bad characteristics of these objects within themselves
  • interjections form the basis for how individuals interact and evaluate their interpersonal relationships
  • evaluating relationships can result in splitting (viewing object representations as either all good or all bad)
  • results in projection of good and bad qualities onto persons within one’s environment
  • splitting helps people control their anxiety and even their objects, by making them predictable
  • splitting distorts reality
  • object relations theory helps explain reasons for marital choice and family interaction patterns

 

  • Treatment techniques
  • transference (the projection onto a therapist of feelings, attitudes, or desires)
  • used to understand dominant feelings within a family and identify which emotions are being directed toward what people
  • helps with the expression of pent-up emotions (i.e., catharsis)
  • dream and daydream analysis
  • helps identify and analyze what needs within the family are not being met and that may need attention
  • confrontation
  • pointing out behavioral contradictions or conflicts with expressed wishes
  • focusing on strengths
  • concentrating on strengths helps change the family’s focus
  • life history
  • identifies past and present interactional patterns
  • affirms value and acceptance of all family members
  • promotes trust in the therapist
  • provides insight for family members
  • complementarity
  • the degree of harmony in the meshing of family roles
  • interpretation
  • brings unconscious conflicts between family members into consciousness (makes the covert overt)
  • helps to increase family members’ insight into how the past is continuing to affect the present
  • Role of the therapist
  • teacher
  • good enough mother (e.g., nurturing, encouraging)
  • catalyst (e.g., activates, challenges, confronts, interprets, integrates family processes)
  • emphasis on family as well as individual interactions
  • Process and outcome
  • therapist’s interpretation of events
  • insight by family members
  • interpretations best offered at the preconscious level
  • insights translated into new and more productive ways of behaving and interacting
  • differentiation (i.e., balance of rational and emotional selves and separation of self and others in a non-anxious way)
  • if differentiation is not possible, crisis resolution (reduction in symptoms) is utilized, focusing more on supporting defenses and clarifying communication
  • Unique aspects of Psychodynamic Family Therapy
  • focus on the importance of the unconscious in influencing human behavior
  • raises awareness of intrapersonal and interpersonal connections, such as invisible loyalties
  • examines basic defense mechanisms and their influence on family interactions
  • emphasizes the historical origins of dysfunctions and the treatment of persons and families so affected
  • explains how persons form attachments and how family members function as a result
  • Comparison with other theories
  • linear, not circular
  • requires long-term commitment of time and money
  • requires higher than average intellectual ability
  • requires abstract thinking skills
  • lacks empirical research

 

Bowen Family Therapy

 

  • Among the first systemically based approaches for working with families
  • Also known as transgenerational family therapy due to its historical focus
  • Major theorists
  • Murray Bowen
  • the originator of this approach
  • started working with families at the Menninger Clinic
  • studied “mother-patient symbiosis”
  • studied dynamics of families with schizophrenic children
  • initiated the founding of AFTA
  • Premises of the theory
  • theory and therapy cannot be separated
  • patterns passed down from previous generations must be examined and changed to avoid repetition in current families
  • risk for problems associated with family members who are emotionally overinvolved (i.e., fused) with each other or emotionally cut off (psychologically or physically) from each other
  • low anxiety results in few problems for people or families
  • eight basic concepts of Bowen Family Therapy
  • differentiation
  • a level of maturity reached by individuals who can distinguish themselves from their families of origin and separate their rational and emotional selves.
  • differentiation is the opposite of fusion.
  • continuum from autonomy (an ability to think through a situation clearly) to undifferentiated, also called fusion or undifferentiated family ego mass (emotional dependency on one’s family members)
  • emotional system
  • emotional reactivity
  • emotional cutoff
  • fusion with others
  • ability to take an “I-position”
  • multigenerational transmission process
  • patterns and strategies of coping with stress that are passed on from generation to generation
  • selection of marital partners at one’s own level of differentiation
  • nuclear family emotional system
  • low levels of anxiety produce stress, illness, and chronic dysfunction
  • high levels of anxiety produce rapid emotional equilibrium after the stress passes
  • family projection process
  • tendency to produce offspring at the same level of differentiation as the couple
  • poorly differentiated spouses keep emotional distance from one another
  • when anxiety gets too great, result may be marital conflict, physical or emotional illness in one spouse, projection of the problem to the children, or a combination of these
  • triangles
  • the basic building block of any emotional system
  • the smallest stable relationship system
  • some triangles are healthy, others are not
  • triangles are a frequent way of dealing with anxiety in which tension between two persons is projected onto another object
  • detriangulation helps people separate their feelings from their intellect, reducing anxiety
  • multigenerational genograms (a type of family tree) helps people detriangulate
  • homework assignments to visit their families and ask questions also help reduce anxiety

 

  • sibling position
  • people can develop fixed personality characteristics based on their functional birth order
  • societal regression
  • the deterioration or decline of a society struggling against too many toxic forces (e.g., overpopulation and economic decline) countering the tendency to achieve differentiation
  • Treatment techniques
  • focus is on the process of differentiation
  • genograms
  • a visual representation of a person’s family tree
  • minimum of three generations
  • tracks relationship changes
  • repetitive patterns
  • coincidences
  • impact of change and life cycle transitions (e.g., off schedule events)
  • trends
  • shifts from emotional reactivity to clear cognitions
  • genopro.com
  • going home again
  • clients/family members instructed to return home to get to know their family of origin better
  • individuals may need to practice staying calm before returning home
  • detriangulation
  • the process of being in contact and emotionally separate
  • two levels
  • resolving anxiety over family situations and not projecting feelings onto others
  • separating one’s self from becoming a focus when tension or anxiety arises in the family, avoiding scapegoating or blaming
  • person-to-person relationships
  • helping two family members relate to each other about each other without talking about others or about impersonal issues
  • differentiation of self
  • the degree to which a person is able to distinguish between the subjective feeling process and the more objective intellectual (thinking) process
  • may involve all the previous techniques as well as confrontation between family members and the therapist
  • asking questions
  • a main tool of Bowen therapists
  • helps people to understand the reactions of those in their families better
  • Role of the therapist
  • differentiation of the therapist is crucial
  • objectivity and neutrality are important therapist characteristics
  • coaching
  • teaching
  • having family members talk through the therapist to reduce emotional reactivity
  • setting an example of a reasonable, neutral, self-controlled adult
  • helping clients look for “clues” to identify where family pressures have been expressed and how the family has adapted
  • assist with drawing genograms
  • interpret multigenerational patterns of fusion and cut offs
  • Process and outcome
  • family members will understand intergenerational patterns and gain insight into historical experiences that influence current interactions
  • family members increase levels of differentiation
  • primary unit of treatment is the individual or couple; whole families usually not seen
  • best outcome is when spouses work together as a team

 

  • Unique aspects of the Bowen Family Therapy approach
  • focus on family history and avoiding replication of past negative patterns of interaction
  • use of the genogram
  • therapy and theory are consistent and inseparable
  • systemic in nature
  • controlled focus
  • cognitive orientation
  • effective with individuals or client families
  • Comparison with other theories
  • well established
  • strong emphasis on theory and practice
  • criticism that it is not gender sensitive
  • some research support
  • historical focus may encourage families to examine their history rather than the present
  • insight promoted before action
  • effective with clients and families experiencing severe dysfunction or low differentiation
  • the theory underlying the approach is its own paradigm
  • requires a large investment of time and money due to its long term structure
  • the number of people who can benefit from this type of therapy is limited

 

Key Terms

 

autonomy   in Bowen theory a designation for the level of differentiation in a person which signals the ability to think through a situation clearly. In ethics, the right of individuals to make decisions and choices.

 

catalyst   the role that a psychodynamic family therapist plays by moving into the “living space” of the family and stirs up interactions.

 

crisis resolution   a treatment modality used in crisis situations where the therapist focuses most on supporting defenses and clarifying communication in order to help a family.

 

detriangulation   the process of being in contact with others and, yet, emotionally separate.

 

differentiation (of self)   a level of maturity reached by an individual who can separate his or her rational and emotional selves. Differentiation is the opposite of fusion.

 

family projection   the tendency of couples according to Bowen to produce offspring at the same level of differentiation as themselves.

 

fused   when someone is emotionally overinvolved with someone else.

 

fusion   the merging of intellectual and emotional functions so that an individual does not have a clear sense of self and others. There is a discomfort with autonomy in relationships, wishes to psychologically merge with another, and difficulty tolerating differences of opinion. Fusion is the opposite of differentiation.

 

genogram   a visual representation of a person’s family tree depicted in geometric figures, lines, and words; originated by Bowen.

 

going home again   a Bowenian technique in which the family therapist instructs the individual or family members with whom he or she is working to return home in order to better get to know the family in which they grew up. By using this type of information, individuals can differentiate themselves more clearly.

 

good enough mother   a mother who lets an infant feel loved and cared for and thereby helps the infant develop trust and a true sense of self.

 

interlocking pathology   a term created by Ackerman to explain how families and certain of their members stay dysfunctional. In an interlocking pathology, an unconscious process takes place between family members that keeps them together.

 

invisible loyalties   unconscious commitments that grown children make to help their families of origin, especially their parents.

 

multigenerational transmission process   the passing on from generation to generation in families of coping strategies and patterns of coping with stress. In poorly differentiated persons, problems may result, including schizophrenia.

 

off-schedule events   major life events, such as marriage, death, and the birth of children occurring at different times than is the norm.

 

pseudo-individuation/pseudo-self   a pretend self. This concept involves an attempt by young people who lack an identity and basic coping skills to act as if they had both.

 

societal regression   the deterioration or decline of a society struggling against too many toxic forces (e.g., overpopulation and economic decline) countering the tendency to achieve differentiation.

 

tickling of defenses   Nathan Ackerman’s term for provoking family members to open up and say what was on their mind.

 

transference   the projection onto a therapist of feelings, attitudes, or desires.

 

transgenerational family therapy   another term for Bowen family therapy.

 

triangle   the basic building block of any emotional system and the smallest stable relationship system in a family.

 

triangulating   projecting interpersonal dyadic difficulties onto a third person or object (i.e., a scapegoat).

 

undifferentiated   an emotional dependency on one’s family members, even if living away from them.

 

undifferentiated family ego mass   according to Bowen, an emotional “stuck togetherness,” or fusion, within a family.

 

 

Classroom Discussion

 

  1. Psychodynamic approaches have been criticized for having a strong historical focus, the concern being families may focus on their history rather than present issues and problems. What are the advantages and disadvantages of only focusing on an historical approach?  How would Murray Bowen or Nathan Ackerman respond to this criticism?

 

  1. Objectivity and neutrality are important therapist characteristics in these two approaches. What are some potential areas for therapists to be aware of and what are some ways to insure higher levels of objectivity and neutrality?

 

  1. You are working with a client family and begin to to assist them in developing a three generation family genogram. The claim for reimbursement that you file for this family is rejected by the managed care organization, which is refusing to pay for genograms.  As a basis for filing an appeal of your claim, make a strong case for the value of genograms in therapeutic work.

 

 

Multiple Choice Questions

 

  1. Psychodynamic and Bowen Family Therapy have many similarities, including:
  2. both are based on psychoanalysis
  3. both are focused on the here and now
  4. theory and therapist cannot be separated
  5. all of the above

 

  1. Provoking family members to open up and say what is on their mind is a technique known as”
  2. focusing on strengths
  3. complementarity
  4. family projection process
  5. tickling of defenses

 

  1. Splitting is a way of evaluating relationships that result in viewing object representations as:
  2. all good or all bad
  3. predictable or unpredictiable
  4. internalized or externalized
  5. interlocking pathologies

 

  1. A psychodynamic family therapy treatment technique used to understand dominant feelings within a family and identify which emotions are being directed toward what people is called:
  2. dream and daydream analysis
  3. confrontation
  4. transference
  5. complementarity

 

  1. Psychodynamic family therapy is primarily _____ in nature.
  2. short term
  3. action oriented
  4. linear
  5. systemic

 

  1. The result of successful separation from your family of origin and distinguishing your rational and emotional selves is:
  2. differentiation
  3. emotional reactivity
  4. emotional cut off
  5. triangulation

 

  1. A genogram is a visual representation of a person’s family tree, going back at least three generations. It is useful in all the following ways except:
  2. tracks relationship changes
  3. shifts family members from clear cognitions to emotional reactivity
  4. identifies repetitve patterns
  5. demonstrates the impact of change and life cycle transitions

 

  1. A key therapist role shared by psychoanalytic and Bowen family therapy is:
  2. good enough mother
  3. coach
  4. catalyst
  5. teacher

 

 

  1. _____ is a frequent way of dealing with anxiety in which tension between two persons is projected onto another object.
  2. family projection process
  3. multigenerational transmission process
  4. emotional cut off
  5. triangulation

 

  1. In Bowen Family Therapy, the term for patterns and strategies of coping withh stress that are passed down from generation to generation is called:
  2. transference
  3. family projection process
  4. multigenerational transmission process
  5. triangulation

 

 

True/False Questions

 

  1. Differentiation is the opposite of fusion.

 

True ___    False ___

 

  1. The basic building block of any emotional system is the ‘good enough mother.’

 

True ___    False ___

 

  1. Bowen Family Therapy is systemic in nature.

 

True ___    False ___

 

  1. A criticism of Psychodynamic family therapy and Bowen Family Therapy is the long term commitment of time and money required for successful treatment outcomes.

 

True ___    False ___

 

  1. Psychodynamic family therapy may not be appropriate for families that are abstract in handling situations.

 

True ___    False ___

 

 

 

 

 

 

 

 

Chapter 10

Experiential Family Therapy

 

Chapter Overview

 

  • Emerged out of the humanistic-existential psychology movement of the 1960s
  • Most popular in the early days of family therapy
  • Emphasis is on immediate, here and now, intrapsychic experience
  • Emphasis on affect (i.e., emotions) and awareness and expression of feelings

Major Theorists

 

  • Virginia Satir
  • social worker and teacher
  • one of the original members of the Mental Research Institute in Palo Alto, CA
  • known for a nurturing, warm, and genuine style
  • published Conjoint Family Therapy in 1964
  • strong and charismatic leader in the field
  • originator of family communications theory
  • utilized group family therapy
  • Satir’s model of family therapy is now called “communication/validation family therapy”
  • Carl Whitaker
  • psychiatrist
  • pioneering work with schizophrenics
  • utilized co-therapists to increase effectiveness
  • coauthored The Family Crucible with Augustus Napier
  • difficult to separate the therapist from the therapy
  • intuitive, spontaneous, and unstructured
  • major contribution was working with families in an uninhibited and emotional way
  • challenged people to gain control of their lives, examine their own view of reality, and live more fully in the present
  • Whitaker’s approach is called “symbolic-experiential family therapy”
  • “experience, not education . . . changes families”

Premises of the theory

 

  • Individuals are not aware of or suppress their emotions
  • Results in a climate of ‘emotional deadness’ where people avoid each other
  • Emphasis on expression of feelings and increased sensitivity
  • Focus is on the present
  • Concentration on increasing self-awareness by actively experiencing the here and now
  • Attachment theory is a major component of the experiential approach

 Treatment Techniques

 

  • The effectiveness of this approach depends on the personhood of the therapist
  • Two groups of experiential family therapists
  • few techniques and a strong emphasis on use of self, spontaneity, and creativity (e.g., Whitaker)
  • use of highly structured activities congruent with the personality of the therapist (e.g., Satir and the majority of experiential therapists)

 

  • Therapists who use few techniques: Carl Whitaker
  • seven active interventions
  1. redefine symptoms as efforts for growth
    • helps families see previously unproductive behaviors as meaningful
  2. model fantasy alternatives to real-life stress
    • change may be fostered by going outside the realm of the expected or conventional
  3. separate interpersonal stress and intra personal stress
    • important to distinguish between them because there are often different ways of resolving them
  4. add practical bits of intervention
    • concrete and practical information may assist in making needed changes
  5. augment the despair of a family member
  • enlarging or magnifying a family member’s feelings to increase understanding by other family members
  1. promote affective confrontation
  • directing family members to examine their feelings before exploring their behaviors
  1. treat children like children and not like peers
  • play with children and treat them in an age appropriate manner
  • Therapists who use structured techniques: Virginia Satir
    • techniques are used to increase family members’ awareness and alter their relationships
    • modeling of effective communication using “I” messages
      • replaces unclear and nonspecific messages with clear and direct personal positions
      • promotes leveling or congruent communication
      • Four communication roles that do not contribute to congruency
  1. blamer is one who attempts to place the focus on others and not take responsibility for what is happening
  2. placater is one who avoids conflict at the cost of his or her integrity
  3. distracter is one who says and makes irrelevant statements that direct attention away from the issues being discussed
  4. computer (or rational analyzer) is one who interacts only on cognitive or intellectual level and acts in a super-reasonable way
    • sculpting
  • family members are placed into positions during the therapy session symbolizing the actual relationships as seen by one or more members
    • sculpting consists of 4 steps
  1. setting the scene
  • therapist helps the sculptor identify a scene to explore
    1. choosing role players
  • individuals are chosen to portray family members
  1. creating a sculpture
  • sculptor places each person in a specific metaphorical position spatially
  1. processing the sculpture
  • sculptor and other participants derole and debrief about experiences and insights gained from the exercise
  • choreography
    • family members are asked to symbolically enact a pattern or relational sequence similar to a “silent movie”
    • reenact 2 to 3 times to increase depth of experience
    • discuss what occurred and what family members would like to change
  • humor
    • can be a risky intervention
    • if successful, humor will reduce tension and promote insight
    • if unsuccessful, humor may alienate some or all family members
    • humor can be used to point out the absurdity of rigid positions or to relabel a situation to make it seem less serious

 

  • touch
    • putting one’s arms around another, patting a person on the shoulder, shaking hands
    • respect personal boundaries of clients
    • represents care and concern but can be overdone or used inappropriately
  • props
    • materials used to represent behaviors or to illustrate the impact of actions
    • may be metaphorical or literal
    • ropes, blindfolds
  • family reconstruction
    • helps families discover dysfunctional patterns in their lives stemming from their families of origin
    • reveals sources of old learning
    • develops a more realistic picture of who their parents are as persons
    • paves the way for family members to discover their own personhood
    • begins with a “star” or “explorer” who maps out his or her family of origin in visual ways
    • a “guide” (usually the therapist) helps develop a chronology of significant family events
    • Three entry points or tools for a family reconstruction
      1. family map – a visual representation of the structure of three generations of the star’s family
      2. family life fact chronology – a listing of all the demographics and significant events
      3. wheel or circle of influence – a visual representation of those who have been important to the star and who have had an impact, positively or negatively on him or her
    • star completes the exercise by working with a group of at least 10 people and enacting important family scenes
  • Other experiential techniques
  • play therapy
  • interventions that use play media as the basis for communicating and working with children
  • in child-centered play therapy, the therapist accepts the child with unconditional positive regard and allows the child complete freedom of expression
  • in experiential family therapy, play therapy is usually done within the context of a family session
  • filial therapy
  • an approach in which trained play therapists train parents to be therapeutic agents with their own children
  • techniques include didactic instruction, demonstration play sessions, at-home laboratory play sessions, and supervision
  • goal is to positively impact the parent-child relationship
  • strong research support
  • family drawings
  • joint family scribble
    • each member makes a brief scribble, followed by the whole family incorporating their scribbles into a unified picture
    • promotes awareness of what it is to work both individually and together
  • conjoint family drawing
    • each family member draws a picture “as you see yourself as a family”
    • each family member shares his or her drawing and perceptions that emerge are discussed
  • symbolic drawing of family life space
    • therapist draws a large circle and instructs family members to include within the circle everything that represents the family and to place outside the circle everything those people and institutions that are not part of the family
    • family is instructed to symbolically arrange themselves, through drawing, according to how they relate to each other
    • family is asked to discuss what was drawn and why, as well as to share each members perspective on family dynamics and interactions

 

  • puppet interviews
    • one of the family members is asked to make up a story using puppets
    • acting out stories with puppets can help children feel safe enough to talk about what is happening in real life
    • a variety of puppets is desirable
    • works well with young children, shy children, or selectively mute children
    • in actual practice, this technique is limited
  • Role of the therapist
  • therapist is an active participant
  • co-therapists increase effectiveness by allowing greater utilization of intuition
  • in Whitaker’s model, the therapist at times engages in spontaneous and absurd activities designed to raise emotion, anxiety, and insight and to break down rational defenses
  • in Satir’s model, the therapist is a facilitator and resource person who helps families understand themselves and others better and promotes clear communication
  • more structured experiential family therapists use props or other objects
  • in general, experiential family therapists
    • establish a warm, accepting, caring, respectful, hopeful environment with an orientation toward change and improvement
    • verbalize presuppositions of hope the family has
    • help family members clarify goals and to use their natural abilities
    • promote growth through stimulating experiences that provide opportunities for existential encounter
    • behave as real, authentic people
    • do not encourage projection or act as blank screens for families
    • not only must have a commitment to the approach but must also be active risk-takers to be effective
  • Process and outcome
  • family members should become more aware of their own needs and feelings and share these impressions with others
  • more capable of autonomy and intimacy
  • treatment is designed to promote individual growth without an overriding concern for the needs of the whole family
  • some experiential family therapists insist on the whole family, preferably three generations, attending sessions
  • according to Whitaker, therapy consists of three stages
  • engagement is when the therapists become personally involved with their families through the sharing of feelings, fantasies, and personal stories
  • involvement is when therapists concentrate on helping the families try new ways of relating through the use of playfulness, humor, and confrontation
  • disentanglement occurs after families have made constructive changes and rules and roles have been modified
  • according to Satir, therapy consists of three stages
  • making contact (e.g., shaking hands, attending) to raise self-worth
  • chaos and disorder is when people are engaged in tasks, taking risks, sharing hurt and pain
  • integration and closure occurs as issues in stage two are worked on and family members are assisted to understand themselves and issues more thoroughly
  • the family is terminated when
  • transactions can be completed
  • family members can see themselves as others do
  • there is clear communication
  • family members can share openly and honestly and take responsibility for outcomes
  • primary goal of therapy is growth, sensitivity, the sharing of feelings, and congruence between inner experiences and outward behaviors
  • family must win the ‘battle for initiative,’ becoming actively involved and responsible for making changes
  • therapist must win the ‘battle for structure’ by setting up the conditions under which the therapy will proceed
  • Unique aspects of experiential family therapy
  • training programs set up for communication/validation family therapy (Avanta Network) and filial therapy (National Institute of Relationship Enhancement)
  • this approach is difficult to research but there is some evidence of the efficacy of Satir’s approach and for filial therapy
  • focus on immediate experiences
  • treatment tends to be of short duration and more direct than historical based approaches
  • emphasizes people as well as structures within the change process
  • Comparison with other theories
  • approach depends on sensitive and charismatic therapists
  • families are encouraged to participate physically in activities
  • focus on the present rather than on the past may keep therapists form dealing with historical patterns that need changing
  • individual growth and intrapersonal change is emphasized rather than family growth and interpersonal change
  • emphasis on the here and now without offering assistance about preparing themselves for the future

 

 

Key Terms

 

absurdity   statements that are half-truths and even silly if followed to a conclusion. Whitaker and symbolic-experiential family therapists often work with families by using absurdities.

 

affect   feelings or emotions.

 

Avanta Network   an association that carries on the interdisciplinary work of training therapists in Satir’s methods.

 

battle for initiative   the struggle to get a family to become motivated to make needed changes.

 

battle for structure   the struggle to establish the parameters under which family therapy is conducted.

 

blamer   according to Satir, a person who attempts to place blame on others and not take responsibility for what is happening.

 

choreography   a process in which family members are asked to symbolically enact a pattern or a sequence in their relationship to one another. Choreography is similar to mime or a silent movie.

 

communication stance   an experiential family therapy procedure of Satir’s in which family members are asked to exaggerate the physical positions of their perspective roles in order to help them “level.” See also leveling.

 

communication/validation family therapy   a term often used to describe Virginia Satir’s model of working with families.

 

communications theory   an approach to working with families that focuses on clarifying verbal and nonverbal transactions among family members. Much communication theory work is incorporated in experiential and strategic family therapy.

 

computer or rational analyzer   according to Satir, a person who interacts only on a cognitive or intellectual level.

 

distractor   according to Satir, a person who relates by saying and doing irrelevant things.

 

engagement   the process where experiential therapists become personally involved with their families through the sharing of feelings, fantasies, and personal stories.

 

family life fact chronology   a tool employed in family reconstruction in which the “star” creates a listing of all significant events in his or her life and that of the extended family having an impact on the people in the family.

family map   a visual representation of the structure of three generations of the “star’s” family, with adjectives to describe each family member’s personality.

 

family reconstruction   a therapeutic innovation developed by Satir to help family members discover dysfunctional patterns in their lives stemming from their families of origin.

 

filial therapy   a hybrid form of child-centered play therapy in which parents (or other primary caregivers) engage in play therapy with their own child in order to address the child’s problem in the context of the parent/child relationship.

 

group family therapy   seeing a number of unrelated families at one time in a joint family session

 

guide   a family therapist who helps the star or explorer, during family reconstruction, chart a chronological account of family events that include significant events in the paternal and maternal families, and the family of origin.

 

humor   an initiative and therapuetic procedure family therapists may use with families by pointing out the absurdity of their rigid positions or relabeling a situation to make it seem less serious.

 

“I” statements   statements that express feelings in a personal and responsible way that encourages others to express their opinions.

 

leveling   “congruent communication” in which straight, genuine, and real expressions of one’s feelings and wishes are made in an appropriate context.

 

placater   according to Satir, a person who avoids conflict at the cost of his or her integrity.

 

play therapy   a general term for a variety of therapeutic interventions that use play media such as toys as the basis for communicating and working with children.

 

props    materials such as ropes and blindfolds used to represent behaviors or to illustrate the impact of actions.

 

sculpting   an experiential family therapy technique in which family members are molded during the session into positions symbolizing their actual relationships to each other as seen by one or more members of the family.

 

self-worth  Satir’s term that corresponds closely with self-esteem. Satir compared one’s feelings of self-worth to a pot. The fuller the pot is the more persons feels alive and have faith in themselves.

 

star or explorer   a central character in family reconstruction who maps his or her family of origin in visually representative ways.

 

symbolic experiential therapy   the name of the approach (sometimes also known as experiental symbolic therapy) given to Carl Whitaker’s theory of working with families.

 

symbolic drawing of family life space   a projective technique in which the therapist draws a large circle and instructs family members to include within the circle everything that represents the family and to place outside of the circle those people and institutions not a part of the family. After this series of drawings, the family is asked to symbolically arrange themselves, through drawing, within a large circle, according to how they relate to one another.

 

wheel or circle of influence   that circle of individuals who have been important to the star or explorer through family reconstruction.

 

 

Classroom Dscussion

 

  1. It is said that in Experiential Family Therapy, “the effectiveness of the approach depends on the personhood of the therapist.” What are the personality characteristics of a good experiential family therapist?  Would you be a good fit for this approach?  Discuss why or why not and give specific characteristics and rationale.

 

  1. Discuss Carl Whitaker’s statement “experience, not education . . . changes families.”

 

  1. What evidence is there for the effectiveness of this approach? How would you determine when termination is indicated?  How would you measure success?  What types of clients and/or client problems do you think would be suitable for experiential family therapy?  What types of clients and/or client problems do you think would not be suitable?

 

 

Multiple Choice Questions

 

  1. The major emphasis of experiential family therapy is:
  2. behavior
  3. interpersonal relations
  4. affect and expression of feelings
  5. irrational beliefs

 

  1. Experiential family therapy is interested in exploirng:
  2. the past
  3. the present
  4. the past and the present
  5. the future

 

  1. The following theorist belongs to the group of experiential family therapists who practice with few techniques and a strong emphasis on self, spontaneity, and creativity:
  2. Virginia Satir
  3. Carl Whitaker
  4. Peggy Papp
  5. Fred and Bunny Duhl

 

  1. In Satir’s communication roles, the _____ avoids conflict at the cost of his or her integrity.
  2. blamer
  3. placater
  4. distracter
  5. computer

 

  1. A technique in experiential family therapy in which family members are physically placed into positions symbolizing actual relationships as seen by one or more members is called:
  2. sculpting
  3. choreography
  4. use of props
  5. family reconstruction

 

  1. If successful, using _____ will reduce tension and promote insight. If unsuccessful, it may alienate some or all family members.
  2. touch
  3. props
  4. choreography
  5. humor

 

  1. A tool used in family reconstruction is:
  2. conjoint family drawing
  3. sculpting
  4. wheel or circle of influence
  5. all of the above

 

  1. The use of _____ is thought to increase the effectiveness of treatment by allowing greater utilization of intuition.
  2. humor
  3. co-therapists
  4. touch
  5. education

 

  1. Although their methods were different, Satir and Whitaker agreed that the primary goal of experiential family therapy is:
  2. unlocking the past
  3. educating the family
  4. growth, sensitivity, and sharing of feelings
  5. family growth and interpersonal change

 

  1. _____ is a general term for a variety of therapeutic interventions that use play media as the basis for communicating and working with children.
  2. filial therapy
  3. experiential therapy
  4. child therapy
  5. play therapy

 

 

True/False Questions

 

  1. In Experiential Family Therapy, the therapist is an active participant.

 

True ___    False ___

 

  1. Treatment is designed to promote family growth.

 

True ___    False ___

 

  1. Filial therapy is a hybrid of child-centered play therapy in which therapists work with children to increase their awareness of who has been important to them in their life.

 

True ___    False ___

 

  1. The role of the ‘distracter” is to place the focus on others and not take responsibility for what is happening.

 

True ___    False ___

 

  1. There is strong research evidence for the efficacy of experiential family therapy.

 

True ___    False ___

 

 

 

 

 

 

 

Chapter 11

Behavioral and Cognitive-Behavioral Family Therapies

 

Chapter Overview

 

  • One of the oldest approaches in the helping professions
  • Began with a primary focus on behavior but has expanded to include cognitions
  • Behavioral family therapy began with parent-child problems and is based on social learning theory
  • Currently embraces a more interactional style of explaining and treating family behavior problems
  • Functional family therapy is a systemic type of behavioral family therapy
  • Cognitive-behavioral family therapy began in the 1970s and acknowledged the important role of cognitive factors (e.g., thoughts, beliefs) in causing and/or maintaining maladaptive behaviors

Major Theorists

 

  • F. Skinner
  • first to use the term behavior therapy
  • originated the concept of ‘operant conditioning’ (i.e., people learn through rewards and punishments to respond behaviorally in certain ways)
  • Gerald Patterson
  • primary theorist to apply behavior theory to family problems in the 1960s
  • primary rewards (e.g., candy, point systems, time-out, and contingent attention) used with parent-child problems
  • developed family observational codes to assess dysfunctional behavior
  • authored programmed workbooks for parents to help parents, children,  and families modify behaviors
  • played a critical role in influencing other behaviorists to work from a systemic perspective with families
  • Neil Jacobson
  • strong research foundation, especially blending academic and clinical outcome research
  • research in 1995 revealed that 20% of male batterers have lower heart rates during times of physical assault
  • developed the concept of ‘acceptance’ or loving your partner as a complete person and not focusing on differences, as a strategy to promote change
  • prolific writer and workshop presenter

 

Premises of the theory

 

  • All behavior is learned and people act according to how they have been previously reinforced
  • Behavior is maintained by its consequences and will continue unless more rewarding consequences result from new behaviors
  • Maladaptive behaviors, not underlying causes, should be the targets of change
  • Primary concern is with changing present behavior, not dealing with historical developments
  • Assessment is ongoing throughout treatment
  • It is not necessary to treat the entire family
  • Behaviorists concentrate on teaching functional and appropriate new skills
  • Behavior therapy is not considered completely systemic but does have an emphasis on family rules and patterned communication processes
  • Social exchange theory (the rewards and costs of relationships) is viewed by some as the basis for a behavioral economy
  • Cognitive-behavioral theory holds that the relationship-related cognitions individuals hold, shape couple and family relationships
  • Health-promoting, relationship-related cognitions promote growth
  • Negative relationship-related cognitions lead to distress and conflict
  • Resistant in family members may be based on irrational beliefs

Types of behavioral and cognitive-behavioral family therapies

 

  • Therapies
  • more forms of treatment than any other approach, with the exception of strategic family therapy
  • Behavior Parent Training
  • also referred to as parent-skills training
  • goal is to change parents’ responses to a child or children, both through thoughts and actions
  • linear in nature
  • initial task is to identify and define a specific problem behavior, and its antecedents and consequences
  • parents are trained in social learning theory
  • didactic instruction and written materials utilized to change behaviors and thoughts
  • techniques include role playing, modeling, behavioral rehearsal, and prompting
  • problem behavior is charted throughout treatment
  • therapist rewards successful efforts through encouragement and praise
  • psychoeducational approaches are particularly effective for at-risk parenting behaviors
  • parents are trained in nonviolent resistance where the emphasis is on commitment and acceptance rather than control
  • Functional Family Therapy
  • all behavior is adaptive and serves a function
  • behaviors helps families achieve one of three interpersonal states
  1. contact/closeness (merging)
  2. distance/independence (separating)
  3. combination of 1 and 2 (midpointing)
  • therapy is a three stage process
  1. assessment
  • focuses on the function of the behavioral sequence
  1. change
  • clarifying relationship dynamics
  • interrelating thoughts, feelings, and behaviors
  • interpreting functions of behaviors
  • relabeling behavior to reduce blame
  • discussing how change impacts the entire family
  • shifting treatment from the individual to the whole family
  1. maintenance
  • educating the family
  • skills training for dealing with future difficulties, specifically communication, team building, and behavioral management (e.g., contracting)
  • Behavioral treatment of sexual dysfunctions
  • Masters and Johnson pioneered cognitive-behavioral approaches to working with couples in the treatment of sexual dysfunction in the late 1960s
  • Four phases of sexual responsiveness
  1. excitement
  2. plateau
  3. orgasm
  4. resolution
  • learning and behavioral techniques important tools in treating sexual dysfunctions
  • squeeze technique for treating premature ejaculation
  • teasing technique for treating performance anxiety
  • primary treatment is the conjoint therapy using a dual-sex therapy team
  • extensive sexual histories are taken
  • approach is systemic in orientation
  • Helen Singer Kaplan combined behavioral treatments with psychoanalytic techniques
  • couple sexual dysfunctions can stem from intrapsychic conflict, interpersonal couple conflict, and anxiety
  • Joseph LoPiccolo and associates report success with behavioral sex therapy techniques including
  • reduction of performance anxiety
  • sex education including the use of sexual techniques
  • skill training in communications
  • attitude change methodologies
  • Cognitive-Behavioral Family Therapy
  • similar to cognitive-behavioral therapy but broader and more extensive
  • cognitive treatment focus
  • modifying personal or collective core beliefs (i.e., schema)
  • teaching families to think for themselves and to think differently when it is helpful
  • behavioral treatment focus
  • expressive and listening skills used in communication
  • problem solving skills
  • negotiation and behavior change skills
  • Treatment techniques
  • positive reinforcement
  • extinction
  • shaping
  • desensitization
  • contingency contracts
  • cognitive/behavior modifications
  • General behavioral and cognitive-behavioral approaches
  • education
    • attending lectures, reading books together, viewing videos as a group, having group discussion based on learning
  • communication and problem-solving strategies
    • instruction, modeling, positive reinforcement
  • operant conditioning
  • mostly used in parent-child issues
  • teaches parents to use time-out and shaping procedures
  • contracting
  • used with families expressing severe levels of hostility
  • contracts build in rewards for behaving in a certain manner
  • Specific behavioral and cognitive-behavioral techniques
  • classical conditioning
  • a neutral stimulus is paired up with another event to elicit certain emotions through association
  • a person is associated with a gratifying behavior, such as a kind word or pat on the back
  • coaching
  • therapist helps families make appropriate responses by giving them verbal instructions and a chance to practice
  • contingency contracting
  • a written schedule or contract describing terms for trading or exchanging behaviors and reinforcers between two or more individuals
  • extinction
  • process of withdrawing previous reinforcers to return behavior to its original level
  • replacement behavior is positively reinforced
  • positive reinforcement
  • a material or social action that increases desired behaviors
  • for a reinforcer to be positive, the person must be willing to work for it
  • quid pro quo
  • something for something
  • often the basis for behavioral marital contracts
  • reciprocity
  • the likelihood that two people will reinforce each other at approximately equitable rates over time
  • marriage is often viewed as based on this principle
  • shaping
  • the process of learning in small, gradual steps
  • also referred to as ‘successive approximation’
  • systematic desensitization
  • dysfunctional anxiety is reduced or eliminated through pairing it with incompatible behavior, such as muscular or mental relaxation
  • gradual procedure
  • time-out
  • removal of persons from an environment in which they have been reinforced for certain actions
  • isolation for a limited amount of time results in the cessation of the targeted action
  • best accompanied by a retraining program where rewards are given if the undesirable behavior does not occur for an agreed-upon time period
  • job card grounding
  • used with adolescents and pre-adolescents
  • an age appropriate type of time-out
  • small household jobs are listed on index cards
  • when problem behavior occurs, the adolescent is given one of the jobs to complete and is grounded until the job is complete
  • grounding
  • used with adolescents where the person is removed from stimuli, thus limiting reinforcement from the environment
  • usually means the adolescent is required to attend school, perform household chores, and stay in his or her room unless eating meals, doing chores, or attending school
  • adolescents are not permitted to use the phone, watch television, use the computer (except for school work), have visitors, etc. until the job is completed or time has been served
  • charting
  • clients are asked to keep an accurate record of the problem behavior in order to establish a baseline (data on problem behavior before interventions are made)
  • from baseline data, interventions can be made to reduce the problem behavior
  • Premack principle
  • family members use high probability behavior (preferred behaviors) to reinforce low probability behavior (non-preferred behaviors)
  • family must first do less pleasant tasks before they are allowed to engage in pleasurable activities
  • disputing irrational thoughts
  • uses the ABC format (event, thought, emotion)
  • through disputing irrational thoughts, the couple or family will develop more rational thoughts and behaviors
  • thought stopping
  • used when a family member unproductively obsesses about an event or person
  • therapist has person engage in ruminating on a certain thought and interrupts the rumination by shouting “stop”
  • instruction is given for the person to interrupt the thought process internally
  • neutral or healthy thoughts replace the nonproductive or unhealthy thoughts
  • self-instructional training
  • focus on people instructing themselves in changing negative self-talk
  • self-statements help recall desirable behaviors or interrupt automatic behaviors

 

  • modeling and role playing
  • have family members act “as if” they were different
  • new behaviors are practiced and modeled
  • therapist gives feedback and correction as appropriate
  • “shame attack”
  • a family member does something he or she has dreaded and learns he or she is no worse off for having engaged in the activity (e.g., asking for something and not getting it)
  • family members can use ‘stress inoculation’ to break down potentially stressful events into manageable units and then to link all the parts together
  • Role of the therapist
  • therapist is the expert, teacher, collaborator, and coach
  • assists the family to identify dysfunctional behaviors and thoughts and works to set up behavior and cognitive-behavioral management programs
  • engages in modeling, giving corrective feedback, and teaching how to assess behavior and cognitive changes
  • Anatomy of Intervention Model (AIM)
  • introduction
  • assessment
  • motivation
  • behavior change
  • termination
  • therapist must be able to exhibit relationship skills such as warmth, humor, nonblaming, and self-disclosure
  • cognitive-behavioral therapists spend more time discussing issues with family members than do behavior therapists
  • therapists must have persistence, patience, knowledge of learning theory, and specificity in working with family members
  • Process and outcome
  • family members learn to identify, modify, change, or increase certain maladaptive behaviors and/or thoughts to increase functioning
  • behavioral family therapy focuses on parenting skills, positive family interactions, improving sexual behaviors
  • cognitive-behavioral family therapy is effective with family stress, adult sexual dysfunctions
  • blending of behavioral and cognitive-behavioral family therapies is common in practice
  • Unique aspects of behavioral and cognitive-behavioral approaches
  • emphases
  • use of learning theory
  • strong research orientation
  • approach has continued to evolve, expand, and incorporate new ideas
  • treatment is short term
  • focus is not on pathology (i.e., medical model)
  • ahistorical approach
  • assessment does not include looking for biological or chemical causes of behavior or cognition
  • Comparison with other theories
  • less systemic than other approaches
  • linear orientation may limit the introduction of a more complete family change process
  • no focus on the affective domain
  • lack of spontaneity and dependence on techniques may result in losing rapport with families
  • by not considering historical data, family patterns and dynamics may be misunderstood
  • family action is stressed over insight which may lead to change without understanding
  • integration of concepts and methods from other approaches may make cognitive-behavioral strategies appropriate as an adjunct to treatment when another approach is used

 

Key Terms

 

acceptance   1. Neil Jacobson’s term for loving your partner as a complete person and not focusing on differences. Such a strategy may promote change in couples. 2. the therapist’s personal and professional comfortableness with a family.

 

act as if   a role-playing strategy where persons act as if they are the persons they want to be ideally.

 

Anatomy of Intervention Model (AIM)   a cognitive-behavioral strategy where the therapist learns to play many roles and be flexible. It involves five phases: (1) introduction, (2) assessment, (3) motivation, (4) behavior change, and (5) termination.

 

baseline   a recording of the occurrence of targeted behaviors before an intervention is made.

 

behavioral therapy   the therapeutic approach that proposes that all behavior is learned and that people act according to how they have been previously reinforced. Behavior is maintained by its consequences and will continue unless more rewarding consequences result from new behaviors.

 

behaviorism   a form of treating individuals where therapists focus on changing observable behaviors through such methods as reinforcement, extinction, and shaping.

 

charting   a procedure that involves asking clients to keep an accurate record of problematic behaviors. The idea is to get family members to establish a baseline from which interventions can be made and to show clients how the changes they are making work.

 

classical conditioning  the oldest form of behaviorism, in which a stimulus that is originally neutral is paired up with another event to elicit certain emotions through association.

 

cognitions   thoughts.

 

cognitive behavior theory   the idea that the cognitions individuals hold, shape how they think, feel, and behave.

 

cognitive behavior couple therapy   an approach to working with couples that takes into account the impact of cognitions (i.e., thoughts) and behaviors on modifying couple interactions.

 

cognitive-behavioral family therapy   an approach to working with families that takes into account the impact of cognitions (i.e., thoughts) and behaviors on modifying family interactions.

 

four phases of sexual responsiveness   excitement, plateau, orgasm, and resolution.

 

functional family therapy   a type of behavioral family therapy that is basically systemic.

 

parent-skills training   a behavioral model in which the therapist serves as a social learning educator whose prime responsibility is to change parents’ responses to a child or children.

 

Premack principle   a behavioral intervention in which family members must first do less pleasant tasks before they are allowed to engage in pleasurable activities.

 

schema   core beliefs of an individual or couple.

 

shame attack   a process within role playing where someone does something he or she has previously dreaded, for example, asking for an allowance. Individuals who use this technique find that when they do not get what they asked for, they are not worse off for having asked.

 

shaping   the process of learning in small gradual steps; often referred to as successive approximation.

 

social exchange theory   an approach that stresses the rewards and costs of relationships in family life according to a behavioral economy.

 

social learning theory   a theory that stresses the importance of modeling and learning through observation as a primary way of acquiring new behaviors.

 

squeeze technique   an approach used in sexual therapy in which a woman learns to stimulate and stop the ejaculation urge in a man through physically stroking and firmly grasping his penis.

 

stress inoculation   a process in which family members break down potentially stressful events into manageable units that they can think about and handle through problem-solving techniques. Units are then linked so that possible events can be envisioned and handled appropriately.

 

successive approximation   see shaping

 

teasing technique   a sexual therapy approach in which a woman learns how to start and stop sexually stimulating a man.

 

 

Classroom Discussion

 

  1. Behavioral and cognitive-behavioral family therapy do not focus on the affective domain. How does this limit the usefulness of the approach?  How would you work with a client who focuses primarily in the affective domain?

 

  1. What types of client problems might be best suited for these approaches? What client issues would not be appropriate for these approaches?

 

  1. Conduct a role play in which the class attempts to identify the function of a behavioral sequence and then relabels the behavior to reduce blame.

 

 

Multiple Choice Questions

 

  1. _____ was the primary therapist to apply behavior theory to family problems in the 1960s.
  2. B.F. Skinner
  3. Gerald Patterson
  4. Joseph LoPiccolo
  5. Neil Jacobson

 

  1. A basic premise of behavioral family therapy is
  2. all behavior is learned
  3. underlying causes should be the target of change
  4. all family members must be treated
  5. the importance of insight in the change process

 

  1. An approach that stresses the rewards and costs of relationships in family life according to a behavioral economy is called:
  2. shaping
  3. social learning theory
  4. social exchange theory
  5. schema

 

 

 

  1. All of the following are behavioral treatment techniques except:
  2. positive reinforcement
  3. tracking
  4. extinction
  5. contingency contracts

 

  1. In _____ people learn through rewards and punishments to respond behaviorally in certain ways.
  2. classical conditioning
  3. shaping
  4. stress inoculation
  5. operant conditioning

 

  1. In _____, a neutral stimulus is paired up with another event to elicit certain emotions through association.
  2. classical conditioning
  3. shaping
  4. stress inoculation
  5. operant conditioning

 

  1. A written schedule describing terms for trading or exchanging behaviors and reinforcers between two or more individuals is known as:
  2. social exchange theory
  3. quid pro quo
  4. teasing technique
  5. contingency contract

 

  1. _____ spend more time discussing issues with family members than do _____.
  2. behavior parent training therapists; functional family therapists
  3. cognitive-behavioral therapists; behavioral therapists
  4. behavioral therapists; cognitive-behavioral therapists
  5. sex therapists; play therapists

 

  1. _____ is an age appropriate type of time out for adolescents and preadolescents.
  2. acceptance
  3. shame attack
  4. squeeze technique
  5. job card grounding

 

  1. Behavioral and cognitive-behavioral family therapy are focused on
  2. the present
  3. the past
  4. the future
  5. all of the above

 

 

True/False Questions

 

  1. Family observational codes are used by behavioral family therapists to assess dysfunctional behavior.

 

True ___    False ___

 

  1. Neil Jacobson developed the concept of ‘acceptance’ or loving your partner as a complete person and not focusing on differences.

 

True ___    False ___

 

  1. The ‘squeeze technique’ is used for treating performance anxiety.

 

True ___    False ___

 

  1. In the assessment stage of functional family therapy, the focus is on clarifying the relationship dynamics.

 

True ___    False ___

 

  1. In behavioral and cognitive-behavioral family therapy, family action is stressed over insight.

 

True ___    False ___

 

 

 

 

Chapter 12

Structural Family Therapy

 

Chapter Overview

 

  • Based on the experiences of Salvador Minuchin at the Wiltwyck School
  • Active and often aggressive family members resulted in the development of dramatic and active interventions for effectiveness
  • Continues to be a popular family therapy approach
  • Symptoms are best understood in the context of family interaction patterns
  • Changes in organization or structure must take place before symptoms can be relieved

 

Major Theorists

 

  • Salvador Minuchin
  • psychiatrist
  • wrote Families of the Slums based on his work at the Wiltwyck School
  • became the Director of the Philadelphia Child Guidance Clinic in 1965
  • developed a training program for paraprofessionals providing services to the poor
  • developed treatment techniques for psychosomatic families, particularly with anorectics
  • wrote Families and Family Therapy, a clearly written and influential book
  • prolific writer and workshop presenter
  • Premises of the theory
  • pragmatic
  • every family has a structure that organizes the ways in which family members interact
  • family structure is revealed only when the family is in action
  • emphasis on the whole family and its subunits
  • ‘coalitions’ are alliances between specific family members against a third
  • ‘stable coalitions’ are fixed and inflexible unions that become a dominant part of the family’s everyday functioning
  • ‘detouring coalitions’ occur when the pair holds a third family member responsible for their difficulties or conflicts with one another, thus decreasing stress on themselves or their relationship
  • the family is the unit of treatment
  • ‘subsystems’ are smaller units of the system as a whole and exist to carry out the tasks of the family
  • spousal subsystem is composed of the marriage partners and works best when there is complementarity of functions
  • parental subsystem is made up of those responsible for the care, protection, and socialization of the children and works best in a cohesive and collaborative manner
  • parental subsystems change as children grow
  • cross-generational alliances contain members of two different generations and may involve collusion to obtain certain objectives or needs, such as love or power
  • sibling subsystem contains members of the same generation
  • ‘boundaries’ are the physical and psychological factors that separate people from one another and organize them
  • ‘clear boundaries’ are rules and habits that enhance clear communication and relationships
  • ‘rigid boundaries’ are inflexible and keep people separated from each other, making it difficult to relate in intimate ways, and may result in emotional detachment from other family members
  • ‘diffuse boundaries’ do not have enough separation among family members and encourage dependence
  • a ‘parentified child’ is one who is given responsibilities and privileges that exceed what would be developmentally consistent with his or her age
  • therapists must be careful to not mistake normal family development and ‘growing pains’ for pathological patterns
  • ‘alignments’ are ways that family members join together or oppose one another in carrying out family activities
  • ‘roles’ are prescribed and repetitive behaviors involving a set of reciprocal activities with other family members or significant others; behaviors family members expect from each other and themselves
  • ‘rules’ are implicit or explicit guidelines that determine behaviors of family members and may be adhered to regardless of changes in the family
  • ‘power’ is the ability to get something done and is related to authority and responsibility
  • ‘dysfunctional sets’ are the repetitive family reactions to stress, repeated without modification
  • Treatment techniques
  • two general types of techniques, those used in establishing a therapeutic alliance and those focused on the change process
  • joining
  • therapist makes contact with the family, expressing interest in each member
  • therapist takes a leadership role in initiating the treatment process
  • important to join with powerful as well as angry family members
  • four techniques of joining
    1. ‘tracking’ is when the therapist follows the content of the family, uses open ended questions, is nonjudgmental, and give objective feedback
    2. ‘mimesis’ is when the therapist adjusts the manner or content of his or her communications to become more like the family
    3. ‘confirmation’ of a family member occurs when the therapist uses an affective word to reflect an expressed or unexpressed feeling of a family member; also may involve a nonjudgmental description of the behavior of a family member
    4. ‘accommodation’ is how a therapist joins the family by making personal adjustments in order to achieve a therapeutic alliance
  • Disequilibrium techniques
  • techniques aimed at changing a system by creating a different interactional sequence and producing a different perspective of reality
  • ‘reframing’ is used to change a perception by explaining a situation from a different context; helpful in helping negative situations to be viewed more favorably and to promote movement
  • ‘punctuation’ involves the therapist selectively describing or highlighting a transaction as a means of changing the perception of everyone involved
  • ‘unbalancing’ is a procedure in which the therapist temporarily supports an individual or subsystem against the rest of the family, forcing the rest of the family to respond differently and expand their roles and functions
  • ‘enactment’ brings the action into the therapy room by asking family members to show the therapist how they interact during problematic behavioral sequences; redirects communication among family members instead of between the family and the therapist
  • working with spontaneous interaction focuses attention on a particular behavior, allowing the therapist to point out the dynamics and sequences and to focus on process not content
  • boundary making helps the family define, redefine, or change the boundaries within the family
  • ‘intensity’ involves the use of strong affect, repeated interventions, or prolonged pressure to change maladaptive behaviors
  • ‘restructuring’ is the process of altering existing hierarchical and interactive patterns to increase family functioning and symptom reduction; accomplished through enactment, unbalancing, directives, and boundary making
  • ‘shaping competence’ is when the therapist reinforces family members for doing things right or making their own appropriate decisions
  • ‘diagnosing’ is a proactive method to describe and/or map out the systemic interrelationships of all family members; usually done early in the therapeutic process
  • ‘adding cognitive constructions’ supplements action oriented techniques by using words, such as advice or information, to help families help themselves.
  • ‘pragmatic fictions’ are pronouncements that help families change
  • ‘paradox’ is a technique in which a confusing message is sent to the family designed to frustrate or confuse them and provide them motivation to search for alternatives

 

  • Role of the therapist
  • observer
  • expert
  • active and directive
  • requires high energy and precise timing
  • therapist role changes over the course of therapy
  • first phase – therapist joins the family and takes a leadership position
  • second phase – therapist maps out the underlying family structure
  • final phase – therapist helps transform the family structure
  • assumes responsibility for setting up and directing therapeutic activities and interventions
  • therapist is never a ‘player’ in the family interactions, but works to change the family structure without becoming a part of it
  • Process and outcome
  • process of change is gradual but steady
  • successful treatment results in symptom resolution and structural change
  • action is emphasized over insight
  • ‘homework’ is given for activities outside the sessions to practice new behaviors
  • family members learn to relate to one another in more functional and productive ways
  • dated and outgrown rules are replaced
  • parents are placed in charge of children
  • differentiation among distinct subsystems occurs
  • goal is structural change
  • Unique aspects of structural family therapy
  • a versatile approach applicable in many situations, especially with juvenile delinquents, alcoholics, anorexics, low SES families, minority and cross-cultural populations
  • sensitive to the effect of culture on families
  • strong emphasis on terminology and ease of application
  • structural family therapy helped family therapy become accepted in the medical and psychiatric communities
  • strong emphasis on symptom removal and family reorganization
  • pragmatic focus on problem-solving
  • active therapist involvement in bringing about change
  • Comparison with other theories
  • structural family therapy is a well developed, action-oriented and pragmatic approach
  • as well articulated and illustrated as any other family therapy
  • criticized for being too simple and lacking complexity
  • criticized for being sexist and reinforcing sexual stereotypes
  • focus on the present with no emphasis on past patterns or family history
  • sometimes difficult to distinguish from strategic family therapy
  • focus on process, not content
  • therapist takes a great deal of responsibility for initiating change
  • short time frames for treatment
  • may limit family empowerment because the therapist is active and in control of the process

 

Key Terms

 

adding cognitive constructions   the verbal component of structural family therapy, which consists of advice, information, pragmatic fictions, and paradox.

 

alignments   the ways family members join together or oppose one another in carrying out a family activity.

 

boundaries   the physical and psychological factors that separate people from one another and organize them.

 

clear boundaries   rules and habits that allow and encourage dialogue and thus help family members to enhance their communication and relationships with one another.

 

coalition   an alliance between specific family members against a third member. See also detouring coalition; stable coalition.

 

complementarity   the degree of harmony or reciprocity in the meshing of family roles.

 

complementary relationship   relationships based on family member roles or characteristics that are specifically different from each other (e.g., dominant versus submissive, logical versus emotional). If a member fails to fulfill his or her role, such as be a decision maker or a nurturer, other members of the family are adversely affected.

 

confirmation of a family member   a process that involves using a feeling word to reflect an expressed or unexpressed feeling of that family member or using a nonjudgmental description of the behavior of the individual.

 

cross-generational alliance (coalition)   an inappropriate family alliance that contains members of two different generations within it, for example, a parent and child collusion.

 

detouring coalition   a coalition in which a pair holds a third family member responsible for their difficulties or conflicts with one another.

 

diagnosing   a proactive structural family therapy technique where the systematic interrelationships of all family members is described early in the treatment process.

 

diffuse boundaries   arrangements that do not allow enough separation between family members, resulting in some members becoming fused and dependent on other members.

 

dysfunctional sets   are the family reactions, developed in response to stress, that are repeated without modification whenever there is family conflict. For example, one spouse might verbally attack the other, bringing charges and countercharges, until the fight escalates into physical violence or the couple withdraws from each other.

 

enactments   the actions of families that show problematic behavioral sequences to therapists, for example, having an argument instead of talking about one.

 

homework   tasks clients are given to do outside of therapy session. Marital and family therapies that are noted for giving homework assignments are behavioral, cognitive-behavioral, psychodynamic, systemic, structural,and postmodern approaches.

 

Institute for Family Counseling   an early intervention program at the Philadelphia Child Guidance Center for community paraprofessionals that proved to be highly effective in providing mental health services to the poor.

 

intensity   the structural method of changing maladaptive transactions by having the therapist use strong affect, repeated intervention, or prolonged pressure with a family.

 

joining   the process of “coupling” that occurs between the therapist and the family, leading to the development of the therapeutic system. A therapist meets, greets, and forms a bond with family members during the first session in a rapid but relaxed and authentic way and makes the family comfortable through social exchange with each member.

 

mimesis   a way of joining in which the therapist becomes like the family in the manner or content of their communications—for example, when a therapist jokes with a jovial family.

 

paradox   a form of treatment in which therapists give families permission to do what they were going to do anyway, thereby lowering family resistance to therapy and increasing the likelihood of change.

 

parentified child   a child who is given privileges and responsibilities that exceed what would be considered developmentally consistent with his or her age. Such a child is often forced to give up childhood and act like a parent, even though lacking the knowledge and skills to do so.

 

parental subsystem   the subsystem made up of those responsible for the care, protection, and socialization of children

 

pragmatic fictions   pronouncements that help families and family members change, such as when a therapist tells children that they are acting younger than their years.

 

punctuation   the way a person describes a situation, that is, beginning and ending a sentence, due to a selective perception or emotional involvement in an event.

 

reframing   a process in which a perception is changed by explaining a situation from a different context. Reframing is the art of attributing different meaning to behavior.

 

rigid boundaries   inflexible rules and habits that keep family members separated from each other.

 

roles   prescribed and repetitive behaviors involving a set of reciprocal activities with other family members or significant others; behaviors family members expect from each other and themselves.

 

rules   implicit or explicit guidelines that determine behaviors of family members.

 

shaping competence   the procedure in which structural family therapists help families and family members become more functional by highlighting positive behaviors.

 

sibling subsystem   that unit within the family whose members are of the same generation, for example, brothers and sisters. The concept of sibling position is important in both Adlerian and Bowen family therapy.

 

spousal subsystem   the subsystem composed of marriage partners

 

stable coalition   a fixed and inflexible union (such as that of a mother and son) that becomes a dominant part of a family’s everyday functioning.

 

structural family therapy’s major thesis   a thesis stating that an individual’s symptoms are best understood when examined in the context of family interactional patterns. A change in the family’s organization or structure must take place before symptoms can be relieved.

 

structure   an invisible set of functional demands by which family members relate to each other.

 

subsystems   smaller units of the system as a whole, usually composed of members in a family who because of age or function are logically grouped together, such as parents. They exist to carry out various family tasks.

 

tracking   a way of joining in which the therapist follows the content of the family (i.e., the facts). triangulating  projecting interpersonal dyadic difficulties onto a third person or object (i.e., a scapegoat).

 

unbalancing   therapeutically allying with a subsystem. In this procedure, the therapist supports an individual or subsystem against the rest of the family.

 

 

Classroom Discussion

 

  1. Structural family therapy was developed during Salvador Minuchin’s time at the Wiltwyck School, a residential facility with active and often aggressive residents and family members. Because of these origins, interventions are often active, dramatic, and intense.  Discuss this unique approach to family therapy and, in particular, what is meant by structural family therapists who state “family structure is only revealed when the family is in action.”

 

 

  1. In this approach, the therapist takes a leadership role in initiating the treatment process. It is crucial to join with everyone, especially powerful as well as angry family members.  What is the rationale behind the need to join in this way and what might you say or do to accomplish this?

 

 

  1. In describing the role of the therapist in structural family therapy, the therapist should never be a ‘player’ in the family interaction, but instead works to change the family structure without becoming a part of it. Discuss how this can be done and why it is important to not become a part of the family structure.

 

 

Multiple Choice Questions

 

  1. In order to highlight and modify interactions in the family, structural therapists must use intensity to
  2. interrupt rigid patterns of conflict-avoidance
  3. break families loose from their patterns of equilibrium
  4. extend interactional sequences beyond the point where dysfunctional homeostasis is reinstated
  5. all of the above

 

  1. “Unbalancing” involves
  2. realigning relationships between subsystems
  3. therapeutic neutrality
  4. restorying the family’s narrative
  5. taking sides

 

  1. Boundaries are physical and psychological factors that separate people from one another and help organize them. The healthiest boundaries are:
  2. clear
  3. rigid
  4. diffuse
  5. stable

 

  1. Subsystems may include all the following except:
  2. spousal
  3. sibling
  4. cross-generational
  5. parental

 

  1. _____ are ways that family members join together or oppose one another in carrying out family activities.
  2. enactments
  3. dysfunctional sets
  4. pragmatic fictions
  5. alignments

 

 

 

  1. There are four techniques for ‘joining’ with family members. Which technique is how a therapist joins the family by making personal adjustments in order to achieve a therapeutic alliance?
  2. tracking
  3. mimesis
  4. confirmation
  5. accommodation

 

  1. The technique of changing a perception by explaining a situation from a different context is called:
  2. enactment
  3. pragmatic fictions
  4. reframing
  5. restructuring

 

  1. This approach has a focus on:
  2. the present
  3. the past
  4. the future
  5. all of the above

 

  1. In structural approach to working with families, the focus is on _____, not _____.
  2. content; process
  3. process; content
  4. discussion; action
  5. action; discussion

 

  1. An alliance between specific family members against a third member is called a(n):
  2. rigid boundary
  3. alignment
  4. coalition
  5. dysfunctional set

 

True/False Questions

 

  1. Structural family therapy is said to be an approach that is sensitive to the effect of culture on families.

 

True ___    False ___

 

  1. Structural family therapy is collaborative approach in which the therapist and client family share responsibility for setting up and directing therapeutic activities and interventions.

 

True ___    False ___

 

  1. If successful, structural family therapy results in more functional boundaries and more positive ways of interacting among family members.

 

True ___    False ___

 

  1. The structural family therapy approach has been criticized for being too simple and lacking complexity.

 

True ___    False ___

 

  1. A parentified child is considered a dysfunctional role because, in the structural approach, it is best that parents are placed in charge of children.

 

True ___    False ___

Chapter 13

Strategic Family Therapies

 

Chapter Overview

 

  • Influenced by the work of Milton Erickson
  • Treatment goal is change
  • Strategy for each specific problem
  • Insight and history are not part of treatment
  • Two major variations
  • Mental Research Institute
  • Family Therapy Institute of Washington, DC

 

Strategic Family Therapy

 

  • Goal is to change behavior by manipulating it and not to instill insight
  • Milton Erikson’s approach had three major facets
  • accepting and emphasizing the positive
  • using indirect and ambiguously worded directives
  • encouraging or directing routine behaviors so that resistance is exhibited through change rather than through normal and continuous actions
  • Major theorists
  • Jay Haley
  • masters in communication
  • worked with and influenced by Gregory Bateson, Milton Erickson, and Salvador Minuchin
  • joined Mental Research Institute (MRI) staff
  • adapted Erikson’s individual approach to work with families
  • first editor of Family Process
  • established the Family Therapy Institute of Washington, DC with Cloe Madanes in 1974
  • prolific writer, trainer, supervisor, and workshop presenter
  • influential books include Problem Solving Therapy in 1976 and Leaving Home in 1980
  • Cloe Madanes
  • raised in Argentina
  • read Freud; majored in psychology
  • worked as a research assistant for Paul Watzlawick at the Mental Research Institute
  • worked as a clinician in a large mental hospital in Argentina
  • employed by Salvador Minuchin at the Philadelphia Child Guidance Clinic
  • attracted to strategic family therapy
  • married Jay Haley
  • opened up Therapy Institute of Washington (D.C.) with Haley
  • innovator of strategic practices including the pretend technique
  • used gentler approach to strategic family therapy than Haley
  • created unique and powerful techniques for working with sexual offenders
  • Premises of the theory
  • short term treatment of about 10 sessions with focus on change
  • focus on solutions, often opposite of what has been attempted before
  • ‘family rules’ are the overt and covert rules families use to govern themselves
  • ‘family homeostasis’ is the tendency for families to stay in the same patterns of functioning unless challenged to change
  • ‘quid pro quo’ refers to the responsiveness of family members to treat each other in the way they are treated; something for something
  • ‘redundancy principle’ is the fact that a family interacts within a limited range of repetitive behavioral sequences
  • ‘punctuation’ refers to a belief that people in a transaction believe that what they say is caused by what others say
  • ‘symmetrical relationships and complementary relationships’ highlight the fact that relationships within a family are both symmetrical (among equals) and complementary (among unequals)
  • ‘circular causality’ is the idea that one event does not “cause” another but that events are interconnected and factors behind behavior are multiple
  • Treatment techniques
  • techniques are very innovative
  • not helpful to tell families what they are doing wrong
  • behavior change must precede changes in feelings and perceptions
  • interventions are tailored to fit each family
  • ‘reframing’ is the use of language to bring about a cognitive shift and alter the perception of the situation
  • ‘directives’ are instructions from the family therapist for the family to behave differently
  • nonverbal messages (e.g., silence, voice tone, posture)
  • direct and indirect suggestions (e.g., “go fast” or “you may not want to change too quickly”)
  • assigned behaviors (e.g., when you think you won’t sleep, force yourself to stay up all night)
  • directives increase the influence of the therapist in the change process
  • ‘paradox’ is a controversial and powerful technique and has several variations
  • ‘prescribing the symptom’ is giving the family permission to do something they are already doing in order to decrease resistance
  • ‘restraining’ is when the therapist tells the family they are not capable of changing
  • ‘prescribing’ is instructing the family to enact a problem behavior in front of the therapist
  • ‘redefining’ is attributing positive connotations to problem behaviors
  • ‘ordeals’ help clients to give up symptoms that are more troublesome to maintain than they are worth
  • the ordeal is a constructive or neutral behavior that must be performed before engaging in the undesirable behavior
  • the goal is for the client to give up the symptomatic behavior in order to avoid performing the constructive behavior
  • ‘pretend’ is when family members are asked to pretend to engage in problem behavior, helping them to change through experiencing control of previously involuntary action
  • ‘positioning’ involves the therapist accepting and exaggerating what the family is saying to help the family see the absurdity of what they are doing
  • Role of the therapist
  • active, flexible and creative
  • therapist is responsible for planning strategies to solve problems
  • “symptom focused and behaviorally oriented”
  • first task is to define a presenting problem in such a way that it can be solved
  • problem is defined as one the family has control over and that involves a power struggle
  • essential to make changes within the first three sessions
  • each case is handled uniquely
  • extensive use of homework
  • Process and outcome
  • goal is to resolve, remove, or ameliorate the problem the family agreed to work on
  • families learn how to address other problems in a constructive manner
  • four common procedures for successful outcomes
  • defining a problem clearly and concisely
  • investigating all solutions that have been previously tried
  • defining a clear and concrete change to be achieved
  • formulating and implementing a strategy for change
  • emphasis on process rather than content
  • focus on breaking up ‘vicious cycles’ of interaction and replacing them with ‘virtuous cycle’ that highlight alternative ways of acting

 

  • Unique aspects of strategic family therapy
  • flexible approach that works well with a variety of client families
  • effective in cases of enmeshment, eating disorders, and substance abuse
  • the entire system does not have to be involved in treatment
  • emphasis on innovation and creativity
  • works well in combination with other therapies, including behavioral, and structural approaches
  • Comparison with other theories
  • concentrates on one problem and helps focus family resources quickly and efficiently
  • criticized for being too “cookbookish’ and ‘mechanical’
  • existence of schizophrenia is not acknowledged by Jay Haley
  • strategic family therapy requires considerable training and skills to implement some of its methods
  • short term nature may not adequately address the seriousness or extent of problems
  • lack of collaborative input from client families
  • therapist takes the blame if treatment does not produce the desired results

 

Milan Systemic Family Therapy

 

  • also known as the Milan approach
  • stresses the interconnectedness of family members and second-order change

 

  • Major theorist
  • Mara Selvini Palazzoli
  • native of Italy, trained as a psychoanalyst
  • was frustrated by results of her work with patients who had eating disorders
  • along with other systems-minded psychiatrists founded the Center for the Study of the Family in Milan, where they developed the Milan model
  • continued studying family systems after Milan team split up in 1980
  • described her client-families as engaged in a series of games, which serve to stabilize and benefit family members
  • Premises of the theory
  • therapists take a circular view of problem maintenance and a planned orientation to change
  • a family’s symptoms serve as a “thermometer” of sorts, revealing the relational health of the family
  • focus of therapy is on family communication patterns and conflict between competing hierarchies
  • therapists maintain therapeutic neutrality, which allows them to assess family dynamics without losing objectivity and without assuming the family’s responsibility for generating its own problem solutions
  • Treatment techniques
  • paradox, in which the therapist indirectly challenges the family’s view of its current situation and suggests opportunity for change
  • hypothesizing, in which the therapeutic team formulates hypotheses regarding a family’s symptoms prior to the family’s first session and as therapy continues and the therapeutic team has additional information about the family
  • positive connotation, in which the therapist positively reframes a family’s or family member’s behavior
  • circular questioning, used by the therapist to expand family members’ perceptions
  • invariant/variant prescriptions, used by the therapist to break up power struggles and encourage healthy boundaries by the parent(s)
  • rituals, used by the therapist to create new behaviors and new perceptions within the family
  • Role of the therapist
  • therapists is both expert and “co-creator”
  • takes a nonblaming stance, is neutral
  • gives directives
  • is not trying to overtly change the family, but is in essence challenging families to consider new behaviors and new perceptions
  • Process and outcome
  • 10 or fewer sessions
  • family members are able to see how their behaviors affect one another
  • family members realize their interconnectedness and shared responsibility for problem-solving
  • family members create new, more effective behaviors and perceptions
  • families are equipped to sustain new, improved functioning
  • Unique aspects of systemic therapy
  • Emphases
  • systemic family therapy is flexible and effective with many family types dealing with many types of issues
  • therapists employ a team approach to working with families, which is expensive but effective
  • Peggy Papp is an example of a therapist who has successfully utilized multiple team members in systemic family therapy
  • focuses on one problem over a short period of time as a way of helping families gain momentum in their efforts toward change
  • Comparison with other theories
  • Milan approach more accepted in Europe and used less elsewhere due to its nonintervention roots
  • espouses a controversial view of schizophrenia
  • tailors interventions to the unique therapeutic needs of a family

 

 

Key Terms

 

assigned behaviors   a strategic therapy technique where clients are asked to perform certain actions such as staying up when they begin to feel sleepy.

 

circular causality the idea that one event does not “cause” another, but that events are interconnected and that the factors behind a behavior, such as a kiss or a slap, are multiple.

 

complementary relationship   relationships based on family member roles or characteristics that are specifically different from each other (e.g., dominant versus submissive, logical versus emotional). If a member fails to fulfill his or her role, such as be a decision maker or a nurturer, other members of the family are adversely affected.

 

direct and indirect suggestions   a technique used in strategic family therapy that is a part of a usually purposefully ambiguous but important message to a client family such as “go slow” or “you may not want to change too quickly.”

 

directive   an instruction from a family therapist for a family to behave differently. A directive is to strategic therapy what the interpretation is to psychoanalysis—that is, the basic tool of the approach.

 

family rules   the overt and covert rules families use to govern themselves, such as “you must only speak when spoken to.”

 

games   negative family behaviors that stabilize and benefit families

 

homeostasis   the tendency to resist change and keep things as they are, in a state of equilibrium.

 

homework   tasks clients are given to do outside of therapy session. Marital and family therapies that are noted for giving homework assignments are behavioral, cognitive-behavioral, psychodynamic, systemic, structural,and postmodern approaches.

 

Milan approach  another term for systemic family therapy, stresses interconnectedness of family members while emphasizing the importance of second-order change in families

 

ordeal   a technique in which a therapist assigns a family or family member(s) the task of performing a specific activity (i.e., an ordeal) any time the family or individuals involved display a symptom they are trying to eliminate. The ordeal is a constructive or neutral behavior (e.g., doing exercise), but disagreeable to the person directed to engage in it.

 

paradox   a form of treatment in which therapists give families permission to do what they were going to do anyway, thereby lowering family resistance to therapy and increasing the likelihood of change.

 

positioning   acceptance and exaggeration by the therapist of what family members are saying. If conducted properly, it helps the family see the absurdity in what they are doing.

 

positive connotation   a type of reframing in which each family member’s behavior is labeled as benevolent and motivated by good intentions.

 

prescribing   a strategic family therapy technique in which family members are instructed to enact a troublesome dysfunctional behavior in front of the therapist and to work it out past the point where they usually get stuck.

 

prescribing the symptom   a type of paradox in which family members are asked to continue doing as they have done. This technique makes families either admit they have control over a symptom or give it up.

 

pretend technique   a technique originated by Cloe Madanes in which the therapist asks family members to pretend to enact a troublesome behavior, such as having a fight. Through this procedure, individuals transform an involuntary action into one that is under their control.

 

punctuation   the way a person describes a situation, that is, beginning and ending a sentence, due to a selective perception or emotional involvement in an event.

 

quid pro quo   literally, something for something.

 

redefining   a stratgic family therapy technique of attributing positive connotations to symptomatic or troublesome actions. The idea is that symptoms have meaning for those who display them, whether such meaning is logical or not. Redefining is one way of lowering resistance.

 

redundancy principle   the fact that a family interacts within a limited range of repetitive behavioral sequences.

 

reframing   a process in which a perception is changed by explaining a situation from a different context. Reframing is the art of attributing different meaning to behavior.

 

restraining   a type of paradox where therapists tell a client family that they are incapable of doing anything other than what they are doing. The intent is to get the family to show they can behave differently.

 

rituals   specialized types of directives that are meant to dramatize significant and positive family relationships or aspects of problem situations.

 

strategic therapy   a term coined by Jay Haley to describe the therapeutic work of Milton Erickson in which extreme attention was paid to details of client symptoms and the focus was to change behavior by manipulating it and not instilling insight.

 

symmetrical relationship   a relationship in which each partner tries to gain competence in doing necessary or needed tasks. Members within these units are versatile. For example, either a man or a woman can work outside the home or care for children.

 

therapeutic neutrality, or neutrality   the therapist’s stance that allows him/her to assess family dynamics without losing objectivity or taking responsibility for the family’s problem-solving efforts

 

 

 

 

 

Classroom Discussion

 

  1. Paradoxical interventions are controversial and powerful techniques used by strategic family therapists in the change process. What are these interventions and what makes them so controversial?  Take a position for or against the use of paradox and defend your position.

 

  1. In strategic family therapy, the therapist is responsible for planning strategies to resolve problems. How does this therapist’s role differ from other approaches you have studied?  What are the conditions necessary for therapists to feel comfortable with the level of responsibility called for in this model?  What do you think about assuming this level of responsibility?

 

  1. Explain why it is important to highlight differences among family members and give some examples of how you

might do this as a strategic family therapist.

 

  1. Compare and contrast strategic family therapy and Milan systemic family therapy, paying particular attention to theoretical underpinnings, role of the therapist, techniques, and process and outcome.

 

 

Multiple Choice Questions

 

  1. Strategic family therapy has been strongly influenced by the work of:
  2. Murray Bowen
  3. Milton Erikson
  4. David Espston
  5. Virginia Satir

 

  1. Goals in strategic family therapy include all the following except:
  2. behavior change
  3. symptom removal
  4. breaking up vicious cycles of interaction
  5. instilling insight

 

  1. In strategic family therapy, instructions from the therapist for the family to behave differently are called
  2. ordeals
  3. hypothesizing
  4. invariant prescriptions
  5. directives

 

  1. An example of a paradoxical technique would be:
  2. homework
  3. prescribing the symptom
  4. positive connotation
  5. positioning

 

  1. A strategic family therapy technique with a goal for the client to give up symptomatic behavior in order to avoid performing a constructive behavior is known as:
  2. restraining
  3. prescribing
  4. ordeal
  5. pretending

 

 

 

 

  1. A method of interviewing in which questions are asked to highlight differences among family members is known as:
  2. a therapeutic double bind
  3. circular questioning
  4. positive connotation
  5. a family ritual

 

  1. The reason that strategic and structural family therapy overlap is due to _______ who worked in both strategic and structural family therapy environments.
  2. Paul Watzlawick
  3. Selvini Palazzoli
  4. Cloe Madanes
  5. Jay Haley

 

  1. Strategic family therapy has been found to be successful in treating families and their members who display such dysfunctional behaviors as ______
  2. enmeshment
  3. eating disorders
  4. substance abuse
  5. all of the above

 

  1. The strategic family therapist works as an expert and is overtly active believing that it is essential to make changes in people and families within the first _____ sessions.
  2. two
  3. three
  4. four
  5. five

 

  1. Strategic family therapists believe that families interact within a limited range of repetitive behavioral sequences known as the ________ principle.
  2. neutrality
  3. family dance
  4. redundancy
  5. redefining

 

  1. Directing parents to go out together for various periods of time without telling their children where they are going and when they will return is an example of what technique?
  2. paradox
  3. homework
  4. variant prescription
  5. invariant prescription

 

  1. Therapeutic neutrality means that the therapist does which of the following?
  2. takes an active role in the therapy
  3. joins with the family
  4. encourages family members to generate solutions to their own problems
  5. reframes negative communication

 

 

True/False Questions

 

  1. Strategic family therapy has been criticized for being too ‘cookbookish’ and ‘mechanical.’

 

True ___    False ___

 

 

  1. In strategic family therapy, the first task is to define a presenting problem in such a way that it can be solved.

 

True ___    False ___

 

  1. Strategic family therapy works well in combination with some other therapies, but particularly with experiential and Bowen family therapy.

 

True ___    False ___

 

  1. The ‘brief’ part of strategic family therapy refers to the duration of treatment.

 

True ___    False ___

 

  1. The pretend technique that Cloe Madanes formulated is based on the idea that individuals change through experiencing control of a previously involuntary action.

 

True ___    False ___

 

  1. Use of a therapeutic team within Milan systemic family therapy is cost-efficient and ineffective.

 

True ___    False ___

 

  1. By giving positive connotations to behaviors, therapists simultaneously reduce resistance to treatment by the family and establish rapport.

 

True ___    False ___

 

 

Chapter 14

Solution-Focused Brief Therapy and Narrative Family Therapy

 

Chapter Overview

 

  • Solution-focused and narrative theories are two of the most recent theoretical developed approaches in the field of family therapy
  • Solution-focused family therapy concentrates on finding solutions rather than dealing with problems
  • Narrative family therapy focuses on helping people solve difficulties by depersonalizing them and rewriting their own family stories

 

Solution-Focused Family Therapy

 

  • Major theorists
  • Steve deShazer
  • studied with Milton Erickson
  • began his career at the Mental Research Institute
  • established the Brief Family Therapy Center in the late 1970s
  • an ecosystemic approach that uses a team approach whenever possible
  • team members are called ‘consultants’
  • died in 2005
  • Insoo Kim Berg
  • born into a prosperous Korean family
  • learned through Korean War to value people over things
  • married Steve deShazer
  • served as Executive Director of the Brief Family Therapy Center
  • founder of the Solution-Focused Brief Therapy Association
  • author or co-authored 10 books on solution-focused therapy
  • died in 2007
  • Bill O’Hanlon
  • trained as a family therapist
  • studied with Milton Erickson
  • influenced by Erikson, he shifted attention from problems to solutions
  • approach now called ‘possibility therapy’
  • pragmatic approach
  • Michele Weiner-Davis
  • bachelors degree from Grinnell; social work masters from Kansas
  • marital & family therapist outside Chicago
  • author of Divorce Busting, Keeping Love Alive and other popular books
  • set up Divorce Busting Center in Boulder, Colorado
  • a popular media personality/professional
  • Premises of the theory
  • based on social constructionism (i.e., knowledge is time- and culture-bound)
  • treatment includes social, historic, and cultural contexts of families/persons
  • reality is not objective but a reflection of observation and experience
  • language influences the way people see the world
  • there is no absolute truth; all meaning is constructed
  • dysfunctional families get stuck in repetitive, unproductive attempts to solve their problems
  • solution-focused family therapy breaks up repetitive nonproductive behavior patterns and sets up situations with a more positive view and active participation in doing something different
  • causal factors are not important
  • identifying problems from non-problems is important
  • exceptions to problem behavior are emphasized
  • all families have resources and strengths to resolve complaints
  • treatment is short term
  • history is not emphasized
  • all families want to change
  • only a small amount of change is necessary
  • Treatment techniques
  • treatment is collaborative with clients
  • primary technique is to co-create a problem with a family that they want to solve
  • set up a hypothetical solution by asking the ‘miracle question’ (“If a miracle happened tonight and you woke up tomorrow and the problem was solved, what would you do differently?”)
  • miracle questions require family members to suspend present time frames and enter a different reality
  • ‘exceptions’ are times when family members are temporarily free from their problem because the family goal is actually happening
  • ‘scaling questions’ are used to identify concrete, behavioral levels and to assess for movement toward treatment goals (“On a scale of one to ten, how far do you think you have come in solving your problem?”)
  • scaling questions are also used to challenge family members to think about what is needed to get to the next level
  • emphasis is on ‘second-order (qualitative) change’ or a basic change in organization and structure
  • ‘compliments’ are written messages praising families for their strengths and are always used as lead-ins to giving family tasks or assignments
  • ‘clues’ are interventions that mirror the usual behavior of a family and are intended to alert a family that some behavior is likely to continue
  • ‘skeleton keys’ are procedures that have worked before and that have a universal application that can help families unlock a variety of problems
  • five interventions with universal application
  1. “Between now and the next time we meet, I want you to observe, so that you can tell me next time, what happens in your (life, marriage, family, or relationship) that you want to continue to happen.”
  2. “Do something different.” This encourages families to explore a range of possibilities
  3. “Pay attention to what you do when you overcome the temptation or urge to . . . perform the symptom or some behavior associated with the complaint.” This helps families understand that symptoms are under their control
  4. “A lot of people in your situation would have . . .” This helps families realize there are more options than those they are currently exercising
  5. “Write, read, and burn your thoughts.” This creates an opportunity to write about past times and then read and burn the writings the next day
  • Role of the therapist
  • determine how active a client family will be in the change process
  • visitor – not involved in the problem, not motivated to make changes, not part of the solution; best approach is to respect them, try and establish rapport, and hope they’ll become customers eventually
  • complainant – complain about situations, can describe problems even though they are not invested in solving them; best approach is to assign them activities where they can focus on exceptions, respect them, do not push them, hope they can become customers
  • customers – can not only describe a problem and their involvement in the problem, but are invested in solving it; best approach is to engage the person in solution oriented conversations and co-create assignments to reproduce behaviors that are exceptions to the problem
  • therapist helps clients access resources and strengths
  • therapist uses ‘pre-suppositional questions’ to lead families to believe that a solution will be achieved (e.g., What good thing happened since our last session?” and “How did you make that happen?”)
  • “several keys may fit the lock (or problem) well enough to open the door to change,” this illustrates the belief that “solutions do not need to be as complex as the presenting problem”
  • the treatment team is used to map or sketch out the course of successful intervention that will be a proper solution fit for the family and provide multiple perspectives about the problem
  • therapist assists the family in defining clear, specific goals and to create desired behaviors (i.e., solutions)
  • clients are encouraged to make small changes rapidly
  • clients are encouraged to focus on changes in behavior and perceptions and the mobilization of family strengths and resources
  • ‘gender solution-focused genograms’ can help identify gender role messages that may be negatively influencing their present behaviors
  • Process and outcome
  • focus is on seeking solutions and accessing internal resources and strengths
  • the concept of pathology is not a part of treatment
  • client families are viewed as cooperative and wanting to change
  • families are frequently commended for a member’s behavior
  • change is inevitable
  • future oriented
  • finding exceptions to problem behaviors is important
  • asking of optimistic questions presupposes that change can happen
  • reinforcement of small but specific movement
  • treatment ends when “the agreed upon outcome has been reached”
  • Unique aspects of solution-focused family therapy
  • solution-focused therapies focus on and are directed by the family’s theory (i.e., their story)
  • therapists assist the family in defining their situations clearly, precisely, and with possibilities
  • the past is not emphasized, except when it calls attention to the present
  • the focus is on change rather than on achieving a clinical understanding
  • emphasis is on empowering families and unlocking their resources and strengths
  • emphasis on achievable goals, such as small changes in behavior
  • change is inevitable and clients want to change
  • Comparison with other theories
  • unlike Bowen or psychoanalytic theory, virtually no attention is paid to history
  • like strategic and systemic family therapy, solution-focused family therapy is brief regarding the situation focused on and the time of treatment
  • like behavioral family therapy, treatment ends when a behavioral goal has been reached
  • like systemic family therapy, a team is used to help the family help it self
  • like MRI strategic therapy, solution-focused therapy works to help client families change thoughts and actions to increase life satisfaction, although solution-focused therapists trust the family and use family resources more than MRI strategic therapists
  • solution-focused therapy is an effective adjunct to conventional medical treatment for migraine and holds promise for other headache symptoms

Narrative Family Therapy

 

  • Major theorists
  • Michael White
  • began working as a family therapist in Australia in the 1970s
  • influenced by the work of Gregory Bateson, Edward Bruner, Michael Foucault, and feminist theorists
  • narratives are ‘lived experiences’ that may be overshadowed by problem-saturated stories
  • comparison and evaluation is a source of life problems
  • people’s problems viewed as related to the stories they have about themselves
  • people’s problems are not systemic in nature
  • problem stories are related to oppressive cultural practices
  • one description of reality is no better than any other
  • White died in 2008, had set up Adelaide Narrative Therapy Centre
  • Premises of the theory
    • non-systemic approach
    • consistent with postmodernism and social constructionism
    • there are no universal principles or truths
    • based on narrative reasoning (i.e., stories, sub-stories, meaningfulness, and liveliness) rather than logico-scientific reasoning (i.e., empiricism and logic)
    • emphasis is on empowering client families to develop unique and alternative stories about themselves that will lead to novel options and strategies for living
    • ‘reauthoring’ is a way for families to highlight different stories than those that have been dominant
    • externalization of problems is used where problems become separate entities that the whole family needs to solve as a team
  • Treatment techniques
  • externalization of the problem results in:
    • decrease in unproductive conflict between persons
    • decrease in the sense of failure an unresolved problem has on persons
    • increase of cooperation among family members to problem solve and dialogue with each other
    • opening up of possibilities for action
    • freeing of persons to be more effective and less stress in approaching problems
  • influence of the problem on the person
  • used to increase the person’s awareness and objectivity (e.g., “How has the problem influenced you and your life and your relationships?”)
  • influence of the person on the problem
  • increases awareness of personal response(s) to a problem
  • helps people realize their strengths or potential in facing a situation
  • breaks a fixed perception or behavior pattern and creates possibilities for solving the problem in new ways
  • raising dilemmas
  • helping client families to examine possible aspects of a problem before the need arises
  • predicting setbacks
  • setbacks are almost inevitable
  • setbacks are best dealt with when they are planned for or anticipated
  • using questions
  • questions challenge families to examine the nature of the difficulties they bring to therapy and the resources they have available to handle their problems
  • ‘exception questions’ identify instances when a situation reported to be a problem was not true; most begin with ‘when’ or ‘what’
  • ‘significance questions’ are designed to reveal the meanings, significance, and importance of the exceptions
  • letters
  • writing letters to families after therapy sessions can extend the dialogue and remind families what happened in the session;
  • David Epston uses letters as case notes
  • celebrations and certificates
  • celebrations
  • used to bring closure to therapy
  • tangible affirmations of defeat of a problem
  • marks a new beginning
  • should be festive
  • certificates
  • should be tailored for the family and their situation
  • should be printed and affixed with a logo (e.g., apathy example in book)
  • Role of the therapist
  • collaborator and non-expert
  • utilizes basic relationship skills
  • does not view symptoms as serving any function
  • problems viewed as oppressive to families
  • questioner who works to find unique outcome or exceptions when families experience problems
  • examines the meaning of situations for families
  • therapist assists families to separate themselves from old, problem saturated stories
  • therapist helps families to construct new stories in which they, not their problems, are in control (i.e., reauthoring)
  • therapist searches for ‘unique outcomes’ or times when client families acted free of their problems, even if they were not aware of doing so
  • Process and outcome
  • three phases
  • deconstructing the dominant cultural narrative
  • client family challenged to examine exceptions
  • externalizing the problem
  • asked to change their behaviors and collectively address problem
  • reauthoring the story
  • reconstruct their story so that problems are less dominant and significant
  • narrative family therapy has been applied to couple relationships, substance abuse, adolescent sexual offenders, schizophrenia, post-traumatic stress disorder, AIDS, anorexia/bulimia, and grief
  • Unique aspects of narrative family therapy
  • emphasis on reauthoring of life stories
  • deconstruction of taken-for-granted realities and practices
  • externalize family problems to increase cooperation among members
  • search for exceptions rather than problems
  • plan for setbacks and the raising of dilemmas as a way of anticipating and planning for future problems
  • send letters to client families about their progress
  • celebrations and certificates issued when goals are achieved
  • Comparison with other theories
  • based on postmodern, social constructionist points of view
  • among the most intellectual and cerebral of any family therapy approaches
  • no normative patterns for families to strive for; each family determines their own life story and culture
  • strong emphasis on the use of language
  • little attention paid to family history, which is similar to solution-focused, strategic, systemic, and behavioral therapies
  • originated outside the United States
  • focus on collaborative therapeutic relationships, which is similar to solution-focused family therapy
  • not a systems oriented approach
  • centered on the importance of verbal behavior, the use and influence of language

 

 

Key Terms

 

brief therapy   a term used by deShazer for working with families which is sometimes called “brief family therapy.” It has to do more with the clarity about what needs to be changed rather than time. A central principle of brief therapy is that one evaluates which solutions have so far been attempted and then tries new and different solutions to the family’s problem, often the opposite of what has already been attempted.

 

certificates   printed documents, often affixed with a logo that are given at the end of narrative therapy to bring closure to the process and affirm that a problem has been defeated.

 

clue   an intervention in deShazer’s brief therapy approach that mirrors the usual behavior of a family. It is intended to alert a family to the idea that some of their present behavior will continue.

 

complainant   a solution-focused term to describe a client who complains about and describes a situation or problem.

 

compliment   a written message used in brief family therapy designed to praise a family for its strengths and build a “yes set” within it. A compliment consists of a positive statement with which all members of a family can agree.

 

consultants   the term given to the deShazer team in brief family therapy. Consultants observe a family session behind a one-way mirror and transmit messages to the therapist at a designated break time in the session.

 

customers   a solution-focused term for clients who are not only able to describe a problem and how they are involved in it but who are willing to work to solve it.

deconstruction   a narrative family therapy procedure that uses questions as a therapeutic tool to help clients more closely examine taken-for-granted realities and practices.

 

exceptions   a term used in solution-focused family therapy for “negative” or “positive” space (or time when a family goal may be happening).

 

exceptions questions   queries in narrative or solution-focused therapy directed toward finding instances when a situation reported to be a problem is not true. Most exceptiion questions begin with “what” and challenge the family’s view of the world as well as offer them hope that their lives can be different because some change has already taken place.

 

externalize problems   a method of treatment in narrative therapy devised by White and Epston in which the problem becomes a separate entity outside of the family. Such a process helps families reduce their arguments about who owns the problem, form teams, and enter into dialogue about solving the problem.

 

letters   a procedure in narrative family therapy where an epistle that is mailed to a client by a therapist serves as a medium for continuation of the dialogue between the therapist and family members and as a reminder of what has occurred in therapy session. In some cases, letters are case notes.

 

miracle question   a brief therapy technique in which a therapist poses a question such as “If a miracle happened tonight and you woke up tomorrow and the problem was solved, how would you know?”

 

presuppositional question   a question used in solution-focused therapy, such as “What good thing happened since our last session?”, that supposes a certain type of response.

 

reauthoring   a narrative family therapy approach for highlighting different stories in life than those that have been dominant. Such a process not only changes a family’s focus but opens up new possibilities as well.

 

scaling   a solution-focused technique of asking questions using a scale of 1 (low) to 10 (high) to help clients assess situations.

 

second-order change   a qualitatively different way of doing something; a basic change in function and/or structure.

 

significance questions   queries in narrative and solution-focused therapy that are characterized as unique redescription questions. They search for and reveal the meanings, significance, and importance of the exceptions.

 

skeleton keys   in deShazer’s brief therapy approach, those interventions that have worked before and that have a universal application.

 

social constructionism   a philosophy that states experiences are a function of how one thinks about them and the language one uses within a specific culture. From this perspecitve all knowledge is time- and culture-bound. It challenges the idea that there is objective knowledge and absolute truth. Narrative and solution-focused therapy are based on social constructionism.

 

solutions   desired behaviors in solution-focused therapy.

 

unique outcomes   clients’ storied experiences that do not fit their problem-saturated story.

 

visitors   a solution-focused term to describe clients who are not involved in a problem and are not part of a solution.

 

 

Classroom Discussion

 

  1. Discuss the three types of questions used in Solution-focused therapy. Give an example of each.  According to Solution-focused therapy, discuss how each facilitates client change/improvement.

 

  1. What types of clients and client problems are best suited for Narrative models of treatment? Is this approach effective only with high functioning clients, or can it be used effectively to treat more serious problems (e.g., substance abuse, sexual abuse, or severe mental illness)?

 

  1. Solution-focused family therapists do not consider causal factors important. How is it possible to work with families without a clear understanding of the underlying problem?  How does shifting from a problem orientation to a solution focus facilitate change and improvement?

 

 

Multiple Choice Questions

 

  1. Solution-focused family therapy is based on:
  2. psychoanalysis
  3. humanistic-existential psychology
  4. social constructionism
  5. humanistic-existential psychology

 

  1. In Solution-focused therapy, _____ factors are not important.
  2. causal
  3. social
  4. cultural
  5. all of the above

 

  1. This question, used by Solution focused therapists, is intended to direct family members’ attention to times in the past or present when they did not have the problem.
  2. exception question
  3. miracle question
  4. scaling question
  5. none of the above

 

  1. _____ are Solution-focused family therapy procedures that have worked before and that have a universal application that can help families solve a variety of problems.
  2. clues
  3. skeleton keys
  4. pre-suppositional questions
  5. compliments

 

  1. In Solution-focused therapy, the best approach to use with ‘complainants’ is to:
  2. respect them, try and establish rapport, and hope they will become customers eventually
  3. assign them activities where they can focus on exceptions, respect them, and hope they will become customers eventually
  4. engage them in solution oriented conversations and co-create assignments to reproduce behaviors that are exceptions to the problem
  5. none of the above

 

 

 

 

 

  1. In Narrative family therapy, _____ is a way for families to highlight different stories than those that have been dominant.
  2. deconstruction
  3. externalization
  4. reauthoring
  5. celebration

 

  1. “There are no universal principles or truths” is a theoretical premise most consistent with:
  2. narrative family therapy
  3. solution-focused family therapy
  4. experiential family therapy
  5. none of the above

 

  1. A treatment technique in the narrative family therapy model is _____, which is used to solve problems in that the problem becomes a separate entity that the whole family needs to solve as a team.
  2. externalization
  3. reauthoring
  4. celebration
  5. significance

 

  1. The role of the therapist in Narrative family therapy is:
  2. expert
  3. consultant
  4. collaborator
  5. director

 

  1. Questions designed to reveal the meaning and importance of exceptions are called:
  2. exception questions
  3. unique outcomes
  4. reauthoring questions
  5. significance questions

 

True/False Questions

 

  1. In Solution-focused family therapy, all families are believed to have the resources and strengths to resolve complaints.

 

True ___    False ___

 

  1. Unlike Bowen or psychoanalytic theory, in Solution-focused family therapy virtually no attention is paid to history.

 

True ___    False ___

 

  1. Narrative family therapy is a systemic approach based on social constructionism and postmodernism.

 

True ___    False ___

 

  1. In Narrative family therapy, normative patterns are used as models for families to strive for.

 

True ___    False ___

 

  1. Like most other family therapy approaches, Narrative family therapy is based on logico-scientific reasoning (i.e., empiricism and logic).

 

True ___    False ___

 

Chapter 15

Working with Substance-Related Disorders, Domestic Violence, and Child Abuse

 

Chapter Overview

 

Substance-Related Disorders and Families

 

  • “Disorders related to the taking of a drug of abuse (including alcohol, to the side effects of medication, and to toxin exposure” American Psychiatric Association, 1994, p. 175)
  • Almost 60% of the world’s production of illegal drugs as well as a substantial percentage of legal alcohol products are consumed in the US
  • 1 in 11 Americans suffers from severe addictive problems
  • One third of all American families are affected by alcohol problems
  • Illicit drug use is highest among Native Americans, lowest among Asian Americans
  • Two types of general alcohol use disorders
  1. alcohol abuse – a problem pattern where the drinking interferes with work, school, or home life in addition to problems with the law and society
  2. alcohol dependency – the person is unable to control the drinking even after trying
  • Substance abuse related disorders are considered to be family based
  • Families play a role in the development and maintenance of substance abuse
  • Pseudo-individuation may result in young people in families of addicts lacking basic coping skills and failing to achieve real identities

Manifestation of Substance-Related Disorders

 

  • Couple and family manifestations
  • unhealthy or dysfunctional methods of responding to substance abuse are usually tried first, such as
  • shielding the substance-related abuser from the negative consequences of his or her actions; minimizes the seriousness of the abuser’s actions
  • denial of the existence of the disorder; family fails to acknowledge the problem and may blame problem on external circumstances
  • negative feelings such as fear, anger, shame, or guilt result in relating to the world and each other in a despondent or anxious manner
  • unhealthy roles may be assumed that help the family to survive
  • enabler – a spouse or other family member on whom the abuser is most dependent and who allows the problem to continue and become worse
  • family hero – an adult or oldest child who functions to provide self-worth for the family
  • scapegoat – often a child who attempts to distract the family away from the abuser by acting out and being blamed for the family’s problems
  • lost child – usually a child who suffers from rejection and loneliness and offers a substance abuser family relief
  • family clown – often the youngest member who functions to provide the family with humor, thus reducing tension
  • deterioration of the couple or family itself by behaviors such as drinking or taking drugs together; not common but does occur
  • focus on the substance abuser occurs when the family spends the majority of their time focused on the substance abuser (e.g., begging, pleading, blaming, shaming)
  • misuse of family resources can occur when the rest of the family suffers due to a lack of money and effort to purchase family necessities

 

  • Individual manifestations
  • children may be confused about their self-identity and self-worth, resulting in controlling behavior in relationships to gain security
  • children in alcoholic environments are twice as likely to develop social and emotional problems (e.g., low academic achievement and law violations)
  • lower levels of attachment and bonding to others may make intimate relationships, such as marriage, more difficult
  • focus of energy and time on resolving issues related to the family of origin (e.g., numbness, confusion, guilt, denial, compulsive behavior)
  • inability to form long-lasting and intimate relationships

Engaging Substance-Related Disorder Families in Treatment

 

  • Family based treatments are among the most effective approaches for substance abuse treatment
  • Despite being a preferred method of treatment for families with substance abusing members, few family therapists report treating such families
  • Getting families to agree to come to treatment is a difficult challenge
  • Concerned significant others (CSO) can help engage families in treatment
  • old method was to surprise the substance abuser at a meeting known as “the intervention” in which CSOs would confront the abuser about the problems he or she had caused
  • modern approach is for CSOs to meet with therapists to learn behavioral skills designed to influence the substance abuser, with the goal to get the abuser into treatment
  • an effective approach with high success rates reported (64%)
  • Shift in focus to first forming a therapeutic system, diagnosing potential obstacles to engaging the family including involving the family system and issues involving the therapeutic system
  • Engaging the identified patient (IP)
  • usually an extremely powerful member of the family whose development has been arrested and who is resistant to therapy
  • therapist should make contact with the IP immediately and seek to ‘explore the IP’s goals’
  • Engaging disengaged family members
  • often the father or another family member who is “allegedly unwilling” to enter family therapy
  • direct contact can help convince such a family member that they have much to contribute to the therapeutic process
  • Engaging fearful or suspicious family members
  • reframe the therapeutic process to achieve family agreement on the specific nature of what will be worked on, thereby increasing their feeling of being more in control

 

Approaches for Treating Substance-Related Disorders

 

  • Families after engagement
  • many families have a high degree of resistance to therapy
  • relapse is common (up to 90% having at least one relapse in a four year follow up period)
  • using systems and supports in the community can reduce resistance and decrease relapse
  • community reinforcement approach (CRA) is highly effective and one of the top five treatments for substance abuse
  • physical, emotional, social, and vocational issues influence each other and must be addressed in therapy
  • ‘environmental influences’ or the physical aspects of a family’s life are important to initially address (e.g., stopping the abusive behavior, getting the abuser ‘dry’)
  • ‘multisystemic framework of family therapy’ is an approach based on social ecology or interconnected systems; recognizes that problem behaviors derive from many sources of influence and occur in the context of multiple systems
  • after the substance abusing behavior has stopped, work begins on interactional and activity changes both within and outside the family system

 

  • with adolescent IPs, it is important to clarify the drug consumption
  • experimenting – easier and more straightforward approaches work best
  • dependence and addiction require professional intervention
  • other issues that must be addressed
  • feelings
  • defense mechanisms
  • work by individuals within families
  • taking responsibility for behaviors
  • Structural-Strategic family therapy
    • one of the first approaches to recognize substance abuse as a family systems problem
    • begins with stopping the abusing behavior (e.g., detoxification, support groups)
    • techniques include
  • family mapping
  • searching for family strengths
  • use of praise
  • respecting and working within cultural traditions
  • Bowen family therapy
  • works well for codependency
  • ‘codependency’ describes a dynamic in a family involving an overresponsible family member (usually a spouse) and an underresponsible family member (the substance abuser)
  • Bowen approach works to increase differentiation and create a healthy balance of individuality and togetherness
  • family members learn to distinguish between subjective feelings and objective thoughts
  • family members increase flexibility, adaptability, and independence
  • techniques include
  • genograms
  • “I” position statements
  • reconnection of emotional cutoffs
  • Behavioral family therapy
  • works well, particularly for alcohol abuse
  • written behavioral contracts are effective in making specific behaviors explicit and measurable and providing alternative behaviors
  • written agreements tend to decrease the non-abuser’s anxiety and need to control the alcoholic and his or her drinking
  • Adlerian therapy
  • based on the premise that family members are discouraged
  • goal is to increase the social interest of family members
  • problem is shifted from a disease focused to a socially focused
  • group work can be helpful in raising self-esteem and increasing parenting and social skills
  • Systematic Training for Effective Parenting (STEP) helps parents understand family relations better and improve communication with children
  • Multifamily therapy
  • treating several families at one time
  • cost effective and high success rate
  • family members may experience their own dynamics in other families easier than in the context of their own family
  • women may benefit greatly from this approach and remain in therapy longer than other approaches

 

  • Use of community resources and prevention
  • often essential to supplement other treatment
  • family members gain information, insight, coping skills, and support
  • examples include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Al-Anon
  • prevention approaches
  • keep persons or families from engaging in substance abusing behaviors
  • make other activities with positive outcomes available and central to their lives (e.g., art, athletics, meaningful work, community activities)
  • for teen alcohol abuse
  • give kids accurate information about alcohol use
  • present information through a ‘teen-respected’ source
  • help kids say yes to life, not just no to drugs
  • parent networking
  • set strict rules about drinking with kids
  • continue pressure to ‘take back communities’
  • primary prevention efforts require substantial community support and resources to be effective
  • secondary and tertiary prevention efforts work to prevent relapses, increase understanding of family dynamics, and provide support

 

Domestic Violence and Families

 

  • Domestic violence is defined as “aggression that takes place in intimate relationships, usually between adults” (Kemp, 1998, p. 225)
  • and “an attempt by one to control the thoughts, beliefs, or behaviors of an intimate partner or to punish the partner for resisting one’s control” (Peterman & Dixon, 2003, p. 41)
  • Approximately one-third of all married couples experience physical aggression
  • Referred to as
  • spousal abuse
  • partner abuse
  • marital violence
  • intimate partner violence
  • Includes physical, sexual, psychological, and economic abuse
  • Common forms are grabbing, slapping, pushing, and throwing things at one another
  • The worst form of domestic violence is ‘battering’ – severe physical assault or risk of serious injury
  • Gottman identified two types of male batterers
  1. violent only within the relationship and so afraid of abandonment that he monitors his partner’s independence and is jealous of her every move, especially moves toward independence, such as getting a job
  2. violent with just about everyone, exhibiting belligerent, provocative and angry behavior
  • well documented association between alcohol intoxication and battering (60% to 70% rate of alcohol abuse among men who batter)
  • Assessment of domestic violence
  • assessment is difficult due to legal barriers (e.g., court orders that mandate separation of family members) and psychological barriers (e.g., stigma surrounding domestic violence)
  • violent families tend to go to great lengths to keep the abuse a family secret
  • violent families often minimize the amount of violence and its impact on the family
  • assessing the power imbalance within the family helps individuals transition from violent to nonviolent behaviors and assists in learning the difference of each
  • ‘open assessment’ shifts the focus from blame to how the violence has impacted the entire family and the dynamics associated with emotional expression, family finances, sexuality, and social connections

 

 

Approaches for Treating Domestic Violence

 

  • Two major positions about responsibility and domestic violence influence treatment options
  1. both parties are equally responsible for the violence (conjoint or couples therapy)
  2. the perpetrator is unilaterally responsible for the violence (intimate justice theory and education)
  • Conjoint or couples therapy
  • involves seeing the couple together
  • requires an assessment of safety issues
  • the man’s participation must be voluntary
  • special agreements must be established, that is, material on domestic violence will not be disclosed by the woman or the therapist until the woman is ready
  • an optimal therapeutic stance must be achieved, that is a context of self-protection that recognizes the emotionally disturbing, dehumanizing, and intimidating nature of domestic violence
  • conjoint or couples therapy may work if the following additional criteria are met
  • a history of only minor and infrequent psychological violence or abuse
  • no risk factors for lethality, such as prior use or threat of weapons
  • the man admits and takes responsibility for the abusive behavior and demonstrates an ongoing commitment to contain his explosive feelings without blaming others or acting them out
  • the couple talks about their wishes and the current relational dynamics
  • agreement is reached about new ways to behave and relate
  • Intimate justice
  • incorporates the ethical context of domestic violence in intimate relationships
  • encourages therapists to confront, challenge, explore, and educate clients about abuse of power in emotional systems
  • closely related to solution-focused approaches
  • emphasis on empowerment and disempowerment, internalized beliefs about how partners should be treated, and abuses of power in one’s family of origin
  • effective with couples who voluntarily enter therapy
  • Educational treatment
  • commonly based on intimate justice theory and cognitive behavior theory
  • Duluth model
  • a cognitive-behavioral model
  • people learn violent behaviors because they are reinforced in cultural and societal circles
  • people can unlearn these behaviors and learn new ones using cognitive-behavioral means, such as education
  • long term social and educational programs (i.e., at least a year) are more effective than short term
  • perpetrators must be held accountable for their actions

 

Child Abuse and Neglect in Families

 

  • Child abuse is maltreatment of a child due to acts of commission
  • physical, sexual, and psychological abuse
  • Child neglect is maltreatment of a child due to acts of omission
  • neglect and abandonment
  • Abusive families are usually chaotic and have relationship deficits
  • Effects of child abuse include
  • aggression
  • delinquency
  • suicide
  • distrust of others
  • poor school performance
  • later substance abuse
  • cognitive, academic, and psychological impairment
  • Childhood abuse can influence adult behavior (e.g., decreased life satisfaction, depression, low self-esteem)
  • Childhood sexual abuse (CSA) includes
  • unwanted touching (i.e., fondling)
  • making sexual remarks
  • voyeurism
  • intercourse
  • oral sex
  • pornography
  • CSA is significantly underreported, especially for boys
  • Most abuse of boys is done by perpetrators outside the family
  • Most abuse of girls is predominantly intrafamilial
  • Psychological abuse or emotional neglect is more constant in nature and more damaging throughout life

 

Approaches for Treating Child Abuse and Neglect

 

  • Treatment is complex and involves legal, developmental, and psychological issues
  • All states require mental health professionals to report child abuse and neglect
  • Before treatment can begin, legal issues must be resolved
  • Child abuse may not be treated until adulthood when other complications overlay the original problems
  • Therapists should not take the focus off the abuser, which may lead to a belief that the therapist is excusing the abusive acts
  • Focus on assisting the abuser to delay impulsive acts and the entire family to recognize and use alternatives other than violence
  • Motivation for change is highest right after an abusive act when the family is in crisis and the abuser usually feels badly about their behavior
  • Bowen family therapy can be effective in bridging historic issues from childhood and current adult behaviors associated with the history
  • Behavioral approaches can be effective in modifying behavior triggered by memories of the abuse
  • Group meetings attended by mothers and children in addition to family/network meetings alone can increase self-esteem and outcome

 

 

Key Terms

 

alcohol use disorder   a term for alcohol problems that include two levels: alcohol abuse, a problem with drinking that interferes with work, school, and home life, and alcohol dependency, a disorder in which persons are unable to control their drinking of alcohol.

 

battering   violence that includes severe physical assault or risk of serious injury.

 

child abuse   maltreatment of a child through acts of commission.

 

child neglect   maltreatment of a child through acts of ommission.

 

child physical abuse   the bodily abuse of a child which may range from mild to severe.

 

childhood sexual abuse   such acts as unwanted touching, i.e., fondling, intercourse, voyarism, making sexual remarks, oral sex, and pornography perpetrated by someone known or related to a child or by a stranger.

 

codependency   a dynamic within a family where one member of the family underfunctions (such as a substance abuser) while another member of the family overfunctions (such as the codependent family member).

 

community reinforcement approach (CRA)   use systems and resources in the community in which these people live to help them recover from substance abuse.

 

domestic violence   aggression that takes place in intimate relationships usually between adults.

 

Duluth Model   a cognitive-behavioral model of domestic violence treatment premised on the idea that people learn violent behaviors because of being reinforced for them in cultural and social circles. They can therefore unlearn these behaviors and learn new ones through cognitive-behavioral means, such as education.

 

enabler   a spouse or other family member on whom a substance abuser is most dependent and who allows the abuser to continue and become worse.

 

environmental influences   the physical aspects of a family’s life.

 

family clown   a member of a substance abuse family whose function is to provide the family with humor and thus reduce tension.

 

family hero   an adult or child who functions to provide self-worth for the family of a substance abuser.

 

identified patient (IP)   a family member who carries the family’s symptoms and who is seen as the cause of the family’s problems.

 

intimate justice theory   a theory of ethics that is used in the treatment of abuse and violence in intimate relationships. The theory confronts disempowerment abuses of power in a partnership while challenging internalized beliefs on how one should treat one’s partner.

 

lost child   a child in a substance abuse family who suffers from rejection and loneliness.

 

multifamily therapy   treating several families at the same time.

 

multisystemic therapy   a research-backed theory and treatment, originated by Scott Henggeler, that views individuals, especially “difficult-to-reach children,” as nested within a complex of interconnected systems that encompass individual, family, and extrafamilial (peer, school, neighborhood) factors. Behavior is seen as the product of the reciprocal interplay between the individual and these systems and of the relations of the systems to each other. Developmental factors are included in assessment and cognitive-behavioral interventions are used.

 

pseudo-individuation/pseudo-self   a pretend self. This concept involves an attempt by young people who lack an identity and basic coping skills to act as if they had both.

 

scapegoat   a family member the family designates as the cause of its difficulties (i.e., the identified patient).

 

Systematic Training for Effective Parenting (STEP)   an Adlerian based program that can help parents increase their understanding of family relations as well as improve their communications with their children.

 

 

Classroom Discussion

 

  1. Couple and marriage therapy approaches appear to be well researched and highly effective. Given that, why is it that so few couples seek marital  or couples therapy when there is abuse of any kind in the family? What do you think could be done to increase the numbers of such families?

 

  1. In cases of substance abuse, unhealthy or dysfunctional methods of responding to the abuse are typically tried first. Given the enormous personal, family, financial, and societal impact of substance abuse, how would you explain the tendencies for family members to deny the existence of the abuse and to shield the abuser from the negative consequences of their actions?

 

  1. In cases of domestic violence, there are two major positions about responsibility and domestic violence which influence treatment options:
  • both parties are equally responsible for the violence (conjoint or couples therapy)
  • the perpetrator is unilaterally responsible for the violence (intimate justice theory and education)

 

Take a position and defend the appropriateness of each approach, including the necessary conditions for selecting each one.

 

 

Multiple Choice Questions

 

  1. When families protect the abuser from the consequences of his or her actions and minimize the seriousness of the substance abuser’s actions, this is called _____.
  2. denial
  3. shielding
  4. enabling
  5. scapegoating

 

  1. A spouse or other family member on whom the abuser is most dependent and who allows the problem to continue and become worse is called a(n):
  2. enabler
  3. family hero
  4. scapegoat
  5. lost child

 

  1. The modern method of using concerned significant others in substance abuse treatment is to:
  2. get them involved with support groups such as Al-Anon
  3. teach them behavioral skills designed to influence the substance abuser
  4. have them confront the abuser about the problems they have caused
  5. have them surprise the abuser at a meeting known as “the intervention”

 

  1. While many systemic therapy approaches work well in substance abuse situations, one approach is very cost effective and has a high success rate. This approach is:
  2. Structural-strategic
  3. Bowen
  4. Behavioral
  5. Multisystemic

 

  1. The worst form of domestic violence is
  2. spousal abuse
  3. partner abuse
  4. marital violence
  5. battering

 

  1. There is a well-documented association between _____ and battering.
  2. fear of abandonment
  3. jealousy
  4. alcohol intoxication
  5. all of the above

 

  1. One of the conditions necessary before selecting conjoint couples therapy is
  2. an assessment of safety issues
  3. an emphasis on empowerment
  4. full disclosure of the violence
  5. unilateral responsibility for the violence

 

  1. An approach to treating domestic violence that is based on the ethical context of domestic violence in intimate relationships is called
  2. Bowen family therapy
  3. conjoint couples therapy
  4. intimate justice
  5. Adlerian therapy

 

  1. Treatment of child abuse and neglect is complex and involves _____ issues.
  2. historical, cultural, societal
  3. environmental, community reinforcement, legal
  4. legal, developmental, psychological
  5. social ecology, behavioral, emotional cutoff

 

  1. In child abuse cases, motivation for change is highest _____ an abusive act.
  2. right after
  3. right before
  4. during treatment for
  5. after treatment

 

 

True/False Questions

 

  1. Almost 60% of the world’s production of illegal drugs as well as a substantial percentage of legal alcohol products are consumed in the US

 

True ___    False ___

 

  1. Substance abuse related disorders are considered to be family based.

 

True ___    False ___

 

  1. Most families with substance abusing members are seen in family therapy.

 

True ___    False ___

 

  1. Approximately half of all married couples experience physical aggression.

 

True ___    False ___

 

  1. Child sexual abuse is significantly underreported, especially for boys.

 

True ___    False ___

 

  1. Before treatment for child abuse or neglect can begin, historical issues from childhood and current adult behaviors associated with the history must be addressed.

 

True ___    False ___

 

 

 

 

 

Chapter 16

Research and Assessment in Family Therapy

 

Chapter Overview

 

  • Family therapy has incorporated research based procedures since the early days of the field
  • In the initial development of family therapy, research came first and therapy was secondary
  • Many practitioners later abandoned research and assessment due to ethical, moral, and legal considerations as well as the complicated nature of family therapy research
  • There was a resurgence in research interest in the 1990s with increased incidence of published research articles and increased sophistication and quality of research procedures
  • Family assessment focuses on dimensions of particular families and is based on theoretical models of family function and dysfunction
  • formal or informal tests
  • behavioral observations
  • Family therapy research is even more refined in the 21st century, with researchers like John Gottman studying real-life, real-time couple interactions and conveying research outcomes in practical ways to couples
  • Family assessment is less well developed and more complex compared to individual assessment

Importance of Research in Family Therapy

 

  • Knowledge – better understanding of phenomenon which leads to competence
  • Confirming and Verifying – concrete evidence that certain procedures work
  • Accountability – the ability to prove that family therapy is effective
  • Practicality – the influence of research findings on clinical practice
  • Uniqueness – research findings help establish both similarities and distinct differences with other mental health counseling approaches

Research Findings in Family Therapy

 

  • In general, most individuals and families improve with couple and family therapy, especially when compared with control groups
  • marriage and family interventions are more effective than no treatment with effects of treatment maintained at follow-up
  • improvement rates are similar to improvement rates in individual therapy
  • deterioration rates are similar to deterioration rates in individual therapy
  • family therapy is as effective as individual therapy for some personal problems, such as depression
  • family psychoeducation programs decrease relapse and rehospitalization rates among patients whose families receive such services
  • different kinds of marriage and family interventions tend to produce similar results
  • brief therapy (20 sessions or less) is as effective as open-ended or long-term therapies
  • participation of fathers in family therapy is much more likely to bring positive results than family therapy without him
  • co-therapists and co-therapy have not been shown to be more successful than sessions conducted by one therapist
  • persons receiving individual, marital, or family therapy reduce their health care use after therapy (the offset effect); largest reductions associated with conjoint therapy
  • therapists with good relationship skills are more successful than those with poor skills
  • marriage therapy outcomes are greater than family therapy outcomes; attributable to more difficult family therapy presenting problems
  • psychosomatic and substance abuse problems respond well to a modified version of structural family therapy
  • the type of family, its background, and its interactional style do not relate to family therapy success or failure
  • marriage and family treatments are moving more towards evidence based approaches
  • strong research by Jose Szapocznik and associates with Hispanic/Latino and African American families
  • development of brief strategic family therapy
  • development of Structural Ecosystems Therapy (SET)
  • development of Strategic Family Systems Rating (SFSR)
  • development of one-person family therapy (OPFT)

Two Types of Family Therapy Research

 

  • Qualitative research
    • rooted in anthropology and sociology
    • emphasis on open-ended questions
    • use of extended interviews with small numbers of individuals/families
    • results are often written up in an extended interview or autobiographical form
    • often used in theory building
    • visual and verbal data reporting rather than numerical data reporting
    • participatory evaluation research
  • differs from other approaches in the degree of participants’ involvement
  • engages and empowers participants
  • more democratic than other types of research
  • Quantitative research
    • rooted in scientific traditions of physics, chemistry, and biology
    • most common form of research
    • emphasis on closed-ended questions
    • use of large sample sizes to gather information
    • data are gathered in a precise form, frequently using standardized instruments, and reported in a statistical format
    • results are used to “prove” or “disprove” theories and assertions
    • findings often focus on interventions that made a difference in treatment
    • quantitative research one reason family therapy is seen as a science

Difficulties in Family Therapy Research

 

  • Family relationships are complex (e.g., What within the family will be the focus of attention? The IP, marriage, whole system, cross-generational relationhips, etc.)
  • Environmental factors can impact research findings (e.g., home setting or laboratory setting?)
  • Time commitment, number of researchers needed, and expenses are great in family therapy research
  • Ethical and regulatory standards (e.g., National Research Act, Belmont Report) require close attention to rigorous ethical and procedural regulations
  • Research design
    • ‘exploratory research’ – a qualitative approach used when issues are still being defined
    • ‘descriptive research’ – the design is set up to describe specific variables
    • ‘developmental research’ – focuses on studying changes over time
    • ‘experimental research’ – classic research methodologies with hypotheses, dependent/independent variables with at least one variable manipulated
    • ‘correlational research’ – measures the degree of association or relatedness between two variables; usually conducted after the fact
  • Sampling
  • ‘random sampling’ represents an entire group of families
  • ‘random assignment sampling’ gives each family an equal chance of being selected; increases generalizability of results
  • ‘probability samples’ are drawn from a known population such that it is possible to calculate the likelihood of each case being included
  • ‘simple random sample’ – every family has an equal chance of being selected
  • ‘systematic random sample’ – first family selected at random, then every nth family is automatically included
  • ‘stratified sample’ – random samples are drawn from different strata or groups of a population
  • ‘nonprobability sample’ is used when representiveness of a whole population is not as important and the information itself
  • ‘convenience sample’ – using local families known by the researcher
  • ‘snowballing’ – a sampling method in which participating families are asked to refer other families
  • ‘purposiveness’ – involves choosing families because they are thought by the researcher to be representative of the whole population
  • Instrumentation
  • self-report instruments
  • easy to distribute to large numbers of families inexpensively
  • scoring is objective
  • easy to establish external validity
  • information helps family members understand other members’ concerns
  • easier to self-disclose through paper and pencil rather than usual ineffective ways
  • questionable construct validity
  • direct observational assessment
  • characterized by the use of coders, raters, or judges
  • weaknesses include interrater reliability and other biases
  • can be expensive and time consuming
  • videotaped observations with multiple observer ratings can be cost effective
  • Procedure
  • research procedures are not neutral but, instead, reflect the epistemology (e.g, world view) of the investigator
  • outcome research measures the impact of changes
  • process research examines the ‘how’ and ‘why’ of therapeutic effectiveness
  • time consuming and labor intensive
  • reveals which treatments are effective under which conditions and with what types of client situations
  • Theory
  • theory, research, and practice are interrelated in family therapy
  • research is generally based on questions rooted in theory and theoretical assumptions
  • Statistics
  • research results are usually reported statistically
  • statistics are used to report levels of change
  • descriptive statistics provide clinically relevant and readable statistics that are useful to family therapists
  • problem in reporting statistics related to whether sample was normally distributed or skewed
  • Validity/Reliability
  • the extent to which a measuring instrument measures what it was intended to measure
  • ‘content validity’ – the degree to which an instrument actually taps into representative beliefs or behaviors that it is trying to measure
  • ‘criterion validity’ – the degree to which what is measured actually relates to life experience, i.e., external criteria, especially behaviors
  • ‘construct validity’ – the degree to which a measured performance matches a theoretical expectation, measures of similar construct
  • Reliability
  • the consistency or dependency of a measure
  • the degree to which the assessment measures differences between families
  • perfect reliability is expressed as a correlational coefficient of 1.0 (which is seldom achieved)

The Importance of Assessing Families

 

  • Assessment procedures are methods used to measure characteristics of people, programs, or objects
  • Assessment differs from testing
  • testing is usually a task in which people are asked to do their maximum best
  • assessment usually evaluates typical performances, behaviors, or qualities; it is broader than any test measure
  • assessment assist therapists to better understand a family’s structure, control, emotions/needs, culture, and development
  • The Diagnostic and Statistical Manual (DSM) is based on the medical model and is individually oriented
    • little attention has been given in the DSM to marital and family diagnostic categories
    • historically, relationships have not been diagnosed in the same way as mental disorders; the DSM has instead used other codes to describe relational/interpersonal problems or conditions
  • Besides DSM diagnoses, there is Tomm’s acronym approach to wellness and dysfunctional cycles in families, i.e., “HIPS” & “SLIPS”
  • Tomm’s model is a useful way of understanding how families change with time, events, and circumstances
  • Assessment information can help families better understand the dynamics within their relationships, clarify goals, and gain a sense of perspective
  • Assessment information documents services, the reasons behind services, and provides baseline and change data to increase accountability and professionalism

 

Dimensions of Assessing Families

  • Based on a systemic orientation
  • Utilizes the transactions between individuals rather than the characteristics of each given individual
  • Behavior is analyzed regarding its power to influence other family members and the variables of the ecosystem that have influenced it
  • Four elements of assessment (Fishman, 1988)
  • contemporary developmental pressures on the family
  • history
  • structure
  • process
  • Provides multiple perspectives of the family

Methods Used in Assessing Families

 

  • Informal assessment
  • observational data
  • assessment of a couple’s ability to create positive experiences in the relationship (Couples Creativity Assessment Tasks)
  • Family Assessment Form
  • Formal assessment
  • more than 1,000 assessment instruments available for family therapists
  • assessment areas include intimacy, power, parenthood, and adjustment
  • despite the wealth of assessment instruments available, family therapists are reluctant to use them because
  • using assessment instruments can remove family therapists from the cutting edge of innovative practice
  • some therapists lack adequate training in family assessment
  • family therapists who do assessment tend to use individually oriented assessment instruments, such as the MMPI-2 and the MBTI

 

 

Key Terms

 

assessment   the administration of formal or informal tests or evaluation instrument(s) along with behavioral observations.

 

assessment procedure   any method used to measure characteristics of people, programs, or objects.

 

construct validity   the degree to which an instrument measures what it reports to measure.

 

content validity   the degree to which an instrument actuals taps into representative beliefs or behaviors that it is trying to measure.

 

correlational research   a design that calculates the degree of association or relatedness between two variables. This type of research is usually ex post facto (after the fact) rather than a priori (before the fact). With correlational research it is difficult to state in any precise way what factors were most influential and with whom.

 

criterion validity   the degree to which what an instrument measures actually relates to life experience.

 

descriptive research   a design set up to describe specific variables, for example, subpopulations.

 

developmental research   a design that focuses on studying changes over time such as a longitudinal study.

 

direct observational assessment   a measurement characterized by the use of coders, raters, or judges, who usually are not participants in the interpersonal system being studied and whose task is to unitize and assign meaning to some aspects of the process.

 

epistemology   the study of knowledge.

 

experimental research   a design that adheres to classic “hard science” methodologies, such as an hypothesis and dependent/independent variables. In an experimental research design, at least one variable is manipulated.

 

exploratory research   a qualitative approach often taken to define issues, the design usually consist of interviews.

 

formal assessment   the use of field-tested instruments.

 

informal assessment   observational data related to either natural or game-playing situations that may or may not be quantified.

 

interrater reliability   the degree to which raters agree on what they observe.

 

National Research Act   (Public Law 94-348) the federal governments response to unethical research practices on human subjects prior to the mid-1970s. The National Research Act set up regulations governing human research including the establishment of institutional review boards (IRBs).

 

nonprobability samples   a sample where that is nonrepresentative of a population, i.e., one where not everyone has had an equal chance of being selected.

 

offset effect   the phenomenon where people reducing their use of health care following some type of therapy, i.e., individual, marital,family, or another behavioral health intervention. The idea is that following therapy, people are better able to cope with life events more effectively thus reducing their need or tendency to express emotional concerns physically.

 

participatory evaluation research   a type of research in which clients are trained as individuals or focus groups to be involved as coresearchers in data analysis interpretation and write-up.

 

probability sample   a sample drawn from a known population in such a way that it is possible to calculate the likelihood of each case being included in the sample.

 

qualitative research   research that is characterized by an emphasis on open-ended questions and the use of extended interviews with small numbers of individuals/families. Results are written up in an autobiographical form. This research is often used in theory building.

 

quantitative research   research that is characterized by an emphasis on closed-ended questions and the use of large sample sizes to gather information. Data are gathered in a precise form, frequently using standardized instruments, and reported in a statistical format. Analyzed and deductive conclusions are made that tend to “prove” or “disprove” theories and assertions.

 

random assignment sampling   a procedure where everyone has an equal chance of being selected.

 

reliability   the consistency or dependency of a measure.

 

sample   a limited number of families representative of an entire group of families.

 

self-report instrument   an instrument where a person reports what he or she thinks or feels about a matter, e.g., like or dislike doing a certain activity.

 

stratified sampling   a method in which random samples are drawn from different strata or groups of a population.

 

systematic random sample   a sampling design in which the first person to be studied is selected at random, and then every nth person is automatically included.

 

Tomm’s Acronym Family Systems Approach to Diagnosing Families a six stage system for diagnosing the pathology and health of families using acronyms such as PIPS (Pathologizing Interpersonal Patterns) and HIPS (Healing Interpersonal Patterns) to represent where families are in time and circumstances.

 

validity   the extent to which an instrument measures what it was intended to.

 

 

Classroom Discussion

 

  1. The family therapy field incorporated research based procedures early in its development and has enjoyed a resurgence in research since the 1990s. Where do you think the field should be headed in regard to research?  What is needed to maintain a strong research focus?

 

  1. Why are marriage and family practitioners reluctant to embrace research and assessment in clinical practice? What do you think could be done to retify this situation?

 

  1. Theory, research, and practice are interrelated in family therapy in that research is generally based on questions rooted in theory and theoretical assumptions. Give an example of this interrelationship, using journal articles or other research studies to illustrate how these parts connect.

 

 

Multiple Choice Questions

 

  1. Regarding the importance of research in family therapy, research findings help establish both similarities and distinct differences with other mental health practitioners. This is called
  2. accountability
  3. practicality
  4. uniqueness
  5. none of the above

 

 

  1. In general, most individuals and families _____ with couple and family therapy, especially when compared with control groups.
  2. improve
  3. worsen
  4. stay about the same
  5. relapse

 

  1. _____ approaches decrease relapse and rehospitalization rates among patients whose families receive such services.
  2. couples therapy
  3. marriage therapy
  4. psychoeducation
  5. brief

 

  1. According to research findings, participation of _____ in family therapy is much more likely to bring positive results than family therapy without their participation.
  2. fathers
  3. mothers
  4. co-therapists
  5. extended family

 

  1. Persons receiving individual, marital, or family therapy reduce their health care use after therapy, with the largest reductions associated with conjoint therapy. This is called
  2. the offset effect
  3. generalization
  4. reliability
  5. epistemology

 

  1. Qualitative research emphasizes _____, while quantitative research emphasizes _____.
  2. closed ended questions; open ended questions
  3. open ended questions; closed ended questions
  4. large sample sizes; precise data gathering
  5. precise data gathering; large sample sizes

 

  1. Match the following terms with the numbered definitions:
  2. exploratory research
  3. descriptive research
  4. developmental research
  5. experimental research
  6. correlational research
  7. designed to describe specific variables (B)
  8. measures the degree of association or relatedness between two variables; usually conducted after the fact (E)
  9. focuses on studying changes over time (C)
  10. a qualitative approach used when issues are still being defined (A)
  11. classic research methodologies with hypotheses, dependent/independent variables with at least one variable manipulated (D)

 

  1. A _____ is used when the representiveness of a whole population is not as important as the information itself.
  2. systematic random sample
  3. convenience sample
  4. probability sample
  5. nonprobability sample

 

 

 

  1. _____ is the extent to which a measuring instrument measures what it was intended to measure.
  2. validity
  3. reliability
  4. interrater reliability
  5. accountability

 

  1. _____ is the degree to which an assessment measures differrences betwen families.
  2. validity
  3. reliability
  4. interrater reliability
  5. accountability

 

 

True/False Questions

 

  1. In the initial development of the field of family therapy, therapy came first and research was secondary.

 

True ___    False ___

 

  1. Brief therapy (20 sessions or less) is not as effective as open-ended or long-term therapies.

 

True ___    False ___

 

  1. The Diagnostic and Statistical Manual (DSM) is based on the medical model and is individually oriented.

 

True ___    False ___

 

 

  1. Tomm’s acronym approach (i.e., the “HIPS and Slips” approach) is a systems-oriented approach to diagnosing pathology and health in families and helps to understand how families change with time, events, and circumstances

 

True ___    False ___

 

  1. Observation data is used in informal assessement.

 

True ___    False ___

 

  1. Family therapists who do assessment tend to use individually oriented assessment instruments.

 

True ___    False ___