Outlines of Readings
Psychotherapy with Families
Core Techniques in Family Therapy by David Seaburn, Judith Landau - Stanton, and Susan Horwitz. In Mikesell, et al. (1995). Pages 5 - 26. Outlined by Jared Warren
I. Introduction
A. Today's family therapists: multiple orientations, integrative models
B. Development of family therapy mirrored other major changes in society
Traditional roots vs. New approaches
II. Core family therapy interventions
A. Here and now interventions
1. Common elements: focus on current family structure and interactions; goal oriented, solution focused; generally brief in nature; emphasis on behavioral change over insight; therapist responsible for facilitating change
2. Reenactment and enactment. - Problematic interaction is demonstrated, then alternative is practiced
3. Reframing/positive connotation/noble ascription and symptom prescription: framing problem in more positive way
4. Restructuring the family in session: identifying repeating patterns or changing physical positioning of family members; family sculpting
5. Defining the problem and establishing goals and action plans
6. Family psychoeducation: therapist as educator
7. Between session homework tasks: linked to family goals
8. Therapist's use of self with the family: personal nonspecifics(?); Therapist's use of self - disclosure, humor, etc. To modify energy or anxiety during therapy
B. Transgenerational interventions
1. Common elements: transgenerational processes across time influence development of current problems; problems often arise during transitional periods; resolving relationship issues with family of origin promotes current problem solving
2. Genogram development: map relationship patterns and transitional conflicts
3. Trips home: address source of problem relationships; self - differentiation
4. Inviting extended family into therapy: work directly on family of origin issues
5. Symbolic inclusion of family of origin: utilizing "ghosts" of family members not present; sculpting family of origin; empty chairs
C. Ecosystemic approaches
1. Common elements: sensitivity to extrafamilial factors in the development of problems; utilization of larger systems resources in assessment and treatment; therapist's role as orchestrator (vs. Performer) and detective."
2. Interventions are biopsychosocial and collaborative in nature
3. Many techniques associated with other approaches may be used
4. Use of network sessions
III. Application of core interventions
A. Here and now interventions
B. Transgenerational interventions
C. Ecosystemic approaches
IV. Integration
A. Most therapists make use of a variety of core techniques
B. Clinical example: transitional family therapy emphasis on family competence creating continuity between past, present, and future current difficulties may stem from previous behavior patterns that were once adaptive, but have now become entrenched and problematic
V. Integrative interventions
A. Initial phase of treatment
1. Hypothesizing joining and mapping
2. Establishing goals for treatment
3. Assessing family strengths
4. Formulating the transitional perspective
B. Mid phase of treatment prioritizing, planning, and working on identified goals treatment system expanded to include important resources exploration of other issues using transitional map
C. Final phase of treatment family becomes more in charge of therapy direction family should recognize its own capacity to deal with future difficulties
Haley, Jay (1976). Problem - Solving Therapy. Pages 9 - 80. Outlined by Sarah Sifers
I. Conducting the first interview
A. Before the interview - approach each family as unique. It makes sense to work with the whole family to make progress more quickly and to get more perspectives on the family's difficulties it is also helpful to include any other significant people in the family's lives such as school personnel and significant others.
B. Social stage. The therapist should allow the family members to sit where they would like and should introduce him or herself to each individual. The therapist should match his tone to the mood of the family and observe their interactions. At this point the therapist should be careful not to get into a coalition with anyone, to keep distant members involved, keep conclusions tentative, and keep observations to him or herself
C. Problems stage. This stage begins when the therapist inquires why the family is there and other such questions. The hierarchy of the family should be respected, however everyone's perspectives should be valued. The article gives a number of suggestions for structuring the inquiry. The therapist should be interested and encourage sharing while intervening in the case of interruptions, but not offering advice, interpretations, or asking for feelings. It is important for the therapist to continue his observations, but not share them.
D. Interaction stage - during this stage the therapist is still in charge, but encourages family discussion about the presenting complaints.
E. Goal setting stage : during this stage the therapist gets the family to operationalize the problem behavior and set a goal to be achieved
F. Ending the session. The session should end with the therapist giving a directive and setting the next appointment.
II. Giving directives
A. Purpose of directives: to have the family behave differently and, therefore, have a different experience within the family; to have involvement with the therapist outside of sessions; and to gather information.
B. Types of directives telling the family what to do hoping they will do it and telling the family what to do hoping they will rebel. Directives also can indicate a behavior to be done or to be stopped (stopping tends to be more difficult to do)
C. Motivating the family. Requires that the therapist help each family member find something that they will gain from the intervention. It can involve making a family feel more desperate or more optimistic. Some families react better to large tasks and others to smaller ones
D. Good directives. Are feasible for the family, target the presenting complaint and problematic family interactions; are clearly stated (not suggested); include all family members; and are reviewed with family including a discussion of ways to avoid the task the article gives a list of 18 examples of directives used in family therapy.
E. Task report : are the family's report in the next session where the therapist should congratulate a family for completing their task or hold them accountable if they have not. The therapist should cast all difficulties of the family as resulting from the failure to do the task and not let the family do the task next week to motivate them to cooperate in the future.
E. Metaphor : can be used to approach subjects that the family cannot talk about and can be used to change the problematic activity be focusing on a similar activity that the family is better able to discuss.
F. Paradoxical directives: can target the entire family or one individual and requires them to "prove the therapist wrong " often family members are asked to perform exaggerations of the presenting complaint to maintain changes the therapist may state that he or she expects a relapse or even ask the family for one the article describes the stages of designing a paradoxical approach, which takes skill and practice to implement.
Engaging the Family: an Integrative Approach by Timothy Weber and Felise Levine. In Mikesell, et al. (1995). Outline by Patty Salehpour
I. The beginning is the most important part of family therapy
A. core components of engaging the family
1. Establishing leadership
a. Establishing leadership of the self
b. Fostering distributed leadership
c. Crafting a learning organization
2. Creating the holding environment
a. Emotional containment
b. Rapport and joining the family
c. Listening to yourself
d. Modeling relational ethics
e. Attending to inclusion
f. Play and imagination
g. Claiming a right to a private existence
B. Being yourself as a person/therapist
II. Stages of Engaging
A. The pre-session
1. Prelude to the therapeutic encounter
2. The initial phone call
3. Generating hypotheses
B. The session
1. The greeting
2. The orientation
3. Exploring the backgrounds
a. Genograms
b. Family chronology
c. Ecosystemic map
4. Exploring the foreground
a. Presenting problems
b. Attempted solutions
5. Defining goals
6. The prompt
7. The contract
C. The post-session
1. Debriefing
2. Self-assessment
3. Hypotheses
4. Individual work
5. Couples work
6. Family work
Marital and Family Assessment: a Multifaceted, Multilevel Approach by Snyder, Cavell, Heffer, & Mangrurm in Mikesall et al. (1995). Pages 163 - 182. Outlined by Amanda Sobel
I. Principles and guiding assumptions
A. Marital and family assessment is both qualitatively and quantitatively distinct from assessment of individuals
1. Focus on need for other members of the family to change
2. Offers unique opportunity to observe directly - problematic interpersonal exchanges of clients and to contrast these with subjective appraisals of these events
3. Number of participants makes family therapy more complex and the pace is different
4. Level of hostility expressed typically exceeds that experienced in individual therapy
B. Assessment is vital to effective intervention
C. Assessment should be guided by theory
D. Assessment must occur on multiple levels
E. Levels of assessment: individuals, dyads, nuclear families, extended family systems and related systems interfacing with the immediate family, and community &,cultural system
F. Assessment must proceed from multiple perspectives: subjective, objective behavior and observer reports
G. Assessment is an ongoing, recursive process
H. Assessment should be based on empirical foundation
II. A conceptual model
A. Five dimensions: cognitive, affective, communication and interpersonal, structural and developmental, and control, sanctions, and related behavioral domains
B. Systems perspective: the nuclear family system comprises two or more individuals involved in one or more dyadic relationships
C. Use multiple assessment strategies, including both formal and informal self - report and observational techniques
D. Assessing individual family members - strengths and limitations, self - reflection, adopting each other's perspectives, motivation, emotional or behavioral difficulties; level of development and previous fife experiences, resources and liabilities, capacity for insight; cognitive style, attitudes, and distortion; content intensity, and mutability of each individual's affect; capacity for behavioral self - control; medical conditions, developmental considerations
E. Assessing dyads - patterns of interaction, relationship conflicts, cohesion, communication difficulties, problem identification, couples' approaches to conflict (use of reasoning, verbal
Aggression, and physical aggression), relationship satisfaction, commitment, cognitions
(assumptions, standards, attention, attributions, expectancies); adaptability, distribution of power, developmental context
F. Assessing nuclear systems - functional family systems possess both flexibility and hierarchy, family routines, family hierarchy (differential allocation of authority, responsibilities, privileges across family members); developmental context (chart development across life span, changes, norms, rules, parental approaches to discipline, models of family decision making, differences in parental discipline)
1. Models of family decision - making: unilateral model of decision making, consultative model, collaborative model, and democratic model
2. Parental disciplinary style: authoritarian parenting, authoritative parenting, permissive parenting
G. Assessing extended system : significant others outside extended family including family, friends, sexual relationships outside the marriage
H. Assessing community and cultural system : formal and informal, family values and expectations, assumptions and attributions, cultural expectations contribute to patterns of interaction within the family regarding expression
II. Selection of assessment strategies (see table 1, page 177)
A. Individual level - broad band multidimensional measures (mmpi, cbcl, peabody, pic)
B. Dyad level - self - report and observational techniques (msi, psi, paics)
C. Family systems level - self - report and observational techniques (fes)
D. Extended family and community/cultural levels - formal assessment techniques are lacking (genogram)
1. Self - made measures - most commonly used clinical and research measurement strategy for the study of human relationships, following the clinical interview
a. Advantage : convenient and easy to administer, obtain much information, normative samples, disclosure about events and subjective experiences, important data concerning internal phenomena, useful in planning and evaluating marital or family therapy
b. Limitation : susceptibility to deliberate and unconscious efforts to bias, vulnerable to individual differences in interpretation and errors in - recollection, influence respondents' nontest behavior, few fine grained details concerning moment to moment interaction
2. Observational strategies: provide data regarding - actual exchanges among family members relevant to empirically driven systems of clinical intervention, less susceptible to respondent bias, costly - and labor intensive
3. Selection criteria for a measure: relevance to presenting complaints, availability and appropriateness of norms, inclusion of multiple, informants, traditional psychometric properties, cost, social validity, linkage to theory, usefulness in planning, implementing, and evaluating clinical interventions
III. Integration of clinical findings
A. Common limitations of clinicians' - problem - solving models the better informed about the psychology of couples and families
B. The better our ability to assess a particular couple or family
C. The adequacy of clinical decisions restricted by psychometric soundness of assessment procedures
D. Structured approaches to interpreting and integrating data should be used where possible
E. presentation of the initial assessment findings to family - members - should provide the opportunity for clarification and corrections to omission and misinterpretations of assessment data (reframing, collaborative alliance, promote understanding, active exchange, hypotheses, goals)
Genograms and the Family Life Cycle by McGoldrick & Gerson in Carter and McGoldgrick (1988). Pages 164 - 189. Outlined by Amanda Sobel
I. Purpose of genograms
A. Family life cycle network
B. Graphic pictures of family history and pattern, showing the basic structure, family demographics, functioning, and relationships
C. Shorthand used to depict the family patterns at a glance
D. Schematic map of the family
II. Genogram format
A. Symbols used to describe family membership and structure - place significant others on the right side of the genogram (marriages, divorces, children, members of current household)
B. Family interaction patterns (very close relationship, distant, estrangement, conflictual)
C. Medical history - list only major chronic illnesses and problems, include dates in parentheses
D. Other family information of special importance (ethnic background and migration date, religion or religious change, education, occupation or unemployment, military service, retirement, trouble with law, physical abuse or incest, obesity, alcohol or drug abuse, smoking, dates family members left home, current location of family members)
III. Marriage and remarriage
A. Since the life cycle is circular and repetitive, one can start at any point to tell the story of a family.
B. Marriage or remarriage brings two families together in the genogram
C. Be sure to include the ages of each family member
D. Unresolved issues in early developmental periods often lead to problems in later phases
E. Looking at triangles and patterns at different life stages may be helpful
The remarried family has two important triangles: the first marriage family and the second marriage family. Spouses and children from each family should be clearly deliniated
IV. The transition to parenthood and families with young children
A. Parents must bear responsibility of child rearing while trying to maintain their relationship
B. Reveals stressors that make phase difficult for parents
C. Sibling constellation
D. Mother - father - child triangles
E. Birth of first child marks transition to - a new family
F. Explore stressors and traumatic events and losses - track effect
G. Systemic perspective - loss is viewed - as a major transition that disrupts family life cycle patterns of interaction
V. Families with adolescents
A. Task is to prepare family for a qualitative change in relationships between generations
B. Triangles likely to develop
C. Genograms often reveal family boundaries and multigenerational. Patterns
D. Genograms sometimes indicate peers and whether family boundaries include outsiders
VI. Families at midlife: launching children and moving on
A. Allows anticipation of the development of next generation
B. Children leave home to be on their own and reveals, duration of launching phase
C. Short circuiting of this phase or its prolongation may affect future life cycle transitions
VII. Marriage, the next generation
Provides valuable clues to difficulties and issues involved in joining together of 2 family traditions in a new - family
VIII. Parenthood, the next generation
A. Be alert to child - rearing issues and normative strains in the marriage
B. Birth of the last child may be an important turning point in the family
C. Be alert for other family members addition to the household mid possible triangles
D. The death of a parent marks a critical point in the fife cycle and is a painful reminder of one's mortality and that the mantle of tradition and responsibility has been passed to the next generation
IX. Families in later life
A. During the phase of aging, the family must come to terms with the mortality of the older generation, while relationships must be shifted as each generation moves up a level in the developmental hierarchy
B. Genograms reveal which child is delegated as caretaker of aging parents, as well as struggles and triangles
C. Sibling cutoffs and conflicts reflect triangles
D. Helpful in predicting or understanding reactions of family members at different points in the life cycle
E. Loss of family member difficult to mourn and therapists should be alert to dysfunctional patterns that develop
Communication Theories. In D. Karpowitz (1991). Pages 162 - 196. Outlined by Patty Salebpour
I. Basic axiom
A. One cannot not communicate
B. Attempt to define the relationship between sender and receiver
C. Punctuation
D. Distinction between digital and analog model of communication
E. Interaction can be viewed as symetrical, complementary or parallel
F. In any communication the message sender perceives some kind of response from the receiver
II. Self - worth and communication
A. High "pot"
B. Low "pot"
C. Poor communication
1. Fight reaction
2. Flight reaction
III. Uniqueness must be considered in effective communication
IV. Principles of emotion and communication that facilitate or hinder effective relationship development and maintenance
A. Emotionality principle
B. Rationality principle
C. Trust principle
D. Concern principle
E. Norms - emotion principle
F. Self esteem principle
G. Defensive communication principle "defense mechanism"
H. Anxiety principle
V. Effective communication
A. Awareness of self
B. Awareness of the
C. I can only change me
D. For effective communication I must be aware of myself, tune into the other and do what I can to make the communication effective
VI. Styles of communication
A. The blamer - "I am ok, you're not ok"
B. The placater - "You're ok I am not ok'
C. The computer - "I am ok, you're ok, but let's talk about it"
D. The distracter - "I am not ok, you're not ok
E. Leveling or being real
VII. Psycholinguistics
A. Transformational grammar
B. Surface structure
C. Deep structure
D. Distortions, over generalizations, deletions
VIII. The transactional model
A.Three ego states
1. The parent
a. Nurturing parent
b. Prejudicial parent
c. Critical parent
2. The adult
a. Fixed
b. Contaminated
c. Decommissioned
3. The child
a. Adapted child
b. Nurturing child
c. The little professor
B. Transactions
1. Parallel
2. Crossed
3. Ulterior
C. Games
1. Rappo
2. Poor me
D. Scripts
Santa Claus
IX. Improving communication technique
A. Sharing
B. Echoing
C. Three "Yeses"
X. Principles for resolving disagreements in relationships
A. Five possible outcomes
1. Everyone agrees to one person's perspective
2. Everyone agrees to a compromise
3. Everyone agrees to tolerate the difference
4. The relationship can end
5. No solution can be reached
B. Interpersonal crisis management
1. Gain rational control of self
2. Make an interim decision
3. Come back and discuss the situation later, so a plan will be developed for the future.
C. Gordon's "no lose" problem - solving method
1. Define the problem
2. Brainstorm
3. Eliminate unacceptable solution
4. Choose the best solution
5. Implement the solution
6. Follow up
D. Bach & Wyden's suggestions
1. Discuss to reach a solution not to blame or hurt the other
2. No physical violence allowed. Leave the room temporarily to gain self - control, then return
3. Make requests not demands
4. No stamp collecting
5. Don't hit below the belt
6. Don't refuse to discuss
7. Don't involve third parties such as parents when the issue is preference
8. Don't play psychologist
9. Don't play archeologist
10. Don't make speeches
11. Don't use emotional blackmail
E. Remember that two ounces of prevention are worth a pound of cure
1. Decide who is in charge & of what situations
2. Family member deserve the best etiquette
F. Family Council
1. Hold weekly
2. All family members attend and participate
3. Leadership is passed around to all family members old enough to do it
4. Any member of the family can bring up any problem
5. Make decisions by consensus (small families) or clear majority (large families)
6. Teach values briefly
7. Make it fun
The Family Life Cycle by R. Gerson in Mikesell, et al. (1995). Outlined by David Peres
I. Family life cycle models
A. Carter and McGoldrick (1988) stages
1. Launching of single young adults
2. Joining of families through marriage
3. Families with young children
4. Families with adolescents
5. Launching children and moving on
6. Families in later life
B. Emphasis on multigenerational nature of family life cycle
II. Universality - changes in roles and uniqueness of modern family
III. Family growth phases
A. Coupling
1. Preparation
2. The making of a new family unit
3. Foundations for further growth
B. Expansion
1. The birth of children
2. Development of support and autonomy/self - reliance of children
C. Contraction
1. Adolescence and leaving the primary family - launching
2. Boundaries within larger extended family maintained
IV. Family life cycle stages
A. Unattached young adult
1. Beginning of coupling phase
2. Development of a strong and secure sense of self
B. Family formation through coupling
1. Coupling is established
2. Adjustment of needs toward the demands of the relationship
3. Maintaining old family ties and adjusting to new
C. Family with young children
1. Expansion and acceptance of new family members
2. Maintaining the quality of the couple's relationship is crucial
D. Family with adolescents
1. Transitions as boundaries expand then contract
2. Maintain a loose routine and flexibility toward change
E. Launching children and moving on
1. Contraction and utilization of resources and focus of energies
2. Loss of children and reestablishment of primacy of marriage
F. Family in later life - maintaining the support system
Uncertainties of old age and coping with loss and physical decline
G. Crises
1. Erikson's challenges
2. Historical context
3. Examine
a. Challenges of the current family life cycle stage
b. Unresolved issues from previous life cycle stages
c. Unresolved issues of previous generations
d. Failure to "grow up" - lack of child independence
e. Failure to find a mate or commit
f. End of "honeymoon"
g. Marital dissatisfaction following birth of children
h. School or behavior problems adolescent rebellion empty nest retirement
i. Caretaking of older persons
j. Loss - particularly a child or suicide
k. Divorce
1) Some of the previous challenges may continue to exist
2) When the divorce occurs in the life cycle may be critical
l. Remarriage
Multiple family structures at various stages of family life cycle
From Conflict to Resolution by Susan M. Heitler (1990). Outlined by Amanda Sobel
I. Chapter 2 - the cooperative pathway from conflict to resolution
A. Mapping the route
1. Expression of the initial positions - opening wishes, positional bargaining
2. Exploration of underlying concerns - value, feeling, statements about oneself, "I"
3. Selection of mutually satisfying solutions - potential courses of action
4. Intrapsychic conflict resolution
5. Interpersonal conflict resolution - depth and breadth
B. Communication skills
1. Expression of initial positions - expressing position verbally and nonthreatening saying
a. Saying, bring the issue out into the open
b. Listening-explore positions, active
c. Symmetry - equal air time
d. Summarizing - full review of points made
2. Exploration of underlying concerns
a. Teamwork - opposition gives way to cooperation, "I" to "we," reframe, why
b. Self - acceptance and acceptance of the other - say whatever tomes into awareness
c. Specific details - lay the groundwork for consensual solutions
d. Depth - exploring underlying concerns
3. Selecting mutually satisfying solutions
a. Summarizing statements
b. Generating options
c. Selection of a solution
d. Checking for unfinished business
e. Final closure
II. Chapter 10 - overview of the therapeutic journey
A. Treatment components for conflict resolution
1. Symptoms - assessment of presenting symptomatology and, if necessary, interventions to reduce symptom
2. Content - clarification of the content of troubling conflicts and resolution of these conflicts
3. Process - clarification of the characteristic patterns for processing conflicts and development of healthier resolution patterns
4. Assumes that individuals, couples and families need to deal with conflicts in all three realms: intrapsychic, interpersonal, and systemic
B. Assessment: organizing and drawing conclusions from the data
1. Symptoms - the solutions to, symbolic expression of, or by products of poorly resolved conflicts, making an initial " laundry list"
2. Content: actual personal, family and work problems, and the underlying feelings, needs, and values that cause a problem to feel conflictual
3. Patterns: the processes by which conflicting wishes, feelings, and thoughts are handled
C. Treatment: from conflict to resolution
1. Treatment of symptoms
2. Treatment of a content - laundry list is agenda, express conflicting wishes, explore underlying concerns, choose mutually satisfactory solutions
3. Treating the process - new ways of tackling disagreements
III. Chapter 11 - Essential treatment decisions
A. Who should be seen in treatment?
1. Individual therapy can negatively impact: spouses
2. Consider patient's current social system
3. Married people treated in couple format, children treated in family format, single treated in individual therapy, adolescents treated in individual and family therapy
4. Reasons to schedule individual sessions
5. The caucus - when an impasse is blocking progress; issue of confidentiality?
B. Beginning the session
1. Establish continuity, review of homework, determination of the agenda
2. Brief review of prior session
3. Overview of where patients are in overall treatment process
4. Determination of agenda for next session
5. Summary at end of session - articulate goals
C. Addressing symptoms
1. Need attention when they create excessive discomfort, interfere with patient functioning, interfere with treatment, or - pose danger to patient and others
2. Use medications, behavioral therapies, and paradoxical techniques
D. Sequencing process and content
1. Laundry list - walking through conflicts
2. The process is the problem
E. How does therapy end?
1. Sense of closure, resolution of specific conflict
2. Summarizing statement
3. Reflection
4. Review the patient's initial laundry list
Domestic Violence and Sexual Abuse: Multiple Systems Perspectives by Geffner, et al. In Mikesell, et al. (1995). Outlined by David Peres
I. Family therapy: a controversial option
A. Issues
1. Allegiance to the generally accepted principle of systemic (circular) causality
2. The role of family structure that contributes to abuse
3. Therapist neutrality vs. an advocacy position
B. Abuse is seen as both individual and family in origin
C. Blending of advocacy and reconstructive approaches
Victim does not take responsibility for abuse
II. Preconditions for conjoint family therapy
A. Abusive men exploring new directions (amend) policy
B. Counseling begins when:
1. No reports of violence for over 5 months
2. Perpetrator accepts responsibility for violent acts
3. Clients able to cooperate and actively participate in treatment groups
4. Successful individual treatment prior to beginning family therapy
C. Franks and Rao do not agree with criteria for conjoint treatment
D. Granting releases and ensuring family safety
E. Blend of individual and family techniques recommended
III. General issues
A. Multiple systems perspective (msp)
Treatment should intervene at each level of complex system
B. Stages
1. Creating a context for change
a. Gaining control over clients' destinies
b. Change can happen though difficult
c. Recognition of other characteristics of family besides violence
d. Creating a safe environment and openness
e. Assessment of the family
f. Understanding the function of denial
g. Normalization, negative consequences of change, pretend techniques
2. Challenging patterns and expanding realities
a. Interruption of dysfunctional behavior patterns
b. Victim - survivor - offender cycle - > alternatives
3. Consolidation
a. Talking and reporting change
b. Exploration of the future
IV. Treatment of spouse or partner abuse
A. Issues
1. Conjoint therapy is debated
2. Generally equivalent or better success than male only focus
3. Preconditions include that battered woman wants to be in program and relationship and is not intimidated into making this choice
4. Assessment of continued risk
B. Conjoint therapy
1. Individuals assume personal responsibility for behavior
2. Batters can stop abuse
3. Violence and intimidation are not acceptable
4. Clients have the resources for behavior change
5. The therapist can facilitate and motivate the clients
C. Opportunities for role play and confront distorted beliefs
D. Mediation issues
1. Balancing power
2. Empowering and ensuring initiative of woman
V. Children's reactions to parental conflict, abuse, and violence
A. Recognition of child emotional factors
B. PTSD symptoms
VI. Treatment issues and programs for children observing abuse
A. Parent - child groups in coordination with individual treatment
B. Individual child issues
VII. An overall treatment approach
A. Ensuring safety of members
B. Stabilize a safe home environment
C. Skill learning goals
VIII. Techniques for children using conjoint family therapy
A. Preparation sessions
B. Children learn to express feelings
C. Code words and time outs
IX. Treatment of sexual abuse
A. Predominant styles
1. An inappropriate need for affection
2. An eroticized style of interaction
3. An aggressive and hostile style
4. Violent rage
B. Stage 1: individual psychological factors
1. Therapist begins to understand and observe patterns
2. Exploration of the nonoffending parent's history of trauma and abuse
3. Assessment of child's symptoms
4. Concluded when early case management concerns are achieved
5. Individual sessions
C. Stage 2: group therapy
1. Subsystem sessions
a. Poor boundaries
b. Sibling sessions
c. Extended family members
d. Informing social services and legal system
2. Couple sessions
a. Nature and future of relationship discussed
b. Communication and conflict resolution are ongoing issues
c. Discussions about sexuality and sexual problems explored
d. Link between partner's family of origin and current situation examined
D. Stage 3: final stage -
Possibility of recurring abuse?
Treating Marital Infidelity by Don-David Lusterman. In Mikesell et al. (1995), Pages 259 — 269. Outlined by Jared Warren
I. The frequency of marital infidelity
A. Early estimates of extramarital sex (EMS) ranged around 50% of husbands and 26% of
wives - may have been overestimates.
B. More recent estimates (national opinion research center) suggest 21% of men and
12% of women have had at least one extramarital sexual relation. These estimates appear to be more valid than previous ones.
C. Current surveys do not differentiate between types of EMS.
II. Protracted marital infidelity (PMI)
Betrayal of explicit and implied trust and intimacies is a major issue during the discovery phase.
A. Choice of terminology
1. Categories of EMS may be defined by:
a. Time
b. Degree of emotional involvement
c. Sexual intercourse or abstinence
d. Secret or not
e. Single or bi-lateral EMS
f. Heterosexual or homosexual
g. Number of partners
2. Author's terms
a. Infidelity - conveys breach of faith
b. Infidel - focuses attention on breach of faith
c. Victim - portrays the experience of the discoverer
B. The impact of discovery
Is the response based on jealousy? (not really)
a. Some therapists erroneously label the victim's reaction as jealous behavior.
b. Pathologically jealous mate will have had a long history of unprovoked jealousy.
C. The psychology of trauma
1. Similarities between discovery of PMI and PTSD
2. Complication in treatment is the fact that the victim generally does not immediately leave the marriage.
a. Persistent stimuli associated with the event (e.g. daily contact with mate, discovery of new bits of information about the deception, community gossip).
b. Innocuous incidents may cause traumatic reaction to resurface (e.g. spouse comes home late from work).
3. Lusterman's DSM format description of typical reaction to discovered infidelity.
III. Treatment issues
A. Orienting couples about the therapy
1. Explain that victim's reaction to discovered infidelity is normal and nonpathological.
2. Explain that goal is moving couple toward a better marriage or a better divorce.
3. Individual sessions will likely happen at some point.
B. How confidentiality forwards treatment
1. Confidential individual sessions allow for determining if affair is still happening
2. Moratorium on extramarital relationship; otherwise therapist will continue to see couple separately.
3. Discussion of individual's sense of further viability of marriage
C. How defining trauma forwards treatment
Case example: initial goal is to help move the couple beyond the crisis stage
D. Moving beyond the crisis phase
1. The victim needs reassurance from spouse that suspicion and fear are understandable, and that the situation may be talked about as much as is necessary.
2. Infidel often struggles with feelings of defensiveness and self - justification.
3. Infidel must be supportive and honest as new discoveries are reviewed
4. Infidel must express remorse for the constant lying and deception.
5. Growing empathic understanding between couple enables progress to happen.
IV. Phases of treatment
A. Restoring trust
1. Initial trauma of betrayal of trust is explored
2. Help victim transcend the "victim position"
B. Examination of predisposing factors
1. Review marriage as it existed prior to infidelity
2. Examine and remedy predisposing factors
C. Rapprochement
1. Enabling couple to build skills of self - disclosure and problem - solving
2. Decision between continuation of marriage or separation and divorce
V. Undiscovered infidelity
A. Therapist maintains confidentiality if revealed, but advises that he/she would encourage spouse to explore suspicions
B. No conjoint therapy until spouse reveals infidelity
Divorce Mediation: a New System for Dealing with the Family in Transition by Sauber, Beiner, and Meddoff in Mikesall et al. (1995). Outlined by Amanda Sobel
I. What is divorce mediation?
A. Intervention in the lives of each family member involved in the marital dissolution
B. Help couples resolve conflicts and to make their own decisions concerning child custody and visitations, division of property, child support, and spousal support
C. Mediator acts as neutral third party to help couples reach agreements assess the system and intervene to promote future cooperation of the couple memorandum of understanding
II. Factors in mediation
A. The skill and style of the mediator
B. The family system involved
C. Complexity of the issues
D. Intensity of the conflict
III. Characteristics - of divorce mediation approaches
A. Integrative mediation
1. Laid-back, laissez faire approaches
2. Collaboration by psychologist and attorney mediators
3. No formalized or standardized set of rules
4. Single financial data sheet instead of separate budgets
5. Emphasis on solution of mutual - problems
B. Structured mediation
1. Authoritarian approach
2. Rigid rules and timetable specified in mediation contract
3. Goal-oriented system geared to quick resolution of issues
4. Rigid structure may help equalization of power
C. Therapeutic mediation
1. Emotion-oriented approach
2. Resolution of emotional issues before substantive issues are addressed
3. Concentration on family system and familial relationships
4. Crisis therapy where children may be included in the sessions
5. Approach most familiar to those in mental health field
D. Negotiatory mediation
1. Business-oriented approach
2. Emphasis on leaving both parties in best financial position
3. Separate negotiating sessions to break impases
4. Emotional conflicts resolved quickly or referred to a therapist
5. Approach used in labor and international negotiations
E. Interdisciplinary mediation
1. Therapist-attorney team approach
2. Mediators follow rigid role definitions of their professions
3. Conjoint approach uses joint sessions of mediators and spouses
4. Dual mediators of opposite sexes may prevent triangulation and bias
IV. Choosing a mediation system
A. Consider advantages and and disadvantages of individual sessions with each spouse
B. Advantage of individual sessions: enables the mediator to learn about underlying emotional issues, when spouses are not in the same room
C. Disadvantages of individual sessions: triangulation, biase, divulge information spouse needs to know
V. Dealing with power imbalance
A. Gender-based power imbalance
B. Power factors
C. Interrupt intimidating negotiating response patterns
D. Do not tolerate patterns of humiliation or domination
E. Insure that both parties are informed
F. Sign a contract for full disclosure and negotiate in good faith
G. Stop session if name calling, threats, or ridicule, occurs
H. Take mediated outcome through legal review
A Family Systems Approach to Sex Therapy and Intimacy by David M. Schnarch. In Mikesell, et al. (1995). Outlined by Patty Salehpour
I. Introduction
A. Psychodynamics are reintegrated in to sexual therapy to deal with resistance to the behavioral approach
B. Couples are concerned with the context of the marriage beyond the issue of sexual dysfunction
C. These approaches are based on the common sense notion that sex is a natural function that can be restored through disinhibition and reeducation. Reeducation may cause new problems because therapists focuses on dysfunction also.
II. Raising the topic of sex
Clinician must raise the topic of sex. The therapist’s should make the couple comfortable and bring down the level of anxiety.
III. Intervening to enhance differentiation
A. Harness natural sexual systemics to develop and maintain eroticism and intimacy in the emotionally committed relationship.
B. The major organizing principle is the improvement model of sexual function and behavioral change.
C. Differentiation - maintaining a clear sense of self in the face of pressure by the loved one to conform to his/her conceptualization of intimacy in marriage. Find out who one is with a partner who is usually over eager to tell one his/her conceptualization of who one should be.
D. Differentiation - differs from childhood differentiation where the goal is not to get away from someone. It is the ability to balance the needs for autonomy and togetherness. The challenge is to develop involvement with the loved one without losing oneself in the process.
E. Even knowing who one is doesn't keep one from getting anxious if one’s self-definition is only in relation to one’s partner. Differentiation is knowing who and what one is. It provides the ability to tolerate anxieties in exploring sexuality.
F. Each individual comes for therapy but wants to change their partner not themselves. Each must hold on to the essence of self. Clear self-delineation enhances intimacy and sexuality.
G. Sensate focus may have untoward side effects
IV. Sexual therapy compared with marital therapy
A. Marital conflict may reduce sexual intimacy
B. Reduced sexual intimacy may cause individuals to conclude their partner no longer loves them
C. Therapy must concentrate on both the individuals and the system
V. Sexuality in the context of relationship. See the couple's sexual problem in its broader context.
A. Examples
1. Career and its relation to self-esteem
2. Menopause and change in attitude about sexual intimacy
3. Not communicating about fears and worries and instead start acting distracted and uninterested
4. Worry about sexual activities of their children and feel powerless to control them
5. Contrast their children sexual pleasure with their own relationship
6. Loneliness caused by sexual dysfunction
7. The person with least sexual desire controls sex
B. One partner can always force the other to choose between loyalty to self and loyalty to the marriage situation. For example, one partner can push the other partner to have sex but cannot force the partner to desire sex.
C. When the normal problems of marriage are handled properly, the couple may reach higher levels of differentiation and also deepen their intimate and erotic relationship
V. Understanding sexual function: the quantum model
A. Quantum therapy — a model of sexual functioning which offers a multisystem view of sexual relations that focus on helping people achieve more than utilitarian genital function.
B. The theory considers many dimensions of sexual experience
1. Depth of involvement
2. Profoundness of sex
3. Intimacy
4. Sexual style at the limits of their sexual potential
C. The human is capable of bringing high meaning and profound intimacy to sex and of combining sexuality and spirituality in mutually enhancing ways.
D. For all of our apparent interest in intimacy and rejection of orgasm as the focus of sexual union, orgasm is still at the heart of contemporary models of sexual response. The integrative model must both treat sexual dysfunction, help people to explore the limits of their sexual potential and explore the depth of human emotional intimacy.
VI. Four stage sexual response
A. Human sexuality includes unique abilities and problems
B. Intimacy can occur during sex and at other times.
C. Sexual stimulation is more than sensory excitation. It also includes hightened emotional arousal.
D. The total level of stimulation is composed of tactile input and the receiver's emotional processes. E. Physical stimulation and emotional processes are interactive variables that can potentate, mitigate or debilitate each other.
F. The treatment of sexual dysfunctions involves increasing the total level of physical and emotional stimulation. This is accomplished by optimizing both the receiver's internal processes and the tactile stimulation he or she receive. This increases the likelihood of achieving response threshold levels and is therefore the key to functional genital response.
G. There is often a difficulty in one dimension or the other. Some people achieve little more than the degree of arousal required for reflexive functioning . Either unhelpful touch or misdirected meaning can reduce total stimulation and create sexual dysfunction.
VII. Optimize stimulus transmission
A. Anything that interferes with the transmission of stimulation (from peripheral nerve receptors to the central nervous system and back to the genitals) can limit sexual function. For example, deficits caused by disease; injuries; prescription and recreational drugs; vascular, neurological, or hormonal problems; alcoholism; diabetes; multiple sclerosis; or renal failure.
B. Optimize physical stimulation. This includes:
1. Increasing the duration and intensity of pleasuring received during sex
2. Improved communication about sexual preferences
3. Reduction in guilt inducing behaviors
C. Raise or lower thresholds
1. Aging for men develops more ejaculatory control
2. Conditioning like physiological processes (e.g., peripheral vasodilation which can be modified through biofeedback training alpha wave conditioning) treatment strategy for premature ejaculation help men keep total stimulation below the level of orgasm while engaging in activities which increases women’s sexual arousal.
3. Stimulation lowering methods such as the "stop - start" or "squeeze technique" sometimes reshape the couple’s behavior repertoire and emotional system surrounding sex.
D. Optimize the receiver's internal process
1. People's involvement during sex varies anywhere from ineffectively superficial contact to a level of involvement for achieving orgasm to profound engagement and transcendent spirituality.
2. Sometimes people have fears of not pleasing their partner during the sexual relation and that can cause sexual dysfunction.
VIII. Traditional sex therapy versus an intimacy-based approach
A. Sensate focus and related procedures may cause individuals to think only about themselves and not their partner. This self-absorption may cause the partner to feel ignored and used by his/her partner and caused him/her to experience lower sexual desire.
B. Developing effective intimacy and opening the door for profound sexual union
1. Deepening emotional in-the-moment involvement
2. Broadening the sexual repertoire of behaviors, techniques and tones may lead to more profound partner engagement and involvement of the core self
3. Increasing the level of intimacy, intimacy tolerance and meaningfulness of encounters
4. Expanding the psychic energy exchange through investment in eroticism and exchange of sexual vibes
5. Removing antagonistic anxiety while increasing pleasure
6. Reducing situational distractions
7. Optimizing the emotional tone of sexual interaction by decreasing interfering marital dynamics
8. Resolving object relation transference storms and enhancing anxiety tolerance and ability to self soothe one's own frustration and disappointment
9. Developing the ability to achieve orgasm without destroying intimacy
10. Making love with eyes open and face to face may increase intimacy and exploration of sexual potential
IX. Common clinical disorders
A. Primary anorgasmia
B. Secondary anorgasmia
C. Dyspareunia
D. Vaginismus
E. Erectil dysfunction
F. Premature or Delayed ejaculation
G. Desire disorders
X. Enhancing differentiation and anxiety tolerance
A. Different than traditional sexual therapy and focus on anxiety tolerance as intimacy therapists work on personal growth rather than anxiety tolerance. This approach can take longer than traditional therapy. In this system, therapists try helping people use their sexuality to grow to the point they are truly capable of loving and capable of solving marriage and intimacy problems.
B. Below are techniques used by traditional sex therapists which may trigger increased fusuion because they don't enhance differentiation.
1. Contracting
2. Bans on intercourse
3. Constructed paradoxical suggestions
4. Alignment with "the relationship " or "the marriage" as client
5. Aligning with the therapy positive spouse to counterbalance a partner reluctant for therapy
6. Empathizing or commiserating with clients' pain particularly when they are in an emotional regression
7. Pacing therapy so clients do not become "nervous" and thus ultimately letting the least differentiated partner control the therapy through his or her anxiety (as that partner has done in their marriage)
8. Encouraging negotiation and compromise over disparate sexual frequency or preferences and/or marital disputes
C. The self-differentiation and intimacy stratagems have following impacts:
1. Self soothing one's own anxieties optimizes the receiver's internal processes during sex reducing the like hood of distractions and dysfunction.
2. Partners are better able to recover from disappointment and occasional dysfunction with only minor residual impact .
3. Spouses are less affected by their partner’s anxiety, they are more able to push the boundaries of sexual norms in their relationship and increasing self - disclosure through display of eroticism, decreasing sexual boredom and facilitating more depth of involvement in sex (greater tolerance for intimacy) .
4. There is an increased shift from other-validated to self-validated intimacy and less dependence on lock step mutuality. There is greater acceptance from one's partner and less susceptibility to manipulations, threats and withholding .
5. Decisions about sexual behavior are more likely to be based on reason feelings rather than emotional reactivity or need to reduce anxiety.
Family Treatment Of Alcohol And Drug Abuse by M. Stanton and A. Heath in Mikesell, et al. (1995). Outline by Lori Rice.
I. Introduction
A. Everyone is affected in the family when an individual has a drug/alcohol substance problem
B. Family Patterns in Addiction
1. Higher frequency of multigenerational chemical dependency, particularly alcohol, plus a propensity for other addictive behaviors such as gambling.
2. "Symbiotic" relationships often seen between male addicts and their mothers
3. More overt alliances, for example, between the addict and an overinvolved parent
4. Parental behavior that does not mimic schizophrenia
5. More primitive and direct expression of conflict in addictive families
6. Drug-oriented peer group to which the addict retreats following family conflict. This group gives the addict an illusion of independence.
7. Preponderance of death themes and premature unexpected, and untimely deaths in the addicts family
8. "Pseudoindividuation" of the addict across several levels, from the individual-pahrmacological level to that of the drug subculture
9. Frequent acculturation problems and parent-child cultural disparity within families of addicts
II. Clinical Intervention in Family Therapy: preliminary considerations
A. Abusers denial
B. Need for concurrent treatment for nonabusing members
III. Stages of Family Therapy
A. Stage I: Problem definition and contracting
1. establish alliances with senior family members
2. assume a nonblaming stance toward the entire family
3. the substance abuse should be labeled a family problem
4. use of a genetic, disease interpretation of addiction helps to reduce guilt, blame, and shame
B. Stage 2: Establishing the context for a chemical-free life
1. Refer family members to 12-step programs
2. with couples, use spouse support groups whenever possible
3. have no expectation that the change will occur
4. be prepared to deal with issues of unexpected deaths and unresolved losses at this stage
C. Stage 3: Ceasing Substance Abuse
1. arrange inpatient detoxification for the addicted substance abuser if this is indicated
2. agree to let the family attempt detoxification with the abuser on an outpatient basis
3. allow outpatient recovery using the family as the treatment team
D. Stage 4: Managing the Crisis and Stabilizing the Family
E. Stage 5: Family Reorganization and Recovery
1. Shift extremes of reciprocal role behavior form rigid complimentary to greater symmetry or more flexible complementary
2. Help the couple/family resolve issues of power and control
3. directly address the pride structures of both partners so that new forms of role behavior are permitted without the need for alcohol
4. Help the couple achieve whatever level of closeness and intimacy is desirable for them
F. Stage 6: Ending Therapy
IV. Special issues
A. Convening issues
B. Management of cases
C. Medications and management
D. Involving Parents in decisions
F. Codependence
G. Confidentiality