Advanced Methods in Counseling and Psychotherapy PART 1 Revised Feb 04 2018

WESTERN TIDEWATER COMMUNITY SERVICES BOARD
PART 1
Notes on the Philosophy and Practice of
Individual, Couple and Family Therapy
Demetrios Peratsakis, LPC, ACS
Revised February 04, 2018
Advanced Methods in
Counseling and
Psychotherapy©

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There is nothing more liberating than madness!
These Notes
The ideas contained herein have been instrumental in helping to guide my clinical work.
In particular, the material on symptom and symptom formation, while original, owes much of its
intellection to Adler, Bowen and Haley.
As a collection, these Notes were first copyrighted in 2012 and are subject to continual revision, which is
the reason for their preferred format.
I am grateful to Western Tidewater Community Services Board for providing the opportunity to revise
them and for helping to make them available to the public for the purpose of training and supervision.

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Table of Contents
1. Introduction and Acknowledgements
2. The Philosophy of Psychotherapy
3. The Treatment Process
4. Notes on Clinical Syndromes
5. Clinical Supervision
6. Handouts and Good Reads

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ACKNOWLEDGEMENTS AND DEDICATION
“There's no coming to consciousness without pain.”
- Carl G Jung
Psychotherapy is the practice of healing psychological injury and fostering personal growth and
adjustment to change. It relies on great familiarity with a broad variety of clinical techniques as well as a
sound understanding of the nature of human behavior. It is a very deliberate process that places enormous
responsibility on the clinician for challenging, as well as supporting, individuals in their struggle to
redefine themselves in a new way of being.
As with most crafts, one’s skill originates from the practice of more seasoned instructors. I wish to thank
Robert Sherman and Richard Belson without whom these notes, as well as my own abilities, would have
been greatly diminished.
Background
As substance abuse counselors in New York City during the 1970s a small group of us saw the need for
more advanced clinical training. At the time, we operated outpatient clinics under the supervision of
AAMFT Supervisor Neil Rothberg, Director of the ASPECTS Drug Counseling and Prevention Programs
for the borough of Queens. By early 1980, we had begun supervision under the auspices of Dr. Robert
(Bob) Sherman, AAMFT Clinical Supervisor, Author, co-founder of Adlerian Family Therapy, long-time
Fellow at the North American Society of Adlerian Psychology, and Chair of the Department of the
Marriage and Family Therapy Programs at Queens College, which he founded.
The next 12 years proved defining. Until his retirement in 1992, Robert supervised my training,
supervision, and adjunct faculty work at Queens College -teaching Diagnosis and Intervention in Couple
and Family Therapy, 784.1; and, Family Growth and Pathology, 784.5. He arranged small group sessions
with noted Adlerians Kurt Adler, MD (1980), Bernard H. Shulman, MD (1980), Harold Mosak (1980-
1981) and Larry Zuckerman (1982-1983) and a series of live-practice instruction with Family Therapy
greats Maurizio Andolfi (1981), Carlos Sluski, MD (1983), Murray Bowen, MD (1984), James Framo
(1985), Bunny Duhl (1986), Monica McGoldrick (1987), Carl Whitaker, MD (1988), Jay Haley (1989),
Salvador Minuchin, MD (1990 and 1991), and Peggy Papp (1992). From him, we learned about power
and intimacy and the importance of disengaging power-plays and redirecting their focus to a common
good. From him, we learned the art, as well as the science, of psychotherapy.

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In 1990, I began a more intensive course of study in structural-strategic therapy, attending a two-day
clinical with Patricia and Salvador Minuchin and enrolling in a two year apprenticeship with Dr. Richard
Belson, Director of the Family Therapy Institute of Long Island. Belson was on faculty with Jay Haley
and Cloe Madanes at the Family Therapy Institute of Washington, D.C (1980 to 1990), on the editorial
board of the Journal of Strategic and Systemic Therapies (1981 to 1993) and on faculty at the Adelphi
University School of Social Work. The practicum involved 30-session of live-supervision and strategic
family therapy with a team that met in a modified Greek-chorus arrangement. The format proved
instructive, employing such tactics as rituals and ordeals, paradox, tag-team therapy, the Gandhi
technique, and structured acts of contrition and reparation. To remedy corrosion wrought by treachery,
betrayal, and shame, and to then use atonement -the process of penance and redemption, was especially
profound and compelling.
On several levels this rather unique period of clinical growth was a gift. It defined me as a clinician,
supervisor and program administrator -most recently with PD19 (2000 to 2005) and Western Tidewater
community services boards (2005 to present). It better defined me as a person and deepened my sense of
spiritual purpose. Most especially, it added immeasurably to my appreciation of therapy and supervision
as formidable tools for transformation and transcendence.
Above all others, I am grateful to Robert Sherman for his guidance, wisdom and enduring friendship.
- Demetrios Peratsakis, MS, PD, LPC, ACS

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THE PHILOSOPHY AND PRACTICE
OF PSYCHOTHERAPY
On the Art of Seeing in Psychotherapy
“For a sorcerer, reality, or the world we all know, is only a description that has
been pounded into you from the moment you were born. The reality of our day-to-
day life, then, consists of an endless flow of perceptual interpretations which we
have learned to make in common. I am teaching you how to see as opposed to
merely looking, and stopping the world is the first step to seeing.”
- Carlos Castaneda, The Teachings of Don Juan
Chapter
1

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Orientation to Practice
The Center for Disease Control (CDC) and the National Institute of Mental Health (NIMH) estimate that
in any given year almost 25% of the adult public suffers from a serious, debilitating mental health
condition, 26% of whom suffer from chronic depression.
Given the scope of the problem, it’s fairly important that one acquire a solid theoretical footing as well as
experience in a broad array of clinical technique. This can be a challenge, for while there are several
hundred forms of therapy, there is no general consensus on the most basic precepts within our field, such
as what constitutes personality, drives motivation, or purposes social interaction.
My own preference is to subscribe to the philosophy of Alfred Adler. His core tenet on social interest, or
“Gemeinschaftsgefuhl”, seems intuitive and in keeping with social and evolutionary psychology; in
essence, that the main purpose of our existence, the very thing that gives purpose to life, is our continual
striving to better society and belong in a meaningful way with others.
_____________________ . _______________________
The beliefs expressed herein represent the more important principles and points of view that I have found
to be helpful over time. Ultimately, of course, the best instruction comes from the work itself and the
intimacy one is honored to develop with a stranger. This is, after all, is the reason that we are called to the
field, for there is no greater privilege than to share in the abject suffering of another and to find solace and
strength in their hope and striving for relief and redemption.

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1. General Theoretical Premises
Despite almost a thousand distinct forms of therapy, no single model of treatment has emerged as
sufficiently compelling to become the chosen model of care. There is scant agreement on how best to
understand human nature and the development of personality, what constitutes the origin of symptom
formation, why the role of the therapist differs markedly between theories, or how best to determine the
most appropriate course of treatment for a specific condition or injury. Consider such pervasive health
disorders as psychosis, addiction or depression; for each, we have no common ground on etiology, course
of illness, or method of treatment.
I find it helpful, therefore, to keep some basic tenets and truisms in mind:
ON HUMAN NATURE
1. WE ARE SOCIAL BEINGS
o This fact is central to our survival and inherently defines our human nature.
o As such, belongingness is the fundamental purpose of human nature. Problems are by-products of
social interaction; in this regard all problems are relational, as is their resolution or cure (Adler).
o Intimacy and the striving for meaningful purpose is at the core of all human interaction
o Conflict and cooperation are continuous by-products, with conflict resulting in tension when
unresolved. Often, they lead to power-struggles remedied through force or punishment or through
passive-aggressive acts such as failure, depression, or illness.
o Our needs are universal. “What we all need” -- courtesy of Mark Tyrrell:
- feel safe and secure day to day
- give and receive attention
- have a sense of some control and influence over events in life
- feel stretched and stimulated by life to avoid boredom
- have fun sometimes and feel life is enjoyable
- feel intimate with at least one other human being
- feel connected to and part of a wider community
- be able to have privacy and time to privately reflect
- have a sense of status, a recognizable and appreciated role in life
- have a sense of competence and achievement
- a sense of meaning about life and what we do
o Emotions are universal; the expression, extent and triggers may differ, but mood and feeling are
universal. This is the basis for compassion and love.

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2. BELIEVING IS SEEING
There is an old idiom which states that “Believing is seeing”. In truth, the opposite has more bearing, that
“Seeing is believing”; we interpret events and then feel and act accordingly, continuously reaffirming our
self-concept and our convictions about others and the world around us.
 Action is a combination of behavior, emotion and will. It is not random but purposive, consistent
with and representative of the inner goals and beliefs of the individual. In this regard, we can view
each action as a representative snap-shot or microcosm of the individual’s world-view, the context
within which the individual defines their interaction with others and their beingness in the world. In
great part, this is why the search for the root of a compliant is unnecessary; everything of importance
will eventually emerge in session if the therapist pushes for change.
 Behaviors and emotions create responses in others, which, in turn reaffirm the individual’s
subjective experience of self in social interactions. This feedback loop maintains a continuum to
perception, thereby preserving consistency of the manner in which one operates within the world. In
a fundamental way, one behaves in a manner that elicits responses in others which reaffirm one’s
beliefs about their beingness and subjective experience of the world.
 While behavior and emotion is driven by belief, insight is not always a sufficient or necessary
prerequisite for change. One may act differently and evidence change in their belief system even if
they do not understand the purpose of the action or its intent. Arguably, insight is beneficial as it
encourages change to remain anchored as well as to become more generalized in its effect:
o When one thinks differently, one behaves differently
o When one behaves differently, one thinks differently
 The session is the primary venue for experimentation and the practice of new ways of thinking,
feeling and behaving. It is a medium by which to experience trust, intimacy and acceptance.
 Casework supervision is the most instructive venue for clinical training. It provides actual situations
around which to discuss clinical premise and methods in practice. Is a transformational process that
involves the Supervisor, Counselor and Client in a change relationship similar to the therapy
process: it encourages insight and self-introspection; problem identification, prioritization and
solution determination; the confrontation of one’s own convictions and prejudices; and the
opportunity to assume personal risk in exchange for self-discovery and maturational growth.
 Lastly, a word about theory. In order to become expert as a clinician, one needs to operate from a
theoretical framework. While counseling can still be effective without it, there remains a need for a
more comprehensive foundation if one is to fully understanding 1) the development of personality;
2) the origination and role of symptoms; 3) the change process and what constitutes personal and
social growth; and 4) a means for evaluating the progress of treatment as well as for predicting the
impediments to change.
 The golden maxim for advanced clinical work is simply, “Know Thy Theory, Know Thy Client, and
Know Thy Self”.

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3. CHANGE IS PERMANENT
Change is a continuous characteristic of life. Adaptation to change is therefore a necessary condition, a
requirement for survival placed on the individual, their family, and on the greater social group. Given
that, it is how the individuals adapts to change that determines whether they, or others within their circle,
will incur what is regarded as a problem. In this regard, all problems are difficulties with adapting to
change, normative or cataclysmic.
The simple rule is that how one adapts to change determines whether they, or those around them, will
experience that which we regard as problems (Haley). Clients desire relief from the necessities of change.
 Life is a series of progressive, developmental stages called the Family Life Cycle, with defined tasks
and challenges accompanying each new phase of life. These are the necessary functions of change
and the growth inherent in becoming human and belonging to a community with others.
 Today’s solution is often tomorrow’s problem. The reason for this is that instead of tackling the more
arduous or painful parts of change, there is tendency to rely on stop-gap measures. These may offer
temporary relief but often fail to reconcile the cause of the distress.
 Long-term reliance on inadequate solutions typically results in the creation of new problems or an
exacerbation of the original need for change. Rigidity and problem-avoidance lessen the potential for
innovation and change. In this regard, chronic problems may be nothing more than the continual
reapplication of insolvent solutions to change.
 Inadequate solutions will in fact over time be labeled as symptoms and dysfunctions. They are, in
fact, safeguarding mechanisms developed by individuals and families in response to chronic distress.
They may aid in the process of coping and adaptation and therefore serve as a method of stabilization
or healing.
 Structures, which define most of our social interactions, help reduce conflict and increase
cooperation. Structures are critical to innovation and growth and include such social constructs as
roles and rules, legacies and myths, family subsystems, and patterns of interaction.
 Presenting Problems are, in essence, caused by unresolved conflict or trauma. The most pervasive and
insidious trauma is betrayal of the trust in an intimate relationship. Trauma creates sadness, fear, and
anger, quickly leads to guilt and shame and when unresolved results in anxiety, depression and rage.
This is why it so essential to identify and reconcile the anger or revenge component of a syndrome
and its target.
 The role of the therapist is active and dynamic, working in the here-and-now to create opportunities to
practice new ways of being, and thereby to engender change. Most work should occur in session
under the direct supervision of the therapist. Balancing safety while encouraging risk is an important
product of the therapy session. Described in greater detail later, the simple assumption here is that if
the individual could effectively contend with risk outside of treatment, there would be little value
undertaking its review in therapy.

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"Toward what purpose, function or goal is the behavior targeted?"
"Who is the target of the behavior, symptom or condition?”
“What happens when the behavior is expressed? Who does what?”
“If this problem wasn’t the problem, what (or who) would the problem be?”
4. PURPOSIVENESS
Action is not random; it is goal-directed and consistent with one’s beliefs and world-view. This is not
simply a matter of the outcome of a sequence of behaviors or actions, but of all sequences. This premise,
from Alfred Adler, adds immeasurable strength to one’s clinical insight.
 The primary goal of all human behavior is social belonging; to be valued and accepted as part of the
community while maintaining significance and a unique sense of self. Each of us holds beliefs about
how best to do this, how best to belong and function with others. We interpret all action against these
beliefs, or schema, interpreting the world and our place in it. This is our world-view; moreover
o We face the common challenge of maintaining self-esteem as we strive for social belonging,
navigating between our fear of injury by others and hope for acceptance, love and redemption.
o Our actions represent a constant striving for self-actualization, from a perceived sense of minus
(-) towards a perceived sense of the more positive (+) (Adler)
o Our own behavior shapes the thoughts and feelings of others, who behave in a manner that
reaffirms our own (worldview re-affirmation). In part, we create the reactions in others that drive
our interpretations in order to reaffirm our beliefs. One’s world-view imbues their outlook on the
world and drives their interpretations: “meanings are not determined by situations, but we
determine ourselves by the meanings we give to situations” –Alfred Adler.
o As a simple assessment of their world-view ask the client to describe the following:
 How I view the world?
 How I view myself?
 How I view men?
 How I view women?
 How I view sex? and
 How I view marriage or a committed partnership?
o As a simple assessment tool
Ask yourself: “Who else is involved (living or dead) and how?”
Ask yourself: “If this was not the problem, who or what would be?”

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5. POWER: THE ROOT OF CONFLICT AND COOPERATION
Power is the expression of our will, of our intent. It is, in effect, our ability to influence outcome and is at
the core of every human interaction.
 Social interaction continuously creates conflict, as individuals strive to influence events and
circumstances to their advantage. Interests and desires are reconciled so immediately as to go
unnoticed by the members except in those instances where an apparent disagreement arises. While the
benefits of cooperation are intuitive, those of conflict may be less apparent; conflict creates change:
o Conflict excites and encourages people to grow
o Conflict fosters an awareness that problems exist
o Reconciling conflicting views can lead to better solutions
o Managing conflict is quicker and more efficient than letting conflicts fester
o Challenging old assumptions can lead to changes in outdated practices and processes
o Conflict requires creativity to find the best outcomes
o Conflict raises awareness of what is important to individuals
o Managing conflicts appropriately helps build self-esteem and maturity
 Most often, a problem is the result of a power-play, real or symbolic, between the individual and
some intimate others, the individual and society, or the individual and themselves.
 The misuse of power may be expressed overtly in acts of violence, such as rape, domestic abuse, or
bullying, or through betrayal, in such actions as sabotage, incest and infidelity. It may also be
expressed covertly, in such passive-aggressive acts as suicide, depression, failure, illness or
inadequacy. While we normally consider these to be conditions that befall an individual, we will see
later how creative and telling the use of these conditions may be in controlling others and asserting
one’s will. Power, is expressed overtly as well as covertly; in fact, while diabolical the covert use of
power can be exceedingly successful, often influencing outcome while avoiding responsibility for the
change. This perspective, mainly from Adler, attaches an extremely powerful motive to behavior and
patterns that may appear weak and ineffectual, yet are insidious in their control and influence.
 Emotional pain results from severe, interpersonal conflict or trauma, either from loss, tragedy or
betrayal of the trust of an intimate relationship. The resulting psychological injury expresses as
depression and anxiety and is fueled by guilt, anger and shame (GASh)
 The role of psychotherapy is to disengage and redirect the underlying power-play to cooperation and
collaboration in a manner that wins for the individuals involved.

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6. PSYCHOLOGICAL INJURY AND THE DEVELOPMENT OF SYMPTOMS
Anxiety --and its many expressions of fear, including dread, panic, worry, hesitation, and, Depression,
along with its various states of sadness, such as remorse, grief, despair, and despondency, are affective
conditions fueled by guilt and shame. Because guilt and shame are rooted in the opinion of others, a
corresponding sense of anger and resentment occurs at the perceived injustice or critique; Guilt, Anger
and Shame (GASh) corkscrew into a repetitive cycle called rumination. This may deepen into
unexpressed rage, manifested as depression or anxiety --chronic or pervasive sorrow or distress.
 The root cause of emotional pain is the hurt caused by various forms of trauma, which I categorize
as falling into one of three forms: tragedy, loss and betrayal. Unresolved, the ensuing damage, or
psychological injury, is a degree of harm to one’s self-concept and self-esteem -- one’s sense of self
in relation to others and to their feelings of trust, intimacy and power. This reduces one’s sense of
self-worth, their estimated value with others. Psychological injury is harm to one’s sense of worth
and value as compared by the individual or as weighed by others.
 The resulting depression and anxiety is fueled by continual thoughts and feelings of Guilt, Anger and
Shame (GASh). Guilt and Shame originate from one’s estimation of wrongness within the moral
code, while Anger originates from one’s sense of betrayal at society, at others, for an unjust
appraisal. Secondary Symptoms evolve as protective mechanisms, which in turn can create
unresolved problems and stifle adaptive growth. Symptoms may develop as a means to gain or re-
gain control, to stabilize and reorganize the individual and their relationships. As such, symptoms
accumulate meaning and power with the ability to influence outcome. Over time, the behaviors may
concretize into established transactional patterns or habits (symptoms) that become rigid and
resistant to change.
 As psychotherapists, we are concerned when these become problematic and serve as a means of
controlling, perhaps even punishing others, or as a method, often socially acceptable, of excusing or
avoiding responsibility for change. Most social misbehavior is an act of punishment or revenge
against others or else a means of mitigating or avoiding responsibility –an excuse for blaming the
depression, drink or illness. Responsibility carries the burden of accountability to others, and along
with it, the possibility of failure. When one is depressed or alcoholic, they control their own failure
and thereby retain power.
 Demarcating trauma into one of its three broad kinds assists the therapist in determining the area of
healing necessary: Tragedy, Loss, or Betrayal.
o Tragedy results in a sense of great vulnerability, fear and need for safety; one becomes
preoccupied with avoidance.
o Loss results in a sense of pervasive emptiness and a sense of grief; there is a great
preoccupation with filling the void, of replacement, of filling the hollowness one experiences.

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o Betrayal of an intimate relationship is extremely devastating, resulting in overwhelming
feelings of anger and rage and a desire for revenge. Power-plays occur where the overt
expression of rage has been thwarted.
7. PSYCHOLOGICAL SYMPTOMS AND THEIR PURPOSE
While a strong understanding of symptom origination might seem to be the cornerstone of our work, there
exists little agreement on what constitutes a symptom, what sustains it and how best to resolve it in
accordance with some model or framework. A myriad of first line questions confronts the clinician: Is the
behavior not controllable or a “Can but won’t”? When do every day problems become a dysfunction?
When symptoms are debilitating, does one treat the symptoms or the underlying concern? Why do
conditions express in certain symptoms, at certain times and within certain individuals?
It order to effectively gauge and reconcile these concerns one must adhere to a particular frame of
reference, an explicit theory of human behavior and model of clinical methods and practice. Moreover, to
be reliable a theory -or philosophical premise, must explain the development of personality and the nature
of symptoms within the context of social interaction; the explanation must show how behavior furthers
adaptation, is essential to survival or of benefit to the human species (evolutionary psychology).

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ADDITIONAL EXCERPTS ON PURPOSE, SYMPTOM FORMATION AND THERAPY:
Purpose and Will
In 1920, Alfred Adler postulated that our thoughts and behaviors are unified toward a specific goal, a
central schema around which all action within one’s world is interpreted: “We cannot think, feel, will or
act without the perception of some goal”; and, “Every psychic phenomenon, if it is to give us any
understanding of a person, can only be grasped and understood if regarded as a preparation for some
goal”. That a defined set of guiding beliefs imbues every action, feeling and expression has profound, far
reaching implications for psychotherapy. It suggests that power, the manifestation of will, is aimed
toward some unified outcome and that it underlies each and every one of our interactions. In essence, that
power is targeted toward operating in the world in a manner that is consistent and predictable in its
meaning.
Adler went further and posited that psychological symptoms, the unwanted vestiges of depression,
anxiety and pain, were purposive as well. According to the Adlerian, Dreikers, “The purpose of a
symptom is to safeguard against the danger of discovering one’s own lack of value.” (Foundations of
Adlerian Psychology, page 6). That psychological symptom may serve a purpose in the overall
functioning of the individual and his social system, seems greatly counter to our customary belief. This is
important. Wrongly so, we tend to think of psychological symptoms as the result of something that has
happened to us. That something has befallen us, the psychological symptom being the expression of
some underlying condition, trauma or illness -a concept borrowed from the biomedical tradition. The
analogy often cited is that of fever expressed as a “symptom” of some underlying infection, illness or
disease. This is a serious misconception.
This alternative interpretation holds strong implications for our understanding of pain and psychological
injury. Consider the process: when one experiences emotional pain, they feel angry, sad and afraid. If
unresolved, the injury results in the conditions we call depression (sadness/rage) and anxiety (fear/rage);
feelings that are continually fueled by thoughts of guilt and remorse accompanied by resentment and
anger. Depending on the extent of the injury, the experience is rage, which will be expressed overtly or
covertly, often in socially acceptable symptoms or conditions. By closely examining the result or purpose
of the symptom, its depression or anxiety, one can readily determine the expression of will and its
intended target or goal. Since how one belongs with others is at the heart of all social interaction, the goal
will always be consistent with the individual’s belief system and how they view themselves in relation to
others.
Symptom as Purpose
Adler reasoned that all behavior, as well as its emotional counterpart, was purposive, that the individual
continually reaffirmed their worldview and the manner in which they interact with others. Given his belief
that problems are a product of social relationships, symptoms operated in some manner connected to
others, some function specific and germane to social interaction. The idea that a symptom might serve a

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purpose in the relationship system was rather radical until the advent of cybernetics and family systems
therapy. It implied that the set of behavior had an intended outcome in reaction, to others. Adler expanded
greatly on his original belief which gave rise to a new interpretation of symptoms as by-products of power
and conflict that went unresolved. This idea first was proposed under his thesis of the Goals of
Misbehavior, whereby he categorized progressive discouragement in children as being expressed as one
of four kinds of misbehavior: attention seeking, power, revenge and inadequacy. The portrayal of
symptomatic behavior as either overt or covert expressions of aggression was groundbreaking in its
approach and brilliance. His work, along with the writings of his son, Kurt, and other noted Adlerians,
including Harold Mosak, the Ansbachers, the Dinkmeyers, and Sherman, postulated that even such
conditions as depression, anxiety, gambling, addiction and suicidality could be, in fact, aggressive acts of
revenge aimed at over-powering others through a modified form of rage. While this may not seem readily
apparent, a close examination of how the behavior impacts significant others provides invaluable insight
as to the potential purpose and target of such acts.
With the advent of family therapy, the idea that a symptom might have meaning and purpose within the
larger family system appeared more intuitively sound. This rendered the traditional perspective on
symptoms and their conditions open for reconsideration. The idea that depression could be a by-product
of the relationship and possibly support some interactional function echoed Alder’s beliefs that symptoms
were purposive within the social context. It is rather that our popular notion on symptoms, as some
external manifestation of an internal state, like fever is to infection, is a serious and dangerous
misconception. It broadly pervades our field giving rise to the mistaken belief that treating the symptom is
akin to treating its cause. Recidivism, is compelling evidence that symptom management, even with such
powerful tools as medication or behavior modification, is insufficient for more lasting change. There is
an added problem to the intrapsychic perspective; it negates the social milieu as the defining characteristic
of one’s psychology. Simply stated, human emotion has evolved as a form of social communication and
is, therefore, inextricably bound in human interaction. Psychological symptoms are, therefore,
interpersonal creations that require interpersonal, relational solutions to arrest their expression. Perhaps
the most elegant of the family systems perspectives was offered by Bowen, who stated that “when anxiety
increases and remains chronic for a certain period, the organism develops tension, within itself or in the
relationship system; the tension may result in physiological symptoms, emotional dysfunction, social
illness or social misbehavior.” According to Bowen, chronic distress would express as physiogenic and
psychological symptoms within our intimate relationships, those with our parents or caregivers, our
partners, or in one or more of our children.
Ultimately, as psychotherapists, our main attention is drawn to the functional value acquired by the
symptom, rather than its origin. How symptoms originate as a form of communication around which
membership is organized is of the utmost interest. We evidence that the interactional patterns harden over
time and acquire history with well-defined roles and rules and expectations; in essence, a structure around
which membership is organized, boundaries are defined and power reconciled. In particular, it fulfills the
mutual purposes of its participants, providing a vehicle for communication and attachment and the open

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expression of love, trust and responsibility. This accounts for its broad prevalence in all societies and
cultures and its persistence as an entity with social value
Symptom as Avoidance
I was first introduced to Kurt Adler, MD and Bernard H. Schulman, MD by Robert Sherman in 1980
during a small group seminar presentation by Harold Mosak. This rather unique experience took place at
the temporary headquarters of the North American Society of Adlerian Psychology on 37 West 65th
Street in New York City. The exchange provided great insight into how symptomatic behavior and
complex syndromes, including depression and anxiety, could assist in the avoidance of responsibility for
the personal and social tasks of life. This was an entirely radical perspective that greatly changed my view
of behavior and the expression of will.
It is the supposition that a symptom could serve as a pretext for avoiding responsibility. That while
responsibility harbors the potential for success, it also ensures the possibility of failure. Misbehavior,
social illness or inadequacy may appear to foretell failure, but while the individual expresses the
symptom, they remain in control. Moreover, the position may be of great power, as the will and efforts of
others are thwarted and proven incapable of ending the struggle. When one examines the centrality of
symptomatic behavior one recognizes its underlying association with power and power-struggles. The
dysfunction provides some foci around which the family may organize, preserves the their emotional
fusion, reaffirms their respective roles, and by impugning the symptom bearer avoid responsibility for
change and blame. As one of the founding theorists in family therapy, Adler went on to conclude that
avoidance might provide protection for each of those participating in the interactional pattern. That such
symptoms may be shared, with participants joined in a repetitive cycle of reinforcing behavior, implies
that its members may also share in the benefits of the specific avoidance. In essence, family and social
behavior surrounding long-term, patterned dysfunction could prove useful as symbiotic symptoms for the
mutual avoidance of responsibility to change.
Symbiotic Avoidance
Symptom reaffirmation occurs as the behavior and emotion have meaning consistent with the individual’s
world-view; it is fashioned by the family of origin, and reaffirmed by the activities of childhood and
adulthood with others:
1. We define ourselves in relation to others and in regard to how we can belong in a meaningful way
2. We define functions and participate in roles that reaffirm our definitions, including rules of social
engagement, boundaries, power, and so on
3. Symptoms serve one’s overall purpose and personality, they are a by-product of social
relationships and assist us in our belongingness with other
4. Symptoms are safe-guarding mechanisms that may also enable us to avoid responsibility

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5. The symptom acquires meaning and power –in essence history and permanence, as others
participate more actively in it. This allows them to avoid responsibility, as well
6. The more symbiotic the avoidance, the more rigid and reluctant the system will be to change.
Everyone fights to preserve the status-quo.

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GENERAL PERSPECTIVES ON THERAPY AS A PROCESS OF CHANGE
 Psychotherapy is the highly deliberate art of manipulating experience.
 The difference between counseling and psychotherapy is the degree to which the therapist is
willing to accept personal responsibility for change
 A problem is the result of a power-play, real or symbolic, between the individual and others, the
individual and society, the individual and themselves. The role of psychotherapy is to disengage
and redirect the power-play
 Clients come for therapy not because they desires change, but because they failed to
accommodate to change
 Session must be a continuous opportunity to practice new ways of thinking, behaving and feeling;
a new way of being. If they could do it out there, they wouldn’t need to discuss it in here
 Expect to “kill” your first fifty clients (Robert Sherman/Harold Mosak)
 Never work harder in therapy than your client does
 Nothing impedes therapy more than a therapist’s own fears
 Believe what one does and does not do, not what one says; match behavior with belief, belief
with behavior, and both with intent
 Never parent children unless you are planning to adopt them
 You can be a therapeutic friend or a friendly therapist, never both
 Never do more than is necessary
 Therapy is failure prone; never let a client tie your hands
 Never ask for permission unless you are willing to accept a “No”
 Never accept secrets
 To be authentic, a therapist must be willing to accept the stark ugliness of another’s acts or
desires
 Make the covert, overt
 Sit within arm’s reach of the client

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 Measure success by how far one has come
 Make the covert, overt
 How therapy ends is more important than how it begins
 If one is not actively discouraging, one is passively encouraging
 Every client is a forced referral
 To change the symptom, challenge its power; to challenge its power, change its reality
 Some clients are vampires and some therapist-slayers; they endeavor to prove their superiority by
vexing the therapist
 The Ideal is unreal
 Therapy provides the opportunity to discover the price to be paid for change
 Change in any part, will induce change in the whole
 Betrayal demands revenge
 Suicide and depression are extremely powerful forms of revenge
 Never interrupt when work is being done; always interrupt, when work is not being done
 The client’s behavior is intended to distract from feeling their pain; challenge the distracting
behaviors and the pain will emerge for healing.
 True intimacy provides a mirror onto one’s self; this is why all who feel worthless fear it
 The power of the therapist is embedded in the deliberateness with which they accept or do not accept
the client’s response to a directive or task before proceeding
 When all else fails
a. prescribe the symptom
b. invite a consultant or co-therapist to session
c. add or subtract a member to session
d. convert the client to a therapist
e. pronounce the client cured
 The best clinicians are willing to immerse themselves in the pain, rage, or insanity of another

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GENERAL PERSPECTIVES ON THE THERAPIST AS AN AGENT OF CHANGE
“Psychoanalysis is in essence a cure through love” -Sigmund Freud (1906)
“ …if the therapist doesn’t change, then the patient doesn’t, either” -Carl Jung
People are extremely resourceful, resilient and self-correcting, typically requiring no professional help for
the myriad of challenges and problems that arise in life. While counseling may provide immeasurable
support, it is poorly understood as a process and medium for change.
 What constitutes normalcy, dysfunction and cure? To what extent are their definitions dependent
upon custom, consensus or norms? When is treatment complete?
 Why do problems or symptoms take particular forms? Why do they strike certain individuals
within a family or group and not others? Why do they express at certain times and not a month or
a year earlier or later? Are symptoms intergenerational?
 Does the format, including frequency and length of sessions, duration of treatment, and variation
in the schedule of meeting times, impact treatment outcome and, if so, how?
 Given the variety of theoretical formats is any more beneficial for certain conditions or
syndromes? Since each can be effective, what common elements are essential? How has
medication management and cultural trends affected overall interest in care?
Despite its commonplaceness, counseling is prone to failure adding to the challenges that confront the
clinician. To maximize the opportunity for success the therapist must be exceedingly well trained
 They must possess a good working contextual framework for understanding human behavior
(theory)
 They must be knowledgeable in clinical syndromes, how they develop and the role that symptoms
play within the individual’s sense of self and their relationship systems
 They must understand that although our prejudice is to view the individual as the loci of problems,
that as social beings whose problems are by-products of our relationship systems, we must
continually identify and call attention to the relational components that create and maintain them.
 They must be knowledgeable in matters related to mood and emotion, including anger, sadness,
guilt, fear and hurt me and their corresponding manifestations such as violence, depression, shame,
anxiety and revenge

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 They must have mastery over simple as well as advanced psychotherapeutic techniques and
understand the interplay between assessment, intervention, and change
 They must have insight into their own problems, values, and beliefs and how this benefits and
detracts from the therapeutic milieu
 They must have insight into the stigmas and morays surrounding complex social conditions such
as addiction, homosexuality, single-parenthood and extra-marital affairs
 They must understand how common misconceptions about cognitive ability or intelligence, even
among treating professionals, can effect treatment and service options
 They must understand the major disability categories, including intellectual and developmental
disabilities, mental health and substance use disorders for children as well as adults
Having responsibility for the process, the therapist must understand their role in creating and controlling
the opportunity for change.
Therapy allows for the continuous possibility of a genuine, human-to-human encounter. As the counselor
develops greater “therapeutic relational competence” (Watchel, 2008), their power as an agent for change
matures and grows. In this manner, both therapist and client grow through authentic encounter with each
other (Connell et al.,1999; Napiers & Whitaker, 1978):
 Be authentic and fully accept and care for the person, not despite their foibles and imperfections,
but because of them.
 Find compassion for the vileness of another’s thoughts, actions or past and discover “What is not
so terrible about them?”
 Fully embrace that the outcome of therapy is your responsibility and that clients do not fail but are
failed by therapy.
 Make session a safe haven in which to practice new ways of thinking, feeling and interacting. Do
so by your own willingness to experiment, be in the moment, and experience risk.
 Whenever possible, pull clients into your own energy, optimism and sense of hope.
 Self-disclose; it is “an absolutely essential ingredient in psychotherapy – no client profits without
revelation” (Yalom).
 Don’t push and the client won’t improve; push too hard and the client will leave. Push, apologize,
then push some more.

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 Freely step into the abject terror of another’s pain, knowing that for at least those few moments
they are no longer alone.
 Push for the outpouring of shame, sadness or rage, despite your own primal fear of losing control
or being consumed.
The therapist
o is active and personable in session, seeing the primary task as one to educate the client(s)
about the benefits and dangers of change, while providing them the opportunity to do so
o is responsible for the outcome of the treatment, including if it fails and insight and change do
not occur
o controls therapy by their own behavior, by what they accept and do not accept
o gives directives, prescribes rituals and orders tasks within session and for homework
o manipulates mood; escalating and diffusing distress, joy, sadness and rage
o manipulates space and time and interrupts behavior cycles, sequences and other patterns
o challenges, blocks, re-directs and reframes communications
o sits within arm’s reach of the client, moves people, and re-partners members in collusions,
alliances and triangles
o ascribes overt meaning to covert intent
o believes what is done or not done, not what is said
o regards behavior and emotion as purposive and moves to match behavior with belief, belief
with behavior, and both with intent
o never rescues, allowing the client(s) to act due to duress
o never asks for permission, never accepts “secrets”, never parents (gets parents to parent)
o understands that how therapy ends is more important than how it begins
o understands that if one is not actively discouraging, one is passively encouraging
o understands that every referral is a forced referral
o understands reluctance (“nothing venture, nothing lost”) and that the therapeutic process is a
dynamic struggle for change and sameness

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o understands that clients have a right (at times an obligation) to leave, to not change, or to die
o understands that treatment structure is arbitrary and that one can and should redefine the
duration, length, place and frequency of therapy
o crafts the session as an arena to practice new ways of thinking and behaving
o accepts that the treatment process is isomorphic and transforming and is willing to be subject
to change and growth as well
o never (ever) works harder than the client(s)
o never (ever) moves ahead until the directive or work assignment is done; and
o never (ever) interrupts the opportunity for change

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Common Therapist Follies
Irrespective of one’s level of experience, I find that certain convictions fundamentally impede the ability
to work in the here-and-now. This, in itself, greatly diminishes the clinician’s ability to be spontaneous
and to go wherever the line of inquiry leads, to practice without the limits of self-imposed presumptions.
1. More is Better: the need for more information before acting.
2. Fixing Yesterday: that one must reconcile the past, in order to unravel the present.
3. Digging for Gold aka The Prospector Syndrome: the need to keep digging in the hope that
some nugget of gold will be found that will make sense of the entire puzzle.
4. DSM-ing (aka Don’t See Me): the obsession with labeling and boxing behavior up in immutable
categories. This one is particularly insidious as it robs the clinician of a more intimate experience
of the client and fosters the mistaken belief that behavior can be described outside of its context.
An article in the International Journal of Clinical and Health Psychology (2014) 14, 208-215, by
Sami Timimi, makes the point well: “…psychiatric diagnoses are not valid or useful. The use of
psychiatric diagnosis increases stigma, does not aid treatment decisions, is associated with
worsening long-term prognosis for mental health problems, and imposes Western beliefs about
mental distress on other cultures….”
5. OK to KO: If I press them, I’ll impress them. Shoving clinical insight at patients in the hope that
they will own it and be impressed by one’s cleverness.
6. The Problem is Unwanted. Often, while the problem may be horrific it may be more desirable
than its alternative.
7. Less is More: the tendency to rationalize the exclusion of important members from therapy.
Working in the here-and-now is based on the belief that the client's interpersonal issues will
eventually emerge in therapy; in their view of themselves, of others, of the world and of the demands
placed upon them. Moreover, it specifically recognizes that transference/countertransference -or the
manner of interacting with significant others, will disclose itself in the relationship with the therapist
and be open to direct manipulation.
To work in the here-and-now requires that one be fully engaged or “listening with the third ear”, a
method of active listening and active reflection. By listening for the feeling tone, one can directly
explore that client’s pain as well as the underlying convictions they have created to protect
themselves from harm. If one believes, as I do, that we each desire and actively seek solace and
support, love and the opportunity to be genuinely intimate and trusting with others, we can better
understand the means by which one shields themselves from hurt, to safe-guard themselves from
others and from their own fears of inadequacy and lack of worth.

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Tid-bits on Therapy
Harold Mosak, a great theoretical Adlerian and master tactician, wrote extensively on Life-style and
practical matters for clinical practice.
Mosak’s Rules of Therapy (circa 1981)
1. You will survive!
2. Your patient will probably survive, too!
3. Know your patient
4. No tactic is a panacea
5. Keep moving, stay in motion
6. You must know your theory
7. Never play the patient’s game
8. Develop your own style
Peratsakis’ advice to Fred S. before his first family therapy session (circa Fall Semester 2017)
1. Try not to embarrass yourself
2. If you do, don’t’ tell anybody you know me
3. All kidding aside, if you make it through your first session without throwing up on anyone, you’re
doing pretty good
4. When it ends ask yourself: “Was that worse than I thought it would be?”
If I Had to Pick My Top Three?
1. Accept full responsibility for change, including if change does not occur
2. Never proceed until the client has completed the task or met the terms of the therapist
3. View everything as relational and get others, living or dead, into session

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THE TREATMENT PROCESS
While many theories have been proposed regarding human nature and the treatment of problems that arise
in the course of one’s lifetime, the main tasks of adulthood were first identified by Adler and expanded on
by Dreikurs and Mosak (1987): Friendship, Occupation, Love, Self, and Spirituality. Maslow’s Hierarchy
of Needs is also an excellent paradigm for examining the developmental transitions of life: Physiological,
Safety, Belongingness, Love, Esteem, Self-actualization, and Self-transcendence.
Existentialism and existential therapy posits four critical ‘angsts’ as drivers of our search for meaning
which undoubtedly must be considered as part of our motivations, including death, freedom and its
attendant responsibility, existential isolation, and finally meaninglessness. It is for this reasons that I
prefer Adlerian Family Therapy’s basic premise, that meaning is created by one’s fellowship with others
and the purpose of life is to belong and improve the condition of others (social interest). While there may
be no meaning to life, itself, beyond promulgation of the species, belonging in a significant way with
others is the driving purpose of everyone’s life.
Chapter
2

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Assessment Principles
1. First Impressions
Whether by phone or in-person, one’s initial reaction to the client can be telling. What is their persona,
what picture of themselves do they portray to the world and which parts of that are consistent and
enduring? What’s your immediate reaction and how do they make you feel as you meet with them? While
prejudicial, our first-line assessment typically originates with how one presents to us, as this is often
emblematic of how others see them and, often, how they intend to be experienced by others. If so, what is
the message they are conveying about their current situation and about themselves; why do you wish for
me to see and experience you in this way?
2. Presenting Problem and its History
Problems and symptoms are manifestations of an inherent dysfunction or rigid pattern of interacting and
serve as a metaphor for the change that is required. They are purposive as stop-gap measures that preserve
a level of safety between the imperative to change and the desire to remain the same.
Exploring the history of the Presenting Problem is therefore critical to understanding the problematic
sequence and pattern of behaviors that maintain it.
Careful review the Presenting Problem (PP) or chief complaint (separate than the “reason for the
referral”) to determine
a. Nodal events at the time of its onset or exacerbation;
b. Sequence of interactions that uphold the problem;
c. Persons involved in problem or its attempted resolution;
d. PP Outcome: guesses about the pluses and the minus that result as a consequence of the PP or
behaviors of the IP (Identified Patient)
If the reason for the initial referral differs markedly from the PP, especially if it appears that the referral
was made at the behest of others, this should be carefully questioned (challenged) as it could readily
speak to motivation for treatment. By tracking who is involved with the presenting problem, especially
with attempts to manage it within the family, one is often clued into the underlying target or intent of the
behaviors. As noted elsewhere in these notes, it’s an interesting set of questions that one should apply to
better understanding the symptomatic complaint and its potential meaning and function for the individual
and those intimate to them: Why this particular problem? Why now? Why has the problem expressed in
this member of the family and not another? Does it mask some other problem or set of problems, such as
possibly couple discord, difficulty with separation from the family, intimacy, or the expression of anger
and hurt?

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3. Power
 Influence and control within the relationship system
 Determines style of communication and decision-making (how love, caring, anger, and so on is
expressed and understood)
 Defines level of trust for meeting and not meeting personal and group needs
 Establishes rules for interdependence and independence, for closeness and distance between
members, for who participates and joins
Examine the decision-making, problem-solving and conflict resolution pattern of the client(s). It’s silly to
think of these as skills, as this denotes an ability that some have, and some may not, or that the presenting
problem somehow exists because of the client’s inability to self-remedy. People are very self-correcting
and resolve a myriad of problems throughout the day. In this regard, the Presenting Problem is actually a)
the result of a stalemate (power-play) within the family relationships or b) a behavior pattern that the
individual employs to avoid responsibility and reaffirm their belief about how best to operate in the world
with others. This second possibility, keeping in mind that both may be true, is a power-play, as well,
although much more deceptive. It is a power-struggle between the individual and the set of morals or
convictions they have been impressed with that now represents authority and the demands of others. The
world says “You will!” and the client says “I won’t!” To better assess the power dimension, examine who
gets their way and how and what is the reaction of it by others.
4. Unresolved Trauma
While this may not become immediately clear, a close examination of the emotional pain that has
occurred due to unresolved psychological injury is critical to the therapy process, even if is not the
specific subject of treatment. As indicated elsewhere in my Notes (on depression), it is helpful to consider
trauma as cumulative in its effect and as falling into one of three umbrella categories: Loss, Tragedy and
Betrayal of an intimate relationship. Each adds greatly to one’s experience of vulnerability and the
symptoms of depression and anxiety that form as protective measures. (This is a critical issue, for while
depression and anxiety carry problems of their own, efforts to eradicate or mitigate can strip them of their
value and importance in helping to protect the individual or their family). Psychological injury is, in fact,
the harm to one’s sense of trust with others or in their own ability to protect themselves from harm. In this
manner, depression, anxiety and all secondary symptoms could be seen as methods of protecting oneself
from feelings of worthlessness and from experiencing added harm by others.
5. Level of Functioning
While each of us may view ourselves as independent and separate, our personality and sense of self was
forged by family, then friends and the society at-large. There is, therefore, a relational component to each
of our actions, beliefs and behaviors that reaffirms our way of being in the world and shapes our
adaptation to the continuous myriad of changes that constitute existence. Our success in continually

36
changing while retaining important elements of our sameness is what defines the success of our
adaptation and consequently whether problems will surface that warrant some form of remedy.
This, in turn, determines relational patterns that are problematic:
o Boundary problems: excessive enmeshment or disengagement
o Alignment problems: alliances (tag-team) or collusions (secret pacts)
o Triangulations/Triangles: shift or rotate anxiety; participation may or may not be voluntary
o Cut-offs and ghosts retain conflict and stress
o Power problems: confusion or misuse of influence/control (hierarchy)
6. Motivation for Change
 Flexibility and resiliency
 Factors as well as an understanding of who wants the change and why and who prefers to retain the
current manner of being.
 Desires for change as well as fear of change are important to evaluate.
Family Life Cycle and Role Assignments
 Roles or positions are assigned/assumed from the family of Origin, then added to in time
 They consist of patterns of behavior that is expected to be maintained; they acquire “moral
character” and are relatively enduring
 Role behavior is reciprocal and interactive
 Roles and positions have “status”, thereby determining placement on the power-hierarchy (power),
leading to alliances, collusions and triangulations
A broad, more intuitive perspective comes from life stage processes such as those highlighted in The
Family Life Cycle model by McGoldrick and Carter. While not prescriptive, these are seen as ongoing
social maturation issues placed against social and familial processes. They often overlap and require
continual renegotiation of the status quo as an adaptation to natural change:
1. The Unattached Young Adult
a. Accepting emotional and financial responsibility for self
b. Differentiation of self in relation to family of origin
c. Development of intimate peer relationships
d. Establishment of self re work and financial independence
2. Couple/Partnership
a. Commitment to new relationship
b. Formation of marital or partner system
c. Realignment of relationships with extended families and friends to include spouse

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3. Families with Young Children
a. Accepting new members into the system
b. Adjusting marital/partner system to make space for child(ren)
c. Joining in childrearing, financial, and household tasks
d. Realignment of relationships with extended family to include parenting/grand-parenting
roles
4. Families with Teens
a. Increasing flexibility of family boundaries to include children's in-dependence and
grandparent's frailties
b. Shifting of parent child relationships to permit adolescent to move in and out of system
c. Refocus on midlife marital and career issues
d. Beginning shift toward joint caring for older generation
5. Launching Children and Moving On
a. Accepting a multitude of exits from and entries into the family system
b. Renegotiation of marital system as a dyad
c. Development of adult to adult relationships between grown children and their parents
d. Realignment of relationships to include in-laws and grandchildren
e. Dealing with disabilities and death of parents (grandparents)
6. Families in Later Life
a. Accepting the shifting of generational roles
b. Maintaining own and/or couple functioning and interests in face of physiological decline;
exploration of new familial and social role options
c. Support for a more central role of middle generation
d. Making room in the system for the wisdom and experience of the elderly, supporting the
older generation without over-functioning for them
e. Dealing with loss of spouse, siblings, and other peers and preparation for own death. Life
review and integration
Similar processes of adaptation have been described for Divorced and Separated Families; Single-family
Families; and Remarried, Reconstituted and Blended Families. While the life cycle of a family describes
the proper development of a family and its members, it does not fully stress the underlying processes
inherent in the social interactions. These are simple, yet exceedingly profound in their implications. These
include: Intimacy, Power and the drive for Meaningful Belonging, or the process of improving oneself as
an individual and as a member of the community.

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Notes on the Practice of Psychotherapy
October 28, 20015
The Goal of the Therapy Process
Overall Goals of Treatment and of the Therapist
While clients seek treatment for relief from the distress of their situation or symptom(s) the job of the
therapist is to create a remedial process by which adjustment to change can occur.
This should be done in a supportive and caring manner, the therapist calling into question one’s
customary way of being while coaxing and cajoling change. To do so, the therapist must challenge the
meaning and power of the problem while providing opportunities to practice new ways of thinking,
behaving, feeling and interacting. When done skillfully clients change, modifying their sense of self and
their relationship to others and to the world at-large.
In this regard, the clinical session is an incubator for work with the process of therapy becoming a long
series of opportunities created deliberately to experience change.
Confrontation and Challenge
In clinical terms, “challenging” is the process of confronting the client’s interpretation of events, the basis
for how information is incorporated into reaffirming one’s own belief system.
“Effective confrontation promotes insight and awareness, reduces resistance, increases congruence
between the client’s goals and their behaviors, promotes open communication, and leads to positive
changes in people’s emotions, thoughts and actions” MacCluskie (2010).
Linda Finley (Finlay, L. Relational Integrative Psychotherapy: Process and Theory in Practice,
Chichester, Sussex: Wiley, 2015) listed several key principles to effective challenging:
1) It helps to believe in the value of challenge: it plays a vital role in moving a client towards new ways
of thinking, feeling and behaving. And, while we might find challenging hard to do, authentic,
honest straight, well-meaning comments may actually be less damaging than empathic confluence or
‘pussyfooting’ around.

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2) Challenging should be done relationally. In the early stages of therapy, simply attuning to the client
in a non-judgmental way may be all the challenge that is needed. Later, once the relationship is in
place, and trust has been established, more muscular/provocative challenges might be appropriate.
3) Challenges issued need to be in the clients’ interest and not simply be a self-serving product of our
own frustration, impatience or irritation. Sometimes this is easier said than done, particularly if we’re
caught up in powerful counter-transferences and projective identifications. So we need to be
reflexive about our urge to challenge towards finding more constructive modes which can be
received in non-defensive ways.
4) Empathy and compassion need to be to the fore when challenging such that our clients will hopefully
be able to understand that our challenges arise out of caring concern. In other words, the challenge
occurs in the wider context of the therapy. When giving such challenges, it can be useful to use the
‘on the other hand...’ type of intervention. For example, “I can feel something of how hard it is for
you to talk about that. On the other hand, I think it would be helpful to put it into words.” Or, “I’m
hearing you say you’re calm. On the other hand, I see your foot tapping and I’m wondering if your
body is saying something different(?)”.
5) Aim for a proportionate, optimal level of challenge. Too much challenge when the person isn’t ready
to receive it, can be shaming, overwhelming and destructive, and is likely to just cement defensive
resistance. Insufficient challenge means we end up in confluence, colluding with costly stagnation.
6) Asking permission to challenge or to give feedback can pave the way. “I’d like to offer you a
challenge. Are you up for it?” Then the client is enlisted as an ‘ally’ and the challenge is dialogical
rather than a one-way exercise of power.
7) It can help to encourage self-challenge towards enabling the client to be more self-aware and take
responsibility for choices. For example: “As you’re sharing these different stories of dating with
me, I’m seeing a bit of pattern where it seems you tend to end up feeling used and betrayed. Is this
a familiar pattern? Would you be willing to think about your own role in this?”
8) Often it is more productive to challenge unused strengths rather than weaknesses. To give an
example, it might be more constructive to acknowledge the client’s capacity to care for others if not
themselves, rather than calling them an unhealthy ‘rescuer’.
9) Challenge may often best issued with shared gentle humor – of course, this needs to evolve mutually
(laughing with, not at) and be sensitively done.
10) We, too, need to stay open to being challenged (e.g. by clients or by our supervisor) if we are to
grow and develop as therapists. At the very least it can provide a useful way of modeling the
behavior for clients.

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Interventions and Tactics
While confrontation can take several forms, a directive is a very discreet intervention given as a
prescription, homework, exercise, ordeal or other form of assignment.
 Directives are very deliberate, often manipulative, tasks assigned to provide practice in new ways of
thinking and behaving
 Task performance provides an opportunity for reassessment and, in turn, redirection
 If resistance to a task occurs, the apprehension should be confronted and the power-play, if present,
disengaged and redirected
 Ordering a task or directive:
◦ Simple introductions that communicate the experimental nature of the task work best. This
denotes that the experience is exploratory and time-limited. Examples include: “Let’s try
something…”; “Some people find this helpful…” ; “Let’s do an experiment…”; “I’m going to
have you do something that may be uncomfortable… ”
◦ Typically, it is beneficial to advise the client that the task may be difficult or prone to failure. This
increases the likelihood of success through lower expectations or a recoil.
◦ Once a directive is given, it is important to expect that the task is acted upon until complete.
While some apprehension is natural, outright refusal must be immediately addressed before
moving forward. Irrespective of the rationale, it is likely a power-play with the therapist.
◦ Once a task has been assigned, the therapist's job is to redirect any straying or delay back to task,
itself. This can build tension within the therapist who may become inpatient and feel an urgency
to rescue the client from their discomfort. If the client is unable to complete the task, the therapist
should explore a) what would happen had the task been able to be completed, and b) what was
going on for the person while struggling to complete the task.
Contracting
Contracting is an exceedingly complex and sophisticated process by which agreement is reached to
provide clinical treatment toward a specified goal or outcome, While unwanted, the symptom or
presenting problem will likely have acquired functional value, serving both as a source of stress and its
release, and providing a focal point around which behavior is organized and patterned. It is, therefore, of
great importance to assess the potential consequences and risk to change.

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A common, misconception is that therapy begins once the presenting problem has been sufficiently
clarified; in actuality, it is the very act of clarification that is the true onset of therapy:
◦ Why is the client seeking treatment at this time? Why not a month or two ago, or next month or
the month after? What has changed to create the urgency at this time?
◦ What is it about the problem that is so objectionable? Does it happen all the time or is it selective
with regard to circumstance, time, people or place?
◦ The symptom must have a relational component. A reliable treatment plan must, therefore, who
participates, in real or imagined ways, in the pattern of dysfunctional behavior. Begin by
exploring who the problem affects and how.
◦ Validate the person who has the power to return the member(s) to treatment and take care to not
alienate them. In the same manner, one must validate the Presenting Problem, returning to
reaffirm its importance after each bout of challenge to its authenticity and role.
◦ Contract goals must have concrete, behavioral components that are measurable and that can be
clearly delineated for evaluating progress and risk. How does one determine success and what is a
reasonable timeframe to achieve that particular goal?
Challenging the Symptom and the World View
A good psychotherapist continually asks herself “What, or who, would be the problem if this was not?
Individualism is an illusion. As social beings, we do not exist outside the context of others. While each of
us may view ourselves as independent and separate, our personality and sense of self was forged by
family, then friends and the society at-large. There is, therefore, a relational component to each of our
actions, beliefs and behaviors that reaffirms our way of being in the world and shapes our adaptation to
the continuous myriad of changes that constitute life (see Tasks of Adulthood; Family Life Cycle). Our
ability to continuously change while retaining important elements of our sameness is what defines the
success of our adaptation and consequently whether problems will arise that require remedy.
 Therapy begins with “contracting”, a highly sophisticated process whereby agreement is drawn on
◦ what is the chief complaint (presenting problem or symptom)
◦ what is the desired goal (s) or outcome of treatment
◦ how is success to be understood or measured, in behavioral terms, and
◦ who is to participate in session and under what terms or conditions
 While labels and diagnoses may be useful as short-hand descriptors, they represent the beliefs of
others and can readily cloud one’s initial impressions as to the current level of functioning and

42
motivation for change. They are also individual and dissuade concentration on the relational
component of the problem.
 Presenting Problems and symptoms are manifestations of dysfunctional structures or patterns of
behavior and serve as a metaphor for the change that is needed. They are purposive as stop-gap
measures that preserve a level of safety between the imperative to change and the desire to remain the
same. Exploring the history of the Presenting Problem is therefore critical to understanding the
problematic sequence and pattern of behaviors that maintain it.
 Motivation for change and treatment avoidant behaviors and obstacles are important to periodically
review and reaffirm. Given the impetus for sameness, the desire as well as the risk of change must be
continually reevaluated. Is the price of change worth the investment in time, energy and
consequence?
Perspectives on Symptom Development
1. Behavior (and emotion) is purposive (Adler)
 The individual continually reaffirms their worldview and the manner in which they must
interact with others
2. Problems are a product of social relationships
 Individuals develop relationships with individuals that reaffirm their own affirmations
 There is a relational component to every normative and para-normative event
 Individuals and families undergo developmental change (stages)
3. Social interaction develops structure whose pattern of behavior and rules determine the
effectiveness of functioning or the development of symptoms (Minuchin). Similarly, faulty
adaption to change will concretize over time into dysfunctional structures (Haley).
4. Despite being unwanted, symptoms play an important role in the safety and well-being of the
individual and their family or social system:
◦ “When anxiety increases and remains chronic for a certain period, the organism develops
tension, within itself or in the relationship system; the tension may result in physiological
symptoms, emotional dysfunction, social illness or social misbehavior” (Bowen)
◦ Symptoms are a defense against anxiety (Freud)
◦ Structural: change the system, in order to change the symptom (Minuchin)
◦ Strategic: change the symptom, in order to change the system (Haley/Madanes)
◦ Problems are faulty interactions among people during adaptation to life-cycle changes

43
◦ Symptoms are safe-guarding mechanisms (Adler)
◦ Treatment is sought not for change, but due to the failure to adequately adapt to change.
Symptom = “Adaptive response” (Haley) = “Solution” that is now the “Problem”.
5. The presenting problem is both a representation of the problem and index of treatment progress
6. Timing: symptoms typically manifest during periods of duress (crisis or impasse)
◦ Normative (universal issue, even if not experienced): marriage, parenthood, families with
adolescents, ‘empty nest’, partner/child death, aging
◦ Para-normative (common but not universal issue): divorce, re-marriage, trauma, war,
severe illness
7. Removal of a symptom or problem can threaten the individual and the system:
◦ a worsening of the existing symptom or problem (rebound);
◦ the creation of a new symptom, symptom-bearer or problem (deflection);
◦ the development of physical or psychiatric illness (conversion); or
◦ the abandonment of treatment (escape)
8. Treatment failure or failure to change will be used to justify
◦ the severity of the symptom and the struggle
◦ the inadequacy of the member to change
◦ the inadequacy of the therapist to accomplish change
◦
As the sequence of behavior maintains the dysfunctional interaction, its interruption will, necessarily,
alter the symptom, presenting a direct challenge to its rigidity and inevitability. Ways to interrupt the
sequence include reversing the order of the steps (having the symptom come first), removing a step or
adding a new one, removing a member of the loop or adding a new one, and practicing the sequence at
times and places that are not customary (controlling the symptomatic pattern).
Behavior rehearsal or demonstrating the sequence in session is a subtle yet profound means of identifying
the steps of the sequence while creating an opportunity to experience and exercising control over the
symptom:
a) Create a new symptom.
b) Move to a more manageable symptom
c) I.P. another family member. (create a new symptom-bearer)
d) I.P. a relationship
e) Reframe or re-label the meaning of the symptom.
f) Change the intensity of the symptom/pattern. (Inflate/Deflate)
g) Change the frequency or rate of the symptom/pattern

44
h) Change the duration of the symptom/pattern
i) Change the time (hour/time of day/week/month/year) of the symptom or pattern.
j) Change the location (in the world or body) of the symptom/pattern
k) Change some quality of the symptom or pattern.
l) Perform the symptom without the pattern; short-circuiting.
m) Perform the pattern without the symptom.
n) Change the sequence of the elements in the pattern
o) Interrupt or otherwise prevent the pattern from occurring.
p) Add (at least) one new element to the pattern.
q) Break up any previously whole element into smaller elements
r) Link the symptoms or pattern to another pattern or goal
s) Point to disparities
Note:
4 A-D courtesy of Minuchin and Fishman; E – courtesy of Adler; F-S courtesy of
O’Hanlon, 1982.
5 Pattern or element may represent a concrete behavior, emotion, or individual family member.

46
Notes on the Practice of Psychotherapy
Copyright © February 08, 2016
The Family Psychotherapy Process
Family Counseling is the preferred method of treatment when the Presenting Problem (PP) involves a
child or a youngster as the Identified Patient (IP). The role of the therapist is to work with the Executive
(Parenting) Subsystem to accept responsibility for the family’s problem and work as a team to put in
place an appropriate solution. Conflict, trauma and other obstacles that impede the cooperation must be
remedied along the way.
Family Dynamics
Belonging is a necessary condition of the human experience. As the primary social group, the family
helps ensure that basic needs are met, socialization occurs, and that members cooperate to navigate the
complex social relationships of human interaction. Many skills are central to this, chief among them trust
and the intimacy it creates.
As competing interests surface and lead to disagreement conflict must be negotiated and, as necessary,
mediated by the parents or executive subsystem. Unresolved, conflict deteriorates trust and undermines
intimacy.
Given the interest in seeking treatment, the therapist can presume that the parenting system has reached
an impasse and is voiding its natural abilities as adults to properly guide and re-direct the children. This
originates from one of two circumstances: a) dysfunction or impairment in the psychological healthiness
of one of the parents; or b) sustained conflict within the couple or executive relationship, typically due to
a long standing history of mistrust and betrayal. If a child is the Identified Patient, tension has invariably
been deflected through concern about his or her behavior or welfare (triangulation). The interactional
pattern that is formed will be characterized by enmeshment with one of the parents or collusion between a
parent and child(ren) against the remaining parent. In dire circumstances, both mechanisms are present.
For this reason, four key, interrelated concepts are explored below. The first two, power and intimacy, are
fundamental if often opposing dynamics; they are associated with trust and support and therefore with the
ability of the family to display cooperation. The third is trauma, which may result in inadequacy in a
parent or as unresolved conflict between members. Unresolved trauma impacts the power dimension of
the parenting roles. Lastly, it is important to examine the family’s ability to cope with life’s processes of
growth and their consequent imperative to change (Family Life-cycle).

47
Power and Intimacy
A strong, interrelated connection exists in relationships between Intimacy and Power. Intimacy creates
power by strengthening the trust agreement between persons that share a common purpose or goal. Power
increases the safety and protective value of sharing, thereby increasing closeness and the social bond.
Both come into play when a trust agreement is violated and the betrayal leads to mistrust or trauma.
Power
 Influence and control within the relationship system
 Determines style of communication and decision-making (how love, caring, anger, and so on is
expressed and understood)
 Defines level of trust for meeting and not meeting personal and group needs
 Establishes rules for interdependence and independence, for closeness and distance between
members, for who participates and joins
 Is expressed in socially defined structures characterized by parental and intergenerational
influences. In a healthy family, everyone cooperates in conflict resolution, problem solving and
decision making, with the parents (executive subsystem) providing the final say
 Power structures, include:
a) Rules: pattern of interactions or behavior; how (and when) things are to be done and by whom
b) Hierarchies: who directs others, typically through established levels of authority and
responsibility; the executive/parental subsystem should serve at the top
c) Alliances (Coalitions, Collusions; Triangles): relationships and agreements around issues to add
or detract power for a common cause or purpose and thereby shape outcome. Unresolved power
struggles lead to covert partnering in the form of collusions and triangles to alleviate stress or
reconcile power imbalances.
d) Roles: expectations of behavior within a given setting of who participates and how; established
assignments for performing specific functions and tasks
i. Roles or positions are assigned/assumed from the Family of Origin, then added to in time
ii. They consist of patterns of behavior that are expected to be maintained; they acquire
“moral character” and are relatively enduring
iii. Role behavior is reciprocal and interactive with other roles
iv. Roles and positions have “status”, thereby determining placement on the power-hierarchy,
leading to alliances, collusions and triangulations
e) Symptom: a pattern of interaction involving an unresolved struggle for power. As the pattern
rigidifies, triangulation, acts of revenge, dysfunctional alliances, illness and other methods are
employed to disengage the impasse and unbalance the stalemate or deadlock. Cooperation
erodes permitting pressures to mount and tensions to develop in one of the partners, the
couple’s relationship or one or more of the children. This will result in “physiological
symptoms, emotional dysfunction, social illness or social misbehavior” (Bowen).

48
Efforts to tip the balance of power and preserve functionality may occur in overt or covert
ways:
a) collusion: gaining power through alliances with others (ie. Parent and child against other
parent)
b) inadequacy: retaliating or neutralizing others through failure, incompetence, illness or
depression
c) violence: over-powering through rage, bullying, intimidation or verbal, physical and sexual
abuse
d) vengeance: weakening through hurt, including punishing, withholding, suicide, and acts of
revenge
Intimacy
Closeness, affection and trust in a relationship, developed and expressed through sharing vulnerabilities,
and enjoying positive involvement, and shared understanding. Intimacy structures include:
a) Boundaries are proximity measures defined by the level of comfort with emotional sharing,
interdependence, and intensity between members. A product of the level of intimacy and trust in
the relationship, it is balanced by the degree of separateness or independent personhood
(individuation) of the individuals. When not appropriately balanced, the connectivity between
members is reciprocal; over-involvement (enmeshment) in one relationship usually means that the
same person is disengaged or under-involved (diffuse) from someone else. For example,
i. A wife who is enmeshed with a child and disengaged from her husband, or
ii. A father who is very close and enmeshed with his older son who hunts with him, and
disengaged with his daughter who is quietly depressed and cutting herself
Rule of Thumb: healthy boundaries are moderate and balanced; the “Goldilocks” measure is
symbolized by lines (“boundaries”) that denote the relationship’s degree of permeability:
 Too Soft: Diffuse, too weak, too open, or “enmeshed”; symbolized as “…………………….”
 Too Hard: Rigid, too fortified, too closed, or “disengaged”; symbolized as
“________________”
 Just Right: Appropriate, retain a healthy balance; symbolized as “._._._._._._._._._._._”
b) Subsystems: relatively enduring subgroupings within the family based on age (or generation),
gender and interest (or function); ie. parental, spousal, sibling, men/women. Common
denominators/characteristics, shared “rights” or “plights”, provide a vehicle for intimacy.

49
a. Alliances: Power structures of shared purpose that create the opportunity for cooperation and
therefore intimacy.
b. Love, Friendship and Sex: specialized relationships that increase intimacy (pair-bond) through
trust and a common agreement on the terms of the use of power.
Trauma (see Notes on Trust, Revenge and Forgiveness)
Trust is the fundamental agreement between people to risk hurt in exchange for acceptance and love. This
is the marital contract that is at the core of the parenting, and therefore the executive subsystem.
It is for this reason, that the consequences of betrayal are so dire to the ability and interest to be mutually
supportive and effectively cooperative, a key process of marriage and the parenting role. When anger and
resentment become defining characteristics of the relationship, the less assertive member will rely on
more passive-aggressive methods to control and punish. Invariably, children will enter the power struggle
and become embedded in the dysfunctional pattern between the couple. Comfort and solace may be found
by one’s relationship with a child, creating a level of dependency and hyper-responsiveness we call
enmeshment. Where power-plays occur the weakened or at-risk parent may collude with a child
(children) to leverage control and aide in determining outcome.
Disengaging the power-play and addressing the unresolved conflict in the marriage is key for the trust
agreement to be renewed and the child disentangled from the adult power and intimacy structures.
Life-cycle
Life-cycle is the context within which developmental change occurs. Stress develops into symptoms at
points of intersection when family of origin rules (Vertical stressors) are too rigid and insufficiently
flexible to adapt smoothly to trauma or normative developmental change. This is illustrated in the
diagram below which denotes the concentric context we are each embedded within (Systems Levels) and
the merging pressure to remain the same (Vertical Stressors) and the imperative to change (Horizontal
stressors):

50
Carter and McGoldrick identify six family life cycle stages and their respective processes and tasks,
somewhat modified herein. Because the processes are universal, understanding the Stages helps identify
and predict inherent in the developmental changes each family undergoes.
 Launching the young adult/Differentiation of self in relation to the Family of Origin
Each member is born into a uniquely formed inter-generational social group (family of origin) that
defines their identity and remains an integral part of their life until death. The challenge is for each
member to retain the benefits of remaining an integral part of their birth family while sufficiently
separating to form one’s own adult life and new social unit, a process that the entire family contributes to
and supports and paves the way for how other siblings may “graduate”. While a culminating event,
separation occurs incrementally through childhood and accelerates through adolescents. Most problems
intensify if not wholly originate, from difficulties encountered during this stage (and adolescents). Barring
childhood trauma from sexual abuse, war or catastrophe, this period is most prone to trauma as power
struggles intensify between the executive subsystem and the rising young adult.
Tasks:
◦ due to greater autonomy and independence, parents can no longer require compliance or obedience;
power must be renegotiated; threat and shame are less effective, requiring greater mutual agreement
the young adult must separate without becoming cut-off, fleeing or getting themselves ejected
◦ the young adult must accept emotional responsibility for self and clarify own values & belief system
◦ the young adult must develop intimate peer relationships with the prospects of pair-bonding and sex
◦ the young adult must establish self in work/higher education and a path to financial independence
◦ family members provide support by accommodating to change in roles, functions, and chores
◦ family members provide flexibility to allow movement in and out of the family
◦ parents (executive subsystem) must provide continued support without enabling
Problems occur when young adults fail to differentiate themselves from their family of origin and recreate
similar, typically flawed emotional transaction patterns in their own adult social relationships and in their
family of formation. While work, school and adult peer relations can provide an opportunity to reconcile
unresolved issues these also provide a venue in which to reaffirm them. Serious problems occur when
families do not let go of their adult children encouraging dependence, defiance or rebellion.
 Developing the Couple Relationship: Intimacy and Trust
◦ The task of this stage is to accept new members into the system and form a new family separate and
distinct from the couple’s families of origin.

51
◦ Couples may experience interpersonal difficulties in intimacy and commitment. The development of
trust and mutual support is critical
◦ Negotiation of the sexual component of the relationship system
◦ Negotiation of Power, boundaries and rules of the marriage; identifying/protecting against threats
◦ Problems consist of enmeshment (failure to separate from a family of origin) or distancing (failure to
stay connected).
 Parenting/Families with Young Children
◦ Child-rearing and the task of becoming caretakers to the next generation
◦ Adjusting marital system to make space for child (ren)
◦ Joining in childrearing, financial, and household tasks
◦ Realignment of relationships with extended family to include parenting and grand-parenting roles
◦ Couples must work out a division of labor, a method of making decisions, and must balance work
with family obligations and leisure pursuits.
◦ Problems at this stage involve couple and parenting issues, as well as maintaining appropriate
boundaries with both sets of grandparents.
 Families with Adolescents
◦ In stage four, families must establish qualitatively different boundaries for adolescents than for
younger children. Individuation accelerates and movement in and out of the family increases.
◦ Problems during this period are typically associated with adolescent exploration, friendships,
substance use, sexual activity and school; peer relations take a primary place as does self-absorption
◦ Parents may face a mid-life crisis as they begin to regard their own life accomplishments and foresee
the promise of an empty nest or diminishment of the parenting role; refocus on midlife marital and
career issues
◦ Increasing flexibility of family boundaries to include children's independence and grandparent's
frailties; beginning shift toward joint caring for older generation
 Launching Children and Moving On
◦ The primary task of stage five is to adapt to the numerous exits and entries to the family
◦ Renegotiation of marital system as a dyad
◦ Development of adult to adult relationships between grown children and their parents
◦ Realignment of relationships to include in-laws and grandchildren
◦ Dealing with disabilities and death of parents (grandparents)
◦ Problems may arise when families hold on to the last child or parents become depressed at the empty
nest or due to loss. Ease of separation tied to contentment in the marriage/adult life and future plans
◦ Problems can occur when parents decide to divorce or adult children return home

52
 Families in later life
◦ The primary task of stage six is adjustment to aging and physical frailty
◦ Maintaining own and/or couple functioning and interests in face of physiological decline;
exploration of new familial and social role options
◦ Support for a more central role of middle generation
◦ Making room in the system for the wisdom and experience of the elderly, supporting the older
generation without over-functioning for them
◦ Dealing with loss of spouse, siblings, and other peers and preparation for own death.
◦ Life review and integration
◦ Problems consist of difficulties with retirement, financial insecurity, declining health and illness,
dependence on one’s adult children, the loss of a spouse or other family members and friends.

54
The Family Therapy Process
1. Join the executive subsystem as a coach, build an alliance with each member and
accommodate to the family’s temperature and style:
1. Review practical concerns, including access to treatment, update to referral source,
billing, required participants, and household basics and so on
2. Determine the source of power and who can mobilize the family to action well as to
return and continue attending treatment
3. From the onset, challenge assumptions about the Identified Patient (IP) and the symptom;
examine its purpose to the Identified Patient, the family and its members
4. From the onset, challenge assumptions about the Presenting Problem; track the
interactional pattern that maintains it and examine what it fosters as well as avoids
5. Continually do a temperature check of reactions clinical directives and challenges to the
symptom or presenting problem; address overt and covert expressions of anger
6. Consistently validate the family’s power; take a one-down position and reframe progress
as the family’s love for and commitment to one another
7. Create intimacy through use of self and personal history, family bragging, praise,
celebrations, teamwork and friendly competitions
8. Consistently reaffirm the inherent privilege of the family’s acceptance (of the therapist)
and their courage in sharing their pains, their secrets and their shames
2. Empower the Parenting/Executive Subsystem
While families undergo Life-cycle stages, child-focused problems, by default, refer to the
authority and responsibilities inherent in the parenting or executive team. Accordingly, family
therapy centers almost exclusively on the task of parenting and child-rearing and addressing those
obstacles to its effective operation.
a) Empower the Parenting or Executive Subsystem
Make it a Team
 Join as a coach and mentor
 Define its membership, role and authority
 Create a partnership “truce” and implement a new time-line or identify
 Foster cooperation and mutual support

55
 Teach decision-making and conflict-resolution skills
 Provide education on developmental and life-cycle task processes
 Explain the purpose of power-plays, symptoms, dysfunctions and illnesses
 Help members practice expressions of mutual support and tenderness
 Ally with the Executive Subsystem as Co-therapists
o Strategize and plan interventions and solutions
o Model appropriate behavior; adult issues should be handled in couple session
o Block inappropriate communications and collusions/coalitions
o Practice parenting in session
Remove Obstacles to Effective Team Work
 Remedy distrust due to hurt from old or recurring betrayals
 Confront power-plays and misuse of power, including bullying and displays of inadequacy
or powerlessness
 Block interference from in-laws, family and friends
 Address unresolved personal dysfunction, family-or-origin issues and trauma
The goal of therapy, therefore, is to produce one of two outcomes:
a. to engage the parent(s), keeping the child as the IP, until the power-play can be dis-
engaged and redirected toward resolving the Presenting Problem (PP), then fully moving
the focus unto the couple’s relationship to work through their conflicts and betrayals. If
the coupe moves toward separation and divorce, the therapist can expect to either treat
the (“marry”) the remaining spouse in treatment or else have the system revert to its
previous child focus.
b. to engage the parent, keeping the child as the IP while beginning to address the
underlying trauma or dissatisfactions. The therapist then nudges the parent into individual
therapy or else can expect the system to revert to a child focus.
3. Make kids age appropriate
Throw kids out of spousal alliances; match authority, responsibilities and benefits by age;
promote (or demote) older teens and young adults with “parental” responsibilities. During
emergencies, single-parents may temporarily promote an older teen/young adult into the exec
subsystem, but generally the custodial parent must go it alone with support from the therapist,
other adult(s) or group.
4. Get parents to parent
Adult(s) are presumed to be sufficiently equipped to parent effectively unless they cease to
display such competency for a specified purpose. The reason (s) is always tied to issues of power:

56
i. the custodial adults are at an impasse due to unresolved conflict which has resulted in a
power-struggle or power-play
ii. the ineffectual adult has surrendered their power and adapted a sense of inadequacy due to
trauma, fear or depression
iii. the ineffectual parent has surrendered their power as a direct act of defiance or revenge, or
iv. the ineffectual parent(s) has worry over abandonment and is avoiding individuation in a
more appropriate manner.
5. Get parents to address individuation issues with teens and young adults (see Life Cycle)
6. Challenge power inequities:
1. dis-engage and redirect power-plays toward a common purpose, task or problem
2. Ensure that functions are clarified, roles are assigned and that authority (power) matches
responsibility
3. Bridge disengaged members and cut-offs and create breathing room and independence for
enmeshed members; interrupt/block inappropriate communications and direct proper
exchanges. Be careful family doesn’t collude against this effort.
7. Address hurt, trauma and trust issues as major barriers to effective governance and growth
8. Examine ghosts
Confront family myths, cut-offs, or other legacy issues that interfere or serve as road-blocks to
effective problem-solving or growth. Do this verbally, through imagery and through empty-chair
techniques.
9. Force enactment
Encourage in-session practice of new behavior patterns and new forms of expression; assign
related homework, continually reaffirming that behavior rehearsal is critical to solidify new ways
of being.
10. Have fun and get the family to laugh!

Advanced Methods in Counseling and Psychotherapy PART 1 Revised Feb 04 2018

Advanced Methods in Counseling and Psychotherapy PART 1 Revised Feb 04 2018

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Advanced Methods in Counseling and Psychotherapy PART 1 Revised Feb 04 2018