Orienting Questions: System's Thinking Couple and Family Therapy

Question 1

What are some models that have proven family therapy to be effective

Answer 1

Johnson (Emotionally Focused Treatment, Functional Family Therapy (Sexton), Multisystemic Family Therapy (Henggler, Bourdain & Brunk), Eco-Systemic Family Therapy (Jones & Lindblad-Goldberg), and Gottman’s Couple Therapy

Question 2

Why was CBT shown to be effective at first

Answer 2

was during the jump in the medical model, and CBT was measurable
-Got a jump start because it was quick and measurable which people looked for in healthcare

Question 3

Difference between evidence based therapy and evidence supported practice

Answer 3

-Evidence Based Therapy is the strict of the strict, there is a manual for a certain population, and we can randomized controlled trials

-Evidence Supported Practice (ESP) is just that there are theories behind what you are doing and evidence behind it as well
-A way to practice with unique cases that had a lot going on

Question 4

What happened in the early 1980s with Family and Couple Therapy

Answer 4

-Couple and Family Therapy was more complex, in regard to determining what was successful in treatment.
-But, once researchers began to understand how to study family therapy, the data has consistently been positive.

Question 5

What did Gurman and Kirshen find

Answer 5

-MFT is efficacious and FT is often more effective or as effective an individual when the problem is attributed to a family conflict.
-Both behavioral and non-behavioral were superior (2/3) to no treatment

Question 6

What did Shadish, Ragsdale, Glaser, and Montgomery find?

Answer 6

-during met-analysis found that the effect size for couples and family therapy was comparable to other psychotherapy modalities.
-Family was at least as effective as individual, but, some studies showed superior treatment for individual children with conduct problems.
-Couples therapy shows to be a little bit less effective, because often times people do not want to always be there

Question 7

Pinosf and Wynne research?

Answer 7

-Their research from 1995 concluded that sufficient data exists to support that family therapy is effective and
-There is no evidence of family therapy causing harm

Question 8

What are the four primary common factors in family therapy

Answer 8

Conceptualizing the problem in relational terms, Disrupting Dysfunctional Relational Patterns, Expanding the direct treatment system, and Expanding the therapeutic alliance

Question 9

explain conceptualizing the problem in relational terms

Answer 9

-Rather than saying Tom is depressed, saying there is something happening between people that is causing Tom to be frustrated
-Other factors that may not be causing the problem, but you cannot separate from the problem
-This position stands in sharp contrast from the premise that problems exist in the person (DSM)
-Relational often works when the problem is viewed from a relational lens (Davis & Piercy, 2007)
-Problems, as dealt with by most models, are seen as patterns learned in family of origin and are then seen by cognitive, affective and behavioral aspects that drive the current maladaptive cycle.

Question 10

explain disrupting dysfunctional relational patterns

Answer 10

-How do individual therapists disrupt patterns?
-Anything that reduces a dysfunctional, ongoing pattern is something effective psychotherapy-wise
-Many people do not realize that they are stuck in an ongoing loop, until it is pointed out to them
-All of the fully empirically supported relational models have some technique to disrupt dysfunctional interpersonal patterns.
-Family therapists are serving the system, typically do not have close relationships with individuals like in individual therapy

Question 11

explain expanding the direct treatment system

Answer 11

-One learns more about the patient system, specifically the interpersonal factors
-The therapist gains a better alliance with multiple members for the “in person” aspects
-Bringing in the people that you are talking about, instead of just hearing about the unsupportive boyfriend, bring him in
-In order to bring people in, you have to come to a clear agreement about what will be shared with the people you are bringing in; treatment will not be successful if there are secrets, people have to be open, Browning has people sign a consent form that secrets cannot happen and if they do he will talk about it with everyone or have the person share it themselves
-Meet individually or in subsystems, have to make it clear that if something that is shared that is toxic to the entire family, he cannot be held to keep that information

Question 12

what can be the results of expanding the direct treatment system

Answer 12

-The collective observing ego is more likely to have strong empathy if more people understand what is happening
-A transforming break-through is more likely when it occurs in the presence of many others.
-The problem-maintaining structure is easier to determine when one sees it in action.
-Whether dealing with the larger system directly or indirectly, the breaking of dysfunctional patterns in consistently mentioned as useful.

Question 13

explain expanding the therapeutic alliance

Answer 13

-Important for all therapies
-Multiple alliances happening, alliances within the system and also therapist’s alliances with others in the system

Can be a Two edged-sword
-Not all alliances are equally important
-Have to have some sort of alliance with everyone, have to at least respect each person’s position
-The issue of multiple alliance is not well researched

Question 14

explain practical application of the common factors

Answer 14

-What is the function of the problem in the family?
-Is there a pattern that can be interrupted or altered?
-Whom might I invite to treatment?
-How do I keep some alliance with all, but not be too overly aligned with anyone (unless this is an intervention in itself)?

Question 15

how does family therapy differ from individual

Answer 15

-Focus
-Number in the room
-Confidentiality
-Reducing negativity in the room

Question 16

How to reduce negativity

Answer 16

Always keep on the lookout for the negative energy increasing. If so:
-Reframe
-Move to process
-Sub-system
-Information through you
-You become the script-writer (Dan Wile)

Question 17

explain reframe primer

Answer 17

A reframe is an alternate perspective, that is not a trick, but, in fact, is equally possible. You, the clinician, need some evidence that your alternate perspective (the reframe) might be equally true.
-When you give a reframe, you should have some evidence to support the reframe
-Pose it as a possibility
-Be careful when reality testing is at play
-“While you say your mom never supports you, is it possible she is not sure what would even be supportive to you? You mentioned that she has no idea what nursing training even involves.”

Question 18

explain moving to process

Answer 18

-The two family members are caught in a back and forth about a topic that no one will be right. You move to reflecting on their relationship.
-Nice part of systems work, you can leave the content behind, even though you two disagree you care so much about the person that you care enough to hear the other’s perspective

-Any time you go from content to process you are almost always going to lower the temperature in the room
-“You two have found a topic that guarantees that neither one of you will ever win the argument. You two have fundamentally different ideas of what “being responsible” is. But notice how much you want the other to respect your opinion. There is a strange closeness that comes from desperately wanting the other to acknowledge your view.”

Question 19

explain becoming a scriptwriter

Answer 19

-Each family member disqualifies the opinion of the other over and over.
-Ex. You are working with a couple and know the two are mad at each other, the guy feels like the woman needs to know he cares about her but is not showing affection; you stop her and say I think what he is trying to say is…. “in your family no one really hugged, no one showed affection, you do care, but you are not sure how to show it”
-As you do it, you glance at the guy and see if you are getting it right
-You are putting the words in, and you are constantly checking in to make sure you are getting it right

“I suspect that Tom is saying that he really wants you to trust that he is taking your concern seriously, but since he doesn’t say it exactly the way you want, you don’t believe him. Is that true, Tom, you do understand why Larry is worried about your behavior at work?”

Question 20

explain circular causality

Answer 20

problems are sustained by an ongoing series of actions and reactions, and one need not return to the first cause.

Question 21

explain equifinality within different models and family therapy

Answer 21

there are multiple ways to get to the same end
-You can do different techniques to get to the same end point of success

Question 22

is family therapy group therapy

Answer 22

-NO
- Distorted perception within a family
- Strangers
-Short History
-Revealing is easier to strangers
-Less fallout
-Everyone is equal

Question 23

explain cybernetics

Answer 23

through the process of feedback loops, a system is self correcting.

Question 24

explain homeostasis within family therapy

Answer 24

-tendency towards an equilibrium, if a change occurs, drift back to homeostasis
-Both right and wrong, in early family therapy it was with very dysfunctional families so it was believed that we have to do crazy intense interventions to blow the entire family up and then rearrange it
-This is not always wrong, but there are often times families that are not this dysfunctional and it could just be a minor push that creates change, homeostasis says that this is not possible, but this is not true
-Can be helpful, but not an equal factor across all families
-A family that has low levels of homeostasis is easier to change, not so caught in the idea that this is how we function

Question 25

teological vs. mechanistic

Answer 25

-Teleological thinking (outside—in) (think systemic) does not rule out Mechanistic thinking (inside—out)

-Just because there is a mechanistic thing does not mean you can think about it in systemic terms
-They can both exist, not mutually exclusive
-Behavior may serve a systemic function and still be biological (e.g. bedwetting)

Question 26

explain Donald Jackson’s researchwith individuals in therapy

Answer 26

Patients are losing their positive growth when they are returned to their families.
-Individuals in individual psychology, helped generate the idea that there must be systems issues at work

Question 27

explain the Bateson group

Answer 27

Haley, Satir, and Weakland
-Researchers, examining the role of family interaction.
-These people wrote a pivotal article (Toward a Theory of Schizophrenia. 1956)
-The article is wrong, but it got a lot of people thinking about what is happening in the schizophrenic family

Question 28

what was wrong with the Bateson article

Answer 28

It is wrong because it established the idea of a double bind
-Double bind: two types of communication (verbal and non-verbal) and they clash
-Ex. Son goes to hug mother, mother freezes and he puts arms down, “you do not want to hug your mother?”

It didn’t cause schizophrenia, this is where they made the mistake
-They were correct there is something in going on in this family that causes communication issues and double binds; but double bind does not cause schizophrenia
-Got people thinking about what is communication and how it affects family, can we use better communication and help these families to become healthier

Question 29

what happened with family therapy in the late 1950s and early 1960s

Answer 29

Family Therapy began to be respected, still the new kid on the block, but, increasing interest from multiple people.
-People began to do it, use it and understood the importance of understanding the family when it comes to understanding individual behavior

Question 30

explain one way mirror

Answer 30

Suddenly, people were able to observe the family in therapy, how they discussed issues, how they offered support or criticism.
-This helped rocket family therapy

Question 31

First and Second order change

Answer 31

First Order Change (nothing wrong with this, sometimes it is fine, simply addressing the direct problem, people change and it can work, a lot of CBT is targeting this)
-The system is unchanged

Second Order Change (not always expected change, ex. The finger puzzles that you have to push to get your fingers out not pull which seems logical)
-The system itself changes
-People realize that something seems logical might not be helpful, treating a child like a younger child to try and protect them is actually harming them
-When straight forward stuff is not enough, you move to second order change

Ex. First order, helping child get their homework done; second order change, family changes how they talk to child and ask him to get his homework done

Question 32

general advice for therapists (do not have to know everything)

Answer 32

No family is exactly following a script, but, some background (in the research literature) can be helpful (e.g. adoption, ADHD, stepfamily…)
-Nothing is in a vacuum, everything affects everything else
-Have to respect and understand family diversity (e.g. step family is distinct from the original family), each family is a culture

You must like, or at least not dislike, every family member
-Be honestly curious, families will know you are trying to understand why things happen in this family and who does what when

If you are lost, listen more closely—always be curious
-Honor their respect of you by showing respect, and having good manners

-If someone asks a question, unless you have a very good reason not to, answer it

Don’t laugh harder than your clients
-Sometimes families will do this to get away from the therapy and the work that actually needs to be done

Understand the systemic functioning of the people in this family (why might dad do what he does?)

If you are stuck, consider a bi-lateral comment (e.g. So, dad, when Tommy starts to complain, you a triggered and feel he is disrespectful, while you Tommy feel that you can’t ask a question without being told you are being rude? Is that accurate?)
-Question that relates to two people in the room

Understand the “Bruise” concept (Papernow)
-Almost everyone has some issue that you need to be aware of, if there is a bruise and you touch it again, you are going to hurt them again
-Ex, someone is dumped by a partner, they are likely to feel frightened when someone is mad at them because they have this bruise, if you are doing therapy and see someone react in a way that is larger than it should be think if there is a bruise
-Ask where the reaction is coming from, show curiosity; not necessarily go into depth but with couples or family you would automatically go to the other; how does their experience impact your interactions with her?

Is there any particular subsystem that should be seen in this family?

Have I discussed Confidentiality?

Don’t forget, if an experiential intervention fits, they are often helpful.

Keep track when anyone expresses love and support, find a way to return to that comment later.
-If someone says “of course I love Johnny, but…”, bring back to the conversation the fact that they admitted to love them; term is too potent to let it drop off

Notice miscommunication
-Help people who are not really hearing each other
-Can possibly have them repeat what they are saying in a different way
-Miscommunication is a great way to clarify what is happening

Productive disagreements can be permitted to continue, unproductive or scary disagreements must be stopped.
-If arguments become counterproductive, you have to listen for this so you can shut this down
-Can stop arguments when you force a triangle (therapist gets involved in the argument) or you can technically raise your voice a little bit and tell them to stop the argument (come down as more of a parent figure)

Clients need to feel safe.

The Reframe may be one of our most useful tools, when accurate.

Question 33

explain bruise

Answer 33

-Almost everyone has some issue that you need to be aware of, if there is a bruise and you touch it again, you are going to hurt them again
-Ex, someone is dumped by a partner, they are likely to feel frightened when someone is mad at them because they have this bruise, if you are doing therapy and see someone react in a way that is larger than it should be think if there is a bruise
-Ask where the reaction is coming from, show curiosity; not necessarily go into depth but with couples or family you would automatically go to the other; how does their experience impact your interactions with her?

Question 34

explain bi-lateral comment

Answer 34

(e.g. So, dad, when Tommy starts to complain, you a triggered and feel he is disrespectful, while you Tommy feel that you can’t ask a question without being told you are being rude? Is that accurate?)
-Question that relates to two people in the room