Unit 7 D1 CASE EXAMPLE This summary refers to the case of Paul, whose treatment was used to illustrate aspects of IPT in the “Process of Psychotherapy” section. As noted, 22-year-old Paul presented to his university's student health services complaining of a number of symptoms he had been experiencing over the past couple of months: feeling sad and empty, difficulty concentrating, poor sleep, loss of appetite, and fatigue. Paul's clinical interview confirmed a diagnosis of major depression, and his score of 18 on the Hamilton Rating Scale for Depression (HAM-D) confirmed that he was suffering from a severe depressive episode. Based on his low scores on measures of suicidality and neurovegetative symptoms, the therapist decided not to recommend medication at this time. While taking a psychiatric history, the IPT therapist learned that Paul was the second of two children. His father was a partner in a big law firm; his mother had stayed at home to raise Paul and his sister, Sarah. Paul had been an anxious child, and although he had always had two or three close friends, he struggled to meet new people. He had always been close to Sarah, who was very protective of her younger brother. On the one hand, his relationship with his sister gave him a sense of security, but on the other it occasionally left him feeling deficient. Whereas Paul was shy, an average student, and lacked confidence, by contrast Sarah was outgoing and academically gifted. Paul felt close to his mother but had a difficult relationship with his father, who seemed to identify much more with his sister. He was quick to praise Sarah and celebrate her academic excellence, but he was often dismissive and sarcastic toward Paul, whose lack of direction seemed to puzzle and frustrate him. Paul had always gotten by at college with mediocre grades, despite having suspected attention deficit hyperactivity disorder (ADHD), although a formal assessment was inconclusive. He was not passionate about any particular subject area and had chosen to major in sociology because it “seemed easy and kind of general.” However, now that he was in the spring semester of his final year, this choice of major had left Paul unsure what he wanted after he graduated in the summer. He felt like he might do better with a career that was concrete and action oriented: “less academic and, you know, more practical.” Paul's depressive episode started after the winter break. He was finding it hard to concentrate and struggling with his courses; in particular, his anxiety that he might fail stats had led Paul to think that maybe he should “just drop out.” Being given the “sick role” at this point in treatment seemed to reduce somewhat Paul's anxiety and persuade him to hold off making drastic decisions about his college and professional future. It also helped him start considering practical solutions to his most pressing current problems, in particular how to handle his failing grade in his stats class. Having conducted the interpersonal inventory, the IPT therapist hypothesized that Paul's depressive episode had been triggered by his uncertainty about what to do after college (a role transition) and exacerbated by the pressure and high expectations resulting from his tense relationship with his father (an interpersonal dispute). The fact that his sister had recently gotten engaged and been accepted into law school had left Paul feeling even more inadequate and lost. This interpersonal formulation made sense to Paul, and he and the therapist agreed to focus their work together in therapy on his upcoming postcollege role transition and his interpersonal dispute with his father. In the middle phase of treatment, the therapist worked with Paul to help him clarify his role transition by separating his feelings and views from other people's, coming up with options about his next career step, and identifying individuals who could help him in this transition by providing information or support. The therapist also helped Paul become more aware of how his father's derogatory remarks affected his depression and assisted Paul in learning to set limits with him. Over the next few weeks, Paul's depressive symptoms began to improve, and increasingly he took an active role in therapy. Paul explained his situation to his stats professor and, based on her advice, decided to take an incomplete grade for the course. He also made an effort to spend more time with his friend Lisa, and in doing so became friends with her roommates. These accomplishments gave Paul a sense of interpersonal mastery and a new sense of confidence. Paul also became more proactive about planning what to do after college. Reflecting on how much he had enjoyed taking an introductory EMT course, he did some Internet research and talked with a career counselor about next steps in exploring this as a potential career. Paul also worked hard at setting limits in his interactions with his father. Although he felt they “weren't any closer,” he became better at establishing limits and over the course of therapy their phone conversations began to affect Paul's mood less. Having declined steadily, four sessions before treatment termination, Paul's HAM-D depression score briefly increased by several points. Reflecting that this was quite normal for a patient nearing the end of treatment, the therapist assuaged Paul's anxiety about ending therapy, reminding him of the considerable progress he had made over the previous few months. In the final phase of treatment, Paul and his therapist took stock of the progress he had made: the improvements in his depression, his increased interpersonal mastery, and the progress he had made in his postcollege role transition and interpersonal dispute with his father. This discussion became a springboard to discuss Paul's ongoing progress after therapy, the problems that might trigger a future depressive episode, and the resources available to Paul to deal with them. Paul reflected that he felt proud of his gains during therapy and pleased about his decision to take a second EMT course after graduating. He was realistic about his relationship with his father, noting that although he was now giving him more space, when it came to his career plans, his father still did not really “get it.” He felt good about his relationship with his mother, who had been very supportive of his treatment and encouraging with regard to his plans for the future. Now that Paul felt more secure in himself and his future, he was also able to enjoy his sister's success more. When, in the last session, Paul and the therapist discussed treatment termination, Paul reflected that although things “weren't perfect,” he felt he would “do all right.” Before the termination of treatment, the therapist made sure to keep the door open by letting Paul know that if ever he needed more help he could recontact her. Eighteen months later, Paul did call. He reported that in general things were going well. He had not had any more depressive episodes, had become a full-time EMT, and was enjoying the work. He had made a few new friends, and although mostly he was focusing on his career, had been dating casually. However, although he was getting on well with his mother and sister, his relationship with his father remained distant. Paul still felt that in his father's eyes he was “just an EMT” and resented feeling “like I somehow disappointed him, or something.” Recently, Paul's father had suffered a heart attack, which had left Paul feeling anxious and as though he should try to “patch things up between us.” The therapist congratulated Paul on the gains he had made and reminded him of the importance of separating his own feelings and views from those of others. She helped him accept that his current relationship with his father might be “as good as it gets” and gave him an opportunity to mourn the fact that he might not ever get to be as close to his father as he would have liked. This realization, while sad for Paul, made him feel “less bad, less … responsible for how things are between Dad and me” and appeared to reduce his anxiety about their relationship. (Wedding 367-369) Wedding, Danny. Current Psychotherapies, 10th Edition. Cengage Learning, 20130312. VitalBook file. The citation provided is a guideline. Please check each citation for accuracy before use. Unit 7 D2 CASE EXAMPLE Background Although the appearance of troublesome symptoms in a family member is typically what brings the concerned family to seek help, it is becoming increasingly common for couples or entire families to recognize they are having relationship problems that need to be addressed at the family level. Sometimes, too, therapy is seen as a preventive measure. For example, adults with children from previous marriages who are planning to marry may become concerned enough about the potential problems involved in forming a stepfamily that they consult a family therapist before marriage. Frank, 38, and Michelle, 36, who are to marry within a week, referred themselves because they worried about whether they were prepared or had prepared their children sufficiently for stepfamily life. The therapist saw them for two sessions, which were largely devoted to discussing common problems they had anticipated along with suggestions for their amelioration. Neither Frank's two children, Ann, 13, and Lance, 12, nor Michelle's daughter, Jessica, 16, attended these sessions. Michelle and Frank had known each other since childhood, although she later moved to a large city and he settled in a small rural community. Their families had been friends in the past, and Frank and Michelle had visited and corresponded with each other over the years. When they were in their early 20s, before Frank went away to graduate school, a romance blossomed between Frank and Michelle and they agreed to meet again as soon as feasible. When her father died unexpectedly, Michelle wrote to Frank, and when he did not respond, she was hurt and angry. On the rebound, she married Alex, who turned out to be a drug user, verbally abusive to Michelle, and chronically unemployed. They divorced after two years, and Michelle, now a single mother, began working to support herself and her daughter, Jessica. Mother and daughter became unusually close in the 12 years before Michelle and Frank met again. Frank also had been married. Several years after his two children were born, his wife developed cancer and lingered for five years before dying. The children, although looked after by neighbors, were alone much of the time, with Ann, Frank's older child, assuming the parenting role for her younger brother, Lance. When Frank met Michelle again, their interrupted romance was rekindled, and in a high state of emotional intensity they decided to marry. Problem Approximately three months after their marriage, Frank and Michelle contacted the therapist again, describing increasing tension between their children. Needing a safe place to be heard (apparently no one was talking to anyone else), the children—Ann and Lance (Frank's) and Jessica (Michelle's)—eagerly agreed to attend family sessions. What emerged was a set of individual problems compounded by the stresses inherent in becoming an “instant family.” Frank, never able to earn much money and burdened by debts accumulated during his wife's long illness, was frustrated and guilty over his feeling that he was not an adequate provider for his family. Michelle was jealous over Frank's frequent business trips, in large part because she felt unattractive (the reason for her not marrying for 12 years). She feared Frank would find someone else and abandon her again, as she felt he had done earlier, at the time of her father's death. Highly stressed, she withdrew from her daughter, Jessica, for the first time. Losing her closeness to her mother, Jessica remained detached from her stepsiblings and became resentful of any attention Michelle paid to Frank. In an attempt to regain a sense of closeness, she turned to a surrogate family—a gang—and became a “tagger” at school (a graffiti writer involved in pregang activities). Ann and Lance, who had not had the time or a place to grieve over the loss of their mother, found Michelle unwilling to take over mothering them. Ann became bossy, quarrelsome, and demanding; Lance, at age 12, began to wet his bed. In addition to these individual problems, they were having the usual stepfamily problems: stepsibling rivalries, difficulties of stepparents assuming parental roles, and boundary ambiguities. Treatment From a systems viewpoint, the family therapist is able to work with the entire family or see different combinations of people as needed. Everyone need not attend every session. However, retaining a consistent conceptual framework of the system is essential. The therapist had “joined” the couple in the two initial sessions, and they felt comfortable returning after they married and were in trouble. While constructing a genogram, the therapist was careful to establish contact with each of the children, focusing attention whenever she could on their evolving relationships. Recognizing that parent-child attachments preceded the marriage relationship, she tried to help them as a group develop loyalties to the new family. Boundary issues were especially important because they lived in a small house with little privacy, and the children often intruded on the parental dyad. When seeing the couple together without the children present, the therapist tried to strengthen their parental subsystem by helping them learn how to support one another and share childrearing tasks. (Each had continued to take primary responsibility for his or her own offspring in the early months of the marriage.) Jealousy issues were discussed, and the therapist suggested they needed a “honeymoon” period that they had never had. With the therapist's encouragement, the children stayed with relatives while their parents spent time alone with each other. After they returned for counseling, Frank's concerns over not being a better provider were discussed. He and Michelle considered alternative strategies for increasing his income and helping more around the house. Michelle, still working, felt less exhausted and thus better able to give more of herself to the children. Frank and Lance agreed to participate in a self-help behavioral program aimed at eliminating bed-wetting, thus strengthening their closeness to one another. As Lance's problem subsided, the entire family felt relieved of the mess and smell associated with the bed-wetting. The therapist decided to see Ann by herself for one session, giving her the feeling she was special. Allowed to be a young girl in therapy and temporarily relieved of her job as a parent to Lance, she became more agreeable and reached outside the family to make friends. She and Lance had one additional session (with their father), grieving over the loss of their mother. Michelle and Jessica needed two sessions together to work out their mother-daughter adolescent issues as well as Jessica's school problems. Follow-Up Approximately 12 sessions were held. At first the sessions took place weekly; they were later held biweekly and then took place at 3-month intervals. By the end of a year, the family had become better integrated and more functional. Frank had been promoted at work, and the family had rented a larger house, easing the problems brought about by space limitations. Lance's bedwetting had stopped, and he and Ann felt closer to Michelle and Jessica. Ann, relieved of the burden of acting older than her years, enjoyed being an adolescent and became involved in school plays. Jessica still had some academic problems but had broken away from the gang and was preparing to go to a neighboring city to attend a junior college. The family contacted the therapist five times over the next 3 years. Each time, they were able to identify the dyad or triad stuck in a dysfunctional sequence for which they needed help. And each time, a single session seemed to get them back on track. SUMMARY Family therapy, which originated in the 1950s, turned its attention away from individual intrapsychic problems and placed the locus of pathology on dysfunctional transactional patterns within a family. From this new perspective, families are viewed as systems with members operating within a relationship network and by means of feedback loops aimed at maintaining homeostasis. Growing out of research aimed at understanding communication patterns in the families of schizophrenics, family therapy later broadened its focus to include therapeutic interventions with a variety of family problems. These therapeutic endeavors are directed at changing repetitive maladaptive or problematic sequences within the system. Early cybernetic views of the family as a psychosocial system have been augmented by the postmodern view that rejects the notion of an objectively knowable world, arguing in favor of multiple views of reality. Symptomatic or problematic behavior in a family member is viewed as signaling family disequilibrium. Symptoms arise from and are maintained by current, ongoing family transactions. Viewing causality in circular rather than linear terms, the family therapist focuses on repetitive behavioral sequences between members that are self-perpetuating and selfdefeating. Family belief systems also are scrutinized as self-limiting. Therapeutic intervention may take several forms, including approaches that assess the impact of the past on current family functioning (object relations, contextual), those largely concerned with individual family members' growth (experiential), those that focus on family structure and processes (structural) or transgenerational issues, those heavily influenced by cognitivebehavioral perspectives (strategic, behavioral), and those that emphasize dialogue in which clients examine the meaning and organization they bring to their life experiences (social constructionist and narrative therapies). All attend particularly to the context of people's lives in which dysfunction originates and can be ameliorated. Interest in family systems theory and concomitant interventions will probably continue to grow in the coming years. The stress on families precipitated by the lack of models or strategies for dealing with divorce, remarriage, alternative lifestyles, or acculturation in immigrant families is likely to increase the demand for professional help at a family level. Consumers and cost-containment managers will utilize family therapy even more often in the future because it is a relatively short-term procedure, solution oriented and dealing with real and immediate problems. Moreover, it feels accessible to families with relationship problems who don't wish to be perceived as pathological. Its preventive quality—helping people learn more effective communication and problem-solving skills to head off future crises—is attractive not only to families but also to practitioners of family medicine, pediatricians, and other primary care physicians to whom troubled people turn. As the field develops in both its research and clinical endeavors, it will better identify specific techniques for treating different types of families at significant points in their life cycles. (Wedding 403-406) Wedding, Danny. Current Psychotherapies, 10th Edition. Cengage Learning, 20130312. VitalBook file. The citation provided is a guideline. Please check each citation for accuracy before use.
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