Marriage and Family Therapy
According to Burnham (1986), the family therapy field began in the 1950s whereby theoreticians and practitioners in the therapeutic field looked at the family as a system. This system is seen as an entity with interacting parts wherein the parts evolve with each other with the goal of maintaining and protecting existing living patterns and, at the same time, adapting to whatever changes that come their way through the creation and promotion of new living patterns.
Conoley Conoley (2009) asserts that the development of family happiness should be the focus of family therapists as happiness causes individuals and families to grow. As people go through their lives day after day, interacting with others that are part of their lives, it becomes clear that happiness plays a significant part in peoples lives as they pursue the idea of optimal living.
In this paper, the concepts and aspects of family therapy and couples counselling and how they are applied in a clinical setting are examined. Family therapeutic intervention suggests that family relationships play a crucial role in the modification and improvement of behavior.
Case Study Andrews Story
Back in 2005, Andrew underwent therapy for post traumatic stress disorder (PTSD). After graduating from high school, Andrew enlisted in the U.S. Army in 2001, a few months before the 911 event. When the 911 attack occurred, his training became more intensive. In 2004, his company was sent to Iraq for a year. During one of their patrols, they were attacked by enemy soldiers. Andrew recalled being scared since it was his first mission. The sounds of bombs and gunfire were deafening, he says, but then, his training kicked in and he, along with his company, were able to neutralize the threat posed by the enemy soldiers. Andrew says that they were very lucky that night because no one in their company was killed and they only sustained minor injuries. However, the task of shooting another human being, despite being viewed as the enemy, weighed on his mind. After the year was up, Andrew went back to the States and stayed with his parents in their house in Pennsylvania.
Andrew plans to pursue a college education by taking up political science. Even though Andrews parents were overjoyed that their son was able to come home safe, they were still troubled by the changes theyve seen in Andrew. He has become irritable and withdrawn and his stance is always tense, a far cry from the energetic and lively young man he used to be. One night, Andrew suddenly woke up because he allegedly heard gunshots and bombs setting off. He quickly got up and looked for his rifle and grew frantic when he couldnt find it. His parents were woken up by the noise coming from Andrews room and they found him trashing the room as he looked for his rifle. It took a few moments for his parents to calm him down and tell him that he is not in Iraq anymore. After this incident, Andrews parents decided to consult a psychotherapist and relayed the situation in the hopes of having an idea of what to do in case a similar incident happens again. The therapist suggested to set a family therapy counselling. The sessions would run for once a week and will taper off to twice a month depending on their progress.
By looking at the scenario above, it shows us that Andrew is suffering from a mild case of PTSD. This is a common occurrence among U.S. combat soldiers who were deployed from WWII up to Operation Enduring FreedomOperation Iraqi Freedom (OEFOIF). Furthermore, those who are serving in the army and the Marines are most likely to develop PTSD as compared to those who are serving in the Navy and the Air Force. However, most combat soldiers diagnosed with PTSD or other mental health problems refuse to seek help in fear of damaging their military career, and if they did seek help, they consult the private health sectors and do not seek help from federal agencies such as the DoD or VA.
In a study of OEFOIF deployed U.S. Army and Marines conducted by Hoge et al. (2006), they found that the prevalence of reporting a mental health problem was 19.1 among service members returning from Iraq, compared with 11.3 after returning from Afghanistan, and 8.5 after returning from other locations.
In view of the scenario above, I will apply Bronfenbrenners Theory of Social Ecology and determine the steps needed to develop a comprehensive assessment and treatment plan that fits the scenario.
In order to develop an effective treatment plan, it is first necessary to provide a better understanding of the concept of Bronfenbrenners Social Ecology Theory. Bronfenbrenner (1977) defines the ecology of human development as
The scientific study of the progressive, mutual accommodation, throughout the life span, between a growing human organism and the changing immediate environments in which it lives, as this process is affected by relations obtaining within and between these immediate settings, as well as the larger social contexts, both formal and informal, in which the settings are embedded (513).
Bronfenbrenners theory also identified environmental systems that affect human development, namely, the microsystem, mesosystem, exosystem, macrosystem, and chronosystem.
Microsystem is defined as the complex of relations between the developing person and environment in an immediate setting containing that person. This would include settings such as home, school or the workplace (1977). According to Berk (2000), the microsystem is the layer closest to the child and contains the structures with which the child has direct contact. Microsystem structures include family, school, neighbourhood, or childcare environments.
The mesosystem is comprised of the interrelations among major settings that contain the developing person at a particular point in his or her life. In this system, the childs interactions would encompass among family, school, peer group, church, or camp. Basically, the mesosystem can be characterized as a system of Microsystems (Bronfenbrenner, 1977).
The exosystem is described as an extension of the mesosystem. It is a system that embraces other specific social structures, both formal and informal, that do not themselves contain the developing person but it can affect the immediate settings in which that person is found, and thereby influence, delimit, or even determine what goes on there. Under exosystem, the structures encompassed include the world of work, the neighbourhood, the mass media, government agencies whether local, state or national, the distribution of goods and services, communication and transportation facilities, and informal social networks (Bronfenbrenner, 1977). Berk (2000) explains it further by stating that, in this larger social system, the child does not function directly, however, he or she does feel the positive or negative force involved with the interaction with his own system.
Meanwhile, macrosystem refers to the overarching in-stitutional patterns of the culture or subculture, such as the economic, social, educational, legal, and political systems, of which micro-, meso-, and exo-systems are the concrete manifestations (Bronfenbrenner, 1977).
According to Berk (2000), the macrosystem is considered as the outermost layer in the childs environment and is comprised of cultural values, laws and customs.
In the chronosystem, the pattern of environmental events during the persons life is the main factor. According to Bronfenbrenner (1990), the elements that comprises this system can be either external, such as the timing of a parents death, or internal, such as the physiological changes that occur with the aging of a child. Basically, time or critical periods affect the persons development.
Now that we have a better understanding of the social ecology theory, we can apply it to the scenario mentioned above.
Application of Bronfenbrenners Social Ecology Theory to a Family Therapy Scenario
In the scenario involving Andrew, the ecosystem factors that need to be taken into consideration would be the micro-, meso-, and chrono-systems. In the first interview, the situation would be awkward and stiff, even though the family members have sufficient time to deal with the anxiety of what they are about to do. Their commitment to attend the session indicate a recognition within the family of the problems their facing in connection with their situation. This is where the microsystem factor comes in as the structures in which Andrew has direct contact with, at the time, include home and the neighborhood. The parent will play a central part in the treatment plan as they will provide support to Andrew. In the family therapy session, a parent training intervention will also be incorporated. According to Walrond-Skinner (1976), during the initial interview, a kind of struggle will take place between the family and the therapist. Consequently, if a successful negotiation resulted from the struggle, a new system will be formed comprising of the family group and the family therapist. Walrond-Skinner (1976) also says that
Although the family has been able to produce sufficient motivation to come to the first interview, it is the therapists interventions during this crucial first session which will enable the family to come again. Therefore, the first session needs to be a therapeutic, working encounter, or what is called a real meeting of persons, so that the family goes away feeling that change is possible, without the total destruction of its present system (37).
At the outset of the treatment, the therapist is placed in a difficult position as the family views the source of the problem on one of its members. In the scenario above, although the parents are not outright laying it on Andrew, they believe that their son is the one who needs help and that they are there for the sessions to support their son and find out their task in order to help their son. The therapists task then is to shift the focus of the treatment to the family group and make them all realize that change and growth is required for all of them.
Another method that will be used in the treatment plan is the therapists use of his own personality during the course of treatment. This is a distinctive feature of family therapy wherein the family therapists primary focus is the real world of the familys current relationships. Even though the therapists task is to allow the projection of the clients internal images to him, the therapist can also use the whole of his psychodynamic make-up in a manner which will enable him to enter into the family system (Walrond-Skinner, 1976).
The therapy session would also entail the definition of the problem. In the case of Andrew, the problem will be talked about in order to draw out the horrors of war that he has experienced. This will be a lengthy process and must not be rushed.
To further help with the therapy session, a psychotherapy checklist is needed. (See Appendix A). The checklist can help the therapist determine the ecological factors that need to be taken into account in this session.
Family vs. Individual Therapy
In psychotherapy, there are instances wherein the therapist needs to determine whether a case requires the treatment of the individual alone or it requires a family therapy counseling. Let us compare first the two. One thing that we can all agree on is that family and individual therapy are both approaches designed for the treatment and understanding of human behavior. However, both have aspects that need to be considered in certain cases.
In individual therapy, there is concentrated focus. The therapist, despite venturing at times on the environment surrounding the patient, will focus mainly on the behavior of the patient and will pattern the assessment and treatment plan on the said person. Another difference of individual therapy from family therapy is the use of internalization of personal dynamics. Basically, individual therapy involves conversation that is both focused and collaborative about the clients feelings, thoughts, history and experiences. This kind of therapy is designed to allow the emergence of the clients strengths, solve clients emotional and mental problems, enable the development of courage and self-respect, and the facilitation of personal satisfaction.
Meanwhile, in family therapy, the focus is more on the external. This means that the surrounding environment, whether or not the patient has direct contact in it, and the patients social structures are analyzed and shown equal attention so as to peel off the layers that affect the patient. This would encompass the family, workplace, peer groups and neighborhood in the therapy sessions. Another aspect of family therapy that differentiates it from individual therapy is the concept of changing organizations. This involves helping the family toward a systemic change as they are made to realize that their interactions with each other can affect and influence the behavior of other family members. Simply put, family therapy focuses on issues that are affecting all the members of the family and determine how each member reacts to it and help them adjust. In family therapy, the goal is to strengthen family bonds and encourage support within the family.
To determine whether it is better to use one form of therapy over the other, we can cite a study that was conducted regarding the treatment of schizophrenia (Best Practice, 1999). The objective of the study was to present the best available information on the use of Group Therapy (GT) and Individual Therapy (IT) in the treatment of schizophrenia. A specific portion of the study dealt with the effect of individual therapy combined with family therapy compared with individual therapy alone for the prevention of a relapse in subjects diagnosed with schizophrenia from both high and low Expressed Emotion (EE) families.
The study defined the EE concept as
The belief that the critical attitudes towards a person with schizophrenia and the over-involvement with that person are predictive of a relapse. For example, family members with critical andor over-protective attitudes toward a person with schizophrenia can affect a relapse of that person (Best Practice, 1999).
The study found that subjects from high EE families are more likely to relapse compared to subjects from low EE families. With regard to the effectiveness of group versus individual psychotherapy in the treatment of schizophrenia, the study found that group psychotherapy was significantly more effective than individual psychotherapy at improving outcome ratings at both 12 and 24 months post-treatment. The study also provided therapy protocols designed for individual and family therapy in the treatment of schizophrenia. In IT, insight and control of symptoms were developed through education and support so that patients will learn to cope with life stressors and to recognize the beginnings of stress. This is continued for 12 months with 3 months of day treatment and 9 months of community treatment. Meanwhile, the family therapy protocol consists of psychoeduation, communication training and problem solving training. This will be continued for 12 months with 3 months of day treatment and 9 months of community treatment.
Media Representation of Family and Couples Counseling
The media has always had a major impact on the thoughts and actions of people. This has raised concern from the field of psychotherapy as the portrayal of psychologists, psychotherapists and psychological disorders have been far from accurate. The misrepresentation in the popular media of what psychology is all about has caught the interest of the American Psychological Society that they, in turn, established a committee to monitor the way psychologist, particularly therapists, were portrayed in movies, books and television shows.
One example is the movie Mr. and Mrs. Smith. In the film, the main characters, John and Jane Smith have been married for six years and in an attempt to save their marriage, they decided to see a marriage counselor and undergo couples therapy. The beginning of the film shows the couple as they are about to start the therapy session. The struggle between the client and the therapist is somewhat seen in the film as John Doe stated that they did not need to be there which clearly indicates resistance. The struggle can only be seen from the part of the patient and did not show the therapist. The film attempted to show a psychodynamic psychotherapy approach in the therapy session in that the clients and the psychotherapist sit face-to-face, although the therapist was never shown in the film. The interactive process which is a feature of psychodynamic psychotherapy is not depicted in the film, which makes it appear that it is a mixture of psychodynamic psychotherapy and psychoanalysis. This can be gathered from the way the therapist is portrayed as silent as he is situated far away from the couple and never says anything, allowing the main characters to continue to ramble. Although the film managed to make the therapy session appear as helpful and beneficial for the couple, the portrayal of the therapist still leaves a lot to be desired. There was no counseling process shown in the film. It depicts the stereotypical view of therapists as someone who just lets their patients or clients talk on and on while the therapist is half-heartedly listening and doodling on a pad of paper, and even though this wasnt how the therapist is portrayed in the film, it still gives off the feeling that it is a parody of the therapy session. Although this is not a favorable example of a therapy session, I believe, however, that it will not have much of an impact on a potential client in the sense that, the movie, fortunately, is not a psychologically-themed film.
Cultural Factors in a Therapeutic Relationship
Case Study
In 2000, a Latino family of three underwent a family therapy session. The family, which consists of both parents and their only teenage daughter, were to have their first family therapy session. The couple decided to consult a family therapist mainly because they are a loss at what to do with their daughter. The problem is that they fear for their daughters health as she is anorexic. Her skeleton-like figure caused her parents to send her to a nutritionist but the efforts were all in vain. A friend of theirs suggested that they consult a therapist regarding the problem. The Latino couple were at first against the idea. The connotation is that, if someone sees a therapist, then he or she is definitely crazy. They initially refused to believe that their daughter may be suffering from a mental disorder. The situation has affected the family and made the home environment tense. When the friend made the suggestion that they should undergo a family therapy counseling, the couple adamantly refused to consider the idea but their friend talked them into it and convinced them that it is for their own daughters good that they go as a family. During the familys first session, the sense of struggle appeared within the therapeutic relationship. In this scenario, the Latino couples culture and religious beliefs challenged the therapists work.
This scenario is becoming common in the U.S. seeing that the country is now tagged as the nation of immigrants. In view of this, the psychotherapy field has been facing a dilemma as they now cater to a wide range of clients of diverse ethnicities, races, socioeconomic levels, nationalities, and religions (Falicov, 1998).
Falicov (1998) further described the challenges being faced by psychotherapists in the U.S. today as she stresses the efforts of therapists, which is
To acquire sufficient cultural literacy and competence with the aim of understanding and being able to respect the cultural beliefs of the client, and at the same time, avoid the stereotypical evaluations that deprive clients of their individual histories and choices (5).
Also, mental health providers are adding to the dilemma being faced by psychotherapists today as mental health providers are limited in the treatments they offer by the very concepts and methods they use, which may be traced to their training, as it is rather imbued with the constructions and ideologies of mainstream American culture (Falicov 1998 5).
The need for therapists to be aware of cultural factors in psychotherapy is supported by Berry (1992) as he states that
There is a triangular relationship between the client, the therapist, and the society that serves as a useful point of departure to identify similarities and differences. The essential similarity is that cultural beliefs and practices prevalent in a society enter into the psychotherapeutic process because they form part of both the therapists and patients definitions and understandings of the problem (364).
According to Falicov (1998), one way to address this problem is for therapists to adopt a perspectivism approach. In the case of the scenario above, the therapist must consider the therapy encounter from a cultural perspective also. By doing so, the therapist becomes part of the ecology and not just an observer. The therapist must alter his or her views about families and family therapy seeing that it stemmed from his or her ecological niche, which consists of the therapists preferred brand of theory and professional subculture. Falicov (1998) describes the perspectivism approach as the adoption of a relational understanding of all descriptions especially when working with clients that are culturally diverse.
When working with Latino families, Falicov (1998) has presented an approach that can help therapists address the cultural factors in psychotherapy. It is known as the multidimensional ecosystemic comparative approach (MECA). Under the said approach, there are four dimensions that can be used to describe and compare similarities and differences among cultural groups. The four dimensions include migration, ecological context, family organization, and family life cycle. By having an understanding of the similarities and differences in the culture of therapist and client, the therapist will be able to use it to enhance their therapeutic relationship.
Theory of Change in Psychotherapy
The change process is considered a complex and lengthy process in the therapeutic relationship. Over the past few decades, the concept of group therapy has steadily gained prominence as more and more therapists find it to be an effective method in affecting behavioral change in individuals. However, the point here is that, it does not matter which of the individual and group therapy approaches is more effective, but rather, the successful treatment of concerned individuals. If there is one thing that practicing clinicians agree on is the fact that affecting change is the goal of psychotherapy.
From my personal experience of administering therapeutic sessions and observing other therapists, one thing that I believe that makes a successful therapeutic relationship is the establishment of trust between the therapist and the client. Without it, the therapeutic relationship would never develop leading to more disastrous results. The therapists approach is crucial at this stage because it can determine what will be the outcome of the therapy session. I have seen some instances where the therapists approach during the first meeting caused a client to be wary and antagonistic towards the session, ending in the client deciding to discontinue the session.
Before proceeding further, an understanding of what constitutes the change process in psychotherapy is needed. According to Schein (n.d.), whether at the individual or group level, the theoretical foundation of the change process involves unlearning, without loss of ego identity, and difficult relearning, as the individual attempts to restructure hisher thoughts, feelings, attitudes and perceptions. Schein (n.d.) also states that the individuals decision to learn and undergo the change process stems from the sense of dissatisfaction or frustration one feels when expectations or hopes are disconfirmed.
With regard to my theoretical approach to the change process, I lean more towards the integrative approach. According to the Institute of Integrative Psychotherapy (n.d.), integrative psychotherapy is a therapeutic approach that deals with the inherent value of each individual. It also refers to the joining together of the affective, cognitive, behavioural, and physiological systems within a person. Nowadays, it is very rare to find a therapist that subscribes to just a single theoretical orientation. I find it more effective to apply various theoretical approaches in terms of assessment, diagnosis and treatment. As the world changes at a rapid pace, people often find themselves in situations where they are unable to cope. In view of this, the complaints and issues being faced by people has also become more complex. This is the reason why I subscribe to the need for therapists to change as well in order to provide effective intervention and treatment methods to their clients.
Convergence of Theoretical Approaches
In my practice, I subscribe to the notion that there is no single clear-cut way in terms of psychotherapeutic approach. Although it is a given that every approach is effective in their own way, some would be more effective depending upon the individuals, both the therapist and the client, particularly in what they are hoping to achieve in the therapy session. I support Hackneys (1992) views regarding the field of psychotherapy at present, in which he states that
If one examines theoretical integrity today, based upon what counselors faithful to that theory do with clients, a convergence of theories appears to be occurring. Humanistic theories have been infiltrated by some classical behavioral interventions. Behavioral approaches acknowledge the legitimacy of feelings and the appropriateness of affect change. Cognitive approaches are frequently referred to as cognitive-behavioral. Systemic approaches utilize many interventions that one can only describe as cognitive in nature (Hackney, 1992).
This perspective is further proof that more and more therapists are finding it more advantageous to implement an integrative approach in their practice rather than the one size fits all approach they used to implement.
Elements to a Unifying Language in Therapy
Despite the implementation of various therapeutic approaches in my practice, I always keep in mind the four elements common to all forms of therapy. By doing this, I am able to effectively apply the different theoretical approaches that I feel would suit the clients needs. Duncan et al. (1997) states that the four common curative elements constitute the unifying language in therapy, as each one is central to all forms of therapy despite theoretical orientation, mode (i.e., individual, group, family), or dosage (frequency and number of sessions). These four elements, in order of their relative contribution to change in therapy, are extratherapeutic factors therapy relationship factors model and technique factors and expectancy, hope, and placebo factors.
Theoretical Approaches
In this section, I will discuss some of the theoretical approaches that I apply in my practice. Each one, I find, offers something that allows the client and I to establish a therapeutic relationship. By combining these theoretical approaches depending on the clients problems, an intervention and treatment plan is formulated leading to a therapy outcome that both parties will find acceptable and effective.
The Object Relations Theory can be defined as psychodynamic approach which deals with the development of interpersonal relationships within the family, particularly in the mother-infant relationship. According to Sexton et al. (2003), in object-relations theory, the mother plays a crucial role in a childs survival. The mother not only ensures the survival of the child but she also provides nurture and love to the child and has the important task of presenting the child to the family group and making sure that they will acknowledge and let the relationship grow. This will enable the infant to grow and develop character, as well as develop the capacity to relate with other people. Though it has a psychoanalytic foundation, the object-relations theory also puts into context the family group which makes it a better approach to use in terms of the practice of couple and family therapy, unlike the classical psychoanalytic approach which focuses on the influence of sexual and aggressive instincts on human development.
Sexton et al. (2003) states that the couple relationship has a somewhat similar structure to the mother-infant relationship in that
The individuals conscious and unconscious internal object relationships are projected into the spouse who has been chosen for having the capacity to resonate with, fit, and identify with the projection. In the healthy marriage, the spouse also has the capacity to separate from the unconscious projections and modify them, but in the unhealthy marriage the projections are confirmed and form a closed system that stifles the growth of the individuals (66).
I can relate to this approach because my mother also has been a significant factor in my growing years until I reached a certain age when I was made aware about this. I realized that it could have an effect on my relationships with other people. Some of the couples that I have encountered in my practice have experienced the same issue. The married couples are unaware that they have projected the maternal image, or their experiences and image of their respective mothers, into the relationship, thus putting a strain in their marriage.
Another approach that I can tailor-fit in a therapy session, depending on the case, is the Mental Research Institute (MRI) interactional approach, which is classified under the brief therapy approach. Duncan et al. (2003) described the MRI interactional approach as providing a theoretical perspective of both human problems and change. The MRI approach posits that individuals and families who are evolving through the life cycle, encounter chance or transitional incidents which causes problems to emerge. There are two conditions in which a circumstance or everyday difficulties can turn into a problem the first is the mishandling of the difficulty and the second is that, despite the failure of the original solution attempt, more of the same is applied resulting in a vicious cycle.
During counselling sessions, there are times when I implement the structural family therapy approach. In structural family therapy, some of the underlying assumptions indicate that families or people possess an innate competence and capability in terms of solving their problems and just need guidance. My role in this approach is not to solve the problem but to act as consultants and life coaches. The preconceived notions of the therapist on what would be ideal for the family is not present here.
I find this approach to be effective because it is a collaborative effort. The individuals that are under session are guided by me to find the solution to their problems.
Another approach that I find effective in family therapy sessions is the postmodern social construction perspective which has a somewhat similar approach with structural family therapy. The postmodern social construction therapy can be described as the examination of the assumptions that clients make with regard to their problems. This approach places the therapist along with the client as they seek new meaning and action towards what they conceive as the state of happiness. The predetermined notions of the therapist on what the client needs is not visible here, thus, making the therapist appear not as an outside expert but as a companion (Goldenberg Goldenberg, 2007). The therapeutic interventions applied in this approach includes the collaboration between the therapist and family members as they all participate under an assumption of shared expertise. Dialogue between the therapist and the family members occur with the aim of considering other alternatives that can better their lives by helping them shake loose from a set or fixed account of their lives (Goldenberg Goldenberg, 2007).
Agents of Change
In my practice, there are several change agents that I find central to my therapeutic sessions. This is in support of Truax and Carkhuffs (2007) position that there are four learning modalities or channels that can be found in psychotherapy, namely, reinforcement of human relating, reinforcement of self-exploration, elimination of specific anxieties and fears, and reinforcement of positive self-concepts and self-valuations. I have applied these factors as change agents in my practice because these are attributes that therapists use to affect behavioural change.
Part 2
Object Relations and Psychodynamic Approaches
The Object Relations Theory can be defined as psychodynamic approach which deals with the development of interpersonal relationships within the family, particularly in the mother-infant relationship. According to Sexton et al. (2003), in object-relations theory, the mother plays a crucial role in a childs survival. The mother not only ensures the survival of the child but she also provides nurture and love to the child and has the important task of presenting the child to the family group and making sure that they will acknowledge and let the relationship grow. This will enable the infant to grow and develop character, as well as develop the capacity to relate with other people. Though it has a psychoanalytic foundation, the object-relations theory also puts into context the family group which makes it a better approach to use in terms of the practice of couple and family therapy, unlike the classical psychoanalytic approach which focuses on the influence of sexual and aggressive instincts on human development.
Sexton et al. (2003) states that the couple relationship has a somewhat similar structure to the mother-infant relationship in that
The individuals conscious and unconscious internal object relationships are projected into the spouse who has been chosen for having the capacity to resonate with, fit, and identify with the projection. In the healthy marriage, the spouse also has the capacity to separate from the unconscious projections and modify them, but in the unhealthy marriage the projections are confirmed and form a closed system that stifles the growth of the individuals (66).
In their book, Sexton et al. (2003) presented a scenario wherein the object-relations, couple, and family therapy (ORCFT) approach was applied. In the scenario, a projective identificatory system was identified in the couples straining relationship wherein the maternal image, or their experiences and image of their respective mothers were projected into the relationship.
In the object-relations therapy that was applied to the couple, the projective identificatory factor was addressed as the therapist made them realize that it is considered as a disabling factor in their marriage in that they allowed the image of their family-origins into their relationship, particularly during the child-rearing years of their marriage, which was when the issues started to emerge. In the scenario, the therapist made the couple review their family histories and assisted them in letting go of the working models they had developed in their families of origin, allowing them to have the freedom to create a more equal family structure where each contributions are valued. The authors also provided clinical assessment methods that can be used in ORCFT such as, establishing a frame, establishing an alliance, nonstructured interview, beginning with symptoms and how each member thinks about them, and observing defensive patterns, just to name a few.
Brief Therapy vs. Postmodern Social Constructivism
In this section, I will provide a comparison between the InteractionalSolution
Focused Brief Therapy approach and the Postmodern Social Construction perspective and determine which approach is more beneficial in certain cases.
According to Duncan et al. (2003), the brief therapy approach emerged due to the growing disillusionment of therapists with psychodynamic therapy in terms of family therapy. In brief therapy, the best of both worlds is represented in that it encompasses the formative ideas of family therapys past, which was generated and taught by the most prominent scholars in the field of therapy. Consequently, it can also serve to connect the therapies of a different era, such as those that are pushing for therapeutic change through language and relationship.
In their essay, Duncan et al. (2003) described the Mental Research Institute (MRI) interactional approach as providing a theoretical perspective of both human problems and change. Specifically, the MRI approach is based on an understanding of any selected bit of human behavior in terms of its place in a wider, ongoing, organized system of communicative interaction (cited in Duncan, 2003, 102). The MRI approach posits that individuals and families who are evolving through the life cycle, encounter chance or transitional incidents which causes problems to emerge. There are two conditions in which a circumstance or everyday difficulties can turn into a problem the first is the mishandling of the difficulty and the second is that, despite the failure of the original solution attempt, more of the same is applied resulting in a vicious cycle.
Under the MRI interactional approach, the assessment methods consist of inquiries and response elicitation. The therapist begins by asking each individual about the problem, specifically, what they are saying and doing in performing the problem. The next step is to inquire what they are doing to resolve the problem. Next, the therapist will inquire about the clients minimum goals of treatment. The final part of the assessment would involve the understanding of the clients so-called position, which can be defined as the strongly held beliefs, values and attitudes that influence the clients behavior in relation to the presenting problem and affect participation in therapy (ctd. in Duncan, 2003, 104).
On the other hand, the Solution-Focused Brief Therapy (SFBT) has three central philosophy in which it operates. The first is If it aint broke, dont fix it This philosophy is in contrast to traditional models of practice wherein therapists look for underlying illnesses or unrecognized problem states other than the ones that are being complained about in the first place (Duncan et al., 2003).
The second SFBT philosophy is Once you know what works, do more of it Basically, this rule implies that focus in therapeutic work should be pinpointed on those times when there is no occurrence of the problem and help the client repeat and maintain these exceptional periods (Duncan et al., 2003).
The last SFBT philosophy is If it doesnt work, then dont do it again, do something different This is similar to one of the conditions mentioned in the MRI approach, which implies that interventions that do not work on the client should be discontinued and that the therapist needs to move on and find other ways to help the client (Duncan et al., 2003).
There are specific characteristic features found in the SFBT approach. These include the miracle question scaling questions an intra-session break, and a postsession message that includes compliments and a homework task or suggestion (Duncan et al., 2003).
Meanwhile, the postmodern social construction perspective can be described as the examination of the assumptions that clients make with regard to their problems. This approach places the therapist along with the client as they seek new meaning and action towards what they conceive as the state of happiness. The predetermined notions of the therapist on what the client needs is not visible here, thus, making the therapist appear not as an outside expert but as a companion (Goldenberg Goldenberg, 2007). The therapeutic interventions applied in this approach includes the collaboration between the therapist and family members as they all participate under an assumption of shared expertise. Dialogue between the therapist and the family members occur with the aim of considering other alternatives that can better their lives by helping them shake loose from a set or fixed account of their lives (Goldenberg Goldenberg, 2007).
Personally, I prefer the brief therapy approach because it is more straightforward and focuses on the complaint or problem itself. The social construction approach is too broad. In the end, the approach to be used in a clinical setting would depend on the case itself.
Cognitive Behavioral Intervention
In this section, I will select three cognitive behavioral interventions and apply them to some of the cases that I have encountered.
The interventions that I have chosen include cognitive therapy, relaxation training and social problem solving.
The first case involves a middle-aged man who is suffering from work-related stress and depression. The man has been working for the same company for 12 years and he has slowly risen up to the ranks due to hard work, skill and perseverance and eventually was promoted to a managerial position which he now is occupying for more than three years. However, for the past year, the man slowly began to feel unproductive and also began to commit mistakes, though not enough to completely jeopardize the company, but the work-related mistakes kept on piling and the man began to feel worthless and depressed.
In this case, cognitive therapy can be implemented in order to reverse the negative thoughts that are causing the client to become distressed. In the therapy, the therapist and the client will discuss what the problem is and how it can be resolved. Focus will be on the negative beliefs that has taken root in the clients thinking.
Relaxation training can also be implemented in this case to complement cognitive therapy. Relaxation exercises and meditation will be helpful in relieving stress particularly in those that have demanding jobs. Relaxation training can also be an effective intervention tool for soldiers with PTSD.
Another case involves a male high school student who becomes depressed and refuses to go to school mostly by skipping classes. The therapy would consist of identifying the problem, in which cognitive therapy will also play a significant role in order to turn the negative notions the client has associated with school. Another strategy that can be used by the therapist is the use of social problem solving. The therapists task is to encourage the client to develop social problem-solving skills in order to get to the root of the problem and its resolution. The skills involved would include
Noticing signs of feelings
Identifying issues or problems
Determining and selecting goals
Generating alternative solutions
Envisioning possible consequences
Selecting the best solution
Planning and making final check for obstacles
Noticing what happened and using the information for future decision making and problem solving (Elias Tobias, 1996).
Part 3
Case Analysis
John Q, a 34 year old construction worker, and his wife, Becky, a 28 year old pharmacy technician, presented to the clinic after Mr. Q was discharged from a two-week psychiatric hospitalization. Mr. Q was hospitalized for suicidal ideation subsequent to a confrontation with his wife in which she confessed to being involved in a six-month Internet relationship with a man she met in an online community. Mr. and Mrs. Q have both suffered from periodic depression since late adolescence without psychiatric treatment of any kind. Mr. Q reported having had suicidal thoughts in the past and attempting to slit his wrists once when Mrs. Q postponed their wedding ceremony.
Mr. and Mrs. Q report a lack of intimacy and open communication in their marriage, with both partners becoming easily irritated at the other. There is heavy use of profanity, sarcasm, and stonewalling in their arguments. Mrs. Q stated she has repeatedly complained to her husband that he is uninvolved and unconcerned about the lack of engagement in their marriage. Mr. Q reported that his wife has been acting secretive and suspicious for the past two years, and that is why he has withdrawn from her, feeling unable to trust her. They have
six-year-old twin sons and have lost two babies to miscarriages since the birth of their sons. Neither partner is certain of whether or not they want to remain committed to each other in this marriage.
In the case analysis above, the theoretical approach that can address the familys needs is the MRI interactional brief theory. The assessment methods will, of course, encompass the inquiry about the problem and its resolution the minimum goals treatment and the client position. Cognitive behavioral intervention can also be implemented in the therapy session.
Structural-Strategic Comparison
The basic concept of the Strategic Family Therapy approach is for the therapist to devise a strategy that will, in an indirect manner, produce change in the family system. There are two main models in this theory, namely, the MRI briefcommunication model and the Haley and Madanes strategic approach. The difference between the two is that the MRI model focuses only the problem that causes behavioral change and is not interested in long term change, insight, or how the function serves in the family. On the other hand, the Haley and Madanes model is interested in both long and short sequences and those that reflect chronic problems in the family structure. Some of the methods implemented in the strategic family therapy include reframing, paradox, changing the sequences of interactions, metaphor, rituals, and other strategic devices (Barker, 1998).
In structural family therapy, some of the underlying assumptions indicate that families or people possess an innate competence and capability in terms of solving their problems and just need guidance. This is why the therapists role in this approach is not to solve the problem but to act as consultants and life coaches. The preconceived notions of the therapist on what would be ideal for the family is not present here.
In terms of applying it to a multicultural practice, the structural family therapy approach is more ideal. As mentioned in Part 1, one of the dilemmas being faced by therapists in the U.S. at present is that the nation is so diverse. Cultural factors need to be addressed by the psychotherapy field as people from different cultures are migrating in the U.S. Having knowledge of the different cultural backgrounds would be ideal, but that is not the case, and since therapists are being restricted by these cultural factors in attaining a therapeutic relationship with clients, the structural family therapy can be the answer to the problem since the resolution of the familys problem doesnt rest solely on the therapist but is a collaborative effort.
Maintaining a Cohesive Integrative Approach
According to the Institute of Integrative Psychotherapy (n.d.), integrative psychotherapy is a therapeutic approach that deals with the inherent value of each individual. It also refers to the joining together of the affective, cognitive, behavioural, and physiological systems within a person. On the other hand, eclectic psychotherapy deals with the application of various schools of psychological theories and implementing it in therapy with the aim of determining what theoretical approaches or therapeutic techniques will work for certain cases.
I find myself leaning more toward the integrative psychotherapy approach because it is more rounded and complete in terms of therapeutic treatment and it more concerned with the how and whys of treatment which is more like my style, unlike the eclectic approach which deals with the method of what works in terms of treatment.
Literature Review
In this age of digital technology and globalization, it is noticeable how posttraumatic
stress disorder (PTSD) cases continue to rise around the world. PTSD is not a recent phenomena, however, it is only recently that it has caught the publics attention and interest due to the ready availability of information from various media. It is only now that we are beginning to familiarize ourselves with how traumatic events affect survivors and their loved ones. In this section, I will discuss the concept of PTSD, its prevalence, etiology, assessment, diagnosis, treatment and prognosis.
In her article, Dryden-Edwards (n.d.) defines PTSD as an enotional illness that usually develops out of experiences that are frightening or life-threatening. People who are experiencing PTSD exhibit symptoms such as avoidance, whereby they tend to avoid places, things, or people that remind them of the said event, and hyperarousal, where they tend to be hypersensitive to normal life experiences.
Kinchin (2004) further describes PTSD as resulting from an exposure to an event which is outside the range of normal human experience. The traumatic events experienced by PTSD victims are categorized into three, namely, intentional human causes, unintentional human causes and acts of nature (Schiraldi, 2009). Some potentially traumatic events and stressors included under intentional human causes inclulde abuse (sexual, physical and emotional), torture, criminal assault, terrorism, bombing, etc. Unintentional causes would encompass industrial accidents, fires, motor vehicle accidents or plane crashes. Acts of nature include hurricane, typhoon, tornado, earthquake, or volcanic eruption, among others (Schiraldi, 2009).
It is very likely that PTSD has existed since human beings have been exposed to traumatic events, but it is only in 1980 that it has been formally recognized as a diagnosis (Dryden-Edwards, n.d.). In its early years since its formal recognition, PTSD is mostly associated with soldiers and rape victims.
There are three groups of symptoms that therapists refer to when diagnosing PTSD. These include the recurrent re-experiencing of trauma avoidance, and in extreme cases, developing phobia of places, people and events that remind PTSD sufferers of the traumatic event and chronic physical signs of hyperarousal and increased sensitivity (Dryden-Edwards, n.d.).
In the clinical practice guideline released by the U.S. Department of Defense Deployment Health Clinical Center (DHCC), there are several assessment tools they employ in diagnosing PTSD including NCPTSD Assessment Tools ISTSS Assessment and Treatment Resources Clinician-Administered PTSD Scale (CAPS) annd the Standard Health Assessment Tools (Guidelines, n.d.). With regard to assessing PTSD in children and adolescents, clinicians will use a rating scale or conduct a structured psychiatric interview. Some of the PTSD tools used include the Diagnostic Interview for Children and Adolescents-Revised (DICA-R), the Diagnostic Interview Schedule for Children-Version IV (DISC-IV), and the Schedule for Affective Disorders and HYPERLINK httpwww.medicinenet.comscriptmainart.asparticlekey470Schizophrenia for School Age Children (K-SADS) (Dryden-Edwards, n.d.).
Some of the usual techniques used by psychotherapists in treating PTSD include providing information about the illness, discussing the trauma with the sufferer, providing information on managing PTSD symptoms, and exploration and modification of inaccurate notions about the trauma. Another effective treatment technique is educating sufferers about PTSD. The objective of this technique is that it dispels inaccurate ideas of individuals about their condition and the shameful feelings they have. Cognitive therapeutic approaches are also used in the treatment of PTSD such as the eye movement desensitization and reprocessing (EMDR) therapy. This approach focuses on observing the rapidly moving finger of a PTSD sufferer while heshe talks about the traumatic event heshe experienced. Medications also help in treating PTSD. Some of the usual medications prescribed by therapists include antidepressants like fluoxetine, sertraline and paroxetine (Dryden-Edwards, n.d.).
According to Cohen (n.d.), the prognosis of PTSD varies for every individual. Others exhibit a surprising return to normal functioning while some were observed with persistent and fluctuating symptoms of the disorder.
Emotionally Focused vs. Behavioral
The foundation of emotionally focused therapy (EFT) is based on the experiential process of psychotherapy, and at the same time, it employs approaches of systems theory and attachment theory (Crawley Grant, 2005). In their book, Greenberg Johnson (1988) presents their argument that emotions play a potentially adaptive role in human relationships, particularly in couples relationships, stating that emotions amplify the effects of motives on behavior and orient individuals to face or turn away from different objects in their environment. With regard to couples or marriage therapy, EFT views couple relationships as inherently systemic and interactional. EFT focuses on gaining an understanding of the cyclical and destructive interaction patterns that affect the relationship of a couple (Crawley Grant, 2005).
On the other hand, behavioral therapy, as described by Niolon (1999), focuses on the present and not on past history. Some of the central premises that it observes include
1. behavior is maintained by its consequences in a more or less complex linear model. Symptoms are learned responses that are caused by dysfunctional reinforcement (often involuntary).
2. behavior change is best brought about by accelerating positive behavior and decreasing aversive control, as well as by improving communication and problem solving skills.
3. Focus on dyadic interactions primarily.
4. Treatment is tailored to specific family (Niolon, 1999).
Both of these approaches are helpful in a family therapy setting as they both have things to offer in terms of family development and addressing marital relationship issues. Personally, I prefer the EFT approach because I subscribe to the fact that emotions govern our lives, particularly our behavior and thought processes. EFT also considers the history of the parties involved, unlike the behavioral approach which only focuses on the here and now resulting in the recurrence of the problem.
Multisystemic vs. Functional
Multisystemic Therapy (MST) is a therapeutic approach that is designed to address antisocial behaviour in adolescents through the employment of a community-based treatment focusing on both the youth and their support systems (American Youth, n.d.). Site assessment is critical aspect of the said approach in that it considers the social system in which juvenile offenders navigate. This supports the theory that antisocial behaviour in adolescents is related to characteristics of the individual, the family, the peer system and the community (American Youth, n.d.).
Evidence Based Practice
One statement that therapists know for a fact is that evidence based practice is an essential and realistic goal for the future of marriage and family therapy. Before I present my analysis on this statement, it is necessary to establish a definition of evidence based practice. According to Pucci (2005), it can be defined in two ways. The first is that it is a therapeutic approach designed to emphasize the pursuit of evidence on which to base its theory and techniques, as well as to encourage its clients to consider evidence before taking action. The second definition implies that it is an approach that is supported by research findings, and those findings provide evidence that it is effective. With regard to the abovementioned premise concerning evidence based practice, I think that it is an effective tool that can be used in marriage and family therapy because patients or clients will respond better to treatment if they believe that it has worked before. However, not everyone has similar cases and a lot of factors have to be considered. The evidence based approach can be used as somewhat of a framework but assessments and evaluations still needs to be tailored to the patients case.
There are several steps needed to implement evidenced based practice in psychotherapy. The first is to ask important questions about the patients or clients case. Second, is to acquire the best available evidence with regard to the case. Third, is to provide a critical appraisal of the evidence and examine it in terms of validity and applicability to the problem at hand. Next, is the application of the evidence through collaborative decision making with the affected individuals. The last is the assessment of the outcome and dissemination of the results.
Ethical Dilemmas
There are lots of instances where family therapists are placed in a position where they have information about one member of the family there are counselling which could negatively affect further their relationship. This is called an ethical dilemma. Family therapists need to be careful when handling such situations because it could cause a setback to the progress that the family has achieved so far.
I have encountered an ethical dilemma when I counselled a couple who decided to undergo couples counselling. The husband has been suffering from work-related stress for the past several months causing some problems with the couples marital relationship due to the husbands irritability and inattentiveness. After several sessions, the couple shows signs of reconciling their differences and the husband is also able to handle the stress properly. In one of the individual-based sessions, the wife admitted that she had sexual relations with other than her husband during the time when they were having problems. She met the other man through a chat line and she felt guilty afterwards. The wife ended it after a couple of weeks. The wife is debating whether to be honest about it to her husband. I was faced with an ethical dilemma because I believe that disclosure is the right thing to do for the relationship to succeed. However, in this case, disclosure may cause harm to the other partner and may react violently. The other partner was doing well so far and if the information would be revealed it may cause a setback to his progress. I advised the wife to keep the information to herself and suggested further individual sessions with her to address the issues she has been facing. Looking back, I would still act the same way because this is a matter where disclosure may cause further harm than a solution to the problem.
Case Analysis I
You have been working with a family for three sessions when the 9 year old daughter reveals information that raises the possibility of physical abuse. Both the 9 year old daughter and the 7 year old son are by all reports, well behaved, polite, and mild mannered children. They perform well in school and are active in extracurricular activities. The father, a 45 year old bank executive, and the mother, a 44 year old housewife, are often critical of their children, comparing them to others and imposing their decisions on the children. In previous family sessions you have also observed that both parents demonstrate a high level of frustration, problems controlling their angeryelling, getting up and into each others faces, throwing or knocking things over, requiring repeated redirection to calm down, and have inappropriately high expectations for their children.
You recommend to the parents that it would be helpful for you to conduct a separate session with the children as they are often quiet in family sessions. The parents, however, will not allow you to interview the children in their absence. Despite your reservations, you accommodate their wishes and end the session on a positive note. When the family appears for the next session, the 7 year old has a bruise on his face that he claims is from a skateboarding accident.
As a family therapist, my task is to provide treatment for the whole family. However, the main concern is the children. Although there is a possibility of child abuse in this case, it would still be a suspicion and deciding hastily is not an option. I would consult first with other mental health professionals on how to handle the situation properly and determine if there is a need to submit an abuse report. Separate sessions for the parents and the children will be insisted. Although confidentiality is important in therapy, therapists also need to consider the possibility of whether a critical event in between sessions has occurred causing physical harm to others. Medical intervention is needed in this case as a possible physical manifestation of violence can be glimpsed.
Case Analysis II
You are counseling a couple, Mr. and Mrs. C., who are both mid level managers at
separate businesses in the metropolitan area and are in their late 30s. They met over the Internet eight years ago, have been married seven years, and have a 6 year old son. Mr. C tends to be quite traditional and straight laced while Mrs. C. is more extraverted and adventurous. They both insist that they are completely in love with each other and will do anything to work out their marital differences. After six sessions of marital counseling in which you have become extremely frustrated at the complete lack of cooperation, compromise, or progress of any kind, you decide to schedule individual sessions with each partner. The couple agrees and they independently schedule their sessions.
During your interview with Mrs. C, she is quite calm and agreeable until asked directly about any extramarital activity. At this point, she becomes defensive and then tearfully acknowledges having been intimately involved with a male coworker for the past three years. She insists that she wants to remain married to her husband and is adamant that she will not reveal her affair to him nor end the affair.
During your interview with Mr. C, he confesses that he believes a big part of his marital problems is due to his mistrust of his wife and his paranoia that she is cheating on him. He reports that he has confronted her repeatedly and she denies any infidelity, which he believes. Mr. C breaks down in tears, angry at himself for being unable to let go of his fears and suspicions even through he is convinced they are all a figment of his imagination and that his wife has been faithful to him. Mr. C is certain he wishes to save his marriage and wants to continue in marital counseling.
In this case, the stakeholder in this ethical dilemma is Mr. C as he is one in which the secret is being withheld upon. The course of action that needs to be taken is to reveal the information to Mr. C. This decision is due to several factors. The first is that, even though they care about each other, Mrs. C refuses to end the affair. Another factor is that it is causing Mr. C a lot of stress as he is unable to let go of his suspicions regarding his wifes infidelity. This may cause further harm to the mental condition of the husband in the long run. However, their 6 year old child should also be included in the therapists decision making process as this could affect the child negatively.
Safety Planning
In marital counseling cases where there is a history of domestic violence between spouses, it would be more appropriate to conduct a separate session for each partners, for starters. Individual issues need to be addressed first before a therapist can proceed to conducting a joint session with the couple. A safety plan needs to be implemented in order to protect the victimized partner without angering or alienating the abusive partner. This can be done during the separate sessions without the knowledge of the abusive partner. According to Coombs (2005), the safety plans include the encouragement of the victimized partner to establish an escape route should the need arise for the victimized partner to leave home on short notice advising victimized partner to keep important documents and belongings in an accessible place and assist in familiarizing victimized partner on community resources such as shelters and womens support centers that can help the client. Coombs (2005) also offers advise on how family therapists can help the partner at risk on dealing with situations where there is a high risk of victimization. One is to advise the partner at risk to avoid provoking his or her partner by taking out a restraining order. Another is to formulate strategies that will keep the party concerned safe when critical events occur. Also, the partner at risk can also try to discuss the other partners anger without being too confrontational (227).
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