Test Bank For Family Therapy Concepts and Methods, 12th Edition by Michael Nichols, Sean Davis by ACADEMIAMILL

Contents Preface

Introduction: The Foundations of Family Therapy

Chapter 1: The Evolution of Family Therapy

Chapter 2: The Fundamental Concepts of Family Therapy

Chapter 3: Basic Techniques of Family Therapy

Chapter 4: Bowen Family Systems Therapy

Chapter 5: Strategic Family Therapy

Chapter 6: Structural Family Therapy

Chapter 7: Experiential Family Therapy

Chapter 8: Psychoanalytic Family Therapy

Chapter 9: Cognitive-Behavioral Family Therapy

Chapter 10: Family Therapy in the Twenty-First Century

Chapter 11: Tailoring Treatment to Specific Populations and Problems

Chapter 12: Solution-Focused Therapy

Chapter 13: Narrative Therapy

Chapter 14: Comparative Analysis

Chapter 15: Research on Family Intervention

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Preface This new edition is produced as an ebook as well as in print. The Pearson Enhanced eText contains the following digital enhancements embedded in the chapters. Videos: Links to video clips of therapists have been embedded for students to view throughout the chapters of the Pearson eText. Students are prompted to reflect on and analyze the videos via an accompanying question in the book margins. Chapter Quizzes: At the end of each chapter Summary, students will find two self-assessments marked by a checkmark icon. In the Pearson eText, students click on the icon and the quiz appears. The first one prompts them to test their knowledge of chapter concepts by taking a multiple-choice quiz. The second quiz icon at the end of the chapter prompts students to apply their knowledge of chapter concepts by responding to open-ended questions by typing their response and submitting it for immediate feedback. These self-assessments can reinforce understanding of key chapter concepts and support application of newly learned content. To reinforce use of these assessments above, incorporate them in your syllabus. Videos can be used in a variety of ways: assigned to watch particular videos associated with chapter reading, assigned as part of a journaling exercise or another written or discussion exercise. Note: Students use their Access Code Card to register for access online to the Pearson eText. This Access Code Card most likely accompanied the new edition (if you adopted the package of book + eText access code card). OR you might have adopted the eText alone, without a print component OR the student might have purchased the eText online. If you have questions about this, contact your Pearson sales representative. The book Preface notes new content additions to this new edition.

Introduction: The Foundations of Family Therapy

Introduction: The Foundations of Family Therapy INTRODUCTION Family therapy isn’t just a novel set of techniques; it’s a whole new approach to understanding human behavior -- as fundamentally shaped by its social context. There are a relatively small number of systems dynamics that, once understood, illuminate the challenges of family life and enable therapists to help families move through predictable dilemmas of life more successfully.

SUMMARY OF KEY POINTS AND ISSUES The Story of Holly’s Therapy Holly’s story illustrates how meeting with a patient’s family can suddenly make that person’s symptoms understandable. Holly’s depression began to make sense when the therapist met with her parents and discovered that Holly was afraid that if she grew up and left home her mother would be left behind in a bad marriage. Even a therapist untrained in family dynamics may gain enormous insight by inviting a patient’s family for a consultation.

The Myth of the Hero While our culture celebrates the uniqueness of the individual, we cannot deny our inescapable connection to our families. We do many things alone, but we are defined and sustained by a network of human relationships. Yet when we do think about families, it is often in negative terms. Talk of ―dysfunctional families‖ frequently amounts to little more than parent bashing. People feel controlled and helpless not because they are victims of parental failings, but because they don’t see past individual personalities to the structural patterns that govern families. Plagued by anxiety or depression, some people turn to individual therapy for help and, in the process, turn away from the relationships that propelled them into therapy in the first place. When they seek the safety and privacy of therapy, the last thing they want to do is take their families with them.

Psychotherapeutic Sanctuary The two most influential approaches to psychotherapy, Freud’s psychoanalysis and Carl Rogers’s client-centered therapy, were both predicated on the assumption that therapy should be conducted in private, isolated from interfering influences. Problems were thought to arise from upsetting interactions with others and were best alleviated in a confidential relationship between patient and therapist. In many ways, psychotherapy displaced the family’s function of dealing with the problems of everyday life.

Family Versus Individual Therapy Individual and family therapy each offer an approach to treatment and a way of understanding human behavior. Individual therapy provides a concentrated focus to help people face their fears and learn to become more fully themselves. Treatment is directed at the person and his or her individual make-up. In contrast, family therapists believe that the dominant forces in our lives are located externally -- in the family. Therapy based on this framework is directed at changing the organization of the family. Family therapy exerts influence on the entire family because each and every family member is changed, and continues to exert synchronous changes on each other. A family approach is often preferable for treating problems with children, complaints about marriage or other intimate relationships, family feuds, or symptoms that develop around the time of a life-cycle transition. Individual therapy may be especially useful in cases where people identify something about themselves that they’ve tried in vain to change while their social environment seems stable. Although psychotherapy can succeed by focusing on either the psychology of the individual or the organization of the family, both perspectives -- psychology and social context -- are necessary for a complete understanding of individuals and their problems. In the early days, therapists were encouraged to learn modes of treatment that

Introduction: The Foundations of Family Therapy

focused on either the individual or the family, because they were considered different enterprises. Today, family therapists often treat individuals, recognize the impact of psychopathology, and see family therapy as an orientation more than a technique. Individual therapists also recognize the importance of family dynamics and direct their efforts to understanding and changing patterns of relationships. In short, a good therapist looks at the whole picture - barriers that exist in the environment as well as those in a patient’s mind. Working with the whole system requires a focus on the family unit and each individual’s personal experience.

Thinking in Lines; Thinking in Circles Mental illness has traditionally been explained in linear terms, medical or psychoanalytic. Emotional distress is treated as a symptom of internal dysfunction with historical causes. Such linear explanations take the form of A  B. Recursive, or circular, explanations take into account interaction and mutual influence, A  B. The illusion of unilateral influence, or linear thinking, tempts therapists to see problems rooted in individuals, especially when they only hear one side of a story. But once they understand that reciprocity is the governing principle of relationship, therapists can help people get past thinking in terms of villains and victims. Learning to think in circles rather than lines empowers clients to look at the half of the equation they can control. The power of family therapy derives from bringing parents and children together to transform their interactions. Instead of isolating individuals from the emotional origins of their conflict, problems are addressed at their source.

The Power of Family Therapy The power of family therapy derives from including people with a significant impact on the identified patient and addressing their interactions. Instead of relying of a client’s account of relationship problems, those relationships are brought into the consulting room. Moreover, when positive changes are initiated in family therapy, the fact that the whole family is included means that changes in each of them can continue to reinforce progress. The downside of this is that the inclusion of other family members may allow individuals to blame each other for problems and quarrel about who is responsible for what. Getting past blaming in order to help family members recognize their own role in family problems is part of the art of family therapy.

SUGGESTED LEARNING ACTIVITIES Films Salvador Minuchin: Unfolding the Laundry Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Minuchin demonstrates his structural approach with a large blended, recently married, dual-career family with five stepchildren. The IP is the youngest son (age 11) who is acting out. Minuchin defocuses attention on the IP, relabels the sibling behavior, and focuses his attention on the couple. VIDEO, 147 minutes. Paul Watzlawick: Mad or Bad? Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) In his consultation with a family whose 25-year-old son presents with chronic somatic symptoms, Watzlawick employs the strategic use of Ericksonian-style questions. The systemic function of symptoms in protecting the family from other problems is highlighted. VIDEO, approximately 136 min. Luigi Boscolo and Gianfranco Cecchin: What to Call It? Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) This Milan team consults with a couple and their 27-year-old daughter who has a history of hospitalizations for delusions and manic depressive symptoms. Pre-, inter-, and post-session hypothesizing includes beliefs about genetic origins, double binds, incest, and hopes of priesthood. Therapists

Introduction: The Foundations of Family Therapy

demonstrate therapeutic neutrality through a range of historical and circular questions. VIDEO, approximately 138 min. Virginia Satir: Of Rocks and Flowers Distributor: Golden Triad Films To order: www.goldentriadfilms.com/films/satir.htm Satir works with a blended family in which the couple has been married for a year. The husband, a recovering alcoholic, is the father of two boys, ages 4 and 2, who were repeatedly abused by their biological mother. The children are highly active and violent on occasion. The wife, abused by her previous husband who was also an alcoholic, is pregnant and afraid the boys will abuse her own child. In a moving segment, Satir interacts only with the two young children--she has them touch her face gently, reciprocates, and then asks if they would like to do the same with their parents. Then she gently coaches the parents how to touch and respond to the children. Following the session, Virginia comments on her use of touching, both in this session and generally. Carl Whitaker: Usefulness of Non-Presented Symptoms Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Whitaker consults with a grandmother, mother, and two pre-adolescent sons. The women are recent widows and the boys were abused by their deceased, alcoholic father. The intergenerational rules that hypnotize people to act in destructive ways are searched out, as the family is challenged to deal with issues in a healthier fashion. VIDEO, approximately 93 min.

Internet Resources Have students look up two or three of the web sites listed below that feature the field of family therapy. Instruct students to write a one-page reaction paper outlining the purpose, nature, and activities of the national organizations in family therapy, major family therapy training institutions, and publishers in the field of family therapy. Several suggested sites include: American Association for Marital and Family Therapy (www.aamft.org): provides resources for family therapy practitioners, training video for purchase, instructions on how to become a student member, licensing requirements, announcements for AAMFT sponsored conferences, and information on how to make local referrals to AAMFT-licensed practitioners, etc. American Family Therapy Academy (www.afta.org): provides resources to practitioners, seeks to promote research and teaching in family therapy, lists information on how to become a member, etc. Ackerman Institute for the Family 49 East 78th St New York, NY 10021-0405 (www.ackerman.org): lists training conferences, continuing education opportunities, training materials for rent or for sale, etc. Allyn and Bacon (www.abacon.com/ftvideos) and Guilford Press (www.guilford.com) have special sections devoted to family therapy. You may also have students search the internet and compile a list of the most useful web sites devoted to family therapy, and distribute the list to each class member for their resource files.

Discussion Questions 1. What do you believe to be the necessary and sufficient conditions for real therapeutic change to occur: a brief but decisive intervention in the family system or long-term exploration of one’s personality? Some argue that changes initiated via family therapy are lasting because change is exerted throughout the entire system--and each family member changes and continues to exert synchronous change on each other. Others assert that long-term, insight-oriented therapy is necessary to prevent a patient’s personal pathology from reasserting itself.

Introduction: The Foundations of Family Therapy

2. The choice of individual versus family therapy can be based on technical considerations (e.g., which approach works best for a given problem--marital conflict, school phobia, alcoholism) or philosophical issues (e.g., what is one’s understanding of human nature and behavior, and the therapist’s role in treatment). Discuss how your own views of therapy are shaped by each of these considerations. 3. As a client, which form of therapy would you be more comfortable with, individual or couples or family? What’s the relationship between being comfortable and being in the most effective form of treatment? 4. Have students interview 3-4 people and ask them about what strategies, successful and unsuccessful, they have used to try to improve their relationships with important others. As a class, have students discuss responses to their inquiries and attempt to extract themes characteristic of successful vs. unsuccessful relationship strategies. 5. In a family like Holly’s, when conflict develops between a child and stepparent, what is gained by seeing the problem as triangular (rather than as a result of personalities)? What is gained be seeing the problem as transitional? 6. Does the myth of the hero have a greater influence on young men than on young women? To what extent is this changing? What are some cultural narratives (novels, television shows, movies) that support the myth of the hero? Are certain story lines that feature women as action heroes opening up space for women or simply putting them into masculine myths? 7. Have the class generate a list of problems for which students believe families typically enter family therapy. Categorize each problem on the list with respect to locus of the problem using a scale ranging from 1(linear causality) to 7 (circular or reciprocal causality). Divide the class into smaller groups and have each group take a portion of the presenting problems and brainstorm creative ways to translate linear explanations into circular or systemic explanations. (See Assessment section in Chapter 6.) Reconvene the class and review students’ ideas about how to shift family members’ constructions of presenting problems from linear/intrapsychic to systemic/interpersonal. 8. How could a family systems perspective be incorporated into the treatment offered at a college counseling center? (See Chapter 4.) 9. Ask students what is a family? Hopefully what will emerge is something about a group of people organized is such a way that the properties of the whole go beyond a collection of individuals. Then ask what is psychotherapy? What should emerge is some notion that psychotherapy (as opposed to counseling) involves some sort of transformation. Family therapy, therefore, considers the family as a group with superordinate properties and attempts to produce change in its organization. 10.

Compare and contrast individual and family therapy. What types of clients and problems may be best suited for each and why? Provide examples to illustrate your answer. Is it possible to integrate individual and family treatment? Take a position and argue for or against.

11.

What do you believe to be the necessary and sufficient conditions for real therapeutic change to occur: a brief but decisive intervention in the family system or the long-term exploration of individual personalities? Some argue that changes initiated via family therapy are lasting because change is exerted throughout the entire system--that each family member changes and continues to exert synchronous change on each other. Others believe that long-term insight-oriented therapy is necessary to prevent the patient’s personal pathology from reasserting itself. Take a position for or against and cite evidence to support your view.

12.

Define linear and circular thinking, and give an example of a treatment model based on each.

13.

What advantage does family therapy offer over individual therapy in maintaining positive therapeutic change? What disadvantage does family therapy create in initiating positive therapeutic change?

Introduction: The Foundations of Family Therapy

14.

What is gained by seeing family problems, such as those seen in Holly’s family, as transactional? As triangular?

15.

Identify: (a) linear (b) recursive

Supplemental Readings Anderson, C., and Stewart, S. 1983. Mastering resistance: A practical guide to family therapy. New York: Guilford Press. Guerin, P.J., Fay, L., Burden, S., and Kautto, J. 1987. The evaluation and treatment of marital conflict: A four-stage approach. New York: Basic Books. Hoffman, L. 1981. The foundations of family therapy. New York: Basic Books. Imber-Black, E., ed. 1993. Secrets in families and family therapy. New York: Norton. Isaacs, M.B., Montalvo, B., and Abelsohn, D. 1986. The difficult divorce: Therapy for children and families. New York: Basic Books. Kerr, M.E., and Bowen, M. 1988. Family evaluation. New York: Norton. Minuchin, S., Nichols, M.P., and Lee, W-Y. A four-step model for assessing families and couples: From symptom to system. Boston, MA: Allyn & Bacon. Nichols, M.P. 2009. Inside family therapy, 2nd ed. Boston: Allyn & Bacon. Minuchin, S., and Nichols, M.P. 1998. Family healing: Tales of hope and renewal from family therapy. New York: Touchstone/Simon & Schuster. White, M., and Epston, D. 1990. Narrative means to therapeutic ends. New York: Norton.

Chapter 1: The Evolution of Family Therapy

Chapter 1: The Evolution of Family Therapy INTRODUCTION In the 1950s, family therapy emerged independently in four different places: John E. Bell began family group therapy at Clark University; Murray Bowen treated families of schizophrenics at the Menninger Clinic and later at NIMH; Nathan Ackerman began his psychoanalytic family therapy in New York; and Don Jackson and Jay Haley started communications family therapy in Palo Alto. The family is the context of most human problems. Like all human groups, the family has emergent properties -- the whole is greater than the sum of its parts. The systemic properties of a family fall into two categories: structure and process. The structure, or organization, of families includes triangles, subsystems, and boundaries. Among the processes that describe family interactions -- emotional reactivity, dysfunctional communication, pursuer-distancer-the most basic is circularity. Rather than worrying about who started what, family therapists treat human problems as a series of moves and countermoves in repeating cycles. In this chapter, the author examines the antecedents and early years of family therapy.

Leading Figures Early Family Researchers. Gregory Bateson, Don Jackson, Jay Haley; Theodore Lidz; Murray Bowen; Lyman Wynne. Pioneers in Family Treatment. Milton Erickson, Nathan Ackerman, John E. Bell, Murray Bowen, Don Jackson, Jay Haley, Salvador Minuchin, Ivan Boszormeny-Nagy, Virginia Satir, Carl Whitaker.

Important Terms circular causality: the idea that events are related through a series of interacting loops or repeating cycles. complementary: relationships based on differences that fit together, where qualities of one make up for lacks in the other. cybernetics: the science of communication and control mechanisms that focuses on the way systems maintain stability and control through levels of feedback. double-bind: Bateson and colleagues’ concept for the conflict created when a person receives contradictory messages on different levels of abstraction in an important relationship and cannot leave or comment. marital schism: Lidz’s term for overt marital conflict. marital skew: Lidz’s term for a marriage in which one spouse dominates the other. metacommunication: given that every message has two levels, report and command, metacommunication is the implied command or qualifying message. morphogenesis: the process by which a system modifies its structure to adapt to new contexts (and a swell word to impress people at cocktail parties). pseudohostility: Wynne’s term for superficial bickering that masks pathological alignments in schizophrenic families. pseudomutuality: Wynne’s term for the facade of family harmony that characterizes many schizophrenic families. quid pro quo: literally ―something for something‖; an equal exchange. rubber fence: Wynne’s term for the rigid boundary surrounding many schizophrenic families, which allows only minimal contact with the surrounding community. undifferentiated family ego mass: Bowen’s early term for emotional ―stuck-togetherness‖ or fusion in the family, especially prominent in schizophrenic families.

SUMMARY OF KEY POINTS AND ISSUES The Undeclared War Traditionally clinicians believed that in order to treat hospitalized patients it was necessary to exclude family contact. Now we know better. In the 1950s hospital therapists began to notice that when a patient improved, someone else in the family often got worse. These same therapists observed that patients frequently improved in the

Chapter 1: The Evolution of Family Therapy

hospital, only to get worse when they went home. Case studies dramatized how parents sometimes used their children’s problems -- to give them a sense of purpose, or as a buffer to protect them from intimacy they found difficult to handle -- and how some children accepted that role. And while the official story of family therapy was one of respect for the institution of the family, therapists often took on a sense of mission in rescuing scapegoated victims from the clutches of their families. While it was eventually reasoned that changing the family might be the most effective way to change the individual, the shortsightedness of isolating patients from their families in psychiatric hospitals continues (c.f., Elizur & Minuchin’s Institutionalizing Madness). Some 45 years after the development of family therapy, psychiatric hospitals still often segregate patients from their families.

Small Group Dynamics Group therapy influenced the beginning of family therapy through the literature on group dynamics and through some of the pioneers of family therapy (e.g., John Bell, Rudolph Dreikurs), who were trained as group therapists. One of the reasons that studies of group dynamics were relevant to family therapy is that group life is a complex blend of individual personalities and superordinate properties of the group. The obvious parallels between small groups and families led some therapists to treat families as though they were just another form of group. The first to apply group concepts to family treatment were John Elderkin Bell and Rudolph Dreikurs. Several group concepts were borrowed for use in family therapy. Kurt Lewin’s notion that groups are psychologically coherent wholes, rather than collections of individuals, is one such concept. His ideas about the need for ―unfreezing‖--a shakeup that prepares a group to accept change--foreshadowed early family therapists’ attempts to disrupt family homeostasis. Wilfred Bion’s study of group dynamics (fight-flight, pairing, dependency) guided systemic thinkers’ understanding of group properties, with their own dynamics and hidden structure. Warren Bennis described group development as consisting of two main phases, each with several subphases. The notion that groups go through predictable phases was used by family therapists who conducted therapy in stages, and who later consolidated these ideas to form the concept of the ―family life cycle.‖ Role theory has been useful in understanding families, because roles tend to be reciprocal and complementary. What makes complementarity resistant to change is that complementary roles reinforce each other-- and each person waits for the other to change. Group theories tend to be ahistorical, maintaining a focus on the ―here-and-now.‖ A focus on process (how people talk), rather than content (what they talk about), is key to understanding the way a group functions. This process/content distinction, formalized in the study of group dynamics, had a major impact on family treatment. Family therapists learned to attend more to how families talk than to the content of their discussions. However, as family therapists gained more experience, they discovered that the group therapy model was insufficient for families. Therapy groups are composed of strangers with no past or future outside the group, whereas families consist of intimates who share a history and a future together, the same myths and defenses, etc. Families also contain generational differences -- their members are not peers who should relate as equals.

The Child Guidance Movement At the turn of the twentieth century, major social reforms led to the creation of child welfare laws and greater respect for children’s rights. The child guidance movement was born out of these concerns, and founded on the widening belief (e.g., Alfred Adler) that treating problems of children was the best way to prevent the development of problems in adulthood. Gradually, child guidance workers concluded that tensions in the family were often the real source of children’s difficulties. The typical treatment in child guidance centers consisted of a psychiatrist seeing the child while a social worker met with the mother. The mother was seen primarily to improve her parenting skills. Throughout the 1940s and 1950s researchers in child guidance clinics believed that parental psychopathology caused child pathology. It was during this time that Frieda Fromm-Reichmann introduced her concept of the schizophrenogenic mother-aggressive, domineering mothers thought to foster schizophrenia in children. Eventually the emphasis in child guidance shifted to viewing pathology as inherent in family relationships -- a shift with profound consequences. Psychopathology was no longer located solely within the individual. Parents were no longer seen as villains and children as victims. Once the nature of family interactions was seen as the problem, this changed the very nature of treatment and resulted in a more optimistic prognosis. Instead of trying to separate

Chapter 1: The Evolution of Family Therapy

children from their families, child guidance workers began to help families support their children. While John Bowlby experimented with family therapy, Nathan Ackerman first successfully carried it out.

Marriage Counseling Marriage counseling began as a relatively informal procedure and is still widely practiced outside of traditional mental health settings--e.g., by ministers, family doctors, and lawyers. Psychoanalytic and behavioral therapists experimented with both concurrent and conjoint couples sessions, and then, with Jay Haley and Don Jackson, couples therapy was absorbed into the new discipline of family therapy. But although Nichols follows the convention of considering couples therapy a subtype of family therapy, the practice of couples therapy (especially in psychoanalytic, cognitive-behavioral, emotionally-focused, and integrative models) tends to permit more in-depth focus on both dyadic exchanges and on the psychology of the partners.

Research on Family Dynamics and the Etiology of Schizophrenia The initial breakthroughs in family therapy were achieved by clinical researchers. In Palo Alto, Bateson, Haley, Jackson, and Weakland discovered that schizophrenia made sense in the context of pathological family communication. The two great discoveries of this talented team were: (1) multiple levels of communication, and (2) destructive patterns of relationship that are maintained by self-regulating interactions of the family group. At Yale, Theodore Lidz found patterns of instability and conflict in the parents of schizophrenics, patterns that appeared to profoundly affect the pathological development of children. Lyman Wynne at NIMH (and later Rochester), demonstrated how communication deviance in a family may contribute to schizophrenia. Role theorists, like John Spiegel, described how individuals were cast into social roles within families, and the polemical R.D. Laing pointed out that when parents ―mystify‖ (distort) their children’s experience, the children may learn to project a ―false self‖ and keep their real selves buried. These researchers observed that the behavior of schizophrenics fit with their families. Unfortunately, they assumed that, because schizophrenia made sense in the context of the family, the family must therefore be the cause of schizophrenia. Moreover, they concluded that family dynamics (i.e., double binds, pseudomutuality, etc.) were products of the ―system,‖ rather than features of individuals who shared certain qualities because they lived together.

From Research to Treatment: The Pioneers of Family Therapy In the 1950s research on family dynamics and schizophrenia led to the pioneering work of the first family therapists. These pioneers had distinctly different backgrounds and clinical orientations -- not surprisingly, the approaches they developed to family therapy were also quite different. This diversity still characterizes the field today. John Bell started seeing families in the 1950s. Although he was a significant pioneer in family therapy, his influence on the field was not great. Bell’s approach was based on the group therapy model. In his ―family group therapy,‖ he relied primarily on stimulating an open discussion in order to help families solve their problems. Three specialized applications of group methods to family treatment were multiple family group therapy, impact therapy, and network therapy. Multiple family group therapy, developed by Peter Laqueur, involved seeing four to six families together and treating them like traditional therapy groups as well as using encounter group techniques. Multiple impact therapy was used at the University of Texas in Galveston by Robert MacGregor and his colleagues as a way to have maximum impact on families over the course of several days. Network therapy, developed by Ross Speck and Carolyn Attneave, was the most influential of these specialized group models. In network therapy, a patient’s entire social network is convened by teams of therapists who help them mobilize support for families in crisis. Of the Palo Alto group, Don Jackson and Jay Haley were the most influential in developing family treatment. Jackson turned his back on his psychoanalytic training and focused on the dynamics of interchange between people. His concept of family homeostasis became the defining metaphor of family therapy’s early years. (Note: Today we can see how an emphasis on homeostasis and the cybernetic metaphor led therapists to become more mechanics than healers. In their zeal to rescue family scapegoats, therapists provoked some of the resistance they complained of.)

Chapter 1: The Evolution of Family Therapy

Many of Jackson’s concepts, such as the marital quid pro quo, complementarity, and symmetry are still used by family therapists today. Like Jackson, Jay Haley concentrated on the marital dyad. He believed that everyday relationships were shaped by struggles for control. Symptomatic behavior was seen as an insidious way to control people while denying that one is doing so. Within the therapeutic relationship, patients attempt to control the therapist. According to Haley, the therapist’s job is to outwit patients in such a way as to defeat their resistance. For a more complete description of Jackson’s and Haley’s work, see Chapter 5. Virginia Satir was another member of the Palo Alto group who played a major role in the development of family therapy. In her work with families, she concentrated on clarifying communication, expressing feelings, and fostering a climate of mutual understanding. Her 1964 book, Conjoint Family Therapy, did much to popularize the family therapy movement. Murray Bowen believed that pathological dynamics found in schizophrenic families were present to a lesser extent in all families. Bowen experimented with different methods of working with individuals, couples, and families until about 1964, when he developed the method that stands today (see Chapter 4). Bowen believed that the best way to become a family therapist was to resolve emotional problems within one’s own family of origin. The goal of Bowen therapy is to help patients achieve differentiation of self in the context of family relationships, to teach them enough about family systems to handle future crises, and to develop the motivation to continue working toward further differentiation after therapy is terminated. Differentiation is best accomplished by developing individual relationships with each parent and with as many family members as possible. In addition to his work with couples, Bowen often worked with individual family members. Bowen saw family therapy both as a method and an orientation. As an orientation, it means understanding people in the context of emotional systems. Some argue that Bowen’s work with individual family members is more focused on family issues, systems concepts, and emotional processes, than almost any other family therapy approach. Nathan Ackerman never lost sight of the fact that people are individuals as well as members of families. Like Jackson and Bowen, he came to family therapy from psychoanalysis. While he maintained an emphasis on psychodynamic conflict, he also demonstrated a keen sense of the overall organization of families. The creative flexibility of Ackerman’s approach makes it difficult to describe, yet there were clear themes in his work. He thought it necessary to be deeply committed and involved with families. He believed in the existence of an interpersonal unconscious within each family. His techniques suggest that he was somewhat more concerned with the content of family conflicts than with the process by which family members dealt with them, and more interested in secrets and hidden conflicts than in distance, proximity, and patterns of communication. While his clinical writings present few systematic strategies for working with families, he was a brilliant artist of family therapy technique, interacting with families in an active, open, highly emotional and effective manner. His contributions as a teacher may be his most important legacy. Carl Whitaker’s view of psychologically troubled people was that they are alienated from their emotions, thus incapable of autonomy or real intimacy. Whitaker eschewed theory in favor of creative spontaneity. He pioneered the use of cotherapy in family treatment, believing that a cotherapist allowed family therapists to react spontaneously in sessions without fear of unchecked countertransference. His ―Psychotherapy of the Absurd‖ was designed to open individuals up to their own feelings and help them share those feelings within the family. For a description of Whitaker’s experiential approach, see Chapter 7. Another seminal thinker, Ivan Boszormenyi-Nagy, came to family therapy from psychoanalysis. In 1957, he founded the Eastern Pennsylvania Psychiatric Institute (EPPI) in Philadelphia, a center for research and training in treatment for families and schizophrenia. He attracted a number of highly talented colleagues, including James Framo, David Rubenstein, Geraldine Spark, and Gerald Zuk. Nagy’s most important contribution was introducing ethical accountability into family therapy. He believed that family members should base their relationships on trust and loyalty. Depending on the integrity and complementarity of their needs, marital partners develop trustworthy give-and-take relationships. His term ―invisible loyalties‖ describes the unconscious commitments and guilt that children take on to help their families, often to the detriment of their own well-being.

Chapter 1: The Evolution of Family Therapy

Though not one of the first family therapists, Salvador Minuchin entered the field early and his accomplishments rank among the most influential. Minuchin and his colleagues (Haley, Montalvo, and Rosman) developed structural family therapy, among the most widely used systems of family therapy. Minuchin’s (1974) Families and Family Therapy is the most popular book ever written on family therapy. Structural family therapy begins with the observation that family transactions, when they are repeated, develop a patterned regularity, or structure. The nature of family structure is determined by emotional boundaries, which keep family members close or distant. Problems arise when families fail to modify their structure to fit changing circumstances. The techniques of structural family therapy fall into two general strategies. First, a therapist must accommodate to a family in order to join with them. Once the initial joining is accomplished, a structural therapist uses restructuring techniques -- active, directive maneuvers designed to disrupt dysfunctional structures by strengthening diffuse boundaries and softening rigid ones. For more on structural family therapy, see Chapter 6.

LESSONS FROM THE EARLY MODELS The first family therapists turned to models from group therapy and communications theory to guide treatment of families. Group family therapy was developed by clinicians who had a background in group therapy and others who applied group dynamics concepts to families. It was an approach widely used in the 1960s, but no longer. Today we realize that families have unique properties that cannot effectively be treated with a group therapy model. The communications theory that emerged from Palo Alto in the 1950s had an enormous impact on the entire field of family therapy. Its adherents focused on the process of communication, rather than its content. The paradigms of the communications model, derived from general systems theory, cybernetics, and information theory, were so well received that they have been absorbed by the whole field. Eventually, its proponents branched off to form new schools, especially the strategic, experiential, and structural approaches to family therapy. The great advance of systemic thinking is that behavior in families is the product of mutual influence. The danger in forgetting that systems metaphors are only metaphors leads to overestimating the system’s power over individuals. Systems influence but do not determine our behavior. Family therapists taught us that our behavior is governed in unseen but powerful ways by the actions of others. Family rules and roles operate as invisible constraints influencing all that we do. These ideas are liberating; if one is playing a role (i.e., based on rigid gender stereotypes), then it’s possible to play a new one (e.g., based on a broader, more authentic definition of self). Yet systems thinking in the extreme rejects selfhood as an illusion. Systems thinkers implied that the family role plays the person, rather than the other way around. Whether acting in unison or separately, it must be the individuals in the system who act to bring about change in the family. In sum, while systems thinking reminds us of our connection with others, the systems metaphor is not a complete model for human systems. Although individuals respond to forces outside themselves, they are also people with names who experience themselves as centers of initiative, with imagination, reasoning, creativity, memories, and desires.

THE GOLDEN AGE OF FAMILY THERAPY The 1970s and 1980s saw the flowering of the classic schools of family therapy -- Bowenian, psychoanalytic, behavioral, experiential, and, especially, structural and strategic. Those two decades may have been the high-water mark of family therapy’s enthusiasm and vitality. Subsequently, however, a reaction set in both to the aggressiveness of the interventions and to the competitiveness of the different schools. Today, family therapists favor a more collaborative approach to families and are likely to integrate theories and techniques from various models.

SUGGESTED LEARNING ACTIVITIES Films The Case of the Dumb Delinquent Philadelphia Child Guidance Center, Mike Schmidt Video Department, 34th St. and Civic Center Blvd., Philadelphia, PA 19104. Minuchin interviews a 13-year-old pre-delinquent boy and his single mother. Minuchin highlights the complementary patterns that link mother to son, through skillful use of

Chapter 1: The Evolution of Family Therapy

relabeling and reframing, and challenges the mother’s plans for institutional placement. VIDEO, 3/4 inch Cassette, S-VIDEO, approximately 38 minutes. Virginia Satir: Of Rocks and Flowers Distributor: Golden Triad Films. To order: www.goldentriadfilms.com/films/satir.htm Satir works with a blended family in which the couple has been married for a year. The husband, a recovering alcoholic, is the father of two boys, ages 4 and 2, who were repeatedly abused by their biological mother. The children are highly active and violent on occasion. The wife, abused by her previous husband who was also an alcoholic, is pregnant and afraid the boys will abuse her own child. In a moving segment, Satir interacts only with the two young children--she has them touch her face gently, reciprocates, and then asks them if they would like to do the same with their parents. Then with the parents, she gently coaches them how to touch and respond to the children. During the post- session interview, Virginia comments explicitly on her use of touching, both in this session and generally. Carl Whitaker: Usefulness of Non-Presented Symptoms Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Whitaker consults with a grandmother, mother, and two pre-adolescent sons. The women are recent widows and the boys were abused by their deceased, alcoholic father. The intergenerational rules that hypnotize people to act in destructive ways are searched out, as the family is challenged to deal with issues in a healthier fashion. VIDEO, approximately 93 min. Carl Whitaker and Gary Connell: Creating a Symbolic Experience Through Family Therapy Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Note: Whitaker is spelled ―Whitake‖ in the catalogue. Whitaker demonstrates his Symbolic Experiential Therapy in his interviews with two extended families. VIDEO. Paul Watzlawick: Mad or Bad? Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) In his consultation with a family whose 25-year old son presents with chronic somatic symptoms, Watzlawick employs strategic use of Ericksonian-style questions. The systemic function of symptoms in protecting the family from other problems is highlighted. VIDEO, approximately 136 min. Jay Haley & Judge Clinton Deveaux, In the Maze: Families and the Legal System Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) This video offers guidelines for compulsory therapy as an alternative to incarceration. VIDEO. Virginia Satir: The Use of Self in Therapy #7953 Discovery Education: 800-213-8395. The Use of Self, draws on Satir’s legacy of clinical recordings to demonstrate the tenets of her theory and practice. Therapy footage is interspersed with expert commentary. Explored are methods to empower family members, bolster self-esteem, reframe problems, and communicate with congruence. VIDEO, 30 minutes. Virginia Satir: The Lost Boy Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Satir conducts an experiential session with a large intact family with ten children whose presenting problem is grief following the loss of one of the children who is still missing a year after his abduction. This session provides a good demonstration of Satir’s open, directive, spatial style. VIDEO, approximately 80 min.

Chapter 1: The Evolution of Family Therapy

Discussion Questions 1. Have students choose a supplemental sources on the pioneer of their choice (e.g., Gregory Bateson, Murray Bowen, Jay Haley, Virginia Satir, Lyman Wynne, etc.) to read and present to the class. Presentation of theoretical papers should address the following issues: the author’s theoretical formulations, ideas about normal family development, how behavior disorders develop in the family, goals of treatment, techniques used in treatment, and ideas about how and why change occurs in therapy. Presentation of researchers should include: research questions posed, types of research design used (i.e., qualitative vs. quantitative, and specify type), interpretation of findings, and implications of the research findings for the field. 2. What are the pros and cons of segregating hospitalized mental patients from their families? 3. What are some of the motives for blaming parents (especially mothers) for the problems of their children? What are some of the clinical consequences of this type of thinking? 4. List the various early leaders of family therapy on individual note cards -- Gregory Bateson, Theodore Lidz, Lyman Wynne, Milton Erickson, Nathan Ackerman, John E. Bell, Murray Bowen, Don Jackson, Jay Haley, Salvador Minuchin, Virginia Satir, and Carl Whitaker, etc. Break the class into groups of 3-4 students each and divide the note cards among groups. Have students identify and discuss the major contributions of each leader to the field of family therapy. How have their ideas fared in the current climate of family therapy? 5. What are some of the ―basic assumptions‖ (in Bion’s terms) operating in some of the groups of which your students have been a part? 6. What roles did students play in their families growing up? What potential roles went unfulfilled or unnoticed? 7. To what extent does it make sense to treat couples therapy as just a form of family therapy rather than a specific discipline in its own right? 8. Discuss the major concepts in early communication theory that have been incorporated into other schools of family therapy (i.e., complementarity, cybernetics, homeostasis, metacommunication, positive and negative feedback loops, symptom functionality, etc.). Which have had the greatest impact on the direction in which the field is developing? 9. Trace the demise of group family therapy. What were its major contributions to the field? What were its major failings? In which settings under which conditions, with which types of families and family problems might group family therapy show greater effectiveness? 10. Discuss Speck and Attneave’s network therapy. For what situations might this approach be particularly useful (e.g., families with chronic illness, ethnic minority families, non-traditional families such as single parent families and gay and lesbian families), and why? 11. Discuss the pros and cons of manipulating people to change. Do the ends justify the means? Is it ethical or clinically indicated to change someone outside of his or her awareness?

Role Plays/Observations 1. Have students break into groups of 2-3. One student (a client), should describe a problem (e.g., frequent fights with partner; difficulty getting along with co-workers; parent of an adolescent child who is acting out; workaholic, etc.), and the others should ask questions about what he or she has done in response to the problem. The goal of the exercise is to discover problem-maintaining behavior, and maybe suggest that the client try something different. Reverse roles until all students have played both client and interviewer. 2. Divide the class into groups of 3 or 4. Ask two students to play a couple and to choose an emotional topic for discussion, something on which they are likely to disagree (e.g., finances, housekeeping responsibilities, frequency of visits with parents, sex, communication problems). Instruct one or both partners to deliberately talk

Chapter 1: The Evolution of Family Therapy

about ―you‖ and the way things ―are‖ and ―should be,‖ rather than saying ―I think,‖ ―I wish,‖ ―I feel.‖ Stop after 10 minutes -- observers should notice and comment on how destructive this habit is. Next instruct each member of the ―couple‖ to speak in the first person singular (e.g., I feel..., I think..., My thought is that....); making personal statements about personal matters (e.g., ―I would like to visit my family...‖ versus ―You should want to visit with my family during the holidays‖), and speaking directly to, not about, each other. Discuss the contrasting experiences of the students who were role-playing across the first and second role play. Discuss observers’ perceptions of these differences. Ask students to consider implications for treatment.

3. Divide the class into small groups, perhaps 4-5 each, and have students conduct two types of role plays, approx. 15 minutes each, using communications family therapy techniques. Instruct two students to play a couple with relationship difficulties, one to play the therapist, and one or two students to observe. In the first role play, instruct the therapist to use a direct approach in treating the couples’ presenting difficulties by making their rules of communication explicit and teaching them principles of clear communication (e.g., using the first person singular--I, me, mine--when referring to one’s thoughts and feelings about an issue, making personal ―I‖ statements, speaking directly to and not about the other). In the second role play, two students should role play a couple with relationship difficulties. This time instruct the therapist to use a more indirect strategy by attempting a paradoxical intervention (e.g., prescribing the symptom, reframing the problem, creating a therapeutic double-bind, etc.). Encourage the therapist to call a timeout during the role play session in order to confer with observers and design an effective paradoxical intervention. Following the role plays, instruct the groups to discuss the effectiveness of the direct vs. indirect style of intervention. What were the couples’ experiences as targets of the interventions? Which felt more effective? In each case, was the therapist able to induce change in the couples’ style of communicating, ways of thinking about the problem, etc.? Which intervention style fits best with students’ own personal styles? 4. Have students break into groups of 3-4. Have two students role-play a conversation in which each reacts with emotional responses to the other’s statements. Observers should take note of what happens. Next have them roleplay a similar conversation, but this time instruct them to acknowledge what the other said before they respond. Have the group discuss each role play. What impact did acknowledgment of the other’s perspective have on the quality of the interaction? Discuss the implications for conducting couples therapy.

Supplemental Readings Ackerman, N.W. 1966. Family psychotherapy--theory and practice. American Journal of Psychotherapy. 20:405414. Bateson, G., Jackson, D.D., Haley, J., and, Weakland, J. 1956. Toward a theory of schizophrenia. Behavioral Science. 1:251-264. Bell, J.E. 1975. Family therapy. New York: Jason Aronson. Bowen, M. 1961. Family psychotherapy. American Journal of Orthopsychiatry. 31:40-60. Erickson, M. H. 1980. The collected papers of Milton H. Erickson, Vols. I, II, and III. New York: Irvington. Fromm-Reichmann, F. 1948. Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry. 11:263-274. Gritzer, P.H., and Okun, H.S. 1983. Multiple family group therapy: A model for all families. In B.B Wolman & G. Stricker (Eds.), Handbook of family and marital therapy. New York: Plenum Press. Guerin, P.J. 1976. Family therapy: The first twenty-five years. In Family therapy: Theory and practice, P.J. Guerin, ed. New York: Gardner Press. Gurman, A. S. ed. 1985. Casebook of marital therapy. New York: Guilford Press. Haley, J. 1963. Strategies of psychotherapy. New York: Grune and Stratton. Haley, J. 1986. The power tactics of Jesus Christ, 2nd ed. Rockville, MD: The Triangle Press. Haley, J. 1996. Learning and teaching family therapy. New York: Guilford Press. Jackson, D.D. 1965. Family rules: Marital quid pro quo. Archives of General Psychiatry, 12:589-594. Kaslow, F.W. 1980. History of family therapy in the United States: A kaleidoscope overview. Marriage and Family Review. 3:77-111. Lidz, T., Cornelison, A., Fleck, S. and Terry, D. 1957. Intrafamilial environment of schizophrenic patients II: Marital schism and marital skew. American Journal of Psychiatry. 114:241-248. Maturana, H. R., and Varela, F. J. 1987. The tree of knowledge. Boston: New Science Library.

Chapter 1: The Evolution of Family Therapy

Minuchin, S. 1974. Families and family therapy. Cambridge, MA: Harvard University Press. Satir, V. 1972. Peoplemaking. Palo Alto, CA: Science and Behavior Books. Von Bertalanffy, L. 1962. General system theory—A critical review. General Systems, 7: 1-20. Watzlawick, P., Beavin, J.H., and Jackson, D.D. 1967. Pragmatics of human communication. New York: Norton. Weakland, J.H., and Ray, W.A. (Eds.). 1995. Propagations: Thirty years of influence from the Mental Research Institute. Binghamton, NY: Haworth. Whitaker, C.A. 1976. A family is a four-dimensional relationship. In Family therapy: Theory and practice, P.J. Guerin, ed. New York: Gardner Press. Wynne, L.C. 1978. Knotted relationships, communication deviances, and metabinding. In Beyond the double bind, M.M. Berger, ed. New York: Brunner/Mazel. Wynne, L.C., Ryckoff, I.M., Day, J., and Hirsch, S. 1958. Pseudomutuality in the family relationships of schizophrenics. Psychiatry. 21:205-220.

Chapter 2: The Fundamental Concepts of Family Therapy

Chapter 2: The Fundamental Concepts of Family Therapy INTRODUCTION Family therapy involves a whole new way of thinking about human behavior -- as fundamentally organized by its interpersonal context. In order to answer questions about how families develop and change, how healthy and unhealthy families differ, and why family sometimes resist steps to improve relations, the founders of family therapy imported concepts from anthropology, biology, philosophy, linguistics, computer science, and engineering. These concepts defined the early practice of family therapy. Over the course of its development, family therapy has continued to attend to ever wider levels of context, from the first days when therapists looked beyond individuals to their families, and then gradually shifting to focus on underlying family structure, multigenerational processes, and cultural influences.

Leading Figures Mary Ainsworth, Harlene Anderson, Gregory Bateson, Ludwig von Bertalanffy, Murray Bowen, John Bowlby, Kenneth Gergen, Harry Goolishian, George Kelly, Salvador Minuchin, Norbert Wiener.

Important Terms attachment: a feeling of secure connection to a loved one. black box metaphor: the idea that because the mind is so complex, it’s better to study people’s input and output (behavior, communication) than to speculate about what goes on in their minds. boundary: psychological and physical barrier that protects and enhances the integrity of individuals, subsystems, and families. circular causality: the idea that events are related through a series of interacting loops. complementary: relationships based on differences that fit together, where qualities of one make up for lacks in the other. constructivism: an epistemological paradigm, in which knowledge is viewed as actively constructed by an individual. culture/ethnicity: shared patterns of behavior derived from settings where people live vs. common ancestry through which people evolve shared customs. cybernetics: the study of self-regulating systems, especially analysis of the flow of information in closed systems. deconstruction: a postmodern approach to explore meaning by taking apart and examining taken-for-granted categories and assumptions, making possible newer and sounder constructions of meaning. disengagement: psychological isolation that results from overly rigid boundaries around individuals and subsystems in a family. double bind: a conflict created when a person receives contradictory messages on different levels of abstraction in an important relationship, and cannot leave or comment. enmeshment: loss of autonomy due to a blurring of psychological boundaries. equifinality: the ability of living systems to reach a given final goal from different initial conditions and in different ways. family life cycle: stages of family life from separation from parents to marriage, having children, growing older, retirement, and finally death. family rules: descriptive term for ingrained patterns of interaction. family structure: the organization that governs how family members interact. feedback loop: a return of a portion of the output of a system used as feedback to regulate the system. function of the symptom: the idea that symptoms often distract or otherwise protect family members from threatening conflicts. general systems theory: a biological model of living systems as whole entities that maintain themselves through continuous input and output from the environment; developed by Ludwig von Bertalanffy. hierarchical structure: family functioning based on clear generational boundaries, where the parents maintain control and authority. homeostasis: the tendency of a system to maintain a steady state of equilibrium. linear causality: the idea that one event is the cause and another is the effect; in behavior, the idea that one behavior

Chapter 2: The Fundamental Concepts of Family Therapy

is a stimulus and the other is the response. metacommunication: every message has two levels, report and command; metacommunication is the implied command of a qualifying message. morphogenesis: the process by which a system changes its structure to adapt to new contexts. negative feedback: any signal that reduces deviation and brings a system back to its homeostatic state. open system: a system that exchanges information or materials with its environment, as opposed to a closed system that does not; living systems are, by definition, open systems. positive feedback: any signal that amplifies deviation and takes a system further away from homeostasis. postmodernism: contemporary antipositivism, viewing knowledge as relative and context-dependent; questions assumptions of objectivity that characterize modern science; in family therapy, challenging the idea of scientific certainty, and linked to the method of deconstruction. process/content: distinction between how members of a family or group relate and what they talk about. reframing: relabeling a family’s description of behavior to make it more amenable to therapeutic influence; for example, describing someone as ―lonely‖ rather than ―depressed.‖ second-order change: basic change in the structure or rules of a system. social constructionism: like constructivism, challenges the notion of an objective basis for knowledge; knowledge and meaning are shaped by culturally shared assumptions. structure: overall organization of a system that regulates and stabilizes patterns of interaction. subsystem: smaller units in families, determined by generation, gender, or function. symmetrical: in relationships, equality or parallel form. systems theory: a generic term for studying a group of related elements that interact as a whole entity; encompasses general systems theory and cybernetics. triangle: a three-person system; according to Bowen, the smallest stable unit of human relationships.

SUMMARY OF KEY POINTS AND ISSUES Cybernetics Defined as the study of machines that regulate themselves, the science of cybernetics was introduced to family therapy by Gregory Bateson, who was interested in feedback processes of systems. Cybernetics focuses attention on family rules that govern a family’s homeostatic range, negative feedback or mechanisms that families use to enforce those rules, sequences of family interaction around a problem that characterize the system’s reaction to it, and what happens when a system’s negative feedback is ineffective, triggering positive feedback loops. While positive feedback loops or runaways can destroy a family if they get out of hand, they also can help systems adjust to changed circumstances. The family theory most influenced by cybernetics was the communications school. Cybernetically-oriented therapists strive for second-order change (change in the family rules), distinguishing it from first-order change (some behavior changes but it’s still governed by the same rules). A major faction of Bateson’s group went on to advance the cybernetic notions of homeostasis and feedback loops, kept a mechanistic focus on observable behavior sequences, and used the black box metaphor to justify their position. The cybernetic metaphor came under attack in the 1990s as overly mechanistic.

Systems Theory A system is an organized group of elements that function as a unit. Thus, attempts to understand the individual components of system, whether a complex piece of machinery or a family, without taking into account how they interact is likely to be incomplete. The clinical implication of this is that a family is more than a collection of personalities; it is an organized network of relationships. Systems, including families, can be understood by looking at process and structure -- patterns of interaction and the arrangement of the interacting components. Don Jackson’s notion of family homeostasis emphasized how families resist change. Today we can see the early emphasis on homeostasis as exaggerating the conservative properties of families.

Chapter 2: The Fundamental Concepts of Family Therapy

Bateson believed that linear causality was a poor model for describing the world of living things (though useful for the world of forces and objects) because it neglects to account for communication and relationships. Consider the implications of kicking a stone versus kicking a dog. Circular causality suggests that problems are sustained by an ongoing series of actions and reactions: a logical but unproductive search for who started the problem (i.e., a linear cause) is unnecessary to promote a change in interaction. General systems theory was developed by Ludwig von Bertalanffy, an Austrian biologist. This version of systems thinking can help family therapy move beyond the mechanistic thinking of the field’s earlier years. Bertalanffy was critical of cybernetics and believed that science had become reductionistic through its tendency to analyze phenomena by dissecting systems to study their parts in isolation. He urged scientists to think interactionally and study whole systems. He advanced ideas such as equifinality--the ability to reach a given final goal in a variety of ways--and open systems, which continuously interact and exchange material with their environment. He voiced concern about the conservative implications of ―homeostasis,‖ because he believed that open systems were also change or growth seeking. In sum, many of his systems concepts can influence the field toward becoming more collaborative and compassionate. These ideas include: concept of a system as more than the sum of its parts; emphasis on systems as subsystems of larger systems; human systems as ecological organisms vs. mechanisms; concept of equifinality; spontaneous activity vs. homeostatic reactivity; importance of ecological beliefs and values vs. valuelessness; constructivism vs. positivism.

Constructivism Constructivism is an epistemological paradigm according to which knowledge is actively constructed by the observer. Because our experience of the world is filtered through our own minds, our perception is always subjective. The implications for family therapy are a greater emphasis on cognition and on the subjective experience of individual family members. The constructivist epistemology -- or what Immanuel Kant called ―perspectivism‖ -- was introduced to psychology in George Kelly’s personal construct theory and to family therapy in the technique of reframing. Harry Goolishian and Harlene Anderson employed a constructivist perspective in their collaborative language-based systems approach. Anderson and Goolishian advocated a stance of ―not-knowing‖ in which therapists avoid taking the role of allknowing expert in order to allow clients’ ideas to emerge in nondirective therapeutic conversations. They were not only emphasizing the importance of subjective (primarily cognitive) experience over behavior, but also reacting against what they perceived as the aggressiveness of some family therapy approaches. Thus, constructivists moved family therapy in the direction of individuals’ cognitive experience and away from some of the traditional emphases of family therapy -- including the importance of interpersonal conflict and systemic interactions.

Social Constructionism Social constructionism expands constructivism to take into account that the way we perceive the world is shaped by our social context. Therapy from this perspective is a process of deconstructing (socially shaped) unhelpful narrative accounts of experience and helping people reconstruct more promising ways of looking at things. The most direct application of social constructionism is found in narrative therapy, which creates a shift in people’s experience by helping them reexamine their socially constructed accounts of experience. Solution-focused therapy works by drawing clients’ attention away from trying to figure out their problems to help them rediscover forgotten coping abilities already in their repertoire.

Attachment Theory Attachment theory explains the human longing for connection as a biologically based drive that bonds children and their parents. John Bowlby and Mary Ainsworth showed how infants use attachment figures (usually parents) as a

Chapter 2: The Fundamental Concepts of Family Therapy

secure base for exploring the world. The child who is securely attached approaches the world with confidence, while children who are insecurely attached alternate between avoiding and clinging to others. Attachment theory suggests that adult relationships depend on the attachment histories of both partners. Partners who grew up securely attached feel lovable and confident enough to expose their vulnerability to each other. Partners who grew up insecurely attached may be easily threatened and defensive. Instead of showing their needs directly, they show only their defenses. Although the application of attachment theory to the understanding of couples has been productive clinically (e.g., in the emotionally focused couples therapy of Susan Johnson), there is little research support for the assumption that childhood attachment styles correlate with adult attachment styles in intimate relationships.

The Working Concepts of Family Therapy Interpersonal Context. The fundamental premise of family therapy is that people are products of their interpersonal context. The family is often (but not always) the most relevant context for understanding and treating people and their problems. Complementarity. Complementarity refers to the reciprocity that is the defining feature of relationships. While clients typically describe events from a linear perspective -- ―My wife nags,‖ ―I’m a little passive‖ -- family therapists consider such descriptions as only half of a complementary pattern. A man who experiences his wife as nagging may be inattentive to her requests; while a person who experiences himself or herself as passive may have a partner who is domineering. The point of complementarity isn’t to shift responsibility, but to recognize that in a relationship one person’s behavior often fills in the blanks left by the other’s. Circular Causality. Using the concept of circularity, family therapists changed the way psychopathology is considered, from something caused by events in the past to part of ongoing feedback loops. Assigning beginning and end points to problems is arbitrary. Every action in a circular loop is influenced by and, in turn, influences every other action. Rather than searching for underlying causes, family therapists try to interrupt these circular patterns of interaction. Triangles. According to Murray Bowen, the smallest stable unit of relationship is three, because when two people are unable to resolve problems between them, one or both will turn to a third party to diffuse anxiety and conflict. Understanding the triangular nature of human interaction expands a family therapist’s lens and opens up greater possibilities for intervention. Triangulation tends to stabilize relationships -- but also to freeze conflict in place. Process/Content. Focusing on the process of communication (how people talk), rather than its content (what they talk about), reveals how their relationship works. If, for example, a mother and father can’t agree on discipline, the problem may not be so much the content of their disagreement but the process by which they don’t seem able to work together to come up with an appropriate resolution. Although the content of family discussions often engages therapists’ feelings--especially around anxiety-provoking issues--effective therapy must address the process by which family members attempt to work together. Family Structure. The idea that families can be understood best by assessing the boundaries between various subsystems within them became a cornerstone of the field (see Ch. 6). When boundaries are too open, relationships are enmeshed; when boundaries are too closed, relationships are disengaged. Boundaries around the executive subsystem are of particular importance because the hierarchy of a family is crucial to its well-being. Therapists interested in changing a family’s structure track the sequences of interaction that are manifestations of that structure, rather than just those events that revolve around the presenting problem. Once a sense of a family’s organization has been discerned, a structural therapist sets about reorganizing this arrangement by adjusting boundaries, strengthening hierarchies, and challenging dysfunctional coalitions. Family Life Cycle. Most schools of family therapy have incorporated the concept of the family life cycle in their thinking. The concept was borrowed from sociology and introduced to the field by Jay Haley; it divides a family’s development into stages with different tasks to be performed at each stage. Betty Carter and Monica McGoldrick enriched this conceptual framework by adding a multigenerational point of view and including stages of divorce and

Chapter 2: The Fundamental Concepts of Family Therapy

remarriage. Approaches that consider the family life cycle embrace goals of helping families recognize and work through developmental transitions. Family Narratives. Narrative therapists help people identify oppressive stories and to construct new, more empowering accounts of their lives. Many who have adopted the narrative metaphor have abandoned systems thinking. They aren’t interested in family dynamics or the history that might have led to family problems. Instead, they focus on a new set of techniques that help family members change personal and family narratives (see Ch. 13). Gender. To understand families and their conflicts it’s important to realize that men and women have traditionally been socialized with different expectations and assumptions. Moreover, men and women continue to live and work in a culture with institutionalized gender biases. While therapists may disagree about the need to introduce gender issues in treatment if family members fail to do so, there can be little disagreement about the need to be sensitive to how such issues pervade the lives of families. Culture. For years the field was blind to the impact of the larger culture in which families are embedded. The feminist critique in the 1980s helped turn our focus toward the impact of our culture’s attitudes toward women, people of other races and ethnicities, people with different lifestyles, and people who are poor. No longer is it acceptable to consider a family in isolation from such factors as patriarchy, racism, homophobia, classism, poverty, crime, work pressures, and materialism.

SUGGESTED LEARNING ACTIVITIES Films The Women’s Project: New Clinical Issues in Family Therapy, Betty Carter, Peggy Papp, Olga Silverstein, and Marianne Walters Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Presented in this Keynote address delivered at the AAMFT annual conference are the fifteen years of collaboration which have raised the consciousness of the field to the context of gender and the interface of feminist and systems theory. VIDEO. Frank Pittman: The Values of Therapy Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Issues of social conscience, character, and therapeutic correctness are illustrated through provocative movie clips. VIDEO. Salvador Minuchin Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Minuchin discusses his therapeutic style, its impact on the live consultation and the roots of therapists’ styles. VIDEO, 1994, 120 minutes. Empowering Black Families in Therapy: Nancy Boyd-Franklin Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Boyd-Franklin presents her model for working with Black families including extended family involvement, informal adoption, spirituality, and larger systems issues of racism and the intrusion of outside agencies. VIDEO, 120 minutes. Conversations about Murray Bowen Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and

Chapter 2: The Fundamental Concepts of Family Therapy

then clicking on ―Search This Web Site.‖) James Framo, Edwin Friedman, Norm Paul, Lyman Wynne, Kathleen Kerr, Michael Kerr, and colleagues discuss the life and legacy of Murray Bowen.

Discussion questions 1. Pose the following questions to encourage students to explore the role of values in family therapy. Is family therapy value free? Should it be? Take a position and generate arguments for or against. How might your own values about families affect your approach to working with them in therapy? What specific values (if any) do you consider important to developing a therapeutic relationship with a family in treatment? 2. What values about family life seem to be politically correct these days? 3. Prior to reading about various approaches of family therapy presented later in the text, it may be useful for students to explore their own opinions and beliefs about families by considering the following questions. Each of the pioneers of family therapy were faced with the same set of questions for which there were no previous answers. Note to instructors: Students should be encouraged to judge the merits of the approaches to family therapy described in the text based on how effective, ethical, and ecologically or politically sensitive each approach is, and how well each approach fits with the student’s own values, personal style, and intuition. Evaluations of these approaches should not be based on which purportedly describes ―real‖ family process.  How do families operate? How do they develop?  What is the difference between healthy and pathological families?  What is the relationship between a family member’s symptoms and the family’s operation?  How can families change the way they operate?  Why do families sometimes resist taking obvious steps toward improvement?  What should be a therapist’s role in treating a family? 4. Is there anything inherent in systems theory that necessitates ignoring individual characteristics (such as personality and psychopathology) or cultural influences (such as ethnicity and gender roles)? 5. Why have social constructionists tended to neglect systems theory? Is this necessary to putting the insights of social constructionism into practice? 6. To what extent should a family therapist take the role of expert? Perhaps assign students to debate this issue -citing specific examples of published reports of therapeutic interventions. 7. Have students take turns generating a list of complaints and some possible complementary complaints. e. g., ―My wife nags‖; ―My husband never listens to me – or never does what I ask him to.‖ 8. Have students generate a list of (clinical) problems, then various linear explanations: medical, behavioral, and psychodynamic. Then suggest dyadic explanations for the same problems; then triadic explanations. 9. How would you put to clinical use the finding that abusive men have anxious attachment histories? 10. Why is it so hard to achieve and maintain a systemic perspective when working with clinical problems? 11. Today’s students generally reject the idea that men and women are raised with different expectations. Are different values for men and women a thing of the past, or something that has changed – but not completely?

Chapter 2: The Fundamental Concepts of Family Therapy

Supplemental Readings Bertalanffy, L. von. 1968. General system theory. New York: George Braziller. Carter, E., and McGoldrick, M., eds. 1999. The expanded family life cycle: Individual, family, and societal perspectives. 3rd ed. Boston: Allyn and Bacon. Davidson, M. 1983. Uncommon sense: The life and thought of Ludwig von Bertalanffy. Los Angeles: J.P. Tarcher. Haley, J. 1985. Conversations with Erickson. Family Therapy Networker, 9(2): 30-43. Luepnitz, D.A. 1988. The family interpreted: Feminist theory in clinical practice. New York: Basic Books. McGoldrick, M., Giordano, J., and Pearce, J.K. eds. 1996. Ethnicity and family therapy 2nd ed. New York: Guilford Press. Weinberg, G. 1975. An introduction to general systems thinking. New York: Wiley. Wheatley, M. 1992. Leadership and the new science: Learning about organization from an orderly universe. San Francisco: Berrett-Koehler Publishers.

Chapter 3: Basic Techniques of Family Therapy

Chapter 3: Basic Techniques of Family Therapy INTRODUCTION This chapter offers guidelines for getting started in family therapy. The initial phone contact should be used to gather information and arrange for the whole family to come in for a consultation. In the first session it’s important to establish an alliance with everyone present, to explore the presenting complaint and its interpersonal context, and to formulate a tentative hypothesis about what might be keeping the family from resolving its problems. In the first or second session, the family should be offered a treatment contract, which should define the conditions of treatment (time, place, fee, etc.) and offer the family hope that the therapist will be able to help them. Suggestions are offered for the remaining stages of treatment, through and including termination and follow-up. The second section of this chapter is devoted to more extensive suggestions about assessment, emphasizing certain issues that should be explored even when families don’t bring them up. Marital violence and sexual abuse are examples of clinical problems likely to require specialized approaches, and guidelines are offered for working with these difficult cases. Finally, suggestions are made for working collaboratively with the managed care industry and for establishing a fee-for-service private practice.

Leading Figures Virginia Goldner, Michael Johnson, Marsha Sheinberg, Gillian Walker.

Important Terms circular causality: the idea that actions are related through a series of recursive loops. complementary: relationships based on differences that fit together, where qualities of one make up for lacks in the other. empathy: the ability to put yourself in someone else’s shoes and understand how that person feels. family homeostasis: tendency of families to resist change in order to maintain a steady state. family life cycle: stages of family life, from separation from parents to forming a couple, having children, growing older, retirement, and so on; each stage typically requires some structural modifications in the family. family rules: a descriptive term for redundant behavioral patterns. feedback: the return of a portion of the output of a system, especially when used to maintain the output within predetermined limits (negative feedback), or to signal a need to modify the system (positive feedback). genogram: a schematic diagram of the family system, using squares to represent males, circles to represent females, horizontal lines to indicate marriage, and vertical lines for children. homework: therapeutic tasks assigned for clients to carry out between sessions. identified patient: the symptom bearer or official patient as identified by the family. hypothesis: a formulation explaining why clients have a particular problem and what is keeping them from resolving it. linear: simple explanations of cause and effect, where A causes B. managed care: a system in which third party companies control health care costs by regulating the conditions of treatment. medical model: the idea that psychological disorders reside in individuals, just like medical diseases. presenting problem: the specific complaint clients come in with, phrased in their terms. process/content: distinction between how members of a group (or family) relate and what they talk about. reframing: relabeling a family’s description of behavior to make it more amenable to therapeutic change; for example, describing someone as ―discouraged‖ rather than depressed. resistance: anything clients do to oppose or retard the progress of treatment, often for purposes of self-protection. structure, family: the way a family is organized, involving closeness and distance, which

Chapter 3: Basic Techniques of Family Therapy

defines and stabilizes the shape of relationships. subsystems: smaller units in systems, in families these are determined by generation and function. symmetrical: in relationships, equality or parallel form. systemic context: the network of surrounding people, including family, friends, and important others. therapeutic alliance: the working partnership between therapist and clients. treatment contract: an explicit agreement between therapist and clients regarding the terms of treatment.

SUMMARY OF KEY POINTS AND ISSUES GETTING STARTED The goal of the initial phone call is to get an overview of the presenting problem and arrange for the family to come for a consultation. When clients resist the suggestion to bring in the whole family, the therapist should try to understand the reasons for their reluctance. It’s generally not useful to imply ―that everyone is part of the problem‖ or that the consultation is a prelude to ―family therapy.‖ Rather, simply saying that the clinician needs everyone to attend in order ―to get as much information as possible‖ or ―to get everyone’s point of view‖ is usually sufficient to ensure the family’s attendance. Finally, a reminder call before the first session may cut down on the no-show rate. The primary objectives of the first interview are to build an alliance with the family and gather information to formulate a hypothesis about what’s maintaining the presenting problem. Because family members are often anxious or uncertain about the need for their participation, it’s important to listen respectfully to everyone’s perspective on the problems that brought the family to treatment and to acknowledge any reluctance to participate. Some therapists use genograms to diagram the extended family history, while others concentrate more on the family’s immediate situation. Two especially useful kinds of information are solutions that don’t work and transitions in the family life cycle. Moreover, although most of the emphasis may be on a family’s problems, it’s important not to overlook their strengths and successes. In addition to exploring the content of a family’s problems, it’s useful to observe the process and structure of their interactions. Often it turns out that families have trouble solving their problems not because they lack ideas because they aren’t working together effectively. By the end of the first or second session, the therapist and family should agree on a treatment contract specifying the family’s goals and such conditions of treatment as meeting times, attendance, and fees. The early phase of treatment is devoted to refining the therapist’s hypothesis into a formulation of what is maintaining the presenting problem and beginning to work with the family to resolve it. While the therapeutic alliance must be maintained at all times, the emphasis now shifts from joining the family to challenging them to look at other options. While strategies and techniques vary, effective therapists are forceful and persistent in their pursuit of change. Among common strategies are challenging the idea that one person is the problem and that family members are not affected by one another. Regardless of how the therapist might question assumptions or interactions, it’s essential to respect and acknowledge clients’ feelings and points of view. Homework assignments may be used to test a family’s flexibility or to help them practice new coping strategies. Supervision can help therapists check the validity of their formulations and more effectively implement change strategies. In the middle phase of treatment therapists take a less directive role and begin to encourage family members to rely more on their own resources. If change is initiated in the early phase, the middle phase is the time for consolidating those changes. During this phase therapists are advised to encourage family members to talk more among themselves and to increasingly test their own coping resources. Therapists should make certain that they haven’t begun to assume responsibilities that render family members dependent. For most family therapists termination comes when a family has resolved the presenting problem and begins to feel that they can now manage their lives without professional help. At this time, it’s useful to review with the family

Chapter 3: Basic Techniques of Family Therapy

what they’ve learned in the course of therapy and to anticipate and plan for upcoming challenges. In many cases a therapist may wish to terminate with the implication that the family can return if they feel the need in the future.

Family Assessment While clinicians vary in the extent to which they do formal assessments, the authors suggest that most family therapists spend too little time on this essential endeavor. When exploring the presenting problem, it’s important not to jump to conclusions. Listen carefully to the family’s account of the problem and ask detailed questions to elicit not only one description but each family member’s perspective. Pay attention both to the problems described and to how family members respond to those problems. It’s also important to understand the referral route. Who made the referral, and why? What does this person or agency expect, and what expectations have they created in the client family? In systems oriented family therapy, it’s important to help families shift from a linear perspective (the symptomatic family member is the only problem) and medical model thinking (he or she is his or her diagnosis) to an interactional perspective. To accomplish this shift, a therapist needs to broaden the focus from the identified patient (IP) and his or her symptoms to the entire family and their interactions. Other important considerations in the assessment include the systemic context (important others, including people outside the family, relevant to the presenting problem), the stage of the family life cycle (which may provide a clue to the system’s being stuck in transition), the family’s structure (including the possibility of overinvolvement or neglect on the part of various family members), and communication problems. Any suspicion of drug or alcohol abuse, domestic violence, sexual abuse, or extramarital affairs should be explored carefully. In many cases, individual interviews may be indicated for exploring these toxic problems. Finally, even though client families may not raise these issues themselves, therapists should be sensitive to gender inequalities, cultural idiosyncrasies and strains, as well as ethical issues, including the importance of confidentiality (and its limits in cases where outside agencies are involved), as well as the balance of fairness among family members.

The Ethical Dimension Most of the ethical principles of family therapy seem like common sense – therapy should be for the benefit of the clients, not the therapist; clients are entitled to confidentiality; and so on – but sometimes common sense goes out the window when something triggers a therapist’s anxiety, or desire, or pity, or the belief that this client or therapeutic situation is special. For this reason therapists are well advised to study the ethical standards of their profession, and if they even think about violating them, at the very least, seek a second opinion from a respected colleague.

Family Therapy with Specific Presenting Problems Most therapists no longer believe that any one therapeutic model can effectively be applied to any and all clinical problems. Among the cases for which it may be particularly important to tailor the approach to the problem are marital violence and sexual abuse. Even those (e.g., Virginia Goldner and Gillian Walker) who advocate the use of couples therapy in cases where there has been physical violence believe that the first priority should be that both partners take responsibility for ensuring that no further incidents of violence are tolerated. Once the batterer has accepted accountability for his actions and committed himself not to repeat them, and his partner realizes that she must take steps to guarantee her own safety at the first hint of violence, it may then be possible to explore the couple’s relationship dynamics. Planned time-outs are widely recommended to defuse arguments as soon as they begin to escalate, while inquiring into the specific details of conflict may help reduce the global judgments that drive up emotionality. In cases where a child has been sexually abused, the first priority is to ensure that the abuse does not recur. Establishing support systems to break through the isolation that allows sexual abuse to take place is one of the goals with the family, as is taking steps to make sure that children and their adult caretakers maintain appropriate boundaries. A combination of individual and conjoint sessions may be useful to give children a forum to talk about

Chapter 3: Basic Techniques of Family Therapy

their painful and embarrassing experiences, while ultimately supporting the parent(s) in their role as the child’s caretakers.

Working with Managed Care Rather get fall into an adversarial (and self-defeating) relationship to managed care companies, therapists are advised to learn how the system works, find out how to get on provider panels, and develop cooperative relationships with case managers. Willingness to accept difficult cases, responding promptly, providing concrete goals and strategies, and writing well-defined treatment plans are among the steps recommended to help clinicians work effectively with the managed care industry.

Community Mental Health In some settings it is common for families to have more practical needs – housing, financial, medical – than settling family conflicts. Therapists working in such settings or with such clients should learn how to access and coordinate community resources – as well as empowering families to take advantage of them.

Fee-for-Service Private Practice Therapists who choose not to accept managed care insurance can compete in the marketplace if they have established reputations or unique skills. Advanced training is one way to attract fee-paying clients. Establishing an excellent reputation in the community is important in attracting clients willing to pay full cost for treatment. While they may not be everyone’s cup of tea, marketing and networking are also important in building a private practice.

SUGGESTED LEARNING ACTIVITIES Role Plays/Observations 1. Have students take turns role-playing therapists talking on the phone to clients requesting help for one family member. The therapist’s job is to listen sympathetically but convince the caller to bring the entire family for a consultation. 2. Generate a list of complaints that callers might request therapy for and have the class come up with hypotheses about what might be going on in a family that’s maintaining these problems. Note the extent to which the class considers process dynamics, family structure, psychopathology, and psychodynamics. Do they avoid considering or over-rely on any of these important dimensions? 3. Conduct a first interview with a role-play family. Ask students to role play a family with a rebellious adolescent who is failing the 10th grade. Father has recently been laid off from his job as a distribution manager and mother has had to return to work for a temping agency and is barely making minimum wage. Two other siblings are in the family, a 12-year-old daughter who is a model child, and a 10-year-old brother. Demonstrate to the class during a 15-20 minute role-play how a family therapist works to build an alliance with family members and develop some hypotheses about what family patterns are maintaining the problem. Break and discuss observations, reactions, and questions. N.B. Although an instructor can suggest a particular scenario, role plays often work best when students are left to invent their own scenarios. 4. Have students conduct a family observation. Be sure to have students obtain permission from the family to audio or video the session. Have students take extensive notes on their observations. One suggestion is to divide your note-taking paper into 3 sections—speaker, content, process observations. Be alert for expressions, body movements; note interruptions, topic changes, and times that one family member disconfirms another by ignoring, changing the topic, or speaking about another with a third family member. Who sits closest to whom? Who’s furthest away from whom? Does this proximity and distance reflect the level of involvement between members or not? Who talks to whom? How would you describe the climate of the family, what they talk about and the way they interact during periods of calm versus any periods of higher tension/anxiety? Try to track a few

Chapter 3: Basic Techniques of Family Therapy

of the process dimensions during the observation and then review the tape to conduct a more thorough analysis of the interactions. What evidence did you observe for the existence of homeostasis, negative feedback loops, complementarity, what family rules seemed to exist?, and any paradoxical communications. Students should apply their knowledge of family systems theory learned thus far to record and discuss their perceptions of family interactionse.g., parents with each child, husband and spouses with one another. Students can be instructed to submit a written report or prepare a presentation of their observations for class. Spend some time in class reviewing sections of video and discussing students’ observations.

Films Paul Watzlawick: Mad or Bad? (American Association for Marriage and Family at http://www.aamft.org/resources/index.htm then select ―AAMFT Tape Store.‖ In his consultation with a family whose 25-year old son presents with chronic somatic symptoms, Watzlawick employs strategic use of Ericksonianstyle questions. The systemic function of symptoms in protecting the family from other problems is highlighted. VIDEO, approximately 136 min. Jay Haley & Judge Clinton Deveaux, In the Maze: Families and the Legal System (American Association for Marriage and Family at http://www.aamft.org/resources/index.htm then select ―AAMFT Tape Store.‖ This video offers guidelines for effective compulsory therapy as an alternative to incarceration. VIDEO. Virginia Satir: The Use of Self in Therapy #7953 (Menninger Video Productions, distributed by Altschul Group Corporation, 1560 Sherman Ave., Ste. 100, Evanston, IL 60201. Michele Baldwin, Ph.D., co-author with Satir of The Use of Self, draws on Satir’s legacy of clinical recordings to demonstrate the tenets of her theory and practice. Therapy footage is interspersed with expert commentary. Explored are methods to empower family members, bolster self-esteem, reframe problems, and communicate with congruence. VIDEO, 30 minutes. Virginia Satir: The Lost Boy (American Association for Marriage and Family Therapy at http://www.aamft.org/resources/index.htm then select ―AAMFT Tape Store,‖ or call 1-800-776-5454). Satir conducts an experiential session with a large intact family with ten children whose presenting problem is grief following the loss of one of the children who is still missing a year after his abduction. This session provides a good demonstration of Satir’s open, directive, spatial style. VIDEO, approximately 80 min.

Class Discussion 1. Ask the class to generate a list of suggestions for cutting down on the no-show and cancellation rates. Do students think it would be more effective for the therapist to place a reminder call before the first consultation session or ask the family to take the responsibility for calling to confirm their attendance? Have students role play talking on the phone to a client who has called to cancel, in which (a) the therapist politely accepts the client’s excuses, and then (b) doesn’t readily accept the client’s explanation and instead acts as though it isn’t okay not to show up--polite skepticism. 2. Under what circumstances should a therapist refuse to meet with a family if not everyone shows up? 3. What are the pros and cons of taking a formal history, including a genogram? 4. When terminating with a family, what are the advantages and disadvantages of suggesting that they may wish to return for further sessions some time in the future? 5. What are some of the dangers of couples therapy with violent couples? What are the dangers of not seeing such couples together? Discuss the role of countertransference in the clinician’s response to the issue of marital violence.

Chapter 3: Basic Techniques of Family Therapy

6. Is it possible to work effectively with clients if the therapist cannot empathize with them? What are some of the kinds of people that students have trouble empathizing with? What can be done to help a therapist increase his or her ability to empathize with such difficult clients as the hostile father, the controlling mother, the rebellious teenager, etc.? Have students role play families with hard-to-empathize-with members – and have the student who acknowledges trouble empathizing with certain types of people to be the one who plays those individuals. 7. Propose (or have students generate) ethical practice dilemmas where traditional clinical values (neutrality, confidentiality, etc.) might conflict with legal or ethical principles or common sense.

Supplemental Readings Anderson, C., and Stewart, S. 1983. Mastering resistance: A practical guide to family therapy. New York: Guilford Press. Minuchin, S., and Fishman, H.C. 1981. Family therapy techniques. MA: Harvard University Press. Minuchin, S., Nichols, M. P., and Lee, W-Y. 2007. Assessing families and couples: From symptom to system. Boston: Allyn & Bacon. Nichols, M. P. 2009. The lost art of listening, 2nd ed. New York: Guilford Press. Patterson, J. E., Williams, L., Grauf-Grounds, C., and Chamow, L. 1998. Essential skills in family therapy. New York: Guilford Press. Sheinberg, M., True, F., & Fraenkel, P. 1994. Treating the sexually abused child: A recursive, multimodel program. Family Process, 33: 263-276. Taibbi, R. 2007. Doing family therapy: Craft and creativity in clinical practice, 2nd ed. New York: Guilford Press. Trepper, T.S., & Barrett, M.J. 1989. Systemic treatment of incest: A therapeutic handbook. New York: Brunner/Mazel. Walsh, F. 1998. Strengthening family resilience. New York: Guilford Press.

Chapter 4: Bowen Family Systems Therapy

Chapter 4: Bowen Family Systems Therapy INTRODUCTION Bowen family systems therapy is the most comprehensive theory of family dynamics. Bowen’s conceptual focus was the multigenerational family system; his actual unit of treatment was an individual or a couple. According to Bowen, each of us carries within us unresolved emotional reactivity to our parents, leaving us vulnerable to repeat similar patterns in our adult relationships. These unresolved issues with our original families may be the most important unfinished business of our lives.

Leading Figures Murray Bowen, Philip Guerin, Thomas Fogarty, Michael Kerr, Betty Carter, and Monica McGoldrick.

Important Terms detriangling: the process by which an individual removes himself or herself from the emotional field of two people in a relationship. differentiation of self: the ability to distinguish between thoughts and feelings and to choose between using one’s intellect or merely reacting to emotions. On an interpersonal level, it is the ability to experience both intimacy and autonomy. emotional cutoff: flight from unresolved emotional attachment to family. emotional fusion: a blurring of psychological boundaries between self and others, and a blurring of emotional and intellectual functioning. family life cycle: stages of family life, from separation from parents to marriage, having children, growing older, retirement, and finally death. genogram: a schematic diagram of the family system, using squares to represent men, circles to indicate women, horizontal lines for marriages, and vertical lines to children. multigenerational emotional processes: emotional processes – fusion, triangulation, distancing, cutoffs, anxious attachment, overinvolvement, projection of conflicts – that operate over generations in interlocking patterns. process questions: queries to explore how individuals are reacting and behaving in relationships, designed to increase self-focus. relationship experiments: assignments designed to help family members try behaving differently in key relationships in order to experience what it’s like to act counter to their usual emotionally driven responses. sibling position: is thought to predict what part a child might play in the family emotional process, in conjunction with specific knowledge about a particular family. societal emotional process: a background influence affecting all families; describes how an increase in social anxiety results in a gradual lowering of the functional level of differentiation in the community. triangles: third persons or activities used to distract two people in a relationship from resolving their own problems. triangulation: detouring conflict between two people by involving a third person, stabilizing the relationship between the original pair. undifferentiated family ego mass: Bowen’s early term for emotional fusion in the family, especially prominent in schizophrenic families.

SUMMARY OF KEY POINTS AND ISSUES Sketches of Leading Figures Murray Bowen began his career in the late 1940s at the Menninger Clinic where he focused on the emotional reactivity between schizophrenic patients and their mothers. In 1954 Bowen moved to NIMH where he initiated a project of hospitalizing whole families containing a schizophrenic member. In the process he discovered that the emotionality he’d previously observed between mothers and children characterized the whole family. It was this

Chapter 4: Bowen Family Systems Therapy

emotionality, or fusion, that Bowen came to see as the core problem in human relationships. Overcoming emotional fusion and achieving a mature level of differentiation of self became the primary goal of Bowen family systems therapy. Bowen moved to Georgetown University in 1959 and there over the course of thirty one years developed a comprehensive theory of family therapy and taught a whole generation of prominent students, including Philip Guerin, Thomas Fogarty, and Michael Kerr. Other influential students of Bowen’s model were Betty Carter and Monica McGoldrick, known for their work on the family life cycle and for efforts on behalf of feminism and cultural sensitivity.

Theoretical Formulations Bowen’s theory centers around two counterbalancing life forces -- togetherness and individuality. Unbalance in the direction of togetherness results in fusion, while unbalance toward individuality leads to emotional cutoff. The capacity for differentiation of self helps people avoid getting caught up in reactive polarities. The central premise of Bowen theory is that conflictual emotional attachment to one’s family must be resolved before one can differentiate a mature, healthy personality. The theory’s five defining constructs are described below. 1. Differentiation of Self: the degree to which one balances (a) emotional and intellectual functioning and (b) intimacy and autonomy in interpersonal relationships. More differentiated individuals can have strong feelings but can shift to logical reasoning for decision making and problem solving when they choose. In contrast, undifferentiated persons tend to act solely on the basis of emotions. They either conform or rebel. 2. Emotional Triangles: All emotionally significant relationships are shadowed by third parties -- relatives, friends, even memories. Triangling lets off steam, but freezes conflict in place, and can become a chronic diversion that undermines relationships. Most family problems are triangular, which is why working only on twosomes may achieve limited results (e.g., teaching a mother techniques for disciplining her son won’t resolve the problem if she’s overinvolved with the boy as a result of her husband’s distance). 3. Nuclear Family Emotional Process: Prolonged levels of stress in a family results in one of four dysfunctional patters: marital conflict, dysfunction in one spouse, dysfunction in one or more children, or emotional distancing. 4. Family projection process is the process by which parents transmit their lack of differentiation to their children. Spouses with unresolved family-of-origin issues create a family environment that leads to an intense focus on one or more or the children. The child who becomes the object of the projection process becomes the one most attached to the parents (positively or negatively) and the one with the least differentiation of self. With the parent focusing his or her anxiety on the child, the child’s ability to adapt is stunted, often precipitating dysfunction. 5. Multigenerational Emotional Process: In each generation, the child most involved in the family’s fusion moves toward a lower level of differentiation of self, while the least involved child moves toward a higher level of differentiation. Individuals at similar levels of differentiation seek out and marry one another. They establish the emotional atmosphere in their new family, which in turn influences their children’s abilities to regulate their own emotionality and tolerate emotional separation. This concept takes the notion of emotional illness beyond the individual to the extended family. Problems in identified patients are a product of their relationships with their parents, which is a product of the relationship of their parents, continuing back for generations. 6. Emotional Cutoff: personified in the reactive emotional distancer, who is relatively undifferentiated in spite of appearing independent from others. This individual tends to deny the importance of his family, often boasts of his emancipation from parents, and displays an exaggerated facade of independence. The emotionally cut-off person finds intimacy threatening. 7. Sibling Position: According to Bowen, children’s birth order has a predictable influence on their characters. This is a familiar and popular notion – which is probably true, but perhaps not as easy to generalize about as some people think.

Chapter 4: Bowen Family Systems Therapy

8. Societal Emotional Process: describes the emotional process in society as a background influence on families. This concept describes how an increase in social anxiety can result in a gradual lowering of the functional level of differentiation in the community. Monica McGoldrick and Betty Carter have added gender and ethnicity to these theoretical notions by calling attention to gender inequalities and ethnic differences in families. Without understanding how cultural norms and values differ among ethnic groups, therapists may impose their own ways of looking at things on families whose perspectives aren’t dysfunctional but simply different.

Normal Family Development Families are thought to vary along a continuum of differentiation, from low to high. Optimal development occurs when family members are relatively well differentiated, anxiety is low, and parents are in good emotional contact with their own families. Family members who are well-differentiated are able to distinguish thinking from feeling and remain independent, though in connection with their nuclear and extended families. People tend to choose partners at similar levels of differentiation, because the emotional attachment between them is similar to what they experienced in their families of origin. Carter and McGoldrick (1999; 1988) have described the family life cycle as a socially-embedded process of expansion, contraction, and realignment of the family relationship system to support the entry, exit, and individual development of family members. The life cycle stages are: 1. 2. 3. 4. 5. 6.

leaving home: young adults separate from their families and become autonomous without cutting off or reactively fleeing to new relationships. joining of families through marriage: requires commitment to the new couple. Problems reflect a failure to separate from families of origin or emotional cutoffs that put too much pressure on the twosome. families with young children: adjustment to make space for children, cooperation in the tasks of parenting, keeping the marriage alive. adolescence: flexible boundaries to permit greater independence as children struggle to become autonomous individuals launching children and moving on: parents let their children go and take hold of their own lives. families in later life: parents adjust to retirement, sudden loss of vocation, and increased proximity.

Development of Behavior Disorders Symptoms in a family reflect (a) the level of chronic anxiety and (b) the level of differentiation in the family system (not simply in the individual). The more well-differentiated the person, the more resilient he or she is, and the more flexible and sustaining his or her relationships. The less differentiated the person, the less stress it takes to produce symptoms. Bowen espoused a diathesis-stress model of symptom development (based on family dynamics rather than biology). Undifferentiation in the family of origin leads to marital problems in the nuclear family, which are projected onto a spouse or child who then becomes symptomatic. Increases in the level of anxiety or emotional arousal in the family may also produce symptoms; typically the most vulnerable person (child, adolescent, or adult) develops symptoms. Whatever the presenting problem, the dynamics are similar: undifferentiation in families of origin leads to couples problems, which are projected onto a symptomatic partner or child.

Goals of Therapy The goal of Bowen family therapy is to decrease anxiety and increase differentiation of self. Therapists strive to help individuals gain insight into the forces of the family system and how they have shaped his or her life. Tracing the pattern of family problems means paying attention to two things: process and structure. Process refers to patterns of emotional reactivity; structure, to patterns of interlocking triangles.

Chapter 4: Bowen Family Systems Therapy

Conditions for Behavior Change Bowen therapists do not encourage dialogue among family members but rather talk to them one at a time in an attempt to, first, defuse conflict, and, second, to help individuals explore their own role in family problems. Lowering anxiety and increasing self-focus are the primary vehicles of change.

Therapy Assessment. Bowenian assessment begins with a description and history of the relationship context of the presenting problem. Genograms are used to chart the history of the nuclear family and to trace significant relationship patterns (triangles, cutoffs, etc.) through at least three generations. Therapeutic Techniques. Therapy is conducted through the use of process questions-- interrogatories that encourage family members to think about how they react and respond to other family members. The underlying message is that although problems take place in a relationship, individuals are responsible for their own reactions and behavior. A variety of treatment formats are used: families, couples, and individuals. According to Bowen, an understanding of how family systems operate is more important than specific techniques. Bowen therapists tend to ask questions designed to lower anxiety, help clients to think--not react emotionally to each other--and tease out patterns of relationships. In Bowen therapy, process questions are used to slow people down, diminish reactive emotions, and start them thinking about how they are involved as participants in interpersonal patterns. As partners talk, the therapist concentrates on the pattern of their interaction, not the details under discussion. If a couple begins arguing, the therapist becomes more active, calmly questioning one, then the other. Asking for detailed descriptions of events is one of the best ways to calm overheated emotions. When a therapist joins a couple, a therapeutic triad is formed. Staying detriangled requires a calm tone of voice, talking more about facts than feelings, and not taking sides. Establishing person-to-person relationships with as many family members as possible requires getting in touch and speaking personally with them, not about other people or impersonal topics. In the process of opening and deepening personal relationships one learns about the emotional forces in his or her family. The goal is to relate to people without gossiping or taking sides, and without attacking or defending. Change is begun by learning about one’s larger family -- who made up the family, where they lived, what they did, and what they were like. Genograms are useful for organizing this material. The goal when working with one person in therapy is the same as working with larger units: differentiation of self. Bowen’s personal success at differentiating from his own family convinced him that a single highly motivated individual can be the fulcrum for changing an entire family system (Anonymous, 1972). This translates to developing person-to-person relationships, seeing family members as people rather than as emotionally charged images, learning to observe oneself in triangles, and finally, detriangling one’s self. Prerequisites to differentiating a self in one’s extended family include: some knowledge of how family systems function and strong motivation to change.

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Divide the class into groups of 4-5 and ask students to conduct a 10-15 minute role-play using process questions. One student should play the therapist, two students play a couple entering treatment, and at least one student observer is needed. Next, generate a potentially heated topic for discussion -- for example, parents’ differing views on child rearing or division of labor in the home, their adolescent son or daughter’s curfew during Christmas vacation from college, their son or daughter’s wish to buy a motorcycle or get a tattoo, deciding to get an abortion; inviting a son or daughter’s gay or lesbian partner to an important family event. Process questions are designed to slow the couple down, diminish reactive anxiety, and start them thinking about how they are

Chapter 4: Bowen Family Systems Therapy

involved as participants in their interpersonal patterns. As the partners talk, the therapist should concentrate on the process of their interaction, not the details under discussion. Remind the therapist that his or her job isn’t to settle disputes; it’s to help the couple do so. The aim is to get clients to express thoughts and opinions to the therapist in the presence of their partners. If the couple begins arguing, instruct the therapist to become more active, calmly questioning one, then the other. The therapist should ask for detailed descriptions of events in order to calm overheated emotions. Have the class discuss each role-play. What impact did the therapist’s process questions have on the quality of the couple’s interactions? How did the couple experience the therapist’s interventions? 2. Divide the class into groups of 3-4. Generate several potentially-heated topics for discussion -- for example, parents’ views on discipline, household chores, spending time together, spending time alone, whose family to spend the holidays with, conflicts about sex, political perspectives on welfare, abortion rights, prayer in the schools, affirmative action, etc. Have students form ―marital‖ dyads and role-play a conversation with a ―therapist‖ in which each reacts to the other’s statements with emotional responses, and by using the pronouns ―we‖ and ―us‖ instead of ―I‖ and ―you.‖ Observers should take note of what happens and discuss what they see. Next, have them role-play a similar conversation, but this time instruct them to first acknowledge what the other person said before they respond, and to use the personal pronouns ―I‖ and ―you.‖ Have the group discuss each role play. Identify in Bowenian terms the phenomena observed (i.e., lack of differentiation, emotional reactivity, fusion, triangles). Do the couples attempt to form triangles with the therapist? How does the therapist respond? 3. Have students role play a parent or sibling whom they find it difficult to deal with. Have these students select a classmate to play him or herself. After a few minutes of having the ―difficult family member‖ and ―student‖ discuss their conflicts, invite a third student to play the role of a Bowenian therapist interviewing the two using process questions. 4. Have one student play a young adult who consults a counselor about solving a personal problem. Have half the class generate a list of solutions to take direct action on resolving the problem. Have the counselor then ask the student a series of process questions to uncover possible emotional processes in the family that might make it hard for him or her to follow the good advice. (The goal of this exercise is not to find solutions but to uncover possible reasons for resisting or avoiding them.)

Exercises 1. A week prior to this class, you may wish to assign students a chapter from Born to Rebel by Frank Sulloway, an empirically-based study of birth order effects. In class, ask students to divide into 4 groups according to their sibling positions in their own families of origin: oldest, middle, youngest, and only children. Have members of each group discuss their early childhood experiences and what roles and ways they developed of fitting in within their families. Ask the group to elect one student to note and record any trends within the group. Reconvene as a class and ask each spokesperson to present their group trends. Compare and contrast trends noted by students in light of what Sulloway (1996) has found about the sibling position of that group. 2. Ask students to respond to and briefly discuss their answers to the following open-ended sentences related to their own families of origin, individually or in groups of 3-4: The family I come from could best be described as . . . In my family, my mother/father was always the one who . . . In my family, everyone always thought that I . . . One topic that we didn’t discuss in my family was . . . The greatest strength about my family was . . . A good thing my father taught me was . . . A good thing my mother taught me was . . . A bad thing my father taught me was . . . A bad thing my mother taught me was . . . The thing my father does that I tend to overreact to is . . . Disagreement in my family was handled by . . . An emotion rarely expressed openly in my family was . . .

Chapter 4: Bowen Family Systems Therapy

In my family, my father/mother was closest to . . . In my family, I usually felt closest to . . . In my family, I usually felt most distant from . . . When we were out in public together, my family . . . What I like best about my family is . . . If I could change anything about my family, it would be . . . I’ve learned that in my family, I will never . . . 3. Have students interview both parents about their family history and note key family dynamics, relationship triangles, etc. (Be sure to have students ask their parents how they met and about their courtship.) Ask students to discuss their experiences about the task and of applying their knowledge of Bowen constructs to their own families. Urge them to talk to their parents (one at a time) in person – and to not push parents to become too anxious. Have them introduce this talk by saying it is a class assignment. 4. Have students generate a list of things they believe family members should not do -- cheat on their partners, abuse drugs or alcohol, blame other people for mutual problems, use abusive language, etc. Then have them discuss how they could overcome feeling judgmental in order to work effectively with a family in which some members did those things. Suggest an exercise in which a person who objects to certain behavior role-play such a person explaining to a student ―therapist‖ why and how he or she got into that habit and why it’s hard to stop doing it. Alternatively, have the judgmental student interview a classmate who plays the objectionable role.

Films Family Interview (Western Psychiatric Institute and Clinic Library, 3811 O’Hara St., Pittsburgh, PA 15213-2593, 412-246-5011). Murray Bowen interviews a young couple who have been referred for therapy because of suspected child abuse. VIDEO, 70 minutes. David Schnarch: Constructing the Sexual Crucible Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Bowen Theory and Object Relations Theory are integrated in this approach that facilitates shifts in couple dissatisfaction and conflict into greater differentiation of self and sexual intensity and intimacy. VIDEO, 120 minutes. The Best of Family Therapy (Western Psychiatric Institute and Clinic Library, 3811 O’Hara St., Pittsburgh, PA 15213-2593, 412-246-5011). An interview of Murray Bowen, conducted by Michael Kerr, Director of Training, Georgetown University Family Center. Bowen discusses specific aspects of Bowen Theory. VIDEO, 50 minutes. On Not Becoming a Wicked Stepmother Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Betty Carter conducts a consultation with a couple of different ethnic backgrounds, who have been married six months and are struggling to blend 5 children from previous marriages. Difficulties involve discipline issues, allegiances to natural parents, and redefining workable, satisfying roles. The couple is instructed on elements of timing and normality while working through the family genogram to illustrate a new paradigm for families. VIDEO, 120 minutes. Family Reaction to Death (Western Psychiatric Institute and Clinic Library, 3811 O’Hara St., Pittsburgh, PA 152132593, 412-246-5011). A lecture presented by Murray Bowen on what death and dying mean within the context of the family system. VIDEO, 60 minutes. Bowenian Therapy with Dr. Phil Guerin (Allyn & Bacon, P.O. Box 10695, Des Moines, IA 50336-0695, 1-800-2783525, www.abacon.com/ftvideos).

Chapter 4: Bowen Family Systems Therapy

Class Discussion Note to instructors: To assist students in learning to conceptualize normal family development from a multigenerational perspective, have students consult Carter and McGoldrick’s (1999) text on the expanded family life cycle (see below). 1. Give studens several weeks’ notice to prepare their own family genograms by consulting various members of their nuclear and extended families. In class, divide students into groups of 3 or 4 and have them review their genograms. Encourage students to explore key triangles in their families and relationship processes (e.g., instances of emotional fusion or reactive distancing, general level of differentiation in the family, etc.). Reconvene as a class and explore students’ reactions to the exercise and information shared. What sort of experiences did they have when contacting family members to obtain information to complete the genogram? 2. Consider Bowen’s notion that people seek out partners with identical levels of differentiation of self. Do you think this is true? Why might people marry partners at similar levels of differentiation? According to Bowen, why would a mismatch fail? 3. Discuss the strengths and weaknesses of Bowen family systems therapy. For example, Bowen’s approach is thought to be long on theory but short on specific techniques to treat families. What might be considered the major contributions of this approach to the field of family therapy? How might a lack of technique be a good thing? Consider theoretical adequacy, specificity of constructs, strategies and techniques, role of the therapist, and types of client problems best suited for this approach. What is lost and what is gained by an approach that de-emphasizes work with the whole nuclear family and doesn’t work with family interactions and dialogue? Follow-up: How often have you seen any group of family members having a discussion about emotionally loaded topics that doesn’t degenerate into bickering and emotional reactivity? 4. Compare Bowen theory to other family systems approaches (e.g., structural, psychoanalytic, strategic, and experiential), with respect to the criteria presented above. 5. Have the students read a novel or biography (e.g., The Prince of Tides or The Great Santini by Pat Conroy, The Mambo Kings Play Songs of Love by Oscar Hijuelos, Dreaming of Cuba by Christina Garcia, Jazz or The Bluest Eye, Beloved, or Song of Solomon by Toni Morrison, Atonement by Ian McEwan), and prepare a genogram of the protagonist’s family. Students should bring the completed genograms that emphasize the relationship patterns (e.g., triangles and cutoffs) across generations to class and divide into groups of 3 or 4. Discuss how the family of origin and the protagonist’s degree of successful differentiation (or resolution of reactivity to the family) shaped the protagonist’s life and other people in contact with him or her. Have more than one student read the same book. 6. When are triangles in relationships okay, and when not? 7. To what extent is the pursuer/distancer phenomenon a function of gender? 8. How does the pursuer-distancer dynamic play out in gay and lesbian couples? 9. What is lost and what is gained by asking process questions to family members one at a time versus encouraging family members to talk directly with each other? 10. What are the advantages and disadvantages of constructing genograms versus talking with family members about their immediate concerns and then working backwards as necessary? 11. Have students generate a list of suggestions for a person who wishes to get closer to or understand better a parent who is deceased or completely estranged. 12. Are ―relationship experiments‖ significantly different from advice giving? Have students give examples of relationship experiments that are and are not different from the usual advice a counselor might give.

Chapter 4: Bowen Family Systems Therapy

Supplemental Readings Anonymous. 1972. Toward the differentiation of a self in one’s own family. In Family interaction, J. Framo, ed. New York: Springer. Bowen, M. 1976. Family reaction to death. In Family therapy: Theory and practice, P.J. Guerin, ed. New York: Gardner Press. Carter, B., & McGoldrick, M. 1999. The expanded family life cycle: Individual, family, and social perspectives. 3rd ed. Boston: Allyn & Bacon. Framo, J.L. 1992. Family of origin therapy. New York: Brunner/Mazel. Guerin, P.J., Fogarty, T.F., Fay, L.F., and Kautto, J.G. 1996. Working with relationship triangles: The one-two-three of psychotherapy. New York: Guilford Press. Guerin, P.J., Fay, L., Burden, S.L., and Kautto, J.B. 1987. The evaluation and treatment of marital conflict: A fourstage approach. New York: Basic Books. Hardy, K.V., and Laszloffy, T.A. 1995. The cultural genogram: Key to training culturally competent family therapists. Journal of Marital and Family Therapy, 21(3), 227-237. Kerig, P.K. 1995. Triangles in the family circle: Effects of family structure on marriage, parenting, and child adjustment. Journal of Family Psychology. 9: 28-43. Kerr, M., & Bowen, M. 1988. Family evaluation. New York: Norton. Lerner, H.G. 1985. The dance of anger: A woman’s guide to changing patterns of intimate relationships. New York: Harper & Row. Lerner, H.G. 1989. The dance of intimacy: A woman’s guide to courageous acts of change in key relationships. New York: Harper & Row. Lindahl, K.M., Clements, M., and Markman, H. 1997. Predicting martial and parent functioning in dyads and triads: A longitudinal investigation of marital processes. Journal of Family Psychology. 11: 139-151. McGoldrick, M., and Gerson, R. 1985. Genograms in family assessment. New York: Guilford Press. Nichols, M. P. 2009. The lost art of listening, 2nd ed.. New York: Guilford Press. Schnarch, D. 1997. Passionate marriage: Sex, love, and intimacy in emotionally committed relationships. New York: Norton. Skowron, E. A., and Friedlander, M.L. 1998. The Differentiation of Self Inventory: Development and initial validation. Journal of Counseling Psychology. 45: 235-246. Sulloway, F. 1996. Born to rebel. New York: Pantheon.

Chapter 5: Strategic Family Therapy

Chapter 5: Strategic Family Therapy INTRODUCTION The communications model that emerged from Palo Alto in the 1950s had a profound impact on the field of family therapy. Its taught us to focus on the process of communication, rather than its content. The paradigms of communication theory--derived from general systems theory, cybernetics, and information theory--were so well received that they were absorbed into virtually all other schools of family therapy. In this chapter, the authors present three models that emerged from the evolution of communications theory: (a) the Mental Research Institute (MRI) model; (b) the brief strategic therapy of Jay Haley; and (c) the Milan systemic school. All three approaches focus on solving problems using strategic interventions designed to bypass resistance, downplay intrapsychic processes, and believe that: (1) therapy should be brief; (2) people aren’t pathological; and (3) change can occur rapidly. While they share a common heritage, these models also contain distinct differences in the methods used to achieve those goals.

Leading Figures Communications Theory: Gregory Bateson, Milton Erickson, Jay Haley, Don Jackson, John Weakland, Paul Watzlawick,Virginia Satir. MRI: Don Jackson, Paul Watzlawick, John Weakland, Richard Fisch, Jules Riskin, Janet Beavin, Arthur Bodin. The Haley/Madanes Approach: Jay Haley, Cloe Madanes, James Keim, Jerome Price. Milan Associates: Luigi Boscolo, Gianfranco Cecchin, Mara Selvini Palazzoli, Guiliana Prata.

Important Terms circular questioning: a method of interviewing developed by the Milan associates in which questions are asked to highlight differences among family members. communications theory: the study of relationships in terms of the exchange of verbal and nonverbal messages. cross-generational coalition: an inappropriate alliance between a parent and child who side together against a third family member. cybernetics: the study of control processes in systems, especially analysis of the flow of information in closed systems. directives: homework assignments designed to help families interrupt homeostatic patterns of problem-maintaining behavior. double bind: a conflict created when a person receives contradictory messages on different levels of abstraction in an important relationship and cannot leave or comment. family ritual: technique used by the Milan group that prescribes a specific scenario for family members to perform, designed to change a family system’s rules. family rules: a descriptive term for redundant behavioral patterns. feedback: the return of a portion of the output of a system, especially when used to maintain the output within predetermined limits (negative feedback), or signal a need to modify the system (positive feedback). first-order change: superficial change in a system which itself stays invariant. hierarchical structure: family functioning based on clear generational boundaries, where the parents maintain control and authority. homeostasis: a balanced steady state of equilibrium. metacommunication: the implied command or qualifying part of a message. neutrality: Selvini Palazzoli’s term for balanced acceptance of family members. ordeal: paradoxical intervention in which the client is directed to do something that is more of a hardship than the symptom. paradoxical directive: a strategic technique in which a therapist directs clients to continue their symptomatic behavior as a way of putting it under therapeutic control. positive connotation: Selvini Palazzoli’s technique of ascribing positive motives to family behavior in order to avoid resistance to therapy.

Chapter 5: Strategic Family Therapy

pretend techniques: Madanes’ playful paradoxical intervention in which family members are asked to pretend to engage in symptomatic behavior. The paradox is if they are pretending to have a symptom, the symptom can’t be uncontrollable. reframing: relabeling a family’s description of behavior to make it more amenable to therapeutic change; for example, describing someone as ―lonely‖ rather than ―depressed.‖ restraining: a strategic technique for overcoming resistance by suggesting that a family not change. second-order change: a basic change in the structure and functioning of a system.

SUMMARY OF KEY POINTS AND ISSUES Sketches of Leading Figures The communications model grew out of Gregory Bateson’s schizophrenia project in the late 1950s. The progenitors of this approach were Bateson, from the theoretical perspective, and Milton Erickson, whose directive techniques found their way into the communications model via Jay Haley and John Weakland. The Mental Research Institute (MRI) was where Jackson, Haley, and Satir first began practicing the communications approach to family therapy. In the late 1960s, some of the MRI staff members transformed what had been a relatively straightforward therapy based on encouraging clear communication into a brief strategic model (MRI) in which directives and paradoxical instructions were used to manipulate families into altering problem-maintaining sequences of behavior. The MRI model was enormously influential in the 1970s and early 1980s. Haley left MRI in 1967 to join Salvador Minuchin at the Philadelphia Child Guidance Clinic. There he learned to incorporate structural concepts into his thinking and developed his abiding interest in training and supervision. In 1976 Haley, along with Cloe Madanes, established his own institute in Washington, D.C. The Washington School, as the Haley-Madanes model came to be known, was a blend of structural principles and strategic techniques. The Milan systemic model was developed in Milan (where else?) by a team of four psychiatrists under the direction of Mara Selvini Palazzoli. This model featured a sophisticated application of Bateson’s ideas in a structured therapeutic format. Following the publication of Paradox and Counterparadox in 1978, the Milan model became popular in strategic circles in this country. Among its advocates were Lynn Hoffman, Peggy Penn, and Karl Tomm.

Theoretical Formulations Communications theory described families as error-activated, goal-directed systems, and analyzed their interactions using cybernetic theory, general systems theory, and information theory. Families were conceptualized as rulegoverned systems, maintained by homeostatic feedback mechanisms. These properties account for the stability of normal families and the inflexibility of dysfunctional ones. Communications theorists focused on what went on between, rather than within, family members. The black box concept, adopted from telecommunications, ignored the internal complexities of individuals and concentrated solely on their input and output. Likewise, the past was disregarded in order to concentrate on current sequences of behavior. In their popular account of communications theory, Pragmatics of Human Communication, Watzlawick et al. (1967) proposed several axioms about the interpersonal impact of social discourse. First, one cannot not communicate. Given that all behavior is communicative, everything one does has a communicative impact. Second, all messages have both a report and command function. The report (or content) of a message conveys information directly, while the command (or implication) is a request or statement about the definition of the relationship. In healthy relationships, the command aspect of communication remains in the background, while problematic relationships are characterized by struggles over the nature of the relationship. Relationships are defined as either complementary (different in ways that fit together) or symmetrical (similar, and often competitive). The hallmark of strategic therapy is novel strategies designed for solving family problems. Strategic formulations theories are more problem-centered and pragmatic than other approaches because they are interested in changes in behavior rather than changes in understanding. Insight is eschewed in favor of tasks and directives. Moreover, because strategic therapists prefer to circumvent rather than work through resistance, their directives are sometimes paradoxical.

Chapter 5: Strategic Family Therapy

Milton Erickson had a major impact on the thinking of strategic therapists. He maintained a problem-focused approach to treatment, believed that people can change quickly, and that therapists are responsible for the success or failure of treatment. Many paradoxical techniques in use today were based on his application of hypnotic principles to resistant patients. a) MRI Group. Their approach to problems is based on cybernetic theory (see Chapter 2). Successful treatment consists of identifying positive feedback loops that surround problems; uncovering family rules that maintain those interactions; and finding a way to change the feedback loops or rules through reframing and the use of directives. The approach is pragmatic, time-limited, and problem-focused. b) Haley and Madanes. Haley emphasized the vertical elements of structure -- who’s in charge in the family’s hierarchy. He thought that relationship problems were often based on struggles for control. Haley combined aspects of the structural and strategic approaches into his treatment. The rules around the family hierarchy are crucial to understand for effective assessment and treatment. Although his techniques were strategic, his conceptualization of family dynamics and goals for treatment were structural. A family’s dysfunctional sequences are maintained by hierarchy and boundary problems. One of Haley’s unique contributions was his therapy-in-stages perspective, which encouraged therapists to follow a step-by-step process in therapy. Madanes also emphasizes the functional aspect of symptoms, particularly the incongruous hierarchy created when children use their symptoms to influence their parents. She categorizes family problems according to four basic intentions of the family members involved in them: (1) the desire to dominate and control; (2) the desire to be loved; (3) the desire to love and protect others; and (4) the desire to repent and forgive. c) Milan Associates. Like Haley, this group focused on power games in the family. Their primary question was, ―What kind of game is this family playing (that maintains the presenting problem)?‖ They would offer ―positive connotations‖ to the game (meant to disarm resistance) and then prescribe a ―ritual‖ to undermine it. The idea was that if you change behavior, ideas will change. Frequently, they used a ―counterparadox‖: ―If you stop playing this game, terrible things will happen.‖ The Milan associates focused on several generations of families, and used this multigenerational perspective to understand symptom development. Their hypotheses involved elaborate networks of covert family alliances and coalitions across generations. They believed that patients use symptoms to protect one or more family members in order to maintain the network of family alliances.

Normal Family Development Normal families were described by communications theorists as functional systems, which depend on two processes: negative feedback and positive feedback--to foster stability and adaptation. Researchers studying children at risk for psychiatric disorders have concluded that clear and logical communication from parents is important in promoting healthy adjustment in children. a) The MRI group believes that there is no one model of normality for families; therefore, it is a mistake to impose any such framework on clients. They take no position on how families should behave and confine their task to eliminating the problems families present to them. b) Haley and Madanes’s assumptions about normal family functioning were based on structural theory: Families should have clear hierarchies with parents firmly in charge. Haley also emphasized the impact of life-cycle stages on a family’s structure. c) The Milan Associates also maintained a non-judgmental stance on family functioning. They claimed to hold no preconceived normative models or goals for their families, and strived to maintain an attitude of ―neutrality‖ or ―curiosity‖ about the families they treat.

Chapter 5: Strategic Family Therapy

Development of Behavior Disorders The function of symptoms from the communication therapists’ perspective was to maintain the homeostatic equilibrium of family systems. Dysfunctional families were seen as trapped in rigid patterns of communication. In these families, novelty was treated not as an opportunity for growth but as a threat to stablity. Destructive negative feedback loops exist when families fail to accommodate to changed circumstances, as for example, by responding to an adolescent’s striving for independence as negative feedback and continuing to treat her as a child. A destructive positive feedback loop (or ―runaway‖) would be illustrated by an argument that escalates into a violent confrontation because neither party listens to the other, and both insist on having the last word. There are three explanations among the strategic models for the way problems develop. 1. The cybernetic view is held by the MRI group: difficulties become chronic problems through persisting in misguided attempted solutions that either maintain the status quo or lead to positive feedback escalations. 2. The structural view was shared by Haley and Madanes, and the Milan Associates: problems are the result of flaws in the family’s hierarchy and intergenerational boundaries. 3. The functional view was shared by Haley and Madanes, and the Milan Associates: problems are the result of people protecting or controlling each other indirectly, so that problems serve a function for the family system.

Goals of Therapy At first communications therapists sought merely to improve communication. Later they concentrated specifically on those communicative interactions around a family’s presenting problem. Because they began to see relationships (within families and between families and therapists) as struggles for control, therapy became a contest in which therapists sought to outwit families and manipulate them into changing their patterns of interaction. a) MRI group. Therapy works by bringing about a simple reversal of problem-maintaining sequences. No insight, education, or reorganization of family relationships is required for change to occur. b) Haley and Madanes. Haley’s goal was the structural reorganization of the family hierarchy and generational boundaries. His intermediate goals were to resolve the family’s presenting problem. Madanes expanded her goals to include harmony and balance in the family members’ lives, for them to love each other and to experience being loved. This version of strategic therapy relied heavily on creative therapeutic directives. c) Milan Associates. Goals of the early Milan team consisted of interrupting family games and reframing motives for family members’ behaviors. This did this using ―positive connotation‖ -- a double-edged statement that praised family members (especially the identified patient) for having the family’s interests at heart, while at the same time describing their behavior as dysfunctional. Later, Selvini and Prata focused on disrupting and exposing the ―dirty games‖ that family members play with each other. Boscolo and Cecchin strove to collaborate with families to form systemic hypotheses about problems and help the family decide whether they want to keep those problems.

Therapy Assessment. Communications therapists did little in the way of formal assessment, while their strategic offshoots zeroed in on particular aspects of families’ behavior around the presenting problem. a) MRI group. Assessment consists of carefully defining the presenting problem and then figuring out what responses were responsible for perpetuating it. Because misguided solutions often turn out to be the real problem, these are what MRI therapists target. b) Haley and Madanes. The Haley/Madanes approach also begins with a careful elucidation of the presenting problem and the sequences of interaction surrounding it. But these therapists also attempt to figure out what structural anomalies -- especially weak parental hierarchies and cross-generational coalitions -- may underlie a

Chapter 5: Strategic Family Therapy

family’s problems. They also consider what the interpersonal payoff of an identified patient’s symptoms might be (e.g., not having to go out and find a job). c) Milan Associates. The Milan team comes up with a preliminary hypothesis (based on the assumption that the presenting symptoms serve some kind of homeostatic or protective function for the family) and then test this hypothesis via ―circular questioning.‖ The goal of the assessment is to arrive at a systemic explanation for the function the presenting complaint serves in the family’s ecology.

Therapeutic Techniques The strategic approaches are the most technique-driven of all family therapies. All of the models presented in this chapter use reframing, directives, and paradoxical interventions. a) MRI’s Brief Therapy Center follows a six-step treatment procedure, conducted in a maximum of ten sessions: 1. Introduction to the treatment setup; 2. Inquiry and definition of the problem; 3. Estimation of the behavior maintaining the problem; 4. Setting goals for treatment; 5. Selecting and making behavioral interventions; and 6. Termination. b) Haley and Madanes. Haley blended strategic techniques with structural goals for treatment. His approach to an initial interview consists of four stages: 1. Social stage: greet family, make them comfortable; 2. Problem stage: elicit each member’s view of the problem; 3. Interaction stage: observe the family discuss their problem; and 4. Goal-setting stage. Directives play a central role in Haley’s problem-solving therapy. Madanes uses a range of ―pretend techniques‖ and assigns tasks to bypass resistance. She also developed a sixteen-step model for treating families in which there has been sexual abuse. Some of these steps include getting the abuser to apologize to the victim while on his knees, getting the family to apologize for not protecting the victim, and making sure that the abuse does not recur. The current form of Haley/Madanes therapy, called ―strategic humanism,‖ still involves giving directives based on therapist hypotheses. However, these directives are more oriented toward increasing family members’ abilities to soothe and love than to gain control over one another, thus shifting the focus away from the power elements of hierarchy and toward finding ways to increase family harmony. c) The Milan Model. The original Milan model was highly strategic; sessions were held once a month for a maximum of 10 sessions. Treatment sessions had a standard format: 1. Presession, 2. Session, 3. Intersession, 4. Intervention, and 5. Post-session discussion. The primary intervention consisted of either a ritual or a positive connotation. Following the Milan team’s split, Selvini Palazzoli and Prata maintained the model’s strategic bent, stopped using paradoxical interventions, and began assigning a specific ritual, called the ―invariant prescription,‖ to all families they treated. Boscolo and Cecchin developed a more collaborative, non-directive style of therapy. Their therapy centers around ―circular questioning.‖ Instead of asking someone ―How do you feel?‖ a circular question would ask, ―How do you suppose your mother feels?‖ ―If you start eating, how do you think your mother will react?‖ The idea is to use questions to spread the problem throughout the whole family. As a result of the evolution of family therapy away from strategizing toward collaborating, the original Milan model was eventually abandoned.

Chapter 5: Strategic Family Therapy

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Divide the class into groups of 3-4 and have students conduct a role play using the MRI approach. Instruct two students to play a young couple, one student to play a therapist, and one to observe. The young couple is bothered by their parents’ tendency to treat them like children by doing everything for them. Despite their adequate salaries, the parents continue to send money and lavish gifts on them. The therapist is to perform a paradoxical intervention by helping the couple discourage their doting parents by becoming less competent rather than more competent. The therapist should instruct the couple to act helpless and dependent with the parents, exaggerating this position to an extreme. The observer should provide feedback regarding the effectiveness of the therapist’s intervention. Was the therapist able to enlist the couple’s compliance, etc.? 2. Conduct a series of role plays to allow students to practice the ―circular questioning‖ developed by the Milan associates. One student should take the role of therapist, one student may observe, and three students should make up a family (e.g., mother, father, 13-year-old child) seeking treatment. The family has entered treatment because they are concerned about their child’s depression, the onset of which coincided with the paternal grandfather’s death. After his death, the paternal grandmother came to live with the family. Grandmother and mother now fight a lot. However, the family should inform the therapist only of the presenting problem, the child’s depression. The therapist’s job is to question the family to elicit each member’s perception of the family relationships, presenting problem, cause and effect, etc. The observer should look for the frame of the presenting problem to shift from an intrapsychic one in the child, to a systemic view of the child’s problem, i.e., because of difficult changes in the family structure. 3. Have students break into groups of 2-3. One student (a client) should describe a problem (e.g., frequent fights with mate; difficulty getting along with co-workers; parent of an adolescent child who is acting out; workaholic, etc.) and the others should ask him or her questions about what he or she has done in response to the problem. The goal of the exercise is to discover problem-maintaining behavior, and maybe to suggest trying something different to the client. Reverse roles until all students have played both client and observer. 4. In order to help examine the pre-session planning stage of the Milan group, have students break into groups of 56. Imagine the following scenario: a working mother calls because she is worried that her 10-year-old daughter refuses to go to school. The mother reports that this has gone on for the last 6 mos. and they have tried everything. The mother reports that her husband was laid off several months ago due to an accident at work. There is also a 12-year-old who’s had a few run-ins with the police, but mother reports he is a wonderful child: it’s the daughter who needs help. Have students brainstorm hypotheses and come up with questions to test out these hypotheses. 5. Divide the class into small groups (4-5) and have students conduct two types of role plays using communications therapy techniques. Instruct two students to play a couple with relationship difficulties, one student to play a therapist, and one or two students to observe. In the first role play, instruct the therapist to address communication problems directly--by calling attention to them and making suggestions (e.g., ―I-statements,‖ speaking directly to each other, and so on). In the second role play, instruct the therapist to use a more indirect strategy by attempting some kind of paradoxical intervention (prescribing the symptom, reframing the problem, creating a therapeutic double bind, etc.). Encourage the therapist to call a time-out during the role play to confer with colleagues to design a paradoxical intervention. What where the couples’ experiences as targets of intervention? Which felt more effective? Which intervention style seemed more congenial to which students? 6. Have students break into groups of 3-4. Have two students role play a conversation in which each reacts with emotional responses to the other’s statements--observers should take note of what happens. Next have them role play a similar conversation, but this time instruct them first acknowledge what the other has said before they respond. Have the group discuss each role play. What impact did acknowledging the other’s perspective have on the quality of the interaction? Discuss the implications for how one would conduct couples therapy. 7. Have students conduct a family observation. Be sure to have students obtain permission from volunteer families to audio or video sessions. Take notes on your observations. One suggestion is to divide your note taking into 3

Chapter 5: Strategic Family Therapy

sections: speaker, content, process observations. Be alert for expressions, body movements, interruptions, topic changes, and times that one family member disconfirms another by ignoring, changing the topic, disparaging the speaker, or bringing in a third party. Who sits close to whom? Who’s farthest away from whom? Does this proximity and distance reflect the level of verbal involvement between members or not? Who talks to whom? How would you describe the emotional climate in the family, what they talk about and the way they interact during periods of calm versus periods of higher tension? Try to track a few of the process dimensions during the observation and then review the tape to conduct a more thorough analysis of the interactions. What evidence did you observe for the existence of homeostatic mechanisms, negative feedback loops, complementarity, what family rules did you observe, any paradoxical communications? Students should apply their knowledge of family systems theory to analyze their observations, with particular attention to various pairings -- parents with each child, parents with each other, etc. Students can be asked to submit written reports to the class. Spend some time in class reviewing sections of the video and discussing class reactions.

Films Paul Watzlawick: Mad or Bad? Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) In his consultation with a family whose 25-year old son presents with chronic somatic symptoms, Watzlawick employs the strategic use of Ericksonian-style questions. The systemic function of symptoms in protecting the family from other problems is highlighted. VIDEO, approximately 136 min. Luigi Boscolo and Gianfranco Cecchin: What to Call It? Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) This Milan team consults with a couple and their 27-year old daughter who has a history of hospitalizations for delusions and manic depressive symptoms. Pre-, inter-, and post-session hypothesizing includes beliefs about genetic origins, double binds, incest, and hopes of priesthood. Therapists demonstrate therapeutic neutrality through a range of historical and circular questions. VIDEO, approximately 138 min.

Class Discussion 1. Ask the class to consider the following example: sixteen-year-old Tommy recently began refusing to go outside his house. Instruct the class members to discuss how each branch of the strategic and systemic therapies (e.g., an MRI therapist, a Haley-style strategic therapist, a Madanes-style strategic therapist, and a Milan-style systemic therapist) would explain Tommy’s problem, how the problem developed, and which interventions might be used to treat Tommy and his family. 2. Strategic therapy has pioneered the team approach to therapy, in which a team of therapists observe treatment sessions behind one-way mirrors and sometimes react as well. Discuss the advantages and disadvantages of using the team approach to family therapy. 3. Discuss and evaluate the strengths and weaknesses of strategic and Milan systemic approaches. What might be considered the major contributions of these approaches to the field of family therapy? Consider their theoretical adequacy, specificity of constructs, strategies and techniques, roles of the therapists, and types of client problems best suited for these approaches. 4. Compare the strategic/systemic therapies to other family systems approaches studied thus far (e.g., structural, psychoanalytic, experiential, and Bowen family therapies), with respect to the criteria presented above. 5. Discuss the use of paradoxical interventions. Are they necessarily distancing and manipulative? If provocative interventions are successful in breaking destructive family pattern, what is necessary to sustain positive changes? To what extent are families inherently resistant to change?

Chapter 5: Strategic Family Therapy

6. Discuss the major concepts within early communications theory that have been incorporated into other schools of family therapy (e.g., complementarity, cybernetics, feedback, homeostasis, metacommunication, function of the symptom, etc.) Which has had the greatest impact on various approaches? Which of these concepts are useful but neglected in today’s approaches? 7. Discuss the critical perspective that paradoxical interventions function to keep a therapist ―one-up‖ and distanced from a family. Although paradoxical interventions can break a family pattern, should one assume that such changes will be lasting? On the other hand, are paradoxical techniques useful for helping therapists avoid getting sucked into seriously disturbed families? 8. The use of paradoxical techniques (e.g., provoking change by telling them not to) is based on the premise that families are inherently oppositional (or at least resistant). Explore students’ views on this: do they agree or disagree, and why? 9. Today’s students generally see the strategic models as gimmicky and outdated, but ask them to consider what ideas in these models remain useful for understanding people and their problems, and how to bring about change.

Supplemental Readings Bateson, G., Jackson, D.D., Haley, J, and Weakland, J.H. 1956. Toward a theory of schizophrenia. Behavioral Science. 1: 251-264. Erickson, M. 1980. The collected papers of Milton Erickson, Vols I, II, and III. New York: Irvington. Eron, J. and Lund, T. 1993. An approach to how problems evolve and dissolve: Integrating narrative and strategic concepts. Family Process, 32: 291-309. Fisch, R., Weakland, J., and Segal, L. 1982. The tactics of change. San Francisco: Jossey Bass. Grove, D. and Haley, J. 1993. Conversations on therapy. New York: Norton. Haley, J. 1976. Problem-solving therapy. San Francisco: Jossey Bass. Haley, J. 1986. The power tactics of Jesus Christ and other essays. 2nd edition. Rockville, M.D.: Triangle Press (distributed by Norton). Haley, J. 1996. Learning and teaching therapy. New York: Guilford Press. Keim, J. 1998. Strategic family therapy. In Case studies in couple and family therapy: Systemic and cognitive perspectives. F. Dattilio, ed. New York: Guilford Press. Madanes, C. 1990. Sex, love, and violence: Strategies for transformation. New York: Norton. Rohrbaugh, M., Tennen, H., Press, S., and White, L. 1981. Compliance, defiance, and therapeutic paradox: Guidelines for strategic use of paradoxical interventions. American Journal of Orthopsychiatry. 51: 454466. Selvini Palazzoli, M., Boscolo, L., Cecchin, G., and Prata, G. 1978. Paradox and counterparadox. New York: Jason Aronson. Shoham, V., Rohrbaugh, M.J., Stickle, T. R., and Jacob, T. 1998. Demand-withdraw couple interaction moderates retention in cognitive-behavioral versus family-systems treatments for alcoholism. Journal of Family Psychology. 12: 557-577. Watzlawick, P., Beavin, J., and Jackson, D.D. 1967. Pragmatics of human communication. New York: Norton. Weakland, J., and Ray, W. (Eds.). 1996. Propagations: Thirty years of influence from the Mental Research Institute. Binghamton, NY: Haworth.

Chapter 6: Structural Family Therapy

Chapter 6: Structural Family Therapy INTRODUCTION Unlike most other schools, structural family therapy doesn’t merely look at interactions between individuals but considers the overall family structure that organizes those interactions. A structural analysis reveals patterns of enmeshment and disengagement that result in either too much or not enough interaction between individuals and subgroups in the family. This approach also provides a blueprint for treatment, from assessment to restructuring interventions, and relies on the use of enactments – in-session dialogues that permit therapists to see and influence the actual process of family interactions as well as the underlying structure that supports them.

Leading Figures Salvador Minuchin; Braulio Montalvo; Bernice Rosman; Harry Aponte; Jorge Colapinto; Marianne Walters; Jay Lappin; Michael Nichols; Charles Fishman.

Important Terms accommodation: elements of a system tend to adjust to coordinate their functioning; people may have to work at it. boundary: emotional barriers that protect and enhance the integrity of individuals, subsystems, and families. cross-generational coalition: an inappropriate alliance between a parent and child who side together against a third member of the family. disengagement: psychological isolation that results from overly rigid boundaries around individuals or subsystems in a family. enactment: an interaction stimulated in structural family therapy in order to observe and then change transactions that make up family structure. enmeshment: loss of autonomy due to a blurring of psychological boundaries. family structure: the functional organization of families that determines how family members interact. hierarchy: structural organization in which there is a clear executive subsystem, in families usually (but not always) the parents. intensity: Minuchin’s term for challenging maladaptive interactions using strong affect, repeated intervention, or prolonged pressure. joining: accepting and accommodating to families in order to gain their trust and circumvent resistance. reframing: relabeling a family’s description of behavior to make it more amenable to therapeutic change; for example, describing someone as ―having a strong voice‖ rather than ―domineering.‖ shaping competence: reinforcing positives rather than confronting deficiencies. structure: recurrent patterns of interaction that define and stabilize the shape of relationships. subsystem: smaller units in families, determined by generation, gender, or function.

SUMMARY OF KEY POINTS AND ISSUES Sketches of Leading Figures Salvador Minuchin, an analytically trained child psychiatrist, started experimenting with family therapy in the early 1960s at the Wiltwyck School for delinquent boys. To work with the inner city families at Wiltwyck, Minuchin and his colleagues, including Braulio Montalvo and Dick Auerswald, developed an active approach that focused on the chaotic structure found in many of these families. In 1965 Minuchin became director of the Philadelphia Child Guidance Clinic where he, along with Jay Haley, Braulio Montalvo, Bernice Rosman, Marianne Walters, and others, refined structural family therapy and built one of the premier training facilities in the world. After leaving Philadelphia in 1981, Minuchin moved to New York and started his own training institute. Following Minuchin’s retirement in 1966, the center in New York was renamed the Minuchin Center for the Family, and the work of structural family therapy is still carried out there. Among Minuchin’s most well-known students are Jorge Colapinto at the Minuchin Center; Jay Lappin in Delaware; Michael Nichols at the College of William and Mary; and Charles Fishman in Philadelphia.

Chapter 6: Structural Family Therapy

Theoretical Formulations Three constructs comprise the essential components of structural theory: family structure, subsystems, and boundaries. Family structure refers to the overall organization within which family members interact, i.e., how, when, and to whom family members relate. The shape of a family’s structure is partly universal (all families have some kind of hierarchical structure), and partly idiosyncratic (every family tends to have complementary ineractions unique to that family -- if one parent is extremely involved with the children, the other will likely be less so). Family structure only becomes evident when one (a) observes the actual interactions among family members over time, and (b) possesses knowledge of a theoretical system that explains structure. Families contain subsystems of members who join together to perform various functions. Subsystems consist of individuals, dyads, and various groups of family members. Some obvious groupings include the parental and sibling subsystems. Every family member plays many roles in several groups. Covert coalitions (e.g., between mom and son, or dad and daughter) are often more significant than the obvious groupings. Interpersonal boundaries serve to protect the autonomy of the family and its subsystems. Boundaries vary from rigid to diffuse. Rigid boundaries are overly restrictive and allow little contact, resulting in disengagement. Disengagement leaves individuals and subsystems independent but isolated, fostering autonomy but limiting nurture. Enmeshed subsystems have diffuse boundaries: they offer heightened mutual support, but at the expense of independence and autonomy. Enmeshed parents are protective, but their children tend to be dependent and may have trouble relating to people outside their family.

Normal Family Development What distinguishes healthy families isn’t the absence of problems, but functional family structures. Adaptive families modify their structure to accommodate to changing circumstances (e.g., developmental transitions in the family); dysfunctional families increase the rigidity of structures that are no longer functional. When two people marry, they must learn to accommodate to each other and negotiate the nature of the boundary between them, which may range from diffuse (too enmeshed) to rigid (too disengaged). The couple must also create a boundary separating them from the outside. When children are born, structural requirements include the creation of an executive parental subsystem (with the parents firmly in charge of nurture and control) and a sibling subsystem (with brothers and sisters allowed to work out their own relationships). As children grow, they require different styles of parenting, and a family must modify its structure to adapt to these developmental challenges.

Development of Behavior Disorders Structural problems arise when a family’s structure fails to adjust to changing circumstances. Adaptive changes in structure are required when a family or one of its members faces external stressors or when transitional points in development are reached. Family dysfunction results from a combination of stress and failure to reorganize to cope with it. Stressors may be environmental (a parent is laid off, the family moves) or developmental (a child reaches adolescence, parents retire). The family’s failure to handle adversity may be due to inherent flaws in their structure or merely to their inability to adjust to changed circumstances. Structural therapists use a variety of symbols to diagram structural problems (see text). These diagrams clarify what changes are likely to be required for successful treatment.

Goals of Therapy Therapy is directed at altering family structure so that the family can solve its own problems. The goal of therapy is structural change; problem-solving is a by-product of this systemic goal. The structural changes sought are unique to each family and dictated by the type of problems presented and the specific nature of structural rigidity. An important general goal for families is the creation of an effective hierarchical structure, where parents are in charge and functioning together as a cohesive executive subsystem. With enmeshed families, the goal is to

Chapter 6: Structural Family Therapy

differentiate individuals and subsystems by strengthening the boundaries around them. In disengaged families, the goal is to increase interaction by making boundaries more permeable.

Therapy Assessment involves interviewing the entire family and observing patterns of enmeshment and disengagement during enactments. But although the focus is usually on the nuclear family, structural therapists also consider problems in individuals as well in the context beyond the nuclear family to include the extended family as well as social agencies. Structural therapists focus on two types of live, in-session material -- enactments and spontaneous behavior sequences. An enactment occurs when a therapist directs a family to demonstrate how they handle a particular type of problem. As the family enacts the problem-maintaining sequence, the therapist guides the family to modify the enactment, creating new options for the family. Minuchin and his colleagues developed a four-stage model for assessing families (Minuchin, Nichols, & Lee, 2007). Assessment takes place over the course of one or two sessions in which the therapist: (1) broadens to scope of the presenting problem to include the entire family, (2) explores what family members may be doing to perpetuate the presenting problem, (3) briefly explores the history of adults in the family to discover how they learned to see the world as they do, and (4) brings the entire family together to discuss alternative ways of interacting. Therapeutic Techniques. A structural therapist joins the family system, altering boundaries and realigning subsystems to change the family’s structure. The therapist doesn’t solve problems (that’s the family’s job), but helps the family modify its structure so that family members can solve their own problems. In general, the strategy of structural family therapy follows three overlapping phases consisting of the following steps: Phase 1: Opening phase a) joining and accommodating b) working with interaction c) mapping structural patterns Phase 2: Focusing on the underlying structure d) highlighting and modifying interactions Phase 3: Transformation of structure e) boundary making f) unbalancing g) reframing (adding cognitive constructions) Joining means demonstrating understanding and acceptance of a family and its members before any attempt is made to challenge their points of view or the way they are organized. Enactments are used to encourage dialogues and playful or disciplinary interaction with children in order to observe how family members actually relate to one another. Once a structural assessment (patterns of enmeshment and disengagement) is made, the therapist then begins to challenge structures that seem no longer functional. Sometimes a structural therapist will confront family members with what they seem to be doing that isn’t working -- ―The more you do X, the more he does Y; and the more you do Y, the more she does X. ― At other times, the therapist will invite family members to interact in new and more productive ways by setting up enactments that encourage them to function more effectively. In general, structural therapists believe that improved interactions should come first and then be followed by efforts to explain things to family members.

Chapter 6: Structural Family Therapy

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Review the four case examples provided in Discussion Question #1 (see below). Following the class exercise of diagramming the family structure for each case, divide the class into four groups and assign each group a case. Ask each group to generate strategies for a structural family therapist working with their case example family. Each group should (a) come up with strategies for joining and accommodating, (b) plan an enactment, with suggestions for a therapist about how to modify the enactment, and (c) create new options for behavior sequences in the family (refer students to the text for a review of techniques if necessary). Reconvene the class and instruct each group to choose a student to role-play each of the salient roles in their case (e.g., therapist, father, mother, child). Prior to conducting the role plays, each group will describe to the class a proposed enactment, specifying the strategies that may be used to modify the enactment. Next, instruct students from a chosen group to conduct a role play in which the therapist joins the family, initiates an enactment, and then works to modify the dysfunctional sequences, proposing new options for behavior. If the therapist gets stuck, he or she may ―tag‖ another member of the group to take over and continue the role-play. The class should provide feedback to the therapist(s) regarding the effectiveness of their interventions. Was the therapist able to promote and maintain an enactment? How effective was the therapist in modifying to the enactment and producing new behavior sequences, etc.? 2. Divide the class into groups of 5-6. Conduct a series of role plays designed to allow students to practice boundary-making skills. Recall that an important responsibility of structural family therapists is to realign boundaries by increasing either the proximity or distance between subsystems. One student should take the role of therapist, one student should observe, and 3-4 students should make up the family in treatment. The families should have a presenting problem and choose to be enmeshed or disengaged. Therapists should first assess the family boundaries and then intervene to either (a) strengthen the boundaries between subsystems and increase independence, or (b) challenge members’ avoidance of conflict and block detouring to help members increase contact with each other, depending on what the family presents. Observers should look for behavioral changes in the family that indicate clearer boundaries separate the family subsystems. (N.B. Students often have trouble role playing pre-planned dysfunctional patterns; they tend to be polite and to cooperate with whatever the ―therapist‖ asks. Therefore, rather than try to program them in advance to be enmeshed or disengaged or what have you, role plays often work better if they are allowed to develop spontaneously and without much pre-planning.)

Films Anorexia is a Greek Word (Western Psychiatric Institute and Clinic Library, 3811 O’Hara St., Pittsburgh, PA 152132593, 412-246-5011). Minuchin interviews a large, Irish-Catholic family whose 14 year-old daughter has been anorexic. Aspects of the treatment of an anorexic adolescent and her family are highlighted. VIDEO, 115 minutes. The Case of the Dumb Delinquent (Philadelphia Child Guidance Center, Mike Schmidt Video Department, 34th St. and Civic Center Blvd., Philadelphia, PA 19104, 215-242-0949). Minuchin interviews a 13 year old pre-delinquent boy and his single mother. Minuchin highlights the complementary patterns that link mother to son, through skillful use of relabeling and reframing, and challenges the mother’s plans for institutional placement. VIDEO, 3/4 inch Cassette, S-VIDEO, approximately 38 minutes. A Family with a Little Fire (Philadelphia Child Guidance Center, Mike Schmidt Video Department, 34th St. and Civic Center Blvd., Philadelphia, PA 19104, 215-242-0949). Braulio Montalvo conducts a therapy session with a one parent family in which the elder daughter sets fires. The son’s intervention as a parental child prevents interactions between mother and daughter. By joining the flow of family patterns, Montalvo encourages new problem solving sequences. VIDEO, 3/4 inch Cassette, S-VIDEO, approximately 43 minutes. I Think It’s Me (Philadelphia Child Guidance Center, Mike Schmidt Video Department, 34th St. and Civic Center Blvd., Philadelphia, PA 19104, 215-242-0949). Minuchin conducts an initial interview with a family in which the husband exhibits severe paranoid and compulsive behavior for which he has been hospitalized several times.

Chapter 6: Structural Family Therapy

Minuchin unravels the strong hidden coalitions that maintain the symptomatology. VIDEO, 3/4 inch Cassette, SVIDEO, approximately 57 minutes. Master Series 1984: Salvador Minuchin, M.D. (Western Psychiatric Institute and Clinic Library, 3811 O’Hara St., Pittsburgh, PA 15213-2593, 412-246-5011). Recorded at the 1984 AAMFT conference in San Francisco, CA, Minuchin reviews the family’s case history with the presenting therapist, interviews the family, and then discusses the interview with the audience. Salvador Minuchin: Unfolding the Laundry Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink like on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Minuchin demonstrates his structural approach with a large blended, recently married, dual-career family with five stepchildren. The IP is the youngest son (age 11) who is acting out. Minuchin defocuses attention on the IP, relabels the sibling behavior, and focuses his attention on the couple. VIDEO, 147 minutes. A House Divided: Structural Therapy with a Black Family (Western Psychiatric Institute and Clinic Library, 3811 O’Hara St., Pittsburgh, PA 15213-2593, 412-246-5011). Harry Aponte conducts a consultation interview with a blended family consisting of a mother, her 10 year-old son, father, and his 12 year-old son. Within this disengaged family, the 10 year-old is receiving counseling related to a series of petty thefts within and outside the home. VIDEO, 58 minutes. Empowering Black Families in Therapy (Western Psychiatric Institute and Clinic Library, 3811 O’Hara St., Pittsburgh, PA 15213-2593, 412-246-5011). In a program recorded at the 1991 AAMFT conference, Nancy BoydFranklin discusses a structural-based model for working with black families. The extended family, informal adoption, spirituality, racism, and intrusion of outside agencies are issues featured in the program. VIDEO, 120 minutes.

Class Discussion 1. Structural mapping is used to diagram organizational problems in families. Ask the class to consider the following case examples, and (1) diagram the family’s current structure; (2) diagram the ideal family structure at the termination of successful therapy; and (3) give the rationale and structural therapy techniques one would use to accomplish the goals. a) Scapegoating. Husband and wife are unable to resolve conflicts between each other. They divert their focus of concern onto their child; instead of worrying about each other, they worry about the child. This reduces the strain on the father and mother; however, it victimizes the child and is therefore dysfunctional. b) Cross-generational coalition. Husband and wife are unable to resolve their conflicts, so they continue to argue through the children. Father says mother is too permissive; she says he’s too strict. He withdraws, she criticizes, he withdraws further. An enmeshed relationship is perpetuated between mother and child, whereby the mother responds to the child’s needs with excessive concern and devotion. The father remains disengaged, not responding even when a response is necessary. Both husband and wife are critical of each other’s ways, but both perpetuate the other’s behavior with their own. c) School phobia. Parents are enmeshed with their child and give her wonderful care. However they are failing to teach the child to obey rules and respect adult authority, resulting in difficulty negotiating her entrance into school. The child is afraid to go to school, and the parents simply reinforce her fears by allowing her to stay home. d) Failure to accept a stepparent. When divorced or widowed spouses remarry, structural readjustment must occur or the stepfamily will experience transitional conflicts. One such conflict occurs when a mother remarries. A mother and her new husband fail to establish a clear boundary separating the couple from her children. In addition, mother and children fail to allow stepfather to participate as an equal partner in the

Chapter 6: Structural Family Therapy

new parental subsystem. Mother and children insist on maintaining their familiar patterns, without adjusting to the modifications required to absorb the stepfather. He becomes frustrated and angry, resulting in chronic arguing between the parents and abuse of the children. 2. To assist students in learning to conceptualize family structure, have students diagram their own family structure (i.e., preferably their family of origin). Divide students into small discussion groups of 3-4 and have them review their family diagrams. Encourage students to explore various subsystems in their families (including covert, cross-generational coalitions) and the types of boundaries (rigid to diffuse) present. Reconvene as a class and explore students’ reactions to the exercise and the material they shared. 3. Feminist therapists argue that structural therapy targets the mother’s role and ignores the father’s role in (culturally sanctioned) dysfunctional family arrangements. Discuss whether the ―enmeshed mother/disengaged father‖ syndrome and the typical structural family therapy response to it is sexist--by treating a cultural phenomenon as though it were the pathology of individual families. 4. Structural family therapists alter family members’ cognitive constructions about their presenting problems to provide members with a different frame for viewing reality. This in turn enables the family to change the way they relate to one another. Typically the goal is to move family discussions from linear constructions of the problems (e.g., ―There’s a communication problem; he won’t tell me what he’s feeling‖) to systemic ones (e.g., ―He doesn’t tell his wife what he’s feeling because she nags and criticizes; and she nags and criticizes because he doesn’t tell her what he’s feeling‖). Generate a list of typical problems presented by families in treatment which have intrapsychic or linear constructions (e.g., acting-out adolescent, absent father/ husband, school-phobic child, etc.). As a class, transform each of the linearly-constructed problems into structural ones using your knowledge of complementarity in family relations. 5. Discuss the strengths and weaknesses of structural family therapy. What might be considered the major contributions of this approach to the field of family therapy? Consider its theoretical adequacy, specificity of constructs, strategies and techniques, roles of the therapist, and types of client problems best suited for this approach. 6. Discuss the critique that Salvador Minuchin has set an example of a therapist who is overly critical and combative. (Anyone who has seen him work in the past twenty years knows that this perception is no longer valid.) 7. Have students locate a novel or movie in which a family’s problems are portrayed as largely the responsibility of one person. Have them suggest alternative explanations by which a failure of the family to reorganize to cope with changed circumstances, rather than the failing of one family member, may be a more useful way to view the genesis of the problem.

Supplemental Readings Kerig, P.K. 1995. Triangles in the family circle: Effects of family structure on marriage, parenting, and child adjustment. Journal of Family Psychology. 9: 28-43. Minuchin, P., Colapinto, J., and Minuchin, S. 1998. Working with families of the poor. New York: Guilford Press. Minuchin, S. 1974. Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., and Fishman, H.C. 1981. Family therapy techniques. Cambridge, MA: Harvard University Press. (especially ch. 3-13, & 15) Minuchin, S., Lee, W-Y., and Simon, G. M. 1996. Mastering family therapy: Journeys of growth and transformation. New York: Wiley. Minuchin, S. and Nichols, M.P. 1993. Family healing: Tales of hope and renewal from family therapy. New York: The Free Press. Minuchin, S. and Nichols, M.P. 1998. Structural family therapy. In Case studies in couple and family therapy. New York: Guilford Press.

Chapter 6: Structural Family Therapy

Minuchin, S., Nichols, M.P., and Lee, W-Y. 2007. Assessing couples and families: From symptom to system. Boston: Allyn & Bacon. Nichols, M.P. 2009. Inside family therapy, 2nd ed. Boston: Allyn & Bacon. Nichols, M.P. and Minuchin, S. 1999. Short-term structural family therapy with couples. In Short-term couple therapy.. New York: Guilford Press. Santiseban, D., Coatsworth, J., Perez-Vidal, A., Mitrani, V., Jean-Gilles, M., and Szapocznik, J. 1997. Brief structural/strategic family therapy with African American and Hispanic high-risk youth. Journal of Community Psychology. 25: 453-471. Simon, G.M. 1995. A revisionist rendering of structural family therapy. Journal of Marital and Family Therapy. 21: 17-26.

Chapter 7: Experiential Family Therapy

Chapter 7: Experiential Family Therapy INTRODUCTION The experiential emphasis on emotional expression was a useful counterweight to the cognitive and behavioral emphasis of the other schools of family therapy. Experiential therapists drew evocative techniques and structured exercises from Gestalt therapy, encounter groups, and psychodrama. The experiential branch of family therapy (which emphasizes immediate, here-and-now experience and emotional expression) was most popular when family therapy was young. Today, such approaches as internal family systems therapy and emotionally focused couples therapy are revitalizing the experiential approach.

Leading Figures Carl Whitaker; Virginia Satir; August Napier; David Keith; Richard Schwartz; Leslie Greenberg; Susan Johnson.

Important Terms alienation (from experience): occurs when family members restrict their awareness of feelings. conjoint family drawing: family members are asked to draw their ideas about how their family is organized. existential encounter: believed to be the essential healing force in the therapeutic process, whereby the therapist establishes caring, person-to-person relationships with each family member while modeling openness, honesty, and spontaneity. family myths: set of beliefs based on a distortion of historical reality and shared by all family members that help shape the rules governing family functioning. family sculpting: experiential technique in which family members position themselves in a tableau that reveals significant aspects of their perceptions and feelings. mystification: R.D. Laing’s concept that many families distort their children’s experience by denying or relabeling it. parts: term used in internal family systems therapy for a person’s inner voices or subpersonalities. self-actualization: the process of developing and fulfilling one’s innate, positive potentialities.

SUMMARY OF KEY POINTS AND ISSUES The Basic Model Experiential family therapy was influenced by existential, humanistic, and phenomenological theories. The central emphasis of experiential approaches is a commitment to individual awareness and self-expression. People should aim for personal fulfillment, and families are treated more as groups of individuals than as systems. Treatment is designed to facilitate emotional experiencing and help individual family members find fulfilling family roles for themselves. The result is an approach that is relatively atheoretical and offers little systematic conceptualization of family dynamics.

Normal Family Development Healthy families support individual growth in family members and permit, even encourage, a wide range of experiencing. These families allow for individuality as well as togetherness, and members are honest about their feelings and free to be themselves. Parents in these families facilitate their children’s development of healthy channels for expressing their emotions and drives. Dysfunctional families resist feelings and blunt emotional responsiveness. Spontaneous experiencing is considered essential for healthy family functioning (more than either problem-solving skills or a functional family structure).

Development of Behavior Disorders Symptoms are the result of suppression of feelings and denial of impulses, which rob family members of flexibility and vitality. As a result, individuals are incapable of autonomy or real intimacy. The root cause is alienation from experience. Experiential therapists look beyond interactions between family members to consider

Chapter 7: Experiential Family Therapy

intrapsychic problems and ―normal‖ problems (e.g., obesity, smoking, overwork, ―lonely father syndrome,‖ and ―parentified child syndrome‖) in order to explain psychopathology.

How Therapy Works Personal growth (not symptom relief) is the goal of experiential family therapy; this includes increased personal integrity (feelings and behavior are congruent), greater freedom of choice, less dependence, and expanded emotional experiencing. The underlying premise is that emotional growth is best promoted by liberating the affects and impulses of family members. Family relations are revitalized by authentic interactions among members learning to be authentically themselves. If a family is brought together emotionally, children will feel a sense of belongingness and the freedom to individuate.

Therapy Assessment. Experientialists pay less attention to assessment than almost any other school of family therapy. While they eschew categorizing people, they do make an effort to understand the defenses that keep people from experiencing the full range of their feelings. Therapeutic Techniques. Experiential family therapists use a host of evocative techniques and structured exercises (use of touch, roleplaying, and attention to nonverbals) to create personal therapeutic encounters. All of these choices techniques are designed to promote emotional expression and expand experiencing. First, experiential therapists raise the level of anxiety in the family, then they behave in alternately provocative and supportive ways in order to help families take risks to express honest emotion. Therapists are open, genuine, and highly active. Experiential therapists can be divided into two groups with regard to use of therapeutic techniques. One group employs structured devices, such as role playing, family sculpting, and conjoint family drawing to promote affective expression. Another group tends to rely on the force of their own personalities. Virginia Satir in particular was known for her use of touch, which she used to model tenderness, affection, and gentle firmness with children. Two of the newer forms of experiential therapy, emotionally focused couples therapy and internal family systems therapy, are somewhat more systematic. The emotionally focused couples therapist endeavors to help partners get past their reactivity toward each other and to get in touch with their hurts and longings for attachment. Internal family systems therapy works by helping family members identify reactive ―parts‖ of themselves and, using visual imagery, relax those parts so that their more genuine feelings can emerge. In internal family systems therapy, the therapist may ask each family member to describe the parts of themselves that are involved in the problem. The language of parts is thought to facilitate safer, more open communication. Therapy consists of getting all family members’ selves to work together to help each person deal with the parts that are interfering in their family life. The internal family systems approach views resistance as an activation of the protective parts of family members. Therapists should respect those protective parts, as they hold important information about the therapist’s potential impact on the ecology of the system. If the protective parts are shown respect and consideration, therapists will encounter less resistance. Finally, therapists of other schools can use the language of this approach to good effect. For example, in response to family members’ descriptions of a problem a therapist might inquire, ―So part of you says (such and such) about the problem, is that right?‖ ―How do you think the problem would be affected if this part of you didn’t take over?‖ ―What is that part afraid might happen if it let you lead in this area?‖ ―Ask the part to let your Self lead the discussion about the problem this time and see how it goes.‖

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Divide the class into groups of 3-4 and have students conduct a role-play using (a) an internal family systems approach, or (b) emotionally focused couples therapy. Instruct one student to play a young woman coming for treatment, one student to play therapist, and 1-2 observers. The woman entering treatment is bothered by several recent incidences in which she became angry and flew in a rage, surprising and frightening her husband. She grew up in a family that strongly feared overt expressions of anger and was taught to take care of others at her

Chapter 7: Experiential Family Therapy

own expense. Consequently she was cut off from the assertive part of herself and learned to believe that bad things would happen if she asserted herself. However, recently she has been unable to contain her anger, often loses control, and flies into a rage. These events simply confirm her belief that assertiveness and anger are dangerous and should be feared. Observers should provide feedback to the therapist regarding adherence to the treatment approach, effectiveness of interventions, etc. 2. Divide the class into groups of 4-5 and have students conduct a role-play using an internal family systems approach. Instruct one student to play a young adolescent who has been fighting at school and rebelling at home. Two students should play his parents and 1 student, the therapist. Other students should function as observers. Ask the ―patient‖ to describe the conflict between a rebellious part of him and a part that worries about displeasing his parents. Father gets frustrated and angry at the patient, while mother becomes scared of father’s reaction and tries to protect the patient. Have the therapist ask each family member to describe the parts of them that are involved in the problem and other questions, such as: How difficult is it for you to control your parts? How might the problem be affected if you could stay your Self rather than letting your parts take over? How do you want to change your relationship with those parts that interfere in your life? Ask the observers to provide feedback to the therapist regarding adherence to the treatment approach, effectiveness of interventions, etc. Inquire about the family members’ experiences of each therapist intervention. Which seemed to be effective and why? 3. Divide the class into groups of 4-5 and have them conduct a role-play, the goal of which is to increase the experience levels of individual family members (which should lead to more honest and intimate family interactions). Instruct 4 students to play a family in treatment. The family consists of father, mother, preadolescent son (identified patient), and younger sister. The family is concerned with the son’s problem behavior. Mother and sister are discussing this problem behavior in detail while the father remains uninvolved. The therapist should engage the father in a creative manner to heighten his level of experiencing and increase the affective intensity of the session. The therapist’s interventions will hopefully generate enough anxiety to expose any hidden problems in the family, which then may be discussed. Observers should provide feedback to the therapist regarding the perceived effectiveness of his or her interventions. Was the family convinced that the therapist genuinely cares? What were the family members’ reactions to the interventions? 4. Invite the class to do a family sculpting exercise. (Be sure to allow for sufficient time to both conduct the exercise and to discuss students’ emotional reactions and experience.) Students can sculpt their own families of origin or a family with whom they are currently working. Once a student has elected to guide the exercise, have them arrange their classmates in a tableau to dramatize a scene from his or her childhood or adolescence. Then have the student re-arrange the scene along preferred lines, that is, how he or she would like things to be.

Experiential Exercises Note to instructors: The nature of experiential approaches do not lend themselves well to learning through role-play. Therefore, ask students to use themselves and their actual experiences to learn about the effectiveness of this approach. The students may choose to share some personal information with the class; therefore, the instructor may want ask the class to agree to respect each other’s privacy and maintain confidentiality. Moreover, instructors are encouraged to vary the format of the following exercises as necessary, to best fit the developmental level of the class. 1. Ask students to close their eyes and relax for several minutes. Instruct them to become aware of their surroundings, sounds they may not have noticed, smells, texture of things with which they are in physical contact. Go around the room asking students to share what each is aware of in the present, by saying aloud, ―Now I am aware...‖ Circulate through the entire class several times. This exercise will demonstrate to the students how feelings and perceptions drift in and out of one’s awareness. Ask students: Did you become aware of things that you hadn’t noticed before in this room? Did you discover any new awareness? 2. For this exercise in guided imagery, break the class up into groups of 4-6. Ask for a volunteer in each group who is willing to share with their group an experience that occurred when he or she was young. Instruct students to pick something that they would feel comfortable sharing.

Chapter 7: Experiential Family Therapy

Instructions to student volunteers: ―Close your eyes and make yourself comfortable in your chair. Become aware of your breathing, letting it deepen, and relax. As you begin to relax, picture an elevator in front of you, and picture the elevator door opening. Walk toward the elevator door and enter it. As the door closes, be aware that the elevator is going down. As you sense the elevator going down, you may begin to go deeper inside of yourself. When it comes to a floor that you want to get off on, it will stop, and the door will open. Now as you get off the elevator, you will be standing in front of your childhood home. Become aware of yourself when you were a very young child. Imagine yourself as that small child and be that child again. Walk into your home and describe what is happening, as it is happening, in the present tense. Describe where you are. What are you wearing? Who is there with you? Do you notice any smells, any sensations? What are you feeling?‖ (PAUSE) Instruct the students to stay with their feelings. ―Describe to us where you are feeling in your body? What is happening now?‖ (PAUSE) To end the exercise: ―When you feel ready, when you are done experiencing this, you can come back to the elevator and let it bring you back into the room.‖ Discuss the exercise together as a class. Ask the student volunteers: How vivid did their memories become for them? Were they able to remember things that they had not thought about for awhile? Did the process help to bring up some feelings about what happened in the past? What effect might a variation of this technique have with families in treatment? What types of families might be helped with experiential techniques, and with what types might they be less effective? 3. In this guided imagery exercise, have all the students close their eyes and picture a scene from their homes when they were adolescents. Ask the students to visualize a particularly disappointing event involving their parents that occurred at the time, and to imagine the scene in their minds’ eye. They should reflect on what is happening, as it is happening, in the present tense. Ask the students: ―Where are you? What are you wearing? Who is there with you? Do you notice any smells, any sensations? What are you feeling? Where is your mother and what is she doing? Your father? Is anything missing from the picture...or do you wish for something to be taken away? How does the scene end?‖ Next, instruct students to re-enter the scene as their adult selves. ―Imagine talking to your mother. What would you like to say to her? What would you like her to say (or do) in response? Imagine speaking with your father. What would you like to say to him? What do you need him to say (or do) in response? When you feel that the event has been sufficiently resolved, come back into the present and open your eyes.‖ Discuss the exercise together as a class. Ask the students: How vivid did their memories become for them? Were they able to remember a disappointing event that they had not thought about for awhile? Did the process help to bring up some feelings about what happened in the past? What types of responses from their mothers and/or fathers facilitated some resolution of these personal events? 4. Ask students to consider what kinds of emotions and forms of expression they usually don’t feel free with (e.g., the direct expression of anger, an open expression of wishes, etc.). Have students consider how such expression was discouraged in their growing up. Finally, if the students were in therapy, how could they best be helped to learn about and practice expressing this aspect of themselves better? What would be the advantages and disadvantages of having the family present? How would this differ depending on the age of the family members? (Note: This exercise may be done in a private, journal entry to be shared with the instructor in a voluntary fashion; in a small group format; or in the class as a whole, depending on the students’ interest and willingness.)

Films Carl Whitaker: Usefulness of Non-Presented Symptoms Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Whitaker consults with a grandmother, mother, and two pre-adolescent sons. The women are recent widows and the boys were abused by their deceased, alcoholic father. The intergenerational rules that hypnotize people to act in destructive ways are searched out, as the family is challenged to deal with issues in a healthier fashion. VIDEO, approximately 93 min.

Chapter 7: Experiential Family Therapy

Carl Whitaker and Gary Connell: Creating a Symbolic Experience Through Family Therapy Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) (Note: Whitaker is spelled ―Whitake‖ in the catalogue.) Whitaker demonstrates his Symbolic Experiential Therapy in his interviews with two extended families. VIDEO. Augustus Napier, Called by Families: The Journey of the Therapist. Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) (Note: Author may be listed as Gus.) Napier delivers an introspective overview of the field, tracing the rise of family therapy, theoretical developments, historical benchmarks, current trends, and proposes a series of action steps for professionals in the field. VIDEO. Virginia Satir: Of Rocks and Flowers (Golden Triad Films, Inc., 100 Westport Square, 4200 Pennsylvania, Kansas City, MO, 64111, 1983). To order: www.goldentriadfilms.com/films.satir.htm. Satir works with a blended family in which the couple has been married for a year. The husband, a recovering alcoholic, is the father of two boys, ages 4 and 2, who were repeatedly abused by their biological mother. The children are highly active and violent on occasion. The wife, abused by her previous husband who was also alcoholic, is pregnant and afraid the boys will abuse her own child. In a moving segment, Satir interacts only with the two young children--she has them touch her face gently, reciprocates, and then asks them if they would like to do the same with their parents. Then with the parents, she gently coaches them how to touch and respond to the children. Following the session in an interview with Ramon Corrales of the Family Therapy Institute of Kansas City, Virginia comments explicitly on her use of touching, both in this session and generally. Virginia Satir: The Lost Boy Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Satir conducts an experiential session with a large intact family with ten children whose presenting problem is grief following the loss of one of the children who is still missing a year after his abduction. This session provides a good demonstration of Satir’s open, directive, spatial style. VIDEO, approximately 80 min. Susan Johnson: Emotionally Focused Couples Therapy Distributed by Allyn & Bacon. To order: www.ablongman.com/catalog/academic/course Gus Napier: Experiential Therapy Distributed by Allyn & Bacon. To order: www.ablongman.com/catalog/academic/course Or call 617-848-7309. Richard Schwartz: Internal Family Systems Therapy Distributed by Allyn & Bacon. To order: www.ablongman.com/catalog/academic/course Or call 617-848-7309.

Class Discussion 1. Discuss and evaluate the strengths and weaknesses of experiential family therapy. For example, the experientialists remind us not to lose sight of the individual within the family system. They also hold a positive, optimistic view of people and their difficulties. On the other hand, experiential approaches are rather short on theory and provided limited ways of conceptualizing family dynamics, and potential countertransference issues in treatment seem to go unaddressed by many except Whitaker. Discuss the major contributions of this approach to the field of family therapy. 2. What types of client problems might be best suited for experiential family therapy? For which client problems would this approach be contraindicated? 3. Ask the class to make a list of various personality characteristics of a good experiential family therapist? Which therapist characteristics might be applicable to other types of family therapists and which characteristics seem

Chapter 7: Experiential Family Therapy

unique to the experiential family therapist? Inquire of the class which students feel themselves most drawn to this approach. Ask them to describe aspects of themselves that may fit well with the approach. 4. Discuss how Virginia Satir’s use of touch in therapy (e.g., hugging, holding hands, and having children sit on her lap, etc.) might be considered wrong in today’s climate of concern about inappropriate touching. 5. Discuss Carl Whitaker’s provocative approach to working with families. In addition to his seminal paper, ―The Hindrance of Theory in Clinical Work,‖ consider the following statements in your discussion: ―You can fall in love but you can’t fall out‖; ―Psychotherapy is like learning to play the piano. How much, how long, how deeply depends on what you want as an experience--to play hymns or to play Bach or Beethoven‖; ―You really don’t know someone until you know their parents‖; and ―Real hatred is probably never destructive--we don’t want to lose the object of our hatred; hatred has a unifying effect.‖ 6. The impact of the internal family systems model has been limited by family therapy’s long-standing reluctance to consider intrapsychic process. Is the IFS model’s notion that we all have a core Self turning family therapy back toward acontextual, individual therapy? Do people have inner resources that can help them transcend the influence of their family? Or are people so dependent on their context that for them to change, their family must change? 7. Discuss the similarities and differences between internal family systems and other experiential forms of therapy. 8. What are some experiential techniques that might usefully be employed in other forms of family therapy? 9. What advantages are there to a therapist establishing a personal relationship with clients? What disadvantages? 10. What are some of today’s cultural messages that affect how people experience and express their feelings?

Supplemental Readings Greenberg, L.S. and Johnson, S.M. 1986. Affect in marital therapy. Journal of Marital and Family Therapy, 12:1-10. Greenberg, L.S., and Johnson, S.M. 1988. Emotionally focused therapy for couples. New York: Guilford Press. Greenberg, L.S., Ford, C.L., Alden, L., and Johnson, S.M. 1993. In-session change in emotionally focused therapy. Journal of Consulting and Clinical Psychology. 61: 78-84. Johnson, S.M. 1996. The practice of emotionally focused marital therapy: Creating connection. New York: Brunner/Mazel. Johnson, S.M., and Greenberg, L.S. 1988. Relating process to outcome in marital therapy. Journal of Marital and Family Therapy. 14: 175-183. Johnson, S.M., and Williams-Keeler, L. 1998. Creating healing relationships for couples dealing with trauma: The use of emotionally focused marital therapy. Journal of Marital and Family Therapy. 24: 25-40. Napier, A.Y., and Whitaker, C.A. 1978. The family crucible. New York: Harper and Row. Satir, V.M. 1964. Conjoint family therapy. Palo Alto, CA: Science and Behavior Books. Satir, V.M. 1988. The new peoplemaking. Palo Alto, CA: Science and Behavior Books. Schwartz, R.C. 1995. Internal family systems therapy. New York: Guilford Press. Whitaker, C.A. 1976a. The hindrance of theory in clinical work. In P.J. Guerin (ed.), Family therapy: Theory and practice. New York: Gardner Press. Whitaker, C.A. 1976b. A family is a four-dimensional relationship. In P.J. Guerin (ed.), Family therapy: Theory and practice. New York: Gardner Press.

Chapter 8: Psychoanalytic Family Therapy

Chapter 8: Psychoanalytic Family Therapy INTRODUCTION As the field matured, family therapists took a renewed interest in the psychology of the individual. The revival of interest in psychodynamic thinking reflected changes in psychoanalysis that made it more attractive to family therapists, including growth of the more relationship-oriented object-relations theories, interpersonal models, and self psychology. Dissatisfaction with the mechanistic elements of the cybernetic model was another factor that led family therapists to seek greater understanding of personal experience. Currently psychoanalytic family therapists attempt to integrate depth psychology and systems theory into approaches that focus on the individual and the family system.

Leading Figures Psychoanalytic Forerunners: Sigmund Freud, Erik Erikson, Harry Stack Sullivan, Margaret Mahler, Melanie Klein, Ronald Fairbairn, John Bowlby, Heinz Kohut, Otto Kernberg. Psychoanalytic Family Therapists: Nathan Ackerman, Ivan Boszormenyi-Nagy, Henry Dicks, William Meissner, Fred Sander, Roger Shapiro, David Scharff, Jill Savage Scharff, Samuel Slipp, Helm Stierlin, Robert Winer, John Zinner.

Important Terms contextual therapy: Boszormenyi-Nagy’s model that includes relational ethics. countertransference: emotional reaction, often unconscious, on the part of the therapist to a patient. delineations: actions that express parents’ image of their children; may be objective or distorted. entitlement: Boszormenyi-Nagy’s term for the merit a person accrues for behaving in an ethical manner toward others. false self: Winnicott’s term for a defensive facade that characterizes some people’s dealings with others. fixation: partial arrest of attachment or mode of behavior at an early stage of development. holding: providing a safe psychological space in which clients can feel accepted. not judged or blamed. identification: not merely imitation but assimilation of traits of an admired other. insight: understanding and acceptance of unconscious or repressed aspects of one’s personality. introjection: a primitive form of identification; taking in aspects of other people, which then become part of the selfimage. invisible loyalties: Boszormenyi-Nagy’s term for unconscious commitments that children take on to help their families. mirroring: expression of understanding and acceptance of another’s feelings. narcissism: self regard; the exaggerated self-regard often equated with narcissism is pathological narcissism. object relations theory: psychoanalytic theory derived from Melanie Klein and developed by the British School (Bion, Fairbairn, Guntrip, Winnicott) which emphasizes relationships and attachment, rather than libidinal and aggressive drives, as the key issues of human concern. object relations: internalized images of self and others based on early parent-child interactions which govern a person’s relationships with others. projective identification: a defense mechanism whereby unwanted aspects of the self are attributed to another person and that person is induced to behave in accordance with those attitudes. regression: return to a less mature level of functioning in the face of stress. selfobject: Kohut’s term for a person related to not as a separate individual, but as an extension of the self. An appreciative other who acts as a mirror. separation/individuation: process whereby an infant begins, at about two months, to draw apart from the symbiotic bond with mother and develop autonomous functioning. transference: psychoanalytic term for distorted emotional reactions to other people based on unresolved, early family relations. unconscious: psychoanalytic term for memories, feelings, and impulses of which a person is unaware. Often used as a noun, but more appropriately used as an adjective. working through: process by which insights are translated into new and more productive ways of behaving.

Chapter 8: Psychoanalytic Family Therapy

SUMMARY OF KEY POINTS AND ISSUES Sketches of Leading Figures Freud recognized the formative influence of the family, but his therapy was based on the belief that conflicts are best explored in a private therapeutic relationship. Following Freud, object relations theorists, notably Melanie Klein, Ronald Fairbairn, and Donald Winnicott, concentrated less on sexual and aggressive drives and more on interpersonal relationships (and their mental images, or ―objects‖) in which the basic need for attachment is worked out. In the United States, Harry Stack Sullivan and Edith Jacobson emphasized interpersonal relationships in their theories. Meanwhile, in Great Britain, Henry Dicks was the first to apply object relations theory to the treatment of marital conflict. Although many of the early family therapists were analytically trained, most rejected the psychoanalytic model when they began working with families. The exceptions were Nathan Ackerman, Ivan Boszormenyi-Nagy, and Murray Bowen. Family therapy rediscovered psychoanalytic theory in the 1980s, partly because object relations theory and self psychology were more congenial to family therapists and partly because family therapists had become disenchanted with the mechanism of the cybernetic model. Today, psychoanalysis is represented in family therapy in a small but significant number of psychoanalytic family therapists and by a growing recognition that family members are not just cogs in a system but complex personalities with conscious and unconscious conflicts of their own.

Theoretical Formulations The essence of psychoanalysis is the interpretation of (a) unconscious impulses and the defenses that oppose them, and (b) childhood expectations of significant others that distort current relationships. Object relations theory, which focuses on interpersonal relationships and their distortion, bridges the gap between classical psychoanalysis (the study of individuals and their drives) and family therapy (the study of social relationships). According to object relations theory, our identities are formed in relationships -- past and present. That is, we relate to people in the present based on early experiences with caregivers. These early experiences give rise to ―internal objects,‖ mental images of self and others. These internalized objects form the core of our personalities, and in turn largely determine how we relate to others. Kohut’s self psychology focuses on people’s longing to be appreciated, and need to idealize and receive mirroring from their parents. A child raised by accepting and appreciative parents is secure, able to love, and able to stand alone as a center of initiative in adulthood.

Normal Family Development The psychoanalytic model of normal development draws from object relations theory, attachment theory, and theories of the self. The process of growth depends on the ego’s relations with objects, first as interactions with real objects, later as unconscious residues of those interactions. The outcome of good object relations in childhood is a secure and successfully differentiated personality. These characteristics endow a child with the capacity to delay gratification, tolerate frustration, and achieve competent ego functioning; he or she will have a solid sense of self and will be able to tolerate closeness with as well as separateness from others. According to object relations theory, the necessary and sufficient condition for successful completion of separationindividuation is reliable and loving support. Good-enough mothering enables children to achieve a firm sense of identity and a lifelong capacity for mature object relations. In self-psychology, two qualities of parenting are deemed essential for the development of a secure and cohesive self. The first is empathy. Attentive parents convey a deep appreciation of how their children feel. Second is a model for idealization. The child internalizes a sense of strength from identifying with the apparently infinite power of the parents. Boszormenyi-Nagy considered relational ethics to be a fundamental dynamic force, holding family and societal relationships together through reliability and trustworthiness. He emphasized a balance of fairness between people, saying that loyalty and trust are the glue that holds families together.

Chapter 8: Psychoanalytic Family Therapy

From a psychoanalytic perspective, the fate of family development is largely determined by the early development of the individual personalities who make up a family. If the spouses are mature and healthy adults, then the family will be happy and harmonious.

Development of Behavior Disorders Psychoanalytic therapists locate problems within people as well as between them. The origin of psychopathology is attributed to the development of distorted perceptions in childhood -- manifest as ―transference‖ and ―projective identification.‖ Projective identification is a process whereby the subject perceives an object as if it contained elements of the subject’s personality and evokes responses from the object that conform to those projections. Projective identification is an interactional process. For example, parents project anxiety-provoking aspects of themselves onto their children, and then children collude by behaving in ways that fulfill their parents’ fears. More recent descriptions suggest that the critical determinants of poor adult adjustment are inadequate separationindividuation and introjection of pathological inner objects. Failure to develop a cohesive sense of self causes an anxious emotional attachment to the family. Anxious attachment to parents handicaps a person’s ability to develop a social and family life of his or her own. This explains, in object-relational terms, the enmeshment that characterizes so many symptomatic families. Parents’ failure to accept their children as separate beings can take extreme forms. Theorists have remarked that anorexia nervosa results in part from inadequate separation and individuation. Often parents’ own personality disorders prevent them from accepting their children’s need for independence. They respond to their children’s independent ventures with excessive control. The result is that children don’t differentiate their own needs from those of their parents, and they become overly compliant or rebellious. The compliant facade, or ―false self,‖ is adaptive as long as children remain at home with their parents. However, poorly differentiated children usually face a crisis in adolescence when developmental pressures for independence conflict with infantile family attachments. The outcome may be prolonged dependence or a violent adolescent rebellion. According to self psychology, the child whose needs for mirroring and idealization aren’t adequately met goes through life forever hungering to be admired. This hunger may be manifested in showy exhibitionism or a childlike craving for appreciation. From a psychoanalytic perspective, one’s choice of an intimate partner is based partially on the desire to find someone who will gratify unconscious fantasies. Romantic choices are further complicated by the false-self phenomenon. A false self develops in insecurely attached children whereby they learn to hide their real needs and feelings to win approval. During courtship both partners are eager to please; however, once committed, mates reveal themselves, their powerful dependency needs, narcissism, and all. Finally, romantic attraction is influenced by the mutual fit of the partners’ projective systems. On some level, each wants the other to be an idealized parent in order to fulfill frustrated childhood needs. Boszormenyi-Nagy recast traditional psychoanalytic concepts in a language of relational ethics. Problems stem from family members not living up to their responsibilities for caring relationships. His term ―invisible loyalties‖ describes the unconscious commitments that children take on to help their families, often to the detriment of their own well-being. ―Split loyalties‖ are said to occur when parents are so antagonistic to each other that their children are caught in a conflict wherein they can only be loyal to one parent at the cost of disloyalty to the other.

Goals of Therapy The goal of psychoanalytic family therapy is intrapsychic personality change. Ideally, family members are freed of unconscious restrictions so they can interact with one another as whole, healthy persons on the basis of current reality rather than unconscious images of the past. Family members are helped to reintegrate split-off parts of themselves in order to become more fully integrated, which leads to improved relations with others. From an object-relations perspective, therapists are responsible for the provision of sufficiently safe and secure ―holding environment.‖

Chapter 8: Psychoanalytic Family Therapy

At times, psychoanalytic family therapists will opt for crisis resolution, with symptom reduction as the goal. Here treatment is short-term, with the focus on supporting family members’ defenses and clarifying communication, rather than analyzing defenses and uncovering repressed needs and impulses. Boszormenyi-Nagy’s criterion of health was a balance between rights and responsibilities. Depending on their integrity and the complementarity of their needs, intimate partners can develop a trustworthy give and take.

Therapy Assessment. Psychodynamic therapy begins with a dynamic formulation. (Beginning therapists often assume that if they merely sit back and listen, understanding will emerge.) The authors present Bentovim and Kinston’s 5-step strategy for developing a focal psychodynamic hypothesis: 1. How does the family interact around the symptom, and how does that interaction effect the symptom? 2. What is the function of the current symptom? 3. What disaster is feared by the family that keeps them from facing their conflicts more squarely? 4. How is the current situation linked to past trauma? 5. How would the therapist summarize the focal conflict in a short memorable statement? After the roots of current family conflicts have been uncovered, interpretations are made about how family members continue to reenact distorted images from childhood. The data for such interpretations come from transference reactions to the therapist and other family members, as well as from childhood memories. Analytic therapists deal less with recollections of the past than with reenactments of its influence, manifested as transference. Thus, it’s essential to establish an atmosphere in which patients feel safe enough to re-experience conflicts and reactivate early memories. The therapist’s neutrality -- not taking sides, giving advice, or offering reassurance -- enables family members to relax their defenses and reveal basic conflicts and object images, which provide the material for mutative interpretations. Therapeutic Techniques. Psychoanalytic therapists employ four basic techniques--listening, empathy, interpretation, and analytic neutrality--to foster insight and facilitate the process of working through. Conflict between couples is taken as the starting point for exploring intrapsychic and interpersonal dynamics. The analytic therapist helps partners explore their individual emotional reactions. Why do they get so angry? What do they want from each other? What did they expect? Where do these feelings come from? Rather than trying to resolve arguments, analytic therapists interrupt to ask a series of questions about the fears and longings underlying it. The red flag of intrapsychic conflict is affect. Analytic therapists explore strong feeling and inquire into its roots in detail (What were you feeling? When have you felt that way before? What do you remember?). Rather than staying focused on the couple’s current behavior, the therapist looks for openings into the depth of their internal experience and its history. Following Sullivan, most therapists see themselves not as detached observers but as participants in the interpersonal patterns of treatment. In sum, analytic therapists organize their explorations along four channels: (1) internal experience, (2) the history of that experience, (3) how the partner triggers that experience, and finally, (4) how the context of the session and therapist’s input might contribute to what’s going on between the partners. Catherall’s approach to projective identification begins with the therapist blocking a couple’s squabbling and helping the recipient of the projection (the more reactive partner) express what he or she is feeling. The partner is asked to listen without comment. Then the partner is asked to paraphrase what he or she heard the other one as saying. This makes it difficult to avoid confronting those (projected) feelings. Like most psychodynamic interventions, this one is designed to focus not on how people are communicating, but rather on the conflicted feelings that complicate their communications. Finally, it’s important to keep in mind that there are several different approaches to psychoanalytic treatment-notably, Freudian (which focuses on sexual and aggressive drives and defenses against them), object relations (which focuses on internalized distortions of self and other), and self psychology (which focuses on the needs for admiring attention and idealizing).

Chapter 8: Psychoanalytic Family Therapy

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Read aloud the case vignette of Mr. and Mrs. B (see text). Discuss possible hidden wishes and fears that each partner brings to the marriage, and describe the reciprocal process of projective identification that may be occurring. Next, divide the class into groups of 5-6 and have students conduct a 10-minute role play with two students playing Mr. and Mrs. B, two students to play therapist (in tag-team fashion), and one or two observers. Remind the therapists to use the techniques of listening (to establish an analytic atmosphere), expressing empathic understanding (helping the spouses to open up), and making interpretations to clarify the process of projective identification and/or the incomplete resolution of separation-individuation. Observers should provide feedback regarding the use of these techniques. Were the interpretations on target? What were the couples’ experiences of the therapists’ interventions? Which were experienced as helpful? Which interventions detoured the therapeutic process? How successful was the therapist in bypassing or overcoming the couple’s resistance? 2. Using the case vignette about Mr. and Mrs. Z (see text), develop two role plays with the class designed to illustrate techniques to address resistance in treatment. Briefly discuss methods presented in the text for confronting resistance (e.g., empathic listening, use of clarifying statements and uncovering questions, and early identification and interpretation). How not to confront resistance in therapy. For this role play, choose student volunteers to play a therapist and Mr. and Mrs. Z, and encourage the therapist to demonstrate ineffective techniques for dealing with client resistance. Following the role play, discuss interventions used by the therapist. What made the interventions ineffective? Which interventions seemed least effective in alleviating client resistance and promoting engagement in treatment? How did Mr. and Mrs. Z respond to the therapist’s interventions? The effective confrontation of resistance in therapy. Now choose three different volunteers to play the therapist and Mr. and Mrs. Z. This time, the therapist should demonstrate an approach which effectively addresses the couples’ resistance in treatment. Compare the first and second role plays. What was it about the therapist’s interventions and demeanor in role play #2 that made him or her more effective than therapist #1 (i.e., techniques used, timing of interventions, etc.)? 3. This exercise may be conducted in small groups or with the whole class. Ask a student to describe (or preferably, imitate) a public persona (e.g., some pop star’s outrageous and provocative behavior, Barack Obama’s hesitance to be aggressive, etc.). Encourage other students to hazard conjectures as to what that conspicuous behavior is defending against, and suggest ways to confront the defense. For example, one might say to the pop star, ―Could it be, that one reason you work so hard to be different often in an outrageous way is that you can’t bear to feel ordinary and insignificant? What can you remember about feeling that way as a child?‖ Or ―What was it, as a child, that made you need to stop feeling that you were insignificant or ordinary and how did you manage to stop feeling that?‖

Films David and Jill Scharff: Object Relations Couples Therapy Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) The Scharffs demonstrate their integrative approach of using a systems view of marital relationships and an object relations understanding of each spouse’s personality. The focus is on technique, countertransference, and family-of-origin. VIDEO. Master Series 1985: Arnon Bentovim, M.D. (Western Psychiatric Institute and Clinic Library, 3811 O’Hara St., Pittsburgh, PA 15213-2593, 412-246-5011). This program features a couple interviewed by Bentovim in which he reviews the case with the presenting therapist, interviews the couple, and discusses the interview with the audience.

Chapter 8: Psychoanalytic Family Therapy

I Would Like To Call You Mother: Ivan Boszormenyi-Nagy Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Nagy demonstrates his contextual therapy with a four-generational family consisting of a delinquent adolescent, his chronic psychotic mother, grandparents and great-grandmother. Nagy’s model employs multidirected partiality which includes discussing and acknowledging everyone’s positive contributions to counter their mistrust, blaming, and self-defeating invisible loyalties. VIDEO, 105 minutes. David Schnarch: Constructing the Sexual Crucible Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Bowen Theory and Object Relations Theory are integrated in this approach that facilitates shifts in couple dissatisfaction and conflict into greater differentiation of self and sexual intensity and intimacy. VIDEO, 120 minutes.

Class Discussion 1. Discuss the concept of resistance. What are some ways in which resistance is manifested in family therapy? How should an analytic family therapist work with resistance when it appears in treatment? How is resistance sometimes manifested in seminars? What forms does it take? What are students afraid of? Why? What things do teachers do that effectively challenge the resistance, and what do they do that reinforces resistance (e.g., lecture)? 2. Assign students the task of locating examples of therapists covering over problematic behavior without exploring its roots or meaning. (Direct students to look in various videos or written case vignettes to find some examples.) Based on your review of the examples, discuss when a failure to consider the meaning of symptoms/problem behavior might work (e.g., in cases involving those with limited insight? or intellectualizing clients?), and when a consideration of meaning is essential (e.g., in cases involving suppression basic needs, drives, or empathic failures?). 3. Reread the cases in the text. Describe how the use of listening, empathy, interpretation, and analytic neutrality may have been used to facilitate treatment progress. What types of interpretations may have the therapist used to redirect the parents’ focus on their son (i.e., form of resistance) to a focus on themselves and their marital relationship? 4. Psychoanalytic family therapy departs significantly from traditional systemic approaches to family therapy. List and describe the significant points of departure. Do these aspects contribute to or detract from the field of family therapy? In what ways? Discuss the advantages and disadvantages of integrating psychoanalytic and systems approaches. When is it better to be pure and simple, rather than complex and muddled? 5. Compare Winnicott’s concept of ―good-enough mothering‖ to Fromm-Reichmann’s formulation of the ―schizophrenogenic mother.‖ Explore for each term, the potential or real implications for how therapists approach and treat families. 6. Have students view a movie (e.g., Prince of Tides, Breaking Away, The Great Santini, War of the Roses, Ordinary People, Terms of Endearment, A Bronx Tale, Household Saints, Home for the Holidays, One True Thing, My Family, and Best Intentions to name a few) and analyze the protagonist, his or her intimate relationships, and relations with family of origin with respect to the following: degree of separation-individuation, healthy attachment, introjection of pathological objects, and selfobject needs for idealizing and mirroring. Design psychoanalytic couple or family therapy to treat the protagonist. What would be the goals of treatment? What would successful treatment look like? 7. Managed care has had a profound and controversial impact on every aspect of family therapy practice. Is there a place for psychoanalytic family therapy in this era of managed care? Divide the class into two groups and debate the issue. Has managed care improved the quality of services families receive via incentives and regulations

Chapter 8: Psychoanalytic Family Therapy

designed to contain runaway costs? Might unrestricted outpatient family therapy save money that otherwise would be spent on hospitalizations or other more expensive treatments that result from family crises? How will the influence of managed care impact the larger society as a whole in the twenty-first century?

Supplemental Readings Bentovim, A., and Kinston, W. 1991. Focal family therapy. In Handbook of family therapy. Vol. II, A.S. Gurman and D.P. Kniskern, eds. New York: Bruner/Mazel. Fraiberg, S., Adelson, E., & Shapiro, V. 1975. Ghosts in the nursery: A psychoanalytic approach to impaired infantmother relationships. Journal of the American Academy of Child Psychiatry, 14, 387-421. Gurman, A. S. 1981. Integrative marital therapy: Toward the development of an interpersonal approach. In Forms of brief therapy, S. H. Budman, ed. New York: Guilford Press. Mahler, M.S., Pine, F., and Bergman, A. 1975. The psychological birth of the human infant. New York: Basic Books. Meissner, W.W. 1978. The conceptualization of marriage and family dynamics from a psychoanalytic perspective. In Marriage and marital therapy, T.J. Paolino and B.S. McCrady, eds. New York: Brunner/Mazel. Mitchell, S. 1993. Hope and dread in psychoanalysis. New York: Basic Books. Nichols, M.P. 1987. The self in the system. New York: Brunner/Mazel. Scharff, D., and Scharff, J. 1987. Object relations family therapy. New York: Jason Aronson. Scharff, D., and Scharff, J. 1991. Object relations couple therapy. New York: Jason Aronson. Scharff, D. 1992. Refining the object and reclaiming the self. New York: Jason Aronson. Stern, D.N. 1995. The motherhood constellation: A unified view of parent-infant psychotherapy. New York: Basic Books.

Chapter 9: Cognitive-Behavioral Family Therapy

Chapter 9: Cognitive-Behavioral Family Therapy INTRODUCTION The behavioral approach is based on social learning theory, according to which behavior is maintained by its consequences, and therefore can be modified by altering those consequences. Cognitive-behavioral approaches have expanded this formula to include the examination and restructuring of perceptions and attitudes. So, while techniques of reinforcement are applied to target behaviors, families are also taught principles of behavior management along with methods for re-evaluating cognitive distortions and correcting misconceptions. Behaviorists generally don’t see whole families; instead they see those subsystems they consider central to the targeted behavior. Perhaps the greatest strength of behavior therapy is its careful assessment and measurement of change.

Leading Figures Behavioral Forerunners: Ivan Pavlov, Joseph Wolpe, B.F. Skinner. Behavioral Family Therapists: Gerald Patterson, Robert Liberman, Richard Stuart, Robert Weiss, Gayola Margolin. Cognitive-Behavioral Couple/Family Therapists: Albert Ellis, Aaron Beck, Donald Baucom, Andrew Christensen, Norman Epstein, Neil Jacobson, Frank Dattilio, Y. Teichman. Sex Therapists: Virginia Johnson, William Masters, Helen Singer Kaplan.

Important Terms automatic thoughts: spontaneous cognitions, which are mostly conscious. aversive control: use of punishment and criticism to eliminate undesirable responses; commonly used in dysfunctional families. baseline: initial recorded observations of behavior that is intended to be modified in treatment. classical conditioning: respondent learning in which an unconditioned stimulus (UCS), such as food, which leads to an unconditioned response (UCR), such as salivation, is paired with a conditioned stimulus (CS), such as a bell. As a result, the CS begins to evoke the same response, salivation, as a conditioned response (CR); useful in behavioral treatment of anxiety disorders. cognitive-behavioral therapy: treatment based on assumptions that dysfunctional family interactions are maintained by mediating cognitions. Goal is to help clients alter cognitive distortions and learn new behaviors. contingency contract: an agreement between family members that specifies expectations of behavior and consequences for meeting those expectations. extinction: eliminating behavior by not reinforcing it. family schema: jointly held beliefs about one’s own family and about family life in general. functional analysis of behavior: a study of the antecedent stimuli and consequent responses of a particular behavior. modeling: observational learning. operant conditioning: subjects are rewarded for performing certain behaviors; the primary approach in behavior therapy. Premack principle: using high probability behavior (preferred behaviors) to reinforce low probability behavior (nonpreferred behaviors). reinforcement: an event, behavior, or object that increases the rate of a particular response. A positive reinforcer is an event whose contingent presentation increases the rate of responding; a negative reinforcer is an event whose contingent withdrawal increases the rate of responding. reinforcement reciprocity: exchanging rewarding behaviors between family members. schemas: underlying core beliefs. shaping: reinforcing change in small steps. social learning theory: understanding and treating behavior using principles from social and developmental psychology as well as learning theory.

Chapter 9: Cognitive-Behavioral Family Therapy

systematic desensitization: deep muscle relaxation is used to inhibit the effects of graded anxiety-evoking stimuli. theory of social exchange: people strive to maximize ―rewards‖ and minimize ―costs‖ in relationships; in successful relationships, both partners work to maximize mutual rewards, while minimizing costs. time out: a means of extinguishing undesirable behavior by removing the reinforcing consequences of that behavior; typically, making a child sit in a corner or go to his or her room. token economy: a system of rewards using points, which can be accumulated and exchanged for reinforcing items or behaviors.

SUMMARY OF KEY POINTS AND ISSUES Sketches of Leading Figures The learning theory antecedents of behavior therapy are Pavlov’s classical conditioning and Skinner’s operant conditioning. Wolpe’s (1948) systematic desensitization was the first siginificant application of classical conditioning to the treatment of psychological problems. The other major therapeutic application of classical conditioning did not come until the 1970s, in Masters and Johnson’s treatment of sexual dysfunction. Classical conditioning principles have proven useful primarily in the treatment of anxiety-based disorders -- e.g., phobias and sexual dysfunction. The greatest influence on behavioral family therapy came from operant conditioning, according to which the frequency of behavior can be increased by positive reinforcement or decreased by ignoring or punishment. Skinner himself was the first to suggest that behavior problems could be resolved by adjusting the contingencies of reinforcement, and beginning in the 1960s behaviorists began experimenting with applications of operant conditioning to family problems -- especially with children and couples. Behavioral family therapy became increasingly popular in the 1970s, led by Gerald Patterson, Robert Liberman, Richard Stuart, and Neil Jacobson. Beginning in the mid 1980s, behaviorists began to rely more on cognitive strategies, to the point where today cognitive-behavior therapy is the most widely used behavioral approach to working with couples and families

Theoretical Formulations The basic premise of behavior therapy is that behavior is maintained by its consequences. Behavioral problems are caused by dysfunctional patterns of reinforcement between parents and children, or between members of a couple. Behavior will remain resistant to change until more rewarding consequences are introduced. Thibaut and Kelley’s theory of social exchange guided behavior therapists as they shifted their attention from individuals in isolation to family relationships. Social exchange theory states that people strive to maximize rewards and minimize costs in relationships. It provides a basis for understanding the reciprocity that develops in couples. In successful relationships, partners work to maximize mutual rewards and minimize costs, while in unsuccessful pairs, partners concentrate on minimizing costs, and have little expectation of rewards. Unlike systems theorists, behaviorists tend to operate from a linear perspective in the treatment of children (i.e., the parents’ behavior causes the child’s behavior, and the child’s behavior causes family problems). This paradigm uses a dyadic unit of analysis rather than a triadic one. The focus is on changing interactions between two family members, typically parent (usually mom) and child, or spouse and spouse. Little attention is paid to the triadic nature of these relationships--how two people affect and are affected by others in the family. Cognitive therapy, inspired by the work of Albert Ellis and Aaron Beck, emphasizes the need for attitude change to promote and maintain modifications in behavior. Our interpretations of other people’s behavior influences the ways in which we respond to them. Cognitive techniques became more prominent as behavior therapists realized that the straight behavioral approach failed to address the complicating dynamics of couple and family interactions.

Chapter 9: Cognitive-Behavioral Family Therapy

Normal Family Development Problem-solving skills and the ability to resolve conflicts are the most clearly identified criteria for successful marriages. In healthy marriages, partners are able to speak openly and directly about conflicts, keep issues in perspective, and discuss specific behaviors that are of concern to them. Each is willing and able to understand the other’s viewpoint. Behaviorists believe that good relationships are the product of learning effective coping behavior. The capacity for adaptability, flexibility, and change are also emphasized. Family rules should be comprehensive and flexible, and social reinforcement dispensed equitably and frequently. Positive control should be the primary mode of reinforcement, rather than punishment or coercion.

Development of Behavior Disorders Symptoms are viewed as learned responses, involuntarily acquired and reinforced. No underlying meaning of symptoms is sought, nor do behaviorists posit conflict between parents as a cause of problems in children. Attention is concentrated on the symptoms themselves and the environmental responses that reinforce them. Behavior therapy’s basic premise is that behavior will change when contingencies of reinforcement are altered. Cognitivebehavioral therapists believe that dysfunctional attitudes about family roles and relationships are learned growing up in our families. Among the kinds of cognitive distortions that cognitive-behaviorists track are: arbitrary influence, selective abstraction, overgeneralization, magnification and minimization, personalization, dichotomous thinking, labeling and mislabeling, and mind reading.

Goals of Therapy The goals of behavioral family therapy are to increase the rate of rewarding interactions in family relationships, decrease use of coercion and aversive exchanges, and teach communication and problem-solving skills. Therapy begins with a thorough assessment to determine the baseline frequency of problem behavior, following which specifically tailored strategies are designed to modify the contingencies of reinforcement maintaining that behavior. Behavior change remains the primary focus, but more and more behaviorists are including a variety of cognitive strategies to help family members become aware of and modify problematic assumptions and attitudes. In addition to the widespread inclusion of cognitive strategies, behaviorists are becoming increasingly sophisticated about taking into account the systems dynamics in which problem behaviors are embedded.

Therapy Behavioral family therapy is typically practiced as (a) parent training, (b) couples therapy, or (c) treatment of sexual dysfunction.

Behavioral Parent Training Assessment. Careful assessment is the hallmark of cognitive-behavioral therapy. Evaluations are based on defining, observing, and recording the frequency of behavior to be modified, as well as the events that precede and follow it. Because behavior is maintained by its consequences, careful attention is paid to determine the contingencies of reinforcement of the target behavior. In behavior parent training and couples therapy, questionnaires and home observation reports are frequently employed. Assessment is typically on ongoing part of the process of treatment in order to allow therapists to track the impact of their interventions and to help clients learn to observe the consequences of their behavior. Therapeutic Techniques. Once assessment is completed, specific treatment strategies are designed to address the identified problems. By narrowly focusing on the families’ presenting problems, behaviorists have succeeded in developing an impressive array of effective techniques. Most of these techniques rely on operant conditioning, but cognitive strategies have become increasingly important. Operant techniques such as shaping, token economies, contingency contracting, and time-out are frequently used with child and adolescent patients. Respondent

Chapter 9: Cognitive-Behavioral Family Therapy

conditioning techniques involving a modification of physiological responses (e.g., systematic desensitization, assertiveness training, aversion therapies, and sex therapies), and cognitive/affective techniques (e.g., thoughtstopping, rational emotive therapy, modeling, reattribution, and self-monitoring) are used more often when treating adults. Finally, the outcome of treatment is assessed using empirical methods.

Behavioral Couples Therapy Assessment. Behavioral couples therapy begins with a careful and systematic assessment, using clinical interviews, rating forms, and marital satisfaction questionnaires. Assessments focus on the strengths and weaknesses of a couple’s relationship, the quality of their communication and problem-solving skills, and the extent to which they use positive reinforcement as opposed to aversive control. Therapeutic Techniques. Behavioral couples therapy tends to be relatively didactic. Once problems are identified, couples are coached to communicate with each other more effectively, making requests more than complaining. Couples are also taught the value of avoiding aversive control and substituting positive reinforcement. Behavior exchange procedures are taught so that couples learn that doing nice things for each other–rather than complaining and waiting for the other one to make changes–will often initiate a positive spiral.

The Cognitive-Behavioral Approach to Family Therapy In the cognitive-behavioral framework, family relationships, cognitions, emotions, and behavior are viewed as exerting a mutual influence on one another, so that cognitive inferences are thought to evoke emotion and behavior. Likewise, emotion and behavior influence cognition. Compatible with systems theory, the cognitive-behavioral approach to families includes the premise that members of a family simultaneously influence and are influenced by each other. While CBT doesn’t suggest that cognitive processes cause all family behavior, it does stress that cognitive appraisal plays a significant part in the interrelationships existing among events, cognitions, emotions, and behaviors. Assessment. As with all forms of behavior therapy, assessment is emphasized in cognitive-behavioral therapy. Goals are defined and concretized, and specific problems are targeted for intervention. In addition to identifying behavior to be changed and contingencies of reinforcement that may be maintaining it, therapists endeavor to identify schemas, or core beliefs, that may be driving unproductive patterns of behavior. Therapeutic Techniques. The first step in cognitive-behavior therapy is to identify the assumptions behind problematic behavior. If, for example, a mother is overly permissive with her child, it may do no good to encourage her to be stricter if she believes that she has to be nice to the child to make up for having divorced his father. It’s important to discover the family members’ assumptions (automatic thoughts and underlying schemas) rather than for the therapist to make generalized assumptions about what people must be thinking. The second step is to point out the problematic consequences of acting on certain unexamined assumptions. Once the need to modify unproductive assumptions is agreed to, then the therapist and family together can consider new and more flexible ways of behaving. Remember that cognitive-behavior therapy adds consideration of underlying assumptions but does not subtract looking at contingencies of reinforcement. Once clients have learned to identify the automatic thoughts behind their actions, they are encouraged to test their assumptions, and, when appropriate, consider alternative explanations. One of the points the author emphasizes is that the process or identifying and challenging unproductive assumptions should be a collaborative one–that is, therapists should neither assume what clients may be thinking nor should they tell them what to think. Rather therapists should help clients identify their own assumptions, and then test them themselves.

Treatment of Sexual Dysfunction Assessment. Treatment is proceeded by a thorough assessment, beginning with a thorough medical examination (obviously made by referring to a physician) to rule out (or take into account) possible medical reasons for sexual problems (e.g., diabetes, high blood pressure, coronary artery disease). Extensive interviews are conducted to explore both partners’ sexual histories, and the history of their sexual relationship as a couple. Problems are categorized as: disorders of desire, arousal, or orgasm.

Chapter 9: Cognitive-Behavioral Family Therapy

Therapeutic Techniques. Sex therapy generally begins with sensate focus exercises, in which couples are taught to take turns pleasing each other and to communicate their likes and dislikes. Following this, specific procedures are employed depending on the specific nature of the couple’s sexual problem.

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Have two students role-play a conversation in which each reacts with emotional responses to the other’s statements. Observers should take note of what happens and discuss what they see. Next have them role play a similar conversation, but this time instruct them to first acknowledge what the other has said before they respond. Have the group discuss each role-play. Identify in behavioral terms the phenomena observed. What impact did acknowledgment of the other’s perspective have on the quality of the interaction? Discuss the implications for how one would conduct behavioral marital therapy. 2. Conduct a series of role-plays to allow students to practice behavioral assessment. Recall that a behavioral assessment consists of (a) problem identification, (b) functional analysis of behavior, including its antecedents and consequences, and (c) matching treatment to the client. One student should take the role of therapist, 1-2 students may observe, and 3 students should make up the family in treatment. The families should have a presenting problem centered around the child as identified patient. The therapist should begin by interviewing one or both parents to identify the problem behaviors. Instruct therapists to encourage parents to provide descriptions with concrete behavioral referents, and to obtain information which will develop a picture of the interactions between parents and child. (For example, ―What does Johnny do that indicates his laziness?‖ helps to pinpoint the problem, and ―What do you do when he does that?‖ provides a picture of the interaction.) The functional analysis should consist of actually observing and recording the target behavior, its antecedents, and consequences. Finally, the therapist should take a break to confer with the observers to design a treatment package for the family. Once decided upon, the therapist should present the treatment plan and contract with the family for treatment. Observers should provide feedback regarding the thoroughness and effectiveness of the assessment. How effective was the therapist in presenting the treatment plan and contracting with the family? 3. Have students role-play a couples therapy session, first without exploring the couple’s attributions and underlying schemas. Next, with the same couple, conduct a session in which the therapist explores their underlying schemas and expectations about the relationship and their partner, and where they come from. Observers should provide feedback to the therapist regarding the perceived effectiveness of the interventions. Have the observers interview the couple to find out their experiences of the two role plays. From their perspectives, which was more helpful and why?

Films James Alexander: Accentuating the Positive Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Functional family therapy is demonstrated with a family of four and their 16 year-old ―defiant‖ son. Using warmth, confidence, and decisiveness, Dr. Alexander explores each member’s response style to problems and makes inquiries about whether they really work. Each family member’s particular ―traps‖ are identified and linked to family functioning patterns. VIDEO, 105 minutes. James Alexander: Emotional Barriers in Adolescents’ Conflicted Families Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Dr. Alexander demonstrates specific therapeutic philosophies and strategies for lowering the intense negative emotions that impede positive change in families of acting-out youths. VIDEO, approximately 120 minutes.

Chapter 9: Cognitive-Behavioral Family Therapy

Howard Markman: Preventing Marital Distress Through Constructive Arguing Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) This research-based approach demonstrates how divorce results from the inability to handle conflict, not from an inability to express intimacy. Ground rules to help couples handle conflict constructively are presented. VIDEO. Joseph LoPiccolo: Treatment of Sexual Deviation Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Techniques for reducing deviant arousal patterns, anxiety reduction, skill training, and relapse prevention are offered. Dr. LoPiccolo also presents a critique of the ―sexual addiction‖ model. VIDEO. Joseph LoPiccolo: Echoes From the Past Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Within couples therapy, Dr. LoPiccolo focuses on the long-term molestation of a wife through gentle, matter-of-fact questioning and emphasizes collusion of her mother in the incest and her own self-sacrifice to protect her sisters. LoPiccolo normalizes the couple’s frustration and guilt, and makes recommendations for the future course of therapy. VIDEO, 125 minutes.

Class Discussion 1. Behavioral family therapy departs significantly from systemic approaches to family therapy. List and describe the significant points of departure. Do these aspects contribute to or detract from the field? In what ways? 2. What types of client problems seem best suited for behavioral family therapy (i.e., behavioral parent training, couples therapy, and treatment of sexual dysfunction)? For which client problems might these approaches be less effective? 3. Do behavioral family therapists assume that people change when they are propelled into action, or when they develop understanding? Why? 4. Discuss the strengths and weaknesses of behavioral family therapy. What might be considered the major contributions of this approach to the field of family therapy? Consider its theoretical adequacy, specificity of constructs, strategies and techniques, roles of the therapist, and types of client problems best suited for this approach. 5. Discuss similarities and differences between cognitive behavioral therapy and narrative therapy. 6. What is the difference between automatic thoughts and schemas? (Spontaneous cognitions, mostly conscious versus underlying core beliefs, which are not often conscious.) What must a therapist do differently to get at these two types of cognitions?

Supplemental Readings Arrington, A., Sullaway, M., and Christensen, A. 1988. Behavioral family assessment. In Handbook of behavioral family therapy, I.R.H. Fallon, ed. New York: Guilford Press. Baucom, D.H., and Epstein, N. 1990. Cognitive-behavioral marital therapy. New York: Brunner/Mazel. Baucom, D.H., Shoham, V., Mueser, K.T., Daiuto, A.D., and Stickle, T.R. 1998. Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology. 66: 53-88. Dattilio, F.M. 1990. Cognitive marital therapy: A case study. Journal of Family Psychotherapy. 1: 51-65.

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Epstein, N. and Schlesinger, S.E. 1996. Cognitive-behavioral treatment of family problems. In Casebook of cognitive-behavior therapy with children and adolescents, M. Reincke, F.M. Dattilio, and A. Freeman, eds. New York: Guilford Press. Jacobson, N.S. 1981. Behavioral marital therapy. In Handbook of family therapy, A.S. Gurman and D.P. Kniskern, eds. New York: Brunner/Mazel. LoPiccolo, J., and LoPiccolo, L. 1978. Handbook of sex therapy. New York: Plenum. McCauley, R. 1988. Parent training: Clinical application. In Handbook of behavioral family therapy, I.R.H. Fallon, ed. New York: Guilford Press. O’Farrell, T.J. 1993. Treating alcohol problems: Marital and family interventions. Schwebel, A.I., and Fine, M.A. 1992. Cognitive-behavioral family therapy. Journal of Family Psychotherapy, 3: 7391. Stuart, R.B. 1980. Helping couples change: A social learning approach to marital therapy. New York: Guilford Press. Teichman, Y. 1992. Family treatment with an acting-out adolescent. In Comprehensive casebook of cognitive therapy, A. Freeman and F.M. Dattilio, eds. New York: Plenum.

Chapter 10: Family Therapy in the Twenty-first Century

Chapter 10: Family Therapy in the Twenty-first Century INTRODUCTION Most of the challenges that have reshaped family therapy in recent years -- the feminist critique, postmodern skepticism, and social constructionism -- have been in reaction to the field’s early mechanistic concepts and aggressive attitudes. Reflecting a maturing of the field, these movements have raised new questions about the therapist’s style of leadership, and have renewed interest in collaborating with rather than confronting or directing families. As with many revolutionary movements, however, the postmodern shift was not only toward the new but away from the old—away from systems thinking and attention to family dynamics.

Important Terms collaborative therapy: an egalitarian style of therapy, advocated by critics of authoritarian elements of traditional family therapy approaches. constructivism: relativistic point of view that emphasizes the subjective construction of reality--what we see in families may be based as much on our preconceptions as on what’s actually going on. cybering: engaging in sexual activity with someone online. cybersex: sharing of sexual photos and videos, and sexual communications on the Internet. expressed emotion: criticism, hostility, and emotional overinvolvement in families, increases the likelihood of relapse in schizophrenia. feminism: advocating equal treatment of men and women. feminist family therapy: an approach that makes gender equality the primary focus of treatment. first-order cybernetics: the idea that an outside observer can study and make changes in a system while remaining separate and independent of that system. fMRI: functional Magnetic Resonance Imaging, measures increases in blood flow to the most active regions of the brain. hermeneutics: the art of analyzing literary texts or human experience, understood as fundamentally ambiguous, by interpreting levels of meaning. homophobia: fear and aversion to and discrimination against homosexuals. limbic system: emotional circuit in the brain; hypothalamus, hippocampus, and amygdala. medical family therapy: counseling and supportive therapy for families with chronic illnesses. postmodernism: contemporary antipositivism, viewing knowledge as relative and context-dependent; questions assumptions of objectivity. In family therapy, challenging the idea of scientific certainty, and linked to the method of deconstruction. power-over: domination and control. power-to: the ability and resources to perform and produce. psychoeducational family therapy: educational workshops and supportive therapy for families with members suffering from serious mental illness. reflecting team: Tom Andersen’s technique of having observers share their reactions with clients. second-order cybernetics: the idea that anyone attempting to observe and change a system is therefore part of that system. social constructionism: notion that knowledge and meaning are shaped by culturally-shared assumptions. three-generational family systems: a mother, her children, and the children’s grandparent(s). transgender: having a personal identify that differs from one’s biological sex.

SUMMARY OF KEY POINTS AND ISSUES Erosion of Boundaries The boundaries between the discrete schools within the field have eroded. It’s now uncommon to encounter a family therapist who describes himself or herself as a purely structural or behavioral or strategic. Therapists now sample ideas from different schools and from outside the field. Some of this shift is attributable to the death or retirement of the charismatic pioneers of the various schools; some to a growing emphasis on integrating across models; and some to efforts to tailor therapy to the specific needs a certain client groups (rather than the other way around).

Chapter 10: Family Therapy in the Twenty-first Century

Postmodernism Postmodern psychology concerns itself with how people make meaning or construct reality in their lives. According to such thinking there are no objective realities, only points of view. As a result of postmodern skepticism and relativism, family therapists are more humble and have renounced their status as experts relative to clients. The postmodernization of family therapy is seen in: a) loss of faith in unbiased objectivity: led to increased pluralism in the field, and diminished territorial wars among schools of family therapy. Therapists can work with families in a number of useful ways. b) a movement to deconstruct established theories: initiated by the feminist critique which identified the patriarchal biases behind many of the assumptions and practices of family therapy. c) disillusionment with expert opinions: family therapy has become more collaborative, with greater respect for self-help movements and for family members themselves as experts on their own lives. d) interest in the generation of meaning: some leading therapists have rejected systems thinking in favor of the narrative metaphor (e.g., Michael White, Harry Goolishian, Harlene Anderson), focusing on the stories that govern a family’s life. e) interest in diversity and pluralism: researchers, clinicians, and theorists are devoting more time focusing on a variety of family forms created by ethnicity, race, social class, and sexual orientation, and the application of family therapy to special populations and specific client problems.

The Feminist Critique A central premise of the feminist critique is that marriage and family life have subjugated women. The systemic idea of complementarity is viewed as troublesome because it colludes with patriarchal rules by suggesting that husbands and wives have contributed equally to and share equal responsibility for changing their problems. Moreover, while feminist family therapists advocate collaborative therapies and retain an interest in meaning, they oppose relativistic neutrality because they have difficulty trusting the ―normal‖ family, steeped as it is in patriarchal values. Feminists have also challenged family therapy’s view of the dysfunctional family constellation (i.e., the enmeshed mother who needs a father to come to the children’s rescue). Instead, this archetypal family pattern is understood as a product of an historical cultural process. Feminists help families reexamine roles that keep mothers down and fathers out. This requires the elevation of gender as a primary organizing concept for family therapists.

Feminist Family Therapy While most family therapists these days are sensitive to issues of gender and gender inequality, the authors suggest that the designation ―feminist family therapy‖ should be reserved for approaches that make gender equality the primary focus of treatment. Feminist family therapists may practice within a variety of specific models – for example, Betty Carter was a Bowenian, and Deborah Luepnitz is an object relations therapist – they share a focus on conditions that make life unfair for women, social expectations (like cultural standards of physical beauty) that influence men and women, the role of unequal earning power on the politics of the family, and empowerment of men and women, stressing the difference between power-to versus power-over. Although they focus on helping clients achieve gender equality, feminist family therapists do not ignore systems dynamics in their work. Moreover, in calling for husbands and fathers to become more involved in family life, feminist therapists recognize that there may be a price to be paid – especially in terms of career achievement -- for such a shift.

Social Constructionism and the Narrative Revolution Constructivism. Constructivism asserts that reality doesn’t exist as an objective fact, but instead as a mental creation of the observer. How therapists see families is a product of their particular set of assumptions. Constructivism requires greater tentativeness about the validity of one’s observations and a closer examination of the assumptions one brings to encounters with families. Changes in the field as a result of constructivism include: a) elevation of meaning to a position of primary importance over behavioral interaction patterns, b) increased humility about our theoretical models,

Chapter 10: Family Therapy in the Twenty-first Century

c) increased attention to the values behind our assumptions about families and family functioning, d) less willingness to manipulate or control people, and e) increased trust in clients’ resources. Social constructionism is a variant of constructionism that emphasizes the power of social interaction in generating meaning for people. According to one of its main proponents, Kenneth Gergen, the realities we construct are anchored in the language systems and social context in which we exist. Collaborative, Conversational Approaches. These approaches reflect the postmodern influences of linguistics and philosophy on the field of family therapy. Postmodern narrative-constructive therapists are united in their commitment to move therapists out of the expert-in-charge position to form more egalitarian partnerships with clients. In so doing they hope to empower families and to turn therapy into a mutual search for understanding and new options. These approaches call on therapists to make listening to people more important than changing them. Because these theorists downplay technique, their approach is difficult to describe. It’s more of an attitude than a method. Leading figures in this area include Harlene Anderson and Harry Goolishian, Lynn Hoffman, and Tom Andersen. From a postmodern position, therapy becomes a joint effort to deconstruct and reexamine ways of experiencing and looking at problems. Collaborative therapists promote therapeutic conversations, in which therapists follow the thinking and feelings of the family members they’re working with, rather than imposing their own views. The reflecting team is used to help therapists empower families. Observers come out from behind the mirror and exchange ideas about the family while the therapist and family watch and listen. The family is then asked to comment while the team watches and listens. Use of a reflecting team makes the family and staff partners in a joint enterprise. The Hermeneutic Tradition. The term hermeneutics originated in the Greek word for interpretation. Whatever a therapists knows is not simply discovered or revealed -- experience is without determinate meaning and is understood only through a process that organizes, selects what’s salient, and assigns meaning and significance. It requires a therapist to put aside his or her deepest beliefs and be genuinely open to the speaker’s story. The Narrative Revolution. Family therapy in the twenty-first century has again come to emphasize the mind in which problems occur. Social constructionism emphasizes the power of social interaction in generating meaning for people. Families are thought to be shaped by cultural beliefs that are taken for granted and unexamined. The narrative metaphor focuses on understanding how experience creates expectation, and how expectations then shape experience through the creation of organizing stories. Narrative constructivist therapists follow Gergen in considering the ―self‖ a socially constructed phenomenon. A person’s sense of self is thought to emerge when interpersonal conversations are internalized as inner conversations. These conversations are then organized into stories by which we understand our experience. The question is not one of truth, but which points of view are useful and which lead to preferred effects for the client. Therapy becomes a process of helping people reexamine the stories they live by.

Multiculturalism Postmodern sensitivity was fostered by increasing exposure to a multiplicity of cultures. Different family structures are no longer viewed as problematic simply because they don’t match the American middle-class norm. Ethnicity is one of many factors that influence a family’s behavior, values, and belief systems. Monica McGoldrick and her colleagues were among the first to sensitize the field to the importance of being knowledgeable about various ethnic groups. Family therapists now are more likely to consider and explore with a family their ethnic heritage. However, an overemphasis on ethnicity may focus therapists on the differences between themselves and their clients, constraining the therapeutic connection as a result. Therapists are encouraged to respect the ethnic heritage of a family’s particular beliefs but also to consider the effects of these believes.

Race As the ethnic composition of the United Stated continues to evolve, therapists will likely work with more and more families of color. These changes will require a greater understanding of the impact of overt and subtle racism in our client’s and colleagues’ lives, and require that each of us confront our culture’s racial stereotypes. The task of

Chapter 10: Family Therapy in the Twenty-first Century

therapists working with families of color is to understand their symptoms, reluctance to engage in therapy, and distance or hostility (particularly toward white therapists), in the context of their environment and their history of negative interactions with white institutions. Likewise, therapists must recognize a family’s strengths and support or help strengthen their social networks, and look inside and face his or her own attitudes about race.

Poverty and Social Class Many therapists have limited appreciation of the obstacles poor clients face or the devastating psychological impact of poverty. Therapist must educate themselves to the political and social realities of being poor in the U.S. The economy contains built-in disparities that make it difficult for anyone to climb out of poverty and keeps 1 in 4 children in poverty. Few therapists understand how crime and violent behavior of poor youth is related to the culture of trauma and abuse that pervade their childhoods. Only when therapists begin to treat antisocial kids as survivors, as well as perpetrators, of violence, will the vicious cycle be broken.

Immigration Today immigration is a hot-button political issue – especially the question of how open our borders should be. But regardless of where they stand on such political questions, therapists endeavor to understand the unique needs of the immigrant communities they serve. Establishing trust with undocumented immigrants involves repeated assurance that you can be trusted not to report them to the authorities. It’s also well to remember that immigrants are not a monolithic group, and that different generations in immigrant families may have conflicts over acculturation. A therapist’s job is not to take sidcs in such conflicts, but to help families learn to address and resolve their own differences.

Gay and Lesbian Rights Gay and lesbian families are now considered to be one of many diverse family types. To effectively treat same-sex couples, therapists must become knowledgeable both about their own biases and about the lesbian and gay world. In order to be effective with these individuals, therapists must examine their attitudes about sexuality, their unexamined prejudices regarding gay parenting, and seek to understand issues of homophobia and heterosexism. For example, most heterosexuals are relatively naive about certain aspects of homosexual practice and culture, including the whole dynamic of sexual relationships. Gay and lesbian clients may have difficulty trusting straight therapists, because they expect to be misunderstood and their lifestyle not respected. Gay and lesbian families have much to teach mainstream society about gender relationships, parenting, adaptation, strength, and resilience.

Spirituality and Religion As increasing numbers of people find modern life isolating and empty, spirituality and religion are emerging as antidotes to widespread feelings of alienation. In turn, family therapists have begun writing about spirituality, emphasizing the use of spiritual practice to keep one’s heart open—to bring compassion, acceptance, and love to clients. People need to feel connected—not only to their partners and children, but also to something greater that gives meaning to life. In dealing with clients’ religious convictions is important for therapists to demonstrate openness and curiosity – not assumptions or judgment.

Advances in Neuroscience Breakthroughs in the technology of studying brain functioning, such fMRI, PET scan, ERP, and TMS, have produced a growing body of evidence that our brains are programmed in childhood to respond to certain situations in an emotionally reactive way. Emotion, not cognition, may turn out to be the primary organizer of human experience. However, while emerging neuroscientific advances suggest that our brains are wired to respond in certain ways, this doesn’t mean that we have no control over our behavior. The authors suggest not confusing neuroscientific

Chapter 10: Family Therapy in the Twenty-first Century

responses as causal determinants of behavior. Biological events don’t cause human actions – these things occur on different levels of analysis.

Sex and the Internet The authors describe problems associated with sex and the Internet, especially adolescent experimentation and potential victimization by adult sexual predators as well as adults who become addicted to pornography or develop relationships that lead to infidelity. Guidelines for spotting these problems are listed as our various ways of dealing with problems of sex and the Internet. However, the author cautions that total control of this kind of behavior is no more possible than total control of any other kind of family behavior.

Technology and the Family Without some limits on its use, technology can have a destructive influence on families and family members. The authors suggest that limiting children’s screen time to about two hours a day may help prevent them from neglecting other aspects of their lives.

SUGGESTED LEARNING ACTIVITIES Role Plays Note to instructors: To assist students in learning to conceptualize families and normal family development from a multicultural perspective with respect for the family’s ethnicity, students should read McGoldrick’s (1996) work on ethnicity and the family life cycle (Carter & McGoldrick, 1998). 1. These role plays may be conducted in small groups or in the larger class, depending on the instructor’s comfort with the students’ level of awareness about their biases and stereotypes regarding different ethnic groups. Three or four students should volunteer to play a family and identify their particular ethnic background (e.g., AfricanAmerican, Asian, Irish, Italian, Jewish, Latino, etc.). Take several minutes and discuss with the class the family’s current life-cycle stage and the characteristics that typify a family with that particular ethnicity. Choose a therapist and have him or her conduct a 10-minute discussion with the family about their family values. The therapist should explore how the family’s ethnicity, social class, religion, and environs affect family members’ beliefs and practices during this life-cycle stage. Observers should provide feedback to the therapist regarding the quality of the bond established, any aspects of ethnocentric biases in the therapist, etc. Discussion: How can therapists balance appreciation of a family’s ethnic heritage and values with an evaluation of the functionality of those values? What does a black family anticipate from a white therapist? Do they expect a black, Asian, Latino, etc. therapist? How does a family feel about a white therapist who tries hard and pretends to understand them, versus one who is open about who he or she is, and isn’t? What is best: being genuine, open, respectful, and relatively ignorant about the family’s culture; or being knowledgeable and experienced with the family’s culture. (Instructors should make both sides of the debate sound equally plausible in order to generate a discussion.) 2. Ask students to conduct a 15-minute role play using a feminist framework. One student should play a therapist with two student observers and three students to play a family in crisis. The husband vacillates between withdrawal and verbal abuse of his wife and son, who have an enmeshed relationship. The preadolescent son has been suspended from school for fighting. The therapist should use a feminist framework to guide exploration and assessment of this family’s difficulties. What are the family roles and rules that have been established? Explore the nature and extent of family violence. Challenge any patriarchal assumptions that surface and help the family to examine and change family rules and roles that keep the mother down and the father in an outside position in the family. Help the family begin to reorganize so that neither the father or mother remain stuck in their old roles. One student observer will assess the strength of the alliance developed between the therapist and the father, and one will focus on the alliance between the therapist and the mother. Observers should provide feedback to the

Chapter 10: Family Therapy in the Twenty-first Century

therapist regarding sensitivity to feminist issues, ability to join the family and forge an alliance with both the mother and father, etc. 3. Have on student portraying a teenager, and another student play the role of a parent asking the teenager questions about inappropriate internet use.

Discussion Questions/Experiential Exercises 1. The following exercises are designed to help students understand multiculturalism and race relations. a) Divide students into groups of 4-5 and ask them to generate as many thoughts and ideas they have about the following groups of people: African-American, Indian, Irish, Italian, Jewish, Korean, Chinese, and Latino. How do these groups differ from one another? What characteristics do they have in common? What are the roles of men and women in each ethnic group? Asks students to consider that there may be not one but two or more stereotypes. Have students consider how social class interacts with ethnicity (e.g., Jewish intellectuals vs. Jewish business people). Encourage students to be as open and honest as possible. Each group should examine their lists and determine which of their ideas constitute stereotyping. To what extent do students hesitate to say what they think? What makes such things hard to talk about? What is needed in order to establish trust, even to open up? Ask students to try to determine the origins of their stereotypes and how they help and/or hurt them. In this way, students may determine for themselves the origins and factors that maintain their beliefs about others. b) Have students read a novel or view a film that depicts an ethnic culture, past or present: The Help, Precious, The Mambo Kings Play Songs of Love, Love in the Time of Cholera, Beloved, Invisible Man, Go Tell It on the Mountain, The Commitments, Dreaming in Cuban, The Brothers McMullen, The Scent of Green Papaya, I Know This Much Is True, The Ink Well, Soul Food, etc., and discuss in small groups or written format. c) Become familiar with different historical world views that each racial/ethnic group represents. For example, George Washington may be considered an American hero to European Americans, because he owned slaves he might by considered just the opposite by African Americans. 2. The following exercises are designed to assist students in learning about the negative messages gay and lesbians regularly encounter, and about their own homophobia. a) Pick up a copy of your local lesbian and gay newspaper and carry it around with you for a day. Take it with you to lunch; lay it out in a visible way, and pay attention to your own internal response: do you feel vulnerable, self-conscious, ashamed, fearful? b) Try walking around downtown or any public place holding hands with a same-sex classmate or friend and note the responses that get triggered inside as well as those from onlookers. c) In a small group format, discuss your thoughts and ideas about gay and lesbian couples and families. Designate one student as a recorder and list all positive and negative aspects/attributes of same-sex couples and families. What are the unique issues facing same-sex couples who would like to have children? Invite gay or lesbian parents to share their experiences with adoption and/or birth with the class. d) Solidly confront a ―queer‖ joke; march in a gay/lesbian pride parade. e) Show any of the following films in class and discuss: Brokeback Mountain, Maurice, A Single Man, But I’m a Cheerleader, Boys Don’t Cry, Billy’s Hollywood Screen Kiss, Desert Hearts, Before Stonewall, Torch Song Trilogy, Boys in the Band, The Wedding Banquet, Longtime Companion, Home for the Holidays (films about gay/lesbian experiences). 3. In the interests of remaining open and neutral when helping individuals with sexual identity concerns, encourage students to imagine how they might approach prospective clients who are struggling with their sexual orientation.

Chapter 10: Family Therapy in the Twenty-first Century

For example, what would a young graduate student therapist say to a nineteen-year-old boy who hasn’t dated and anxiously wonders if he is gay? ―What’s wrong with that?‖ or ―That’s a perfectly legitimate lifestyle?‖ or ―Why don’t you join a support group for gay men.‖ or ―What’s the problem? or a more neutral inquiry such as: ―What makes you think that?‖ ―How do you feel about that?‖ ―What might be the consequences of your choices either way?‖ 4. Suppose you are a well-educated African-American therapist working in a community mental health center. In working with poor and working-class African-American clients should you join with your clients by using street language (Ebonics)? How about if you are a middle-class white therapist? 5. Propose (or have students generate) ethical practice dilemmas where traditional clinical values – neutrality, confidentiality, etc. – might conflict with legal or ethical statements or common sense. 6. What do you think about the authors’ assertion that neurological events do not cause human actions? In what way is this true? In what way is it not true? 7. If you have children, how do you plan to control their screen time? 8. To what extent has our society achieved equality between men and women, in terms of what children growing up expecting for themselves, in terms of institutional arrangements? 9. Can you think of examples of people accepting something harmful as acceptable because it’s common in some other culture?

Films Putting the Brakes On Mother: Olga Silverstein Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) In this consultation session, a traditional middle-class, intact family present serious school and drug-related behavior problems in the 2 adolescent sons, the eldest of whom is absent from the session. Focus is placed on the theme of defiance versus independence and the ambivalence of both parents and children, caught in the developmental paradox of separation and attachment. VIDEO, 120 minutes.

Class Discussion 1. As the American family is in a stressful time of transition, what concepts do we have in family therapy to help us understand and deal with the protean family forms of the 21st century? 2. The collaborative approach to family therapy can be likened to the experience of a class being led by a teacher who invites students to discuss their points of view, instead of maintaining a hierarchical and directive position, and giving lectures, etc. What are some of the advantages and disadvantages of these two ways of leading: student-driven versus teacher-driven classes? 3. An era of skepticism and reexamination has taken hold in family therapy over the last several years, resulting in changes in some of the field’s core concepts and methods. These changes parallel cultural shifts accompanying the postmodern movement in our society. Discuss the postmodern influence on the field and describe major changes taking place in family therapy. Are these shifts in thinking a good thing? Has the field gone too far? Can one use language-based collaborative approaches to inadvertently collude with families to deny or minimize their problems? 4. Why should a family’s ethnic culture be considered in assessment? 5. Generate a discussion about the men’s movement and its relationship to the women’s movement. What characteristics do they share in common? How do they differ? For example, one difference is that the women’s movement focused on discrimination and outrage, while the men’s on ontological anxiety.

Chapter 10: Family Therapy in the Twenty-first Century

6. Is there a body of therapeutic practice that constitutes ―feminist family therapy‖ or is feminist family therapy more a philosophical point of view? Is it possible to discuss the deep structure of gender polarization without assuming feminine innocence and male, phallic evil? What is the proper balance between the heretofore polarized positions that family violence is an evil done to men by women, or an escalation, albeit unacceptable, of the emotionally destructive behavior that characterizes many intimate partnerships? 7. Is the idea that therapy should be less hierarchical and more collaborative a healthy step in the direction of greater respect for clients, or is it politically correct but clinically neglectful of the need for therapist expertise and leadership?

Supplemental Readings Andersen, T. 1991. The reflecting team. New York: Norton. Avis, J. M. 19889. Integrating gender into the family therapy curriculum. Journal of Feminist Family Therapy. 1: 324. Boyd-Franklin, N. 1989. Black families in therapy: A multisystems approach. New York: Guilford Press. Falicov, C. 1998. Latino families in therapy. New York: Guilford Press. Family Therapy Networker. 1993, July/August. The Black middle class: No refuge from racism [Special issue]. Family Therapy Networker. 1991. Gays and lesbians in therapy [Special issue]. Fowers, B. and Richardson, F. 1996. Why is multiculturalism good? American Psychologist. 51: 609-621. Gergen, K. 1985. The social constructionist movement in modern psychology. American Psychologist. 40: 266-275. Goldner, V., Penn, P., Sheinberg, M., and Walker, G. 1990. Love and violence: Gender paradoxes in volatile attachments. Family Process, 29, 343-364. Goodrich, T.J., ed. 1991. Women and power: Perspectives for family therapy. New York: Norton. Hardy, K.V., and Laszloffy, T.A. 1995. The cultural genogram: Key to training culturally competent family therapists. Journal of Marital and Family Therapy, 21(3), 227-237. Hare-Mustin, R.T. 1994. Discourses in the mirrored room: A postmodern analysis of therapy. Family Process. In press. Hoffman, L. 1990. Constructing realities: An art of lenses. Family Process. 29: 1-12. Luepnitz, D.A. 1988. The family interpreted: Feminist theory in clinical practice. New York: Basic Books. McGoldrick, M., Giordano, J., and Pearce, J. 1996. Ethnicity and family therapy, 2nd ed. New York: Guilford press. McGoldrick, M., ed. 1998. Re-visioning family therapy. New York: Guilford Press. Sue, D.W., and Sue, D. 1990. Counseling the culturally different: Theory and practice, 2nd ed. New York: Wiley. Walsh, F., ed. 1999. Spirituality in families and family therapy. New York: Guilford Press.

Chapter 11: Tailoring Treatment to Specific Populations and Problems

Chapter 11: Tailoring Treatment to Specific Populations and Problems Tailoring Treatments to Populations and Problems Few themes are more important in contemporary family therapy than designing specific treatment approaches for specific problems and populations. The recent trend toward specialization by content area has served to decrease factionalism and increase communication among the many models of family therapy. Myriad books have emerged that focus on how to treat families with a host of specific types of problems and family constellations (e.g., treatment of families with individuals with schizophrenia, bipolar disorder, who are addicted to substances, abuse food, and each other; treatment of single-parent families, divorcing families, step-families, to name just a few). Many of these books transcend particular theoretical orientations and focus on the specific needs of various types of clients. The text offers treatment guidelines for working with single-parent families, African American families, and gay and lesbian families. Some understanding of the dynamics and special burdens of each of these groups is necessary for effective treatment. With single-parent families, for example, finding additional support – both personal and financial – for the custodial parent (usually a mother) is often a prerequisite to helping her make constructive changes in her parenting or social life. With African American families, it is often important to help activate the resources of an extended kinship system in order to support a family. Therapists are encouraged not to ignore fathers in working with this population. In working with gay and lesbian families, therapists are advised to be aware of homophobia – both in their clients and themselves – and to respect the dignity of same-sex relationships but without patronizing them.

Single-Parent Families The authors suggest that working with single-parent is in many ways the same as working with any family – that is, the therapist should address structural problems and problematic interactions. However, single parents do face unique challenges, and it is well for therapists to take these into account.

African American Families White therapists should expect and be prepared to address distrust from some African American families. In such instances, it is a therapist’s job to prove respectful and trustworthy – but without becoming patronizing. Often in working with African American families it may be important to explore an extended family kinship network in support of client families.

Gay and Lesbian Families As with single-parent and African American families, the therapists suggest that these families struggle with the same problems as other families. However, as was true with single-parent and African American families, it is important to understand the unique challenges faced by gay and lesbian families. Therapists are advised to be curious and respectful in dealing with these families, but not to be too anxious to prove how accepting and enlightened they are. Effective family therapy requires empathy and understanding – but it also often requires challenging dysfunctional patterns of behavior.

Transgender Individuals and their Families While it is hard for most therapists to understand the burden of being a transgendered person in our society, it is not hard to be sympathetic. However, it may sometimes be harder to sympathize with the difficulty other family members might have in accepting their transgender family member. Because this population faces such strong and unique challenges therapists may do well to refer such cases to people with more experience than themselves – or at least to educate themselves by doing extensive reading on this population.

Home-Based Services Family oriented home-based services are designed to support families in caring for all of their members rather than referring various individuals to a variety of fractionated services. Home-based work is oriented to helping families

Chapter 11: Tailoring Treatment to Specific Populations and Problems

utilize their own as well as various community resources, in contrast to the traditional family therapy orientation of repairing family dysfunction. The four central components of home-based services are: family support services, therapeutic intervention, case management, and crisis intervention. Home-based workers are advised to set reasonable expectations and to clarify roles in order to maintain professional boundaries and avoid letting their contacts become merely social. Because outreach workers must coordinate their efforts with a variety of other agencies, it’s important to relate to these others as potential partners in the treatment process, not as adversaries. Finally, the author emphasizes the need for home-based therapists to resist the urge to move in and take over for families to avoid the inevitable disappointment and burnout that results from such rescue fantasies.

Psychoeducation and Schizophrenia Carol Anderson and her colleagues have focused their interest primarily on the devastating impact of schizophrenia on families. Schizophrenia is viewed as a thought disorder involving a biological vulnerability of unknown origin that makes people highly reactive to stress in their environment. Anderson’s message to families is that they are not responsible for the patient’s illness. Psychoeducational treatment works to provide information about schizophrenia, and empathy and support for the family’s struggle with the illness. Psychoeducational therapists discuss with families the empirical findings on expressed emotion and teach them how to reorganize to minimize the levels of stress in the family. Families are encouraged to provide an atmosphere of low stimulation and to lower their expectations of the patient, while maintaining structure and firm limits. The psychoeducational model is said to be applicable to any chronic problem, including depression and alcoholism. With respect to goals for treatment, this model demonstrates a shift in focus away from cure and toward coping.

Medical Family Therapy Medical family therapists work with families struggling with chronic illness or disability in much the same way as was described above for families of schizophrenics. They work in collaboration with pediatricians, family practitioners, rehabilitation specialists, and nurses, backed by a growing body of research showing that family therapy has a positive effect on physical health and health-care usage. Medical family therapists advocate that when a patient is diagnosed, the family should receive a psychological consultation as a preventative measure to explore their resources relative to the demands of the illness.

Relationship Enrichment Programs Relationship enrichment programs offer couples guidance in making relationships work, which can be used to address or prevent problems and offer an alternative to seeking therapy. Among the programs described in the text are marriage encounter weekends and the Prevention and Relationship Enhancement Program (PREP). The text also describes some of the skills thought to help make relationships work. These include: accommodation and boundary making, effective communication, learning to solve problems together, being considerate of each other, and finding time for fun.

Discernment Counseling Discernment counseling was developed by William Doherty and his colleagues to work with couples in which one partner favors divorce and the other does not. The focus of this approach is not on improving the relationship but rather in helping the partners explore their options. Note well: there are few cases that stir such powerful countertransference feelings in therapists than helping couples decide whether or not to split up.

Chapter 11: Tailoring Treatment to Specific Populations and Problems

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Have students take turns concocting clinical cases involving sexual abuse and family violence, and then present these cases to the class. Students should discuss whether they would bring in the whole family for treatment or and see subgroups separately. 2. Have students conduct a series of 10-15 minute role plays designed to compare a medical family therapy approach with a systemic approach (e.g., structural, strategic) that overlooks the impact of chronic illness on a family’s functioning. For each role play, four students will play father, mother, and two daughters, and one student will play the therapist. The mother has multiple sclerosis and is hospitalized for depression. As a result, she is being seen in family therapy with her husband and their two daughters. Role play #1: Ignoring the impact of chronic illness on the family. The therapist, a structural family therapist with no sensitivity to issues of chronic illness, is to ignore the issue of the mother’s multiple sclerosis and focus on a underlying problem, which he or she sees as the mother’s overinvolvement with her daughters. His or her agenda is to strengthen the boundaries between mother and daughters and increase independence. Role play #2: Medical family therapy. The therapist is now sensitive to the potentially devastating impact that chronic illness may be having on this family, and views the daughters’ overinvolvement with mother as necessary supports in light of her illness. The therapist should intervene with the family to help clarify the demands that the disease is placing on them. In order to do this effectively, the therapist should find out the onset, course, degree of incapacitation, and likely outcome of the disease. Further, an assessment of the family’s life-cycle stage, mother’s role in the family, and the family’s financial, emotional, and social resources should be assessed. Observers should provide feedback to the therapist regarding the perceived effectiveness of his or her interventions. Reconvene as a class and discuss both role plays. Comment on the nature of the therapeutic alliance formed in each case. In which role play did the family feel they were collaborating with and accepted by the therapist? In which role play did the family feel their concerns were most attended to? 3. Have students take turns talking to couples in which one partner wants to leave and one wants to stay. After the role play, ask the ―therapist‖ to describe his or her feelings about the decision.

Discussion Questions/Experiential Exercises 1. The following exercises are designed to assist students in learning about the negative messages gay and lesbians regularly encounter, and about their own homophobia. a) Pick up a copy of your local lesbian and gay newspaper and carry it around with you for a day. Take it with you to lunch; lay it out in a visible way, and pay attention to your own internal response: do you feel vulnerable, self-conscious, ashamed, fearful? b) Try walking around downtown or any public place holding hands with a same-sex classmate or friend and note the responses that get triggered inside as well as those from onlookers. c) In a small group format, discuss your thoughts and ideas about gay and lesbian couples and families. Designate one student as a recorder and list all positive and negative aspects/attributes of same-sex couples and families. What are the unique issues facing same-sex couples who would like to have children? Invite gay or lesbian parents to share their experiences with adoption and/or birth with the class. d) Solidly confront a ―queer‖ joke; march in a gay/lesbian pride parade.

Chapter 11: Tailoring Treatment to Specific Populations and Problems

e) Show any of the following films in class and discuss: Brokeback Mountain, Maurice, A Single Man, But I’m a Cheerleader, Boys Don’t Cry, Billy’s Hollywood Screen Kiss, Desert Hearts, Before Stonewall, Torch Song Trilogy, Boys in the Band, The Wedding Banquet, Longtime Companion, Home for the Holidays (films about gay/lesbian experiences). 2. What are the pros and cons about asking a single mother’s permission before contacting an absent father? 3. In the interests of remaining open and neutral when helping individuals with sexual identity concerns, encourage students to imagine how they might approach prospective clients who are struggling with their sexual orientation. For example, what would a young graduate student therapist say to a nineteen-year-old boy who hasn’t dated and anxiously wonders if he is gay? ―What’s wrong with that?‖ or ―That’s a perfectly legitimate lifestyle?‖ or ―Why don’t you join a support group for gay men.‖ or ―What’s the problem? or a more neutral inquiry such as: ―What makes you think that?‖ ―How do you feel about that?‖ ―What might be the consequences of your choices either way?‖ 4. Suppose you are a well-educated African-American therapist working in a community mental health center. In working with poor and working-class African-American clients should you join with your clients by using street language (Ebonics)? How about if you are a middle-class white therapist? 5. Given that there are now a host of specially designed models to deal with specific problems, to what extent do you think traditional models – such structural, strategic, and Bowenian – to equipped to deal with such problems? What are some problems that you think almost certainly require a specialized approach?

Films Carol Anderson: It Takes a Toll Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Anderson demonstrates her psychoeducational approach to schizophrenia, manic depression, and alcoholism in this exploratory interview with a large family. Questions revolve around past difficulties, including those with professionals, and the family is validated through an emphasis on their present strengths, invitations by the therapist for suggestions for changes, and empowerment by their therapist. VIDEO, 118 minutes. Donald Bloch Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Bloch’s consultation with a family with chronic illness demonstrates a medical family therapy model of treatment. The interview illustrates the interaction of family and physical illness, techniques for applying family therapy knowledge to such situations, and working in health care environments. VIDEO, 120 minutes. Empowering Black Families in Therapy: Nancy Boyd-Franklin Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Boyd-Franklin presents her model for working with Black families including extended family involvement, informal adoption, spirituality, and larger systems issues of racism and the intrusion of outside agencies. VIDEO, 120 minutes. Race, Class, and Culture: Kenneth Hardy Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Hardy presents a framework for providing family therapy across race and class lines, and examines the pitfalls and challenges around issues of race, class, and culture.

Chapter 11: Tailoring Treatment to Specific Populations and Problems

Managing Madness: Carol Anderson and Michael Goldstein Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) In this Keynote address delivered at the AAMFT annual conference, Anderson and Goldstein outline their approaches which help families manage schizophrenia and summarize research on what works with these patients and their families. VIDEO, 90 minutes.

Class Discussion 1. Under what circumstances do you think a therapist anxious to convey a progress attitude might avoid challenging certain clients? 2. Should treating transgender persons and their families be left to therapists with extensive experience in working with such clients? 3. What do you imagine are some disadvantages to home-based therapy? 4. In working with family violence, how can therapists balance a relativistic world view with values about human safety and the right to self-determination and protection? When is the clinical utility of neutrality limited or counterproductive? When are convictions essential to the change process? How does one confront a batterer about his destructive behavior without condemning him? How can therapists employ their values to therapeutic advantage while maintaining a caring and respectful connection with family members who are struggling with the trauma of violence? 5. What problems do you think should only be treated by therapists with training and experience in dealing with those specific problems? 6. Divide the class into 4 small groups and give them the following case example. Each of the groups is to be assigned a different couple. Read the example and have students discuss in their groups the questions provided below. This couple has one child, age 18 mos., and have come to therapy for assistance in dealing with disagreements over care of the child and resultant marital difficulties. One partner of the couple is a lawyer with a good income from ten years of practice in the community. The other is a tenured college professor, employed at a local college for five years. Group 1: The husband and wife are Caucasian. Their adopted child is Latino. Group 2: The husband is African-American, the wife is Caucasian. Group 3: This is a lesbian couple. Group 4: The husband is Christian, the wife is Jewish. Ask the students to discuss the following questions in their groups: What feelings do they have as individuals about this couple? What feelings as a group do they have about this couple? What personal values do they have about how the couple’s situation might affect their assessment, interventions, treatment goals, etc. for the couple? What value conflicts do they think might occur between themselves, the couple, and their supervisors? When students are finished, discuss the exercise together as a class.

Supplemental Readings Anderson, C.M., Reiss, D., and Hogarty, B. 1986. Schizophrenia and the family. New York: Guilford Press. Avis, J.M. 1992. Where are all the family therapists? Abuse and violence within families and family therapy’s response. Journal of Marital and Family Therapy, 18(3), 225-232. Barnhill, L. 1980. Basic interventions for violent families. Hospital and Community Psychiatry. 11: 547-551. Boyd-Franklin, N. 1989. Black families in therapy: A multisystems approach. New York: Guilford Press. Falicov, C. 1998. Latino families in therapy. New York: Guilford Press. Family Therapy Networker. 1993, July/August. The Black middle class: No refuge from racism [Special issue]. Family Therapy Networker. 1991. Gays and lesbians in therapy [Special issue].

Chapter 11: Tailoring Treatment to Specific Populations and Problems

Goldner, V., Penn, P., Sheinberg, M., and Walker, G. 1990. Love and violence: Gender paradoxes in volatile attachments. Family Process, 29, 343-364. Hardy, K. V. 1996, May/June. Breathing room. The Family Therapy Networker, 52-59. Inclan, J., ed. 1990. Working with the urban poor [Special issue]. Journal of Strategic and Systemic Therapies, 9(3). Laird, J. and Green, R.J. 1996. Lesbians and gays in couples and families: A handbook for therapists. San Francisco: Jossey-Bass. LaSala, M. 2010. Coming out, coming home: Helping families adjust to a gay or lesbian child. New York: Columbia University Press. McGoldrick, M., ed. 1998. Re-visioning family therapy. New York: Guilford Press. Minuchin, P., Colapinto, J., and Minuchin, S. 1998. Working with families of the poor. New York: Guilford Press. Rolland, J. 1998. Chronic Illness and the family life cycle. In The expanded family life cycle: Individual, family, and social perspectives, B. Carter and M. McGoldrick, eds. Boston: Allyn & Bacon.

Chapter 12: Solution-Focused Therapy

Chapter 12: Solution-Focused Therapy INTRODUCTION The solution focused-model is a descendant of the MRI approach, but instead of focusing on what people are doing to maintain their problems, solution-focused therapists look for what clients have done to overcome or cope with their problems. Both models attempt to resolve the presenting complaint as quickly as possible. The MRI model does so by looking for solutions that don’t work, while the solution-focused model looks for neglected solutions that do work. Instead of joining in a search to understand the cause of problems, solution-focused therapists help clients shift their attention from their problems onto the things in their lives that are going well. This shift -- from failures to successes -- is thought to help people stop dwelling on negatives and rediscover positive solutions already in their repertoire. While critics have suggested that this switch from ―problem-talk‖ to ―solution-talk‖ is little more than pep talk, the idea of reinforcing positive behavior may have a useful impact on people’s lives.

Leading Figures Steve de Shazer, Insoo Berg, Eve Lipchik, Yvonne Dolan, Michele Weiner-Davis, Bill O’Hanlon, John Walter, Jane Peller.

Important Terms complainants: a client who complains about a problem, but thinks that someone else has to solve it. compliments: often phrased as questions – ―Wow, how did you do that?‖ – to call attention to what clients have already managed to accomplish. coping questions: questions like ―How did you manage that‖ designed to draw attention to resilience. customer: a client who not only complains about a problem but is motivated to resolve it. exception: De Shazer’s term for times when clients are temporarily free from their problems; focusing on exceptions helps clients build on successful problem-solving skills. formula first-session task: asking clients at the end of the first session to think about what they do not want to change about their lives as a result of therapy; this focuses them on existing strengths. miracle question: asking clients to imagine how things would be if they woke up tomorrow and their problems were solved; used to help clients identify goals and potential solutions. problem-talk: focusing on problems and trying to discover their causes, which solution-focused therapists see as counterproductive. reframing: relabeling a family’s description of behavior to make it more amenable to therapeutic change; for example, describing a child as ―disobedient‖ rather than ―hyperactive.‖ scaling questions: clients are asked to rate how much they want to resolve their problems, how bad the problem is, how much better it is, and so on; used to break change into small steps. solution-talk: conversations about dealing effectively with problems. visitor: someone who’s not really interested in therapy, doesn’t see that they have a problem or that they need to change; such people usually only come to therapy, reluctantly, at someone else’s insistence.

SUMMARY OF KEY POINTS AND ISSUES Theoretical Formulations The solution-focused approach draws many of its assumptions and techniques from the MRI strategic model. It maintains the strategic school’s deemphasis on history and underlying pathology, and a commitment to brief treatment. De Shazer says little about how problems arise. Therapists need only to understand the nature of solutions that can apply across people, not the nature of problems that bring them into treatment. Further, like the MRI model, people are thought to be constrained by narrow views of their problems which then generate rigid sequences of unsuccessful attempts at solutions.

Chapter 12: Solution-Focused Therapy

The solution-focused approach diverges from the MRI model in several important ways. First, solution-focused therapists de-emphasize problems and get clients to think exclusively about solutions that have worked or might work. Second, solution-focused therapists reject the notion of resistance and assume that clients really want to change. Moreover, they believe that people are rather suggestible.

Normal Family Development No model of normal family development is posited. Like the constructivists who believe in the notion of no objective reality, solution-focused therapists believe that therapists should not impose their idea of normality on clients. They disagree with the structuralist’s claim that symptoms are a sign of some underlying problem, covert parental conflicts, deviant communication, repressed feelings, or low self-esteem. Solution-focused therapists are interested only in the complaints clients present, and in helping them reexamine the ways they describe themselves and their problems. They tend to assume that even troubled people are resilient and resourceful.

Development of Behavior Disorders Worrying about what causes problems is deliberately avoided in solution-focused therapy. Because solutions are seen as often unrelated to the ways that problems develop, ―problem-talk‖ and the related preoccupation with figuring out why things went wrong is seen as part of the reason people stay stuck in their dilemmas.

Goals The essential ingredient is solution-focused therapy is helping people amplify exceptions to their problems. Goals of therapy revolve around resolution of clients’ presenting complaints. Attempts are made to create an atmosphere in therapy where people’s strengths can be reemphasized. Sometimes it’s necessary to expand clients’ use of their resources, at other times therapy may require searching for abilities the clients possess but aren’t currently using. One of the key ingredients in this approach is helping clients define goals in small steps, based on the assumption that small changes can initiate a positive spiral. Solution-focused therapists use a standard set of questions and tasks to create an optimistic frame of mind and to start a snowball of solutions rolling. Therapy is quite brief because the client and therapist orient their work in the direction of strengths, ―exceptions‖ to problems, and clear goals and strategies. Early in the development of this approach, all clients were given the same assignment called a ―formula first-session task,‖ in which they are asked to observe what happens in their life and relationships that they want to continue. This technique is used to help clients refocus from bad things in their lives to thinking about and expecting the good; and this shift in perspective is thought to build on itself.

Therapy Assessment. Solution-focused therapists avoid any assessment of problems or how they develop. Likewise, they don’t emphasize the need to include the entire family. Rather, an attempt is made to identify those persons most motivated to change (―customers‖) and to work with these highly motivated members of the family. The focus of the assessment is not on how or why things went wrong, but on how they can be better. In other words, the goal of assessment is to help clients shift their attention from what they don’t want to what they do want. Scaling questions may be used to help define small steps that will lead in a positive direction. Therapeutic Techniques. Therapy begins by helping clients define well-focused positive goals, and then generating solutions based on exceptions. Although therapists don’t wish to dwell on ―problem-talk,‖ they make a point if listening to clients’ descriptions of their problems at least long enough to make the clients feel understood. Then the therapist helps clients develop concrete and manageable goals – phrased not just in terms of what will be happening but in terms of ―how will you be doing this?‖ The clearer the goal, the easier it is to measure progress. And for this purpose scaling questions may be introduced early in the goal-setting process. The miracle question is thought to be especially useful when clients complain in vague terms. Then exception questions help clients rediscover effective coping strategies already in their repertoires.

Chapter 12: Solution-Focused Therapy

Compliments are used to reinforce effective coping strategies and to help restore clients’ belief in their ability to deal effectively with their problems. Taking a break at the end of sessions and returning to give feedback is a standard part of this approach. Three techniques are central to solution-focused therapy; each functions to make problems appear less oppressive and more controllable: 1. Exception question: This question circumvents clients’ global and unremitting perceptions of their problems and directs their attention to times in the past or present when they didn’t have the problem, when ordinarily they would have. The therapist then explores with a client what was different about those times and finds clues to expand the number of exceptions to the problem. Clients begin to see times when they were better able to control their lives. 2. Miracle question: This question, ―Suppose one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different?‖ is used to activate a problem-solving mindset by giving clients a clear vision of their goal in treatment. Further, it helps clients look beyond their problem to what the solution would look like. 3. Scaling questions: These questions, ―On a scale of zero to ten with zero being how depressed you felt when you called me, and ten being how feel the day after the miracle, how do you feel right now?‖ are used to identify concrete behavioral changes and goals, and nurture small changes toward treatment goals. Scaling questions are also used to ask clients to quantify their confidence in their solutions, as a way of anticipating and disarming resistance and encouraging commitment to change. More recently, therapists are questioning the solution-focused emphasis on technique and speculate that qualities of the therapist-client relationship may be at the heart of the model’s effectiveness. Some research has demonstrated that what makes solution-focused therapy unique -- the refusal to talk about problems -- turns out to be problematic. This has led to a call for greater collaboration with clients in order to first acknowledge and validate feelings before introducing solution-focused techniques.

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Divide the class into pairs and have one of the partners discuss a current problem in his or her life while the other listens and then tries to draw attention away from problems toward exceptions and future goals. Have the partners switch roles after ten minutes. Then have students discuss to what extent they felt listened to, and which of the ―solution-focused‖ partner’s efforts felt helpful and which felt dismissive. 2. Conduct a series of role plays designed to allow students to experiment with attempts to listen to and express empathy for a family’s problems and concerns for several minutes before turning to a search for exceptions. Alternate with role plays in which little time is spend in the process of empathic listening. Discuss the two styles. 3. Have one student describe a problem or goal he or she is working on, and have the other help that person to use scaling to set a goal and describe what would be one small step in the right direction.

Films Brief Therapy: Constructing Solutions Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Steve de Shazer demonstrates his solution-focused model of treatment. This approach focuses on client and therapist working together to construct solutions by defining what success will look like and then doing something to make it happen. VIDEO, 120 minutes.

Chapter 12: Solution-Focused Therapy

Success Story Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink line on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Insoo Berg and Steve de Shazer use miracle and scaling questions to demonstrate a method of how the therapist can help the family recognize their progress. A reflecting team discussion and delivery of the message to the family uncovers unrecognized successes. VIDEO, 120 minutes. Solution-Focused Therapy with John Murphy Distributed by Allyn & Bacon. To order: www.ablongman.com/catalog/academic/course

Class Discussion 1. What types of clients and client problems are best suited for solution-focused therapy? 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, personality disorders, or severe mental illness)? 2. To what extent does solution-oriented therapy ignore people’s pain (as some critics of the approach suggest), and to what extent does it facilitate clients’ positive experiences, which in turn empower them to change what is painful in their lives? 3. What are some examples of how solution-focused techniques could be effectively incorporated into the practice of other models? What are some examples of where this attempt might be ill advised?

Supplemental Readings Berg, I. K. 1994. Family based services: A solution-focused approach. New York: Norton. De Shazer, S. 1991. Putting difference to work. New York: Norton. Efran, J., and Schenker, M. 1993. A potpourri of solutions: How new and different is solution-focused therapy? Family Therapy Networker, 17(3): 71-71. Miller, S., Hubble, M., and Duncan, B. 1996. Handbook of solution-focused brief therapy. San Francisco: JosseyBass. O’Connell, B. 2012. Solution-focused therapy, 3rd ed. New York: Sage.

Chapter 13: Narrative Therapy

Chapter 13: Narrative Therapy INTRODUCTION The narrative approach is concerned with the ways people construct meanings rather than how they behave. Clients are thought to be stuck in unproductive ways of perceiving their options. Narrative therapists help clients re-examine the stories of their lives and see that they have acted more bravely than they realize and that they have more resilience than they thought. Narrative therapists also help families re-examine unhelpful influences of various cultural values and institutions. All of these choices measures are designed to help clients shift their perception of themselves from flawed to heroic.

Leading Figures: Michael White, David Epston, Jill Freedman, Gene Combs, Jeffrey Zimmerman, Vicki Dickerson, Stephen Madigan, Kaethe Weingarten, William Madsen, Sallyann Roth. Narrative Forerunners: Harlene Anderson and Harry Goolishian.

Important Terms deconstruction: exploring meaning by unpacking taken-for-granted categories and assumptions, making possible new and sounder constructions of meaning. dominant story: a term used to describe one’s principal (helpful or hindering) view of the world. externalization: a technique used to separate clients from their symptoms, and thought to enable them and those around them to discover times when they have overcome their problems. hermeneutics: the activity of understanding achieved through the interpretation of narrative. mapping the influence of the problem: getting the story of the toll the problem has taken on the clients. mapping family members’ influence on the problem: tracking the ways the clients have been able to deal with the problem. relative influence questions: questions designed to explore the extent to which the problem has dominated the client versus how much he or she has been able to control it. social constructionism: a perspective that knowing and knowledge are socially constructed through language and discourse and are context dependent. reflecting team: Tom Andersen’s technique of having the observing team share their reactions with the family following a session. unique outcome: Michael White’s term for times when clients acted free of their problems, even if they were unaware of doing so; identified to help clients challenge negative views of themselves.

SUMMARY OF KEY POINTS AND ISSUES Theoretical Formulations The central premise of narrative therapy is that the way people interpret their experience has a powerful influence on their lives. Michael White used constructivism to explain how people can re-author their life stories, and he emphasized helping people organize to escape the oppression of problems and/or other people. People’s problems are seen as a product of the stories they hold about themselves – which often come from oppressive cultural practices. Narrative therapy is designed to help free people from feeling like victims of their problems. It’s a highly focused and methodical therapy with specific techniques (mostly questions) and goals. Narrative therapists form collaborative, strengths-oriented relationships with families, focusing on the effects problems have on them, and getting families to explore times when their problems didn’t dominate them.

Normal Family Development Narrative therapists avoid judgments about what is normal or abnormal, and argue for the elimination of all general categories of problems, including diagnoses and systems concepts such as rigid boundaries, cross-generational

Chapter 13: Narrative Therapy

coalitions, and enmeshment and disengagement. Narrative therapists try not to make assumptions about people so as to honor each person’s unique story and cultural heritage. Although they don’t make judgments about what is normal, narrative therapists tend to think of people as having good intentions, being capable, but often victimized by cultural attitudes and institutions.

Development of Behavior Disorders Problems are the products of internalizing our culture’s destructive discourses. Problems arise because people are induced by the dominant culture into subscribing to narrow and self-defeating views of themselves and the world. When the stories people tell themselves lead them to construe their experience in unhelpful ways, they get bogged down with problems and develop ―problem-saturated‖ stories. Once they take hold, these stories make people feel powerless and encourage them to act and relate to others in ways that fit their problem-saturated story, thus leaving them prey to more problems.

Goals The goal of narrative therapy is to help people deconstruct the oppressive stories they take for granted so that they can construct empowering, alternative stories about themselves and their lives. People need to be helped to separate themselves from the problem-saturated stories and disempowering cultural themes they have internalized. Once separated from these unproductive narratives, space is opened for new, alternative and more constructive views of themselves. Specifically, narrative therapists are encouraged to: take an active, collaborative, listening position with strong interest in the client’s story; search for times in clients’ histories when they were strong or resourceful; use questions to take a non-imposing, respectful approach to any new story put forth; never label people and instead treat them as human beings with unique personal histories; and help people separate from the dominant cultural narratives they have internalized, in order to open space for alternative life stories.

Therapy Assessment. Narrative therapists help clients by deconstructing problem-saturated stories in order to reconstruct new and more productive ones. In order to do so, the therapist must explore with clients their stories and the assumptions behind them. Thus, rather than shifting abruptly to a new way of thinking about a client’s experience, it’s incumbent on a narrative therapist to spend time understanding -- assessing -- the client’s narrative and the assumptions, personal and cultural, behind it. A second major part of the narrative assessment is a careful exploration of ―unique outcomes‖ or times when clients resisted the influence of problems in their lives. Therapeutic Techniques. The techniques of narrative therapy are designed to empower people by helping them separate from problem-saturated stories that dominate them and open space for alternative stories that highlight a person’s or family’s past, present, and future agency over their problems and thus the course of their lives. People, not problems, are in charge. This process of ―re-storying‖ proceeds in the following manner: 1.

The therapist gets family members to distance from the problem by externalizing it. Individuals are to speak of the problem as if it were a separate entity, existing outside the family.

The therapist asks a series of questions (―relative influence‖ questions) regarding a person’s or family’s relationship with the problem. Questions are asked about the effect of the problem on their lives, and family members are asked to help the individual beat the problem. Family members begin to see unique outcomes, or times when they have had some control over the problem.

Once family members no longer blame one another or themselves for the problem, they begin working together to fight it.

Chapter 13: Narrative Therapy

Deconstructing destructive cultural assumptions is an important part of most cases. The benefit of this emphasis lies in helping people realize that some of the things that oppress them are based on unhelpful cultural values (for example, that women should be beautiful, thin, and selfless) and institutions that interfere with people’s freedom. Critics suggest that sometimes this politicization of therapy results in helping people feel like victims of outside forces instead of examining their own role in their problems.

Once their clients have begun to think and act in more effective ways to overcome their problems, narrative therapist help them to reconnect with people who will share their new and more positive view of themselves. This is a counterpart of the notion that recovering addicts should avoid associating with people who were part of their drug experience. The (social constructionist) idea is that our efforts are supported (or not) by the sort of people we associate with.

Narrative therapy consists of a series of questions. One set of questions is designed to examine the influence the problem has had over the family members’ lives. The other set of questions maps ―unique outcomes,‖ times that family members have had influence over the problem--these questions are rhetorical, designed to elicit specific responses to help people see that (a) they are separate from the problem, (b) they have power over the problem, and (c) they are not who they thought they were. As family members’ perceptions of the problem change, narrative therapists ask questions regarding how the change affects their stories about themselves and each other (e.g., ―What does this tell you about yourself, your relationship, your son, etc., that is important for you to know?‖). In this way, problems take a back seat as clients begin to ―re-author‖ their self or family story. David Epston pioneered the use of letters in therapy to extend the conversation of therapy beyond the session. These post-session letters often convey a deep appreciation of what the client endured, the outline of their new story, and the therapist’s confidence in their ability to continue to progress.

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Have students conduct 10-minute role plays using a narrative approach. Instruct one student to play a young woman coming for treatment, one student to play therapist, and 1-2 student observers. The young woman entering treatment is bothered by several recent incidences in which she became angry and flew into a rage, surprising and frightening her husband. She grew up in a family that strongly feared overt expressions of anger and was taught to take care of others at her own expense. Consequently she was cut off from the assertive part of herself and learned to believe that bad things would happen if she spoke out. However, recently she has been unable to contain her anger, often loses control, and flies into a rage. These events simply confirm her belief that assertiveness and anger are dangerous and should be feared. Observers should provide feedback to the therapist regarding adherence to the treatment approach, effectiveness of interventions, etc. 2. After viewing a video of Michael White or Stephen Madigan (or the preceding role play) have students construct a letter from the therapist to the client(s) summarizing themes in the session and the direction of therapy. Reconvene the students and have each group share their letters with the whole class and identify the therapist’s expectations about the effect of and possible responses to the letter (by the clients). Discuss the letters with the whole group and give feedback. 3. Exercise: Interviewing Problems. Ask students to divide into groups of 4-5 each and choose a single, nameable problem familiar to most who work with families, e.g., temper tantrums, aggressive behavior, bed wetting, unwanted habits, avoidance, etc. Instruct students not to choose a diagnosis since it reflects a category of behaviors rather than a behavior or problem of which the students would have direct, personal experience. In each group, select 2 people -- A and B -- who have some familiarity or personal knowledge of that special problem. Person A takes on the role of the Problem first. The other group members become researcher/interviewers of The Problem. Instruct the interviewers to act as anthropologists and interview The Problem to learn about its culture and practices. Tell students to just try to get to know the problem -- and not to try changing it in any way.

Chapter 13: Narrative Therapy

Example questions: What areas of Johnny’s life are you causing trouble with? Work? Friends? Do you interfere with his judgment? Opinion of himself? In which of these areas do you think you have the upper hand? What people in his life have kept free from your influence? How have they managed that? What about Johnny is making a bit of trouble for you? Does anything about Johnny and his family make you a bit nervous?

Films Michael White: Escape from Bickering Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink link on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) White consults with a family with an 18-year old son institutionalized for firesetting. Through such techniques as externalizing and mapping the influence of problems, the family is helped to discover new information about themselves. A reflecting team is used to consolidate the family’s ―new story‖ which emerges in the session. VIDEO, 135 minutes. Michael White: Recent Developments in the Narrative Approach Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink link on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) In this interview, White sets a context for family members to work collaboratively with their therapist to separate from ―problem saturated‖ stories and write alternative, preferred ones. VIDEO, 120 minutes. Jeffrey Zimmerman, Victoria Dickerson, Janet Adams-Westcott, Gene Combs, Jill Freedman, William Lax, Stephen Madigan, William Madsen – Narrative Therapy: Training and the Trainer. Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink link on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) This video demonstration illustrates beginning concepts in narrative work and offers a model for teaching narrative ideas and practices. VIDEO, 120 minutes. Jeffrey Zimmerman, Victoria Dickerson, Janet Adams-Westcott, Gene Combs, Jill Freedman, William Lax, Stephen Madigan, William Madsen – Narrative Therapy Practices: More than Externalizing. Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink link on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) This videos focuses on the less established and less discussed, but frequently used practices of narrative therapy. These practices include: reflecting and reflexivity, remembering, situating one’s comments, and the experiential focus. VIDEO, 120 minutes. Narrative Therapy with Stephen Madigan Distributed by Allyn & Bacon. To order: www.ablongman.com/catalog/academic/course

Class Discussion 1. Do personal stories reflect a person’s reality? What is your position on externalizing the problem versus taking responsibility for it? What do people do to organize their lived experience to give it meaning and make sense of their lives? Are power and knowledge inseparable, as Foucault proclaimed? How could you do narrative therapy with a client who is illiterate? Would their stories be more or less powerful? Which is more powerful, the written or spoken language? What is a lived experience of your own that falls outside of your dominant story? 2. Is the idea that therapy should be more collaborative a healthy step in the direction of greater respect for clients, or is it politically correct but clinically neglectful of the need for therapist leadership? 3. Describe the apparent similarities that exist between Carol Anderson’s psychoeducational approach and the narrative approach to treating schizophrenia, in spite of the striking contradictions in their writings. Consider their views on the etiology of schizophrenia, goals for treatment, and prognosis.

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4. Is it necessary to reject systems thinking in order to practice a narrative approach? What might be some advantages and disadvantages of trying to incorporate systemic thinking into narrative therapy?

Supplemental Readings Diamond, J. 2000. Narrative means to sober ends. New York: Guilford Press. Freedman, J. and Combs, G. 1996. Narrative therapy: The social construction of preferred realities. New York: Norton. Madsen, W. C. 2007. Collaborative therapy with multistressed families. 2nd ed. New York: Guilford Press. Roth, S.A. and Epston, D. 1996. Developing externalizing conversations: An introductory exercise. Journal Systemic Therapies, 15, 5-12. Tomm, K. 1993. The courage to protest: A commentary on Michael White’s work. In S. Gilligan and R. Price (eds.) Therapeutic conversations. New York: Norton. White, M. 1995. Re-authoring lives: Interviews and essays. Adelaide, South Australia: Dulwich Centre Publications. White, M. 1997. Narratives of therapists’ lives. Adelaide, South Australia: Dulwich Centre Publications. White, M., and Epston, D. 1990. Narrative means to therapeutic ends. New York: Norton. Zimmerman, J. and Dickerson, V. 1993. Bringing forth the restraining influence of pattern in couples therapy. In S. Gilligan and R. Price (eds.) Therapeutic conversations. New York: Norton. Zimmerman, J. and Dickerson, V. 1996. If problems talked: Adventures in narrative therapy. New York: Guilford Press.

Chapter 14: Comparative Analysis

Chapter 14: Comparative Analysis INTRODUCTION This chapter offers a comparative analysis of the models of family therapy in order to sharpen students’ understanding of the separate approaches and to serve as a guide to their similarities and differences. In the second half of the chapter, various integrative models are described.

Leading Figures Andrew Christensen, Douglas Breunlin, Joseph Eron, Virginia Goldner, Alan Gurman, Scott Henggeler, Neil Jacobson, Howard Liddle, Marsh Linehan, Thomas Lund, William Pinsof, Ramon Rojano, Gillian Walker.

Important Terms decisive interventions:

the distinct and essential techniques of a model.

dialectical behaviorism:

psychoeducational counseling approach for treatment of persons in crisis.

dyadic model:

concepts that focus on interactions between two parties.

integrative models:

models that combine elements of more than one other approach.

monadic model:

concepts that focus on individual personality and psychopathology.

open system/closed system:

distinction between taking into account a system’s exchange with the environment versus treating it as a separate entity unto itself.

pathologic triangle:

destructive arrangement in which a third party comes between two people.

preferred views:

Eron and Lund’s term for how people like to think of themselves and be thought of by others.

process/content:

distinction between the issues clients talk about and the way they talk about that – that is, the dynamics of their interaction.

triadic model:

concepts that take into account how two people’s interactions are typically influenced by third parties.

THEORETICAL FORMULATIONS Families as Systems. Behavioral family therapists say little about systems and treat individuals as separate entities who influence each other through reinforcement. Bowenian, communications, strategic, Milan, and structural therapists all base their approaches on some version of systems thinking. The family therapy approaches that evolved out of the postmodern movement (e.g., Michael White, Harlene Anderson, Tom Andersen, and Steve deShazer) are challenging systems thinking. They de-emphasize family organization and concentrate on the thinking of individual family members. Stability and Change. Families are both rule-governed (tending toward stability) and flexible (capable of adapting to changing circumstances). This dual nature of families--homeostatic and changing--is best appreciated by family therapists in the communications, structural, and strategic schools.

Chapter 14: Comparative Analysis

Psychoanalytic, experiential, and extended family practitioners are inclined to emphasize long-range goals. They assume the families they see are basically flawed and in need of fundamental reorganization. Some newer approaches, like solution-focused therapy assume that change is easy. Process/Content. All schools of family therapy have a theoretical commitment to working with the process of family interaction. Although families usually focus on content issues (e.g., a husband wants a divorce, a child refuses to go to school), most family therapists focus on process issues. Behaviorists

often neglect process in favor of content, isolate behavior sequences from their context in the family, and assume a directive role with families.

Narrative therapists

are more interested in expanding family members’ stories and changing the way they understand themselves, and less interested in process.

Solution-focused

concentrate on successes and encourage positive thinking, little attention to process.

Psychoanalysts and experientialists

may lose sight of process when they concentrate on individual family members and their memories of the past.

Bowenians

emphasize process when they block triangulation and teach family members to take differentiated ―I-positions‖ in relation to each other.

Strategists

seek to interrupt problem-maintaining sequences of family interaction, and maintain a dual focus with content-oriented goals (solve the presenting problem), and process-oriented interventions (use of directives).

Structuralists

focus on process through their work to realign the family’s emotional boundaries and strengthen the hierarchical organization.

Monadic, Dyadic, or Triadic Model. While most family practitioners espouse a systems perspective, in practice they may think primarily in units of one, two, or three persons. Monadic Model. A clinician who thinks of one person in the family as the patient employs a monadic perspective. Psychoanalytic, behavioral, experiential, narrative, and solution-focused schools are based on monadic concepts. Psychoanalysts think about intrapsychic dynamics and family relations as a product of internalized relationships from the past. Behavior therapists accept the family’s definition that their symptomatic child is the problem, and teach parents to change the child’s behavior. Experiential therapists work with individuals to help them uncover and express feelings. Narrative and solution-focused therapists tend to disregard family interactions, while they attempt to redefine problems as alien invaders in an effort to unite families to defeat the problem’s influence. Dyadic Model. Dyadic thinking is based on the understanding that two people in a relationship define each other through their interactions. Most family therapists operate within this model. Some dyadic concepts include: unconscious need complementarity, projective identification, intimacy, quid pro quo, double bind, complementarity, symmetry, pursuer/distancer cycles, and behavioral contracts. Moreover, while concepts such as boundaries, coalitions, fusion, and disengagement are capable of describing triadic interactions, they are often used to refer to dyads only. Triadic Model. Triadic thinking allows us to understand and explain family behavior based on interactions among three people (e.g., Billy shoplifts because his father covertly encourages him to defy his mother). Bowen introduced the concept of emotional triangles into family therapy and did much to emphasize the triadic nature of human relationships. Structural therapists view enmeshment and disengagement between two people as a function of a reciprocal relationship with a third. And while most strategic therapists think in units of two, Haley, Selvini Palazzoli, and Lynn Hoffman maintain an awareness of triadic relationships.

Chapter 14: Comparative Analysis

Boundaries. One of the most useful concepts in family therapy, boundaries describe the relationship of individuals in the context of their families and families in the context of their extended families and communities. The autonomy and connectedness of each subsystem (individuals, siblings, parents, nuclear family) is regulated by a semipermeable boundary between it and the system surrounding it. Murray Bowen and Salvador Minuchin developed the clearest and most useful concepts of boundaries. Bowen described boundaries between individuals and their families; Minuchin described boundaries between various subsystems within a family. In Bowen’s terms, individuals vary on a continuum from fusion to differentiation of self to cutoff. Minuchin describes boundaries as diffuse or rigid, resulting in enmeshment or disengagement.

NORMAL FAMILY DEVELOPMENT Among the ideas presented in the text, the ones most useful for a basic model of normal family functioning include structural hierarchy, effective communication, and family life-cycle development. Members of the Bowenian and psychoanalytic schools have written the most about normal development. While most schools of family therapy aren’t concerned with how families get started, Bowenians and psychoanalysts say a great deal about marital choice. Both schools share an appreciation of depth psychology and both think the quality of an intimate relationship depends on each partner’s internal, introjected object images, in addition to their shared interests and values. According to Bowen, people tend to select partners at similar levels of differentiation to their own. Bowen also believed that the triangular relationship between mother, father, and child is a crucial determinant of all later development. Structural theory distinguishes functional from dysfunctional family structure and clarity of subsystem boundaries. Partners must learn to accommodate to each other and modify their family structure at transitions in the life-cycle. Most other schools of family therapy have only a few isolated concepts for describing the process of normal family development: Communications school:

clear rules of communication are needed to ensure a family’s stability and flexibility.

Behavioral school:

there must be an equitable exchange of interpersonal costs and benefits, and mutual, reciprocal reinforcement between spouses for healthy functioning.

Strategic school:

flexibility in the family system allows for adjustment to changing circumstances and the ability to find new solutions to problems.

Any normative model should be taken as a rough guideline and used flexibly. For example, family therapists now see the single-parent family as a viable alternative to the two-parent model, and gay and lesbian families are recognized as legitimate and healthy choices.

DEVELOPMENT OF BEHAVIOR DISORDERS The following themes help to define important differences of opinion in the field regarding how and why symptoms develop in families. Inflexible Systems. Chronic inflexibility is a central feature of dysfunctional family systems. Acute inflexibility explains why reasonably healthy families become symptomatic at transitions in the life-cycle. Different schools of family therapy describe pathologic inflexibility in different ways. Communications:

rigidity or ambiguity of family rules and absence of positive feedback loops, or mechanisms for changing the rules, leave families unable to adapt to changing circumstances.

Chapter 14: Comparative Analysis

Strategic:

rigid homeostatic functioning and a limited range of responses to problems games lead to family troubles.

Behaviorists:

symptoms result from faulty efforts to change behavior.

Psychoanalytic and experiential:

intrapsychic rigidity in the form of conflicts, developmental arrests, and emotional suppression.

Structural:

overly rigid boundaries between family subsystems cause the pathological functioning seen in markedly enmeshed or disengaged families, and feature prominently in psychosomatic families.

Narrative and solution-focused:

rigidity is the result of living with serious problems, being blamed by mental health professionals, and oppressive cultural belief systems that are internalized by family members.

Pathologic Triangles. Pathological triangles are at the heart of several family therapy explanations of behavior disorders. In psychoanalytic theory, oedipal conflicts are considered the root of neurosis. Pathological need complementarity--is the core psychoanalytic concept of interlocking pathology in family relationships. Bowen’s theory of pathological triangles is the most elegant in the systems perspective. Bowen explains that when two people are in conflict, the one who experiences the most anxiety will triangle in a third person. Structural theory also discusses triangular configurations (whereby a dysfunctional boundary between two people or subsystems is a reciprocal product of a boundary with a third). For example, the concept of pathological triangle is used to explain conflict-detouring triads, where parents divert their conflict onto a child. Among strategic therapists, only Haley and Selvini Palazzoli use a triadic model, seen best in the concept of crossgenerational coalitions. Within these triadic coalitions, a parent and child, or grandparent and child, collude in covert opposition to another adult.

THERAPY Assessment. Cognitive-behaviorists place the greatest emphasis on assessment and use a variety of formal procedures including structured interviews and questionnaires. The emphasis is on obtaining baseline behavioral data on the occurrence of problem behavior and the contingencies of reinforcement maintaining it. Structural therapists also emphasize assessment, but their evaluations are based on observations made during enactments and are designed to uncover structural problems of enmeshment and disengagement. Bowenians and psychoanalysts base their assessments on rich theories of personal and interpersonal dynamics. The Bowenian assessment is a little more formal and relies on genograms, but these must emphasize emotional patterns (triangles, fusion, cutoffs, etc.) not just biographical information. Experientialists do little in the way of formal assessment, but rely on looking for patterns of defensiveness. Two of the newer forms of family therapy, solution-focused and narrative eschew any form of assessment, which they think is part of a pattern of pathologizing that alienates clients from therapists. Decisive Interventions. The definitive interventions of various approaches highlighted in the text are: Psychoanalytic:

interpretation and silence.

Experiential:

confrontation, personal disclosure, and structured exercises.

Behavioral:

observation and teaching (e.g., positive control).

Bowenian:

teaching differentiation, avoiding triangulation, and re-opening cut-off family relationships.

Communications:

making covert communication overt and using directives.

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Strategic:

reframing, use of directives, and positive connotations.

Structural: Solution-focused: Narrative:

enactments and boundary making (i.e., realignment). focusing on successful solutions. externalizing problems and questioning problem-saturated stories.

Integrative Models Most of the models of family therapy have been around long enough to prove their worth: thus the time is ripe for integration. Effective integration, however, involves more than borrowing various theories and techniques -- the important thing is to increase complexity without losing coherence.

Eclecticism While it may seem reasonable to take advantage of a variety of interventions from various models, it’s important to avoid a haphazard approach of borrowing techniques without a coherent theoretical framework. It’s also a mistake to switch from one approach to another when a case gets bogged down. Most cases get stuck at some point, and this may not because of deficiencies in one’s model but because the family is addressing difficult issues. These points of impasse may be times to sharpen the focus of one’s approach, not abandon it for another.

Selective Borrowing Unlike eclecticism, in which interventions are taken from various approaches, selective borrowing means judiciously incorporating a small number of techniques from other models while continuing to practice one consistent approach. Thus, a structural family therapist might find the narrative technique of externalizing a useful addition, or a Bowenian might find the miracle question from solution-focused therapy useful in helping a couple imagine a more positive future for themselves. What’s important is conceptual focus, regardless of what techniques are employed.

Specially Designed Integrative Models Integrative Problem-Centered Metaframeworks Therapy. Doug Breunlin, William Pinsof, and their colleagues developed a unifying framework that distills ideas from different schools of family therapy and organizes them into a set of overarching principles. The model is built around six domains of human experience, or ―metaframeworks‖: intrapsychic process, family organization, sequences of family interaction, development, culture, and gender. The authors assert that each previous school of therapy included ideas about family organization, sequences of interaction, and development, but each emphasized a different aspect of it. Specifically, Bowen concentrated on triangles, Haley focused on hierarchical control, and Minuchin on boundaries and subsystems. Minuchin focused on in-session sequences and Bowen was interested in multigenerational patterns. While family therapy has become interested in culture, gender, and intrapsychic process, the original schools had little to say about these dimensions. Breunlin and his colleagues (1992) offer a guide for using metaframeworks that involves a circular process of having conversations with families about their constraints, collaborating with them to form hypotheses, planning ways to address the constraints, and then reading feedback regarding the plan’s impact.

Models that Combine Two Distinct Approaches The Narrative Solutions Model. Joseph Eron and Thomas Lund’s narrative solutions approach combines the insights of strategic therapy with narrative techniques. This approach revolves around a concept called the preferred view. People begin to act in problematic ways when they experience a discrepancy between their preferred view of themselves, their perception of their own actions, and their impression of how others see them. Conflict is created by disjunctions between individuals’ preferred views of themselves and how they think others view them. To address these discrepancies, Eron and Lund use a combination of reframing from the MRI model and restorying from the narrative approach. They offer guidelines for managing therapeutic conversations that include maintaining

Chapter 14: Comparative Analysis

interest in the client’s preferences and hopes, paying attention to stories that reflect how clients prefer to see themselves, finding stories that are in line with the client’s preferences and that contradict his or her problemmaintaining views, and asking mystery questions. Through use of these techniques, therapists demonstrate to their clients that they are being seen in preferred ways and they begin to notice their own strengths. The problem comes to be seen as a mystery to be explained rather than as a truth. Clients begin to restory how the problem evolved and to reframe their immediate situation. Integrative Couples Therapy. According to the late Neil Jacobson only about 50% of couples treated with behavioral couples therapy showed lasting improvement over the long-term. When Jacobson teamed with Andrew Christensen to add elements of experiential, strategic, Bowenian, and object relations approaches to traditional behavioral couples therapy (communication training, conflict resolution, and problem-solving), their results improved. Behavioral and experiential models are both concerned with the process of communication between couples: behaviorists focus on contracts and reinforcement while experientialists emphasize emotions and compassion. In contrast to the teaching and preaching that characterizes traditional behavioral therapy, integrative couple therapy emphasizes support and empathy. Treatment opens with a formulation phase aimed at helping couples stop blaming and open themselves to acceptance and change. The formulation consists of a theme that defines the primary conflict; a polarization process, describing the couple’s destructive pattern of interaction; and the mutual trap, or impasse that prevents them from breaking the polarization cycle once triggered. To foster acceptance, partners are encouraged to talk about their own experience, in other words to make ―I‖ statements rather than criticize their mates. The listening partner is encouraged to convey empathy for such disclosures. Two primary strategies are used to promote change: behavior exchange interventions (see Chapter 10) such as ―quid-pro-quo‖ and ―good-faith‖ contracts; and communication training. This model represents an important shift toward humanizing the behavioral therapies. Dialectical Behaviorism. Dialectical behaviorism is an eclectic counseling approach developed by Marsha Linehan for people with multiple disorders. The approach uses mindfulness mediation and a variety of cognitive-behavioral counseling strategies. Although developed for work with individuals, it has also been applied with families. Community Family Therapy. Ramon Rojano developed community family therapy in response to the limitations he witnessed while conducting in-office therapy with the poor. Rojano combined structural family therapy with a community psychology and social work and bolstered it with relationships he forged with schools, courts, prisons, and public assistance programs, and with corporate and agency people who could provide jobs. For Rojano, the greatest obstacles poor people face are the sense of powerlessness that comes with being controlled by a multitude of dehumanizing bureaucracies and the hopelessness of having no vision for achieving the American dream of a good job and a nice home. While he helps families find the resources they need, he also encourages goals and plans beyond mere survival, like a college education or home ownership.

SUGGESTED LEARNING ACTIVITIES Role Plays 1. Have 3-4 students volunteer to play a family. The family has entered treatment because the parents are concerned with their 6 year-old, who has been diagnosed with selective mutism. While the child speaks with family members and friends at home, he refuses to speak outside the home, including the family therapy session. There may be an older, overfunctioning child in the family. The parents retain rather traditional beliefs and values. Father is employed outside of the home, while mother sees to the daily care of the children and manages the home. Father is the disciplinarian. The family is close-knit. Select 2-3 students to role-play therapists from different schools (e.g., structural, Bowenian, and narrative) who will interview the family sequentially, in 10-15 minute role plays. Have observers take notes during each role play. At the conclusion, have the group discuss each interview and comment on the similarities and differences they observed. Identify interventions that were unique to a particular school. Discuss how the therapists may have incorporated techniques usually associated with other schools into particular role-play.

Chapter 14: Comparative Analysis

2. Have students conduct 10-minute role plays using a narrative solutions approach. Instruct one student to play a young woman coming for treatment, one student to play therapist, and 1-2 student observers. The young woman entering treatment is bothered by several recent incidences in which she became angry and flew into a rage, surprising and frightening her husband. She grew up in a family that strongly feared overt expressions of anger and was taught to take care of others at her own expense. Consequently she was cut off from the forceful part of herself and learned to believe that bad things would happen if she asserted herself. However, recently she has been unable to contain her anger, often loses control, and flies into a rage. These events simply confirm her belief that assertiveness and anger are dangerous and should be feared. Observers should provide feedback to the therapist regarding adherence to the treatment approach, effectiveness of interventions, etc. 3. Have students conduct 10-minute role plays using selective borrowing of one or two techniques incorporated into a model of their choosing. Other students should function as observers. Ask the observers to discuss whether the selective borrowing was done in a way that was consistent with the original model or not. 4. Have groups of students role play a series of multi-problem urban families and have therapists decide whether and when to focus on the persons and dynamics within the family or on practical issues like jobs and housing a la Ramon Rojano. Discuss under what circumstances one might concentrate on working with the family’s dynamics and when might it be better to reach out to help the family improve the practical circumstances of their lives.

Discussion Questions 1. Is family therapy an art or a science? Divide students into two groups and ask one group to defend therapy as an art, the other group to support therapy as a science. Ask the class to debate the issue by providing theoretical, empirical, and/or logical arguments supporting their view. 2. Is the current emphasis in the field on the art of conversation a repudiation of the scientific underpinnings of family therapy or merely a corrective attempt to rebalance the art and science of therapy? 3.

Ask students to discuss the innate strengths, personal attributes, and aspects of their interpersonal styles that will help make them good family therapists. Next, encourage students to identify certain types of interpersonal responses or personal characteristics that may pose problems in conducting therapy (e.g., a tendency to rescue people, to be overly controlling, intellectualizing, or emotionally reactive). Instruct students (anonymously) to list a few such characteristics on slips of paper provided, and collect them. Discuss with the class the most frequently occurring responses. Discuss how one might work toward resolution of each issue, or at least minimize the extent to which it subverts therapy. In the students’ views, how should personal issues be approached in supervision? If a supervisor sees a personal problem getting played out in therapy, how do students think their supervisors could best bring the issue to their attention and help them manage the issue?

Note to instructors: If the class has little or no experience conducting family therapy, instructors should first normalize the exercise. Communicate to the students that all therapists have issues which might reduce their effectiveness in therapy. The idea is to deal with them in supervision such that have a minimal negative impact in therapy. 4. Provide case examples of families seen in family therapy. Describe the family’s presenting problem and background information. Using multiple theoretical approaches (e.g., Bowenian, experiential, psychoanalytic, strategic, structural, etc.), have students conceptualize each family case; list the goals for treatment; design the course of therapy, including length of therapy and techniques to use; and discuss ways to measure outcome. The purpose of this exercise is to highlight similarities and differences among various schools of family therapy – and to allow students to practice their skills at conceptualizing and designing a course of treatment, and identifying methods to measure outcome. 5. Why do people change? When they’re propelled into action, or when they understand the reasons for their behavior?

Chapter 14: Comparative Analysis

6. Ask students to identify and describe at least two techniques that are relatively unique to each of the following family therapy approaches: psychoanalytic, experiential, behavioral, Bowen, communications, strategic, structural, solution-focused, narrative-constructive, and Michael White’s narrative approach. Explain how each technique follows from or maintains an allegiance with the theory from which it’s drawn. 7. For what types of client problems would students decide to see the whole family? 8. Ask for two groups of two students each to volunteer. Instruct each group to assume that they are fervent members of two different schools of family therapy (e.g., narrative vs. structural; experiential vs. solutionfocused). Use the chalkboard to list the concepts along which each of the major approaches were discussed in this chapter (e.g., stability and change, past or present, the function of symptoms, action or insight, etc.). Construct a 10-15 minute debate by having each student pair take on the persona of their model’s leader and provide a positive perspective on their own approach and a critical perspective on the other, using the dimensions provided. Ask observers to take notes. Switch and select new student dyads and two more approaches. Discuss student reactions and observations at the conclusion. 9. Family therapists have gotten away from the idea that families who seek therapy have something wrong with them. In their efforts to reject what they see as the judgmental stance of their predecessors, many family therapists espouse a more democratic, ―nonhierarchical‖ form of therapy in which clients and therapists are considered partners in a joint enterprise. What’s gained and what’s lost by avoiding thinking of families who seek therapy as having something wrong with them? Is there a difference between thinking of families as having something wrong with them versus thinking of them as doing something wrong -- something that isn’t working? How can you distinguish between a compassionate therapist who avoids blaming and one who’s so anxious to be liked that he doesn’t dare confront clients for fear that they might get mad? How can family therapists avoid a mechanical and distanced emphasis on technique, without losing leverage altogether -- and end up practicing a more warm, congenial but less effective form of family treatment? 10. What professional roles should individual family therapists and national family therapy associations take with respect to larger political and social issues of economic, cultural, and racial injustice? 11. Discuss the similarities and differences between Jacobson and Christensen’s integrative couples therapy and experiential therapies. 12. Ask students to think about their preferred view of themselves (a) along 2 or 3 dimensions, i.e., as a graduate student, a partner/spouse, and a child of their parents, or (b) in relationship to the proudest moments of their lives. Have students jot down a few notes for their own personal use. Next, ask students close their eyes and recall experiences in which they’ve enjoyed others seeing them in the same, preferred ways. Then ask students to think about other times when important others failed to share their preferred view--when certain people see them in ways they don’t prefer. Depending on the level group cohesiveness, safety, and trust among your students, you may wish to facilitate discussion of student’s experiences of conflict OR concordance between their preferred views and how they perceive others as seeing them. 13. Are integrative approaches capable of combining elements from various approaches in order to maximize their usefulness? In synthesizing across schools of family therapy, where should we strike the balance between breadth and focus? 14. How might metaframeworks be used to enhance and better organize research efforts in family therapy? 15. Have students select one of the integrative approaches of particular interest to them and read a chapter or two from the supplemental readings to summarize for the class. Depending on the students’ interests and immediate training needs in theory vs. technique, encourage the class to focus their 10-15 minute presentations to flesh out the what’s or how to’s of the approach.

Chapter 14: Comparative Analysis

16. How would students prefer to be seen by their classmates? How do they think their classmates do see them? How would students prefer to be seen by their instructor? How do they think their instructor views them? With whom are students’ preferred views of themselves more concordant, the instructor or their peers? Why?

Films William Pinsof: An Integrative Approach to Chronic Marital Conflict Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink link on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Bill Pinsof discusses his approach integrating family and individual therapies and their underlying interpersonal and intrapsychic dynamics to tackle the repetitive patterns of couple conflicts. VIDEO, 120 minutes. Neil Jacobson: Behavioral Couples Therapy: Integrating Change and Acceptance Distributor: AAMFT To order: www.aamft.org/family therapyresources/search.asp (Note: this link can also be reached from the AAMFT website by going to www.aamft.org clicking on the pink link on the left marked ―FamilyTherapyResources.net, and then clicking on ―Search This Web Site.‖) Neil Jacobson discusses how his integrated model promotes acceptance through accommodation, compromise, and collaboration between partners to balance his traditional behavioral emphasis on change.

Supplemental Readings Breunlin, D. Schwartz, R., and MacKune-Karrer, B. 1992. Metaframeworks: Transcending the models of family therapy. San Francisco: Jossey-Bass. Chasin, R., Grunebaum, H., & Herzig, M., eds. 1990. One couple, four realities: Multiple perspectives on couple therapy. New York: Guilford Press. Dattilio, F.M., ed. 1998. Case studies in couple and family therapy: Systemic and cognitive perspectives. New York: Guilford Press. Donovan, J.M., ed. 1999. Short-term couple therapy. New York: Guilford Press. Eron, J. and Lund, T. 1997. Narrative solutions in brief therapy. New York: Guilford Press. Henggeler, S. and Borduin, C. 1990. Family therapy and beyond: A multisystemic approach to treating the behavior problems of children and adolescents. Pacific Grove, CA: Brooks/Cole. Jacobson, N.S. and Christensen, A. 1996. Integrative couple therapy. New York: Norton. Jasnow, A. 1978. The psychotherapist--artist and/or scientist? Psychotherapy: Theory, Research and Practice. 15: 318-322. Markowitz, L. 1997. Ramon Rojano won’t take no for an answer. Family Therapy Networker. 21:24-35. Pinsof, W.M. Integrative problem-centered therapy. New York: Basic Books.Sluzki, C.E. 1983. Process, structure, and world views: Toward an integrated view of systemic models in family therapy. Family Process. 22: 469-476.

Chapter 15: Research on Family Intervention

Chapter 15: Research on Family Intervention INTRODUCTION In this chapter, the authors: review common research methodologies with an emphasis on their practical application and their role in the development of the field’s body of knowledge; review what research has taught us about how effective family therapy is for various problems; discuss the debate around what contributes to change in therapy – models or common factors or both; give an example of dissecting a research article in a way that allows clinicians to get useful information out of it, thus practicing from a research-informed stance.

Important Terms allegiance bias: the tendency for researchers to design studies in ways that favor the preferred methods of treatment. box score review: a simple count of how many studies report significant effects. clinical significance: an index of substantive or noticeable change in client functioning as a result of treatment. comparison group: a control group, either no treatment or treatment as usual. common factors: the factors surrounding the delivery of service as well as common elements of treatment across models. cost-benefit analysis: comparing the costs of a treatment to the economic benefits to the clients and community. critical change events: key events in therapy sessions, thought to be instrumental in bringing about therapeutic improvement. effect size: the standard difference between treatment and comparison group outcomes. evidence-based practice: making treatment decisions based on empirically supported treatments. externalizing disorders: those involving behavioral acting out – oppositional defiant behavior, hyperactivity, etc. fidelity checks: periodic efforts to make sure the proper treatment protocol is being following during and experimental investigation. high risk children and families: people in circumstances deemed likely risks to develop clinical problems. internalizing disorders: those involving symptoms, such as anxiety and depression, not behavioral acting out. mediating variable: also: moderating variable: something other than the variable under study that may influence treatment, such as age, drugs, gender, etc. meta-analysis: statistical techniques used to summarize treatment outcome data, using standard deviation units to determine the effect sizes of various measures of treatment outcome. outcome research: the study of the effectiveness of therapy interventions. process research: the study of interactions between the family and the therapist systems, with the goal of identifying change processes in the interactions within and between systems. qualitative methodology: a collection of exploratory research methods designed to discover relationships between variables. The goal is to identify concepts and relationships that fit the data by recycling through data collection and analysis until an overall structure of the data emerges. quantitative methodology: a collection of research methods which employ statistics for testing and verification of hypotheses. randomized clinical trial: testing the effectiveness of an intervention by assigning it randomly to one group while another group, used as a control, is assigned to a different condition. task analysis: a rigorous form of inductive clinical theorizing, in which an ―event‖ in therapy is selected for intensive qualitative and quantitative analysis. First, a theory-derived change model specifying client and therapist performance is hypothesized, then actual cases of the event are studied via intensive single case analysis. The model of client change is refined through iterations between the change model and actual data. Finally, the model is subjected to verification procedures using traditional hypothetico-deductive methods (Greenberg, 1986). treatment manual: a handbook describing the parameters of treatment, used to ensure uniform application of treatment protocols.

Chapter 15: Research on Family Intervention

The search for a Winner: Randomized Controlled Trials Randomized controlled trials, which are used in medicine to compare new treatments to other treatments and control groups, are more difficult to conduct on family therapy. One of the main problems is allegiance bias: another is that only research institutions – where a limited number of models are favored – generally have sufficient financial support for these large-scale studies.

The Search for Consensus: Meta-Analysis Confidence in research findings is greatly increased when results from a large number of studies are combined.

Effects of Family Therapy with Specific Problems Substance abuse For treating drug abusing adolescents and their families multidimensional family therapy, multisystemic family therapy, ecologically based family therapy, functional family therapy, and brief strategic family therapy have all been shown to be effective. For treating adults with substance abuse problems and their families behavioral couples therapy and behavioral family counseling have been shown to be effective.

Conduct disorder Several meta-analyses have found multisystemic therapy, functional family therapy, and multidimensional family therapy to be effective with this hard-to-treat population.

Major mental illness It is ironic that although we now know that the early family therapy notion that families were responsible for schizophrenia was false, it turns out that an important part of the state-of-the-art treatment for schizophrenia is psychoeducational family therapy. A rather extensive body of research has shown psychoeducational family therapy to be effective in helping to prevent relapse in a variety of major mental illnesses.

Couple distress A host of studies have shown couples therapy to be helpful to couples in conflict. The approaches with the most empirical support are integrative behavioral couples therapy and emotionally focused therapy.

Depression Couples therapy has been shown to be an effective treatment for depression, especially for women. Perhaps depressed women may be somewhat more likely to benefit from improved intimate partnerships than men are. The research suggests that both the depressed individuals improve and the relationships improve – which means that the depressed person may be more emotionally supported in the future.

Intimate partner violence Suprisingly, research has shown that about 70% of partners who are violent are women. Situational violence – i.e., violence around a particular issue, rather than a more pervasive pattern of violence – has been shown to significantly decrease following couples therapy. Note well, however, that couples treatment for such cases requires special expertise.

Family Therapy Research Today Common Factors Some researchers have suggested that successful therapy depends not so much on the treatment model but more on a number of factors common to all good therapy – including the therapeutic alliance, various client and therapist variables, hope and expectancy, and various extra-therapy variables.

Therapeutic alliance The quality of the therapeutic alliance is the most well supported common factor in the research literature. Having shared goals and a shared vision about therapy and having a strong emotional connection are among the key ingredients in a good therapeutic alliance. The effective family therapist is warm, supportive, and behaves like a nurturing, authoritative parent or grandparent, fostering a sense of ―we’re all in this together.‖ Results of research on the therapeutic relationship in couples and family therapy suggest that a perceived sense of engagement, cooperation, and collaboration increases over time in treatment, and predicts couples’ evaluations of the depth or value of a session, post-treatment marital satisfaction,

Chapter 15: Research on Family Intervention

and therapist-rated outcome. Reduction of child behavior problems is related to collaborative parent-therapist interactions around setting goals for treatment. Moreover, a family’s alliance with the therapist doesn’t develop uniformly. If a strong alliance with the therapist absent, the likelihood of drop-out is increased. Developing and sustaining a warm working relationship with adolescents may present the greatest challenge for family therapists. Nonetheless, little is known about how a strong emotional bond and sense of mutual collaboration develop in family therapy.

Client and therapist variables Clients who are hard working and proactive and who have good support networks are most likely to do well in therapy. The qualities that make good therapists have proven harder to determine. Neither licensure nor experience, in itself, seem to matter. Being friendly and positive seem to help, while being critical or hostile seem to hurt. Effective therapist seem to adapt their approach to their clients, rather than expecting the clients to adapt to them.

Hope and expectancy Therapy seems to go better when both clients and therapists hope it will. This hope begins with the clients’ faith in their referral sources.

Extra-therapy factors Sometimes circumstances outside of the therapy context have a major influence on therapy’s outcome. A new relationship, a job promotion, or some other positive event can have a big impact on a client’s improvement.

Process and Observational Research Now that a wealth of outcome studies have shown that family therapy works, the focus has shifted to finding out why and how therapy works. One very influential source of process research has been John Gottman and his colleagues, who video couples interacting in therapy and see what correlates with progress, marital satisfaction, and divorce. One of the advantages of process research is that it may be more likely to influence how therapists practice, because while many therapists already assume that their approaches work–and, hence, may not be interested in outcome studies, most therapists are more open to learn how they can improve how they deliver their interventions. Expert family therapists speak more with problem children and their parents than with other family members. Interventions tend to be present oriented and informative, with therapists relying more on questioning, providing information, instructions, and indirect interventions, than on clarifying, reflecting feelings, encouraging, or interpreting. More experienced family therapists are more active, explicit, interpretive, supportive, and more focused on the here-and-now, than their less experienced counterparts. Some families make gains in fewer than 6 therapy sessions, but, for most, success is achieved in longer periods of time, including those with a history of physical or sexual abuse. The highest levels of client resistance tend to occur in the middle phase of behavioral treatment and predict premature termination. Family members demonstrate greater emotional involvement with each other over time. However, greater conflict between parents has been observed over the course of treatment, with corresponding decreases in conflict between each parent and the problem child as therapy progresses. When working with lower SES families, successful therapists are more directive and speak more over time, whereas with middle SES families, less therapist directiveness over time predicted in session gains.

Future Directions The available research indicates that changes in family members are intrapersonal as well as interpersonal and involve the emotional and cognitive as well as behavioral realm of experience. Effective therapists are both authoritative and collaborative. Suggestions for closing the research-practice gap include, involving experienced clinicians more in the planning and conduct of therapy research, and encouraging clinicians to become more informed consumers of this research.

Chapter 15: Research on Family Intervention

Family Therapy Research Today While research in family therapy has grown increasingly sophisticated, it has, unfortunately, continued to have little impact on practicing clinicians. The authors point out that both sides of this divide--clinicians and researchers— contribute to this insularity. Clinicians by failing to educate themselves about statistics and research design, and researchers by not adequately capturing therapy as it is clinically practice and by not involving experienced clinicians more as consultants and participants in their studies. The use of randomized clinical trials and the application of experimental methods in recent years have made the study of family interventions increasingly rigorous. Program evaluations, which often involve field studies, have also been developed to assess the effectiveness of large-scale programs and their impact on the community. Currently there is great emphasis on evidence-based practice-- that is, controlling mental health care costs by limiting payment to programs that have been empirically supported. Studies of family interventions have become increasingly rigorous. The best studies now carefully specify the nature of the intervention using program manuals and fidelity checks, choose the sample carefully to ensure that it meets study requirements, choose comparison condition to reflect typical alternatives to the treatment being tested, use random assignment to conditions, use a variety of measure of outcome, and include follow-assessments. Results from multiple studies can be combined, using either a box score review or the more sophisticated metaanalysis. A meta-analysis not only counts the number of positive findings, but uses statistical methods to equate effect size across studies.

SUGGESTED LEARNING ACTIVITIES Class Exercises/Discussion Questions 1. Is family therapy an art or a science? Divide students into two groups and ask one group to defend therapy as an art, the other group to support therapy as a science. Ask the class to debate the issue by providing theoretical, empirical, and/or logical arguments supporting their view. 2. As an initial introduction to thinking in a scientist-practitioner mode, have student volunteers present a current case for 5 minutes, specifically, to describe the interpersonal interactions that occurred between (a) the client and his or her immediate and extended family, and (b) the student-therapist and client which led to some change (for better or worse) in terms of client functioning. The catch is to insist that students do this in jargon-free, everyday language, e.g., language one’s grandmother would understand. While the case is being presented and discussed, write on the board a list of questions -- translating the content of the students’ discussions into research questions that could be tested about the process and/or outcome of therapy. Assign a student volunteer to type the class’ list of clinically relevant research questions and distribute it next week in class. 3. Divide the class into groups of 4-6 each. Each group has been asked by a community mental health center, where they are consultants, to develop a program to prevent adolescent suicide. Each group is to develop a program that is based on ideas from one or more of the systemic theories of family development and family therapy that have been studied in the course. Students should describe the program in some detail, including the relevant theoretical constructs, concepts, assumptions, types of clients, and how outcome will be evaluated. 4. Divide the class into groups of 5-6. Instruct each group to design an outcome study to deal with a specific client problem. For example, if the client problem is adolescent acting-out, a group may design a treatment outcome study comparing structural, strategic, and experiential family therapy for families with troubled adolescents. The design considerations should include: treatment variables, client variables, diagnostic and assessment methods, measures, sample size, treatment description and duration, control group, ethical considerations, and therapist characteristics. An important aspect of this exercise is to derive a rationale for each selected treatment based on theory, logic, or past research. Each group should justify their choice of a control group in terms of

Chapter 15: Research on Family Intervention

scientific and ethical considerations. After each group designs a study, each study should be presented to the rest of the class. Explore their significance for the theory and practice of family therapy, as well as their limitations. How might each study be strengthened? 5. Ask students to evaluate the existing outcome literature for a select individual or family problem of their choice. The choice of population or problem may or may not be based on a DSM-IV diagnosis. Examples include: eating disorders, marital conflict, oppositional or conduct disorders, adolescent substance abuse, alcohol addiction, nonorganic failure-to-thrive/attachment disorders in infants and toddlers, mood disorders, schizophrenia, etc. Students should choose a topic on which at least 5 empirical studies have been based, in order to make the review worthwhile. Papers or presentations should include a thorough description of the populations or problem under study, including but not limited to: the current theoretical understanding of symptoms and symptoms maintenance; the various treatment approaches studied, including sufficient justification for their use with this population; and a critical review of the literature. They should conclude with a discussion of implications for practice and for future research. Students are also encouraged to provide copies of their references, abstract, and summary table for each class member, so that each benefits from the others work. 6. Discuss the current transformation in family therapy research from a strict reliance on quantitative methods to the increased use and acceptance of qualitative methods. How are they different? How do they converge? In your opinion, which perspective offers more for the immediate future of family therapy? 7. Instructors, discuss with the class your own programs of research in family therapy. Share with students how you first became interested in studying family therapy. Describe the nature of projects you’ve conducted, the progression of research designs used, the cumulative findings, etc. If instructors are not currently conducting family research, invite a guest speaker in to share with the class his or her experiences in conducting family therapy research. 8. In order to facilitate students’ understanding of the process of therapy and its relationship to therapy effectiveness, provide students a list of several process phenomena in family therapy (e.g., therapeutic alliance, split alliance, differentiation of self, enmeshment, triangling, etc.). Have students break into groups of 3-4 each and choose one for their focus. Announce that the goal of the exercise is to design an original program of research. Ask students to discuss in their groups (a) how they would define and operationalize their construct, i.e., as a self-report instrument or observational coding system, gives examples of items, subscales, and operational definitions of categories, etc.; (b) what types of research questions would they ask in their program of research of this topic -- be specific; (c) what types of research designs would they employ, including other variables or measures that should be related and unrelated to their instrument. Each group should present their program of research to the class for feedback and suggestions. 9. Discuss the current gap between research and practice in family therapy. Why does it exist? Are there ways in which students, as future family therapists and researchers, can work to close the gap? Discuss several possibilities which realistically can be achieved in the various settings students will be employed postgraduation.

Supplemental Readings Baucom, D., Shoham, V., Mueser, K.T., Daiuto, A.D., and Stickle, T.R. 1998. Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology. 66:53-88. Bean, R., and Crane, D.R. 1996. Marriage and family therapy research with ethnic minorities: Current status. American Journal of Family Therapy. 24:3-7. Chamberlain, P., and Rosicky, J.G. 1995. The effectiveness of family therapy in the treatment of adolescents with conduct disorders and delinquency. Journal of Marital and Family Therapy, 21:441-460. Consumer Reports. 1995, November. Mental health: Does therapy help? 734-739. Diamond, G., and Siqueland, L. 1995. Family therapy for the treatment of depressed adolescents. Psychotherapy, 32:77-90. Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. 2010. The heart and soul of change: Delivering what works in therapy, 2nd ed. Washington, D.C.: American Psychological Association.

Chapter 15: Research on Family Intervention

Edwards, M.E., and Steinglass, P. 1995. Family therapy treatment outcomes for alcoholism. Journal of Marital and Family Therapy, 21:475-510. Estrada, A.U., and Pinsof, W.M. 1995. The effectiveness of family therapies for selected behavioral disorders of childhood. Journal of Marital and Family Therapy, 21:403-440. Friedlander, M.L., Wildman, J., Heatherington, L., and Skowron, E.A. 1994. What we do and don’t know about the process of family therapy. Journal of Family Psychology, 8:390-416. Goldstein, M.J., and Miklowitz, D.J. 1995. The effectiveness of psychoeducational family therapy in the treatment of schizophrenic disorders. Journal of Marital and Family Therapy, 21:361-376. Jacobson, N.S., and Addis, M.E. 1993. Research on couples and couple therapy: What do we know? Where are we going? Journal of Consulting and Clinical Psychology, 61:85-93. Johnson, S.M., and Greenberg, L.S. 1988. Relating process to outcome in marital therapy. Journal of Marital and Family Therapy, 14:175-183. Newman, F.L., and Tejeda, M.J. 1996. The need for research that is designed to support decisions in the delivery of mental health services. American Psychologist, 51: 1040-1049. Pinsof, W.M., and Wynne, L.C. 1995. The efficacy of marital and family therapy: An empirical overview, conclusions, and recommendations. Journal of Marital and Family Therapy, 21:585-614. Pinsof, W.M., Wynne, L.C., and Hambright, A.B. 1996. The outcomes of couple and family therapy: Findings, conclusions, and recommendations. Psychotherapy, 33:321-331. Prince, S.E., and Jacobson, N.S. 1995. A review and evaluation of marital and family therapies for affective disorders. Journal of Marital and Family Therapy, 21:377-401. Shadish, W.R., Ragsdale, K., Glaser, R.R., and Montgomery, L.M. 1995. The efficacy and effectiveness of marital and family therapy: A perspective from meta-analysis. Journal of Marital and Family Therapy, 21:345360. Sprenkle, D. H. 2012. Intervention research in couple and family therapy: A methodological and substantive review. Joournal of Marital and Family Therapy, 38: 3-29. Sprenkle, D. H., & Piercy, F. P. 2005. Research methods in family therapy 2nd ed. New York: Guilford Press.

Test Bank Questions

Contents Chapter 1: The Evolution of Family Therapy

Chapter 2: The Fundamental Concepts of Family Therapy

Chapter 3: Basic Techniques of Family Therapy

Chapter 4: Bowen Family Systems Therapy

Chapter 5: Strategic Family Therapy

Chapter 6: Structural Family Therapy

Chapter 7: Experiential Family Therapy

Chapter 8: Psychoanalytic Family Therapy

Chapter 9: Cognitive-Behavioral Family Therapy

Chapter 10: Family Therapy in the Twenty-First Century

Chapter 11: Tailoring Treatment to Specific Populations and Problems

Chapter 12: Solution-Focused Therapy

Chapter 13: Narrative Therapy

Chapter 14: Comparative Analysis

Chapter 15: Research on Family Intervention

Answer Keys

Chapter 1: The Evolution of Family Therapy

Chapter 1: The Evolution of Family Therapy 1.1 Multiple-Choice Questions 1)

Lyman Wynne’s term for the facade of family harmony that characterized many schizophrenic families is A) B) C) D)

Hospital clinicians began to acknowledge and include the family in an individual’s treatment when A) B) C) D) E)

Murray Bowen John Elderkin Bell Virginia Satir Carl Whitaker

Frieda Fromm-Reichmann’s concept, ―________ mother,‖ described a domineering, aggressive, rejecting, and insecure mother who was thought to provide the pathological parenting that produced schizophrenia. A) B) C) D)

unfreezing social equilibrium group process field theory

The first to apply group concepts to family treatment was A) B) C) D)

they noticed when the patient got better, someone in the family got worse they realized the family was footing the bill for treatment they realized the family continued to influence the course of treatment anyway A and C none of these choices

Kurt Lewin’s idea of ________ can be seen in action in Minuchin’s promotion of crises in family lunch sessions, Norman Paul’s use of cross-confrontations, and Peggy Papp’s family choreography. A) B) C) D)

pseudocomplementarity pseudomutuality pseudoharmony pseudohostility

undifferentiated schizophrenogenic reactive symbiotic

Gregory Bateson and his colleagues at Palo Alto introduced this concept to describe the patterns of disturbed family communication which cause schizophrenia. A) schizophrenogenesis 1 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 1: The Evolution of Family Therapy

B) double bind C) pseudohostility D) none of these choices 7)

The only means to effectively escape a double bind is to A) B) C) D)

According to Theodore Lidz, marital schism occurs when A) B) C) D)

withdraw from the relationship metacommunicate quid pro quo A and B

one spouse with serious psychopathology dominates the other there is a chronic failure of spouses to achieve role reciprocity one spouse consistently engages in double-binding communication there is a loss of autonomy due to a blurring of psychological boundaries between spouses

Jackson’s concept, ________, that families are units that resist change, became the defining metaphor of family therapy’s first three decades. A) B) C) D)

emotional reactivity quid pro quo family homeostasis A and C

10) This family therapist’s personal resolution of emotional reactivity in his family was as significant for his approach to family therapy as Freud’s self-analysis was for psychoanalysis. A) B) C) D)

Salvador Minuchin Jay Haley Murray Bowen Carl Whitaker

11) This family therapist believed in the existence of an interpersonal unconscious in every family. A) B) C) D)

Murray Bowen Nathan Ackerman Ivan Boszormenyi-Nagy Virginia Satir

12) The group therapy model was not entirely appropriate for families for what reason? A) family members are peers B) families have a shared history C) A and C 2 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 1: The Evolution of Family Therapy

D) none of these choices 13) The Bateson group may be best remembered for the concepts of the double bind and A) B) C) D)

triangles family structure group process metacommunication

14) The tendency of families to resist change in order to maintain a steady state is known as A) B) C) D)

homeostasis the black box concept paradox complementarity

15) According to the text, one problem with treating families as though they were groups like any other group is that A) B) C) D)

it fails to consider the intrapsychic components of family problems it fails to appreciate the need for hierarchy and structure family members are released from their inhibitions there is no problem with treating families like any other group

16) A conflict created when a person receives contradictory messages on different levels of abstraction in an important relationship, and cannot leave or comment is known as a A) B) C) D)

reframe complementarity quid pro quo double bind

17) The goal of family group therapy was to A) B) C) D)

promote verbalization and understanding of unmet needs promote individuation of family members improve family relationships all of these choices

18) Group-oriented therapists promoted communication by concentrating on ________ rather than ________. A) B) C) D)

process/content solutions/problems the system/the individual positive feedback loops/negative feedback loops

19) The family theory of the etiology of schizophrenia which focused on disturbed patterns of communication was founded by Gregory Bateson, Theodore Lidz, and 3 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 1: The Evolution of Family Therapy

A) B) C) D)

Carl Whitaker Lyman Wynne Virginia Satir Mara Selvini-Palazzoli

20) A relationship in which husband and wife both pursue careers and share housekeeping and childrearing responsibilities is A) B) C) D)

complementary unrealistic competitive symmetrical

21) Communications family therapists hypothesized that normal families can maintain integrity in the face of environmental vagaries through A) B) C) D)

positive feedback negative feedback metacommunication therapeutic double-binds

22) According to communications theory, healthy families are able to adapt to changing circumstances through use of A) B) C) D)

positive feedback negative feedback homeostasis therapeutic double-binds

23) One of the major propositions put forth in Watzlawick et al. ’s (1967) Pragmatics of Human Communication, was that all messages have a report and a ________ function. A) B) C) D)

semantic pragmatic paradoxical command

1.2 Short Answer 1)

Explain ―homeostasis.‖

Discuss the advantages and disadvantages of using a systems metaphor to understand and treat families.

In communications family therapy, resistance and symptoms were treated with a variety of paradoxical techniques, known as therapeutic double-binds. Define and give an illustration of a therapeutic double-bind. Why were they considered so powerful?

Chapter 1: The Evolution of Family Therapy

their use is necessary in order to successfully treat families. Take a position for or against the use of paradox and defend your perspective. 5)

Explain the etiology of schizophrenia from a communications theory perspective.

What is the ―black box‖ concept? How does it inform the goals for therapy according to the communications perspective?

Discuss family group therapy’s major contributions to the family therapy field. What were the major limitations that led to its eventual demise?

Describe the double-bind theory of schizophrenia. Historically, why was the theory important? (How might the methods of operationalizing the double-bind phenomenon have affected its lack of empirical support? What methods of measurement could be used to capture the complexity in double bind communication and thus adequately test the validity of the phenomenon?)

Listed below are a number of concepts and methods that have endured and continue to shape the field of family therapy. Choose any three; describe and give an example of each. How can each concept be used to enrich our understanding of families and guide our treatment interventions? (a) (b) (c) (d) (e)

double bind theory family homeostasis metacommunication complementarity process/content distinction

10) What is a negative feedback loop and how or why is it initiated? Provide an example of a negative feedback loop based on a personal observation of a family interaction. 11) How are family systems therapies different from traditional individual therapies? 12) Some would argue that there is a radical divergence between family systems therapies and the more traditional psychotherapeutic approaches. Others would challenge this view, arguing that there are many points of similarity and that the differences are exaggerated. Take one position or the other and defend your stand. 13) Choose two of the individuals below and describe how they helped to launch the family therapy movement. Be specific in discussing their contributions to the field. (a) (b) (c) (d) (e) (f) (g)

Chapter 1: The Evolution of Family Therapy

(h) Salvador Minuchin (i) Virginia Satir (j) Carl Whitaker 14) How is group therapy similar to and different from family therapy? 15) What was the positive impact of research on family dynamics and schizophrenia? What was its negative impact?

Chapter 2: The Fundamental Concepts of Family Therapy

Chapter 2: The Fundamental Concepts of Family Therapy 2.1 Multiple-Choice Questions 1)

Which is not a concept of von Bertalanffy’s general systems theory? A) B) C) D)

sequences of interaction family hierarchy family rules negative feedback

Constructivism first found its way into psychotherapy in the work of A) B) C) D)

family structure homeostasis function of the system family life cycle

Which phenomena are not a focus of cybernetics, as applied to families? A) B) C) D)

systems theory cybernetics constructivism general systems theory

The stages of a family’s life from separation from one’s parents to marriage, having children, growing older, retirement, and finally death, are known as the A) B) C) D)

a system is more than the sum of its parts equifinality homeostatic reactivity

A biological model of living systems as whole entities which maintain themselves through continuous input and output from the environment, developed by Ludwig von Bertalanffy is known as A) B) C) D)

―black box‖ metaphor

Paul Watzlawick Kenneth Gergen George Kelly Michael White

A balanced steady state of equilibrium is known as A) B) C) D)

Chapter 2: The Fundamental Concepts of Family Therapy

The study of control processes in systems, particularly the analysis of the flow of information in closed systems, is known as A) B) C) D)

Narrative therapy differs from solution-focused therapy in being more focused on ________ than ________. A) B) C) D)

functional analysis of behavior cybernetics existentialism general systems theory

exceptions; problems cognitions; interactions attitudes; behavior individuals; families

With the exception of the feminist critique, what has been largely missing in family therapy has been an examination of A) B) C) D)

cultural biases the society we are helping people fit into value systems all of these choices

10) General systems theory, cybernetics, and social constructionism are ________ concepts. A) B) C) D)

epistemological metapsychological clinical metaphysical

11) The greatest conceptual influence on the early development of family therapy was A) B) C) D)

the family life cycle constructivism feminism systems theory

12) The concept of the family life cycle was introduced to the field by A) B) C) D)

Salvador Minuchin Betty Carter and Monica McGoldrick Jay Haley Don Jackson

Chapter 2: The Fundamental Concepts of Family Therapy

A) B) C) D)

behavioral family therapy experiential family therapy communications family therapy structural family therapy

14) Boundaries around the executive subsystem in the family are of particular importance because the family ________ is seen by structural therapists as crucial to the family’s wellbeing. A) B) C) D)

network hierarchy life cycle quid pro quo

2.2 Short Answer 1)

Why should a family’s ethnic background be considered in assessment?

List the stages of the family life cycle (Carter & McGoldrick, 1999) and describe the primary task(s) of each stage. Consider how the therapist would intervene with the family at each of these stages.

List and describe at least three contextual influences on the evolution of family therapy.

What are positive and negative feedback and how do they operate in families?

Listed below are a number of concepts and methods that have endured and continue to shape the field of family therapy. Choose any three and describe them. How can each concept be used to enrich our understanding of families and guide our treatment interventions? a) b) c) d) e) f) g)

importance of family context triadic models family structure psychopathology serving a function in families circular sequences of interaction family life cycle multigenerational patterns

How can general systems theory revitalize family therapy and bridge the chasm between the narrative approaches of the twenty-first century and the traditional schools (i.e., structural, Bowenian, communications, and/or strategic) of family therapy?

Chapter 3: Basic Techniques of Family Therapy

Chapter 3: Basic Techniques of Family Therapy 3.1 Multiple-Choice Questions 1)

The goal of a first interview with a family is to develop an alliance with the family and: A) B) C) D)

Challenging linearity means: A) B) C) D)

To have therapists with similar backgrounds to clients To ask questions To study cultural and ethnic traditions To accept how clients wish to relate within their own families

To treat couples together To treat them separately To see them together and separately To refer the case to a systemic couples therapist

According to the authors a therapist should focus on -------A) B) C) D)

In cases of common couple violence most feminist therapists think it best A) B) C) D)

Subsystems Boundaries Family rules Triangles

According to the authors, the best way to develop cultural sensitivity is A) B) C) D)

Asking how others are involved in the presenting problem Asking for a chronology of the presenting problem Asking for a family history Asking family members for a circular explanation of the presenting problem

All but which of the following is not part of exploring a family's structure? A) B) C) D)

To determine if medication is indicated To get a detailed picture of the identified patient To develop a tentative hypothesis about the what is maintaining the problem To consider whether or not to take the case

A family’s strengths and weaknesses The presenting problem The family life cycle stage of the family The bio-psycho-social milieu

The authors suggest developing a tentative hypothesis about a family's problem: A) After exploring the presenting complain B) After the first session C) After the initial phone call 10 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 3: Basic Techniques of Family Therapy

D) During the first few sessions 8)

At termination a family therapist should A) B) C) D)

Explore the therapeutic relationship Resolve the therapeutic relationship Focus on the things the family has learned Focus on what the family has been doing

The authors recommend. A) B) C) D)

A brief follow-up a few weeks after termination Asking family members how they will handle challenges in the future Allowing families to determine when therapy should end All of the above

3.2 Short Answer 1)

What are the pros and cons of insisting that the entire family attend the initial consultation?

What is the ―problem-determined system‖? Give a couple of examples.

What is essential to accomplish in the first session in order to establish a productive therapeutic alliance with a family?

How can a therapist effectively challenge linear attributions of blame? Give a couple of examples.

Why is it important for a clinician to develop a therapeutic hypothesis, and what are some of the elements that such a formulation should include?

What is the danger of a therapist taking too active and directive a role in the middle stages of a family’s treatment?

Why is traditional couples considered potentially dangerous in the treatment of cases involving marital violence?

What are some of the arguments in favor of treating violent partners together in couples therapy?

What are the first priorities in treating cases involving child sexual abuse?

Chapter 4: Bowen Family Systems Therapy

Chapter 4: Bowen Family Systems Therapy 4.1 Multiple-Choice Questions 1)

A Bowen therapist working with an individual family member in treatment is most likely to do which of the following? A) B) C) D) E)

The primary goal of Bowen family therapy is to A) B) C) D)

avoid the expression of intense emotions avoid contact with dysfunctional family members have parents who are well differentiated be firstborn children A and C

An increase in chronic anxiety in the nuclear family system will tend to ________ less differentiated families, while it will ________ more highly differentiated families. A) B) C) D)

can extricate themselves from all emotional triangles can balance their needs for closeness and autonomy avoid contact with their parents approach life in a purely rational fashion

According to Bowen theory, more highly differentiated individuals will likely A) B) C) D) E)

heighten emotional experiencing in family members increase the family’s repertoire of problem-solving skills improve communication between family members increase the level of self-focus in family members

―Differentiated‖ individuals

A) B) C) D) 4)

create a therapeutic triangle use displacement stories model how to take an ―I‖ position work with a genogram C and D

be absorbed by/promote growth in promote growth in/be absorbed by cause an increase in symptoms in/be absorbed by cause a decrease in symptoms in/promote growth in

Murray Bowen developed his ideas about family therapy while at the NIMH, studying ________ families. Based on his observations of these families’ intense clinging interdependence, he concluded that a lack of differentiation was responsible for all family pathology. A) alcoholic B) depressed 12 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 4: Bowen Family Systems Therapy

C) neurotic D) psychotic 7)

By training family members in 3 areas--teaching differentiation, avoiding triangulation, and ________, Bowen therapists can enable a single individual to transform the whole network of his or her family system. A) B) C) D)

In Bowen theory, the flight from a conflictual emotional attachment to one’s parents is known as A) B) C) D)

avoiding expression of intense emotions reopening cut-off family relationships increasing contact with dysfunctional family members all of these choices

emotional cutoff enmeshment disengagement fusion

In Bowen theory, this is a process wherein the projection of varying degrees of immaturity to different children in the same family occurs. The child who is most involved in the family emerges with the lowest level of differentiation, and passes on problems to succeeding generations. A) B) C) D)

societal emotional process family projection process nuclear family emotional process multigenerational transmission process

10) This Bowenian concept describes the level of emotional ―stuck-togetherness‖ or fusion in the family. A) B) C) D)

unconscious need complementarity lack of differentiation of self triangling A and C

11) According to Bowen, ________ are the smallest stable unit of human relations. A) B) C) D)

dyads triangles foursomes none of these choices

12) The central premise of Bowen theory is that unresolved ________ must be resolved before one can differentiate a mature, healthy personality. A) oedipal conflicts B) emotional experiencing 13 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 4: Bowen Family Systems Therapy

C) emotional reactivity to one’s family of origin D) attachment deficits 13) From a Bowenian perspective, optimal development in the family occurs when all members are relatively differentiated, anxiety is low, and parents A) B) C) D)

form an executive subsystem cut-off from dysfunctional family members avoid heightened emotionality remain in emotional contact with their families of origin

14) People tend to marry spouses at ________ levels of differentiation. A) B) C) D)

varying similar complementary opposite

15) Unlike experiential therapists, Bowenians seek to ________ levels of anxiety in order to increase levels of differentiation of self in the family. A) B) C) D)

increase identify monitor decrease

16) ________ is a prominent technique in Bowen therapy designed to clarify emotional processes involved in altering key triangles. The technique is used in order to help family members become aware of systems processes and recognize their own roles in them--it was first developed for use with emotional pursuers and distancers. A) B) C) D)

relationship experiments coaching use of genograms use of displacement stories

17) According to feminist Bowenians, ________ causes the most problems in American families. A) B) C) D)

patriarchy domestic violence emotional fusion A and C

18) According to the principles of which Bowenian construct, simply teaching a mother better techniques for disciplining her son will fail, because the intervention ignores the problem that she is overinvolved with the boy as a result of her husband’s emotional distance. A) enmeshment 14 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 4: Bowen Family Systems Therapy

B) multigenerational transmission process C) emotional cutoff D) triangles 19) Bowen’s concept ―differentiation of self‖ is most like, which of the following? A) B) C) D)

independence disengagement self-actualization ego strength

4.2 Short Answer 1)

What are emotional triangles? How and why are they formed?

Explain differentiation of self.

What are the multigenerational emotional processes? Give an example that illustrates these processes.

Compare and contrast emotional fusion and enmeshment. How are they alike; how are they different?

According to Bowen theory, a lack of differentiation in the nuclear family will tend to be expressed in one of three ways. List and give an example of each.

A 25-year-old, single man seeks consultation. He is depressed and anxious, and his selfesteem is low. His father expected him to be an attorney like himself, but the client has been unsuccessful in his repeated applications to law school. He lives with his parents, and there is much tension in the home whenever his career plans are discussed. At present he is working as a therapy aide in a state psychiatric center. He enjoys his work but is embarrassed that he is employed beneath the level one would expect for a college graduate. Discuss the case from a Bowenian perspective. Be specific when applying Bowen’s theoretical constructs. Second, indicate how, for this client, the Bowenian approach would differ from a more traditional theoretical approach (individual therapy or vocational counseling).

List the stages of the family life cycle (Carter and McGoldrick, 1988) and describe the primary tasks of each stage. Consider how the therapist would intervene from a Bowenian perspective with the family at each of these stages.

What is the basic procedure Bowenian therapists use with couples and how does this differ from, say, structural family therapy (or narrative, etc.) with couples?

Chapter 4: Bowen Family Systems Therapy

10) To what extent is ―differentiation of self‖ more than just a synonym for ―maturity‖? 11) What is the difference between Guerin’s focus in family therapy versus Bowen’s?

Chapter 5: Strategic Family Therapy

Chapter 5: Strategic Family Therapy 5.1 Multiple-Choice Questions 1)

Both strategic and Milan systemic therapies aim to achieve personality change through A) B) C) D) E)

The strategic and systemic therapies have been most directly influenced by the ideas of A) B) C) D) E)

foster insight negatively reinforce symptoms promote individuation of family members interrupt dysfunctional feedback loops

Relabeling a family’s description of behavior to make it more amenable to therapeutic change is called A) B) C) D)

a positive connotation scapegoating an ordeal prescribing the symptom

A primary goal of communications family therapy was to A) B) C) D)

Gregory Bateson Carl Rogers Virginia Satir Milton Erickson A and D

A paradoxical technique that forces a patient to either give up a symptom or admit that it is under voluntary control is known as A) B) C) D)

use of reframing use of circular questioning hierarchical restructuring use of various paradoxical techniques none of these choices

reframing prescribing the symptom reinforcement reciprocity a double-bind

Basic change in the structure and functioning of a system is known in general systems theory as A) B) C) D)

Chapter 5: Strategic Family Therapy

The development and use of ―pretend techniques,‖ paradoxical interventions in which family members are asked to pretend to engage in symptomatic behavior, is associated with which strategic/systemic therapist? A) B) C) D)

The Bateson group may be best remembered for the concepts of the double bind and A) B) C) D)

Mara Selvini Palazzoli Virginia Satir Cloe Madanes all of these choices

metacommunication family structure group processes triangles

MRI therapists identify 3 categories of client solutions which tend to perpetuate or exacerbate their problems. They include attempting to solve something which isn’t really a problem, taking action to solve a problem but doing so at the wrong level, and A) B) C) D) E)

complying with a paradoxical directive failing to take action, though action is necessary denying that a problem exists B and C none of these choices

10) Though many schools of family therapy believe that the real problem in families is some form of underlying family pathology, ________ family therapists deny that underlying dynamics are the cause of symptomatic behavior. A) B) C) D)

strategic structural Bowenian all of these choices

11) The idea that because the mind is so complex, it’s better to study people’s input and output (e.g., behavior and communication) than to speculate about what goes on in their minds is known as A) B) C) D)

black box concept general systems theory paradox metacommunication

12) All of these choices schools have for their goals of therapy both symptom resolution and transformation in the whole family system, except which? A) MRI B) experiential C) Bowenian 18 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 5: Strategic Family Therapy

D) structural 13) A method of interviewing developed by the Milan associates in which questions are asked to highlight differences among family members, is known as A) B) C) D)

a therapeutic double-bind circular questioning positive connotation a family ritual

14) A technique used by the Milan group that prescribes a specific act for family members to perform--it is designed to change the family system’s rules. A) B) C) D)

circular questioning pretend technique positive connotation family ritual

15) Action and insight are the primary vehicles of change in family therapy. The ________ school emphasizes behavioral change and eschews insight as a medium for change. A) B) C) D)

structural strategic psychodynamic experiential

16) The strategic technique of providing a new label for a family’s description of behavior, in order to make it more amenable to therapeutic change; for example, describing someone as ―lonely‖ rather than ―depressed.‖ A) B) C) D)

interpretation restraining reframing A and C

17) Selvini Palazzoli’s technique of ascribing helpful motives to family behavior in order to promote family cohesion and avoid resistance to therapy is known as A) B) C) D)

ordeal therapy mystification pretend technique positive connotation

18) Jay Haley’s approach incorporates a functionalist viewpoint with his Ericksonian and cybernetic influences, thus combining aspects of the ________ and ________ approaches into his style of treating families. A) structural/behavioral B) Bowenian/behavioral C) strategic/experiential 19 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 5: Strategic Family Therapy

D) structural/strategic 19) Madanes categorizes family problems according to 4 basic intentions of family members involved in them. They are the desire to dominate and control, the desire to love and protect others, the desire to repent and forgive, and the desire to A) B) C) D)

create a family be loved be secure none of these choices

20) A conflict created when a person receives contradictory messages on different levels of abstraction is known as a A) B) C) D)

reframe double bind complementary message quid pro quo

21) The use of ________ is designed to block or change dysfunctional behavior using indirect, seemingly illogical means. A) B) C) D)

therapeutic double-binds paradox directives all of these choices

22) The current form of Haley/Madanes therapy is called ________, and still involves giving directives based on therapist hypotheses, though shifting the focus away from the power elements of family hierarchy. A) B) C) D)

post-modern strategism positive strategism strategic humanism none of these choices

23) The central intervention within the original Milan model consisted of either a ritual or a A) B) C) D)

family sculpting positive connotation therapeutic double bind A and C

5.2 Short Answer 1)

What is the purpose of ―circular questioning‖?

Chapter 5: Strategic Family Therapy

How would a strategic therapist decide which type of directive to use with a family in treatment? 3)

In communications family therapy, resistance and symptoms were treated with a variety of paradoxical techniques known as therapeutic double binds. Define and give an illustration of a double bind. Why were they considered to be so powerful?

Describe the invariant prescription.

What is the ―black box‖ concept? How is it used in the communications approach?

Compare and contrast the strategic and Milan systemic theories. Consider theoretical adequacy; specificity of constructs, strategy, and technique; role of the therapist; and types of client problems best suited for each approach.

How does the therapist’s role differ in Milan systemic versus solution-focused therapy?

What is a negative feedback loop and how or why is it initiated? Give an example. What is a positive feedback loop and how or why is it initiated? Give an example.

Chapter 6: Structural Family Therapy

Chapter 6: Structural Family Therapy 6.1 Multiple-Choice Questions 1)

A family therapist who begins a session by greeting individual family members by name and asking for each person’s view of the problem is demonstrating which strategy? A) B) C) D)

Structural therapists attempt to alter the family’s view of reality by A) B) C) D)

genograms paradoxical directives double-binds enactments

―Unbalancing‖ involves

A) B) C) D) 7)

rigid, enmeshed, diffuse executive, rigid, enmeshed rigid, executive, diffuse rigid, diffuse, enmeshed

Structural family therapists use ________ to observe and then change transactions that make up family structure. A) B) C) D)

teach the family problem-solving strategies alter the family structure strengthen boundaries around rigid family subsystems heighten emotional experiencing

Disengaged subsystems are surrounded by ________ boundaries while ________ subsystems have ________ boundaries. A) B) C) D)

heightening emotional experiencing challenging cognitive constructions realigning boundaries between individuals and subsystems accommodating to the viewpoint of the most powerful family member

The primary treatment goal of structural family therapy is to A) B) C) D)

boundary making highlighting the interactions accommodating joining

realigning relationships between subsystems therapeutic neutrality restorying the family’s narrative taking sides

Chapter 6: Structural Family Therapy

explains structure and A) B) C) D) 8)

Minuchin’s term for psychological isolation that results from overly rigid boundaries around individuals and subsystems in a family is A) B) C) D)

family members’ self-reports live observation a structured assessment interview none of these choices

enmeshment differentiation emotional cutoff disengagement

When two people marry, they must learn to negotiate the nature of the boundary between them, as well as the boundary separating them from the outside. This structural requirement is known as A) B) C) D)

accommodation complementarity disengagement differentiation

10) The goal in structural family therapy when working with enmeshed families is to A) B) C) D)

establish reinforcement reciprocity by teaching methods of positive control differentiate individuals and subsystems by strengthening the boundaries around them increase interaction by making boundaries more permeable all of these choices

11) Structuralists believe the family must first accept the therapist, in a process called ________, which allows the therapist to increase stress and unbalance the family homeostasis, thus opening the way for structural transformation in the family. A) B) C) D)

detouring taking an ―I‖ position restructuring joining

12) When parents are unable to resolve the conflicts between them, a common pattern is to continue to argue through the children. When father says mother is too permissive, she says he’s too strict. He may in turn withdraw, and she responds to the child with excessive concern and devotion. The structural term which best describes the resulting family structure is A) diffuse boundaries between husband and wife B) a cross-generational coalition between mother and child C) overinvolvement between father and child 23 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 6: Structural Family Therapy

D) a pathological triangle 13) An interaction stimulated in structural family therapy in order to observe and then change transactions which make up family structure is called A) B) C) D)

a positive connotation a spontaneous behavior exchange a reframing an enactment

14) During which phase of structural family therapy does assessment occur? A) B) C) D)

opening mapping underlying structure transformation of family structure structural therapists do not use assessments

15) In order to highlight and modify interactions in the family, structural therapists use intensity to A) interrupt rigid patterns of conflict-avoidance B) break families loose from their patterns of equilibrium C) extend interactional sequences beyond the point where dysfunctional homeostasis is reinstated D) all of these choices 16) ________ is another method of modifying interactions, which structural therapists use to help family members employ more functional alternatives already in their repertoire of skills. A) B) C) D)

Positive connotations Shaping competence Detriangling Operant conditioning

17) Minuchin, Rosman, and Baker (1978) reported a 90% improvement rate in the results of their treatment study of structural family therapy in treating A) B) C) D)

drug addiction anxiety disorders depression anorexia

6.2 Short Answer 1)

Why are ―enactments‖ used in structural therapy?

Discuss the pros and cons of the argument that structural family therapy (as practiced by Minuchin) is not a collaborative model. 24 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 6: Structural Family Therapy

A child from enmeshed family is brought into treatment for school phobia. Demonstrate your knowledge of family structure by describing how this presenting problem may be understood as the sign of an enmeshed family. How might members of an enmeshed family system contribute to the maintenance of such a problem?

List and describe the three overlapping phases in the process of structural family therapy. Describe the specific strategies that structural therapists employ in each phase. Use a case example for illustration.

Compare and contrast structural family therapy to the early communications therapy practiced by Don Jackson and colleagues. Consider theoretical adequacy, specificity of constructs, strategies and techniques, roles of the therapist, and types of client problems best suited for each approach.

What are ―boundaries‖ and why are they important in understanding the problems of a newly married couple?

What is family structure and how do families become structured?

Describe and explain the four steps in the Minuchin, Nichols, and Lee assessment model.

Chapter 7: Experiential Family Therapy

Chapter 7: Experiential Family Therapy 7.1 Multiple-Choice Questions 1)

Experiential family therapists believe ________ is/are the primary cause of dysfunction in families. A) B) C) D)

Experiential therapy differs from most systems approaches with respect to its emphasis on ________ versus techniques that specifically facilitate interaction. A) B) C) D)

increased personal integrity greater freedom of choice restructuring of the family system increased sensitivity to one’s needs and feelings

Carl Whitaker, like Murray Bowen, believes that personal growth (i.e., individuation) also requires A) B) C) D)

introjection metacommunication reframing mystification

The goals of experiential family therapy would not include A) B) C) D)

expanding experience improving problem solving restructuring the family hierarchy metacommunication

Laing’s concept that many families distort their children’s experience by denying or relabeling it is known as A) B) C) D)

interlocking triangles unexpressed emotion cross-generational coalitions poor problem-solving

rational thinking family connectedness problem-solving abilities none of these choices

A collection of beliefs based on a distortion of historical reality and shared by all family members, which help shape the rules governing family functioning are known as A) family rules B) invisible loyalties C) family myths 26 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 7: Experiential Family Therapy

D) none of these choices 7)

Within experiential therapy, the ________ is believed to be the essential healing force in the psychotherapeutic process, whereby the therapist establishes caring, person-to-person relationships with each family member while modeling openness, honesty, and spontaneity. A) B) C) D)

A non-verbal experiential technique, in which family members position themselves in a tableau that reveals significant aspects of their perceptions and feelings, is known as A) B) C) D)

interpretation of unconscious conflict existential encounter therapeutic double-bind paradoxical intervention

existential encounter family sculpting family ritual conjoint family drawing

An important concept in experiential family therapy--defined as the process of developing and fulfilling one’s innate, positive potentialities. A) B) C) D)

differentiation of self alienation from experience constructivism self-actualization

10) Experiential family therapy is designed to A) B) C) D)

interpret and work through unconscious conflicts increase family members’ levels of differentiation of self facilitate emotional experiencing in family members none of these choices

11) ________ is considered more important by experiential therapists for healthy family functioning than either problem-solving skills or functional family structure. A) B) C) D)

open, spontaneous experiencing insight symptom relief none of these choices

12) The primary goals of family therapy included all except which of the following? A) B) C) D)

enhanced sensitivity greater freedom of choice expanded emotional experiencing symptom relief

Chapter 7: Experiential Family Therapy

provocative and supportive ways in order to help families learn to express honest emotion. A) B) C) D)

encourage development of transference discourage development of transference raise the level of anxiety in the family lower the level of anxiety in the family

14) Experiential therapists typically use ________ to help minimize countertransference responses to family members in session. A) B) C) D)

live observation co-therapists reflecting teams their own therapy

15) Among experientialists, families are typically conceived of and treated as A) B) C) D)

groups of individuals systems parent and child subsystems none of these choices

16) Johnson and Greenberg have found that emotionally-focused couples therapy is more successful when the therapist first ________ and then ________, in that order. A) B) C) D)

softens the attacking spouse’s stance; engages the withdrawn spouse engages the withdrawn spouse; softens the attacking spouse’s stance facilitates an enactment; encourages expression of secondary emotions encourages expression of secondary emotions; facilitates an enactment

17) The goal of internal family systems therapy is to A) B) C) D)

experience unique outcomes achieve self-leadership de-triangulate B and C

18) Internal family systems theorists use techniques such as ________ from structural family therapy to help people get their polarized parts to deal with each other while blocking the interference of other parts. A) B) C) D)

joining mapping interactions boundary making increasing intensity

Chapter 7: Experiential Family Therapy

A) B) C) D)

educate family members about internal positive feedback loops help family members notice when their parts have taken over solve the family’s presenting problem reposition the family hierarchy

20) The internal family systems therapist uses ________ or sense of when people are and are not leading with their Selves, to help family members maintain Self-leadership as they interact. A) B) C) D)

an analytic third ear a parts detector a quid pro quo metacommunication

7.2 Short Answer 1)

Experiential therapists have downplayed the role of theory in psychotherapy. Describe the rationale offered by such people as Whitaker and Keith for using an atheoretical approach to treating families.

What is an ―existential encounter?‖

Describe the technique of ―family sculpting.‖

Experiential therapy derives from existential, humanistic, and phenomenological thought. Explain the general essence of these lines of thinking, and their implications for treatment. Contrast these existential ideas with the determinism inherent in psychoanalytic thinking.

What evidence is there for the effectiveness of emotionally-focused couples therapy? Discuss the types of couple presenting problems that may be most amenable to change through use of an emotion-focused approach? For which types of presenting problems might it be least effective? How could you test your hypotheses regarding differential effectiveness? Compare and contrast Schwartz’s notion of ―Self leadership‖ and Bowen’s construct, ―differentiation of self.‖

6) 7)

Schwartz’s study of internal family systems (IFS) led him to group the roles that parts commonly adopt when a person has been hurt into 3 categories exiles, managers, and firefighters. Describe and give an example of each. How would an IFS therapist explain the notion of resistance?

Chapter 8: Psychoanalytic Family Therapy

Chapter 8: Psychoanalytic Family Therapy 8.1 Multiple-Choice Questions 1)

The outcome of good object relations in infancy is the emergence of A) B) C) D)

________ is an interactive process in which a subject perceives an object as containing elements of the subject’s personality and evokes certain behaviors and feelings from the object that conform to these perceptions. A) B) C) D)

within between within and between none of these choices

An emotional reaction, usually unconscious and often distorted, on the part of the therapist to a patient or family member in treatment is known as A) B) C) D)

inadequate separation-individuation; introjection of pathological objects repression of aggressive and libidinal impulses; inadequate separation-individuation introjection of pathological objects; enmeshment with family of origin enmeshment with family of origin; repression of aggressive and libidinal impulses inadequate separation-individuation; repression of aggressive and libidinal impulses

Non-psychoanalytic family therapists locate problems between people; psychoanalytic family therapists identify problems ________ people. A) B) C) D)

Separation-individuation Transference-countertransference Reciprocal introjection Projective identification

According to object relations theory, both ________ and ________ will likely result in poor adult adjustment. A) B) C) D) E)

anaclitic object constancy ambivalent attachment libidinal object constancy ego idealism

transference countertransference projective identification introjection

A process whereby an infant begins to draw apart from the symbiotic bond with mother and develop autonomous functioning is known as A) introjection 30 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 8: Psychoanalytic Family Therapy

B) separation-individuation C) projective identification D) identification 7)

According to psychoanalytic perspectives, one’s choice of marital partner is based on A) the desire to maximize ―rewards‖ and minimize ―costs‖ of the relationship B) one’s level of differentiation of self, and similar levels of differentiation in the families of origin C) complementary styles of communication D) one’s desire to find someone with complementary needs who will fulfill one’s unconscious fantasies

According to psychoanalytic theory, marital choice is affected in part by the ________ phenomenon, in which the insecurely attached child grows up learning to hide their real needs and feelings to win approval. A) B) C) D)

false self invisible loyalty introjective double-bind

A process in psychoanalytic family therapy, by which insights are translated into new and more productive ways of behaving and interacting is known as A) B) C) D)

projective identification working through metacommunication interpretation

10) Psychoanalytic family therapists use the technique of interpretation when confronted with ________ in family therapy, because it often takes the form of acting-out. A) B) C) D)

sublimation introjection resistance libidinal impulses

11) Psychoanalytic clinicians identify pathology in families as the result of ________, while structural family therapists locate dysfunction in the boundaries between subsystems. A) B) C) D)

conflict intrapsychic rigidity developmental arrest all of these choices

12) Psychoanalytic family therapists pay particular interest to childhood memories when A) they feel family members’ need reassurance and direction B) family members’ associations and spontaneous interactions cease 31 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 8: Psychoanalytic Family Therapy

C) they are re-enacted in the present, manifested as transference D) none of these choices 13) Unlike ________, psychoanalytic clinicians may not complete their assessment or arrive at a final diagnosis until the end of treatment. A) B) C) D)

experientialists behaviorists structuralists B and C

14) Psychoanalytic family therapy consists of four basic techniques listening, empathy, interpretation, and A) B) C) D)

maintaining analytic neutrality facilitating emotional expression paradoxical directives re-storying

15) According to self psychology, children are more likely to develop a secure and cohesive sense of self when parents provide sufficient opportunities for A) B) C) D)

anaclitic introjection ego splits projective identification idealization

16) Along with the achievement of insight, the processes of ―working through‖ and ________ are considered three specific processes that facilitate change in psychodynamic therapy. A) B) C) D)

reintegrating split-off parts of the ego sublimation reciprocal introjection warding off of libidinal and aggressive impulses

17) The general goals of psychoanalytic family therapy include all except A) B) C) D)

resolution of unconscious conflict anaclitic object constancy differentiation separation-individuation

8.2 Short Answer 1)

Explain ―projective identification.‖

What is resistance? Give an example of how it is manifested in family therapy. How should the therapist work with resistance in treatment?

Chapter 8: Psychoanalytic Family Therapy

Explain the difference between the psychoanalytic techniques of confrontation and interpretation.

Transference occurs in all forms of therapy. What is the general psychoanalytic point of view regarding its significance in treatment? How does the occurrence and use of transference differ in psychoanalytic family therapy and individual psychoanalytic therapy.

Four basic techniques used in psychoanalytic family therapy are: listening, empathy, interpretation, and maintaining analytic neutrality. Define and give an example of how each technique may be used in a treatment session with a couple experiencing marital difficulties.

According to Freud what are the primary human motivations? According to Kohut what are the primary human motivations? Give an example of each and explain how they differ.

What is the difference between Nagy’s concept of ―invisible loyalty‖ and the more familiar and simpler term ―loyalty‖?

What is the difference in impact on the patient between a therapist’s mirroring versus expressing praise and reassurance?

Chapter 9: Cognitive-Behavioral Family Therapy

Chapter 9: Cognitive-Behavioral Family Therapy 9.1 Multiple-Choice Questions 1)

The use of high-probability behavior to reinforce low-probability behavior is known as A) B) C) D)

A behavioral technique using to eliminate behavior by not reinforcing it is known as A) B) C) D)

contingency contracting token economy aversion therapy shaping

Systematic desensitization and assertive training are both examples of ________ techniques. A) B) C) D)

operant conditioning respondent conditioning cognitive/affective techniques none of these choices

This behavioral technique uses a system of points or stars to reward children for successful behavior A) B) C) D)

focuses on triadic constructions of the identified problem aims to restructure the family hierarchy and generational boundaries requires that the entire family to attend therapy supports the parents’ view that the child is the problem

The most commonly used techniques in behavior therapy fall into which category? A) B) C) D)

punishment assertive training contingency contracting extinction

The behavioral parent training model A) B) C) D)

aversive control Premack principle shaping modeling

operant conditioning cognitive/affective respondent conditioning aversion

Chapter 9: Cognitive-Behavioral Family Therapy

B) observation C) objective testing D) projective testing 8)

Assessments conducted in behavioral marriage therapy are designed to evaluate couples on all except which of the following: A) B) C) D)

their ability to discuss relationship problems the manner in which reward and punishment are exchanged their capacity for whole object relationships skill at pinpointing relevant reinforcers in the relationship

Behavioral marital therapists prefer to use ________ to identify problems and understand their etiology. A) B) C) D) E)

interviews written questionnaires direct observation B and C none of these choices

10) According to behaviorists, disturbed marital interactions result from A) B) C) D)

low rates of positive reinforcement exchange positive expectancies low rates of aversive control none of these choices

11) A major treatment strategy in behavioral couples therapy is to A) B) C) D)

increase the rate of aversive control improve communication skills decrease positive control all of these choices

12) The major intent of behavioral exchange procedures is to help couples A) B) C) D)

with severe marital problems establish reinforcement reciprocity resolve sexual arousal disorders evaluate treatment outcome

13) Three types of sexual dysfunction identified by Helen Singer Kaplan, which correspond to three stages of the sexual response include arousal disorders, orgasm disorders, and A) B) C) D)

Chapter 9: Cognitive-Behavioral Family Therapy

14) The assessment stage in the behavioral treatment of sexual dysfunction involves A) B) C) D)

scheduling a medical examination to rule out organic problems establishing goals for treatment conducting extensive interviews to determine the nature of the dysfunction all of these choices

15) Masters and Johnson tend to lump sexual problems into which category of problem A) B) C) D)

anxiety lack of motivation poor technique lack of information

9.2 Short Answer 1)

What is a ―functional analysis of behavior?‖

Describe the essential components of behavioral family assessment using Kanfer and Phillips’ SORKC model of behavior. Provide a case illustration of how this assessment model is applied.

What is a ―quid pro quo‖ contract?

Describe the principle components of behavioral parent training. Use a case example to illustrate your answer. How does the approach differ when applied to families with young children versus families with adolescents?

Explain the cognitive-behavioral view of resistance. How does it differ from the family systemic view of resistance?

Within the field of family therapy, behaviorists place the greatest emphasis on assessment and use the most formal and standardized procedures. List and discuss at least three advantages and three disadvantages of the behavioral emphasis on and techniques of assessment.

How is systematic desensitization used in the treatment of sexual dysfunction?

Explain how problems develop in a family from a cognitive-behavioral perspective.

What is the difference between automatic thoughts and schemas?

Chapter 10: Family Therapy in the Twenty-first Century

Chapter 10: Family Therapy in the Twenty-first Century 10.1 Multiple-Choice Questions 1)

Which of the following are prominent African American family therapists? A) B) C) D) E)

What percent of people in sex addiction programs are women? A) B) C) D)

pluralism constructivism feminism ethnocentrism

The feminist revolution in family therapy differs from the Milan or constructivist revolutions because it A) B) C) D)

structural theory experiential theory systems theory feminist theory

A relativistic perspective that emphasizes the subjective construction of reality, and implies that what we see in families is based as much on our preconceptions as on what is actually going on, is known as A) B) C) D)

10% 25% 40% less than 1%

Which of the following played a major part in the deconstruction of family therapy’s philosophical roots? A) B) C) D)

Laura Markowitz Nancy Boyd-Franklin Ken Hardy B and C All of the above

advocates a non-collaborative model of treatment is a more systemically-based approach has had a relatively minor impact on the field is theoretical and personal

Chapter 10: Family Therapy in the Twenty-first Century

C) Florida D) B and C E) all of the above 7)

Which of the following is not used in the study of brain functioning? A) B) C) D)

Which of the following did not identify himself or herself a collaborative, conversational therapist? A) B) C) D)

fMRI PET scan ERP EKG

Harlene Anderson Kenneth Gergen Lynn Hoffman Harry Goolishian

While the ________ influence in family therapy has led to increased humility about our theoretical models and less urgency to change or control people, some fear that its valueless relativism may lead therapists to collude with troubled families to deny their problems. A) B) C) D)

constructivist feminist psychodynamic multicultural

10) The dysfunctional family constellation which has been most commonly cited by family therapists typically blames the ________’s relationship with the children for family symptoms. A) B) C) D)

mother father grandmother grandfather

11) The archetypal family case of the overinvolved mother and peripheral father is best understood as the product of A) B) C) D)

intrapsychic issues in women societal forces men’s disillusionment with their careers all of these choices

12) Feminist and constructivist styles of therapy differ with respect to which notion? A) constructivists don’t advocate collaboration with the family B) feminists don’t advocate neutrality in their work with families C) feminists believe that all realities are created equal 38 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 10: Family Therapy in the Twenty-first Century

D) all of these choices 13) Another trend of the 1980s, in which many authors discussed how to do family therapy with specific types of problems and family constellations, was the trend toward A) B) C) D)

ethnic diversity increased specialization constructivism medical models of treatment

14) The ________ family therapists have expressed the greatest opposition to functionalism. A) B) C) D)

experiential constructivist Bowenian structural

15) Primary resources for many African American families are A) B) C) D)

the extended kinship system the church community A and B the Democratic party

16) Reflecting teams are used by which family therapists? A) B) C) D)

Bowen family therapists narrative constructive therapists structural family therapists Jay Haley and Cloe Madanes

17) What percent of people in sex addiction programs are women? A) B) C) D)

10% 25% 40% less than 1%

10.2 Short Answer 1)

What is a reflecting team? How does it work? What are the benefits to using a reflecting team in family therapy?

Under what category does DSM-V diagnose addiction to gaming?

Give one example of a presenting problem that should be viewed (conceptualized) differently if expressed by a middle-income white family versus a low-income minority family (African American, Latino, Asian, or Native American). Explain your reasoning. 39 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 10: Family Therapy in the Twenty-first Century

What is constructivism? Some would argue that constructivism’s profound impact on clinical theory and practice has been positive (e.g., therapists have become collaborators with the family in a kinder, gentler therapy). Others would argue that serious problems exist with using constructivism as a clinical foundation, that it leads therapists astray. Take one position or the other and defend your stand.

What is ―functionalism‖? Is the functionalist influence in family therapy now dead? Take one position or the other and defend your stand.

What factors are relevant in determining whether a therapist is equipped to treat a homosexual couple?

Why should a family’s ethnic culture be considered in assessment?

What’s wrong with saying that neurological events cause certain human actions?

What is wrong with the DSM-IV diagnosis: ―gender identity disorder‖?

Chapter 11: Tailoring Treatment to Specific Populations and Problems

Chapter 11: Tailoring Treatment to Specific Populations and Problems 11.1 1)

Multiple-Choice Questions The primary goal of the psychoeducational approach to treatment of schizophrenia is A) B) C) D)

In the section on relationship enrichment programs with of the following was not described as a critical skill for effective functioning as a couple? A) B) C) D) E)

structural psychoeducational psychodynamic behavioral

In addition to its use with families with schizophrenia, the psychoeducational model is purportedly applicable to the treatment of ________ as well. A) B) C) D)

internal family systems therapy medical family therapy solution-focused therapy psychoeducation

While the focus on problem resolution or cure has been family therapy’s trademark, these family therapists are advocating coping with serious psychopathology as a worthy goal. A) B) C) D)

Accommodation Boundary making Sexual compatibility Fun None of the above

The one-day ―survival-skills workshop‖ conducted with groups of family members is used in which treatment approach? A) B) C) D)

to cure the patient of schizophrenia to determine the family’s contribution to the illness to remove the patient from their family environment to maximize functioning and minimize relapse

family violence eating disorders bipolar disorder all of these choices

Medical family therapists believe that the field of family therapy has ignored the impact of ________ on family functioning. A) gender inequalities B) race relations 41 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 11: Tailoring Treatment to Specific Populations and Problems

C) transitions in the family life cycle D) chronic illness 7)

The primary structural problem in most single-parent families is A) B) C) D)

According to the ________ approach to treatment, family stress is thought to cause problems for schizophrenic members, but families don’t cause schizophrenia. A) B) C) D)

an enmeshed mother failure to accommodate rigid boundaries emotional cutoff from extended families

psychoeducation psychodynamic strategic structural

Primary resources for many African American families are A) B) C) D)

the extended kinship system the church community A and B the Democratic party

10) ________ family approaches have demonstrated considerable success in preventing the rehospitalization of schizophrenics. A) B) C) D)

psychoeducational experiential structural none of these choices

11) Research which focuses on the ________ family therapy is scarce. A) B) C) D)

effectiveness of process of therapeutic relationship in outcome of

12) Medical family therapists help families reorganize their resources and prepare to deal with a family illness by relying on their assessment of A) B) C) D) 11.2

onset and course of the illness stage in the family life cycle the family’s resources and degree of isolation all of these choices

Chapter 11: Tailoring Treatment to Specific Populations and Problems

According to the authors, what is the most common structural problem in single-parent families?

What is a ―survival-skills workshop?‖

According to Henggler and Boruin, what should be the number one focus of home-based family therapy?

What is expressed emotion and what role does it play in mental illness?

What is discernment counseling?

What is problematic about the DSM-IV diagnosis: ―gender identity disorder‖?

Chapter 12: Solution-Focused Therapy

Chapter 12: Solution-Focused Therapy 12.1 Multiple-Choice Questions 1)

Early in the development of solution focused therapy, all clients were given the same assignment, ________, in which clients are asked to observe what happens in their life/relationships that they want to continue. A) B) C) D)

The goal-setting process in solution-focused therapy emphasizes A) B) C) D)

long enough to make clients feel understood not at all long enough to define specific problems to be resolved as long as clients want to

Compliments are an example of A) B) C) D)

exception question miracle question scaling question none of these choices

Solution-focused therapists engage in problem talk A) B) C) D)

defining problems concretely defining simple problems not what clients want to stop doing but what they want to start doing exceptions

This question, used by solution focused therapists, is intended to circumvent clients’ global and unremitting perceptions of the problems and directs their attention to times in the past or present when they didn’t have the problem. A) B) C) D)

re-storying task invariant prescription family ritual formula first-session task

empathy positive reinforcement negative reinforcement alliance building

Solution-focused therapy focuses primarily on A) B) C) D)

cognition reinforcement history linguistics behavior

Chapter 12: Solution-Focused Therapy

Steve de Shazer’s term for someone who isn’t willing to work at changing is A) B) C) D)

Solution-focused therapy draws heavily on A) B) C) D)

customer client patient complainant

systems theory constructivism social constructionism social learning theory

Solution-focused therapists use ―scaling questions‖ to A) B) C) D)

quantify outcomes evaluate the success of sessions break change into small steps compare clients

10) Solution-focused therapy was adapted from A) B) C) D)

narrative therapy narrative solutions therapy emotionally focused therapy the MRI model

12.2 Short Answer 1)

List and describe three types of questions used in solution-focused therapy. Give an example of each. According to solution-focused theory, discuss how each facilitates client improvement.

What types of clients and client problems are best suited for solution-focused therapy and the MRI model of treatment? Are these approaches effective only with high functioning clients, or can they be used effectively to treat more serious problems (e.g., substance abuse, sexual abuse, personality disorders, or severe mental illness)?

How does the therapist’s role differ in a variety of different approaches (name or have students pick one or two) versus solution-focused therapy?

Does solution-oriented therapy ignore people’s pain (as some critics of the approach suggest) or does it facilitate clients’ positive experiences, which in turn empower them to change what is painful in their lives?

Chapter 13: Narrative Therapy

Chapter 13: Narrative Therapy 13.1 Multiple-Choice Questions 1)

In narrative therapy, families are asked about ________, times when they have had some control over the problem that have been obscured by their problem-saturated story. A) B) C) D)

The narrative technique of ________ enables family members to distance from their problem by externalizing it, and thus experiencing their control over the problem. A) B) C) D)

Bowen family therapists narrative therapists structural family therapists Jay Haley and Cloe Madanes

Unlike the cybernetic metaphor, which focuses on self-defeating patterns of ________, the narrative metaphor focuses on self-defeating ________. A) B) C) D)

identify the locus of the problem assess the function the problem serves for the family clarify the family’s power over the problem all of these choices

Reflecting teams are used by which family therapists? A) B) C) D)

creating self-leadership family rituals reauthoring the invariant prescription

Narrative therapy consists of a series of questions designed to A) B) C) D)

unique outcomes examples of self-leadership exceptions invisible loyalties

culture(s); emotion(s) cognition(s); behavior(s) emotion(s); cognition(s) behavior(s); cognition(s)

The narrative approach first founds its way into psychotherapy in the hermeneutic traditions in A) B) C) D)

Chapter 13: Narrative Therapy

According to narrative theory, therapists should not A) B) C) D)

Narrative therapists ________ problems in order to free the family and individual family members from blame. A) B) C) D)

take a collaborative, listening position with clients help people separate from the dominant cultural narratives consider the larger historical and political context search for flaws in the family system

re-story externalize prescribe reframe

According to narrative therapy, by maintaining a dominant story of their problems, family members fail to see ________ their problems. A) B) C) D)

the paradox in their contributions to exceptions to underlying causes of

10) The narrative school applied Michel Foucault’s ________ analysis of societies to an understanding of individuals and families as dominated by oppressive, internalized narratives. A) B) C) D)

political social psychological gender-based cultural

11) Narrative therapists search the family’s history for ________, in their efforts to separate them from their problems. A) B) C) D)

multigenerational patterns miracle outcomes sparking outcomes none of these choices

12) In order to fortify gains made in narrative treatment, ________ are organized to discuss how to facilitate the client’s success in countering the effects of their problem story. A) B) C) D)

nurturing teams reflecting teams multiple family groups none of these choices

Chapter 13: Narrative Therapy

relationship pattern, the narrative therapist must A) B) C) D)

prescribe it personify it ignore it and focus on unique outcomes ask the miracle question

13.2 Short Answer 1)

What is a ―reflecting team?‖ What are the benefits to using a reflecting team in family therapy?

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)?

Describe the technique of ―externalizing‖ and illustrate using a clinical example.

Is it necessary to reject systems thinking in order to practice a narrative approach? What might be some advantages and disadvantages of trying to incorporate systemic thinking into narrative therapy?

What is a ―unique outcome?‖

Define and give an example of each of the following narrative questions: deconstruction questions, open space questions, preference questions, story development questions, and meaning questions.

Chapter 14: Comparative Analysis

Chapter 14: Comparative Analysis 14.1 Multiple-Choice Questions 1)

The practice of family therapy has generally preceded ________; thereafter progress in the field typically proceeds in leapfrog fashion. A) B) C) D)

While theories may serve a political purpose and bias observations, they also A) B) C) D)

communications group behavioral structural

Which school tends not to incorporate systems thinking into their practice? A) B) C) D)

structural; experiential communications; Bowenian Bowenian; structural experiential; constructivist

Which school introduced the idea that families are systems--more than the sum of their parts? A) B) C) D)

prevent the artistic component of therapy from being expressed hamper beginning therapists from mastering the proven techniques in the field generally are developed before therapy can be practiced provide conceptual categories to organize observations in therapy

Cognitive-behavioral and strategic therapists tend to emphasize the technical role of the therapist, while ________ and ________ therapists stress the artistic side of the person. A) B) C) D)

politics theory technique science

Milan Bowenian behavioral structural

During the 1970s, most family therapists tended to overestimate the homeostatic forces in families and underestimate their flexibility and resourcefulness--except whom? A) B) C) D)

Chapter 14: Comparative Analysis

Though many schools of family therapy believe that the real problem in many families is some form of underlying family pathology, ________ family therapists deny that underlying dynamics are the cause of symptomatic behavior. A) B) C) D)

While intrapsychic conflict is an inferred psychological concept, ________ is an observed interactional concept. A) B) C) D)

strategic structural Bowenian all of these choices

mystification developmental arrest structural pathology none of these choices

The ________ model of mental disorder, which proposes that an individual develops a disorder when a genetic weakness is sufficiently stressed by an event in the environment, is supported by Bowen theorists and psychoeducational therapists. A) B) C) D)

diathesis-stress general systems object relations none of these choices

10) The concept of ________ describes how when two people are in conflict, the one who experiences the most anxiety will triangle in another person. A) B) C) D)

cross-generational coalitions pathological need complementarity pathological triangles all of these choices

11) Action and insight are the primary vehicles of change in family therapy. The ________ school emphasizes behavioral change and eschews insight as a medium for change. A) B) C) D)

behavioral strategic psychodynamic experiential

12) A primary goal of communications family therapy is to A) B) C) D)

interrupt dysfunctional feedback loops promote individuation of family members reinforce symptoms foster insight

Chapter 14: Comparative Analysis

effective for families than unsupervised change at home. A) B) C) D)

Bowenian structural strategic A and B

14) While most schools of family therapy believe that families are notoriously resistant to change, ________ therapists minimize the importance of resistance. A) B) C) D)

strategic experiential narrative structural

15) One variation of the patient-therapist relationship is exemplified by this model which instructs its therapists to empathize with a family’s predicament while also empowering them to use their own strengths to find solutions, from a position of partnership. A) B) C) D)

solution focused Milan communications A and B

16) The use of ________ is designed to block or change dysfunctional behavior using indirect, seemingly illogical means. A) B) C) D)

therapeutic double-binds paradox directives all of these choices

17) Though most family therapists invite everyone living under the same roof to the first session, members of this school do not insist on seeing the entire family. A) B) C) D)

MRI structural behavioral A and C

18) Teams of observers positioned behind a one-way mirror are most commonly used by ________ family therapists. A) B) C) D)

experiential behavioral Bowenian strategic

Chapter 14: Comparative Analysis

A) B) C) D)

structural Bowenian solution-focused MRI strategic

20) While the broad goals of many family therapy schools are to solve presenting problems and to reorganize families, the primary aim of ________ therapists is to reorganize families. A) B) C) D)

experiential strategic behaviorists structural

21) The only integrative approach to explore intrapsychic processes is the A) B) C) D)

externalization model solution-focused model integrative problem-centered metaframeworks therapy narrative-constructive model

22) Bowen’s notion of triangles, Haley’s focus on hierarchical control, and Minuchin’s concept of boundaries represent examples of the metaframework, A) B) C) D)

sequences internal processes development organization

23) The clinical application of metaframeworks is centered around the practice of ________ rather than finding deficits. A) B) C) D)

externalizing the problem detriangling releasing constraints shifting cognitive constructions

24) Integrative problem-centered metaframework therapists A) B) C) D) E)

have conversations with families about potential constraints collaborate with family members to form hypotheses use a reflecting team to help re-story the family problem B and C A and B

25) ________ therapists take the position that the simplest and least expensive intervention should be tried before using more complex and expensive treatments. A) integrative problem-centered metaframeworks therapy B) narrative solutions therapy C) integrative couple therapy 52 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 14: Comparative Analysis

D) none of these choices 26) The narrative solutions approach combines the insights of ________ with narrative techniques. A) B) C) D)

experiential therapy structural therapy Bowenian theory MRI’s model

27) The narrative solutions approach revolves around the concept of ________, which assumes that people have strong preferences for how they would like to see themselves, and be seen by others. A) B) C) D)

externalizing the problem preferred views emotional reactivity Self leadership

28) Jacobson and Christensen’s integrative couples therapy adds what element to traditional behavioral couples therapy? A) B) C) D)

a functional analysis of behavior narrative reconstruction acceptance communications training

29) In contrast to traditional behavioral therapy, integrative behavioral couple therapy emphasizes A) B) C) D)

insight emotional experiencing accountability support and empathy

14.2 Short Answer 1)

How does the therapist’s role differ in narrative versus structural therapy?

Choose a client with whom you have worked individually whose family history and situation you know fairly well. Briefly describe the presenting concern(s), your original case conceptualization, and the general therapeutic approach you took with this person. Then, discuss in some detail how you could conceptualize the client’s problem and situation from a family systems perspective. Include your assessment of life-cycle stage and of important family dynamics. Finally, describe the family systems approach that you could have taken with this client, how your role, strategy, and techniques would have differed, and what differences in outcome could be expected.

Chapter 14: Comparative Analysis

family, whom you will be seeing for the first time today. Sue, 36, and Tom, 39, present for an initial consultation along with their two children-- Alice, 15, and Ted, 7. Sue does most of the talking, while Alice sits slumped in her chair with a sullen look on her face. Ted looks anxious and stays close to his mother. They have come because Sue is concerned about her children. Alice’s school performance has been deteriorating over the past year; she has gone from a ―B‖ student to a ―C‖ student. She also stays out late many school nights and fights constantly with her parents. Ted has refused to attend school for the past two weeks because, according to Sue, he is afraid of the other children. Tom is not very involved in the raising of the children. He travels frequently on business, and when he’s home, he goes out at night by himself. A.

How might the Sanders’ problems be conceptualized from a family life cycle perspective (i.e., Carter & McGoldrick, 1999)? Feel free to speculate about the possible causes of the problems presented by the family. (1/3 of total points)

Take any one of the theoretical perspectives discussed in the text and describe, from that orientation, how you would work with members of the Sanders family and why. Include expected goals and time frame for treatment, and the strategy and techniques you would employ in treating them. Be specific about how your plan could be suited to the needs of this family. Use only one theoretical approach (even though, of course, many are possible), and support your approach as the treatment of choice. (2/3 points)

Some would argue that there is a radical divergence between the family systems therapies and the more traditional individual psychotherapy approaches. Others would challenge this view, arguing that there are many points of similarity and that the differences are exaggerated. Take one position or the other and defend your stand.

Compare and contrast the strategic and structural approaches. Consider theoretical elegance; specificity of constructs, strategy, and technique; role of the therapist; and types of client problems best suited for each approach.

Compare and contrast the Bowenian and experiential approaches. Consider theoretical adequacy; specificity of constructs, strategy, and technique; role of the therapist; and types of client problems best suited for each approach.

A 37-year old woman who is unhappy with her marriage of 5 years is considering divorce and seeks consultation with you. She has lost 3 pregnancies in the past 3 years. Her 45-yearold husband avoids sex, even though he states he is ―not unwilling‖ to have a child. He is not interested in psychotherapy but might be willing to come in once or twice to see what it’s like.

Discuss how you would approach this case from a systems framework. Be specific about your rationale, the theoretical constructs you would employ, and the recommendation you would give her. Recommend only one approach (even though of course many are possible), and support your approach as the treatment of choice. 54 Copyright © 2021, 2017, 2013 Pearson Education, Inc. All Rights Reserved.

Chapter 14: Comparative Analysis

Which schools of family therapy rely most heavily on paradox. Describe two types of paradoxical techniques. What type of families and family problems might best be treated with these techniques? Discuss the problems associated with the use of paradoxical techniques in treating families.

Explain the goals for an initial telephone contact with a family member, from a family therapy perspective. How might a family therapist attempt to convert a request for individual therapy into a family case?

10) Why and how should a family’s ethnic culture be considered in assessment and treatment? (Pick at least one ethnic minority culture discussed in class and use the Sanders case--#3 above--on which to base your answers.) Be specific and thorough in your answer. 11) Give three examples of presenting problems that should be viewed (i.e., conceptualized) differently if expressed by a middle-income heterosexual couple and their family versus a middle-income gay or lesbian couple and their family. Explain your reasoning. Be specific and provide examples to support your answer. 12) Choose one family therapy approach studied this quarter and critique it from a feminist perspective. Discuss theoretical constructs, strategies and techniques, and role of the therapist. 13) List and give an example of at least four of Eron and Lund’s guidelines for managing helpful conversations within their narrative solutions approach. 14) What’s new about Jacobson and Christensen’s integrative couple therapy? How does the approach differ from traditional behavioral couples therapy? 15) Discuss at least three similarities between integrative couple therapy and Bowen family systems therapy. 16) Describe and give examples of how communication training is used in integrative couple therapy.

Chapter 15: Research on Family Intervention

Chapter 15: Research on Family Intervention Short Answer/Essay 1.

Discuss some of the difficulties encountered in researching the process and outcome of family therapy. Consider samples, instruments, designs, ethics, etc.

Choose one of the following theoretical concepts. Define the concept, then describe an original research program (one or more studies) that you believe would confirm or disconfirm the validity of the concept for understanding families or family therapy. (For example: ―If x is correct, then one should expect x to predict y in the following situations and x to be independent of y in the following situations.‖) Include: rationale for the study, operational definitions/measurement of variables, description of the sample. hypotheses, and limitations. a. b. c. d. e. f. g. h.

differentiation of self therapeutic double bind enmeshment/disengagement triangles homeostatis functionalism pseudomutuality multigenerational transmission of psychopathology

Does family therapy work? Take a position for or against and cite empirical support for your position.

What do we know about the process of family therapy? Base your answer on the available empirical evidence regarding the process of family therapy. Discuss what is not yet understood about the mechanisms of change in family treatment and suggest 2 or 3 directions for future research.

Discuss the empirical evidence supporting the effectiveness of family treatment. For which family problems has it been shown most effective? For which problems is it less effective? Cite relevant research in your responses.

Discuss three types of empirically-supported family treatments for child behavioral disorders.

Describe an empirically-validated treatment for adolescent drug abuse.

Which types of couples generally do best in couples therapy?

Answer Keys

Answers Keys

Multiple Choice Answer Key Chapter 1. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 29. 20. 21. 22. 23.

B D A B B B D B C C B B D A B D D A B D B A D

Chapter 2. 1. 2. 3. 4. 5. 6. 7. 18. 9. 10. 11. 12. 13. 14.

A D D B C B B C D B D C D B

Chapter 3. 1. 2.

Answers Keys

3. 4. 5. 6. 7. 8. 9.

C B B A C D D

Chapter 4. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

E D B C C D B A D B B C D B D A D D D

Chapter 5. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Answers Keys

17. 18. 19. 20. 21. 22. 23.

D D B B D C B

Chapter 6. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

D B B A D D B D A B D B D A D B D

Chapter 7. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Answers Keys

19. B 20. B Chapter 8. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

C D A C B B D A B C D C D A D A B

Chapter 9. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

B D D A B C D C D A B B C D A

Chapter 10. 1. 2. 3. 4.

Answers Keys

5. D 6. A 7. D 8. B 9. A 10. A 11. B 12. B 13. B 14. B 15. C 16. B 17. B Chapter 11. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

D C D B C D A A C A B D

Chapter 12 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

D C A A B A D B C D

Chapter 13. 1. 2.

Answers Keys

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

C B D A D B C A D A B

Chapter 14. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

B D D A C B A C A D B A B C A D D D B D C D C E A D B C D