IX. Cognitive-Behavioral Family Therapy - Chapter 9 — Outline by Lori Rice
A. Introduction
1. Behavioral family therapy traditionally emphasizes: parent training, couples therapy, and treatment of sexual dysfunctions
2. Methods derived from classical and operant conditioning
3. Behaviorist distinguished by methodical, data driven approach
B. Leading Figures
1. Ivan Pavlov - Classical conditioning
a. Unconditioned stimulus (UCS) c. Unconditioned response (OCR)
b. Conditioned stimulus (CS) d. Conditioned response (CR)
2. John B. Watson
3. Joseph Wolpe - systematic desensitization
4. B.F. Skinner - operant conditioning (operant - voluntary behavioral responses in which frequency of response is determined by consequences). General process of operant conditioning
a. functional analysis - determine contingencies of reinforcement
b. intervention
c. fading procedures
4. Family therapy forerunners
a. Gerald Patterson
b. Robert Liberman
c. Richard Stuart
C. Theoretical Formulations
1. learning theory - broad approach to human behavior, integrating principles form social, developmental, and cognitive psychology along with those principles of learning derived from experimental psychology
2. behavioral therapy - all operant and nonoperant forms of behavior therapy
3. cognitive - behavior therapy - approaches inspired by the work of Beck and Ellis that emphasize the need for attitude change to promote and maintain behavior change
D. Normal Family Development
1. Behaviorally defined: a good relationship is one in which giving and getting are balanced (Thibaut and Kelley, 1959).
2. Weiss and Isaac (1978): affection, communication and child care most important behaviors leading to marital satisfaction
3. Contradictions to behavioral definitions: clinical experience demonstrates that some people are dissatisfied despite being married to partners who behave in a very rewarding fashion
E. Development of Behavior Disorders
1. People often inadvertently reinforce precisely those responses that cause them the most distress
2. Liberman (1972) describes family as a system of interlocking reciprocal behaviors
3. Gerald Patterson describes pattern of reciprocal reinforcement in families
4. Azrin, Naster, and Jones (1972) list of defective patterns of reinforcement in marriage
F. Goals of Therapy
1. Modify specific behavior patterns to alleviate the presenting symptoms
2. Therapy is tailored to each family's goals
3. Teach replacement behaviors which are reinforcing
G. Conditions for Behavior Change
H. Techniques
1. Parent training
a. contracting
b. time out
c. Premack principle — high probability behavior is chosen as a reinforcer for behavior with a low probability of occurrence
2. Couples therapy
a. Quid pro quo
b. Good faith contracting
I. Cognitive-behavioral approach to family therapy — emphasizes a balance between cognition and behavior.
X. Family Therapy Enters the Twenty-First Century - Chapter 10 — Outline by Sarah Sifers
A. Family therapy grew in the 60s & 70s, but overlooked some important issues
B. Erosion of Boundaries
1. Boundaries between schools of family therapy have blurred so that therapists use techniques from a variety of sources
2. Family therapists have become less cocky in their approach to clients
3. Targeting beliefs rather than behaviors
4. The influence of the individual is being recognized (full circle of theoretical development)
C. Postmodernism
1. A reaction to modernism which holds that the truth of things could be uncovered through objective scientific observation and measurement.
2. Many fields are experiencing "deconstruction" where former "truths" are shown to be biased social conventions
D. Constructivism - there is no objective reality, only what we create in our minds
1. Therapists should question their observations and examine their assumptions
2. Theory judged on usefulness and ethicalness rather than "rightness"
E. Collaborative, Conversational Approaches
1. Empower families - therapy as a mutual search for options & understanding
2. Reflecting team - observers discuss impressions of family with family and therapist and then family can respond
3. Uses active listening, questioning to understand, assuming therapist knows nothing, reflect, tentatively offer ideas, empathetic conversations, etc.
4. May allow therapists to collude with families to support pathology
F. The Hermeneutic Tradition
1. Therapist's findings are structured by his or her beliefs
2. Setting aside these beliefs helps to understand a client & respect their beliefs
G. Social Constructionism
1. Social interactions generate meaning for individuals
2. Language colors our perceptions
3. People absorb the messages from their environment
4. Personalities can be changed by putting an individual in a new environment
5. Therapy requires establishing a relationship and change the language used
G. The narrative revolution
The narrative metaphor focuses on how experience creates expectations and how expectations shape experience through the creation of organizing stories.
H. Solution-Focused Therapy
1. Goal is to have clients shift from dwelling on the problem to focusing on solutions (any solution they pick is fine)
2. Strengths - oriented, collaborative, short-term (popular with managed care)
I. Feminism and Family Therapy
1. Husband and wife are not equally to blame for family problems because wives are subjugated
2. Mothers are forced by society into maladaptive roles that drive them "insane"
3. Gender should be a major focus of therapy (like generations are)
4. Don't expect moms to do most work; don't judge women by men's standards
J. Family Violence
1. Family therapy's focus on interaction inappropriately relieves perpetrators of some of the blame
2. Family therapy has only recently begun to challenge our culture of violence
K. Multiculturalism
1. Increasing exposure to different cultures
2. Recognizing and respecting cultural differences while examining their functionality with clients
3. Many factors other than race influence family's beliefs
4. Over emphasis on ethnicity can lead therapist to make faulty assumptions and exaggerate differences
L. Race and Class
1. Minority families face challenges that other families may not face (dealing with racism, higher rates of poverty, etc.); however, they also have many strengths
2. Therapists must be sensitive to the issues faced by such families such as the context in which they're living, attitudes about therapy/therapist, etc.
M. Gay and Lesbian Issues
1. Therapist must understand issues that gay and lesbian individuals and families face and the context in which they live (e.g., discrimination)
2. Need for therapists to accept gay and lesbian families as normal
N. Specialized Treatments and a growing trend toward specialized treatments for specific conditions and individuals that span orientations
O. Research Groups - lots of great research going on that is being followed by managed care, politicians, etc., but ignored in the field because it is passe
P. Medical and Psychoeducational Family Therapy
1. Psychoeducation began in the treatment of schizophrenia and focuses on collaborating with families, educating them about the disorder, changing ideas and interactions; repairing damage done by insensitive therapists; support coping skills; deals with family issues outside of the presenting concern (if family asks); etc. It has been shown to be effective with schizophrenia, depression, addiction, alcoholism, and other chronic conditions.
2. Medical family therapy follows a similar approach, focusing on individuals with chronic illnesses or disabilities They cooperate with health care professional and help families cope with illness or disability by targeting interventions to the characteristics of the family and of the health condition.
Q. The Self in the System
1. The involvement of psychodynamic therapists in family therapy and the evolution of psychoanalytic theories compatible with family therapy have encouraged the field of family therapy to consider individual dynamic factors in family therapy
2. Systems theory has also been expanded to cover intrapsychic processes
R. The Influence of Managed Care
1. Managed care focuses on reducing cost of treatments through case management or capitated contracts
2. This has had a huge impact on mental health care, but dissatisfaction with the current situation suggests that there will be continuing change
S. Conclusion - Family therapy has taken a number of criticisms, from within and externally, resulting in therapist becoming more respectful, collaborative, sensitive to differences, and interested in beliefs and values rather than behavior and structure
From Strategic to Solution-Focused: The Evolution of Brief Therapy - Chapter 11 — Outline by Lori Rice
Part I. MRI, Strategic, and Milan Systemic Models - 1990's family therapy rejects model of therapist-as-expert-manipulator in favor of therapist as collaborator.
A. Leading Figures
1. Strategic family therapists
a. Jay Haley
b. Cloe Madanes
2. Members of MRI (Mental Research Institute):
a. Paul Watzlawick
b. Richard Fisch
c. John Weakland
3. Milan Model:
a. Selvini Palazzoli
b. Karl Tomm
B. Theoretical Formulations
1. Strategic Therapist
a. Interested in changing behavior rather than understanding
b. Interested in technique, not necessarily theory
c. Include erickson's belief that the therapist is responsible for change and therapy should be as brief as possible
d. Positive feedback loop
2. MRI Formulations
a. Family rules - underlying premises guide the family. Change order: first order - only behavior or interactions in system change, second order - the rules of the system that governs interactions changes
b. Approach to problem - first, positive feedback loops that act to maintain or exacerbate problems; second, determine the rules or frames that support those interactions; third, find a way to change those rules
c. Doesn't look beyond the reported problem unless family identifies other problems
3. Haley Formulations
a. Believes rules around the hierarchy in the family are crucial and finds a malfunctioning family hierarchy behind most problems
b. Also looks to improve family's boundary problems
c. Implements "plans" and specific strategies for family therapy - differs from MRI because he views human interactions as interpersonal struggles for control and power
4. Milan Formulations
Interested in longer sequences of behavior, but also the way families evolve over generations
C. Normal Family Development
1. MRI - opposed to setting up standards or normality - , adopts "non-normative" stance
2. Milan Associates - adopted "non-normative" stance as well as believing systems usually involve cross-generational alliances. Therefore, families should have clear generational boundaries
3. Haley - based assumptions and thinking of family on a standard of "normality"
D. Development of Behavior Disorders
1.MRI - cybernetic: difficulties are tamed into chronic problems by the existence of misguided attempts to solutions, forming positive feedback escalations
2. Haley - takes into account both short and longer sequences of behavior and involves at least three family members
3. Milan - examines long-term historical sequences involving many family members
E. Goals of therapy - all strategic and systemic therapies primary goal is to resolve the presenting problem
1. MRI - conclude therapy after the presenting problem is solved
2. Haley - structural reorganization of the family, particularly in regards to hierarchy and generational
boundaries Approached in stages with immediate goals for each stage.
3. Milan - form systemic hypotheses about problems
F. Conditions for Behavior Change
1. MRI - change behavior
2. Haley - changes in behavior alter feelings and perceptions
3. Milan - meaning changes behavior
G. Techniques
1. MRI Approach
a. Introduction to the treatment set-up
b. Inquiry and definition of the problem
c. Estimation of the behavior maintaining the problem
d. Setting goals for treatment
e. Selecting and making behavioral interventions
f. Termination
g. Paradoxical treatments such as prescribing the symptom for defiance based families
2. Haley and Madanes Approach - Problem-Solving Therapy
a. Three stages: 1) Social stage, 2) Problem stage and 3) Interactional stage
b. Interventions: 1) Tracking the sequences, 2) Directives and paradoxes, 3) Pretend techniques, 4) Ordeal therapy, 5) Structural goals
3. Milan Approach
a. Standard session: 1) Presession 2) Session 3) Intercession 4) Intervention
5) Postsession
b. Positive connotation - eliminates the implication inherent in reframes that some family members wanted or benefited from the patient's symptoms
c. Rituals - used to engage the whole family in a series of actions that run counter to, or exaggerate, rigid family rules and myths. Also used to dramatized the positive connotation
H. Other Contributions
1. Strategic therapists pioneered the team approach to therapy
2. Alexander's functional family therapy combines behavioral and strategic techniques
I. Evaluating Therapy
1. Clear goal
2. Anticipate ways the family will react to interventions,
3. Understand tracking sequences of interaction, and
4. Use directives creatively
Part II. Solution-Focused Therapy - focuses on solutions that have worked
A Leading Figures at the Brief Family Therapy Center (BFTC)
1. Steve de Shazer and Insoo Berg
2. Eve Lipchik
3. Michele Weiner-Davis
4. Scan Miller
5. John Walter
6. Jane Peller
B. Theoretical Formulations
1. Little to say about how the problems arise
2. Believe people are constrained by narrow, pessimistic views of their problems
3. Against idea that problems serve ulterior motives or that people are ambivalent about their problem
4. Believe people are quite suggestible, and that therapists unwittingly create or maintain problems that, to solution-focused therapists, don’t exist
5. Negotiation of an achievable goal with client
6. Alter client's language
C. Normal Family Development - No absolute reality so therapist shouldn't impose what they think is normal on cliants
D. Development of Behavior Disorders
Category is obsolete
E. Goals of Therapy
1. Resolve presenting problem
2. Shift language from talking about their problems, to talking about solutions
F. Conditions for Behavior Change
1. Strives to work form the client's understanding for the problem and seeks behavioral change
2. Emphasize the construction of solution-oriented narratives
3. Change the way people talk about their problems
G. Techniques
1. Ask clients to observe what happens in their life or relationships that they want to continue
2. Miracle question - "Suppose one night while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different?"
3. Exception question - ignores the problem and directs the client to a time in the past or present when they didn't have the problem when they ordinarily would have the problem
4. Scaling question - "On a scale on one to ten, how confident are you that you will be able to avoid losing your temper this week?"
5. Giving compliments to cheat
H. Evaluating Therapy Theory and Results
Virtually no empirical data
I. Problems
1. Model's injunction to remain constantly positive
2. Is the therapist really having a respectful conversation with a client when the therapist only searches for exceptions and coaxes optimism?
3. Do such insistently upbeat dialogues have the effect of silencing people’s doubts about their problems?
4. Can clients believe the feedback of someone who constantly strives to find things to praise and never challenges or questions them?
XII. Narrative Therapy — Chapter 12 — Outline by Anabella Pavon
A. Narrative therapy
1. Focuses on "understanding how experience creates expectations and how expectations then shape experience through the creation of organizing stories."
2. Central assumption — "Our personal experiences are, at the most basic level, ambiguous. To understand experience, we can't simply look at it or attempt to analyze it. How we understand our experiences is based on how we organize those elements, put them together, assign them meaning, and prioritize them."
3. Problematic cognitions vs problematic behaviors
4. Inspired by systems theory. Now, narrative therapists criticize systems theory and focus on how the problem affects the family as opposed to how the family affects the problem.
B. Sketches of Leading Figures
1. Michael White - engineer turned therapist. Studied Bateson and derived ideas about externalizing problems.
2. David Epston - focussed on narrative metaphor rather than cybernetics. Recognized the need of "supportive communities" to maintain behavior change.
C. Theoretical formulations
1. Jerome Bruner - developed the narrative metaphor in sociology
2. Narrative approach came out of psychoanalysis. Therapists noticed that their client's stories affected their perceptions and interpretations of those perceptions. (i.e., Things get left out if they don't fit the story)
3. Contrast between systems therapists and narrative therapists
a. Systems therapist
1) Looks for flaws in the system
2) Views their assessment as objective
3) "Treats people like objectives to be mainipulated."
4) Doesn't look at historical, political or cultural contexts in which the family exists
b. Narative therapist
1) Takes a collaborative role with the client
2) Looks for times when client has been strong or resourceful
3) Uses questions in anon-threatening respectful way when new stories are introduced
4) Never labels
5) Helps the client break away from "dominant cultural narratives"
4. Problems arise from our culture
5. "Constitutionalist self - a self that is neither good nor bad, but continually reconstituted through interaction "
6. The approach has political components
D. Normal family development
1. Therapists avoid "normal" and "abnormal" - " . . . What's normal has been used to maintain unjust power divisions and oppress certain groups."
2. Try not to make assumptions about individuals, but have some basic assumptions about people
a. People have good intentions
b. People are not their problems
c. People are influenced by those around them
d. People can make different and empowering stories when they can separate from their
problems and from cultural stories
E. Development of behavior disorders
1. Behavioral problems occur when people's stories make them see their lives in a negative way. Problems stay until stories change.
2. Feedback loops aren't the mechanism for narrative therapists. How members involved in exchanges interpret and tell themselves stories affect the individuals. Problems saturate stories.
F. Goals of therapy
1. Therapists don't see themselves as problem solvers. "They're interested in awakening people from the trances they've been lulled into by powerful forces of culture, so they can have a full range of choices."
2. Try to make person and problem separate and use the family to help "fight the common enemy."
G. Conditions for behavior change
1. Behavior change won't occur unless the narrative changes
2. Deconstruction - therapists challenge and question assumptions to take unproductive stories apart and help construct productive stories.
3. Externalize - take a problem and make it a separate entity. Not part of the individual but something acting on the individual.
4. Formation of teams and leagues and letter writing,
H. Techniques
1. Beginning - therapist attempts to see how the family members see themselves, no lengthy history, give clients opportunity to ask questions about therapist.
2. Externalizing: the person is not the problem.
3. Who's in charge, the person or the problem - use of relative influence questions
4. Reading between the lines of the problem story - emphasize positive skills in dealing with problems
5. Reauthoring the whole story - change the person's entire identity, not just the problem
6. Reinforcing the new story - find or develop supportive communities; ask about successes
7. Deconstructing dominant cultural discourses
I. Evaluating therapy theory and results
1. Turned away from the basic of family therapy
2. No more systems thinking
3. Really do impose their perspective on clients
J. A therapy of social justice
K. Summary
1. Useful types of questions
2. Deconstructing questions
3. Opening space questions
4. Preference questions
5. Story development questions
6. Meaning questions
7. Questions to extend the story into the future
XIII. Integrative Models — Chapter 13 — Outline by David Perez
A. Introduction
1. Integration in meeting the complicated, thinking, feeling, acting nature of human beings
2. Possible dangers of eclecticism
3. Integrative models may be the future of family therapy
4. Blending or creating something new
B. Internal Family Systems Therapy
1. Fundamentals
a. Family systems combined with intrapsychic processes
b. Collaborative, co-creating, and empowering
c. At the core, everyone has a compassionate and healing self
2. Subpersonalities
a. Changing the internal relationship of parts
b. Language of parts is also powerful
c. Each of the minds has valuable qualities and is designed to play a role
d. The parts when a person is hurt
1) exiles - contain pain, fear, and sadness from past experiences
2) managers - lock away exiles out of consciousness
3) firefighters - take action to put out feelings from exiles
e. In resistance, the therapist recognizes the importance of the roles
3. The Self
a. Basics
1) Centered, being in the present
2) Can be an active and effective leader internally and externally
b. The Goal of therapy is self-differentiation
c. The therapist creates a context in which it is safe for selves' to emerge and interact freely
1) Recognition of when parts dominate the self
2) Create a vision of how families want to relate
3) Lead discussions of the constraints
4) Collaborate to release constraints
4. Identifying parts and using parts language
Identification and understanding how the parts are functioning
5. Maintaining self leadership - parts or self?
6. A case example of parts with a family with an anorexic child
a. Deactivation of managers
b. Used parts language
c. Track the pattern of parts interactions across people
d. Elicit the selves of family members
e. Work with members' parts privately
g. Warn for parts' reactions to relapses
g. Explore and resolve past traumas individually and in family
7. Model runs contrary to postmodern movements and social constructivists
C. Metaframeworks model - incorporates structural, strategic, and intrapsychic processes
1. Organized around six core domains
a. Organization
b. Sequences
c. Development
d. Culture
e. Gender
f. Internal process
2. Conceptualized as lens to view the world
3. Releasing constraints rather than finding deficits
4. Ongoing rather than finished product
D. Integrative problem-centered therapy
1. Structural and self psychology in a sequential pattern
2. Simplest interventions should be tried first
3. Shifts in models without actual combining of approaches
4. May involve teamwork of therapists
E. Narrative solutions approach
1. Basics
a. Synthesis of strategic and narrative models
b. Problems tend to develop innocently from the mishandling of life transitions or
people begin to think and act in problematic ways when discrepancies exist
between perceived self, perceived behavior, and the perceptions of others.
c. How people hope to be and future self with problem resolution
2. Managing Helpful Conversations
a. Maintain a position of interest in client preferences and hopes
b. Explore how problem keeps people from acting in line with preferences
c. Find past and present stories in line and contradict those not
d. Discuss what future looks like with problem resolution
e. Ask mystery questions
f. Co-create alternative explanations for the evolution of the problem in line
g. Encourage clients to talk to significant others about preferences, hopes, intentions
F. Integrative couple therapy
1. Based on behavior exchange model with emotional acceptance and strategic change
2. Emphasis on support and empathy
3. Formulation - theme, polarization process, and mutual trap
4. Share own experiences rather than attack other - communication training
G. Other Integrative Models
1. Multidimensional family therapy
2. "Difficult-to-treat" populations
XIV. Comparative Analysis - Chapter 14 — Outline by Jared Warren
A. Theoretical purity and technical eclecticism
1. Developments in theory and practice tend to follow a leapfrog pattern
2. Theories may have a biasing effect on the way one perceives clinical data
3. Theories also bring organization to initially puzzling clinical presentations
4. Family systems approaches are more alike than different, though the differences tend
To be maximized
B. Family therapist - artist or scientist?
1. Training and experience do not equal expertness - initial grounding in theory is
Important, then therapists learn to extemporize
2. Therapist's dual role - artist and scientist
3. Human qualities must match technical prowess
4. Effect of constructivism and postmodernism on family systems approaches — many questions
C. Theoretical formulations
1. Families as systems
A. Idea introduced by communications family therapists
B. All approaches conceptualize families as systems, though in practice some models focus more on the individual (behavioral, solution-focused, and narrative models)
2. Stability and change
A. Communications theory - families tend to gravitate toward homeostasis
B. Structural - families have relatively stable structure
C. Families must also change and adapt to circumstances to remain healthy
D. Communications, structural, & strategic schools view families in treatment not as pathological, but as being unable to adapt to changing circumstances
3. Past or present
A. One of the initial primary differences of family therapy from other approaches was its emphasis on the here and now (especially vs. Psychoanalysis)
B. Often the therapists that spend the most time with clients talking about the past are the ones who emphasize the here and now in their writings (e.g. Experiential therapists)
C. Most newer models strike a balance between past and present
4. Communication - different approaches conceptualize communication in very different ways
5. Content/process
A. The "how" of communication vs. The "what"
B. Families are usually focused on the content of the problem - therapist must work with the process
6. Monadic, dyadic, or triadic model - is the focus with the individual (narrative
Therapy, psychoanalytic), dyads (communications), or triads (Bowen, structural)?
7. The nuclear family in context - more focus recently on extrafamilial systems
8. The person as political - therapist advocacy vs neutrality on political, moral issues
9. Boundaries - relationships of all systems within systems; continuum of diffuse to rigid
D. Normal family development
E. Development of behavior disorders
1. Inflexible systems
2. The function of symptoms
3. Underlying dynamics
4. Pathological triangles
F. Goals of therapy
G. Conditions for behavior change
1. Action or insight
2. Change in the session or change at home
3. Duration of treatment
4. Resistance
5. Family - therapy relationship
6. Paradox
H. Techniques
1. Who to invite
2. Treatment team
3. Entering the family system
4. Assessment
5. Decisive interventions
I. Context and applicability of the schools of family therapy
J. Selection of a theoretical position: rational and irrational factors
1. How should we select a therapeutic orientation? - a lot of it has to do with models offered to us in our training, and the selection of mentors in clinical work
2. Good idea to gain expertise in specialty of advisors, then branch out later; but don't get sucked into dogmatic thinking
3. Learn one method really well, but also become familiar with other approaches
4. Too late to shop around after you're out of academic course work
5. We still don't know a lot about what works best for whom
6. Don't rush training - it takes a considerable amount of time and experience
7. Choose an approach that's consistent with your personal style
8. Transition from training to full-fledged therapist: time to expand and specialize
9. Integration of family therapy models with your own personality works only for those who have a thorough background in some form of family therapy
10. In a nutshell: apprenticeship first, then integration