introduction to the counseling profession

Introduction to the Counseling Profession

Chapter 16

Marriage, Couple, and Family Counseling

Chapter Topics

Foundations“Family therapy is a psychotherapeutic approach that focuses on altering interactions between a couple, within a nuclear family or extended family, or between a family and other interpersonal systems, with the goal of alleviating problems initially presented by individual family members, family subsystems, the family as a whole, or other referral sources.”

There are many approaches to family therapy that have emerged out of systems theory.

However, prominent family therapist researchers are now concentrating on integrating system-based approaches to leverage greater effectiveness.

There are two key foundational aspects to family therapy. These aspects are: (a) history, and (b) specialization or profession.

FoundationsHistory

The history of family therapy is relatively brief. It begins in the 1950s, with the seminal contributions of Nathan Ackerman, Theodore Lidz, Lyman Wynne, Murray Bowen, and Carl Whitaker.

All of these psychiatrists, originally trained in the prevailing psychodynamic model, broke away from its restrictive influence and began to see that dysfunctional behavior was rooted in the individual's past and present family life.

Each of these pioneers arrived at this insight relatively independently.

FoundationsSpecialization or Profession?

At present there exists a strong debate as to whether family therapy is a professional specialization or a distinct profession.

Who is going to win the above noted debate? Some suggest that this debate will be resolved as a “both-and.” That is, both MFTs and other mental health professionals will practice family therapy and Marriage and Family Therapy will be viewed as a distinct profession.

Counseling, Prevention, and InterventionThe Initial Interview

The following description owes a great deal to Jay Haley (1987), but also incorporates ideas from other therapists.

The stages of the interview are as follows:

(a) Presession planning(b) Joining(c) Problem statement(d) Interaction(e) In-sesssion conference(f) Goal-setting

Counseling, Prevention, and Intervention

Pre-session Planning Whenever possible, the therapist should determine in advance who will

attend the session, and have at least a general idea of the nature of the presenting problems.

This is called the “battle for structure," and great emphasis is placed on the importance of the therapist determining who will attend the first session. If the therapist does not have control at this stage, therapeutic leverage is lost and the family is less likely to be helped.

“On the basis of the data derived from this initial contact, a pre-session plan should be developed that will include the therapist’s hypotheses about the underlying basis of the presenting problem, areas of inquiry that must be addressed to reject or confirm the hypotheses, and a general plan for the session.”


Joining

Mimesis is a therapeutic skill “used by the therapist to join with the family and become like family members in the manner or content of their communications.”

A third aspect of joining is maintenance. This aspect of joining refers to the therapist sensing the family's structure and acting in such a way as to be included within it.

During the joining stage, the therapist should not allow the introduction of material related to the family problem.

“The most important task of the initial interview is to join with the family, accommodating to their affective tone, tempo, language, and family structure. This is done through mimesis.”


Problem Statement During the joining stage, the therapist has learned something of the

family structure and hierarchy and uses this information to decide to whom the first question should be directed.

The second decision the therapist must make is how the problem question should be framed.

“Haley (1987) recommends that “the adult who seems less involved with the problem be spoken to first, and the person with the most power to bring the family back be treated with the most concern and respect."


Interaction When the problem has been reasonably clarified, or when it has become

clear that the family is not in agreement regarding the nature of the problem, it is time for the therapist to introduce the interaction stage.

In the interaction stage, the therapist's focus will be on determining the patterns of interaction that sustain the problem.

“The purpose of the interaction stage is to determine the family hierarchy, to reveal any stable coalitions, to locate diffuse or rigid boundaries between family subsystems, and hopefully to reveal the chronically repeating interactional sequence that sustains the problem behavior.”


Goal Setting The purpose of the goal‑setting stage is to reach agreement with the

family on a solvable problem and to initiate a process that will alter the social situation in such a way that the problem is no longer necessary.

It is essential that the problem to be solved be stated in behavioral terms so that one will know when it has been solved.

Often the process of operationalizing the complaint will be sufficient to produce a solvable problem.

“As Haley (1987) has said, "If therapy is to end properly, it must begin properly‑-by negotiating a solvable problem and discovering the social situation that makes the problem necessary."

Counseling, Prevention, and InterventionKey Therapy Techniques

Circular Questioning

Each member of the family is invited to tell how he or she sees the relationship between two other family members; or between two different periods; or any other difference likely to be significant to the family.

Reframing

Reframing may include operationalizing, emphasizing complementarity, denominalizing, or positive connotation.

Counseling, Prevention, and InterventionKey Therapy Techniques

Giving Directives

Giving directives refers to creating or selecting an intervention that will attack the hypothesized basis of the presenting problem.

Directives can be categorized as either (a) compliance‑oriented or (b) defiance‑oriented.

Diversity and Advocacy

Cultural Competence Cultural competence is derived from a therapist being aware of his/her

own assumptions about a client’s cultural narratives.

Narrow Rigid Beliefs and Self-Percepts

When an individual or a family is unable to resolve a difficulty, it is assumed that the conscious mind is imposing a narrow, restrictive mind‑set that does not allow the creative recovery of the resources necessary to solve the problem.

“Professional counselors realize their perspectives influence the conceptualization of problems, identification of clients, and implementation of possible solutions. Couple and family counselors examine personal biases and values. They actively attempt to understand and serve couples and families from diverse cultural backgrounds.”

Assessment

Family Dysfunction

Rather than focusing on the internal state of the individual, the family systems approach looks for pathology in the interactions that occur between people who have significance for each other.

The purpose of family therapy is not insight, but behavior change.

“Tolstoy said in the opening line of Anna Karenina, “All happy families resemble one another, but each unhappy family is unhappy in its own way.” Family therapists tend to reverse this position, believing that good family functioning is based in diversity, while family dysfunction is due to narrowness and rigidity.”

Assessment

Family Life Cycle

Inherent in the life cycle concept is the idea that there are certain developmental tasks that must be accomplished during periods of transition from one stage to another. Successful movement to the next development stage requires changes in the roles and structure of the family.

Other potential life-cycle stages that can occur in families are (a) marital break-up, (b) single-parent living, and (3) remarriage.

“Family dysfunction is often the result of a failure to accomplish the developmental tasks demanded by the family life cycle.”

Assessment

Family Fusion (Present or Origin)

At the upper end of the scale, people have achieved emotional separation from their families, are able to act autonomously, and can choose to be rational in emotionally charged situations.

The individual's level of differentiation is closely related to the differentiation of his or her parents, and the process is transgenerational in nature.

“Bowen (1994) conceived a scale of differentiation of self from 0 to 100. At the low end of the scale, people are fused or enmeshed with their families to the extent that they are unable to think or act independently. Their lives are ruled by emotional reactivity.”

Assessment

Family Fusion (Present or Origin)

People with low levels of differentiation (fusion) are particularly reactive to environmental stressors and when under stress are likely to resolve it by (a) withdrawal, (b) conflict, (c) dysfunction of one spouse, or (d) triangulation of a child that results in dysfunction.

People with low levels of differentiation (fusion) are particularly reactive to environmental stressors and when under stress are likely to resolve it by:

(a) Withdrawal(b) Conflict(c) Dysfunction of one spouse(d) Triangulation of a child that results in dysfunction

Assessment

Boundary Problems

According to Minuchin, family boundaries are created by implicit rules that govern (a) who talks to whom, and (b) about what is discussed.

When no rules exist, everyone is privy to everyone else's thoughts and feelings. Thus, family boundaries become diffuse and individuals become enmeshed (fused).

When the rules are too strict and communication breaks down, the boundary is said to be rigid and the individuals disengaged.

The preferred state is to have clear rules that allow for both individuation and togetherness.

Assessment

Dysfunctional Behavioral Sequences

Such patterns can repeat ad infinitum unless some new behavior is introduced into the sequence.

It perhaps needs to be pointed out that the dysfunctional behavior should not be “blamed" on any of the individuals; all are equally involved and each could change the sequence by introducing a new incompatible element.

“Haley (1987) believes family dysfunction is often caused by behavioral sequences that are rigid, repetitive, and functionally autonomous.”

AssessmentHierarchy Problems

Problems can occur when the hierarchy is either absent, ambiguous, or culturally inappropriate; that is, when no one is in charge, when it is unclear who is in charge, or when the person wielding the power is not sanctioned by cultural mores.

Communication Problems

Communication may be inadequate owing to lack of clarity, lack of continuity, incongruent, or when people are unwilling to reveal themselves.

AssessmentFamily of Origin Struggles

Young people who come from a common cultural background may be less likely to experience this problem, but in our multicultural society, the appropriate behaviors for “wife” or “husband” are often unclear, or represent role conflicts.

Often the young couple find themselves acting just like their parents, although they are reluctant to admit it.

Research and EvaluationDoes Therapy Work?

Research that examines whether an intervention works is known as outcome research.

In family therapy, a dearth of outcome research left the above question unanswered until the late 1980s.

Meta-analysis is a research technique by which multiple individual studies can be grouped together to empirically analyze the overall effectiveness of a particular intervention approach.

In a meta-analysis studies, it was found that family therapy is indeed an efficacious mental health treatment approach.

Research and EvaluationWhat are the Professional Practice Patterns of Family Therapists?

MFTs, on average had 24 clients in their active caseload and completed 20 client contact hours per week. The median number of sessions per client was 12.

The clients served by the MFTs presented a multitude of problems at the commencement of treatment. These problems included (a) depression (44%), (b) marital problems (30%), (c) anxiety (21%), and (d) parent-child problems (13%).

Adjustment Disorder was the modal diagnostic category (25%). Other prevalent diagnostic categories included Depressive Disorder (23%) and Anxiety Disorders (14%).

introduction to the counseling profession

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