Introduction to the Counseling Profession

1. Introduction to the Counseling Profession Chapter 16 Marriage, Couple, and Family Counseling

2. Chapter Topics

3. Foundations “Family therapy is a psychotherapeutic approach that focuses on altering interactions between a couple, within a nuclear family or extended family, or between a family and other interpersonal systems, with the goal of alleviating problems initially presented by individual family members, family subsystems, the family as a whole, or other referral sources.” • There are many approaches to family therapy that have emerged out of systems theory. • However, prominent family therapist researchers are now concentrating on integrating system-based approaches to leverage greater effectiveness. • There are two key foundational aspects to family therapy. These aspects are: (a) history, and (b) specialization or profession.

4. Foundations • History • The history of family therapy is relatively brief. It begins in the 1950s, with the seminal contributions of Nathan Ackerman, Theodore Lidz, Lyman Wynne, Murray Bowen, and Carl Whitaker. • All of these psychiatrists, originally trained in the prevailing psychodynamic model, broke away from its restrictive influence and began to see that dysfunctional behavior was rooted in the individual's past and present family life. • Each of these pioneers arrived at this insight relatively independently.

5. Foundations • Specialization or Profession? • At present there exists a strong debate as to whether family therapy is a professional specialization or a distinct profession. • Who is going to win the above noted debate? Some suggest that this debate will be resolved as a “both-and.” That is, both MFTs and other mental health professionals will practice family therapy and Marriage and Family Therapy will be viewed as a distinct profession.

6. Counseling, Prevention, and Intervention • The Initial Interview • The following description owes a great deal to Jay Haley (1987), but also incorporates ideas from other therapists. • The stages of the interview are as follows: • (a) Presession planning • (b) Joining • (c) Problem statement • (d) Interaction • (e) In-sesssion conference • (f) Goal-setting

7. Counseling, Prevention, and Intervention “On the basis of the data derived from this initial contact, a pre-session plan should be developed that will include the therapist’s hypotheses about the underlying basis of the presenting problem, areas of inquiry that must be addressed to reject or confirm the hypotheses, and a general plan for the session.” • Pre-session Planning • Whenever possible, the therapist should determine in advance who will attend the session, and have at least a general idea of the nature of the presenting problems. • This is called the “battle for structure," and great emphasis is placed on the importance of the therapist determining who will attend the first session. If the therapist does not have control at this stage, therapeutic leverage is lost and the family is less likely to be helped.

8. Counseling, Prevention, and Intervention “The most important task of the initial interview is to join with the family, accommodating to their affective tone, tempo, language, and family structure. This is done through mimesis.” • Joining • Mimesis is a therapeutic skill “used by the therapist to join with the family and become like family members in the manner or content of their communications.” • A third aspect of joining is maintenance. This aspect of joining refers to the therapist sensing the family's structure and acting in such a way as to be included within it. • During the joining stage, the therapist should not allow the introduction of material related to the family problem.

9. Counseling, Prevention, and Intervention “Haley (1987) recommends that “the adult who seems less involved with the problem be spoken to first, and the person with the most power to bring the family back be treated with the most concern and respect." • Problem Statement • During the joining stage, the therapist has learned something of the family structure and hierarchy and uses this information to decide to whom the first question should be directed. • The second decision the therapist must make is how the problem question should be framed.

10. Counseling, Prevention, and Intervention “The purpose of the interaction stage is to determine the family hierarchy, to reveal any stable coalitions, to locate diffuse or rigid boundaries between family subsystems, and hopefully to reveal the chronically repeating interactional sequence that sustains the problem behavior.” • Interaction • When the problem has been reasonably clarified, or when it has become clear that the family is not in agreement regarding the nature of the problem, it is time for the therapist to introduce the interaction stage. • In the interaction stage, the therapist's focus will be on determining the patterns of interaction that sustain the problem.

11. Counseling, Prevention, and Intervention “As Haley (1987) has said, "If therapy is to end properly, it must begin properly‑-by negotiating a solvable problem and discovering the social situation that makes the problem necessary." • Goal Setting • The purpose of the goal‑setting stage is to reach agreement with the family on a solvable problem and to initiate a process that will alter the social situation in such a way that the problem is no longer necessary. • It is essential that the problem to be solved be stated in behavioral terms so that one will know when it has been solved. • Often the process of operationalizing the complaint will be sufficient to produce a solvable problem.

12. Counseling, Prevention, and Intervention • Key Therapy Techniques • Circular Questioning • Each member of the family is invited to tell how he or she sees the relationship between two other family members; or between two different periods; or any other difference likely to be significant to the family. • Reframing • Reframing may include operationalizing, emphasizing complementarity, denominalizing, or positive connotation.

13. Counseling, Prevention, and Intervention • Key Therapy Techniques • Giving Directives • Giving directives refers to creating or selecting an intervention that will attack the hypothesized basis of the presenting problem. • Directives can be categorized as either (a) compliance‑oriented or (b) defiance‑oriented.

14. Diversity and Advocacy “Professional counselors realize their perspectives influence the conceptualization of problems, identification of clients, and implementation of possible solutions. Couple and family counselors examine personal biases and values. They actively attempt to understand and serve couples and families from diverse cultural backgrounds.” • Cultural Competence • Cultural competence is derived from a therapist being aware of his/her own assumptions about a client’s cultural narratives. • Narrow Rigid Beliefs and Self-Percepts • When an individual or a family is unable to resolve a difficulty, it is assumed that the conscious mind is imposing a narrow, restrictive mind‑set that does not allow the creative recovery of the resources necessary to solve the problem.

15. Assessment “Tolstoy said in the opening line of Anna Karenina, “All happy families resemble one another, but each unhappy family is unhappy in its own way.” Family therapists tend to reverse this position, believing that good family functioning is based in diversity, while family dysfunction is due to narrowness and rigidity.” • Family Dysfunction • Rather than focusing on the internal state of the individual, the family systems approach looks for pathology in the interactions that occur between people who have significance for each other. • The purpose of family therapy is not insight, but behavior change.

16. Assessment “Family dysfunction is often the result of a failure to accomplish the developmental tasks demanded by the family life cycle.” • Family Life Cycle • Inherent in the life cycle concept is the idea that there are certain developmental tasks that must be accomplished during periods of transition from one stage to another. Successful movement to the next development stage requires changes in the roles and structure of the family. • Other potential life-cycle stages that can occur in families are (a) marital break-up, (b) single-parent living, and (3) remarriage.

17. Assessment “Bowen (1994) conceived a scale of differentiation of self from 0 to 100. At the low end of the scale, people are fused or enmeshed with their families to the extent that they are unable to think or act independently. Their lives are ruled by emotional reactivity.” • Family Fusion (Present or Origin) • At the upper end of the scale, people have achieved emotional separation from their families, are able to act autonomously, and can choose to be rational in emotionally charged situations. • The individual's level of differentiation is closely related to the differentiation of his or her parents, and the process is transgenerational in nature.

18. Assessment • Family Fusion (Present or Origin) • People with low levels of differentiation (fusion) are particularly reactive to environmental stressors and when under stress are likely to resolve it by (a) withdrawal, (b) conflict, (c) dysfunction of one spouse, or (d) triangulation of a child that results in dysfunction. • People with low levels of differentiation (fusion) are particularly reactive to environmental stressors and when under stress are likely to resolve it by: • (a) Withdrawal • (b) Conflict • (c) Dysfunction of one spouse • (d) Triangulation of a child that results in dysfunction

19. Assessment • Boundary Problems • According to Minuchin, family boundaries are created by implicit rules that govern (a) who talks to whom, and (b) about what is discussed. • When no rules exist, everyone is privy to everyone else's thoughts and feelings. Thus, family boundaries become diffuse and individuals become enmeshed (fused). • When the rules are too strict and communication breaks down, the boundary is said to be rigid and the individuals disengaged. • The preferred state is to have clear rules that allow for both individuation and togetherness.

20. Assessment “Haley (1987) believes family dysfunction is often caused by behavioral sequences that are rigid, repetitive, and functionally autonomous.” • Dysfunctional Behavioral Sequences • Such patterns can repeat ad infinitum unless some new behavior is introduced into the sequence. • It perhaps needs to be pointed out that the dysfunctional behavior should not be “blamed" on any of the individuals; all are equally involved and each could change the sequence by introducing a new incompatible element.

21. Assessment • Hierarchy Problems • Problems can occur when the hierarchy is either absent, ambiguous, or culturally inappropriate; that is, when no one is in charge, when it is unclear who is in charge, or when the person wielding the power is not sanctioned by cultural mores. • Communication Problems • Communication may be inadequate owing to lack of clarity, lack of continuity, incongruent, or when people are unwilling to reveal themselves.

22. Assessment • Family of Origin Struggles • Young people who come from a common cultural background may be less likely to experience this problem, but in our multicultural society, the appropriate behaviors for “wife” or “husband” are often unclear, or represent role conflicts. • Often the young couple find themselves acting just like their parents, although they are reluctant to admit it.

23. Research and Evaluation • Does Therapy Work? • Research that examines whether an intervention works is known as outcome research. • In family therapy, a dearth of outcome research left the above question unanswered until the late 1980s. • Meta-analysis is a research technique by which multiple individual studies can be grouped together to empirically analyze the overall effectiveness of a particular intervention approach. • In a meta-analysis studies, it was found that family therapy is indeed an efficacious mental health treatment approach.

24. Research and Evaluation • What are the Professional Practice Patterns of Family Therapists? • MFTs, on average had 24 clients in their active caseload and completed 20 client contact hours per week. The median number of sessions per client was 12. • The clients served by the MFTs presented a multitude of problems at the commencement of treatment. These problems included (a) depression (44%), (b) marital problems (30%), (c) anxiety (21%), and (d) parent-child problems (13%). • Adjustment Disorder was the modal diagnostic category (25%). Other prevalent diagnostic categories included Depressive Disorder (23%) and Anxiety Disorders (14%).