Basic Techniques of Family Therapy

Basic Techniques of Family Therapy By: Elena, Theresa, and Vanessa

The Initial Telephone Call • Goals: (1)Initial overview of presenting problem; (2) Arrange for family to come in for consultation. • Important things to consider: • Brief (no individual alliances) • Establish connection with caller (correspondent) • Schedule 1st interview (identify who should attend, time, and place) • In the case of request for individual Tx, listen with empathy but be firm about the need to meet with whole family.

The First Interview • Goals: (1) Build alliance with family; (2) Develop an idea as to what’s maintaining present problem • May develop hypothesis after initial phone call/test in 1st session (Beware! Do not jump to conclusions) • Consider what adaptive strategies are or have been in effect that help family move forward • Establish rapport and gather info • Greet, orient family to interview room, explain format of session, recap what caller said in initial phone call, solicit feedback

The First Interview • Do’s and Don'ts • No tolerance for shouting matches- ensure that everyone has chance to talk and be heard (don’t fear interrupting) • Over time, can ease rules on arguments (build confidence to control the interactions when they get out of hand) • Draw out reticent family members (they need to be heard!) • Be able to empathize with every family member

The First Interview • Do’s and Don’ts • Ask, “How did you feel about coming in?” (encourages honesty, helps establish therapist as “listener”) • Don’t fall into passive role as a therapists (know when session requires “active intervention”) • Emphasize individual’s and family’s strengths, not just their problems or weaknesses (view as 3-dimesnsional human beings)

The First Interview • Do’s and Don’ts • Pay particular attention to parent-child interactions (provide toys and other stimuli to facilitate your observations) • Use Genograms if necessary (diagrams extended family network) • Solicit what families have tried to improve their problem. Stay mindful of: • Solutions that don’t work • Transitions in the life cycle

The First Interview • Do’s and Don’ts • Explore the process of family interaction by asking how each member relates to the other (ask them to discuss their problems w/ each other) • Strategies: Ask process or circular questions • Aim to answer: What keeps getting the family stuck?

Interviews 1-3 • Once info is gathered and hypothesis formed • Make recommendation to family for course of therapy • Administer a treatment contract : Acknowledge why they came in and that you think you can help • Negotiate: • Meeting times • Frequency & length of sessions • Who will attend • Presence of observers or use of videotape • Fee and insurance Q’s

First Session Checklist • Make contact w/ each fam member and acknowledge his or her point of view • Establish leadership in the group by refereeing sessions • Develop a work alliance (be warm & professional) • Compliment clients on positive attributes • Be empathetic with individuals but respectful of family philosophy • Focus on specific problems and attempted solutions • Develop a hypothesis about present problem • Don’t overlook contributions of other members not present in session who can help • Negotiate a treatment contract- specifying therapists’ framework for structuring Tx • Invite Questions

Early Phase of Treatment • Goals: (1) Refine hypothesis; (2) Figure out what’s maintaining problem; (3) Work to resolve it • Shift from alliance-building to challenging incongruences (actions and assumptions) • Push for Change: may need to use confrontational style (i.e. insist members stop blaming other members and redirect focus to individual contribution to problem)

Early Phase of Treatment • Maintain strong therapeutic alliance • Be ready to intervene! • Be a finisher! Have a strong personal commitment to do what it takes to see fams reach successful resolution • Address interpersonal conflict • Challenge linearity causal, causal , causal! • Point out individuals who keep people “stuck” • “ The more you do X, the more he does Y- and the more he does Y, the more she does X.”

Early Phase of Treatment • Don’t be so quick to give advice. Encourage clients to discover their own resources Ex: Therapist: When you ignore your wife’s complaints, she feels hurt and angry. You may have trouble accepting the anger, but she doesn’t feel supported. Client: What should I do? Therapist: I don’t know. Ask you wife.

Early Phase of Treatment • Homework can be assigned to test flexibility and commitment of the family/individual members Ex: • Having overinvolved parents hire a sitter and go out • Having argumentative partners take turns talking about feelings and listening w/o interruptions

Early Phase Checklist • major conflicts, bring them into the open • Develop/Refine hypothesis: consider, process & structure, family rules, triangles, boundaries • Focus on primary problems and conditions which support them • Assign HW • Confront members to see their own involvement in the problems that trouble them • Push for change • Assess the effectiveness of interventions with supervision tests

Middle Phase of Treatment • Goal: (1) Help fam members express themselves and achieve mutual understanding • Good place to play “passive” role as therapist • Control anxiety that stems from conflicts encourage patterns of listening by having members talk only to them • Alternate talking between member and therapist and member and member • Remain Calm! Client is responsible for the change, not you… • Express curiosity, especially when you REALLY don’t know • Treat clients as equalsdo not patronize

Middle Phase of Checklist • Use intensity to confront when needed • Avoid being overly directive • Foster individual responsibility and mutual understanding • Make sure efforts for change are improving relationships, not making them worse • If meet w/subgroups, don’t forget about the whole family picture • Check for if therapist finds themselves taking an active response to fam member’s needsfind out who in family should have that role and encourage them to do so

Termination • Goals: (1) End therapy once family feels they’ve achieved what they came in for and therapist sees Tx has had max effect. (2) Review what family has learned) • Anticipate upcoming challenges that may cause setbacks • Stress people tend to overreact during 1st sign of relapse • Check in with family a few weeks after termination to see how they’re doing (e.g. letter, phone call, brief follow-up session)

Termination Checklist • Has presenting problem improved? • Is family satisfied with results or are they interested in continuing to improve the relationship? • Does family understand what they were doing wasn’t working and how to avoid similar problems in future? • Do flare ups in the family reflect lack of resolution or a need to readjust to function w/o therapist? • Have members improved relationships outside the immediate family as well as within?

Family Assessment

Family Assessment • The Presenting Problem • Clients come in with their most urgent problem, expecting the therapist to solve it. • "What should we do?" • "What's wrong with Johnny?" • Clients may have been asking themselves these questions for a while and usually have a preconceived notion of the answers. • They also have developed a way to cope with their problems and will stick to it, no matter how ineffective. • Anxiety makes for rigid thinking.

Family Assessment • The Presenting Problem • First, explore the problem. • Listen to the family's account and ensure that everyone present gets their say. • Follow up with detailed questions; these are to not only collect data about the problem but also to explore the family's beliefs about the problem and blame. • "Family therapy is not about solving the problem; it's about repairing the problem-solving mechanism." (Haley)

Family Assessment • The Presenting Problem • Next, open up fixed character explanations (intrapsychic) to explore family members' actions and interactions (interpersonal). • Explore the scope of the problem and look for alternative possibilities. • Give every family member a chance to speak up. • Explore strengths and weaknesses of the identified patient. • Explore others' responses to the identified patient and symptoms.

Family Assessment • The Presenting Problem • The purpose of questioning is to explore and open horizons, not concentrate on a single version of events or an individual. • e.g., "I don't quite understand, but I'm interested. I know about families, but I'm curious about the particular way you organize your life." • Also look into how the family tried to deal with the problem. • Explore how these attempts may have perpetuated the presenting problem. • It rarely matters who started it or what the specific causes and effects are, only that there is a vicious cycle going.

Family Assessment • The Presenting Problem • This sort of exploration empowers the family to discover the nature of their problem and find ways to effectively solve it. • The focus is on resolution of the problem.

Family Assessment • Understanding the Referral Route • Who referred your client? What were their expectations, and what expectations were conveyed to the client? • Is the family's participation voluntary or coerced? Do some or all members see the need for treatment? • Are any other agencies involved in the treatment process? • What is the family's treatment history?

Family Assessment • Identifying the Systemic Context • It's important to learn about the interpersonal context of the problem. • Who is in the family? • Are there important figures in the life of the problem who aren't present? • Are there third parties involved? What is the nature of their input? Does the family see them as helpful? • The most relevant context may be the immediate family, but it's important to look at the other contexts in the patient's life as well (e.g., school, work).

Family Assessment • Stage of the Life Cycle • Problems within a family are sometimes not due to anything members have done but because of transitions in the life cycle. • Spiffy table of family life cycle stages is available on page 105. • Therapist should explore the timing of the presenting problem and possible relation to the life cycle or significant life changes.

Family Assessment • Family Structure • The simplest systemic context for a problem is the dyad. • Family problems are often hidden behind structural and hierarchical issues; hence, knowledge of the family's structure is important. • What are the subsystems in play, and what is the nature of their boundaries? • What triangles are present? • Who plays what role in the family? • Are individuals and subsystems protected by boundaries that allow operation without interference?

Family Assessment • Communication • One of the most common presenting problems in family therapy is communication. • Though conflict doesn't disappear with improved communication, problems are more likely to be resolved if people listen to one another. • Sometimes, families learn that, with a bit more listening and understanding, they don't need to change each other. However, if they haven't improved in this aspect after the first couple of sessions, talk therapy would be difficult.

Family Assessment • Drug and Alcohol Abuse • Substance abuse is very easily overlooked! • Substance abuse is common in depression and anxiety and is associated with violence, abuse, and accidents. • It's not necessary to drill every client about substance use, but if there is some suspicion, ask (and be direct).

Family Assessment • Drug and Alcohol Abuse • What would be some good questions to ask? • Do you feel you are a normal drinker? • How many drinks a day do you have? • How often do you have 6 or more drinks? • Have you ever awakened after a bout of drinking and been unable to remember part of the day or evening before? • Does anyone in your family worry or complain about your drinking? • Can you stop easily after one or two drinks? Do you? • Has drinking ever created problems between you and your partner? • Have you ever gotten into trouble at work because of your drinking? • Do you ever drink before noon?

Family Assessment • Domestic Violence and Child Abuse • If there are any suspicions at all, ask! • Questioning can begin with family members present, but it's a good idea to ask individually after to get better details. • Be aware of mandatory reporting laws. • Reporting can jeopardize the therapist-client relationship, but safety comes first. • If you consider not reporting, consider possible consequences of making a mistake.

Family Assessment • Domestic Violence and Child Abuse • Perpetrators and victims of childhood sexual abuse don't usually volunteer this information. • What sorts of cues should a clinician look for?

Family Assessment • Domestic Violence and Child Abuse • Further exploration is a good idea if the child has: • Sleep disturbance • Encopresis or enuresis • Abdominal pain • Exaggerated startle response • Appetite disturbance • Sudden unexplained changes in behavior • Overly sexualized behavior • Regressive behavior • Suicidal thoughts • Running away • Interviewing suspected child abuse victims require specialized training. Novice clinicians should refer to their supervisors or a specialist.

Family Assessment • Extramarital Involvements • Affairs are common, but the crisis can destroy relationships, even if the affair doesn't involve sexual intimacy. • A cue that an outside relationship is part of a triangle is that it isn't talked about.

Family Assessment • Gender Issues • Gender inequalities and roles can contribute to problems within a family. • Clinicians should be careful to not completely ignore the role of gender in a problem but also to not impose his/her views upon the family. • Ask questions that allow the clients to come to their own conclusions. • Don't assume that partners enter a marriage at equal power or that the complementary power is the only working dynamic in a marriage.

Family Assessment • Gender Issues • Given the changes in gender expectations over the last few decades, conflict due to differences in expectations are fairly common. • What sorts of problems do you expect to occur in a family or couple?

Family Assessment • Gender Issues • When evaluating a couple, ask: "How does each partner experience the fairness of give-and-take in the relationship?" • Do the gender roles established in the couple work for them? • Gender socialization can be a source of stress in a relationship. • Gender socialization is influenced by family dynamics. • e.g., Pursuer-distancer dynamic

Family Assessment • Cultural Factors • Clinicians need to consider both the unique subculture of the family and the larger umbrella that is their cultural background. • Cultural sensitivity is important for rapport. • Clinicians do not necessarily have to share ethnic or cultural backgrounds with the client, but they should be willing to learn about their clients' backgrounds. • Take a one-down position and allow clients to teach you about their culture, experience, and traditions.

Family Assessment • Cultural Factors • "We do these (counterproductive) things because of our culture." • It's important to be open-minded when it comes to learning about others' backgrounds, but statements like these can make things difficult. • It's also difficult to assess statements like this for validity. • Be curious, stay open... but ask questions.

Family Assessment • Cultural Factors • Clients from the same cultural background may not necessarily have the same cultural assumptions. • How do cultural expectations affect the family you're working with? • Warning signs: • Getting married means living "happily ever after" • Sexual satisfaction is something that just comes naturally • Adolescence is necessarily a time of turmoil • Teenagers only want freedom and no longer need their parents' love and understanding

The Ethical Dimension • What are some general ethical responsibilities clinicians have? • Therapy is for the client, not the clinician. • Confidentiality is a right. • Clients need to be made aware of legal exceptions to confidentiality and managed care issues beforehand. • Clients are not to be exploited, and dual relationships with clients should be avoided wherever possible. • Clinicians are obligated to provide the best possible treatment. • For cases where clinicians aren't sure of their qualifications, refer the case to someone who is qualified.

The Ethical Dimension • If there are any doubts at all about an ethical decision, consult! • A good place to start understanding one's ethical responsibilities as a clinician is one's professional ethics code. • In our case, that's the APA Ethics Code.

The Ethical Dimension • Most of the ethical principles are common sense, but the codes have specific guidelines that need to be followed. • However, due to the nature of couples and family therapy, complications can arise. • Family members' entitlements and obligations should be considered during assessment; these include issues of loyalty and commitment. • In session, a child may share something with the therapist; how much of that information can be shared with the parents?

The Ethical Dimension • The APA specifies that psychologists who provide services to several people who have a relationship must share at the outset who's the client and what relationships they will have with each person. • In the event that the psychologist serves conflicting roles, s/he must clarify and modify the rules or withdraw.

The Ethical Dimension • The AAMFT has a direct solution regarding confidentiality. • Without a written waiver, a therapist should not disclose information received from any family member, not even to other family members.

The Ethical Dimension • A female client comes to you and says that she's been having an affair for the past few years. She refuses to tell her husband or end the affair, but this affair is ruining her marriage. What do you do?

The Ethical Dimension • One option to take if you feel that therapy would be ineffective in this situation is to decline to treat under these circumstances and refer to another therapist. • Make sure to take care of all abandonment and continuity-of-care issues! • Another option is to treat the couple in the hopes that the client would eventually break off the affair or tell her husband. • You cannot tell the husband, since you're bound by confidentiality to not reveal information the wife gives you in private.

The Ethical Dimension • The risk of using your own judgment as the arbiter of ethical dilemmas that appear in your office is bias due to your own experiences and values. • Ethics codes are not necessarily aligned with one's moral values. • When in doubt, ask: • What would happen if the client or important others found out about your actions? • Can you talk to someone you respect about what you're doing or considering?

The Ethical Dimension • Red flags for potential unethical decisions: • "But this is special!" • Attraction to the client or situation • Alterations to the therapeutic frame • Violations of clinical norms • Professional isolation

Basic Techniques of Family Therapy