I need help with 4 questions

timer Asked: Jul 21st, 2014

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Please let me know if you can help with the 4 questions.  I have attached Week 1 with the questions and Chapter 1, 2 and 3 that need to be used to answer the 4 questions. Week 1.docx  Chapter 1, 2 and 3.docx  REFERENCES for Chapter 1, 2 and 3.docx

Classic Models of Marriage and Family Therapy (MFT) Please prepare a response to each of the items below. In this interaction you will discuss concepts regarding competency and theory in MFT, research and ethical foundations of MFT theories, and the philosophical foundations of MFT theories (Gehart, 2014). Gehart, D. R. (2014) Mastering Competencies in Family Therapy To help lay the foundation for your study of Classic Models of MFT, prepare to discuss the following using Gehart, 2014 Chapters 1, 2 and 3. • Competency and Theory in MFT: How does one get from trainee to seasoned MFT? What is so important about theory? What does it mean to be competent as a MFT? • Research and ethical foundations of MFT theories: What do we learn from the “common factors” research? Why is evidence-based practice important? What makes ethical principles more than just rules? • Philosophical foundations of MFT theories: What are the systemic principles that provide the foundation for the MFT field? What is “social constructionism”? Consult with your professor about selection of a personal model of MFT. • Additionally, find one concept that you do not fully understand and discuss this concept with your professor in order to gain an understanding of it.
Chapter1 Competency and Theory in Family Therapy The Secret to Competent Therapy There is a secret to providing competent family therapy. Fortunately, it is an open secret, and the goal of this chapter is to sketch a map showing where and, more importantly, how to look for it. You are probably familiar with the basic landscape. You may recognize therapy’s more promising pathways and some of the dead-end routes. But like everyone setting out on a journey, your choice between the high road and the low road would be easier if you knew what was in store for you beforehand. Since I know you will race ahead if I make you wait too much longer, let’s lay out our map on the table right now and get a better sense of this secret on the first page. Mapping a successful therapeutic journey involves five steps. Mapping a Successful Therapeutic Journey These five steps follow a classic method used by all explorers in uncharted territory. And that’s what each new therapeutic relationship is: uncharted territory, an unknown region, a terra incognita. Although it may seem that clients can be easily lumped into groups— depressed clients, distressed couples, children with attention deficit and hyperactivity disorder ADHD, for example—any experienced therapist can tell you that each client’s journey is unique. The excitement—and secret—to competent therapy is mapping the distinctive terrain of each client’s life and charting a one-of-a-kind journey through it. The first step is to delineate as much of the terrain as possible: to get the big picture. What are the contours of the relationships? Where are the comfort zones? Where is the page marked “Here Be Dragons?” As with all maps, the bigger and more detailed the record, the easier it is to move through the territory. In family therapy, our maps are our case conceptualizations, assessments of the client using family therapy theories. Once you have a map of the big picture, you identify the landmarks, the oases and obstacles. You notice where the rest stops are and identify what dangers lie ahead. In therapy, you can recognize the oases as client resources: anything that can be used to strengthen and sup- port the client. The obstacles appear as those potential or existing hindrances to creating change in the client’s life: Are there really dragons there, or is the region just unfamiliar? Like a cartographer surveying the landscape, therapists assess potential hindrances carefully, ruling out possible medical issues in consultation with physicians, identifying psychiatric issues by conducting a mental status exam, and considering basic life needs, such as financial or social resources, through case management. When actual or probable impediments are addressed early in the therapeutic process through clinical assessment, the therapeutic journey is likely to proceed more easily and smoothly. Once you have your map with oases and obstacles clearly identified, you can confidently select a realistic path toward the client’s chosen destination or goal. If you have done a good job mapping, you will be able to choose from among several different paths, depending on what works best for those on the journey: namely, you and the client. This translates to being able to choose a therapeutic theory and style that suit all involved. Seasoned clinicians distinguish themselves from newer therapists in their ability to identify and successfully navigate through numerous terrains: forests, seas, deserts, plains, paradises, and wastelands. The greater a therapist’s repertoire of skills, the more able the therapist is to move through each terrain. Once a preferred path is chosen, the therapist generates a treatment plan, a general set of directions for how to address client concerns. Like any set of travel plans, treatment plans are subject to change due to weather, natural disaster, human error, and other unforeseeable events, otherwise known as “real life.” Therapists can rest assured that unexpected detours, delays, and short cuts (yes, unexpected good stuff happens also) will be part of any therapeutic journey. Once you select a course of action, you need to check frequently to make sure that (a) the plan is working and (b) you are sticking with it. In therapy, this translates to assessing client progress along the way. If the client is not making progress, the therapist needs to go back and reassess (a) the accuracy of the map and (b) the wisdom of the plan. Almost always, it is easy to make improvements in both areas that will get things back on course. The key is assessing client progress often enough to notice when you are off course as soon as possible. Finally, you need to leave a trail to track where you have been. Leaving a trail always helps you and your way back if you get lost: others (as well as yourself) can see why and how you proceeded. Therapists leave a trace of their path by generating thorough clinical documentation, which helps in two highly prized aspects of therapy: getting paid by thirdparty payers (i.e., insurance) and avoiding lawsuits (i.e., the state lets you practice). By making it clear where you are going, you can help everyone concerned better understand your specific route of treatment. So, competent therapy is that simple: five basic steps that this book will walk you through, step-by-step. From Trainee to Seasoned Therapist The difference between trainees and seasoned therapists can be found in the quality of the map, the effectiveness of the path of treatment, and the speed with which it takes to move through the steps. A seasoned therapist may move through the five steps of competent therapy in the first few minutes of a session, whereas a trainee may take more time, collecting information and trying various options. How long it takes is less important than the quality of the journey. This book is designed to help you move through these steps more effectively, whether you are just starting out or have been doing therapy for years. Competency and Theory: Why Theory Matters Although much has changed in the past decade in mental health—better research to guide us, new knowledge about the brain, more details about mental health disorders, increased use of psychotropic medication—the primary tool that therapists use to help people, theory, has not. Therapeutic theories provide a means for quickly sifting through the tremendous amount of information clients bring; then targeting specific thoughts, behaviors, or emotional processes for change; and finally helping clients effectively make these changes to resolve their initial concerns. Even with fancy fMRIs, (functional magnetic resonance imaging) neurofeedback machines, and hundreds of available medications, no other technology has taken the place of theory. However, the changing landscape of mental health care has altered how therapy theories are understood and used. Specifically, theory and how it is being used and understood has been recontextualized by two major movements in recent years: a) the competency movement, which includes multicultural competency; and b) research or evidence-based movement, which is discussed in detail in the next chapter. These movements have not ended the need for theory, but have instead changed how we conceptualize, adapt, and apply theory. Why All the Talk About Competency? All health professions, including mental health, have been abuzz in recent years with talk of competencies, detailed lists of the knowledge and skill professionals need to effectively do their job. The main source of this movement has been external to the field, and has come from stakeholders who believe that professionals should not only be taught a consistent set of skills but their learning should be measured on real-world tasks (for a detailed discussion see Gehart, 2011). Thus, this movement is asking educators to shift their focus from conveying content to ensuring students know how to meaningfully apply the knowledge and skills of their given profession. Each major mental health profession—including counseling, marriage and family therapy, psychology, psychiatry, psychiatric nursing, and chemical dependency counseling— has developed a unique set of competencies. Thankfully, there are many, many similarities across them. Appendix A and B include two of the more commonly used sets of competencies in family therapy: the Marriage and Family Therapy Core Competencies developed by a task force commissioned by the American Association for Marriage and Family Therapy (Appendix A; Nelson, Chenail, Alexander, Crane, Johnson, & Schwallie, 2007) and the Marriage, Couple, Family, and Child Counseling standards (Appendix B) developed by the Commission for the Accreditation of Counseling and Related Educational Programs. On nights when you have insomnia, you may find it helpful and interesting to read through what will be expected of you as a family therapist or counselor, regardless of the title on your license. These competencies are being used to more clearly define what family therapists must know and do in order to be competent. If you are new to the field, this is actually will make the task of learning to be a family therapist far easier: the goals are now clearly defined. This book is designed to help you develop these competencies as quickly and directly as possible. Competency and (Not) You Although at first it may seem insensitive, the vernacular expression commonly used by my teen clients sums up the mind-set of competency best: “It’s not about you.” It’s not about your theoretical preference, what worked for you in your personal therapy, what you are good at, what you find interesting, or even what you believe will be most helpful. Competent therapy requires that you get outside of your comfort zone, stretch, and learn how to interact with clients in a way that works for them. In short, you need to be competent in a wide range of theories and techniques to be helpful to all of the clients with whom you work. If you allow me to go on, you might even begin to see how this makes some sense and might even be in your best interest. Perhaps it is best to explain with an example: you will likely either have a natural propensity for generating a broad-view case conceptualization using therapy theories or have a disposition that favors a detail-focused mental health assessment and diagnosis; humans tend to be good with either the big picture or the details. However, to be competent, a therapist needs to get good at both even if one is easier, preferred, and philosophically favored. Similarly, you may prefer theories that promote insight and personal rejeection; after all, that may be what works for you in your life. However, that may not work for your client, and/or research may indicate that such an approach is not the most effective approach for your client’s situation or cultural background. Thus, you will need to master theories of therapy that may not particularly interest you or even fit with your theory of therapy. Even though you may not like this idea at first, I think that by the time you are done with the book, you might just warm up to it. I first learned this competency lesson when working with families in which the parents had difficulty managing the behaviors of their young children. I was never a huge fan of behaviorism, but it did not take too many hysterically screaming, clawing, and biting two-year-olds before I was preaching the value of reinforcement schedules and consistency. Given my strong—admittedly zealous—attachment to my postmodern approach at the time, I have every faith that you will be driven either by principle (ideally) or desperation (more likely) to move beyond your comfort zone to become a well-rounded, competent therapist. Common Threads of Competencies Whether you are training to be a counselor, family therapist, psychologist, or social worker, you will notice that are common themes across the various sets of competencies. You will want to take particular note of these: • Diversity and Multicultural Competence: The use of therapeutic theory is always contextualized by diversity issues, which means that the application and applicability vary—sometimes dramatically—based on diversity issues, such as age, ethnicity, sexual orientation, ability, socioeconomic status, immigration status, etc. • Research and the Evidence Base: To be competent, therapists must be aware of the research and the evidence-base related to their theory, client populations, and presenting problem. • Ethics: Perhaps the most obvious commonality across sets of competencies is law and ethics; without a firm grasp of the laws and ethical standards that relate to professional mental health practice… well, let’s just say you won’t be practicing very long. A solid understanding of ethical principles, such as confidentiality, is a prerequisite for applying theory well. • Person-of-the-Therapist: Finally, unlike most other professions, specific personal quali- ties are identified as competencies for mental health professionals, which will be discussed in more depth below. Diversity and Competency Over the past couple of decades, therapists have begun to take seriously the role of diversity in the therapy process, including factors such as age, gender, ethnicity, race, socioeconomic status, immigration, sexual orientation, ability, language, and religion. These factors inform the selection of theory, development of the therapy relationship, assessment and diagnosis process, and choice of interventions (Monk, Winslade, & Sinclair, 2008). In short, everything you think, do, or say as a professional is contextualized and should be informed by diversity issues. If you think effectively responding to diversity is easy or can be easily learned or that perhaps your instructors, supervisors, or some famous author has magic answers to make it easy, you are going to be in for an unpleasant surprise. Rather than a black-and-white still life, dealing with diversity issues is more like finger painting: there are few lines to follow, it is messy for everyone involved, and it requires enthusiasm and openheartedness to make it fun. I have often heard new and experienced therapists alike claim that because they are from a diverse or marginalized group, they don’t need to worry about diversity issues. Conversely, I have heard therapists from majority groups say things such as, “I don’t have any culture.” Both parties have much to learn on the diversity front. First of all, we are all part of numerous sociological groups that exert cultural norms on us, with the more common and powerful ones stemming from gender, ethnicity, socioeconomic class, religion, and age. Many, if not most, people belong to some groups that align more with dominant culture and to some that are marginalized. However, it is important to realize that some groups experience far more traumatic and painful forms of marginalization than others, and to further complicate matters, each individual responds to these pressures differently. To illustrate, some people experienced the process of coming out as gay as highly traumatic and want therapists to address these issues gingerly; others find it insulting when therapists assume they feel oppressed due to sexual orientation, because they live in communities that are largely supportive. Furthermore, many Americans seem unaware that there is a very strong and distinct “American culture” of which they are a part; in fact, the various regions of America have very unique characteristics of which therapists need to be aware. As another example, midwestern men typically express their emotions far differently than men in California; therapists who expect the two types of men to handle emotions in a similar way are going to unfairly pathologize one or the other. Suffice it to say, competently handling diversity issues requires great attention to the unique needs of each person, and it is a career-long struggle and journey that adds great depth and humanity to the person-of-the-therapist. In this book, you will begin this journey by examining diversity issues related to each of the theories covered and start integrating these issues into case conceptualization, assessment, and treatment planning. Diversity is so central to using theory that you will find discussions of diversity throughout each chapter, in addition to an extended section at the end of each chapter covering various forms of ethnic, gender, and sexual identity diversity related to the implementation of the specific theory. Research and Competency Another common thread found in mental health competencies is understanding and, more importantly, using research to inform treatment and to measure one’s effectiveness and client progress. In recent years, there has been a powerful movement within the field to become more evidence-based in mental health. This involves two key practices: a) using existing research to inform clinical decisions and treatment planning; and b) learning to use evidence-based treatments, which are specific and structured approaches for working with distinct populations and issues (Sprenkle, 2002). These movements are discussed in detail in Chapter 2 (in perhaps too much detail for some); issues related to the evidence base for each therapeutic theory are also discussed at the end of each theory chapter, with the related evidence-based treatment highlighted. In addition, Chapters 11 and 12 cover leading evidence-based treatments in the field of couple and family therapy. If you were hoping to escape a discussion of research in your theory text, you will initially be disappointed; however, I hope by the end you find the integration an invigorating addition. Law, Ethics, and Competency I often quip with students entering the field that if they think therapists can cut corners with legal or ethical issues, they should transfer to a business program so that they can make some money without worrying about such details and avoid a felony prison sentence after working as an unpaid intern for four plus years. That might be a bit of an exaggeration, but not much. Therapists who fail to develop competence in legal and ethical issues will not last long. Although this book does not directly cover these issues, they are so central to the profession that even before you begin reading about theories and treatment planning, you need a brief introduction so you don’t run off and start applying the concepts in this book to identify the underlying causes of problems in your clients, friends, family, neighbors, pets, and yourself. All mental health professional organization—the American Association for Marriage and Family Therapy, the American Counseling Association, the American Psychological Association, and the National Association of Social Workers— have codes of ethics that their members must follow. Thankfully, there is significant agreement between the various organizations resulting in general agreement on most key issues; federal and state laws also generally agree on the key principles. These issues are covered in depth in Chapter 2. Person-of-the-Therapist and Competency Finally, being a competent therapist requires particular personal characteristics that are often difficult to define. Some qualities are basically assumed to be prerequisites for a professional—integrity, honesty, and diligence—and take the form of following through on instructions the first time asked, raising concerns before they spiral into problems, staying true to one’s word, etc. It is hard to establish competency in anything without these basic life skills. The more subtle issues of the person-of-the-therapist come out in building relationships with clients. To begin with, the research is clear that clients need to feel heard, understood, and accepted by therapists, which often takes the form of offering empathy and avoiding advice giving (Miller, Duncan, & Hubble, 1997). Furthermore, therapists need to identify and work through their personal issues to avoid bias and inappropriately pathologize a client—what psychodynamic therapists call countertransference (see Chapter 6). Although more difficult to quantify, these issues often become quickly apparent by strong emotions or unusual interactions in relationships with clients, supervisors, instructors, and peers. Managing these well is part of being a competent therapist. Finally, a more difficult aspect to define is therapeutic presence, a quality of self considered to have intrapersonal, interpersonal, and transpersonal elements, including elements of empathy, compassion, charisma, spirituality, transpersonal communication, patient responsiveness, optimism, and expectancies—making it elusive and difficult to operationalize (McDonough-Means, Kreitzer, & Bell, 2004). Clients—rather than a professional—are the best judges this subtle quality because in the end, it comes down to how the client experiences the therapist as a human being in the room. Although these competencies are more difficult to measure, they are nonetheless some of the more important to develop. How This Book Is Different and What It Means to You Mastering Competencies in Family Therapy is a different kind of textbook. Based on a new pedagogical model, learning-centered teaching (Killen, 2004; Weimer, 2002), this book is designed to help you actively learn the content and develop real-world competencies rather than simply deliver the content and hope that you will memorize it. Thus, learning activities are a central part of the text so that you have opportunities to apply and use the information in ways that facilitate learning. The specific learning activities in this book are a) case conceptualization, b) clinical assessment, c) treatment planning, and d) progress notes; these translate the theory learned in the chapter to practical client situations. This book teaches real-world skills that you can immediately use to better serve your clients. This book is different in another way: it is organized by key concepts rather than general headings with long narratives sections. This organization—which evolved from my personal study notes for my doctoral and licensing exams back before I had e-mail (and, no, dinosaurs were not roaming the planet then)—facilitates the retention of vocabulary and terms because of the visual layout. Each year I receive numerous e-mails from enthusiastic newly licensed therapists thanking me for helping them to pass their licensing exams—they all say that the organization of the book made the difference. So, spending some time with this text should better prepare you for the big exams in your future (and if you have already passed these, you should be all the more impressed with yourself for doing it the hard way). In a Nutshell: The Least You Need to Know: The chapters begin with a brief summary of the key features of the theory. Although it may not be the absolute least you need to know to get an A in a theory class or help a client, it is the basic information you should have memorized and are able to quickly articulate at any moment to help you keep your theories straight. The Juice: Significant Contributions to the Field: In the next section, I use the principle of primacy (first information introduced) to help you remember one of the most significant contributions of the theory to the field of family therapy. In most cases, well-trained clinicians who generally use another approach to therapy are likely to be skilled and use this particular concept because it has shaped standard practice in the field. This section is your red flag to remember a seminal concept or practice for the theory. Feedback from students indicates this is often one of their favorite sections. (I only hope that isn’t because they skim the rest of the chapter; but, of course, you would never think of such a thing.) Rumor Has It: The People and Their Stories: In this section, you can read about the developers of the theory and how their personal stories shaped the evolution of the ideas. And, yes, some of the rumors are juicier than others. As the focus of this text is how therapy theories are actually used in contemporary settings, I have deemphasized the history and development of the theory, but you will find brief summaries of such history here. The Big Picture: Overview of the Therapy Process: The big picture provides an overview of the flow of the therapy process: what happens in the beginning, middle, and end, and how change is facilitated across these phases. Making Connections: The Therapy Relationship: All approaches start by establishing a working relationship with clients, but each approach does it differently. In this section, you will read about the unique ways that therapists of various schools build relationships that provide the foundation for change. The Viewing: Case Conceptualization: The case conceptualization section will identify the signature theory concepts that therapists from each school use to identify and assess clients and their problems. This really is the heart of the theory and where the real differences emerge. I encourage you to pay particularly close attention to these. You can also read more about case conceptualization in Chapter 13. Targeting Change: Goal Setting: Based on the areas assessed in the case conceptualization and the overall therapy process, each approach has a unique strategy for identifying client goals that become the foundation for the treatment plan. The Doing: Interventions: Probably the most exciting part for most new therapists, the doing section outlines the common techniques and interventions for each theory. In some cases, a section for techniques used with special populations is included if these are notably different than those in standard practice. Putting It All Together: Case Conceptualization and Treatment Plan Templates: After graduation, you will probably thank me most for this section, which provides templates for theory-specific case conceptualization and treatment plans that can be used for addressing depression, anxiety, or trauma with individual clients and confict with couples and families. These plans tie everything in the chapter together (just imagine a little bow on top). Tapestry Weaving: Working with Diverse Populations: This section reviews specific approaches for working with diverse populations using the theories covered in the chapter. Each chapter includes sections on ethnic and sexual identity diversity issues. Research and Evidence Base: Finally, the chapters end with a brief review of the research and evidence base for each theory to offer a general sense of empirical foundations for the theory. In some cases, influential evidence-based treatments (see Chapter 2 for a definition) are highlighted. Online Resources: A list of web pages and web documents are included for those who want to pursue specialized training or conduct further research on the theory. Reference List: Many students pass right over reference lists and forget all about them. But if you have to do an academic papers or literature review on any of these theories, this should be your first stop. In this case, I had several hundred books and articles go through my 12' 3 12' office while writing the editions of this book. Thus, you can certainly shorten the time it takes to locate key resources by pursuing these before you hit the library yourself. (Oh, I forgot, no one steps foot in these places anymore; I meant “surf” the library’s web page while still in your bunny slippers.) Case Example: Finally, each chapter ends with a case vignette, case conceptualization, clinical assessment, treatment plan, and progress note to give you of sense of how the theory looks in action and how to put down on paper. The details for how to complete these forms are in Chapters 13–17. Voice and Tone Finally, I should mention that the voice and tone of this textbook is a bit different than your average college read. Hopefully, you have noticed by now that I am talking right at ya. I also like to add some humor and have some fun while I write. Why? Well, first, I have more fun writing this way. But, more importantly, I want to engage you as if you were one of my students or supervisees learning how to apply these ideas for the first time. Family therapies are relationship-based practices, one in which the parties co-construct knowledge together. So, it’s hard for me to write about these ideas as a detached, faceless author, thereby perpetuating the myth of objectivity in knowledge construction (you’ll better understand why I’m worried about this after reading about the philosophical foundations of family therapy in Chapter 3). So, as I write, I’m imagining you as a real person, eager to learn about how to use these ideas to help others. I am going to try to reach out to you, answer questions I imagine you have, and periodically tap you on the shoulder to make sure you are still awake. Suggested Uses for This Text Suggestions for Thinking About Family Therapy Theories As you read the chapters in this book, you are going to be tempted to identify which ones you like the best and deemphasize the ones that you are less attracted to. This may seem like a great idea at first, but here are some points to consider: Favorite vs. Useful: The theories that the average therapist finds personally useful are probably not the same ones that the average client of a new therapist is likely to find useful. Many therapists are psychologically minded, meaning that they enjoy thinking about the inner world and how it works. However, most new therapists begin working in lower-fee clinics that serve diverse, multiproblem clients and families, many (but not all) of whom are not psychologically minded because they are often struggling with issues of survival and/or come from cultural traditions that place less value on analysis and understanding of the inner world. So, the theory you find most useful to you personally may not be a good fit for your first client. Appreciative: The theories in this book are not casually chosen. They have become part of the standard cannon of theories because generations of therapists have found them helpful. Each has wisdom worthy of study. The one lesson I have learned over the years is that the more theories therapists understand, the better able they are to serve their clients because their understanding of the human condition and its concomitant problems is broader. Thus, I recommend approaching each theory with an attitude of searching for its most wide and useful parts. I facilitate this for you in the “Juice” section of each chapter, which identifies the one concept I believe has near universal utility from the particular theory. Common Threads: Family therapy theories are ironic: in one sense they are very different and inform distinct and mutually exclusive behaviors and attitudes. However, the better you understand one, the better you understand them all. In fact, some therapists, the common factors proponents, argue that theories are generally equally effective because they are simply different modes for delivering the same factors (Miller, Duncan, & Hubble, 1997; you will read more in Chapter 2). So, it is quite possible that commonalities across theories are more important than their differences. Suggestions for Using This Book to Learn Theories First, I recommend that you set aside an hour or two to read about a single theory from beginning to end (from the “In a Nutshell” to “Putting It All Together”) to help get the full sense of the theory. Some chapters have a couple theories in one, so for these, it is fine to read the chapter in chunks. Additionally, some learners may find it helpful to scan the treatment plan (either the template or example at the end of the chapter) or some other section first to provide a practical overview; that said, I have tried to organize the ideas in the way most people seem to prefer. But I encourage you to discover what works best for you, as different learners have different strategies that work best for them. When you are done with a chapter, you might want to try completing a case conceptualization and treatment plan for yourself (you may have to make up a problem if you are nearly perfect) or someone else to get a sense of how this would work. Finally, I strongly recommend that either after reading the chapter or after going to class you take good ol’ fashioned notes. Yes, I mean it. I recommend that you type up (or if you prefer, handwrite) a complete outline of the key concepts in your own words. Why do I advocate such painful torture? When we read long, dense books such as this one, we all fade in and out of alert attentiveness to what we are reading—often lapsing into more interesting fantasies or less interesting to-do lists—and—gasp!—sometimes even skim large sections of the text (no, I am not surprised or offended). The only way to make sure that you really understand the concepts you read about is to put them in your own words and organize them in a way that makes sense to you. If you need to take culminating exams or plan to pursue licensure, you will have to log the concepts in this book into your long-term memory, which requires more than cramming for a final exam. If you are new to graduate and professional school, I am sorry to be the bearer of the sad news: this is not like undergraduate study, where forgetting everything you learned the week after finals was generally not a problem. Being a mental health professional requires that you master and build upon what you learn. You will be expected to know what is in this book for the entire time you are active in the profession (seriously—and if you think that is bad, just wait until you get to a class on diagnosis—you’ll have to memorize an even longer book). So, if your former study habits included all-night cram- ming, gallons of espresso (or other favorite caffeine-delivery system), and little recall after the exam, you might want to try my note-taking tip or some other strategy as you move forward. Suggestions for Using This Book to Write Treatment Plans I want to emphasize that the treatment plan format, templates, and examples in this book are just that: formats, templates, and examples. They do not represent the only approach or the only right approach. They are simply a solid approach based on the common standards and expectations. You most likely will work at a counseling agency or institution that uses another format, but the same general rules (those in Chapter 15) will still apply. That is why understanding the principles of how to write good goals and interventions is more important than memorizing the format. Furthermore, don’t use the templates and examples too rigidly. Feel free to modify the goal statements and techniques to fit the unique needs of your client. I have provided some relatively specific goals as an example of what might work and encourage you to radically tailor these for each client’s unique needs. You will notice that treatment plans in the case study do not rigidly follow the templates; I encourage you to do the same. Suggestions for Use in Internships and Clinical Practice When working as an intern or licensed mental health professional, this book can be useful for teaching yourself theories and techniques in addition to learning how to complete clinical documentation. You will likely find that when you work with new populations and problems, you may be interested in considering how other therapy models might approach these situations. This book is designed to be a prime resource that can be quickly scanned to identify other possibilities. Alternatively, you might have a colleague or supervisor who uses a theory with which you are not familiar. You can use this book to quickly review that theory and keep from looking uneducated. In addition, this book is written to help you appreciate and find common ground across theories, which can be of particular benefit when working in a “mixed theory” context. However, to actually learn to practice any of these theories well, I strongly urge you to take advanced training from experts in that approach. Suggestions for Studying for Licensing Exams Licensing exams are not designed to be unnecessarily tricky or scary, they simply ensure that you have the necessary knowledge to practice therapy without supervision and not harm anybody. And they are a vocabulary test. If you have honestly engaged in your classes, done your homework, avoided cramming for tests and papers, and made it a priority to get decent supervision, you should have a strong foundation for taking your licensing exam. You should already have in your possession books (such as this) that cover all of the content to be studied for the exam. If your exam is to be taken upon finishing a lengthy post-master’s internship, you should use the entire two- to four-year period to read as many books as possible on the theories and materials covered by the exam (that means no novels for a few years). I do not recommend that all of my students take long, expensive “review courses” because such courses are not necessary for those who are proactive in mastering the material on the exam long before they sign up to take it. If you start studying only after you are approved to take the test, you are starting about two to four years too late—and then, yes, you will need to take a crash course. My basic suggestion for studying for a mental health licensing exam is this: read an original text on each major theory during your postdegree internship, use the DSM, and keep up with laws and ethics; and then buy the practice exams (without the study guides) and take them until you consistently get 5% above the required passing score (e.g., 75% if the passing score is 70%). If you nd that you are weak in a particular area, such as theory or DSM, use a text such as this, which is designed for the license review in mind. Once you consistently get 75%, you are ready—with the most learning and the least expense—to take the test. Suggestions for Faculty to Measure Competencies and Student Learning This book is specifically designed to help faculty and supervisors simplify and streamline the onerous task of measuring student competencies as required by the various accreditation bodies. The forms and scoring rubrics for assessing student learning using counseling, psychology, social work, and family therapy competencies are available on the book’s web page for instructors (see login.cengage.com). On this website, instructors will also find free online lectures, PowerPoint slides, sample syllabi, and a test bank. This text may be used as the primary or secondary text in a family therapy theories class or as a primary text in a prepracticum or practicum/fieldwork class. Because of its combination of solid theory and practical skills, it can easily be used across more than one class to develop students’ abilities to conceptualize theory and complete clinical documentation, skills that are not likely to be mastered in a single class. When designing a class to measure competencies and student learning using these treatment plans and case conceptualizations, I recommend initially going over the scoring rubrics with students so that they understand how these are used to clearly define what needs to be done and the expectations for the final product. I have found that is most helpful to provide two to three opportunities to practice case conceptualization and treatment planning over a semester to provide feedback and enable students to improve and build upon these skills in an systematic fashion. Specifically, I have a small group present a case conceptualization and treatment plan with each theory studied based on a video the class watches on the theory; that way they have enough information to actually conceptualize the client dynamics and treatment. Then the entire class can see an example and discuss the thought process of developing the plan. A later or final assignment for the class can be to independently develop a treatment plan for a case (either one assigned by the instructor, from a popular movie, personal life, or actual client). By the end of a semester, with these activities, students will have developed not only competence but also confidence in their case conceptualization and treatment planning abilities. ONLINE RESOURCES FOR STUDENTS Students will find numerous useful resources for the text on the Cengage website (www .cengagebrain.com) and the author’s websites (www.dianegehart.com; www.mastering competencies.com). These include: • Online lectures: MP4 recordings of yours truly discussing content of select chapters • Digital forms for all assignments: case conceptualization, clinical assessment, treatment plan, and progress note • Scoring rubrics for each assignment • Links to related websites and readings • Glossary of key terms ONLINE RESOURCES FOR INSTRUCTORS Instructors will find numerous resources for the book on the Cengage website (login .cengage.com) and the author’s websites (www.masteringcompetencies.com; www .dianegehart.com). These include: • Online lectures by the author • Sample syllabi for how to use this book in a theory class, prepracticum skills class, or practicum class • PowerPoint slides for all chapters • Digital forms for all assignments: case conceptualization, clinical assessment, treatment plan, and progress note • Scoring rubrics for each assignment correlated to each profession’s competencies: counseling, family therapy, psychology, and social work • Test bank • Web quizzes Chapter 2 Research and Ethical Foundations of Family Therapy Theories Lay of the Land This chapter covers two key foundational elements of competent family therapy practice: the evidence base and ethics. The evidence-base section is divided into four major sections: 1. evidence-based practice 2. common factors research 3. evidence-based treatments 4. review of the marriage and family therapy (MFT) evidence base The ethics section covers legal and ethical issues that are particularly salient when working with couples and families. I have invited a colleague, Ben Caldwell, to write this section. He quotes legal and ethical codes by memory, with numbers, and in far more detail than most listeners would prefer. I should also warn you that he rarely offers the black-and-white answers we all hope for. Even so, I am sure even seasoned therapists will learn a thing or two from this section. Research and the Evidence Base In the 21st century, all therapists are expected to be well versed in the evidence base for the treatments they use and the problems they treat, in much the same way that we expect our medical doctors to only use procedures and drugs that have been well researched for our particular medical condition. This may or may not come as a surprise to you, but in many ways, mental health therapists have not been well versed in the evidence base for their field, especially when compared to other medical professions. (FYI: we are considered by most as medical professionals.) For many years, it has been as if researchers and clinicians spoke two different languages, with little communication between parties. In some cases, the research has been too specific or too vague to be useful to the average practitioner. In other cases, therapists work from philosophical positions that do not value research, instead focusing on the individual needs of a particular client. The good news is that translation efforts over the past two decades have made becoming an evidence-based practitioner easier than you might imagine. This chapter covers three strands of research that inform daily practice of family therapy in contemporary practice— evidence-based practice, common factors, and evidence-based treatments—and also introduces you to an excellent resource for quick and easy review of the MFT evidence base. The Minimum Standard of Practice: Evidence-Based Practice More commonly used in the medical field, evidence-based practice uses research findings to inform clinical decisions for the care of individual clients. In a nutshell, evidence-based practice refers to knowing the evidence base related to a specific client’s problem and contextual issues and using that information to make treatment decisions. For example, the research literature is very clear that systemic-structural family therapy approaches are the treatment of choice for adolescents with conduct and substance abuse disorders. Even if you are not formally trained in one of these approaches (see Chapters 4, 5, and 11 to start your training), because the evidence base is so strong ethically, you should use this knowledge to inform your treatment decisions. Think of it this way: If you were this child’s parent, would you want to take your child to a therapist who has his or her own way of doing things based on theory and experience, or to one who uses research on best practices to decide how best to help your child? You’d need a really strong referral to choose the first option. Every therapist should strive to be an evidence-based practitioner. Many would consider it an ethical obligation, because the evidence base is quickly redefining standard practice (see the section below on ethics). Patterson, Miller, Carnes, and Wilson (2004) describe five steps of evidence-based practice for family therapists: Step 1: Develop an answerable question to focus the search for information: What treatments are most effective for teens who cut to relieve emotional pain? Step 2: Search the literature for the best empirical evidence to answer the question: search digital databases such as PsychInfo and scholar.google.com using the keywords adolescents, self-harm, and treatment. Step 3: Evaluate the validity, impact, and applicability of the research to determine its usefulness in this case: Is the study randomized? Were there comparison groups? What was the treatment effect size? Were the findings clinically relevant? Step 4: Determine whether the research findings are applicable to the current client’s situation: What are the potential benefits and risks of applying these findings with this client? Do I need to consider any diversity factors, such as age, ethnicity, class, or family system? Step 5: After implementing the EBP, evaluate the effectiveness in this client’s individual case: How did the client respond? Were there signs of improvement, no change, or worsening? Becoming a evidence-based practitioner requires a willingness to continually learn and adapt one’s practice to integrate the latest findings in the field. It also requires that therapists are responsive to their client’s individual needs—even if researchers indicate that a particular approach works for most clients with a specific condition, you need to evaluate whether it works for yours; if it doesn’t, you need to adjust your approach. Essentially, it comes to down to making a more informed decisions so that you are optimally efficient. As research becomes more clinician friendly and relevant, I anticipate that therapists will have a far closer relationship to their evidence base. Heart of the Matter: Common Factors Research Over the past decade, professional literature has been abuzz over the “common factors debate” (Blow, Sprenkle, & Davis, 2007; Sprenkle & Blow, 2004; Sprenkle, Davis, & Lebow, 2009). Common factors proponents contend that the effectiveness of therapy has more to do with the key elements found in all theories than with the unique components of a specific theory. To simplify the argument even further: the similarities matter more than the differences. This position is supported by meta-analyses (research on several research studies) of outcome studies in the field: when research studies control for confounding variables (such as therapist loyalty, comparison group, or measures of outcome), there is little evidence to support the superiority of one theory over another, both in psychotherapy (Lambert, 1992; Wampold, 2001) and in family therapy, specifically (Shadish & Baldwin, 2002). Within the common factors community, some (Miller, Duncan, & Hubble, 1997) emphasize the common factors while minimizing the role of theory, whereas others take a more moderate approach (Sprenkle & Blow, 2004), maintaining that theories are still important because they are the vehicles through which therapists deliver the common factors, and because specific models may have an added benefit in certain contexts. Sprenkle and Blow (2004) point out that the common factors approach does not require therapists to relinquish therapeutic models but instead to understand their purpose differently. Rather than providing the “answer” to the client’s problems, common factor proponents propose that using a structured treatment inspires confidence from clients in the therapeutic process, allowing therapists to coherently actualize common factors. From this perspective, a therapeutic model is better understood as a tool that increases therapist effectiveness rather than the “one and only true path” that resolves the client’s problem. Lambert’s Common Factors Model The most frequently cited common factors model is grounded in the work of Michael Lambert (1992). After reviewing outcome studies in psychotherapy, Lambert estimated that outcome variance (the degree to which change is attributed to a specific variable) could be attributed to four factors: Lambert’s Common Factors model • Client Factors: An estimated 40%; includes client motivation and resources • Therapeutic Relationship: An estimated 30%; the quality of the therapeutic relationship as the client evaluates it • Therapeutic Model: techniques used n estimated 15%; the therapist’s specific model for treatment and the • Hope and the Placebo Effect: help n estimated 15%; the client’s level of hope and belief that therapy will Often these percentages are cited as facts, but although they are well-informed estimates based on a careful analysis of existing research, the numbers were not generated through an actual research study. They should be considered general trends in the research that inspires therapists to critically reconsider how they can help clients rather than exact percentages. Wampold’s Common Factors Model Wampold (2001) conducted a meta-analysis similar to Lambert’s, but compared only studies that included two or more actual therapy models (rather than comparing a model to the generic “treatment as usual” or a no-treatment control group). He presents evidence for the following: Wampold’s Common FaCtor model • Therapeutic Model: 8%; the unique contributions of a specific theory (compare with 15% in Lambert’s model) • General Factors: 70%; therapeutic alliance, expectancy, hope • Unknown Factors: 22%; variance that is not related to known variables Wampold’s research further underscores that common elements across theories contribute more to positive therapeutic outcomes than the unique elements of a specific theory. Thus, research across theories continually indicates that general or common factors have the greatest impact on outcome; although this result may be due to the limits of research (Sprenkle & Blow, 2004) or other factors, it is the best information to date on the subject. Client Factors Lambert’s (1992) research, which has been made most accessible to clinicians in the work of Miller, Duncan, and Hubble (1997), emphasizes the importance of activating client resources, such as by encouraging clients to create and use support networks and increasing client motivation and engagement in the therapeutic process. Tallman and Bohart (1999) propose that most theories work equally well because of the client’s ability to adapt and utilize whatever techniques and insights the therapist may offer; the therapeutic process effectively becomes a Rorschach (ink blot test) that the client uses to create change. Miller, Duncan, and Hubble (1997) describe two general categories of client factors: 1. Client characteristics include the client’s motivation to change, attitude about therapy and change, commitment to change, personal strengths and resources (cognitive, emotional, social, financial, spiritual), and duration of complaints. 2. Extratherapeutic factors include social support, community involvement, and fortuitous life events. Therapeutic Relationship In both Lambert’s and Wampold’s research, the quality of the therapeutic relationship appears to be more important than the specific model in predicting outcome, a finding that is consistent with much of the traditional wisdom in the field. In an effective relationship, the therapist accommodates to the client’s level of motivation, works toward the client’s goals, and demonstrates a genuine, nonjudgmental attitude. A particularly interesting—and humbling—finding is that the client’s evaluation of the relationship is more strongly correlated with positive outcome than the therapist’s evaluation (Miller, Duncan, & Hubble, 1997). Despite the clear and consistent evidence for the importance of the therapeutic relationship, most outcome studies, especially those on evidence-based therapies, try to control for and factor out the impact of the therapist on treatment, thereby obscuring the role of the therapist in effective treatment (Blow, Sprenkle, & Davis, 2007). Perhaps this is done because it is hard to fully operationalize and measure the therapeutic relationship, or perhaps because researchers want a more scientific-sounding explanation (the treatment did it, not the relationship). Whatever the reason, the evidence-based treatment literature seems to undervalue and underestimate the importance of the therapeutic relationship. However, common factors research redirects therapists’ attention to this important component. Therapists wanting to closely attend to relationship variables can use measures such as the Session Rating Scale (see Chapter 16) to monitor the relationship on a weekly basis. Therapeutic Model: Theory-Specific Factors Theory-specific factors are what the therapist says and does to facilitate change while following his/her therapeutic model. These factors are what therapists and third-party payers consider important. However, as Lambert’s research and estimations indicate, technique may not be as important as is typically assumed, actually being only half as important as the therapeutic relationship. However, it is still an influential factor over which therapists have significant control. Hope and the Placebo Effect: Expectancy Hope and expectancy, or the placebo effect, refer to clients’ belief that therapy will help them resolve their problem. Lambert’s (1992) emphasis on this factor heightens therapists’ awareness of an often-neglected aspect of the therapeutic process, at least in the research literature (Blow, Sprenkle, & Davis, 2007). With this awareness, therapists can more consciously work to instill hope, which is particularly critical in the initial sessions. Diversity and the Common Factors Common factors can be particularly useful when working with diverse clients—whether culturally, sexually, linguistically, or in ability—because diversity always implies unique client resources and challenges, particularly for the therapeutic relationship, choice of approach, and strategies for instilling hope. For example, although gay, lesbian, bisexual, and transgendered clients are often ostracized in the general community, many have extensive informal and formal social support networks; the same is true of many ethnic groups and disabled or chronically ill people. Thus the societal challenge is partially offset by unique resources. Therapists can help clients leverage these resources to better manage the often daunting challenges of being different from the majority. Similarly, with diverse clients, the task of creating a therapeutic relationship in which the client feels accepted rather than judged requires more mindfulness and thoughtfulness because the therapist may not be aware of all the dynamics and traditions of these groups. Education on local diverse communities is of course necessary, but humility and admitting that you do not know the answer is often more important because it cultivates respect and openness (Anderson, 1997). When therapists proceed with curiosity and a willingness to learn, they often discover distinct and effective means for instilling hope from within the client’s culture and primary community, further strengthening the therapeutic relationship. Do We Still Need Theory? The natural question that follows from the common factors debate is: Do we still need theory? As noted by Sprenkle and Blow (2004), some therapists lean toward the “dodo bird verdict,” suggesting that theory matters very little. The more moderate stance of Sprenkle and Blow (2004) emphasizes that “the models are important because they are the vehicles through which the common factors do their work” (p. 126). Following this moderate position, theory still plays a critical role for new and seasoned clinicians, but not the role one might initially expect it to play. Rather than providing a system to help clients alleviate their symptoms and resolve their problems, a theory is a tool that helps the therapist to help the client. Thus, theory may be most relevant for the therapist—not the client. Theory gives therapists a system for interpreting the information they get about clients so that they can say and do things that will be useful. It also helps therapists know how best to relate and respond to clients. Without theory, it is easy to get lost in a sea of information, emotion, and challenging behaviors. Theory gives therapists a systematic way of dealing with the wide range of difficulties clients bring. Thus, choosing a theory involves identifying a theory that makes sense to the therapist and is useful to the therapist in navigating the “wild ride” that is psychotherapy. That said, future research may identify specific circumstances in which certain models work better for certain clients (Sprenkle & Blow, 2004). Show Me Proof: Evidence-Based Therapies Just in case you thought the debate was over, there is yet another thread in the theory debate that is pulling therapists in the apparently opposite direction from the common factors research: empirically supported treatments, often referred to as “evidenced-based therapies.” These therapeutic models, which were developed through research and randomized trials (Sprenkle, 2002), should not be confused with evidence-based practice (EBP; see above), although evidence-based treatments are sometimes referred to as evidence-based practices to keep us all thoroughly confused (this is one instance where the plural refers to something quite different than the singular). When therapists, licensing boards, or funding institutions refer to therapy models as “evidence-based,” they are generally referring to a set of standards that a 1993 task force of the American Psychological Association (APA) established for what was initially called empirically validated treatments (EVTs) and later called empirically supported treatments (ESTs), the change underscoring that a treatment is always in the process of being further studied and refined (American Psychological Association, 1993; Chambless et al., 1996). The APA established several categories for describing empirically supported therapies, and others have developed similar categories. Empirically Supported Treatments (ESTs) and Their Kin Empirically Supported Treatment Criteria Empirically supported treatments (ESTs) meet the following criteria (Chambless & Hollon, 1998; Sprenkle, 2002): • Subjects are randomly assigned to treatment groups. • In addition to the group that receives the treatment being studied, there must also be one of the following: ■ A no-treatment control (usually subjects are on a waiting list) ■ An alternative treatment (for comparison; may be an unspecified approach: “treatment as usual”) ■ A placebo treatment • Treatment is significantly better than the no-treatment control and at least equally as effective as an established alternative. • Treatment is based on a written treatment manual with specific criteria for including or excluding clients. • A specific population with a specific problem is identified. • Researchers use reliable and valid outcome measures with appropriate statistical measures. Criteria for Additional Forms of Evidence-Based Treatments In addition to the criteria for empirically supported treatments, criteria have been set for other evidence-based treatments: • Efficacious Treatments: Meeting more stringent criteria, these treatments must meet the requirements for EBTs and must also undergo two independent investigations (studies conducted by someone who is not closely involved in the development of the treatment or invested in its outcome) (Chambless & Hollon, 1998; Sprenkle, 2002). • Efficacious and Specific Treatments: Meeting the highest standards, these treatments must meet the criteria for efficacious treatments and must also be superior to alternative treatments in at least two independent studies (Chambless & Hollon, 1998; Sprenkle, 2002). EST Pros and Cons The advantages of ESTs are the following: 1. They have greater scientific support. 2. They have written manuals to guide treatment and are highly structured. 3. They target a specific population with a specific problem. The disadvantages of ESTs are these: 1. They have limited applicability because they target a specific and therefore limited population. 2. They are expensive: therapists need highly specific training in the model and also need to be trained in a number of models to function effectively in most work environments. Meta-Analytically Supported Treatments (MASTs) A meta-analysis is a quantitative research method that combines results from multiple studies, generally by examining the effect size or the outcome variance attributed to the treatment. Using meta-analytic studies, Shadish and Baldwin (2002) developed the following criteria for MASTs to broaden the type of research that can be used to establish efficacy while maintaining rigorous scientific standards: • Effect sizes from more than one study of the treatment must be combined meta-analytically. • All studies must be randomized comparisons of the treatment to a no-treatment control group. • Meta-analysis must indicate a statistically significant effect size and a significant test. • Meta-analysis must use sound methods (e.g., aggregating effect sizes). Real-World Applications of ESTs and MASTs In 2002, Shadish and Baldwin identified 24 family therapy theories that fit the criteria for a MAST, whereas only 5 met the criteria for an EST. This difference existed primarily because ESTs require (a) a written treatment manual and (b) a narrowly defined population with a specific problem, whereas MASTs allow for other forms of training and more general populations to demonstrate efficacy. The findings of the APA’s 2005 follow-up report on ESTs highlight the necessity for more broadly defined standards for evidence-based treatments such as MASTs (Woody, Weisz, & McLean, 2005). This survey indicated that although a higher percentage of ESTs were taught in the classroom, clinical training in ESTs dropped significantly from 1993 to 2003. When asked to identify the reasons, supervisors cited “uncertainty about how to conceptualize training in ESTs, lack of time, shortage of trained supervisors, inappropriateness of established ESTs for a given population, and philosophical opposition” (p. 9). Arguably, all but perhaps the last of these obstacles are clearly linked to the exact things that make ESTs unique: written treatment manuals and a narrowly defined population. Thus, although promising, ESTs have some practical limitations at this time, especially for the general practitioner. Research in Perspective Therapists need to keep the evidence-based therapy movement in perspective. Almost all research indicates that any therapy is better than no treatment at all: that is one of the major ideas behind the common factors movement (Miller, Duncan, & Hubble, 1997; Sprenkle & Blow, 2004). The evidence-based therapy approach refines what we know and aims to develop better and more specific therapies; however, this does not mean that nothing in the field has ever been researched or studied before. A more fair and realistic assessment is that family therapy and mental health therapies have an established history of meaningful research, and our ability to do research more precisely continually increases. Research courses have been part of family therapy curricula from the beginning and are increasingly valued and expanded. A research orientation is not new; however, our ability to conduct more meticulous and useful studies is improving. Perhaps it is useful to reflect on the broader picture. More than in many other mental health disciplines, family therapy theories were developed through observational research (Moon, Dillon, & Sprenkle, 1990). Teams of therapists observed sessions through one-way mirrors, developed hypotheses about what might work, tested these hypotheses, and then refined them as they went along. Rather than trying to prove a theory, these therapist-researchers were using outcomes to inform the development of a new frontier in mental health: working with couples and families. This type of research is rigorous in a different dimension than ESTs; namely, it can be usefully applied in everyday work settings by persons with standard training. According to Shadish and Baldwin (2002), many family therapy approaches that draw from this tradition fit the criteria for MASTs: these treatments worked for decades and have been refined and designed to target specific populations in evidence-based treatments, many of which are highlighted in this book. Review of the MFT Evidence Base Finally, I want to let you know about an academic gold mine that makes grad students and their faculty particularly giddy when they finally discover it: the January 2012 edition and the 38th volume of the Journal of Marital and Family Therapy (known to MFT nerds as JMFT; Sprenkle, 2012). You may not have had the best relationships with journal articles up to this point in your education—that is common. But I think this one is going to change all that. In a nutshell, this edition of JMFT includes 12 articles in which experts in the field summarize the entire evidence base for you. It is an academic’s fantasy come true. This is the third of such reviews of the MFT evidence base, making it the only mental health discipline I know of to have such a concise and easily accessible review of the associated research (and trust me, I have looked). This single resource can make evidence-based practice with couples, families, and children a breeze. The areas of research reviewed include: • Conduct disorder and delinquency with adolescents (Baldwin, Christian, Berkeljon, & Shadish, 2012; Henggeler & Sheidow, 2012) • Child and adolescent disorders (Kaslow, Broth, Smith, & Collins, 2012) • Affective disorders (e.g., mood disorders; Beach & Whisman, 2012) • Treatment of couple distress (Lebow, Chambers, Christensen, & Johnson, 2012) • Treatment of couples experiencing interpersonal violence (Stith, McCollum, Amanor-Boadu, & Smith, 2012) • Relationship education for nondistressed couples (Markman & Rhoades, 2012) • Family psychoeducation for severe mental illness (Lucksted, McFarlane, Downing, & Dixon, 2012) • Family therapy for drug abuse (Rowe, 2012) • Couple and family interventions for health problems (Shields, Finley, Chawla, & Meadors, 2012) • Client perceptions of MFT (Chenail, St. George, Wulff, Duffy, Scott, & Tomm, 2012) Legal and Ethical Issues in Couple and Family Therapy Benjamin E. Caldwell, Psy.D. I teach law and ethics for the couple and family therapy program at Alliant International University in Los Angeles. I know, for many of you, that when you hear the phrase “I teach law and ethics,” you brace yourself for cautionary tales of what you had better not do, or else the licensure police will come beating down your door. This section is not like that. I promise. I will start with a brief overview of professional practice standards for psychotherapists (you may already be familiar with those; if not, there are a handful of excellent texts fully devoted to those standards). Then I will review some of the specific areas of difference for therapists working with couples and families. Finally, I will discuss technology and a therapist’s refusal to treat certain clients—two controversial issues that are reshaping professional standards in family therapy today. Lay of the Land: More than Just Rules Here is my one (and only, I promise) paragraph of fear-mongering. People can sue you, or file a complaint against you to your licensing board, any time, for any reason. They can sue you for looking at them funny. They can complain about you for breathing too loudly (or too quietly). They can sue you for not suing them first. If you base your entire practice on trying to never get sued or never have a complaint lodged against you, you are trying to control something that is beyond your control. Now, whether someone will win that lawsuit, or whether a board will do anything about that complaint—that is another story. You can and should take reasonable steps to protect yourself, including knowing your state’s laws, maintaining professional liability insurance, and consulting with colleagues, supervisors, and attorneys whenever necessary. But doing all of those things does not make you ethical. They are like a football player’s shoulder pads: they are great for protection from injury, but they do not make you a great football player. The fact is, being an ethical professional is about much more than simply knowing and following the rules. It is true that rules-based (and, as is often the case, fear-based) teaching about law and ethics does help you to know what the rules are—at least, until the rules change. But being an ethical professional is about knowing what to do when the legal and ethical rules governing our field do not tell you specifically what to do. There are times when those rules are not clear, or when they appear to contradict themselves. In those situations, simply knowing the rules will only leave a therapist confused and anxious, hoping that he or she does not do the wrong thing. It is in those instances when your character as a professional is most revealed. Being an ethical professional means engaging in a thoughtful and careful decision-making process that results in the best outcomes for your clients, within the accepted standards of the field. Those accepted standards are largely consistent across mental health professions. This section is not meant to be a replacement for a full law and ethics course or textbook, and is not meant to cover the full scope of the legal and ethical issues in psychotherapy. (For a complete textbook focused on the legal and ethical issues in couple and family work, I recommend Wilcoxon, Remley, and Gladding’s Ethical, Legal and Professional Issues in the Practice of Marriage and Family Therapy.) Instead, this section is meant to offer particular guidance on those issues most relevant to—or most different in—couple and family therapy. Working with more than one person on a therapeutic issue raises unique concerns, and it is these concerns I will emphasize. A brief, broader overview is necessary to set the stage, but if you are already familiar with general professional ethics in psychotherapy, you can safely skip this part and pick up at “Specific legal and ethical concerns in couple and family work.” The Big Picture: Standards of Professional Practice Practicing any form of therapy in a professional manner means understanding three levels of rules that govern professional behavior: • Laws • Ethics • Standard of Care Laws First, there are laws. Laws are either set by the local, state, or federal government, in the form of legislation, or by judges, whose rulings in some cases establish specific responsibilities for professionals. Tarasoff v. California Board of Regents, which established a therapist’s responsibility to intervene when a client poses an immediate danger to an identifiable victim, is an example of case law impacting psychotherapists. Laws are often about what you must do (like pass a licensing exam in order to practice independently) and must not do (like insurance fraud or sleeping with clients). They do not have exceptions, except those also spelled out in law. For example, you must maintain confidentiality except when a client is a threat to him- or herself or others, and in other instances defined in state and federal law. Regulations are a subset of laws. Instead of being set by a state legislature, regulations are often set by licensing boards through state administrative processes. They do, however, hold the power of law. A key point to remember: laws trump everything else. If a law conflicts with an element of an ethical code, the therapist must abide by the law, but should do so in whatever manner allows for the most adherence to the ethical code. Ethics The second level of standards that govern professional behavior is ethics. Each of the major professional associations in mental health publishes a code of ethics that serves to guide responsible professional behavior. Counselors, social workers, and psychologists have ethics codes published by the American Counseling Association (www.counseling.org), National Association of Social Workers (www.nasw.org), and the American Psychological Association (www.apa.org), respectively. In family therapy, the American Association for Marriage and Family Therapy (www.aamft.org) and California Association of Marriage and Family Therapists (www.camft.org) each publishes its own ethics code. These codes go beyond the rules of the law, and define in more detail the expectations of family therapists. However, no ethical code can be expected to offer specific guidance on every possible scenario that a therapist will encounter. Being an ethical practitioner is about much more than knowing the codes; it is about understanding ethical reasoning so that you can make the best choice of what to do when the legal and ethical rules are not clear. There are a handful of biomedical ethical principles (Beauchamp & Childress, 2009) that may be used when weighing the ethics of decisions in mental health work: • Fidelity refers to keeping promises and upholding loyalty. This can be challenging in couple and family work, where family members may attempt to get the therapist to take sides in their internal struggles. • Justice refers to treating people fairly, bearing in mind that fairly does not always mean equally. • Autonomy refers to the right of clients to make their own decisions and act independently. In family therapy, it is particularly important that a therapist respect a client’s right to make his or her own decisions regarding romantic relationships, such as choosing to cohabit, separate, divorce, or marry; and regarding child care, including custody and visitation. • Bene cience refers to the therapist’s obligation to actively work to benefit clients. If a couple or family does not appear likely to benefit from ongoing treatment, the clients should be referred to another therapist. • Nonmaleficence refers to avoiding harm to clients or others. When ethical guidelines for handling a particular situation are unclear or appear to contradict, it is generally recommended that mental health professionals return to these general principles to assess the risks and benefits of their options. Standard of Care Finally, the third level of standards governing professional behavior is called the standard of care. California’s definition of “reasonable suspicion” of child abuse, which triggers a therapist’s mandated reporting responsibility, is one effort to define the standard of care in law: For purposes of this article, “reasonable suspicion” means that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and experience, to suspect child abuse or neglect. “Reasonable suspicion” does not require certainty that child abuse or neglect has occurred nor does it require a specific medical indication of child abuse or neglect; any “reasonable suspicion” is sufficient. (California Penal Code 11166(a)(1)) In essence, the standard says, “If another therapist would suspect child abuse with the information and training you have, you should suspect it too.” This is what it means to have a standard of care: it is what most people at the same professional level are doing. Case documentation (described in Chapters 13–17) works on a similar principle: While legal and ethical standards do not tend to specify what should be in progress notes, therapists tend to follow standard formatting and include similar content, because that is what their peers do. Even in elements of therapy for which there is no legal or ethical standard, failing to live up to the standard of care is seen as inadequate professional behavior. There is no single place to look for a standard of care in writing. However, if you are unclear about the standard of care on any specific issue, the wise thing to do is consult with the colleagues and supervisors you most respect. They can best inform you what others in the profession are doing. Specific Legal and Ethical Concerns in Couple and Family Work There are several areas specific to couple and family work where the rules differ from individual therapy. These include identifying the patient, documentation, confidentiality, communicating with other systems, working with minors, child abuse reporting, and intimate partner violence. Who Is Your Patient? Perhaps the most difficult challenge in couple and family work is identifying who exactly it is you are treating. In individual therapy, it is easy to identify your patient: look at the person sitting in front of you. Couples and families, however, come to therapy with complex complaints. In some instances, they identify one member of the family as the problem who has brought them to you. In other instances, they say that the entire relationship or entire family is struggling. Who is the therapist treating? The question is not just academic. How you answer it will have an impact on how you organize your treatment plan, how you document the case, how you handle conflict between family members, and even how payment takes place. Indeed, it is likely to reflect your underlying philosophy when it comes to couple and family work. Therapists who specialize in treating couples and families often view themselves as treating the entire system as a unit. These therapists usually label themselves as “relational” or “systemic” in their work. Accordingly, they will keep a single file for the entire family, even if different combinations of family members are present in specific sessions. The treatment plan will be focused on systemic goals involving relationship or family functioning, goals that usually are agreed upon by all members of the couple or family attending therapy. Relational therapists do not ignore individual functioning, but rather they consider it in its interpersonal context. Documentation If the therapist is treating the family as a unit, he or she is likely to be keeping a single file on the entire family. That would mean one treatment plan for the entire family, and one progress note per session, no matter how many family members attended. That also means that under most state laws, the consent of every family member in treatment would be needed to release records to any individual family member requesting them. If you are treating an individual, and other family members sometimes join in therapy to support the individual’s progress toward his or her treatment goals, then it makes the most sense to document the session as part of the individual client’s existing file, noting the involvement of the others. In this case, only the individual receiving treatment needs to consent to the release of their records. Some work settings require therapists doing couple or family work to keep a separate and distinct file for each participant in the therapy. While this does allow for detailed recording of each person’s behavior—something that can get lost when a single progress note is written for a session involving several family members—it also means that the therapist will spend significant additional time documenting each session and needs to be thoughtful about how he or she documents family interaction in an individual’s file. In this instance, each individual could consent to the release of his or her own records, but the person could not request the release of other family members’ files. (State laws on this may vary, so it is of course important to be familiar with the laws of your state.) Confidentiality Confidentiality is both a legal and ethical requirement for psychotherapists, and most of the time it is fairly straightforward: You cannot share what clients tell you. (My treatment contract for many years has included the line, “The therapy office is like Las Vegas. What you say here, stays here.”) There are exceptions to this spelled out in the law: therapists are required to break confidentiality to report child abuse, and when necessary to stop clients who pose an imminent danger to themselves or others. There are many other exceptions to confidentiality spelled out in state and federal law, and it is important that your clients be made aware of both the general rule of confidentiality and its specific exceptions. Confidentiality becomes more complex when working with couples and families. Con- sider a married couple where one partner is having an affair. If that partner tells you about the affair during a phone call, and then tells you something like “I really want to make my marriage work, but I am not ready to end the affair yet. Please don’t tell my spouse,” what should you do? Revealing the secret could lead the couple to give up on treatment, and possibly their marriage. Keeping the secret, however, would mean colluding with the partner having the affair—and if the other partner found out later that you had known about the affair and not told him or her, that person would likely feel betrayed. If you are treating a couple or family, it is vital to have a policy addressing the holding of secrets. The codes of ethics for family therapists do not say what a therapist’s policy on secrets should be, but rather they require that the therapist have a policy on secrets, inform clients in writing of what the policy is, and stick to it. Two schools of thought have emerged about what the ideal secrets policy is: 1. A “no secrets” policy. This policy allows the therapist to communicate anything learned from any individual in the family to any of the other individuals in the family at any time. In short, it says that the therapist will not hold a secret for one family member. There are clear advantages to this policy: Holding secrets creates power imbalances in the therapy room, and could require that a therapist “play dumb” about such important issues as affairs or substance use. Refusing to hold secrets means that any such information, if it comes to the therapist, can be dealt with in the therapy setting. 2. A limited-secrets policy. While family therapists typically do not advocate holding all secrets, there are many who believe it is advantageous to hold some information in individual confidence. Doing so allows for a more thorough and trustworthy assessment process. For example, a couple therapist may see each partner individually during the assessment stage of therapy with plans to work with the couple together afterward. By assessing individually, and being willing to hold secrets from that assessment, a therapist can encourage clients to be more honest about relational issues they may not feel comfortable discussing in front of their partner. Affairs, substance use, and domestic violence are all examples of subjects that clients may be more honest about individually than in front of their loved ones. Whatever policy you choose, it is good to have it as part of your treatment contract when working with couples and families. It is good to discuss the policy with your clients to make sure they understand it. And, most importantly, once you have set your policy, you must follow it. Communicating with Other Systems Family therapists often handle issues relating to divorce, custody, parenting, and family functioning, and as a result often have connections other systems, such as schools and court systems. In some cases, it may be that outside system that hires and pays the therapist, again raising the question of who, exactly, the “client” is. The therapist may be required to submit regular progress reports to the court, for example, on treatment goals that the clients had little to no say in. All family members should be made aware as early as possible in therapy of the nature of the relationship the therapist has with third parties involved in the treatment. All family members should be informed about what information will be shared, with whom, and for what reason. Working with Minors Even if you are intending to do individual therapy, working with minors will make you a family therapist. Family members typically must give consent for the minor to receive treatment, they often want to be included in the therapy process, and they usually have a right to access treatment records. (Each of these varies a bit from state to state, so be sure you are familiar with your state’s laws.) State laws differ as to when a minor can consent on their own for therapy. Generally speaking, someone under the age of 18 cannot enter therapy without the consent of his or her parents. However, some states make exceptions to this. In California, for example, minors age 12 and older can independently consent for therapy if the therapist determines that the minor is mature enough to participate intelligently in treatment. Whether it is part of an individual or family process, any work you do with a minor on his or her own should come with clear boundaries. Bear in mind here that family members may have conflicting motivations. Parents who are fearful for their child’s well-being may want you to tell them everything that happens in an individual meeting with the child. The child, meanwhile, often will prefer a safe place to explore difficult emotional issues without the sense that his or her parents are always peering in. Many therapists resolve this conflict through a written agreement that defines what information will stay between the therapist and the minor, and what information will be shared with the family. (As you may have guessed, this would be common among therapists using a “limited secrets” policy.) For example, if a minor is struggling to navigate peer relationships at school, the minor may not want the therapist to share that information with their parents—and it can be argued that the greater good is served by the therapist holding that information. (The child gets a safe place to be honest about their struggles, and the parents are not harmed by not having that information.) On the other hand, if a minor is engaging in drug or alcohol use, or otherwise endangering his or her physical health, that information would be shared with the parents. Again, whatever policy the therapist chooses to employ when it comes to secrets, the policy should be clear, consistent with the laws of your state, in writing… and followed. Child Abuse Reporting In working with children and families, a therapist often will develop the suspicion that child abuse has taken place. Sometimes this will arise directly from what clients tell the therapist; other times, the therapist makes this assessment based on physical or behavioral evidence of abuse. While state laws vary, psychotherapists typically must report physical abuse, sexual abuse, and neglect to local authorities so that the victim, as well as other potential victims, can be protected. It is vital to be aware of your state’s rules for what must be reported, to whom, and how quickly once the therapist learns of the abuse. Therapists who work with adolescents and their families should be particularly aware of their state’s laws concerning the reporting of consensual sexual activity among minors. States may differentiate between consensual sexual activity that qualifies as criminal and activity that qualifies as abusive (e.g., in some states there are some instances of statutory rape that would be considered criminal but not abusive). Since abuse must be reported, but criminal activity that is not abuse typically cannot be reported, every therapist must remain keenly aware of his or her state’s current laws. The age of your client, the age of their partner, the nature of their relationship (e.g., whether an older partner appears to be exploiting a younger one), and the specific activities they have engaged in all may be relevant to the question of whether their relationship can be considered abusive. Intimate Partner Violence (IPV) Several researchers have suggested that couples therapists more thoroughly assess all couples entering therapy for current and past intimate partner violence (IPV). Without thorough assessment, such violence often goes unreported. Among couples seeking outpatient counseling, in the past 12 months, 36% to 58% have experienced male-to-female violence and 37% to 57% have experienced female-to-male violence (Jose & O’Leary, 2009). Recent or ongoing violence can be a major impediment to successful couple therapy, and is considered a contraindication for emotionally focused therapy (Johnson, 2004), one of the best-validated approaches to couple work. Generally speaking, a therapist cannot break confidentiality to report IPV on its own. If children have witnessed violence between their parents, however, the situation becomes more complex, as does the therapist’s responsibility to protect the children involved. In California, when children have witnessed domestic violence, a therapist can (but is not required to) report this to law enforcement as emotional abuse. Be sure you know your state’s laws on child abuse reporting before filing a report based on children witnessing violence in the home. The treatment of IPV for those convicted of a first or second offense raises specific ethical questions, particularly with regards to weighing potential risks against potential beneffects of treating couples together. At present, treatment is often through court-mandated, gender-specific group therapy (Babcock, Green, & Robie, 2004). Such treatments appear to have small but meaningful impacts on recidivism (Stith, McCollum, Amanor-Boadu, & Smith, 2012). However, they also suffer from high dropout rates, and often draw recidivism data from arrest reports. This makes their measure of recidivism subject to underreporting. For therapists who treat couples, inevitably some of their clients will have a history of IPV. Other couples enter therapy with active, ongoing violence. There has been debate in the literature for years about how these couples should be treated. That debate follows many of the issues noted above, particularly related to balancing the chance of benefit for couples with the risk of harm. Some consider the risk of harm too great to engage in any couple- or family-based treatment for at least several months after the last violent incident, noting concerns that some aggressors may become more violent when treated for IPV in a couple context. Others cite conflicting publications that support seeing couples together when their violence history has been low level and mutual (e.g., Bograd & Mederos, 1999). Depending on where you practice, there may be state, county, or agency rules governing the treatment of domestic violence, particularly if one partner has been convicted of IPV. Current Legal and Ethical Issues in Couple and Family Work Professional standards change over time. Ideally, as a professional, you will take an active role in those changes. The AAMFT Code of Ethics (AAMFT, 2012) calls on family therapists to take an active role in developing or changing laws and regulations regarding family therapy to ensure such rules are in the public interest (principle 6.7). Often the changes in professional standards come about as a result of new forms of treatment or changes in the larger populations we serve. There are two specific issues that are currently reshaping the professional standards for couple and family therapy: technology and therapist values. Technology As videoconferencing and related technology have become more sophisticated, therapists have begun to use technology to provide services to clients who otherwise may not be able to come into the office. Clients who live in rural areas without adequate health care services can be particularly helped by phone or videoconference therapy, as can clients with specific language needs that cannot be met by providers close to them. Providing therapy services over the phone or through the Internet is a challenging undertaking with individuals; with couples and families, it becomes even more challenging. Much of the information a therapist gathers in working with a couple and family has to do with the interaction between clients in session. When the couple or family can only be seen through a computer screen—or, if the therapy is taking place by phone, when the couple or family cannot be seen at all—it becomes much more difficult for a therapist to assess the dynamics being acted out in the room. It may be for this reason that research on therapy that takes place by phone or videoconference has so far focused almost exclusively on individual therapy (Barak, Hen, Boniel-Nissim, & Shapira, 2008). For those therapists who do wish to attempt couple or family work through the phone or the Internet, there are several things to be aware of. First, a therapist’s license only authorizes him or her to work in the state where he or she is licensed. A therapist licensed in Texas, for example, could not do telephone therapy with a couple in New York; the therapist would likely be seen as practicing in New York without a license. 1 Second, therapists providing phone- or Internet-based services must abide by additional ethical requirements, including (a) ensuring that electronic therapy is appropriate, considering the clients’ needs and abilities; (b) informing clients about the potential risks and benefits of electronic therapy; (c) ensuring the security of the connection, to protect privacy and confidentiality; and (d) ensuring that the therapist has appropriate training and experience in using the technology. These requirements are present in both the AAMFT and ACA codes of ethics. The ACA code goes further, requiring that therapists also plan with clients what to do if the connection is lost or a crisis occurs. Finally, there are no well-established protocols for couple and family therapy aided by technology. Technology is also impacting couple and family work in a very different way: by changing how couples and families relate to one another. While electronic communication allows families to maintain connection more easily over great distance, it also is frequently used to facilitate affairs and risky sexual behavior. The negative impacts of online activities are an increasingly common reason given by couples who seek therapy in my practice. However, the negative impacts of online relationships on couples and families are only beginning to be understood from a research perspective (Hertlein & Webster, 2008). Therapist Values At least three court cases have come about in the past several years concerning psychotherapists who said they were unwilling to treat gay and lesbian clients. These have led to a broader discussion in the field about where therapists’ obligations to serve clients end and their right to practice based on their own values begins. It is generally accepted that family therapy cannot be value-free. Any therapist brings his or her values into the therapy room. Indeed, a value for helping the larger community through healthy relationships is often part of why someone becomes a family therapist. In the interest of autonomy, therapists are usually taught to understand clients through the lens of the clients’ values. The CAMFT Code of Ethics calls on therapists to be aware of their own personal values and not impose those values upon their clients. Similar clauses can be found in the ethics codes of the APA, ACA, and NASW. In the court cases, however, therapists have asserted that their values relating to sexuality preclude them from treating gay and lesbian clients. Julea Ward, a counseling student at Eastern Michigan University, refused to treat a lesbian client and worked with her supervisor to ensure the client could be treated by another therapist at the same agency who did not share her conflict. EMU felt that her refusal to treat the client was discriminatory, and told Ward she must complete a remediation plan. She refused to do so, and was expelled from the program as a result. She then sued the university. Jennifer Keeton, a student at Augusta State University, filed a similar lawsuit after also being told she must complete a remediation plan to ensure she would not impose her values regarding sexuality on her clients. She had not refused to treat specific clients, but had made many statements in her classes that made it clear she would not work with gay or lesbian clients. Finally, Marcia Walden, who was working for a contractor for the Centers of Disease Control, was suspended and soon fired after she refused to treat a CDC employee’s same-sex relationship. Walden had referred the case to a colleague who did not share Walden’s opposition to same-sex relationships. These cases each present strong examples of situations in which an ethical code can appear to be contradictory. On one hand, nondiscrimination clauses in all professional ethical codes in mental health suggest that clients cannot be turned away simply on the basis of their sexual orientation. On the other hand, competence clauses, also present in all professional ethical codes in mental health, require that therapists not work with clients that the therapists are not qualified to treat. If a therapist does not feel qualified to treat gay and lesbian clients, which clause becomes more important? The court cases have yet to provide clear case law for therapists to follow. Keeton’s case was dismissed by a federal district court in June 2012, at which time the other cases remained on appeal. Conclusion Even with the best preparation and knowledge, therapists working with couples and families will face situations that leave them unsure of how to proceed. Laws are typically made in reaction to events that have taken place, and so they are not going to cover every new situation that may emerge. Ethical codes are similarly imperfect, and a standard of care does not exist for every situation. Thankfully, as a professional therapist, you have a number of resources available that can help you with difficult decision making. If you face legal or ethical questions in your work with couples and families, it is always better to ask questions before acting than after. Consulting with supervisors and colleagues can help give you a good idea of what other professionals would do in similar situations. Consulting with an attorney will help determine your legal responsibilities; your professional liability insurance carrier is likely to offer free legal consultation, and your professional association may provide the same. For questions about your ethical responsibilities, most professional associations have an ethics committee or ethics consultant who can provide advice to members. Chapter 3 Philosophical Foundations of Family Therapy Theories Lay of the Land Before exploring the various models of family therapy, I want to brie y introduce you to their philosophical foundations. The two closely related philosophical traditions that inform family therapy approaches are systems theory and social constructionism, a particular strand of postmodernism. To some degree or another, all schools of family therapy have been influenced by these two theories, with traditional therapies drawing more heavily from systemic theory and more recent ones from social constructionist theory. The last portion of this chapter will address the question of whom to marry and whom to date in the world of theory. Systemically Influenced Family Therapies and Theories • Systemic and Strategic Theories: Mental Research Institute (MRI), Milan, strategic therapies, and functional family therapy (Chapters 4 and 11) • Structural Family Therapy (Chapter 5) • Experiential Family Therapy Theories: Satir’s human growth model, symbolicexperiential therapy, internal family systems, and emotionally focused couples therapy (Chapters 6 and 11) • Intergenerational Theories: Bowen’s intergenerational and psychoanalytic therapies (Chapter 7) • Cognitive-Behavioral Family Therapies (Chapter 8) • Early Solution-Based Therapies (Chapter 9) Social Constructionist Family Therapies • Later Solution-Based Therapies (Chapter 10) • Narrative Therapy (Chapter 11) • Collaborative Therapy (Chapter 11) Systemic Foundations Rumor Has It: The People and Their Stories The Macy Conferences Not so long ago (1940), in a place not so far away (New York), Josiah Macy (of Macy’s department store fame) assembled an unexpected configuration of scholars and researchers to discuss how groups of things operate to form a system (Segal, 1991). This series of conferences in the early 1940s, the Macy Conferences, gave birth to general systems theory and cybernetic systems theory, which describe how biological, social, and mechanical systems operate. Rather than being developed by a single person, these ideas emerged from interactive dialogue and shared research of numerous experts and scholars on the cutting edge of their fields. Their theories led to a new approach to psychotherapy—family therapy—which is not simply a modality (i.e., working with a family versus an individual) but a unique philosophical view of human behavior. Systemic Theorists The concepts that constitute Communication or Interactional [Systems] Theory emerged not from any one individual, but, rather were the product of the interaction between the members of what has become known as the Palo Alto Group [the Bateson team].”—Weakland, 1988, p. 58 Gregory Bateson Gregory Bateson, who participated in the Macy Conferences with his then wife Margaret Mead, was a British anthropologist who explored cybernetic theory by studying intertribal interactions in New Guinea and Bali (Bateson, 1972, 1979, 1991; Mental Research Institute, 2002). Bateson’s elegant and thoughtful articulations of cybernetic theory influenced numerous disciplines, including communications, anthropology, and family therapy. As part of his research on human communications, he assembled what was later known as the Bateson group: Don Jackson, Jay Haley, William Fry, and John Weakland. For 10 years, he studied communication in families with members diagnosed with schizophrenia, provided consultation on cybernetic theory, and introduced team members to the trance work of Milton Erickson. The result was the double-bind theory of schizophrenia (Bateson, 1972), which reconceptualized psychotic behavior as an attempt to meaningfully respond in a family system characterized by double-bind communications. Bateson’s prior anthropological research helped the team view problematic human behavior as a function of larger social systems rather than being purely intrapsychic. Heinz von Foerster Another participant of the Macy Conferences, Heinz von Foerster was born in Austria and originally studied physics before developing his theories on cybernetic systems, second-order cybernetics, and radical constructivism, a postmodern theory that describes how an individual constructs his or her reality (Mental Research Institute, 2002). His work also contributed to the philosophical foundation for systemic therapies. Milton Erickson Trained in medicine as a psychiatrist, Erickson was a master therapist, well known for his brief, rapid, and creative interventions and considered by many to be the father of modern hypnosis (Erickson & Keeney, 2006; Mental Research Institute, 2002). The early MRI team consulted with Erickson as it developed its brief approach to family therapy. Erickson’s clinical innovations, brief approach, and emphasis on possibilities are rejected in its therapies. Erickson’s work was also highly influential in the development of solution-based therapies (Chapter 9). Bradford Keeney A family therapist, Keeney studied with Bateson in exploring the implications of the cybernetics of cybernetics, or second-order cybernetics, which acknowledges the role of the observer (e.g., the therapist) on what is observed (Keeney, 1983, 1985). In his more recent anthropological work, he has studied shamanism and the cybernetic (i.e., holistic) worldviews of native cultures, most notably the Kalahari Bushmen (Keeney, 1994, 1997, 1998, 2000a, 2000b, 2001a, 2001b, 2002a, 2002b, 2003). He has also used concepts from improvisational theater to develop improvisational therapy (Keeney, 1990) and, with his colleague Wendell Ray, has also developed resource-focused therapy, a strengthfocused, systemic approach (Ray & Keeney, 1994). Systemic Assumptions General Systems and Cybernetic Systems Theories Systems theory has its origin in the cross-disciplinary study that began at the Macy Conferences, which were attended by rocket scientists building self-guided missiles, anthropologists studying intertribal interactions in Bali, and ecologists studying the interactions between species. These researchers discovered that, whether studying mechanical parts, social groups, or animals, they were noticing that systems operated using the same basic principles, which von Bertalanffy (1968) developed into general systems theory. Closely related but more focused on social systems was the cybernetic systems theory articulated by Gregory Bateson (1972), which has had the most in uence on the eld of family therapy. Homeostasis and Self-Correction The term cybernetic means “steersman” in Greek, which hints at the functional principles of cybernetic systems: they are self-correcting, and therefore able to “steer” their own course, in contrast to a computer, for example, which needs an outside entity to steer it (Bateson, 1972). What does a cybernetic system steer toward? Homeostasis. Homeostasis, in the case of families, refers to the unique set of behavioral, emotional, and interactional norms that create stability for the family or other social group. Despite what the name might imply, homeostasis is not static but dynamic. Much like a gymnast constantly moving to maintain her balance on a beam, systems must be constantly in flux to maintain stability. In all living systems, it takes work to maintain balance, whether in mood, habits, weight, or overall health. The key to maintaining stability is the ability to self-correct, which requires feedback. Negative and Positive Feedback You can pretty much guarantee that the concepts of negative and positive feedback will be included on any multiple-choice test about family therapy. Why? Because the disciplinary use of the terms are the opposite of their colloquial use. So remember, the questions about negative and positive feedback are always trick questions—that is, if you haven’t studied. Here’s how to remember their definitions: Negative Feedback: No new information to steersman = the waters are the same = homeostasis. Positive Feedback: Yes, new information is coming to the steersman = the waters are choppy, moving faster, colder = something is changing. Negative feedback is “more of the same” feedback, meaning there is no new news or change (Bateson, 1972; Watzlawick, Bavelas, & Jackson, 1967). In contrast, like “positive test results” in medicine, positive feedback is news that things are not within expected parameters, which may be experienced as a problem or a crisis, depending on the situation. The problem or change could be due to what is generally considered bad news (death of a loved one, a fight with a spouse, a problem at work) or good news (graduation from college and needing to find a job, getting married and starting a new household, moving to a new city for a job). Both good and bad news can create positive feedback loops, which result in one of two options: (a) return to former homeostasis, or (b) create a new homeostasis. In most cases, a system initially responds to positive feedback by trying to get back to its former homeostasis as quickly as possible. After a fight, most couples quickly want to make up and “get back to normal.” After a death, most talk about how getting back to normal will take a while, depending on how significant the deceased person was. However, sometimes it is not possible to get back to the “old normal,” and a new normal needs to be created. The new norm or homeostasis is also referred to as “secondorder change.” First- and Second-Order Change Second-order change describes when a system restructures its homeostasis in response to positive feedback and the rules that govern the system fundamentally shift (Watzlawick, Weakland, & Fisch, 1974). First-order change refers to when the system returns to its previous homeostasis after positive feedback. In first-order change, the roles can reverse (e.g., a former distancer could start pursuing), but the underlying family structure and rules for relating stay essentially the same: someone is pursuing someone. This type of first-order shift is frequent in the early stages of couples therapy when partners shift between being the pursuer and the distancer. For example, at the beginning of therapy, the woman asks for more closeness from her husband, and he asks for more space. As therapy progresses, they may shift roles. Although the problem may appear to be resolved, functionally there has been no shift in the rules that regulate intimacy in the relationship; the partners have just changed roles, so it looks and feels different. A second-order shift with this couple would involve reducing the overall pursuer–distancer pattern and increasing each person’s ability to tolerate more togetherness and more distance. It is also important to remember that second-order change is not always necessary in therapy; it depends on the client’s situation. In therapy, first-order solutions make logical sense; second-order solutions seem odd and illogical because they are introducing new rules into the system. Here’s a clinical confession: in actual practice the distinction between first- and second-order change is often difficult to discern. I sometimes like to say, “That was 1.5-order change.” Perhaps that is because most of us change in small shifts. However, the concept of first- and second-order change enables the therapist to ask whether roles have merely shifted or whether there has been a fundamental change in the ability to negotiate more intense intimacy and tolerate greater independence. “One Cannot Not Communicate” The early work of the Bateson team resulted in Watzlawick et al.’s (1967) classic text, Pragmatics of Human Communication, in which its members proposed the following axiom: “One cannot not communicate.” In addition to blatantly ignoring high school English teachers’ rules about double negatives, this axiom seems to contradict the most common problem presented by couples and families: “We can’t (or don’t) communicate.” So, where did this claim come from? The Bateson team learned from its research with schizophrenic family members that even schizophrenic attempts to not communicate (e.g., nonsense, immobile states, etc.) still sent a message, often communicating a desire to not communicate. Since all behavior is a form of communication, and it is impossible to not be engaged in some form of behavior (at least while we are alive), it follows that we are always communicating. As we all know, silence speaks volumes, as does nonsense, withdrawal, or a frozen pose; thus even the most creative attempts to not communicate send a message. More commonly, the claim “we just can’t communicate” means that one person doesn’t like what the other has to say and that the two are unable to reach agreement, at which point it is helpful to examine the anatomy of the communicated messages—namely, the report and command aspects of communication. Communication: Report and Command (Metacommunication) Each communication has two components—report (content) and command (relationship)— that help therapists conceptualize communication and, more importantly, miscommunication. The report is the content: the literal meaning of the statement. The command is the metacommunication, or the communication about how to interpret the communication (Watzlawick et al., 1967). The command aspect always defines the relationship between two people. For example, the same piece of advice (content), such as “You might want to wear sunscreen today,” can be accompanied by a command that defines either a peer–peer relationship or a one-up–one-down relationship. This is where miscommunication, double-bind communication, and arguments come in. Elements of a Communicated Message Communicated message = Report: Data, information (primarily verbal) + Command: Defining relationship (primarily nonverbal) The concept of report and command helps explain why couples, families, friends, coworkers, and basically any two humans can have elaborate, drawn-out arguments over taking out trash, toilet seat lids, cat litter, toothpaste, and the recalled order of events at last night’s party. These arguments, although appearing to be over “little things,” are really about how the relationship is being defined in relation to the little things; thus, they are about a big thing, namely, how to define each person’s role in the relationship. When arguing over trash and cat litter, couples are usually disagreeing with each other’s message at the command (relationship) level, not the content. It often helps to move the discussion directly to the metacommunication level, communicating about the command aspect of the communication, which, in the case of household chores, may include power dynamics or perceived caring. By directly discussing the metacommunication aspects (e.g., when the wife tells her husband to take out the trash, he feels that she is treating him like a child), the couple can clarify these relational issues, at which point the content issues are usually quickly resolved. Since every communication, verbal or non- verbal, has both report and command functions, the process of “getting meta” is infinite, because the partners can then talk about the metacommunication (command) aspect of the first metacommunication. Psychoeducation note: Although psychoeducation is not a traditional systemic technique, spending a minute or so teaching clients about this issue can help some clients better understand what is going on in their arguments if it fits with your theoretical orientation. Double Binds The double-bind theory goes back to the Bateson group’s (that consisted of Jackson, Haley, Fry, and Weakland) earliest research on families with a member diagnosed with schizophrenia (Bateson, 1972). Watzlawick et al. (1967) identify the following ingredients of a double-bind communication: 1. Two people are in an intense relationship that has high survival value, such as a familial relation, a friendship, a religious affiliation, a doctor–patient relationship, a therapist– client relationship, or a relationship between an individual and his or her social group. 2. Within this relationship, a message is given that is structured with (a) a primary injunction (e.g., a request or order) and (b) a simultaneous secondary injunction that contradicts the first, usually at the metacommunication level. 3. The receiver of the contradictory injunctions has the sense that he or she cannot escape or step outside the cognitive frame of the contradictions, either by metacommunicating (e.g., commenting on the contradiction) or by withdrawing, without threatening the relationship. The receiver is made to feel “bad” or “mad” for even suggesting there is a discrepancy. Common examples are the commands “love me” or “be genuine,” in which one person orders another to have spontaneous and authentic feelings. In their research, the MRI team noticed that this type of communication characterized families who had a member di- agnosed with schizophrenia. A common exchange in these families was a mother who gave her child a cold, distant hug (command aspect communicates distance) and then said, “Why are you never happy to see me?” (report aspect suggests closeness). No matter how the child responds, the mother can prove him or her wrong. Thus the “logical” response is a nonresponse or nonsense response, which characterizes schizophrenic behavior, such as word salad (spoken words that have no real meaning), loose associations (tangentially relating words or topics), or catatonic behavior (rigid, repetitive behavior that has no interactive meaning). Although the double-bind theory does not account entirely for how schizophrenia develops or who develops it, it is still useful for clinicians working with families that get stuck—whether or not there is a member diagnosed with schizophrenia. Common examples of double binds in families that present for therapy are the following: • Someone asks a partner or child to spontaneously “show love” in a specific manner (bring flowers, do chores), but when the person shows love in the way requested, the partner or parent says, “That does not count because I had to ask you to do it.” This becomes a double-bind situation, with no way for the person to show genuine feeling. • A very strict parent makes all the child’s decisions but says, “I trust you to make good decisions.” When the child tries to comment on the incongruency, the parent reverts to “But I do trust you.” Identifying the double bind is the therapist’s first step at intervening in these destructive patterns. Symmetrical and Complementary Relationships Originating in Bateson’s (1972) anthropological work, the distinction between symmetrical and complementary relationships is frequently used to understand family interactions. In symmetrical relationships, the parties have “symmetrical” or evenly distributed abilities and roles in the system: an equal relationship (Watzlawick et al., 1967). Con- flict in symmetrical systems generally takes the form of two equals fighting until there is a winner: each is viewed and experienced as a relative equal, and the outcome is not predictable. In family relationships, symmetrical dynamics are often seen in couples and similar-aged siblings. In contrast, in complementary relationships, each party has a distinct role that balances or complements the other, often resulting in a form of hierarchy. Conflict in these relationships is less frequent because there are clearly defined, separate roles. Complementary dynamics often become a problem with couples when their roles become exaggerated or rigid. Examples of common complementary dynamics include pursuer/ distancer, emotional/logical, visionary/planner, and easygoing/organized. These dynamics can provide a counterbalance that is enjoyable and helpful, especially early in the relationship; however, often these roles become exaggerated and rigid, creating a feeling of “stuckness.” By the time clients present for therapy, often each person appear’s to have individual psychiatric symptoms or deeply ingrained personality traits; at this point it is quite difficult for anyone to still see the roles that each person has taken on as part of the systemic dance. The family therapist’s task is to see these rigid complementary roles as part of the larger system rather than as fixed personality structures. It is then much easier to have hope for change and to be creative in making change. The Family as a System The defining feature of systemic approaches is viewing the family as a system, an entity in itself, with the whole greater than the sum of its parts (Watzlawick et al., 1967). What does this really mean? Systemic therapists view the interactional patterns of the family as a sort of “mind” or organism that is not controlled by any single member or outside entity, such as a therapist. This view results in several startling propositions: • No Single Person Orchestrates the Interactional Patterns. The rules that govern family interactions are not consciously constructed like the U.S. Constitution; instead, they emerge through an organic process of interaction, feedback (reaction), and correction until a norm or homeostasis is formed. In fact, many of the early arguments in a relationship serve as feedback to shape the emerging relationship’s homeostatic norms. In most cases, this whole process occurs with minimal metacommunication about how the relational rules are being formed. • All Behavior Makes Sense in Context. Because all behavior is a form of communication, it makes sense in the context in which it is expressed, within the rules of that particular system. Thus, even the seemingly nonsensical communication of schizophrenia makes sense in the larger family system. • No Single Person Can Be Blamed for Family Distress. Because no one consciously creates the rules, but rather patterns are mutually negotiated through ongoing interactions, it follows that no single person can be fully to blame for family problems. Although individuals do have moral and ethical obligations in cases of abuse, the interactions “make sense” within the broader relational context and rules. • Personal Characteristics Are Dependent on the System. Although a member may display certain characteristics or tendencies, these are not inherent personality characteristics that exist independent of the system; rather, they emerge from the interactional patterns in the system. Thus, even when a family reports, “Suzie has always been like this” (e.g., angry, helpful, forgetful), the therapist takes this to be a statement more about the rules (possible rigidity) of the system than a truth about Suzie. Epistemology The proposition “I see you” or “You see me” is a proposition which contains within it what I am calling “epistemology.” It contains within it assumptions about how we get information, what sort of stuff information is, and so forth . . . certain propositions about the nature of knowing and the nature of the universe in which we live and how we know about it.”—Bateson, 1972, p. 478 Bateson’s ideas about epistemology are foundational to all systemic family therapies. In the strict philosophical sense, epistemology is the study of knowledge and the process of knowing. From his cybernetic investigations, Bateson concluded that most of the propositions that humans assume to be true are erroneous; they appear true because they capture one dimension of an interactional sequence, but they rarely include the broader awareness of how observer and observed reciprocally reinforce and impact each other. Thus, a wife’s complaint that her husband is cold and indifferent does not take into account how their ongoing series of interactions has impacted each of their behaviors and frames for interpretation. Family therapists pay careful attention to the family’s epistemology, the operating premises that underlie their actions and cognitions (Keeney, 1983). Second-Order Cybernetics A later distinction in systemic literature, second-order cybernetics, refers to applying systemic principles to the observing system, such as to the therapy system (therapist observing the family system). In the process of observing another system, a new observer– observed system is created: a second-order (or second-level) system. The therapist can no longer assume to be a neutral, unbiased observer, but is rather an active participant in creating what is observed. The co-creation process happens in several different ways. First, a therapist’s descriptions reveals more about the therapist than about the family, in that any description reects what information the therapist deems most valuable and useful. Second, how a therapist interacts with or treats a family signi cantly impacts the actions and attitudes of the family while in the therapist’s presence. A therapist who engages a family in a detached, professional manner will elicit different behaviors than one who uses a playful, low-key style. Which is more “real”? Neither, or more accurately, both. Each response is a “natural, honest” response for the family system in the context of a particular professional. Therapists who maintain an awareness of second-order cybernetic principles remain continually attuned to how their behavior is shaping that of the client and how their descriptions of clients reflect their own values. This attention to the co-creation of the therapist–client reality became the focus of social constructionist therapists. The Spirit of Systemic Therapists Systemic therapists are known for their ability to see the big picture at all times. Even when a client presents with an individual issue, such as depression or anxiety, systemic therapists always view it within the larger relational contexts in which the symptom makes sense. In addition, they are known for their irreverent (see Chapter 4 for more details) attitude toward problems: whether the symptoms are conflict, feeling blue, drinking, psychosis, or an eating disorder, the systemic therapist is never flustered and never views one as more “serious” than another or more an “individual” versus a “family” problem. Instead, all behavior is simply a means of communicating that makes sense within a particular relational system, with each person in the system doing the best he or she can. Thus, they always refrain from blaming one member of the family for a problem. This is perhaps the most difficult shift in perspective for new therapists. Systemic therapists are able to stay focused on the interconnection of meaning and communication, on the dance between people, rather than get lost in the labeling and unidirectional thinking of individual pathology. They carefully attend to how behavior is always shaped by complex webs of relations within the family, community, and larger society. They view much of what the average person might consider an “individual problem” as part of a much larger set of interactions, of which the problem is only a small part. Their nonpathologizing, nonblaming view offers clients a refreshing and often liberating new way to think about their situation. Above all, they are pragmatic, always considering whether their interventions were useful or not, and if not, arguring out what might be. Social Constructionist Foundations Social constructionist philosophy is a particular strand of postmodern philosophy, which has influenced a wide range of disciplines, including art, theater, music, architecture, literature studies, cultural studies, and philosophy. Because their systemic foundations had already conceptualized reality from a relational perspective, family therapists were the first mental health professionals to embrace postmodern philosophy. Of the various postmodern schools—constructivist, social constructionist, structuralist and poststructuralist— social constructionism has been the most influential in the development of new psychotherapy models, such as solution-focused, collaborative, and narrative therapies (see Chapters 9 and 10). Systems Theory and Social Constructionism: Similarities and Differences The move from a systemic view (particularly the second-order cybernetic perspective) to a social constructionist perspective can be seen as a natural evolution and continuation of systemic concepts, which describe how social interactions shape a person’s experience of reality. Although the vocabulary and metaphors change, the emphasis on relationships and the relational construction of reality do not. The earliest writings in family therapy explored how people construct their lived reality through interpersonal relations ( Bateson, 1972; Fisch, Weakland, & Segal, 1982; Jackson, 1952, 1955; Watzlawick, 1977, 1978, 1984; Weakland, 1951), laying the foundation for postmodern approaches. In fact, many of the original approaches that began systemically, such as Milan therapy and the MRI approach (see Chapter 4), over time evolved to a more constructionist form. Thus systemic and postmodern therapies have more shared views than differences, especially when compared with other nonrelational psychotherapies. Systemic and social constructionist theories share the following assumptions: • A person’s lived reality is relationally constructed. • Personal identity and an individual’s symptoms are related to the social systems of which they are a part. • Changing one’s language and description of a problem alters how it is experienced. • Truth can only be determined within relational contexts; an objective, outsider perspective is impossible. Despite these and other similarities, there are notable differences that can be traced to a shift in metaphor. Systems theory uses a systems metaphor: a family is a system, a group of individuals who coordinate meaning and their understanding of the world. Social constructionist therapies use a textual metaphor: people narrate their lives to create meaning using the social discourses available to them. In addition, social constructionist therapies emphasize the role of the therapist in the co-construction of the client’s reality, much like systemic therapists’ attention to second-order cybernetic dynamics, resulting in a different approach to relating to clients and their problems. Furthermore, constructionist therapists use clients’ language and stories differently than systemic therapies to create interventions. Social Constructionist and Related Theorists Kenneth Gergen A social psychologist, Ken Gergen first introduced social constructionist ideas to the mental health professions in his 1985 article in American Psychologist. His work has laid the foundation for the development of social constructionist therapy approaches, most notably collaborative therapy (Anderson, 1997; Anderson & Gehart, 2007; Anderson & Goolishian, 1992) and to a lesser degree narrative therapy (Freedman & Combs, 1996; White & Epston, 1990). His work has included detailed applications of social constructionism to psychological and social issues (Gergen, 1999, 2001) and to postmodern ethics (McNamee & Gergen, 1999). His most recent work is on positive aging (Gergen & Gergen, 2007). Sheila McNamee Working with Gergen, Sheila McNamee, a communications theorist, has been a leader in translating social constructionist ideas to therapy (McNamee & Gergen, 1992), including an in-depth exploration of ethical issues (McNamee & Gergen, 1999). She has also been at the forefront of developing social constructionist pedagogy (McNamee, 2007). John Shotter John Shotter’s social constructionist work focuses on how people coordinate joint action through shared meanings and understanding (Shotter, 1993). His work emphasizes the ethics of mutual accountability in social relationships (Shotter, 1984). Michel Foucault Rejecting philosophical labels such as a postmodernist, structuralist, or poststructuralist, Michel Foucault (1972, 1979, 1980) was a prolific social critic and philosopher who described how power and knowledge shape individual realities in a given society. A signi cant in uence on Michael White’s narrative therapy (see Chapter 10), Foucault’s work introduces the political and social justice rami cations of language and power in therapy. Ludvig Wittgenstein An Austrian philosopher, Wittgenstein’s philosophy of language (1973) is highly in u- ential in postmodern therapies, notably solution-focused brief therapy and collaborative therapy (Chapters 9 and 10). He describes language as inextricably woven into the fabric of life and argues that language cannot be meaningfully removed from its everyday use, as it commonly is in philosophical and theoretical discussions. Mikhail Bakhtin A Russian critic and philosopher, Bakhtin worked on dialogue and concepts of identity, emphasizing that the self is unfinalizable (can never be fully known) and that self and other are inextricably intertwined (Baxter & Montgomery, 1996). Postmodern Assumptions Skeptical of Objective Reality: “Whatever Exists Is Mute” Postmodernists are skeptical about the possibility of identifying an objective reality, such as x is a healthy behavior and y is not (Gergen, 1985). They describe reality as “mute” (Gergen, 1998), meaning that events and things in life do not come with prepackaged meanings, such as marriage is good, fat is ugly, and cars are bad. Instead, meaning is constructed by communities of people. Reality Is Constructed Postmodernists view all “truths” and “realities” as constructed (you will notice and perhaps be irritated by the frequent use of quote marks to emphasize that a concept is a construction, not a truth). Language and consciousness are necessary to develop meanings and to determine the value of an object or thing (Gergen, 1985; Watzlawick, 1984). Different postmodern schools emphasize and analyze different levels of reality construction; however, they principally recognize that the construction of reality is a complex process that involves all of these levels: • Linguistic Level—Poststructuralism and Philosophy of Language: Focuses on how words shape our reality rather than being a reflection of it, a premise shared by all forms of postmodern thinking. • Personal Level—Constructivism: Focuses on how reality is constructed within an individual organism; most closely associated with later developments of MRI and Milan therapies (Watzlawick, 1984). • Relational Level—Social Constructionism: Focuses on how reality is created in immediate relationships (Gergen, 1985, 1999, 2001); most closely associated with collaborative therapy. • Societal Level—Critical Theory: Focuses on how reality is constructed at the larger, societal level; most closely associated with narrative therapy, which draws heavily on the work of Michel Foucault (1972, 1979, 1980). Reality Is Constructed Through Language Postmodernists generally agree that reality is constructed primarily through language. Language is not neutral: words have real effects in our lives (Gergen, 1985). Most importantly for therapeutic purposes, words are the primary medium for (a) fashioning our identities and (b) identifying what is a problem and what is not (Anderson, 1997; Gergen, 2001). For example, a person can interpret the same set of events (e.g., losing one’s cool) as “having a bad day” or “being a bad person,” each having dramatically different implications for identity and the definition of the problem. This level of reality construction, used in all postmodern therapies, is emphasized by poststructuralists and constructivists. Reality Is Negotiated Through Relationships The meanings we attribute to life experiences are not developed alone but in relationships, with immediate friends and family and more broadly with society and the subcultures of which we are a part (Gergen, 1985). The meaning a person gives to a particular behavior, haircut, job, family relation, sex act, or religious view is always embedded in a web of “local” (immediate) relationships as well as the larger societal dialogue about the particular issue. Thus, how a person views premarital sex, lying, or disciplining children develops through and within the multiple layers of outer dialogues. Postmodern therapists help clients untangle the dialogues around problems so that clients can determine those with which they choose to affiliate. This level of reality construction is emphasized in theories that emphasize social constructionism and critical theory. Shared Meanings Coordinate Social Action Shared meanings and values are needed to coordinate social action, or more simply, get along with others (Gergen, 2001; Shotter, 1993). Without agreed-upon meanings on what is polite and what is rude or what is good and what is bad, it would be impossible for humans to live together—there would be total chaos. Instead, groups of people coordinate meanings and values: we call this culture. Tradition, Culture, and Oppression We cannot make sense of our lives outside of tradition or culture, which refers to not only ethnicity and nationality but any small or large group that has a set of norms. Cultural traditions create a framework for (a) making meaning of our individual lives and (b) successfully coordinating our actions with others. Culture provides a set of values that its members can use to interpret their lives, knowing whether they are living a “good” life. In addition, culture provides a framework for safely and effectively interacting with others, allowing for the shared meanings necessary for marriage, family life, commerce, recreation, and religion. However, selecting certain goods and values over others inevitably labels certain behaviors and qualities as bad and undesirable. If a culture values productivity, it views taking time to relax negatively; if a culture values family, it deemphasizes individuality. Thus all cultures are by their very nature oppressive (Gergen, 1998), because—by definition—they must identify certain behaviors as acceptable and others as unacceptable. The degree to which a culture is oppressive is directly correlated with its ability to be reflexive. Reflexivity and Humanity Any given culture remains humane to the extent that it is reflexive, able to examine its effects on others and to question and doubt its values and meanings (Gergen, 1998). Within any group of people, there are some people for whom the dominant cultural norms fit and others for whom they do not. The extent to which a culture listens and responds to the minority voices within it is the extent to which that culture maintains its humanity, growing and expanding to reduce the oppressive forces that are inescapable if humans are to live with one another. Social Constructionism, Postmodernism, and Diversity Postmodern philosophy, with its suspiciousness about singular “truths,” has profoundly affected most current therapies because it heightens awareness of diversity issues. Post- modernists challenge the concept that norms cannot be fairly established because these norms are created by one group within the society and do not fairly capture the lived experience of others in that society and even less so the reality of other groups or cultures. This is readily seen with gender, socioeconomic status, age, culture, religion, and other factors. Postmodernism proposes that the behaviors, thoughts, and feelings of a white, middle-aged, Protestant male from the Northeast cannot be assumed to be the same as those of an adolescent son of Southeast Asian immigrants who are semi-migrant farmers in California’s Central Valley. They both have their own reality and truth and their respective norms and definitions of the good life; therapists must meet each with this fact in mind. The Postmodern Spirit It is difficult to capture the spirit or general sense of postmodernists, but I am going to try. As you might imagine, they would say such an attempt will fail before beginning because words are always contexualized by their user’s reality and can only convey that reality, not the essence of what is described. As such, the shift to a postmodern epistemology involves an ongoing awareness of how each moment of reality is constructed, how each person gives unique meaning to lived experience. When this realization infuses your view of the world—this may sound dramatic, but I think it is fair to say—your life and relationships will never be the same again. Simply keeping the fluid nature of meaning and reality in the foreground changes how you view and relate to others and any life experience. When your partner is upset about something that seems innocuous to you, you soften and become curious about how your partner is interpreting that event. When a client shares a fear or viewpoint that seems odd or surprising, you become intensely interested in how she came to that understanding of her life and listen to her story, fascinated with how meaning evolved. If ever a couple or family appears in your office with entirely different perspectives on the same situation, this seems only natural to you, and you help them weave together these unique perspectives. Furthermore, you will no longer be able to maintain convictions and opinions like you used to—instead, you will hold all of your views more tentatively, always open to evolving them further. One of the greatest mistakes I see new therapists make is trying to use postmodern techniques without fully adopting the true spirit of postmodernism. As you might imagine, they are not very effective. For postmodern therapists are masters at seeing possibilities, hope, and strengths where other do not. Their assumptions make them optimists extraordinaire. Philosophical Wrap-Up The philosophical foundations of family therapy are key to understanding and effectively implementing the specific approaches in this book. Each approach has found unique ways to use these philosophical concepts in the therapy session. Thus, the same concepts have different practical expressions in the various theories. Nonetheless, they provide connecting threads that can be traced from one theory to the next, resulting in an undeniable kinship. In addition, these theoretical principles are valuable to you in another way: deciding which theory(ies) to use, and how. Eeny, Meeney, Miny, Moe and Other Strategies for Choosing a Theory What theory should I use? Which is the best? Which is the best for me? Do I have to pick a theory? What if I like them all? Can’t I just be eclectic? These are some of the rst questions that students ask as they begin to study family therapy theories. The answers are more complex than one would imagine, leaving honest instructors and supervisors no option but to respond with maddening “both/and” or “yes-and-no” answers (trust me, they do not do this just to torture students for recreation and sport—it really is an honest answer). But let me give you a hint: philosophical foundations are part of the answer. How to Choose: Dating vs. Marrying Much like parents’ advice to their teenage children, in the first few years, I recommend that you casually “date” a theory before you decide to settle down. I am always surprised by new therapists who feel this tremendous pressure to find the “perfect” or “right” theory for them immediately—much like teenagers who are convinced that their first love will be their lifelong partner: it’s possible, just not the most common scenario. You might want to “play the field” for a while to learn what is out there and what works best for you. Fortunately, theory dating generally ends better than romantic dating. After dating a theory, you are almost always forever enriched with new skills and knowledge, which is only sometimes true in the romantic realm. Additionally, the breakup part is almost always gentler. Thus, you can decide to try out a new theory every semester of your training or every year or so in your practice. After dating even two or three, your skill set and knowledge base will have significantly grown. You will have also learned more about who you are and your style as a therapist. At that point, you may find that it is time to settle down with one more than with the others. When that happens, you are ready to define your philosophy. Defining Your Philosophy Once you have spent a few years dating, you may find that you are ready to settle down with one theory. Just as in love, there should be an engagement period during which you clearly define your commitment and get to know your new partner—and family of origin—more intimately. In the case of theory dating, this involves pursuing advanced training in your theory of choice, usually by going to intensive seminars or working with a supervisor who specializes in your theory. Just as in marriage, in which a commitment to one person entails a commitment to an entire family, once you decide to commit to a theory, you are also committing to the broader philosophy that is the theory’s foundation. I believe therapists who are clear about their philosophy of what it means to be human (ontology) and how people learn and change (epistemology) are best positioned to handle the variety of problems with which skilled therapists must learn to work. If you only master the techniques (system of doing), then you are less well prepared for handling the variety of issues that highly competent therapists must master. Although there are many ways to define the philosophical foundations of family therapies, I find it simplest to begin by considering four major categories: modernist, humanistic, systemic, and postmodern. Each has its own approach to defining truth, reality, the therapeutic relationship, and the therapist’s role in the change process. The following table summarizes their differences. Modernism Modernism is founded on the logical-positivist assumptions of an external, knowable “Truth.” In modernist approaches, the therapist assumes an unequivocal role as expert, which is more common in individual and family forms of cognitive-behavioral and psychodynamic therapies (see Chapters 7 and 8; e.g., Dattilio & Padesky, 1990; Ellis, 1994; Scharff & Scharff, 1987). Modernist Assumptions • The therapist is an expert who assumes the primary responsibility for identifying pathology, problems, and goals, often assuming the role of teacher or mentor. • Theory and research are the primary sources of information for identifying problems and diagnosing. • The therapist uses theory and research to select treatment approaches; clients are expected to adapt to the selected treatment. Two family therapy schools fit this category: psychodynamic and cognitivebehavioral therapies. Although broadly grounded in modernist assumptions about knowledge, each theory has its own unique position on the primary source of truth, the means through which it is best identified, and how best to define the therapeutic relationship. Humanism Humanistic therapies (Chapter 6) are founded on a phenomenological philosophy that prioritizes the individual’s subjective truth. They include Carl Rogers’s (1951) client-centered therapy, Fritz Perl’s gestalt therapy (Passons, 1975), Virginia Satir’s (1972) communication approach, Carl Whitaker’s symbolic-experiential therapy (Whitaker & Keith, 1981), and Sue Johnson’s emotionally focused therapy (Johnson, 2004). Humanistic Assumptions • By nature, humans are essentially good. • All people naturally tend toward growth and strive for self-actualization, a process of becoming authentically human. • The primary focus of treatment is the subjective, internal world of clients. • Therapeutic interventions target emotions with the goal of promoting catharsis, the release of repressed emotions. • A supportive, nurturing environment promotes therapeutic change. The work of Virginia Satir and Carl Whitaker most clearly illustrates this philosophical stance, which in family therapy is always combined with a systemic perspective that accounts for the effect of family dynamics on an individual’s emotional inner life. Although Satir’s and Whitaker’s approaches are based on the same philosophical traditions, their therapeutic approaches have dramatically different styles and assumptions, including the best ways to address self-actualization, change, confrontation, and the therapist’s use of self (referring to how therapists use their personhood in session). Systemic Therapy Rather than a formal philosophical school, systemic therapies are grounded in general systems theory, which stresses that living systems are open systems, connected with and embedded within other systems (von Bertalanffy, 1968), and cybernetic systems theory, which emphasizes a system’s ability to self-correct to maintain homeostasis (Bateson, 1972). The latter is more influential in the development of specific therapeutic models, such as the Mental Research Institute’s brief, problemfocused approach (Watzlawick, Weakland, & Fisch, 1974), strategic therapy (Haley, 1976; Madanes, 1981), and the Milan team’s systemic approach (Boscolo, Cecchin, Hoffman, & Penn, 1987). Systems theories emphasize contextual truth, truth generated through repeated interpersonal interactions that set a “norm” and rules for behavior. Systemic Assumptions • One cannot not communicate; all behavior is a form of communication. • An individual’s behavior and symptoms always make sense in the person’s broader relational contexts. • All behaviors, including unwanted symptoms, serve a purpose within the system, allowing the system to maintain or regain its homeostasis or feeling of “normalcy.” • No one individual unilaterally controls behavior in a system. Thus, no one person can be blamed for problems in a couple or family relationship; instead, problematic behavior is viewed as emerging from the interactions between members of the system. • Therapeutic change involves alternating the interaction patterns within the system. Within the field of systemic family therapy, Bateson’s (1972) distinction between firstorder and second-order cybernetics had a significant impact on how therapists worked with families. With first-order cybernetics, the therapist is an objective, neutral observer describing the family as an outsider. Such therapy relies on assessment instruments and the therapist’s perception of the family system. Second-order cybernetic theory applies the rules of first-order cybernetics on itself, positing that the therapist cannot be an objective, outside observer but instead creates a new system with the family: the observer–observed or therapist–family system. This second-order system is subject to the same dynamics as the first, including the drive to maintain homeostasis and rules for relating that are mutually reinforced. Second-order cybernetic theory maintains that whatever the therapist observes in the family reveals more about the therapist’s values and priorities than about the family’s because any description exposes what the therapist pays attention to and what the therapist ignores or misses. Second-order cybernetics laid the foundation for the transition to postmodern therapy, specifically constructivism in the MRI and Milan schools (Watzlawick, 1984). In general, all systems therapists are influenced by both first- and second-order cybernetic theory. In practice, therapists generally emphasize one level of systems analysis or another. Broadly speaking, strategic and structural therapies were based on first-order theory, and the MRI and Milan approaches gravitated toward second-order and later constructivist approaches. • First-order cybernetic approaches lean toward the modernist tendency to find a more objective form of truth. Therapists who practice systemic therapies with a first-order orientation use more assessment instruments of family functioning and rely heavily on the therapist’s perception of the system to guide practice. • Second-order cybernetic approaches lean more toward a postmodern approach to truth (see next section). Their focus is on how the therapist and client coconstruct a second-order system, which has its own unique set of rules for establishing truth. Postmodern Therapy Postmodern therapies are based on the premise that objective truth can never be fully known because it must always pass through subjective and intersubjective filters. Postmodern Assumptions • The human mind does not have access to an outside reality independent of human interpretation; objectivity is not humanly possible. • All knowledge and truth are culturally, historically, and relationally bound and therefore intersubjective: constructed within and between people. • What a person experiences as “real” and believes to be “true” is shaped primarily through language and relationships. • Language and the words used to describe one’s experiences significantly affect how one’s identity is shaped and experienced. • The identification of a “problem” is a social process that occurs through language, both at the immediate local level and at the broader societal level. • Therapy is a process of co-constructing new realities related to the client’s personal identity and relationship with the problem. Within family therapy, three schools of postmodernism are particularly influential (Anderson, 1997; Hoffman, 2002; Watzlawick, 1984): • Constructivism: Constructivists focus on the construction of meaning within the individual organism, on how information is received and interpreted. • Social Constructionism: Social constructionists focus on how people co-create meaning in relationships. They emphasize how truth is generated at the local (immediate) relational level. • Structuralism and Poststructuralism: Structuralists and poststructuralists focus on analyzing how meanings are produced and reproduced within a culture through various practices and discourses. Dancing with Others Once You Marry Once you commit yourself to a theory and philosophical stance, it ironically becomes much easier to dance with others. As you master one theoretical approach and deepen your understanding of its underlying philosophical assumptions, you are able to understand other theories at a greater depth. This is perhaps where the common factors come in. There are similar principles that seem to be at play in all theories, and the more intimate you are with one theory the better able you are to identify these factors in others. It is also the case that you can see more clearly the subtle differences in outcome from philosophical assumptions, word choices, and interventions that differ across theories. As therapists become more aware of the set of philosophical assumptions underlying their theory, whichever school that might be, they learn to skillfully adapt and integrate ideas from other approaches in a way that is philosophically consistent with their own approach. When a therapist is “eclectic” or “integrative” in a way that is not grounded in a single philosophical set of assumptions, that therapist is going to confuse his/her clients. One week, the therapist might use a modernist approach and is an expert who has answers and knows the best way to approach the problem. The next week, the therapist might try to use a postmodern approach in which the client is expected to be the expert and participate more as an equal. The following week, the therapist might then shift to systemic ideas that emphasize the importance of context in defining the problem. As you might well imagine, a client working with this therapist is going to be very confused, because each week the client is required to relate differently to the therapist and to assume a different level of participation. The therapist is also sending contradictory messages as to what is the measuring stick for “truth,” progress, and direction. However, if the therapist is able to keep the philosophical assumptions consistent throughout therapy— what is our measuring stick for truth? what are our roles?—then the therapist can adapt concepts and techniques from other approaches without sending conflicting messages to the client, thus effectively incorporating a wider range of practices within a coherent approach to therapy.
REFERENCES for Chapter 1 Gehart, D. (2011). The core competencies in marriage and family therapy education: Practical aspects of transitioning to a learning-centered, outcome-based pedagogy. Journal of Marital and Family Therapy, 37, 344–354. doi: 10.1111/j.1752-0606 .2010.00205.x Killen, R. (2004). Teaching strategies for outcome-based education. Cape Town, South Africa: Juta Academic. McDonough-Means, S. I., Kreitzer, M. J., & Bell, I. R. (2004). Fostering a healing presence and investigating its mediators. Journal of Alternative and Complementary Medicine, 10, S25–S41. Miller, S. D., Duncan, B. L., & Hubble, M. (1997). Escape from Babel: Toward a unifying language for psychotherapy practice. New York: Norton. Monk, G., Winslade, J., & Sinclair, S. (2008). New horizons in multicultural counseling. Thousand Oaks, CA: Sage. Nelson, T. S., Chenail, R. J., Alexander, J. F., Crane, R. Johnson, S. M., & Schwallie, L. (2007). 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