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Basic Techniques of Family Therapy

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Title: Basic Techniques of Family Therapy


1
Basic Techniques of Family Therapy
  • PSY 660 Seminar in Family Therapy
  • Dr. Katz
  • by Anna Veprinsky

2
First Contact
  • Overview the presenting problem
  • Identify all involved
  • Family members
  • Referral source
  • Others who might be involved with the problem
  • Family therapy vs. Individual therapy
  • Want to hear everyones point of view
  • Reminder call ? no show rate

3
Goals of the First Interview
  • Create an alliance
  • Form a hypothesis
  • Tentative hypothesis should be developed during
    the initial contact with the family (e.g., during
    scheduling of the first session)
  • During the meeting, be ready to refute, not just
    confirm, your hypothesis

4
First Interview Step-by-Step
  • Introduce yourself to the contact person and then
    to other adults
  • Ask adults to introduce their children
  • If there is any equipment in the room (e.g.,
    one-way mirror, video camera, etc.), explain its
    purpose
  • Sessions length and purpose
  • Tell what you know about the issue and ask
    everyone to give their perspective

5
Volatile Families
  • To create a stable and calm environment, ask each
    family member to talk one-at-a-time
  • It is OK to raise your voice, get up and use
    gestures to quiet everyone down when the family
    acts out of control
  • This is not considered impolite in such
    situations
  • Family members who tend to be quiet might need to
    be drawn into the conversation
  • e.g., ask them a question

6
Good Therapy
  • New therapists tend to avoid uncomfortable
    situations by making a small talk or avoiding
    certain topics Passive therapy is not a
    solution
  • This will not lead to anything good
  • Good therapy involves active intervention,
    acknowledgement and respect of clients ideas
  • If you follow these rules, clients are more
    accepting of challenges you present to them
  • Dont just focus on presenting problem
  • Talk about interests and accomplishments
  • Human beings are three-dimensional

7
Gathering Information
  • Some therapists make use of family history and
    genograms
  • Diagrams that describe extended family relations
  • Unlike family tree, genogram includes medical
    history and other factors relating to the issue
    at hand
  • Forming hypotheses about the presenting problem
  • What have you tried to resolve the problem?
  • Observe family interactions

8
Gathering Info. (cont.)
  • Two important kinds of information
  • Solutions that dont work
  • Attempts may be part of the problem
  • Example Overinvolved parents inconsistency
    giving up too quickly
  • Transitions in the life cycle
  • Adjusting to changes in the family
  • Birth of a child
  • Child moving away to college
  • Changing jobs
  • Moving to a new neighborhood

9
Successful Therapy
  • Focus on the familys strengths
  • What have these people done well?
  • What are they goals for the future?
  • What techniques have worked well in the past?
  • What is each persons greatest success?
  • When therapist has no experience in the
    presenting problem
  • Remain curious and respectful of the described
    predicament
  • Dont jump to conclusions

10
Suggesting Treatment
  • This is done after
  • Meeting with the family
  • Understanding family context
  • Formulating a hypothesis about what needs to be
    done
  • Therapist might consult another professional or
    suggest no need for treatment
  • Making recommendations
  • Usually at the end of the first interview
  • Sometimes, after 2-3 sessions

11
Treatment Contract
  • Acknowledge the family on coming in and indicate
    that you can help
  • Agree on
  • Meeting time
  • Frequency and length of sessions
  • Who will attend
  • Presence of a third party or videorecordings
  • The fee
  • Handling insurance
  • State your openness to criticism and importance
    of everyone coming to meetings
  • Emphasize family goals and strengths you observed
    during the meeting (e.g., reinforce the family)

12
The Early Phase of Treatment
  • Refine hypothesis into a formulation about what
    maintains the problem and how to resolve it
  • Shift from alliance to challenging actions and
    assumptions held by the family
  • Figure out what needs to change and push for
    those changes
  • Pushing for change why do people risk change?
  • Relentless commitment to make things better
  • Maintain therapeutic alliance
  • Listen to and acknowledge clients point of view

13
Bringing Interpersonal Conflict into the Room
  • Voluntary visit
  • Couples in conflict or parents feuding with
    their children will speak up about their
    disagreements
  • Visit due to referral
  • …begin addressing the familys problem with the
    outside agencies
  • Example How must the family change to resolve
    their conflict with these authorities?

14
One family member problem
  • When one family member is presented as the
    problem, the therapists goal is to learn how
    other relate to the problem
  • What role do others play in creating the problem?
  • How have other family members responded to the
    presenting problem?
  • When one family member identifies him-/herself as
    the problem
  • The therapist might ask who contributes to the
    problem or who helps in resolving the problem

15
Challenging the System
  • Goal of the challenge is to broaden the problem
    to interactional one
  • See the problem as co-maintained by the
    participants in the family system
  • When challenging stagnant/negative interaction
  • Point out patterns that prevent the interaction
    from moving forward
  • Client(s) may ask for a suggestion
  • Not providing one creates tension and leads to
    looking for other sources to resolve the issue

16
Challenging the System (cont.)
  • Solution-focused alternative
  • Lead the family in the right direction by asking
    about successful strategies that have worked in
    the past and encourage more of such resolutions
  • Never stop listening to feelings and points of
    view

17
Homework
  • Purpose of homework is
  • Test flexibility (willingness to change)
  • Increase awareness of each family members role
    in the problem
  • Suggest new ways of relating to each other
  • Dont assign HW that is likely to generate
    conflict
  • Point of HW is to try something different

18
The Middle Phase of Treatment
  • Primary focus is on helping family members
    express themselves and achieve mutual
    understanding
  • Therapist takes a less active role
  • Step back and observe the family interaction
  • Addressing conflicts directly may lead to anxiety
  • Anxiety prevents listening
  • In this case, the therapist might ask family
    members talk though him/her

19
Maintaining Therapeutic Alliance
  • Four attitudes
  • Remaining calm --- conveys confidence
  • Being curious --- showing genuine interest
  • Empathy
  • Instead of saying, I understand, ask client to
    elaborate on the abstract topic
  • Sometimes, you might understand a part of the
    situation
  • Acknowledge understanding that part, but ask to
    explain the issue you do not understand (ex. man
    hitting his wife understand anger but not the
    physical response)
  • Respect --- Being honest with the client

20
Termination
  • Brief therapy --- as soon as the presenting
    problem is resolved
  • Psychoanalytic therapy --- may last for years
  • For the majority of us
  • When family feels they have achieved their goal
  • Therapists sense that treatment reached the
    point of diminishing returns --- the unit of
    change becomes meager
  • Family visits result in small talk and nothing is
    done

21
Termination (cont.)
  • Family therapy is a learning process
  • Thus, termination focuses on what the family has
    learned when it comes to their interaction with
    one another
  • Ask clients to anticipate future difficulties and
    ask them how they would deal with those
  • In few weeks after termination, check with the
    family to see how they are doing
  • Letter
  • Phone Call
  • Brief follow-up session

22
Family Assessment
  • The presenting problem
  • Although families come in with specific questions
    and want you to provide them with answers, most
    have developed a strategy dealing with the
    problem and tend to repeat this strategy
    regardless of its flaws
  • Stress ? Anxiety ? Rigid Thinking
  • Explore the presenting problem
  • Inquiry should be detailed and empathetic
  • Each family members shall present his/her view
    point and perspective that is acknowledged by the
    therapist
  • Ask detailed questions to understand the precise
    nature of the problem
  • Haley Family therapy is not about solving the
    problem its about repairing the problem-solving
    mechanism

23
Family Assessment (cont.)
  • The goal of questions is not to get more details
    about the problem but
  • To see familys beliefs about what the problem is
    and who has it
  • Moving from intrapsychic to interpersonal
  • Helpful questions
  • Respect for family members feelings and
    skepticism that the problem resides within one
    individual
  • Discover underlying layers
  • Invite new ways of seeing the problem and family
    in general

24
Family Assessment (cont.)
  • Unhelpful questions
  • Accept things as they are described and focusing
    on the individual presenting the problem
  • Next, explore familys attempts to deal with the
    problem
  • What have they tried?
  • What has been helpful? What hasnt been helpful?
  • Has anyone else besides the members present tried
    to help?
  • The therapist may discover what perpetuates the
    problem
  • Circular thinking problems are sustained by an
    ongoing series of actions and reactions

25
Things Influencing Therapeutic Success
  • Is familys participation voluntary or not?
  • What does the referral source expect to gain?
  • Do all family members recognize the need for
    treatment?
  • Previous treatment
  • How did it go?
  • What did they work on?
  • What did they discover?
  • Is anyone currently in treatment?

26
Things Influencing Therapeutic Success (cont.)
  • When formulating a case, understand possible
    changes in the family dynamic
  • Why did the family decide to attend therapy now?
  • Family structure
  • Identify subsystems (e.g., who is with whom)
  • Boundaries (e.g., what is allowed)
  • Triangulation (e.g., two against one)
  • Example sibling rivalry
  • Enmeshed families
  • Disengaged families

27
Things Influencing Therapeutic Success (cont.)
  • Teach family members to listen to each other
  • This does not guarantee an immediate resolution
    of a conflict, but the relationship stays
    stagnant without this skill
  • Before conducting talk therapy
  • Address the question of substance abuse using
    specific straightforward questions
  • Do you feel you are a normal drinker?
  • How many drinks a day do you have?
  • Do you ever drink before noon?
  • Has your drinking ever created problem between
    you and other family members?

28
Things Influencing Therapeutic Success (cont.)
  • Gender roles
  • Generally, one partner presses for more closeness
    (pursuer) while the other one pulls away
    (distancer) pursuer-distancer dynamic
  • Gender socialization
  • Influence of family dynamics (e.g., families the
    partners grew up in)
  • Cultural factors
  • Developing cultural sensitivity leads to trust as
    the therapist shows genuine interest in learning
    about the familys culture
  • Take one-down position --- ask clients to teach
    you about their experiences and traditions

29
Ethics
  • AAMFT
  • When working with families, therapist should not
    disclose any information of one family member to
    the rest without that persons consent
  • Relationship of the therapist to each family
    member should be stated clearly in the beginning
    of the therapeutic relationship
  • Always provide referral do not abandon or
    neglect the client

30
Ethics (cont.)
  • When facing a dilemma, use your judgment
  • Two questions
  • What would happen if the client or important
    others found out about your actions?
  • Can you talk to someone you respect about what
    youre doing or considering?

31
Ethics (cont.)
  • Red Flags
  • Specialness of the case
  • Attractive
  • Alterations in the therapeutic frame
  • Ex. Excessive self-disclosure
  • Violating clinical norms
  • Ex. Not referring someone to a specialist when
    necessary
  • Professional isolation
  • Failing to discuss your decisions with
    professional colleagues

32
Partner Violence
  • Prevailing paradigm
  • Assign the offender to anger management or
    batterer intervention program
  • Refer partner for a treatment in a battered
    womens group
  • Argument for seeing violent couples together
  • Violent men can recognize emotional triggers
  • Their partners can recognize the danger signals
    and thus ensure their own safety

33
Partner Violence (cont.)
  • Two types of partner violence
  • Patriarchal terrorism
  • Violence is used to exercise control over the
    partner
  • Frequent, severe, tends to escalate over time
  • Common couple violence
  • Response to a particular conflict
  • Likely to be mutual
  • Infrequent
  • Tends not to escalate

34
Partner Violence (cont.)
  • Meet with the partners together to see them in
    action
  • Then, meet with each separately to check for any
    missing information
  • To form an alliance with both partners, convey
    respect for them as persons
  • To assess the level of violence, you need to ask
    direct questions
  • How often do conflict lead to violence?
  • When did the most recent event occur?
  • You need to learn if there have ever been any
    injuries, if weapons were ever used, and if the
    woman currently afraid

35
Partner Violence (cont.)
  • When providing treatment, establish zero
    tolerance for violence
  • Make treatment contingent on no further episodes
    of physical aggression
  • Encourage the couple taking turns talking through
    therapist
  • Avoid emotionality --- ask for specific, concrete
    details
  • Start with the last violent episode
  • Be alert for linguistic evasions
  • Double agenda
  • Hold the man accountable for his actions
  • Try to understand him in complex and sympathetic
    terms

36
Partner Violence (cont.)
  • When both partners accept responsibility for
    their actions (e.g., controlling violent impulses
    and ensuring ones safety), explore relationship
    issues that lead to escalating emotional
    reactivity
  • Bring relationship into consulting room ---
    encourage dialogue
  • This allows the therapist to see what is going on
    and direct both partners towards a more
    appropriate behavior
  • Couples are taught more constructive ways of
    addressing their differences

37
Mandated Report
  • When there is a suspicion of domestic violence
    and child abuse
  • Meet with each family member separately to
    investigate your suspicion further
  • Most states require therapists to report any
    suspicion of child abuse (CA is one of them)
  • Symptoms of child sexual abuse include
  • Contact child protective agency
  • Overly sexualized behavior
  • Regressive behavior
  • Suicidal thoughts
  • Running away
  • Sleep disturbance
  • Encopresis or enuresis
  • Appetite disturbance
  • Sudden unexplained
  • changes in behavior

38
Child Sexual Abuse
  • Primary goals
  • Ensure that the abuse does not recur
  • Reduce long-term effects of the trauma
  • Two categories
  • Child protective approach
  • Undermines family integrity
  • Family systems approach
  • Fails to protect the child
  • Therapist should try to work both with the child
    and the family, but when there is incompatibility
    between goals, child safety has to prevail

39
Child Sexual Abuse Before Treatment
  • Any discrepancies between the stories should be
    resolved by social and legal agencies
  • Restrict unsupervised access to children for the
    offender
  • Assess other possible incidents of abuse
  • Offender must take responsibility for his actions
    and receive appropriate treatment for his actions
  • This might have already been done by child
    protective services

40
Child Sexual Abuse Treatment
  • Multimodal approach includes individual, group,
    and family sessions
  • Family sessions focus on increasing support for
    the child
  • When the offender is sent to jail, therapist
    helps the family draw a boundary excluding that
    person
  • If reunion is planned, boundaries are gradually
    reopened
  • Providing a choice
  • Talking about the abuse during conjoint vs.
    individual sessions
  • Client decides when they are ready to talk about
    it
  • Help them recover a sense of control

41
Child Sexual Abuse Treatment (cont.)
  • When talking about complex and contradictory
    emotions, using metaphor of parts of the self
    helps
  • Ex. Does part of you think your mother should
    have figured out what was happening?
  • Individual sessions with the child have a flaw
  • They create secrets
  • Thus, ask the child what can be shared with the
    family and how he/she would like to do it
  • A child might ask the therapist to take a lead in
    opening up the discussion because they want to
    talk about it but find it hard to talk about

42
Managed Care
  • Learn to collaborate effectively with managed
    care
  • Case managers may also become great source of
    referral
  • Managed care companies accept licensed
    practitioners with graduate degrees
  • Can managers prefer practitioners who
  • Accept crisis referrals
  • Work with difficult cases
  • Are accessible
  • Have specialized expertise

43
Managed Care (cont.)
  • Managed care companies maintain databases
    including such information as average number of
    sessions
  • Outliers are warned and referrals tend to
    decrease
  • Maintaining good relationship
  • Provide clear treatment plan
  • Dont lose your temper
  • When cant reach an agreement, follow the
    grievance procedure
  • Do the require paperwork and submit it on time

44
Discussion Questions
  • You get a referral with the colleague saying this
    is the most difficult case they have ever seen.
    Do you take it?
  • You get a phone-call in the middle of the night.
    The woman whispers that her husband is drunk and
    she worries for her safety and safety of her
    children. What do you do?
  • What to do if you notice signs of sexual abuse
    but not 100 sure about it?
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