AMERICAN INDIAN CLIENTS
Therapists working with American Indian clients should
- be familiar with relevant historical events
- build trust and credibility during initial sessions by demonstrating familiarity with and respect for the client’s culture and admitting any lack of knowledge
- adopt a collaborative, problem-solving, client-centered approach that avoids highly directive or confrontational techniques
- and incorporate elders and traditional healers into the treatment process
LaFromboise et al. (1990) recommend network therapy, which incorporates family and community members into the treatment process and situates an individual’s psychological problems within the context of his/her family, workplace, community, and other social systems.
ARAB AMERICAN CLIENTS
Effective therapies for Arab American clients include
- couple or family therapy
- cognitive-behavioral therapy
- and problem-solving approaches
- discussing what to expect from therapy and the therapist-client relationship in the initial session
- addressing concerns the client has about possible incompatibility of therapy with the client’s values and beliefs
- determining each family member’s level of acculturation and degree to which acculturation conflicts contribute to problems
- considering how religious or ethnic discrimination and hostility impact the client
- and considering whether to include culturally relevant rituals into therapy and/or consulting with traditional healers
ASIAN AMERICAN CLIENTS
Asian American clients may prefer a directive, structured, goal-oriented, problem-solving approach focused on symptom-alleviation. Therapists are seen as experts/authority figures.
- encourage clients to take part in identifying goals and solutions
- emphasize formalism in therapy
- establish credibility and competence early in therapy (e.g. disclose qualifying educational background/experience)
- prevent premature termination by providing immediate, meaningful benefits
- and be aware that mental health problems may be expressed as somatic complaints.
Cognitive-behavioral, solution-focused, and other brief therapies may be effective if modified to focus more on the family than the individual and consider cultural and social factors.
There is no single behavior therapy but, instead, a diverse collection of therapies and interventions that are based on the principles of
- classical conditioning
- operant conditioning
- and social learning theory
- emphasize current behaviors
- and adopt a scientific approach to assessment and treatment.
The primary goal of therapy is to alleviate the client’s problems by decreasing maladaptive behaviors and increasing more adaptive ones.
The therapist-client relationship is collaborative, and clients are expected to take an active role in therapy by participating in goal setting, monitoring their own behaviors, and learning and practicing new skills.
The process of therapy can be described in terms of the following steps -
- clarifying the problem
- formulating initial treatment goals
- describing the target behaviors that need to be changed to achieve treatment goals
- measuring each target behavior as soon as it is identified and at regular intervals during therapy
- identifying the antecedents and consequences that maintain each behavior
- designing and implementing a treatment plan
- and evaluating the success of the treatment plan
Cognitive-behavioral therapy (CBT) is based on these assumptions:
- cognition mediates emotional and behavioral dysfunction
- modifying cognitions can change dysfunctional emotions and behaviors
- behavioral and cognitive strategies are both useful and can be integrated.
Beck’s CBT focuses on cognitive schemas, automatic thoughts, and cognitive distortions and proposes that each psychological disorder involves a different cognitive profile, e.g., depression involves the “cognitive triad” of a negative view of oneself, the world, and the future.
The primary goal is to modify the dysfunctional cognitions that maintain maladaptive behaviors and emotions.
CBT is structured, goal-oriented, and time-limited. It incorporates various strategies to achieve therapy goals, e.g., activity scheduling, behavior rehearsal, questioning the evidence, and cognitive rehearsal.
Adler replaced Freud‘s emphasis on the role of instinctual drives in the development of personality with an innate tendency toward social interest, and he viewed mental disorders as being due to adoption of a mistaken style of life that is characterized by maladaptive attempts to compensate for feelings of inferiority, a preoccupation with achieving personal power, and a lack of social interest.
The primary goal of therapy is to help the client develop a healthy style of life that is characterized by social interest and a sense of belonging.
The process of Adlerian therapy can be described in terms of four phases —
- establishing a therapeutic relationship
- exploring the client’s style of life
- encouraging self-understanding
- helping with reorientation (making changes)
AFRICAN AMERICAN CLIENTS
Experts recommend the use of an ecological systemic approach when working with African American clients — for example, Boyd-Franklin’s (1989) multisystems model for African American families addresses multiple systems, intervenes at multiple levels, and empowers the family by utilizing its strengths.
Systems that may be incorporated into treatment include
- the extended family and nonblood kin,
- the church and
- other community resources, and
- social service agencies.
Experts also recommend
- using a time-limited, goal-oriented, problem-solving approach and
- fostering empowerment by promoting egalitarianism in the therapeutic relationship and
- helping the client develop the skills needed to increase the client’s sense of control over his/her life.
The term “cybernetics” was coined by Weiner (1948) to describe systems that are self-regulating by means of feedback loops, which can be either negative or positive:
Negative feedback loops reduce deviation and help a system maintain the status quo, while
positive feedback loops amplify deviation and, thereby, serve to disrupt the system’s status quo.
EMOTIONALLY FOCUSED THERAPY (EFT)
EFT for couples is a brief empirically supported therapy that focuses on the role of emotion in a couples relationship and views relationship distress as the result of attachment insecurity that can be traced to early relationships in a partner‘s family of origin and that produces a predictable sequence of responses when the partner experiences disappointment, hurt, or fear in his/her relationship.
The primary goal of EFT is to expand and restructure the couple’s emotional experiences with each other so they can develop a secure bond and new interactional patterns.
Therapy is organized around three treatment stages:
- Assessment and Cycle De-Escalation
- Changing lnteractional Positions
- Consolidation and Integration
EXTENDED FAMILY SYSTEMS THERAPY
Bowen’s extended family systems therapy extends systems theory beyond the nuclear family and views behavior disorders as the result of a multigenerational transmission process in which progressively lower levels of differentiation are transmitted from one generation to the next.
The primary goal of therapy is to increase the differentiation of all family members. Therapy begins with the construction of a genogram, which depicts the relationships between family members, the dates of significant life events, and other important information.
The therapist often sees two members of the family (spouses) and forms a therapeutic triangle in which the therapist comes into emotional contact with the family members but avoids becoming emotionally triangled.
Freud described the personality as consisting of the id, ego, and superego, and Freudian psychoanalysis emphasizes the impact of unresolved unconscious conflicts involving the id’s impulses that occurred during a person’s childhood on the person’s current personality and behavior.
The primary goal of therapy is
- to reduce or eliminate pathological symptoms by bringing unconscious material into conscious awareness
- integrating previously unconscious material into the personality
- strengthening the ego so that behavior is determined more by rational processes than by instinctual drives.
The therapist acts as a “blank screen” in order to encourage the development of a transference relationship, and the therapist’s primary task is to analyze the client’s transference as well as his/her free associations, dreams, and resistances in order to facilitate the client’s catharsis and insight into the relationship between his/her unconscious processes and current behaviors.
The process of psychoanalysis involves four overlapping phases —
- opening phase
- development of transference
- working through transference
- resolution of transference
GENERAL SYSTEMS THEORY
General systems theory was proposed by the biologist von Bertalanffy (1968) who described a living system as “composed of mutually dependent parts and processes standing in mutual interaction” (p. 33).
He distinguished between two types of systems: A closed system has rigid, impermeable boundaries, does not interact with its environment, and is resistant to change
while an open system has permeable boundaries, interacts with its environment, and is adaptable and receptive to change.
Family therapists view families as primarily open systems.
Gestalt therapists view neurotic (maladaptive) behavior as a “growth disorder” that involves an abandonment of the self for the self-image and is often due to a disturbance in the boundary between the self and the environment that interferes with the person’s ability to satisfy his or her needs and maintain a state of equilibrium.
The major goal of therapy is to help the client become a unified whole by becoming aware of and integrating the various aspects of the self,
and this goal is accomplished through the use of variety of techniques that are designed to lead clients toward greater awareness of their current thoughts, feelings, and actions, including games of dialogue, assuming responsibility, and dream work.
Hispanic/Latino clients often prefer an active, directive, and multimodal approach that focuses on the client’s behavior, affect, cognitions, interpersonal relationships, biological functioning, etc.
Therapy guidelines include
- emphasizing “personalismo” (except during initial contacts when “formalismo” is preferred);
- recognizing that differences in level of acculturation within a family are often a source of individual and family problems
- considering the impact of religious and spiritual beliefs
- being aware that Hispanic/Latino clients may express their mental health problems as somatic complaints
HUMAN VALIDATION PROCESS MODEL
Satir‘s human validation process model is an example of experiential family therapy and views maladaptive behavior as the result of the “interchange of low self-esteem. incongruent communication. poor system operations, and faulty family roles” (Henderson & Thompson. 2011. p. 502).
The primary goal of therapy is to enhance the growth potential of family members by raising their self-esteem and helping them communicate congruently and solve problems more effectively;
and the therapy process can be described in terms of six stages —
- status quo
- introduction of a foreign element
- integration of new possibilities
- new status quo
Satir considered the therapist’s “use of the self‘ to be the key instrument of change and described the therapist as having multiple roles including role model, facilitator, mediator, advocate, and teacher.
INDICATIONS/CONTRAINDICATIONS FOR FAMILY THERAPY
Family therapy is likely to be effective when, for example,
- a family member’s symptoms are manifestations of problems in the family system
- improvement in one family member is likely to cause (or has caused) the development of symptoms in another family member
- a family member has symptoms that are known to be effectively treated by family therapy (e.g. substance abuse, an eating disorder, conduct disorder).
In contrast, family therapy may be contraindicated when
- a family member‘s presenting problem is not related to family functioning
- key family members are unavailable or unwilling to participate in family therapy
- one family member is so severely disturbed that his or her behavior makes family treatment impossible
INDICATIONS FOR REFERRAL
Indications for referral include the following:
- The client’s problems exceed the therapists expertise;
- there is a dual relationship or conﬂict of interest;
- there are significant problems in the therapeutic alliance;
- the therapist is unable to resolve the client’s resistance;
- the therapist or client is relocating;
- the client requests a second opinion;
- the client needs adjunctive services
- at termination, the therapist believes it would be appropriate to refer the client for continuing services from another professional (O‘Leary & Norcross. 1998).
INTEGRATIVE BEHAVIORAL COUPLE THERAPY (IBCT)
IBCT is an extension of traditional behavioral approaches that “assumes that relationship problems result not just from the egregious actions and inactions of partners but also in their emotional reactivity to those behaviors. Therefore, IBCT focuses on the emotional context between partners and strives to achieve greater acceptance and intimacy between partners as well as make deliberate changes in target problems” (Christensen et al., 2006. p. 1 181).
It proposes that it is normal for couples to have areas of differences and disagreement but that these lead to distress when partners habitually respond to them with mutual coercion, vilification, or polarization, and
its primary goal is to end dysfunctional repetitive interactions by fostering acceptance of differences and disagreements.
Therapy focuses on repetitious problematic interactions, which are identified with a functional analysis and then addressed using a combination of acceptance, tolerance, and change techniques.
LESBIAN, GAY, AND BISEXUAL CLIENTS
Interventions used with heterosexual clients are ordinarily acceptable to LGB clients as long as they do not reflect a heterosexist bias and the therapist has adequate knowledge about LGB issues.
Guidelines for working with LGB clients include
- having a lesbian, gay, and bisexual friendly office
- being aware that an LGB client’s problems may be related to exposure to prejudice and discrimination
- internalized homophobia
- a lack of social support
- or other unique issues faced by members of this population without automatically assuming that this is the case
- being familiar with the sexual identity of an LGB client and how it relates to his/her coming-out process
- understanding that there are differences among people who are lesbian, gay, or bisexual in terms of experiences and concerns related to their sexual orientation
- being familiar with community resources that would be helpful to LGB clients
In addition, affirmative forms of psychotherapy (e.g. Chernin & Johnson. 2003) have been developed specifically to help LGB individuals value and accept their sexual orientation.
MILAN SYSTEMIC FAMILY THERAPY
Milan systemic family therapy is based on the assumptions that
- a family is “a self-regulating system which controls itself according to rules formed over a period of time through a process of trial and error” (Selvini-Palazzoli et al.. 1978. p. 3). and
- the “rules of the family game” consist of repetitive patterns of family interactions that are played out in unacknowledged alliances and coalitions and are used by family members to control each other’s behavior.
Systemic family therapy proposes that “dirty games” (games involving deceit and power struggles) lead to symptoms that help protect a family from change.
The primary goal of therapy is to help family members understand their problems in alternative ways so they can identify new solutions (i.e. can “play a different game”).
Milan systemic family therapy uses a therapeutic team and divides each session into ﬁve parts —
- a pre-session team discussion
- the interview with the family
- discussion of the interview by team members
- conclusion of the interview with a prescription given to family members
- a post-session team discussion
NARRATIVE FAMILY THERAPY
Narrative family therapy is based on the premise that personal experience is fundamentally ambiguous and, to make sense of their lives, people develop narratives that give coherence to current experiences and inﬂuence how they interpret future experiences.
Practitioners of narrative family therapy believe that the problem itself (rather than the person or relationship) is the problem and view the family‘s problem as an entity that is separate from the person or family and that is reflected in the problem-saturated story that brought the family to therapy.
The primary goal of therapy is to help clients write more satisfying life stories — i.e., stories that are less problem-saturated and more consistent with the family’s preferred narratives and outcomes.
Therapy is aimed at helping clients change their lives by changing their stories and can be described in terms of five stages -
- describing the problem
- mapping the effects of the problem
- evaluating and justifying the effects of the problem
- identifying unique outcomes
OBJECT RELATIONS FAMILY THERAPY
Object relations family therapy is an adaptation of psychodynarnic family therapy, and its practitioners integrate intrapsychic and interpersonal approaches by replacing Freud’s innate sexual and aggressive drives with an innate need for satisfying relationships.
They propose that a person’s current relationships are related to his/her expectations about relationships, which can be traced to early relations with attachment “objects” (especially the child‘s mother):
When a young child perceives his/her mother to be not only nurturing but also frustrating, the child internalizes images (“introjects”) of the mother to gain internal control over her and, thereby, alleviate his/her own anxiety. These introjects become part of the child’s personality and inﬂuence the way he/she interprets future relationships.
OLDER ADULT CLIENTS
Psychoanalysis, cognitive-behavioral therapy, and other traditional forms of therapy can be effectively used with older clients although certain modifications may be necessary, including
- demonstrating genuineness, accurate empathy, and unconditional positive regard to help foster a therapeutic alliance;
- adopting a multimodal approach that addresses the client’s physical, psychological, and social functioning
- adopting a structured approach and slower pace:
- adapting the intervention to the client‘s environment;
- and modifying therapy to match any age-related changes in the client’s functioning such as slower response speed. decline in working memory
- and increased emotional complexity.
Rogers‘s person-centered therapy is based on the assumptions that people possess an inherent ability for growth and self-actualization and that maladaptive behavior occurs when “incongruence between self and experience” disrupts this natural tendency.
The primary goal of therapy is to help the client achieve congruence between self and experience so that he/she can become a more fully-functioning. self-actualizing person.
This goal is accomplished when the therapist provides the client with three facilitative conditions (empathy, genuineness, and unconditional positive regard) that enable the client to return to his/her natural tendency for self-actualization.
Advocates of postmodernism reject the “belief in the possibility of objective knowledge and absolute truth” and replace it with the assumption that reality “is inevitably subjective and that we do indeed dwell in a multiverse that is constructed through the act of observation” (Becvar & Becvar. 2003. p. 92).
Postmodernism adopts the social constructivist contention that language is the means that people use to express their constructions.
Consequently, advocates of postmodern approaches to therapy contend that constructions such as positive and negative feedback, homeostasis, and boundaries are not objective facts but, instead “linguistic tools with which to describe and understand families” (Goldenberg & Goldenberg. 2012. p. 111).
PSYCHODYNAMIC FAMILY THERAPY
Practitioners of psychodynamic family therapy regard family dysfunction to be the result of unresolved intrapsychic conflicts within individual family members (or, from an object relations perspective, as the result of pathological introjects).
The primary goal of therapy is modification of the personalities of individual family members so that they can relate to one another on the basis of their current situation rather than the past.
Although psychodynamic family therapists rely on psychoanalytic principles as the basis for understanding individual and family dynamics they differ in terms of the extent to which they use traditional psychoanalytic techniques in therapy.
READINESS FOR TERMINATION
The primary factor to consider when determining a client‘s readiness for termination is the achievement of therapy goals; and, ideally, the termination process begins when the therapist and client agree that the goals have been accomplished.
However, in some situations, termination may be appropriate when all goals have not been fully achieved but the client has acquired the skills needed to deal with any remaining problems or because the therapist and client have agreed that therapy has not been successful and should be terminated (Barker. 1992).
SOLUTION-FOCUSED FAMILY THERAPY
Solution-focused family therapy focuses on solutions to problems rather than on the problems themselves and views maladaptive behavior as the result of becoming “stuck” in dealing with a problem due to continued reliance on the same ineffective methods for resolving it.
Practitioners of solution-focused therapy believe that all families have the strengths and resources they need to resolve their problems, and the general goal of therapy is to help the family access and apply their strengths and resources, in therapy, family members are viewed as the “experts,” while the therapist acts as a consultant and collaborator who poses questions and uses strategies to help them achieve their goals.
Commonly used questions include the miracle question, exception questions, and scaling questions.
STRATEGIC FAMILY THERAPY
Haley’s strategic family therapy focuses on transactional patterns and views symptoms as interpersonal events that serve to control relationships.
An underlying assumption of therapy is that behavior change results in changes in perceptions and emotions and, consequently, therapy focuses on symptom relief (rather than insight).
Haley considered the first stage of therapy to be an important determinant of the course of therapy and described it as consisting of four stages —
Strategic family therapists use a variety of strategies to achieve therapy goals, including paradoxical interventions (e.g. ordeals, prescribing the symptom, reframing) that are designed to alter the behavior of family members by
- helping them see a symptom in an alternative way
- helping them recognize that they have control over their behaviors, or
- using their resistance in a constructive way
STRUCTURAL FAMILY THERAPY
Minuchin’s structural family therapy emphasizes altering the family’s structure in order to change the behavior patterns of family members.
Boundaries (rules that determine the amount of contact that is allowed between family members) are one element of the family structure:
When boundaries are overly rigid, family members are disengaged and when they are too permeable, family members are enmeshed.
Family dysfunction is viewed as the result of an inﬂexible family structure that prohibits the family from adapting in healthy ways to maturational and situational stressors,
and the primary goal of therapy is to restructure the family. Therapy is based on the premise that action precedes understanding. and the process of therapy can be described in terms of three steps —
- joining the family
- evaluating the family structure
- restructuring the family
TREATMENT GOALS AND OBJECTIVES
Treatment goals and objectives are identified from a problem list that is derived from the results of a thorough assessment and represent the desired outcomes of therapy.
- restate the client’s presenting problems in positive terms
- describe the changes that are needed to achieve each treatment goal