W#10 FAMILY TREATMENT PLAN (PSYCHOTHERAPY)

Throughout the course, you have been participating in discussions and conceptualizing case studies based on specific therapeutic modalities. You will analyze the Floyd Family Case Study and create a therapeutic treatment plan for the family as a unit. You are free to use any of the therapeutic modalities discussed in this course, as long as you can establish an evidence-based practice! 

This is an opportunity to show your skills and understanding of best practices in psychotherapy. 

– Read the attached article Intimate Partner Violence (PDF) 

– Watch the TED Talk Why Domestic Violence Victims Don't Leave, see link https://www.ted.com/talks/leslie_morgan_steiner_why_domestic_violence_victims_don_t_leave?utm_campaign=tedspread&utm_medium=referral&utm_source=tedcomshare 

– Explore TheHotline to read about domestic violence. Link: https://www.thehotline.org/identify-abuse/understand-relationship-abuse/ 

– Read the Floyd Family Case Study (see attached Word) and answer the questions included in the document. 

– Use the Family Therapy Treatment Modalities Handout (Attached PDF) to develop a Treatment Plan for this family as if they were all coming to your office for treatment together. 

Course textbook: Corey, G. (2016). Theory and practice of counseling and psychotherapy (10th ed.). Boston, MA: Cengage. ISBN: 9781305263727 

The paper submission should be in APA format. Minimum 4 pages.

Free of plagiarism (TURNITIN assignment)

Background: I am currently enrolled in the Psych Mental Health Nurse Practitioner Program, I am a Registered Nurse, and I work in a Psychiatric Hospital.

646 American Family Physician www.aafp.org/afp Volume 94, Number 8 ◆ October 15, 2016

Intimate partner violence (IPV) is a prevalent worldwide health problem, affecting women more commonly than men. IPV is underreported and underrecognized by health care professionals. Even when IPV is recognized, it remains an underaddressed issue. In addition to physical injury and death, IPV causes significant physical and psy- chiatric health problems commonly treated by family physicians. The U.S. Preventive Services Task Force recom- mends screening all female patients of childbearing age for IPV. There are several brief screening tools that have been proven effective at detecting IPV and that can be used in the office setting. Identification of IPV allows the physician to provide better care and improves health outcomes for the survivor. Family physician offices should provide patients with local and national resources. Thorough documentation of injuries sustained from abuse is critical. Although caring for patients unready to leave an abusive relationship may be challenging for the physician, continuous, supportive care improves patient outcomes. (Am Fam Physician. 2016;94(8):646-651. Copyright © 2016 American Academy of Family Physicians.)

Intimate Partner Violence DANIEL DICOLA, MD, Thomas Jefferson University’s Sidney Kimmel Medical College, Excela Health Family Medicine Residency, Latrobe, Pennsylvania

ELIZABETH SPAAR, DO, Pittsburgh, Pennsylvania

I ntimate partner violence (IPV) is a prevalent worldwide health problem, affecting women more commonly than men. It can include physical, emotional,

sexual, and financial abuse, as well as con- trol over contraception or pregnancy and medical care. IPV occurs in heterosexual and same-sex relationships. Patients who are being abused exhibit chronic physical and emotional symptoms in addition to injuries sustained as a result of physical and sexual violence. They are also at risk of death from homicide. IPV is largely underrecognized and underaddressed as a health issue. The World Health Organization has released guidelines to help physicians respond to IPV in women.1

Epidemiology Because IPV is underreported, estimat- ing true prevalence is difficult. Conserva- tive estimates indicate that 20% to 30% of women in the United States have experi- enced IPV in their lifetime.2-4 More than 10% of female college students have reported unwanted sexual intercourse with a partner.2 IPV tends to be repetitive, with an escala- tion in frequency and severity over time.3 Homicide is a common consequence of IPV, resulting in more than 1,000 deaths in the United States each year.4,5 The initial episode of IPV usually occurs before 25 years of age.6

Factors that increase the risk of IPV include alcohol consumption, psychiatric illness, a history of violent relationships in childhood, and academic and financial underachievement.3,6,7

Studies have found higher rates of IPV in Native American and Alaska Native women.6 Immigrants have higher rates of IPV, but it is much less likely to be reported or recognized in this population.8 It is also common in same-sex relationships, among transgender women,9 and among women who are sur- vivors of human trafficking.8 The incidence of IPV in men appears to be less than in women, but IPV is more likely to be under- reported in men.3,10

Acute and Chronic Health Outcomes IPV can lead to acute health outcomes, includ- ing acute physical injury and homicide, as well as chronic health burdens. Table 1 lists short- and long-term health outcomes in women who are abused.2,11,12 IPV affects pregnancy outcomes and reproductive health, leading to higher rates of miscarriage, preterm labor, and low-birth-weight infants.11 Health care costs and decreased productivity are significantly increased in survivors of abuse, amounting to an estimated $2.3 to $8.3 billion per year in the United States.6 Long-term consequences of IPV are more common in female survivors than in male survivors.4

▲

See related editorial on page 600.

CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions on page 598.

Author disclosure: No rel- evant financial affiliations.

▲

Patient information: A handout on this topic is available at http://www. aafp.org/afp/2011/0515/ p1173.html.

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Children living in homes where they witness IPV have the same risk of signifi- cant long-term physical and mental health problems as children who have been abused themselves.13,14 Children witnessing IPV can have increased health care costs and hos- pitalization rates, higher risk of being in an abusive relationship as an adult, lower immunization rates, posttraumatic stress disorder, school-related problems, and sub- stance abuse.13

Screening RECOMMENDATIONS

In 2013, the U.S. Preventive Services Task Force (USPSTF) began recommending rou- tine screening for IPV in all female patients of childbearing age. The USPSTF indicates that current screening tools for IPV are sen- sitive and specific, that screening and inter- vention decrease abuse and harm to patients, and that there is a low risk of negative effects from screening.15,16

A 2014 Cochrane review contradicts the USPSTF and found insufficient evidence that routine screening improves outcomes. It fur- ther concluded that there is inadequate proof that routine screening is benign and cau- tioned that the lack of sensitivity of screening tools may lead to false reassurance by showing lower rates of IPV than the true prevalence.17

The Cochrane review examined fewer studies than the USPSTF, focusing on screening alone and excluding studies such as those of structured clinical interventions. The Cochrane review included only two

studies that examined outcomes of screen- ing and found no improvement in health or reduction in IPV rates as late as 18 months after screening. It included only one study that examined possible adverse effects. The authors justified their focus on screening alone by stating that it is unrealistic to have appropriate interventions available in a typi- cal primary care setting. Review of current

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

All women of childbearing age should be screened for IPV. There is a low risk of negative effects from screening.

A 15, 16

Women who screen positive for IPV should receive intervention services. C 15, 18, 26

There are multiple screening tools effective for IPV (Table 2). C 15, 17, 21

IPV = intimate partner violence.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1. Short- and Long-term Health Outcomes in Women Who Are Abused

Endocrine

Chronic abdominal pain

Gastrointestinal effects

Irritable bowel syndrome

Type 2 diabetes mellitus

Gynecologic

Delay in diagnosing gynecologic malignancy

Dyspareunia

Elective abortion

Pelvic pain

Sexually transmitted infections

Unintended pregnancy

Unsafe sexual behaviors

Musculoskeletal

Chronic pain

Fibromyalgia

Neurologic

Migraine headaches

Information from references 2, 11, and 12.

Psychiatric

Anxiety

Depression

Low self-esteem

Phobias

Posttraumatic stress disorder

Sleep disturbance

Substance abuse

Suicide

Pulmonary

Asthma

Reproductive

Fetal injury

Fetal loss

Low-birth-weight infants

Preterm birth

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648 American Family Physician www.aafp.org/afp Volume 94, Number 8 ◆ October 15, 2016

research, however, shows that even simple interventions, such as providing a wallet card that includes information on IPV, safety planning, or local domestic violence shelters, can improve outcomes.17

Major medical bodies, including the American Academy of Family Physicians,

the American Medical Association, and the American College of Obstetricians and Gynecologists, recommend routine screen- ing for IPV and caution that waiting for more definitive research before addressing IPV puts women at risk.18

SCREENING TOOLS

Screening tools are limited by the patient’s readiness to disclose the abuse. Some patients may not feel ready to admit that they are in an abusive situation, or may fear retri- bution from the abuser even with assurances of confidentiality by the clinician.2,8 How- ever, this should not deter physicians from screening patients with one of the multiple screening tools (Table 219,20) that have been proven sensitive and specific for identifying IPV.15 Shorter, simpler tools are as effective as longer screening instruments.21

TALKING TO PATIENTS

Research shows that patients, with and with- out a history of IPV, favor physicians inquir- ing about IPV at wellness visits. Although most physicians feel they should screen patients for IPV, only a small percentage actu- ally do so, largely because they feel uncom- fortable having such conversations.17,22

Physicians should begin by explaining why they are asking about IPV, whether it be part of screening at a wellness visit or in response to specific physical or mental health issues. The most important aspect of these discussions is for the physician to demon- strate compassion and avoid condescending or judgmental behavior. Direct question- ing about specific abuse experiences should be avoided in favor of a more open-ended approach. Simply asking patients what hap- pened or if they feel safe and valued in their relationship can be the best way to open the dialogue.2,23 Table 3 includes tips for discuss- ing IPV with female patients.24

The patient should always be clothed when discussing IPV. The patient’s partner or chil- dren older than three years should not be present. It may be helpful to establish with patients and those with them ahead of time that it is office policy to conduct a portion of each patient’s visit alone.2,17,23 Physicians

Table 2. Examples of Screening Tools for Intimate Partner Violence

HITS (Hurt, Insult, Threaten, Scream) – self report or physician administered

How often does your partner physically hurt you?

How often does your partner insult or talk down to you?

How often does your partner threaten you with physical harm?

How often does your partner scream at you?

Scoring: never = 1 point, rarely = 2 points, sometimes = 3 points, fairly often = 4 points, frequently = 5 points. A score of greater than 10 points is a positive screen.

Copyright © Kevin Sherin, MD, MPH.

STAT (Slapped, Threatened, and Throw) – physician administered

Have you ever been in a relationship where your partner has pushed or slapped you?

Have you ever been in a relationship where your partner threatened you with violence?

Have you ever been in a relationship where your partner has thrown, broken, or punched things?

A positive answer to any of these questions is a positive screen.

Information from reference 19.

WAST (Woman Abuse Screening Tool) – self report

In general, how would you describe your relationship? No tension, some tension, a lot of tension?

Do you and your partner work out arguments with no difficulty, some difficulty, or great difficulty?

Do arguments ever result in you feeling down or bad about yourself?

Do arguments ever result in hitting, kicking, or pushing?

Do you ever feel frightened about what your partner says or does?

Does your partner ever abuse you physically?

Does your partner ever abuse you emotionally?

Does your partner ever abuse you sexually?

The physician performs scoring subjectively, using clinical judgment.

Adapted with permission from Brown JB, Lent B, Brett PJ, Sas G, Pederson LL. Devel- opment of the Woman Abuse Screening Tool for use in family practice. Fam Med. 1996;28(6):425.

NOTE: More information on screening tools is available from the Centers for Dis- ease Control and Prevention at http://www.cdc.gov/violenceprevention/pdf/ipv/ ipvandsvscreening.pdf.

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should be aware of mandatory reporting and confidentiality laws in their state so they can inform patients of any limits to doctor- patient confidentiality at the onset of any discussion. Some states, for instance, include IPV witnessed by children in their man- datory reporting requirements. For more information about state requirements, go to https://www.futureswithoutviolence.org/ mandatory-reporting-of-domestic-violence- by-healthcare-providers/.

Approach to Patients in an Abusive Relationship Patients who screen positive for IPV may respond in unexpected ways. Many will not be ready to leave the relationship, whether it be for emotional or more practical reasons, such as financial or safety concerns (most homicides by an intimate partner occur in the year after the abused partner leaves the relationship). Concern for children and the hope that a partner will change are also common reasons for staying in an abusive relationship.25 Regardless, it is important for physicians to be supportive and provide or refer for intervention services.15,18,26 Risk of immediate harm should be assessed at the time of IPV identification and at all subse- quent visits.2,17,23

The assessment of the risk of immediate harm should include the following questions (if patients answer “yes” to at least three of these questions, they are at high risk of harm or injury, with a sensitivity of 83% and a specificity of 56%)27:

• Has the physical violence increased over the past six months?

• Has your partner used a weapon or threatened you with a weapon?

• Do you believe your partner is capable of killing you?

• Have you been beaten while pregnant? • Is your partner violently and constantly

jealous of you? Information about safety planning should

be offered to the patient. A safety plan helps prepare the patient to leave if the situation acutely worsens, and they are at immediate risk. It may include making copies of personal documents, making copies of keys, securing

money, and packing a bag with essential items. The patient should identify a safe place to go (e.g., a relative’s house, local domestic violence shelter). Code words should be estab- lished with trusted friends or family so that the patient can call and alert them to immi- nent danger in the presence of the abuser. A list of local and national resources should be provided to the patient, including local shel- ters and the National Domestic Violence hot- line number (800-799-SAFE). If the patient does not feel safe taking a wallet card with this information, important phone numbers may be programmed into the patient’s phone under a code name.2,23 Physicians who are too busy or not comfortable enough to help establish a complete safety plan should pro- vide the patient with resources for further assistance (Table 4).

An ongoing relationship with the same physician improves patient openness to dis- cussing IPV. Being aware of a patient’s expe- riences with IPV allows the physician to gain insight into the patient’s medical and emotional problems, and should prompt the physician to show extra sensitivity with

Table 3. Tips for Discussing Intimate Partner Violence with Female Patients

Respect confidentiality

Discuss intimate partner violence with patients privately, and be open about what physician-patient confidentiality does and does not include

Believe and validate the patient’s experiences

Listen respectfully, and let the patient know that intimate partner violence is a common problem

Acknowledge the injustice; let the patient know that the abuse is not the patient’s fault and that she does not deserve it

Respect autonomy and the patient’s right to make decisions about what to do and when

Assess for high risk of harm or injury, including homicide

Help the patient with safety planning

Does the patient have a safe place to go? Provide resources (Table 4)

Promote access to community services

Give information about local shelters in a way that it is safe for the patient to take with her (e.g., printed on a wallet card, entered into the patient’s phone under a code name)

Information from Centre for Children and Families in the Justice System. Helping children thrive. 2004. http://www.lfcc.on.ca/HCT_SWASM_7.html. Accessed April 1, 2016.

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Intimate Partner Violence

650 American Family Physician www.aafp.org/afp Volume 94, Number 8 ◆ October 15, 2016

physical examinations (explaining each next step in the examination and getting the patient’s approval to move forward is a way of giving the patient back a sense of control over her body). It is critical for the physician to document any injuries thoroughly and provide a detailed record of what happened, including direct quotes from the patient when appropriate. This can aid the patient if charges are pressed.2,23,26,28,29

Prevention The World Health Organization rec- ommends legislative reform and media campaigns to increase IPV awareness. School-based education programs deal- ing with dating violence have been shown to reduce unwanted sexual advances. Early intervention services in at-risk families have been shown to reduce mistreatment of chil- dren and may reduce violent behaviors later in life. Comprehensive services from the health, legal, and law enforcement sectors should be made available to survivors.25

Data Sources: A literature search was conducted in PubMed using the term intimate partner violence. Key sources included USPSTF recommendations and Cochrane reviews. Search dates: October 2013 and March 2015.

NOTE: This review updates a previous article on this topic by Cronholm, et al.30

The Authors

DANIEL DICOLA, MD, is a clinical associate professor of family and community medicine at Thomas Jefferson

University’s Sidney Kimmel Medical College in Phila- delphia, Pa., and is an attending physician at the Excela Health Family Medicine Residency in Latrobe, Pa.

ELIZABETH SPAAR, DO, is a physician in Pittsburgh, Pa.

Address correspondence to Daniel DiCola, MD, Sidney Kimmel Medical College, Thomas Jefferson University, 1 Mellon Way, Latrobe, PA 15650 (e-mail: [email protected] excelahealth.org). Reprints are not available from the authors.

REFERENCES

1. World Health Organization. Responding to intimate part- ner violence and sexual violence against women. 2013. http://www.who.int/reproductive health/publications/ violence/9789241548595/en/. Accessed May 19, 2015.

2. Chang JC. Intimate partner violence: how you can help female survivors. Cleve Clin J Med. 2014;81(7):439-446.

3. Carmo R, Grams A, Magalhães T. Men as victims of inti- mate partner violence. J Forensic Leg Med. 2011;18(8): 355-359.

4. Stöckl H, Devries K, Rotstein A, et al. The global preva- lence of intimate partner homicide: a systematic review. Lancet. 2013;382(9895):859-865.

5. Violence Policy Center. When men murder women: an analysis of 2010 Homicide Data. September 2012. http://www.vpc.org/studies/wmmw2012.pdf. Accessed April 15, 2015.

6. Breiding MJ, Smith SG, Basile KC, Walters ML, Chen J, Merrick MT. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victim- ization—national intimate partner and sexual violence survey, United States, 2011. MMWR Surveill Summ. 2014;63(8):1-18.

7. Centers for Disease Control and Prevention. Inti- mate partner violence: risk and protective factors. http: / /www.cdc.gov/ViolencePrevention / intimate partnerviolence/riskprotectivefactors.html. Accessed May 10, 2015.

8. Modi MN, Palmer S, Armstrong A. The role of Violence Against Women Act in addressing intimate partner vio- lence: a public health issue. J Womens Health (Larchmt). 2014;23(3):253-259.

9. Ard KL, Makadon HJ. Addressing intimate partner vio- lence in lesbian, gay, bisexual, and transgender patients. J Gen Intern Med. 2011; 26(8):930-933.

10. Black MC, et al. Prevalence of sexual violence against women in 23 states and two U.S. territories, BRFSS 2005. Violence Against Women. 2014;20(5):485-499.

11. de Sousa J, Burgess W, Fanslow J. Intimate partner vio- lence and women’s reproductive health. Obstetr Gyn- aecol Reprod Med. 2014;24(7): 195-203.

12. Pavey AR, Gorman GH, Kuehn D, Stokes TA, Hisle- Gorman E. Intimate partner violence increases adverse outcomes at birth and in early infancy. J Pediatr. 2014;165(5):1034-1039.

13. McFarlane JM, Groff JY, O’Brien JA, Watson K. Behav- iors of children who are exposed and not exposed to intimate partner violence. Pediatrics. 2003; 112 (3 pt 1):e202-e207.

14. MacMillan HL, Wathen CN. Children’s exposure to inti- mate partner violence. Child Adolesc Psychiatr Clin N Am. 2014;23(2):295-308, viii-ix.

Table 4. National Resources for Patients Experiencing Intimate Partner Violence

Futures Without Violence

New Home

Posters, brochures, and safety planning cards

National Coalition Against Domestic Violence

http://www.ncadv.org

Online tool for creating a safety plan

National Domestic Violence Hotline

1-800-799-SAFE or http://www.ndvh.org

Help with safety planning and crisis interventions

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15. Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(6):478-486.

16. U.S. Preventive Services Task Force. Intimate partner violence and abuse of elderly and vulnerable adults: screening. January 2013. http://www.uspreventive services task force.org/Page/Document/UpdateSum- maryFinal /intimate-partner-violence-and-abuse-of- elderly-and-vulnerable-adults-screening. Accessed April 1, 2016.

17. O’Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. Screening women for intimate partner vio- lence in healthcare settings: abridged Cochrane system- atic review and meta-analysis. BMJ. 2014; 348:g2913.

18. Singh V, Petersen K, Singh SR. Intimate partner violence victimization: identification and response in primary care. Prim Care. 2014; 41(2): 261-281.

19. Paranjape A, Liebschutz J. STaT: a three-question screen for intimate partner violence. J Womens Health (Larchmt). 2003;12(3):233-239.

20. Brown JB, Lent B, Brett PJ, Sas G, Pederson LL. Develop- ment of the Woman Abuse Screening Tool for use in family practice. Fam Med. 1996;28(6):422-428.

21. Rabin RF, Jennings JM, Campbell JC, Bair-Merritt MH. Intimate partner violence screening tools: a systematic review. Am J Prev Med. 2009; 36(5):439-445.e4.

22. MacMillan HL, Wathen CN, Jamieson E, et al.; McMaster Violence Against Women Research Group. Approaches to screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2006;296(5):530-536.

23. Friedman LS, Samet JH, Roberts MS, Hudlin M, Hans P. Inquiry about victimization experiences. A survey of patient preferences and physician practices. Arch Intern Med. 1992;152(6):1186-1190.

24. Centre for Children and Families in the Justice System. Helping children thrive. 2004. http://www.lfcc.on.ca/ HCT_SWASM_7.html. Accessed April 1, 2016.

25. World Health Organization. Understanding and addressing violence against women: intimate partner violence. 2012. http://www.who.int/iris/ bitstream/10665/77432/1/WHO_RHR_12.36_eng.pdf? ua=1.%25202012. Accessed February 3, 2016.

26. American College of Obstetricians and Gynecolo- gists. ACOG committee opinion no. 554: reproductive and sexual coercion. Obstet Gynecol. 2013;121(2 pt 1):411-415.

27. Snider C, Webster D, O’Sullivan CS, Campbell J. Intimate partner violence: development of a brief risk assess- ment for the emergency department. Acad Emerg Med. 2009;16(11):1208-1216.

28. Shavers CA. Intimate partner violence: a guide for pri- mary care providers. Nurse Pract. 2013;38(12):39-46.

29. García-Moreno C, Zimmerman C, Morris-Gehring A, et al. Addressing violence against women: a call to action [published correction appears in Lancet. 2015; 385(9978):1622]. Lancet. 2015;385(9978):1685-1695.

30. Cronholm PF, Fogarty CT, Ambuel B, Harrison SL. Inti- mate partner violence. Am Fam Physician. 2011;83 (10):1165-1172.

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Major Marriage and Family Therapy Models Developed by Thorana S. Nelson, PhD and Students

STRUCTURAL FAMILY THERAPY

LEADERS Salvador Minuchin Charles Fishman

ASSUMPTIONS: Problems reside within a family structure

(although not necessarily caused by the structure)

Changing the structure changes the experience the client has

Don’t go from problem to solution, we just move gradually

Children’s problems are often related to the boundary between the parents (marital vs. parental subsystem) and the boundary between parents and children

CONCEPTS: Family structure

Boundaries o Rigid o Clear o Diffuse o Disengaged o Normal Range o Enmeshment o Roles o Rules of who interacts with whom, how,

when, etc. Hierarchy Subsystems Cross-Generational Coalitions Parentified Child

GOALS OF THERAPY: Structural Change

o Clarify, realign, mark boundaries

Individuation of family members Infer the boundaries from the patterns of

interaction among family members Change the patterns to realign the

boundaries to make them more closed or open

ROLE OF THE THERAPIST: Perturb the system because the structure is too rigid

(chaotic or closed) or too diffuse (enmeshed) Facilitate the restructuring of the system Directive, expert—the therapist is the choreographer See change in therapy session; homework solidifies

change Directive

ASSESSMENT: Assess the nature of the boundaries, roles

of family members Enactment to watch family

interaction/patterns

INTERVENTIONS: Join and accommodate

o mimesis Structural mapping Highlight and modify interactions Unbalance Challenge unproductive assumptions Raise intensity so that system must change

CHANGE: Raise intensity to upset the system, then

help reorganize the system Change occurs within session and is

behavioral; insight is not necessary Emotions change as individuals’

experience of their context changes

Marriage and Family Therapy Models Page 2

Structural Family Therapy, Continued Interventions disorganize and reorganize Shape competence through Enactment

(therapist acts as coach)

TERMINATION: Problem is gone and the structure

has changed (2nd order change) Problem is gone and the structure

has NOT changed (1st order change)

SELF OF THE THERAPIST: The therapist joins with the system to facilitate the

unbalancing of the system Caution with induction—don’t get sucked in to the content

areas, usually related to personal hot spots

EVALUATION: Strong support for working with psychosomatic children, adult drug addicts, and anorexia nervosa.

SUPERVISION INTERVENTIONS: RESOURCES: Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families. Cambridge, MA: Harvard University

Press. Fishman, H. C. (1988). Treating troubled adolescents: A family therapy approach. New York: Basic Books. Fishman, H. C. (1993). Intensive structural therapy: Treating families in their social context. New York: Basic

Books. NOTES

Marriage and Family Therapy Models Page 3

STRATEGIC THERAPY (MRI)

LEADERS:

John Weakland

Don Jackson Paul

Watzlawick Richard Fisch

ASSUMPTIONS: Family members often perpetuate problems by their own actions (attempted

solutions) –the problem is the problem maintenance (positive feedback escalations)

Directives tailored to the specific needs of a particular family can sometimes bring about sudden and decisive change

People resist change You cannot not communicate–people are ALWAYS communicating All messages have report and command functions– working with content is not

helpful, look at the process Symptoms are messages — symptoms help the system survive (some would say

they have a function) It is only a problem if the family describes it as such Based on work of Gregory Bateson and Milton Erickson Need to perturb system – difference that makes a difference (similar enough to be

accepted by system but different enough to make a difference) Don’t need to examine psychodynamics to work on the problem

CONCEPTS: Symptoms are messages Family homeostasis Family rules — unspoken Cybernetics

o Feedback Loops o Positive Feedback o Negative Feedback

First order change Second order change Reframing Content & Process Report & Command Paradox Paradoxical Injunction “Go Slow” Messages Positive Feedback Escalations Double Binds “One down” position Patient position Attempted solutions maintain problems and

become problems themselves

GOALS OF THERAPY: Help the family define clear, reachable goals Break the pattern; perturb the system First and second order change- ideally second

order change (we cannot make this happen– it is spontaneous)

ROLE OF THE THERAPIST: Expert position Responsible for creating conditions for change Work with resistance of clients to change Work with the process, not the content Directive

ASSESSMENT: Define the problem clearly and find out what

people have done to try to resolve it Elicit goals from each family member and

then reframe into one, agreed-upon goal Assess sequence patterns

Marriage and Family Therapy Models Page 4

Strategic Therapy (MRI), Continued Interventions

Skeptical of change Take a lot of credit and responsibility for change;

however, therapist tells clients that they are responsible for change

Active

INTERVENTIONS: Paradox Directives

o Assignments (“homework”) that interrupt sequences

Interrupt unhelpful sequences of interaction “Go slow” messages Prescribe the symptoms

CHANGE: Interrupting the pattern in any way Difference that makes a difference Change occurs outside of session; insession

change is in viewing; homework changes doing

Change in viewing (reframe) and/or doing (directives)

Emotions change and are important, but are inferred and not directly available to the therapist

TERMINATION:

Client decides when to terminate with the help of the therapist

When pattern is broken and the client reports that the problem no longer exists

Therapist decides

SELF OF THE THERAPIST: Therapist needs to be VERY careful with

ethics in this model; it can be very manipulative (paradox) and a lot of responsibility is on the therapist as an expert

EVALUATION: Very little research done Do clients report change? If so, then it is effective

SUPERVISION INTERVENTIONS: RESOURCES: Watzlawick, P., Weakland, J., &, Fisch, R. (1974). Change: Principles of problem formation and problem

resolution. New York: Norton. Fisch, Richard, John H. Weakland, and Lynn Segal (1982). The tactics of change: Doing therapy briefly.

San Francisco: Jossey-Bass. Watzlawick, P., J. B. Bavelas, and D. J. Jackson. (1967). Pragmatics of human communication. New York: W.

W. Norton. Lederer, W. J., and Don Jackson. (1968). The mirages of marriage. New York: W. W. Norton. NOTES:

Marriage and Family Therapy Models Page 5

STRATEGIC THERAPY (Haley & Madanes) LEADERS:

Jay Haley Cloe Madanes Influenced by

Minuchin

ASSUMPTIONS: Family members often perpetuate problems by their own actions (attempted

solutions) –the problem is the problem maintenance (positive feedback escalations)

Directives tailored to the specific needs of a particular family can sometimes bring about sudden and decisive change

People resist change You cannot not communicate–people are ALWAYS communicating All messages have report and command functions– working with content is not

helpful, look at the process Communication and messages are metaphorical for family functioning Symptoms are messages — symptoms help the system survive It is only a problem if the family describes it as such Based on work of Gregory Bateson, Milton Erickson, MRI, and Minuchin Need to perturb system – difference that makes a difference (similar enough to be

accepted by system but different enough to make a difference) Problems develop in skewed hierarchies Motivation is power (Haley) or love (Madanes)

CONCEPTS:

Symptoms are messages Family homeostasis Family rules – unspoken Intergenerational collusions First and second order change Metaphors Reframing Symptoms serve functions Content & Process Report & Command Incongruous Hierarchies Ordeals (prescribing ordeals) Paradox Paradoxical Injunction Pretend Techniques (Madanes) “Go Slow” Messages

GOALS OF THERAPY: Help the family define clear, reachable goals Break the pattern; perturb the system First and second order change- ideally second order change

(we cannot make this happen– it is spontaneous) Realign hierarchy (Madanes)

ROLE OF THE THERAPIST: Expert position Responsible for creating conditions for change Work with resistance of clients to change Work with the process, not the content Directive Skeptical of change Take a lot of credit and responsibility for change;

however, therapist tells clients that they are responsible for change

Active

ASSESSMENT: Define the problem clearly and find out what

people have done to try to resolve it Hypothesize metaphorical nature of the

problem Elicit goals from each family member and

then reframe into one, agreed-upon goal Assess sequence patterns

Marriage and Family Therapy Models Page 6

Strategic Therapy (Haley & Madanes), Continued INTERVENTIONS:

Paradox Directives

o Assignments (“homework”) that interrupt sequences

Interrupt unhelpful sequences of interaction Metaphors, stories Ordeals (Haley) “Go slow” messages Prescribe the symptoms (Haley) “Pretend” techniques (Madanes)

CHANGE: Breaking the pattern in any way Difference that makes a difference Change occurs outside of session; insession

change is in viewing; homework changes doing

Change in viewing (reframe) and/or doing (directives)

TERMINATION: Client decides when to terminate with the help of

the therapist When pattern is broken and the client reports that

the problem no longer exists Therapist decides

SELF OF THE THERAPIST: Therapist needs to be VERY careful with

ethics in this model; it can be very manipulative (paradox) and a lot of responsibility is on the therapist as an expert

EVALUATION: Very little research done Do clients report change? If so, then it is effective

RESOURCES: Madanes, Cloe. (1981). Strategic family therapy. San Francisco, CA: Jossey-Bass. Madanes, Cloe. (1984). Behind the one-way mirror: Advances in the practice of strategic therapy. San

Francisco, CA: Jossey-Bass. Madanes, Cloe. (1990). Sex, love, and violence: Strategies for transformation. New York: W. W. Norton. Madanes, Cloe. (1995). The violence of men: New techniques for working with abusive families. San Francisco:

Jossey-Bass. Haley, Jay. (1980). Leaving home. New York: McGraw-Hill. Haley, Jay. (1984). Ordeal therapy: Unusual ways to change behavior. San Francisco, CA: Jossey Bass. Haley, Jay. (1987). Problem-solving therapy (2nd Ed.). San Francisco: Jossey-Bass. NOTES:

Marriage and Family Therapy Models Page 7

MILAN FAMILY THERAPY

LEADERS:

Boscolo Palazzoli Prata Cecchin

ASSUMPTIONS: problem is maintained by family’s attempts to fix it therapy can be brief over a long period of time clients resist change

CONCEPTS: family games (family’s patterns that maintain the

problem) o dirty games o psychotic games

there is a nodal point of pathology invariant prescriptions rituals positive connotation difference that makes a difference neutrality hypothesizing therapy team circularity, neutrality incubation period for change; requires long periods of

time between sessions

GOALS OF THERAPY: disrupt family games

ROLE OF THERAPIST: therapist as expert neutral to each family member – don’t get sucked into

the family game curious

ASSESSMENT: Family game Dysfunctional patterns (patterns that

maintain the problem)

INTERVENTIONS: Ritualized prescriptions Rituals Circular questions Counter paradox Odd/even day Positive connotation “Date” Reflecting team Letters Prescribe the system

CHANGE: Family develops a different game

that does not include the symptom (system change)

Requires incubation period

TERMINATION: Therapist decides, fewer than 10-12 sessions

EVALUATION: Not practiced much, therefore not

researched Follow up contraindicated

SUPERVISION INTERVENTIONS:

Marriage and Family Therapy Models Page 8

Milan Family Therapy, continued RESOURCES: Campbell, D., Draper, R., & Huffington, C. (1989). Second thoughts on the theory and practice of the

Milan approach to family therapy. New York: Karnac. Campbell, D., Draper, R., & Crutchley, E. (1991). The Milan systemic approach to family therapy. In

A. S. Gurman & D. P. Kniskern (Eds.), Handbook of Family Therapy (Vol. II) (pp. 325-362). New York: Brunner/Mazel.

Cecchin, G. (1987). Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity. Family Process, 26(4), 405-413.

Cecchin, G. (1992). Constructing therapeutic possibilities. In S. McNamee & K. J. Gergen (Eds.), Therapy as social construction (pp. 86-95). Newbury Park, CA: Sage.

Palazzoli, M. S., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counterparadox: A new model in the therapy of the family in schizophrenic transaction. New York: Jason Aaronson.

Palazzoli, M. S., Boscolo, L., Cecchin, G., & Prata, G. (1978). A ritualized prescription in family therapy: Odd days and even days. Journal of Marriage and Family Counseling, 48, 3-9.

Palazzoli, M., & Palazzoli, C. (1989). Family games: General models of psychotic processes in the family. New York: W. W. Norton & Company. NOTES:

Marriage and Family Therapy Models Page 9

SOLUTION-FOCUSED BRIEF THERAPY

LEADERS:

Steve de Shazer

Insoo Kim Berg

Yvonne Dolan

Eve Lipchik

ASSUMPTIONS: Clients want to change There’s no such thing as resistance (clients are telling us how they cooperate) Focus on present and future except for the past in terms of exceptions; not focused on

the past in terms of cause of changing the past Change the way people talk about their problems from problem talk to solution talk Language creates reality Therapist and client relationship is key A philosophy, not a set of techniques or theory Sense of hope, “cheerleader effect” Nonpathologizing, not interested in pathology or “dysfunction” Don’t focus on the etiology of the problem: Solutions are not necessarily related to

problems Assume the client has strengths, resources Only need a small change, which can snowball into a bigger change The problem is not occurring all the time

CONCEPTS:

Problem talk/ Solution talk Exceptions Smallest difference that makes a

difference Well-formed goals (small, concrete,

measurable, important to client, doable, beginning of something, not end, presence not absence, hard work)

Solution not necessarily related to the problem

Clients are experts on their lives and their experiences

Therapeutic relationships: customer/therapist, complainant/sympathizer, visitor/host

GOALS OF THERAPY: Help clients to think or do things differently in order to

increase their satisfaction with their lives Reach clients’ goals; “good enough” Shift the client’s language from problem talk to solution talk Modest goals (clear and specific) Help translate the goal into something more specific (clarify) Change language from problem to solution talk

ROLE OF THERAPIST: Cheerleader/Coach Offer hope Nondirective, client-centered

ASSESSMENT: Assess exceptions—times when problem isn’t there Assess what has worked in the past, not necessarily related to the

problem; client strengths Assess what will be different when the problems is gone (becomes

goal that might not be clearly related to the stated problem)

INTERVENTIONS: Help set clear and achievable goals (clarify) Help client think about the future and what they

want to be different Exceptions: Amplify the times they did things that

“worked” when they didn’t have the problem or it was less severe

Compliments: -“How did you do that?” -“Wow! That must have been difficult!” – “That sounds like it was helpful; how did

you do that?” -“ I’m impressed with ….” -“You sound like a good ….”

Marriage and Family Therapy Models Page 10

Solution-Focused Brief Therapy, Continued

Interventions

Formula first session task: Observe what happens in their life/relationship that they want to continue

Miracle question: -Used when clients are vague about complaints -Helps client do things the problem has been obstructing -Focus on how having problems gone will make a difference -Relational questions -follow up with miracle day questions and scaling questions -pretend to have a miracle day

Scaling questions

Midsession break (with or without team) to summarize session, formulate compliments and bridge, and suggest a task (tasks used less in recent years; clients develop own tasks; therapist may make suggestions or suggest “experiments”), sometimes called “feedback” (feeding information back into the therapy with a difference)

Predict the next day, then see what happens

TERMINATION:

Client decides

SELF OF THE THERAPIST: Accept responsibility for client/therapist relationship Expert on therapy conversation, not on client’s life or experience of the

difficulty

EVALUATION: Therapy/Research:

Simple (not necessarily easy) Can be perceived that therapist as insensitive- “Solution

Forced Therapy” Crucial that clients are allowed to fully express

struggles and have their own experiences validated, BEFORE shifting the conversation to strengths

Techniques can obscure therapist’s intuitive humanity

Many outcome studies show effectiveness, but no controlled studies

Progress of therapy:

Can clients see exceptions? Are they using solution talk?

SUPERVISION INTERVENTIONS:

RESOURCES: de Shazer, S. (1982). Patterns of brief family therapy: An ecosystemic approach. New York: Guilford. de Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum, E., & Berg, I. K. (2007). More than

miracles: The state of the art of solution-focused brief therapy. New York: Haworth. Berg, I. K., & Miller, S. (1992). Working with the problem drinker. New York: Norton. Berg, I. K. (1994). Family-based services: A solution-focused approach. New York: Norton. De Jong, P., & Berg, I. K. (2007). Interviewing for solutions (3rd ed.). Pacific Grove, CA: Brooks/Cole. Dolan, Y. (1992). Resolving sexual abuse. NY: W.W. Norton. Lipchik, E. (2002). Beyond technique in solution focused therapy. New York: Guilford. Miller, S. D., Hubble, M. A., & Duncan Barry L. (Eds.). (1996). Handbook of solution-focused brief therapy.

San Francisco: Jossey-Bass. Nelson, T. S., & Thomas, F. N. (Eds.). (2007). Handbook of solution-focused brief therapy: Clinical

applications. New York: Haworth. NOTES:

Marriage and Family Therapy Models Page 11

NARRATIVE THERAPY

LEADERS:

Michael White

David Epston Jill Freedman Gene Combs

ASSUMPTIONS: Personal experience is ambiguous Reality is shaped by the language used to describe it – language and experience

(meaning) are recursive Reality is socially constructed Truth may not match historic or another person’s truth, but it is true to the client Focus on effects of the problem, not the cause (how problem impacts family; how

family affects problem) Stories organize our experience & shape our behavior The problem is the problem; the person is not the problem People “are” the stories they tell The stories we tell ourselves are often based on messages received from society or

our families (social construction) People have their own unique filters by which they process messages from society

CONCEPTS:

Dominant Narrative – Beliefs, values, and practices based on dominant social culture

Subjugated Narrative – a person’s own story that is suppressed by dominant story

Alternative Story: the story that’s there but not noticed

Deconstruction: Take apart problem saturated story in order to externalize & re-author it (Find missing pieces; “unpacking”)

Problem-saturated Stories – Bogs client down, allowing problem to persist. (Closed, rigid)

Landscape of action: How people do things Landscape of consciousness: What meaning the

problem has (landscape of meaning) Unique outcomes – pieces of deconstructed story that

would not have been predicted by dominant story or problem-saturated story; exceptions; sparkling moments

GOALS OF THERAPY: Change the way the clients view themselves

and assist them in re-authoring their story in a positive light; find the alternative but preferred story that is not problem-saturated

Give options to more/different stories that don’t include problems

ROLE OF THERAPIST: Genuine curious listener Question their assumptions Open space to make room for possibilities

ASSESSMENT: Getting the family’s story, their experiences

with their problems, and presumptions about those problems.

Assess alternative stories and unique outcomes during deconstruction

INTERVENTIONS:

Ask questions o Landscape of action & landscape of

meaning o Meaning questions o Opening space

CHANGE: Occurs by opening space; cognitive Client can see that there are numerous

possibilities Expanded sense of self

Marriage and Family Therapy Models Page 12

Narrative Therapy, Continued Interventions

o Preference o Story development o Deconstruction o To extend the story into the future

Externalize problems Effects of problem on family; effects of family on

problem Restorying or reauthoring

o Self stories Letters from the therapist Certificates of award

TERMINATION: Client determines

SELF OF THE THERAPIST: Therapist’s ideas, values,

prejudices, etc. need to be open to client, “transparent”

Expert on conversation

EVALUATION: No formal studies

SUPERVISION INTERVENTIONS: RESOURCES: Freeman, Jennifer, David Epston, and Dean Lobovits. (1997). Playful approaches to serious problems:

Narrative therapy with children and their families. New York: W.W. Norton. Freedman, Jill, and Gene Combs. (1996). Narrative therapy: The social construction of preferred realities. New

York: W. W. Norton. White, Michael, and David Epston (Eds.). (1990). Narrative means to therapeutic ends. New York: W.W.

Norton. White, Michael. (2007). Maps of narrative practice. New York: W.W. Norton. NOTES:

Marriage and Family Therapy Models Page 13

COGNITIVE-BEHAVIORAL THERAPY

LEADERS:

Ivan Pavlov Watson Thorndike B. F. Skinner Bandura Dattilio

ASSUMPTIONS: Family relationships, cognitions, emotions, and behavior mutually influence one

another Cognitive inferences evoke emotion and behavior Emotion and behavior influence cognition

CONCEPTS: Schemas- core beliefs about the world, the

acquisition and organization of knowledge Cognitions- selective attention, perception,

memories, self-talk, beliefs, and expectations Reinforcement – an event that increases the future

probability of a specific response Attribution- explaining the motivation or cause of

behavior Distorted thoughts, generalizations get in way of

clear thinking and thus action

GOALS OF THERAPY: To modify specific patterns of thinking and/or

behavior to alleviate the presenting symptom

ROLE OF THERAPIST: Ask a series of question about assumptions, rather

than challenge them directly Teach the family that emotional problems are

caused by unrealistic beliefs

ASSESSMENT: Cognitive: distorted thoughts, thought processes Behavioral: antecedents, consequences, etc.

INTERVENTIONS: Questions aimed at distorted assumptions (family

members interpret and evaluate one another unrealistically)

Behavioral assignments Parent training Communication skill building Training in the model

CHANGE: Behavior will change when the contingencies of

reinforcement are altered Changed cognitions lead to changed affect and

behaviors

TERMINATION: When therapist and client determine

SELF OF THE THERAPIST: Not discussed

EVALUATION: Many studies, particularly in terms of marital therapy and parenting

SUPERVISION INTERVENTIONS:

Marriage and Family Therapy Models Page 14

RESOURCES: Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior

exchange principles. New York: Brunner/Mazel. Jacobson, N. S., & Christensen, A. (1998). Acceptance and Change in Couple Therapy: A Therapist's Guide to

Transforming Relationships. New York: Norton. Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples. Washington, DC:

APA Books. Resources Dattilio, F. M. (1998). Case studies in couple and family therapy: Systemic and cognitive perspectives. New York: Guilford. Dattilio, F. M., & Padesky, C. (1990). Cognitive therapy with couples. Sarasota, FL: Professional Resource

Press. Beck, A. T., Reinecke, M. A., & Clark, D. A. (2003). Cognitive therapy across the lifespan: Evidence and

practice. Cambridge, UK: Cambridge University Press.

NOTES:

Marriage and Family Therapy Models Page 15

CONTEXTUAL FAMILY THERAPY

LEADERS: Ivan

Boszormenyi -Nagy

ASSUMPTIONS: Values and ethics are transmitted across generations Dimensions: (All are intertwined and drive people’s behaviors and relationships)

o Facts o Psychological o Relational o Ethical

Trustworthiness of a relationship (relational ethics): when relationships are not trustworthy, debts and entitlements that must be paid back pile up; unbalanced ledger gets balanced in ways that are destructive to individuals and relationships and posterity (e.g., revolving slate, destructive entitlement)

CONCEPTS: Loyalty: split, invisible Entitlement (amount of merit a person has based on

trustworthiness) Ledger (accounting) Legacy (we behave in ways that we have been programmed

to behave) Relational ethics Destructive entitlement (you were given a bad ledger and it

wasn’t fair so it’s ok to hand it on to the next person— acting out, neglecting important others)

Revolving slate Posterity (thinking of future generations when working with

people) this is the only model that does Rejunctive and disjunctive efforts

GOALS OF THERAPY: Balanced ledger

ROLE OF THE THERAPIST: Directive Expert in terms of assessment

ASSESSMENT: Debts Entitlements Invisible loyalties

INTERVENTIONS: Process and relational questions Multi-directional impartiality: Everybody and nobody feel

special—all are attended to but none are more special Exoneration: Help people understand how they have been

living out legacies and debts-ledgers—exonerate others Coach toward rejunctive efforts

CHANGE: Cognitive: Awareness of legacies, debts

and entitlements Behavioral: Very action oriented—

actions must change

TERMINATION: Never- totally up to

the client

SELF OF THE THERAPIST: Must understand own legacies,

entitlements, process of balancing ledgers, exoneration

EVALUATION: No empirical evaluation

SUPERVISION INTERVENTIONS:

Marriage and Family Therapy Models Page 16

Contextual Family Therapy, Continued RESOURCES: Boszormenyi-Nagy, I. (1987). Foundations of contextual therapy: Collected papers of Ivan Boszormenyi-Nagy.

New York: Brunner/Mazel. Boszormenyi-Nagy, I., & Krasner, B. (1986). Between give and take: A clinical guide to contextual therapy.

New York: Brunner/Mazel. Hargrave, T. D., & Pfitzer, F. (2003). The new contextual therapy: Guiding the power of give and take.

New York: Brunner-Routledge. van Heusden, A., & van den Eerenbeemt, E. (1987). Balance in motion: Ivan Boszormenyi-Nagy and his vision

of individual and family. New York: Brunner/Mazel. NOTES:

Marriage and Family Therapy Models Page 17

BOWEN FAMILY THERAPY

LEADERS: Murray

Bowen Michael Kerr

(works with natural systems)

Edwin Friedman

ASSUMPTIONS: The past is currently influencing the present Change can …