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Family therapy concepts


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Family therapy concepts

  1. 1. Family Therapy Concepts 1By Chris Lobsinger2013
  2. 2. Family Therapy Concepts 1• This four hour workshop is meet tointroduce to participants some of the basicideas and components that are associatedwith a body of knowledge referred to asFamily therapy• In order to present a more congruently itwill be following the Leeds Systemic FamilyTherapy Model as laid out in the LeedsSystemic c Family Therapy Manual, MsHelen Pote et al 2000
  3. 3. Basic concepts of Systemtheory• In the world of systems therapy, linearcausality does not exist. Instead we findan emphasis on reciprocity, recursion,and shared responsibility• A and B exist in the context of arelationship in which each influencesthe other and both are equally causeand effect of each other behaviour
  4. 4. Basic concepts of Systemtheory• Over time, A and b establish patternscharacteristic of their particular relationship• Our perspective is holistic, and our focus is onthe process, or context, that gives meaning toevents instead of only on the individual or theevents in isolation. Our focus is also presentcentred, we examine here-and now interactionsrather than look to history for antecedentscauses.” (Leeds Systemic c Family TherapyManual, Ms Helen Pote et al 2000)
  5. 5. Models of Family Therapy1. What is marriage and family therapy?• Marriage and family therapists practice a uniqueprofession. Family therapy began as a breakawaymovement from psychiatry in the 1950s• Marriage and family therapists may see individuals,couples, families, and/or groups, yet they retain theirinteractional perspective regardless of the configurationof clients• Marriage and family therapists take an interactionalperspective, and build on client strengths, rather thanassumed pathology
  6. 6. What is the philosophy offamily therapy?• Each family operates on the basis of predictablepatterns of interactions• patterns of behaviour being passed andreplicated from generation to generation• Family members are always affected by oneanothers issues. 91): “• (Distant Education for Family TherapyCounselling and Supervising-
  7. 7. Some classifications of familytherapy• Behavioural Family Therapy• Bowen theory• Brief Therapy: MRI• Contextual Therapy• Eriscksonian Family Therapy• Focal Family Therapy• Milan Systemic Therapy• Family Psychoeducational Therapy• Strategic Therapy• Structural Therapy
  8. 8. Types of Family Therapy• Structural Family Therapy (Minuchin, 1974,Colapinto, 1991)• Conjoint Family Therapy (Satir, 1967)• Contextual Therapy (Boszormenyi-Nagy,1991)• Strategic Therapy (Madanes, 1981)• Brief Therapy• Milan Systemic Therapy (Boscolo et al,1987)• Narrative Therapy (Freedman, Combs,1996)
  9. 9. • “It is important to note that Family therapy isprobably a misnomer. When family therapy isbuilt on the assumption of systems theory,amore appropriate label would probably berelationship therapy.”• Family Therapy a systemic integration 3rdedition Dorthy Becvar and Raphael Becvar, 1988p12• *Another alternative is the term systemictherapy
  10. 10. Contrasting individual andfamily Therapy• Individual therapy Family Therapy• Asks why Asks what• Linear Cause and effect Reciprocal causality• Subjective/objective Dualism Holistic• Either/or Dichotomies Dialectical• Value-free Science Subjective/Perceptual• Deterministic/Reactive Freedom ofChoice/Proactive• Laws & Law like External reality Patterns• Historical Focus Here-and now focus• Individualistic Relational• Reductionistic Contextual• Absolutistic Relativistic
  11. 11. CyberneticEpistemology/SystemsEpistemology• Metaphors of pattern Metaphorsof Material• Cybernetics Physics• Mind Body• Communication Energy• Biological World Physical• Organization of whole Ingredientsof whole• Qualitative analysis QuantitativeAnalysis• Mechanistic Explanation VitalisticExplanation
  12. 12. Systems Focus• In working systemically the central focusshould be upon the system rather than theindividual• The system may usefully be thought of asthe household or a wider family system,and may include friends, people ininstitutions (school, work, church)• A consistent view is that these difficultiesdo not arise within individuals but in therelationships, interactions and languagethat develop between individuals
  13. 13. Systems Focus• Rock and dog• Definition of a system• Environment-systems-subsystems• Open and closed system• Wholeness• BoundaryThe interface between the system and itsenvironment is called the boundary of thesystem
  14. 14. BoundaryThe interface between the system and itsenvironment is called the boundary of the system
  15. 15. Circularity• Patterns of behaviour develop within systems, which arerepetitive and circular in nature and also constantlyevolving. Behaviour and beliefs that are perceived asdifficulties will also therefore develop in a circularfashion
  16. 16. Punctuation“Disagreement about how to punctuate thesequence of events is at the root of countlessrelationship struggles
  17. 17. Pursue/Distance
  18. 18. Connections and Patterns• In understanding relationships and difficultieswithin systems it will be important for thetherapist to consider the connections betweencircular patterns of behaviour• The process of therapy should enable familymembers to consider these connections fromnew and/or different perspectives• All communication provides direct access toworld views and world views reflect processedstructure.
  19. 19. Connections and Patterns• Structure is like a snap shot of process• Process is like making a movie basic on thestructure• Structure and process seen as communicationreflect world view
  20. 20. Symmetrical andcomplementary interaction• Symmetrical interaction is characterised byequality and the minimization of difference• complementary interaction is based on themaximization of difference• Rigid symmetrical or complementary patternsmay be problematic• Meta- complementary – A lets or forces B to bein charge• Pseudo-symmetry – A lets or forces B to besymmetrical• Triangulation
  21. 21. Triangulation
  22. 22. Narratives and Language• Behaviours and beliefs form the basis of storiesor narratives• The language that is used to describe thesenarratives and the interactions betweenindividuals constructs the reality of theireveryday lives• At times when stories lived and stories told areincongruous change
  23. 23. Constructivism• This is the idea that people form autonomousmeaning systems and will interpret and makesense of information from this frame ofreference• People cannot make assumptions about whatmeaning will be attributed to the informationthey offer/contribute to others• Thus there is only the possibility of perturbingother people’s meaning systems
  24. 24. Reality• Direct experience of reality (naïve reality) what you seeis what you get.
  25. 25. Constructivism• No direct experience of reality (constructivism) The mapis not the territory
  26. 26. Social constructivism•Social constructivism - elephant and the blind men
  27. 27. Map is the territory
  28. 28. Social Constructionism• Relevant is the idea that meaning is created inthe social interactions that take placebetween people and is thus context dependentand constantly changing• this takes precedence over the concept of asingle external reality
  29. 29. Cultural Context• The therapist should consider the importanceof context, in relation to the cultural meaningsand narratives• The relationship between these narratives, thetherapeutic relationship and its context• The family should be an importantconsideration at the point of referral andthroughout the therapy
  30. 30. Power• The therapist should take a reflexive stance inrelation to the power differentials that exist withinthe therapeutic relationship, and within the familyrelationships• No powerlessness• No Power in a (Batesonian sense)• Victim in oppressor, oppressor in victim
  31. 31. Co-constructed therapy• In therapeutic interactions reality is co-constructed between the therapist (andteam) and the people with whom theymeet• They form part of the same system, andshare responsibility for change and theprocess of therapy• Particular attention should thus be paid tothe contributions that all members of thetherapeutic system make in the process ofchange
  32. 32. Self-reflexivity• The therapist should aim to apply systemicthinking to themselves and thus reject anythinking about families and their processes thatdoes not also apply to therapists and therapy• Self-reflexivity focuses especially on the effectof the therapy process on the therapist• In order to use self-reflexivity it will benecessary for the therapist to be alert to theirown constructions, functioning and prejudices sothat they can use their self effectively with thefamily
  33. 33. Strengths and solutions• The therapist should take a non-pathologising, positiveview of the family system• A family system that enters the therapeutic systemshould be considered as a system that owns a wealth ofstrengths and solutions in the face of difficult situations• It is important for the therapist to recognise that thereis a multi-versa of possibilities available for each familyin the process of change• The therapist can facilitate this process by attending tothe strengths and solutions in the stories that the familysystem brings to therapy
  34. 34. Models of therapeutic changeFeed back - System• In a system where a transformation occurs, thereare inputs and outputs. The inputs are the resultof the environment influence on the system, andthe outputs are the influence of the system onthe environment. Input and output are separatedby duration of time, as in before and after. Orpast and present
  35. 35. Feed back loop• In every feedback loop, as the name suggests,information about the result of the transformation or anaction is sent back to the input of the system in theform of input data• If these new data facilitate and accelerate thetransformation in the same direction as the proceedingresults, they are positive feedback• If the new data produce a result in the oppositedirection to previous results, they are negative feedback
  36. 36. “An appropriate Fiction forbehavioural Science”• Some one needs to provide a fiction for thebehavioural sciences that would work like theelegant fiction upon which physics was built-itsNewtonian Particle. The idea of a recursivenetwork with feedback structure provides auseful fiction behavioural science. (TheAesthetics of change Bradford Keeny theGuildford press New York London 1983)
  37. 37. Positive and negative feedback• Positive feedback leads to divergent behaviour
  38. 38. Positive and negative feedback• positive feedback loop left to itself can leadonly to the destruction of the system, throughexplosion or through the blocking of all itsfunctions• Negative feedback leads to adaptive, or goal-seeking behaviour: sustaining the same level,temperature, concentration, speed, direction
  39. 39. • In a negative loop every variation toward a plustriggers a correction toward the minus, and viceversa. There is tight control; the systemoscillates around an ideal equilibrium that itnever attains. A thermostat or a water tankequipped with a float are simple examples ofregulation by negative feedback
  40. 40. Deviation amplifying feed back(positive feed back)• If the family system is to function effectively; itmust be able to encourage desirable changes inbehaviour and to adapt to changes in the familymembers as they grow older. The positive feedback loop provides the necessary mechanism• Difference that makes a difference• News of difference• Sameness and difference - stability and change
  41. 41. Prescribed practices as in linewith the Leeds model• The prescribed practices described below are things thatwould not be included in a routine therapy session. Itmay be that on one or two occasions it is appropriate touse one of these approaches; however they must beused within a systemic framework that is, using theguiding principles outlined at the start of this manual
  42. 42. Advice• As a systemic therapist you would notusually offer direct advice to the familyabout their interactions or the difficultiesthey are experiencing• advice may be appropriate in helping thefamily work towards their goals, advicemay be offered in a non-directive orreflexive manner. Options should bepresented as choices about which thefamily can make their own decisions
  43. 43. Interpretation• Psychodynamic interpretations about themeaning of symptoms or interactions inrelation to individual or trauma would not beusual for systemic therapists• Rather, meanings are explored in relationaland interactional terms between members ofthe system
  44. 44. Un-transparent/closed practice• Therapists should not remain closed about theirworking practices, ways of thinking andunderstanding the difficulties• They should try to remain transparent byexplaining their practices at the beginning oftherapy, and during therapy as appropriate
  45. 45. Therapist monologues• In the co-created process of therapy therapistsshould not find themselves lecturing or usinglong monologues in their interactions with thefamily• The process should be more like a sharing ofideas between therapist and family, andbetween family members
  46. 46. Consistently siding with oneperson• In taking a neutral stance therapists should not findthemselves consistently siding with one person in thefamilyWorking in the transference• Therapists should be paying attention to the relationaland engagement issues between themselves and thefamily with which they are working but they should notuse the relational aspects between themselves and thefamily
  47. 47. Inattention to use of language• Therapists should not be inattentive tothe use of language used by the family• They should pay attention to the boththe words and phrases used, and themeanings attributed to these
  48. 48. Reflections• Therapist’s simple reflections of the points or phrasesthat are used by the family should be kept to aminimum. Reflections may be used to enhanceengagement and to develop the family’s sense of beinglistened to and understood, but when used, reflectionsshould be followed by questions, and increased curiosityabout the issues presented
  49. 49. Polarised position• Therapists should avoid taking a position which ispolarised from that of the family, or a position which islikely to escalate to a polarised position• The therapeutic team can enable the therapist toachieve this by presenting the multiple perspectivesfrom which the family situation can be understoodSticking in one time frame• Therapists should not stick in one time frame, but movethe focus of their questions and discussion between thepast, present and future
  50. 50. Agreeing/not challenging ideas• Therapists should not be in a continual state ofagreement with the family’s ideas• They should remain curious and challengingabout the nature and content of these ideas,in order to introduce new unexploredpossibilities and ideas
  51. 51. Ignoring information thatcontradicts hypothesis• Therapists should not ignore, or minimiseinformation presented by the family whichcontradicts their own ideas and hypothesesDismissing ideas• The ideas presented by the family about thedifficulties with which they are struggling, orthe process of therapy itself should not bedismissed by the therapist
  52. 52. Inappropriate affect• The therapist’s affect should match that ofthe family, and would be consideredinappropriate if it remained dissimilar fromfamily for an extended period of time• One example might be if the family werefeeling optimistic about change and theprogress they were making, and thetherapist remained pessimistic
  53. 53. Ignoring family affect• Therapists should pay attention to the affect thatthe family is showing in the session, and not ignorestrong expressions of affect during the sessions• This may be particularly relevant when a memberof the family shows distress during the meeting,either by sad or angry behaviourIgnoring difference• Therapists should not ignore issues of differencebetween themselves and the family or within thefamily
  54. 54. Family Therapy concepts Part IIChris Lobsinger 2013
  55. 55. Plan of development• Assessment• Overview of specific goals• Pre-therapy• Initial sessions• Middle-sessions• End- sessions
  56. 56. Assessment Performa family• Demographic Information• Genogram / Ecogram /timeline• Migration and trauma history• Referral information• Needs assessment• Family Structure/process• Change• Cultural formulation
  57. 57. 6. Family Structure/Process• The way in which activities within the home are organizedalong gender, generational lines and roles• The connections which partners maintain with their network offriends and relatives• Partners attitudes towards their children• The way in which the family members perceive the connectionbetween the individual and the world (e.g. Autonomy of theindividual or the individual in relation to family andgenerations/ in relation to culture - dominant/non-dominant)• Coalitions, alliances, boundaries, hierarchy within the nuclearand extended families)• Communication and behavior patterns• Role and relationships clarity• Strengths (eg., coping mechanisms)
  58. 58. Convening SessionsIn deciding whom to invite to the firsts session• Who is living in the household?• Who else is mentioned as important members of the familysystem?• Recent family life events, that may affect attendance e.g.childbirth / separation.• Is further information required from referrers beforetherapy can commence?
  59. 59. Convening Sessions• What professional systems are involved withthe family? In relation to:• i. The presenting issues.• ii. Other issues, such as child protection.• Would it be helpful to initiate a professional/ network meeting prior to the therapycommencing?
  60. 60. Before the initial sessiondiscuss the therapy.• Team working• Attendance issues, who will be coming, howto get there, and• ambivalence about attending.• Therapist’s interest in hearing everyone’sideas• Confidentiality
  61. 61. Pre-therapy preparation• Construct a genogram and ecogram fromreferral information• Summarize the main themes from thereferral• Consider the recent life events of the family• Consider difficulties which may arise aroundengagement and how to address these
  62. 62. Pre-therapy preparation• Consider broader system issues, and definewho is in the network• Brainstormthemes/hypotheses/formulations whichmay be relevant to the family
  63. 63. Genograms• All members of the family system, includingadopted/fostered members• Delineation of the household• All members of the wider system• Dates of birth• Deaths, with dates
  64. 64. Genograms• Partnerships and marriages, with dates• Separations and divorces, with dates• Pregnancies, miscarriages, andterminations, with dates• Occupations / Schooling• Any information that is missing from thereferral information should be noted andenquired about during the initial session oftherapy.
  65. 65. The Ecomap• 1) includes the major systems that are a partof the familys life;• 1) includes the major systems that are a partof the familys life;• 3) portrays an overview of the family in theirsituation by, picturing the important nurturantor conflict connections between the familyand their world;
  66. 66. The Ecomap• 4) demonstrates the flow of resources or thelack and deprivations;• 5) highlights the nature of the interfaces andindicates conflict for mediation and resourcesto be identified and mobilized.
  67. 67. Goals during initial session• Outline Therapy Boundaries & Structure• Engage and Involve all family members• Gather and Clarify Information• Establish Goals and Objectives of Therapy
  68. 68. Goals during middle sessions• Develop and Monitor Engagement• Gather Information and Focus Discussion• Identify & Explore Beliefs• Work towards change at the level of beliefsand behaviors• Return to Objectives and Goals of Therapy
  69. 69. Goals during ending sessions• 1.Gather Information and Focus Discussion• 2. Continue to work towards change at thelevel of behaviors and beliefs• 3. Develop family understanding about behaviors and beliefs• 4. Secure Collaborative Decision re: Ending• 5. Review the process of therapy
  70. 70. Pre-therapy preparation• Construct a genogram from referralinformation• Summarise the main themes from the referral• Consider the recent life events of the family• Consider difficulties which may arise aroundengagement and how to address these• Consider broader system issues, and definewho is in the network• Brainstorm themes/hypotheses/formulationswhich may be relevant to the family
  71. 71. Pre & Post Session Preparation• Summary of the main themes from previous session• Information which requires clarification from previous session• Between session contact the therapist has had with thefamily/wider system• The current formulation/themes/hypothesis of the issues withwhich the family are bringing• Ways forward for the current session which are beingconsidered• Any team – therapist issues which need to be addressed• Any family – family/team issues which need to be addressed• CONSIDER THE 6. FAMILY STRUCTURE/PROCESS
  72. 72. Goals during initial session• Outline Therapy Boundaries & Structure• Engage and Involve all family members• Gather and Clarify Information• Establish Goals and Objectives of Therapy
  73. 73. Outline Therapy Boundaries &Structure• IntroductionsThe therapist should introduce himself orherself as a team member and explain therole and context within which they work(the team and the centre).• Team workingThe therapist should explain that they workas part of a team, and that the team’s roleis to generate ideas and help the therapistunderstand the family / system.
  74. 74. • The confidentiality of any information discussed inthe session should be outlined. Specific statementsabout the boundaries of confidentiality should bemade in relation to other systems.• Structure of the session Information should be givenon the length of the meeting, the breaks, and the useof team feedback through messages or reflectingteams. Explain that during the break,Confidentiality
  75. 75. • Structure of therapy Explain that if the family/teamdecide to meet again, that the meetings will bedecided together by the family / team in accordancewith their needs and wishes.• Questions Time should then be spent giving thefamily an opportunity to ask questions and meet theteam. Agreement to proceed with videoing should beconfirmed, and the family informed that the videowill now be switched on.
  76. 76. Engage and Involve all familymembers•Supportive environment Initially it isvery important for the therapist toprovide a warm, supportive and empathicenvironment, to increase trust andrapport and to build the therapeuticrelationship
  77. 77. • Hear from everyone: Therapists should try to hear fromall members of the system/family, initially connectingwith them all at an individual level, and assessing thelevel of contribution they feel they are able to make tothe discussion• Neutrality: The therapist is trying not only to heareveryone’s views but also to establish their interest indifferent perspectives that may be held within thesystem.
  78. 78. Gather and Clarify Information• The concept of therapy• The system• The presenting difficulties or issues• Solutions and successes to dateAttention should be paid to collectinginformation in a circular manner. Although itwill be appropriate to ask linear questions incollecting information, especially at this earlystage of therapy, circularity can be maintainedby linking multiple linear questions betweenfamily members in a circular way.
  79. 79. Establish Goals and Objectivesof Therapy• The therapist should consider with the systemwhat are their goals and objectives for therapy• The establishment of goals should be achievedin a way which expresses the Possibility ofChange, and should convey the expectationthat change is possible, and likely to occur
  80. 80. Post-session• Review of main interventions and family’sresponse• Ideas for future sessions, themes/issues to followup,• E.g. narrative prompts, unexplored areas, factsto check• Feedback to therapist of team observations• Therapist’s reflections on issues evoked for themby the session• Review of important information shared, e.g. lifeevents, elements of genogram• CONSIDER THE 6. FAMILY STRUCTURE/PROCESS
  81. 81. Case notes• All written records should be non-pejorative, legible,dated, signed, with no abbreviations. Alterations andCorrections should be clearly marked and signed. Casenotes should include:• Family information sheet & Genogram/ecogram-ecomap• Referral information/letter• All other written communications to and from thecentre• Record of attendance• Sessions notes• Notes on telephone contacts to and from the centre
  82. 82. Session notesSession notes should include :• Date and number of session• Who attended therapy• Therapist/Team member names• Main themes of the session – including keylanguage used by family• Team observations – clearly labelled asimpressions• Record of interventions• Key points/ideas/decisions to follow up inlater sessions
  83. 83. Middle sessionsBasic Structure for a session• Pre-session• Session• Message• End session• Post session
  84. 84. Goals during middle sessions• beliefs and behaviors Develop and MonitorEngagement• Gather Information and Focus Discussion• Identify & Explore Beliefs• Work towards change at the level of• Return to Objectives and Goals of Therapy
  85. 85. Develop engagement• The therapist should pay particular attention todeveloping a co-constructed therapeuticrelationship. In addition to attending to the threeaspects of engagement from the initial meeting(supportive environment/hearing fromeveryone/neutrality), attention should be paid to:• Creating and offering choices about the process oftherapy• Resolving issues in the family-therapist-team systemas they arise. This will require therapists to allowsufficient time for team discussions pre and postsessions and time within sessions to discuss theprocess of therapy with families and any concernsor questions they have in relation to this.
  86. 86. Gather information & focusdiscussionThe therapist plays a role in developing this discussion todevelop themes and keep the discussion focused.Information may often focus on the following topics:• The presenting difficulties or issues: Therapists’should be collecting this information in a manner thatenables circular descriptions of behavior to develop• The family and wider system: The therapist will stillgather information about the family and wider systemas is necessary to understand the information andstories being presented by the family• Solutions & Successes: The focus on the successesand solutions available to the family should besteadily increasing throughout therapy
  87. 87. Identify & explore beliefs• The therapist should identify and explore thefamily’s thoughts, beliefs, myths or attitudes,which may be contributing to their dilemmasand difficulties• Circular questions which build up circulardescriptions of behavior can also be used toexplore the beliefs and assumptions which liebehind those behaviors
  88. 88. Identify & explore beliefsTherapists should explore the family’s beliefs in relation to:The presenting difficulties.• E.g. What ideas has your wife come up with to explain thebehavior John is showing?Relationships within the family and with the wider system.• E.g. Who feels it is most important to keep liaising with theschool over this issue?Solutions that have been tried or hypothesized• E.g. What gave you the confidence to keep going with thisnew idea?
  89. 89. Identify & explore beliefsSuccesses in all areas of family life and relationships tothe wider system• E.g. Would that be judged as a success in your family?Therapy process, beliefs about therapy• E.g. What led to your decision not to bring thechildren to today’s meeting?Family behavior during therapy• E.g. Jill is looking distressed, what do you think wasso upsetting for her in talking about the difficultiesyou are experiencing?
  90. 90. Work towards change at thelevel of beliefs and behavioursChallenge existing patterns and assumptions:• To move with the family to a position where theyare able to query their own beliefs, perceptions andfeelings• Th: How would your Nan explain the times whenyou and your mum do get on well together?• John: Well she says we are alright when we stopand listen, sometimes we can just bite off eachother’s heads you see, over nothing, when no-onehas really done anything wrong
  91. 91. Work towards change at thelevel of beliefs and behavioursProvide distance between the family and the problem:• Providing distance to try and free the family from the pressureof the difficulties, so that they are more able to consider andreflect upon them. Alternative perspective circular questionsand those aimed at looking at possible futures can often behelpful in achieving thisExternalize• That is to give the problem an external, objective realityoutside of the person. This can be useful in mobilizing thefamily’s resources to unite in working towards solutions and newways of thinking which challenge the difficulties.• Externalization means to put something outside of its originalborders, especially to put a human function outside of thehuman body. The opposite of externalization is internalization
  92. 92. Reframing – Virginia Satir• Reframing is altering the meaning or valueof something, by altering its context ordescription• Reframing is a powerful change stratagem.It changes our perceptions, and this maythen affect our actions. But does changingour symbolic representation of the realworld actually change anything in the realworld itself?
  93. 93. Reframing – Virginia Satir• A classic example of a reframe by Virginia Satirconcerns a father who complains at thestubbornness of his daughter.• There are situations where she will needstubbornness, to protect herself or achievesomething. Reframing switches to a context thatmakes the stubbornness relevant.• It is from the father himself that she has learnedto be stubborn. By forcing the father to equatehis own stubbornness with hers, this creates acontext in which he either has to recognize thevalue of her stubbornness, or deny the value ofhis own
  94. 94. Open up newstories/explanationsEither by facilitating the family’s evolution of new ideasand narratives, or by the introduction of these ideasby the therapist. All family members will havestories about their lives, the lives of other familymembers, and the life of the family. Exploration ofneglected information may open up the developmentof stories which are more helpful to the family incoping with their concerns. Information which isneglected often concerns:• Successes• Solutions• Exceptions• Alternative views from the network• Other strengths
  95. 95. Elicit solutions• It will be helpful to gather information fromthe family about solutions for the difficultiesthat they have tried or would consider useful• Ideas generated by them are usually mosthelpful and linear questions are often used todevelop an overview of solutions that thefamily have tried or thought of
  96. 96. • Amplify change: In order to maximize thechange or potential change that is occurringthroughout the course of therapy it will beimportant for the therapist to focus onstatements the family present about progress• Enhance mastery: To encourage the family togain a sense of mastery or control over theirsituation, their thoughts, feelings andbehaviors. This should enable the familymembers to take responsibility for their ownroles and actions, and for the process ofchange
  97. 97. Introduce therapist/team ideas• May include the therapist sharing their ideasand hypothesis about the family, individual,or difficulties, for a variety of reasons.Including:• Normalize difficulties• Move the family to new ideas• Connect family’s ideas• Suggest ways to organize the discussion,e.g. Enactments
  98. 98. Linear questioning• Direct linear questions can often be useful ingathering information from the system andclarifying information given, especially at thebeginning of therapyCircular QuestionsCircular questions are aimed at looking atdifference and therefore are a way ofintroducing new information into the system.They are effective at illuminating theinterconnectedness of the family sub-systemsand ideas
  99. 99. StatementsStatements are used by the therapist for 3 mainfunctions:• To clarify and acknowledge a communication fromthe family• To comment on the position or emotional state of amember of the family• To introduce therapist/team ideas, directly or inthe form of a reflecting team.• In using statements therapists should ensure thatthey are not of long duration, and do not becometherapist monologues
  100. 100. Positive connotation• From the Milan systemic group, a complex paradoxicalreframing technique which includes all family membersand the system itself• Each family members contribution to the problem isreframed as an effort to solve problems and help meetthe familys needs
  101. 101. Metaphor• A figure of speech in which a word or phrase thatordinarily designates one thing is used to designateanother, thus making an implicit comparison, as in “asea of troubles” or “All the worlds a stage”(Shakespeare)
  102. 102. Narrative description• Utilizing the interactional dynamics of familytherapy, people can deconstruct oppressiveand debilitating perspectives, replace themwith liberating and legitimizing stories, anddevelop a framework of meaning and direction
  103. 103. THE MIRACLE QUESTION SteveDe Shazer• "If you go to bed tonight and when you awake inthe morning a miracle has occurred overnight andeverything is going well in your marriage, then howwould you know (or indeed how would any on elseknow, like a relative or a friend?......Note: becauseyour are asleep you wont know that there hasbeen a miracle) ...what will be different?...Whatwill you see? What will you be hearing, doing,feeling? What are you going to notice if theproblem is no longer there, what is it that isdifferent about the situation that demonstrates toyou that the problems has been replaced bysolutions?....what else?....
  104. 104. Tasks• Noticing tasks• Between now and next time we meet, we would like you to observe, so that you can describe to us next time what happens in yourfamily that you want to continue to have happen (De Shazer andMolnar 1984)• Writing tasks• Counting tasks• Using a piece of string, count the ( to tie knots in) number of timethat you compliment someone in your family between now and thenext time we meet.• Playing tasks• Hugs without warning• E.G. Given to each participate secretly the job to give a familymember a hug without warning.• Turn taking tasks• E.G. Planning a family activity
  105. 105. • Naming the dilemma• Change pattern• Proscribe problem• Counter paradoxes:• Therapeutic double binds.• For example the family was warned against• premature change. The family feels moreacceptable and un-blamed for how• they are while at the same time challenged tochange.• The belief is that you can’t give a directprescription
  106. 106. Reported responses
  107. 107. Return to objectives and goalsof TherapyThe therapist should return to the issues of goals fortherapy as therapy progresses:• If goals seemed unclear during the initial stagesof therapy, it may take some time and thoughtwith the family for them to consider the areasthey want to change in therapy, or to findpriorities for change.• If goals are achieved, so that goals can berenegotiated, perhaps for change at a widersystem level, or a decision to move towardsthe end of therapy is made• If goals change due to changing circumstancesfor the family
  108. 108. Goals during end sessions• Gather Information and Focus Discussion• Continue to work towards change at the levelof behaviors and beliefs• Develop family understanding about behaviorsand beliefs• Secure Collaborative Decision re: Ending• Review the process of therapy
  109. 109. Gather information & focusdiscussion• The Presenting difficulties or issues• Solutions and Successes to date• The System / Wider system
  110. 110. Continue to work towards change atthe level of behaviour and beliefsIt is more common in end sessions for the focus to be onthe following methods:• Amplifying change: In order to maximize the change orpotential change that is occurring throughout the courseof therapy it will be important for the therapist to focuson statements the family present about progress• Enhancing mastery: To encourage the family to gain asense of mastery or control over their situation, theirthoughts, feelings and behaviors• Challenging existing patterns and assumptions: Tomove with the family to a position where they are ableto query their own beliefs, perceptions and feelings• Reframing: Reframe some of the constraining ideaspresented by the family. Relabelling in a positive way,ideas and descriptions given by family members, in amanner which is consistent with their realities
  111. 111. Developing new stories andexplanations• Successes & Solutions• Strengths• Exceptions• Alternative views from the network
  112. 112. Develop family understandingabout behaviours and beliefsAs therapy ends it will be important for thetherapist to work with the family to developand encourage their understanding of theprocess of the development of difficulties.Underlying family interactional patterns.• Motivations for assumptions, behaviors andfeelings.• Understanding of a family member’s reactionsto other’s behaviors
  113. 113. Collaborative ending decisionThe timing of ending is not always obvious and in aiming to makethe ending process a collaborative process the therapist andtherapy team should be alert to a number of signals in sessions:• Positive feedback from the family: the family situation or theissues they presented are reported as improved or improving• Negative feedback from the therapy: The family reportdissatisfaction about the therapy, or the progress they are making• Therapist notices changes: Missed sessions by the family.Changes in the level of engagement in therapy. Therapist noticespositive changes in the way the family are interacting duringsessions
  114. 114. The team should consider the following issues and thengather the family’s views on these:• Whether the family might feel it was appropriate to endtherapy, do they feel they have achieved what they setout to achieve?• How might the family prefer to end therapy, would theylike a follow up appointment or would they like to re-contact the team if necessary?• Might the family feel it would be important to engineersystems of support, before therapy ends?• With whom should the team share information about thetherapy and what has been achieved, e.g. referrer,school.• A useful and engaging way of saying goodbye to thefamily
  115. 115. Once this information has been shared decisions should bereached about:• When therapy will end.• What follow up arrangements will be made.• What the family might do if difficulties should ariseagain.• Who will be contacted post therapy
  116. 116. Review the process of therapy• It will be helpful for the therapist to invite thefamily to review the process of therapy.• What has been gained/lost for the familythrough therapy?• Any misunderstandings not addressed duringtherapy should be clarified and addressed.• Reasons for therapist’s behaviors andprocedures used.• What might the family do differently if futuredifficulties arise?