The document discusses family systems therapy and outlines key concepts including viewing the family as an interdependent system, assessing family structure and dynamics around power, boundaries, roles and rules, and using structural interventions like mapping the family system and enactments to restructure problematic interaction patterns and balance boundaries. The goal of therapy is to help the executive subsystem function effectively by resolving issues, developing complementary roles and problem-solving skills, and balancing boundaries between family members and subsystems.
Describe the family life cycle
Distinguish the shift from linear to circular thinking.
Describe the influence of Bateson
Describe the core concepts of systemic therapy: phase 1 & 2
A clinical psychologist with over four decades of experience, Donald “Don” Crowe, PhD, operates a private practice in Orinda, California. Throughout his career, Don Crowe, PhD, has assisted individuals, families, and couples using a variety therapeutic approaches, including the Gottman Method.
Describe the family life cycle
Distinguish the shift from linear to circular thinking.
Describe the influence of Bateson
Describe the core concepts of systemic therapy: phase 1 & 2
A clinical psychologist with over four decades of experience, Donald “Don” Crowe, PhD, operates a private practice in Orinda, California. Throughout his career, Don Crowe, PhD, has assisted individuals, families, and couples using a variety therapeutic approaches, including the Gottman Method.
These slides contain detailed description of family therapy including : Introduction, Definition, Aims/Goals, Indication, Contraindication, Functions, Types, Nursing diagnosis and interventions, Nursing responsibilities, Research.
Family, family as system, crisis, crisis intervention, adaptive qualities, family therapy and approaches, stages of family therapy, 12 family strengths by Otto
The References MUST BE THIS BOOK AND WHATEVER SOURCE YOU WANT TO SI.docxhelen23456789
The References: MUST BE THIS BOOK AND WHATEVER SOURCE YOU WANT TO SITE.
Harvey, C. and Allard, J. (2014) Understanding and Managing Diversity (6th ed.) NJ: Pearson- Prentice Hall. ISBN: 9780133548198
MUST BE ATLEAST 300 WORDS WITH TWO CITED SOURCES EACH!
1. Discussion Board Three
Individual Perspectives on Diversity II
Briefly summarize chap 8 and discuss how you can develop the skills needed to increase your Emotional Intelligence.
2. Discussion Board Four
Group Perspectives on Diversity I
How do gender differences impact how we communicate in the workplace? What strategies can be employed to improve communication? Discuss one example of intentional information use in the context of your organization (could be something that you witnessed or something that happened to you) (focus on Ch. 20, 27-28)
3. Discussion Board Five
Group Perspectives on Diversity II
Identify a belief, value or attitude of yours that you can attribute to your religion and examine its impact on your work and career. Discuss how your religion could affect your role and performance in a multicultural workplace.
BOOK INFO BELOW!
The Chapter 8
on The Emotional Connection of Distinguishing Differences and Conflict
Carole G. Parker
In recent years, diversity in organizations has been an exciting, stimulating, frustrating, and intriguing topic. Some organizations continue to struggle for diversity whereas others have a fully integrated diverse workforce. The challenge to increase and manage diversity continues to be critical to organizational goals, particularly as more organizations, large and small, transact business internationally. Some organizations work to appreciate diversity and value differences, whereas others continue to discount differences and diversity. Smart managers today realize the importance of balance in work groups. Attempts to incorporate differences in age, gender, race, culture, sexual preference, and styles of being in their organizations to capitalize on the incredible potential diversity offers are occurring. Managing differences requires energy, commitment, tolerance, and finally, appreciation among all parties involved. Differences among people are not inherently good or bad; there is no one “right” way to deal with differences. Learning to manage and ultimately appreciate differences requires learning, emotional growth, and stretching the boundaries of all participants. Although differences can be challenging, they also lead to very important benefits, both to individuals, groups and organizations.
How Differences Are Often Managed
What action and factors must be uppermost in selecting the most appropriate approach to addressing differences? Often avoidance or repression is used to manage differences. The avoidance of differences often takes the form of associating with individuals of similar backgrounds, experiences, beliefs, and values. This strategy enables an environment of mutual support and predictability. Those.
Lesson 5 of 7 - evolve a high-nurturance family .docxsmile790243
Lesson 5 of 7
- evolve a high-nurturance family
Use Structural Maps
to
Manage Your Family Well
Basic
Premises and
Examples
By Peter K.
Gerlach, MSW
Member,
NSRC Experts Council
site intro >
course outline,
Lesson 5 tasks or
links,
search,
chat,
or
prior page
> here
The Web address of this article is
http://sfhelp.org/fam/map.htm
Updated
09-22-2015
Clicking underlined links here will open a
new window. Other links will open an informational popup,
so please turn off your
browser's popup blocker or allow popups from this nonprofit Web site.
If your playback device doesn't support Javascript, the popups may not display.
Follow underlined links after
finishing this article to avoid getting lost.
This is one of a series of lesson-5 articles
on how to evolve a high-nurturance family.
The
article introduces a powerful tool for
understanding how your family is "built" - "structural mapping."
It may look complicated, but if you experiment with it, you'll find
that it's easy to use.
The article defines family structure, summarizes
some basic premises, shows you how to map the structure of any family, and
proposes baseline 'maps" of healthy biological families.. A related
article shows how to map typical multi-home stepfamily
structures.
This mapping tool can help you answer questions like...
"Who has
the power in our home and family, including dead people and non-relatives?"
"Who's in charge of each of our homes?"
"Who is aligned
and who is conflicted?"
"Is anyone excluded from full family membership?
By Whom? Why?"
"Do we have
major communication blocks in and between our several homes?"
"How does our family structure
react to crises, major
conflicts, and membership changes?
This article assumes you're familiar with...
the intro to this Web site and the premises
underlying it
self-improvement Lessons
1 thru 4
these Q&A items on families
these traits of a
high-nurturance family
how to make and use a family
genogram
About Family
Structure
Here, a
family means a group of people with genetic, legal, and
social bonds who depend on each other for inclusion, identity,
companionship, support, procreation, security and stability. This can
include dead and distant relatives, special friends and professional
consultants, a Higher Power, neighbors, teachers, coaches, baby
sitters, and perhaps influential mentors and media figures.
Structure describes how something is built, like a house, novel,
sailboat, or government. Structures range from stable to unstable and
effective to flawed, depending on what they're designed to do.
Family structure refers to:
W ...
Kurt Adler describes the cause and treatment of Depression according to Individual Psychology, his father's groundbreaking theory on human motivation and pathology.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. Family Systems Therapy
“Seeing” is the insight that occurs when the therapist transcends their singular perspective and views
the individual and the family as inseparable, interdependent systems occurring within the same space and time… --dperatsakis
Note: How to Develop Super-Vision
1. Look from a System’s Perspective
2. Look at the Purpose of the Problem Behavior (how is it empowered; how is it connected to the tasks of life)
3. Look at how and where the system resonates for the clinician
3. Power (Hierarchy; Decision Making)
Boundaries (closeness/distance; independence) and Intimacy (trust)
Conflict (Cooperation, Problem-resolution)
Coalitions (ie Triangle)
Roles
Rules
Complementarities and Differences
Similarities
Myths
Patterns of Communication
Effective Parenting
Warmth (Nurturing, Boundaries)
Control
4. 1. Inflexible response to maturational (developmental) and environmental
challenges leads to conflict avoidance through enmeshment or disengagement
(Goldilocks Rule on Emotional Distance: Too Much vs Too Little)
2. Disengagement and Enmeshment tend to be compensatory (“I’m close here to
make up for being distant elsewhere”)
3. Patterns of Disengagement or Enmeshment lead to Cross-generational
Coalitions (triangulation/triangular structures)
5. 1. Families are comprised of individuals in trust relationships acting alone and in concert to accomplish
and obtain their individual and collective purposes and needs.
• Basic Needs
1) Bio-physiological and Safety needs - food, drink, shelter/warmth and protection from the elements, safety and
security/freedom from fears;
2) Love and belongingness needs - friendship, intimacy, affection and love, sex; and
3) Esteem needs and Self-Actualization needs - achievement, mastery, independence, status, dominance, prestige, self-respect,
respect from others; realizing personal potential, self-fulfillment, seeking personal growth and peak experiences
• Life Tasks include those larger processes that the family, as a group, must accomplish (Life-cycle Tasks) and that each
individual must master (Developmental Tasks) and reconcile (Adler Life Tasks/Existential Anxiety)
2. Families have organized operational structures that include sub-systems, roles and interactional
patterns that aide the group and its individuals in achieving these outcomes and define the manner in
which interaction occurs around tasks functions and responsibilities.
These are partly universal (cultural) and partly idiosyncratic (intergenerational): information (rules and myths) on how to
accomplish tasks and assume responsibility; how gender, roles, and functions are defined; how power and emotion is expressed;
how loyalty, intimacy and trust are conveyed; and so on.
Core Structural-Strategic Family Therapy Tenets
Demetrios N Peratsakis, LPC 5
6. 3. Elements of the Family Organization include:
• Power: the ability to influence the outcome of events
• Hierarchy: established levels of authority and responsibility (executive subsystem at the top)
• Roles: established assignments for performing specific functions and tasks
• Subsystems: subgroupings within the family based on age (or generation), gender and interest (or function); ie.
parenting, spousal; sibling
• Boundaries: invisible barriers that regulate contact between members and regulate the flow of information in and out of
the system. Structural therapists use a “Goldilocks” approach to seeking moderation.
Diffuse, too weak, too open, or “enmeshed”; mapped as
Rigid, too fortified, too closed, or “disengaged”; mapped as
Appropriate boundaries retain a healthy balance; mapped as
◦ boundaries are reciprocal
That means that a weak boundary (enmeshment) in one relationship usually means that the same person is
disengaged from someone else.
Example is wife who is enmeshed with child and disengaged from husband. Mapped as M F
C
Example is father who is very close and enmeshed with older son who hunts with him, and disengaged
with daughter who is quietly depressed and cutting herself. Mapped as F
S D
4. The executive sub-system (no matter the configuration) is the recognized authority responsible for the decision-
making and problem-solving capability of the family. It’s core responsibility is to effectively manage stress and
negotiate conflict as individual members and the group adapts to change.
Demetrios N Peratsakis, LPC 6
7. Problem Origination/Symptom Development
5. Problems occur when the executive subsystem is ineffective at fulfilling its function, typically due to
1. a power-play between its members;
2. dysfunction within one of its members; or
3. incapacity due to trauma, disaster or catastrophe
6. This typically occurs at the confluence of vertical and horizontal stressors
• Vertical stressors are emotional norms and rules transmitted across generations. Examples are family secrets, attitudes,
taboos, labels, legacies, myths, loaded issues.
• Horizontal stressors refer to predictable (developmental crises) and unpredictable current events (life threatening illness,
divorce, etc).
7. Under duress the family intensifies its excessive rigidity around a key interactional pattern, rule or
role (structures) thereby developing a recurring or nodal problem (Symptom)
In essence, the family becomes insufficiently flexible to adapt to change, mend trauma or respond to maturational (or
developmental) and environmental challenges intensifying its stress and conflict.
8. The family adapts measures in response to the intense or prolonged conflict that exacerbate the
problem:
a. conflict avoidance through disengagement or enmeshment
1. Disengagement and enmeshment tend to be compensatory (I’m close here to make up for my distance elsewhere.)
2. This leads to what is called the cross-generational coalition, which is a triangular structure
b. power-struggles, marked by improper alignments, such as collusions, coalitions, alliances and triangulations
c. emotional cut-offs, disavowing contact with key members or supports
d. failure or dysfunction in one or more of its members
Demetrios N Peratsakis, LPC 7
8. 9. Therapeutic Goals: Intervention to transform the structure (restructuring)
• Join family: assume position of leadership
o Important to join with angry and powerful family members
o Important to build an alliance with every family member
o Important to respect hierarchy
Help the Couple or Executive Subsystem form a healthy (Spousal/Parental) Subsystem:
1. Must develop complementary patterns of mutual support, or accommodation (compromise)
2. Must develop a boundary that separates couple from children, parents, in-laws and outsiders. May need to
reconcile family-of-origin issues and concerns.
3. Must claim authority in a hierarchical structure. Partners must be equal and may need to address how each
expresses power or controls the outcome of decisions.
4. Must learn to problem-solve in order to effectively navigate conflict
5. Must reconcile Life-cycle Task processes:
Readiness to move from Couple to Family
Decision about Parenthood
Contending with pregnancy or birth-related concerns, such as difficulty conceiving or pregnancy complications
Integrating the child while negotiating space with in-laws, etc.
Child-care arrangements , separations and concerns
Child-rearing –resolving differences and adopting parenting styles that are balanced and complimentary
Agreeing on family goals and aspirations
Reconcile Power: hierarchy and age appropriateness; responsibility matched with authority; disengage power-plays,
alliances, collusions and triangles
Balance Boundaries: Boundaries must be balanced; strengthened in enmeshed relationships and weakened (or
opened up) in disengaged ones. Clarify Roles and Rules: Who is to do what and when and how? Matching
authority match responsibility.
Help Family Comfort and Care: Members support one another’s growth and encourage affection, tenderness and
mutual support.
Demetrios N Peratsakis, LPC 8
9. 10. Structural (Strategic) Therapeutic Interventions
1. Working with Interaction by inquiring into the family’s view of the problem, and tracking the
sequences of behaviors that they use to explain it.
2. Mapping underlying structure in ways that capture the interrelationship of members -- A structural map
is essential!)
1. Family structure is manifest only with members interact
2. By asking everyone for a description of the problem, the therapist increases the chances for
observing and restructuring family dynamics.
3. Highlighting and modifying interactions
1. Spontaneous behavior sequences (interrupt, re-play, highlight/embellish)
2. Enactments (directives and tasks) -- directed by therapist
4. Restructuring
1. Use of reframing to illuminate family structure
2. Use of circular perspectives, e.g. helping each other change
3. Boundary setting
4. Unbalancing (briefly taking sides)
5. Challenging unproductive assumptions
6. Use of intensity to bring about change
7. Shaping competency
8. Not doing the family’s work for them (refusing to answer questions, or to step in and take charge
when it’s important for the family members to do so.
5. Homework
1. Should be to increase contact between disengaged parties
2. To reinforce boundaries between individuals and subsystems that have been enmeshed
3. Should be something that is not too ambitious
4. Caution family members to expect setbacks in order to prepare them for a realistic future.
Demetrios N Peratsakis, LPC 9
10. Simple Genogram of a Blended Family
Presenting Problem: Don took Ben (17 yo) on a drinking spree; when stopped, police found two open
bottles and a bag of pot in the car. Step-dad wants Don to leave the house; mom (Katal) claims that Don is
depressed and upset about the anniversary of his father’s death
Assignment:
1. What Questions jump out at you? Form some initial hypothesis that should be tested.
2. Who should participate in session and why?
3. List some of the more significant issues that may be concerns
Reminder:
1. Always track who participates in the problem and how
2. Look for themes and patterns, such as roles, boundaries and conflicts
3. Examine cut-offs
Drug Use;
Depression;
Attempted
suicide;
multiple
hospitalizations
Alcoholism;
Depression;
Suicide
22 yo
Drug Use
Bad Temper
Recent crime: petty
theft; assault
D.= Overdose
Alcoholism
Domestic Violence
Local Pastor; got
custody of
children while
mom is in rehab
16 yo; straight
“A” student;
model child
11. 1. Use of Boundary Mapping: problems may be the by-products of inappropriate boundaries
(emotionality); manipulate boundaries with tasks that push to its opposite extreme.
Ie.
M F task M F
.….…… ______ ______..............
Kids ‘push’ to opposite Kids
Key: ……………….………_ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _____________________
Enmeshed Clear Boundaries Disengaged
(Inappropriately diffuse boundaries (Normal Range) (Inappropriately tight boundaries)
◦ Mark boundaries between partners, subsystems, or entire groups; examine skewed
boundaries
◦ Give directives and assign tasks that push individuals with diffuse boundaries closer,
enmeshed further apart. Firm up individual or relational identities and point to disparities
or similarities
◦ Partner enmeshed persons with others in and members outside the nucleus; partner
peripheral persons through teamwork, alliances and collusions
Sample Mapping Directives for Nudging Boundaries
Problem Boundary Pattern: Dad is very peripheral; Mom is over-enmeshed with Daughter and Son:
M F Note: “Risk” comparison for three simple options for testing boundaries
……… ______
Kids (D and S) M F
………………
D S
“The Girls versus the Boys” (relatively “safe” task;
keeps mom attached)
12. 1. Join the executive subsystem as a coach or mentor, build an alliance with each member and accommodate to the
family’s temperature and style:
1. Determine the source of power and who can mobilize the family to action
2. Immediately challenge assumptions about the Identified Patient (and Presenting Problem)
3. Examine the Presenting Problem and what interactional pattern supports it; examine the purpose of the symptom to the family
4. Continually check reactions and comfort with tasks, directives and challenges to the symptom or presenting problem
5. Continually reaffirm family’s power: take one-down and re-frame progress as family’s love and commitment to each other
6. Create intimacy through use of self and personal history, family bragging, praise, celebrations and story-telling
7. Continually validate privilege of working with family, their acceptance and their permission to share pain, secrets and shames
2. Build the executive subsystem: work with the couple as parents and address power-plays, old betrayals and trust issues, personal
dysfunctions with relational components, family-of-origin problems, in-law/friend interferences; help members practice expressions of
mutual support and tenderness
3. Get parents to parent
4. 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
5. Get parents to address individuation issues with teens and young adults
6. Challenge power inequities:
1. dis-engage and redirect power-plays toward 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
7. Address hurt and betrayal and 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!
Demetrios N Peratsakis, LPC 12
13.
14. Systems Thinking
Family of Origin (Genogram)
Developmental Tasks/Stages of the Family Life Cycle
Couples
Marital Discord/Couple Therapy
Typical Presenting Problems
Divorce
Post-Divorce
Remarried Family Formation
17. Ideas on the purpose and function of being a couple vary widely, with most viewing the social and sexual pair-bonding as a vehicle for
the purpose of procreation. At minimum, it is an agreement (contract) between individuals for mutual trust and support that includes an
avenue for the expression of sexual and emotional intimacy not socially acceptable in other relationships.
The quality of the relationship is a product of the individuals’ ability to demonstrate three (3) skills, each dependent on the rest:
1. to demonstrate mutual trust, loyalty and support, including tenderness, affection and love
2. to work toward goals, joint achievements and plans, and
3. to effectively problem solve the myriad of challenges and conflicts that arise as a natural consequence of change.
In it’s simplest terms, the job of the therapist is to challenge the couple into prioritizing a single goal or problem and then assisting
them in working toward its end, trusting that all clinical issues of relevance, both personal and relational, will surface along the way.
Therapy is continuously shaped, and its progress impeded, by three (3) principle factors, each intimate to defining the
individual’s personal sense of Power and, thereby, the couple’s collective ability to successfully negotiate matters of conflict:
1. unresolved matters from the family of origin (“ghosts”);
2. unresolved trauma; and
3. personal progress in reconciling one’s individual tasks of life: work, social interest, love, self-development, and spirituality.
As therapy gets underway, the couple should be advised to postpone any final decision about their relationship until a later time. If
practicable, this should include not actively engaging in any unilateral decisions or actions that could pose a peril, such as seeking
legal counsel, separating or relocating. Given the challenges above, the work will necessarily include assisting the couple with their
decision-making and problem-solving skills; re-instilling trust and working through hurt, betrayal and personal trauma; and exploring
each partner’s family legacy and how it shapes their actions, attitudes and experience with the expression of power:
1. power (decision making; problem-resolution; planning)
2. intimacy (joint accomplishment; affection; trust and loyalty; commitment; friendship; sex)
3. conflict mediation (cooperation; problem-resolution)
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19. Sound relationship but block in communication or cooperation
Pattern of bickering and fighting; great hurt or betrayal; lack of trust
Mutual caring but lack of passion and “zing”
Complaint about Family of Origin or In-laws (triangulation; intrusion; immaturity in partner)
Re-marriage/Blended family problems
Sexual dysfunction
Dysfunction in One Partner (ie. depression, phobias)
Special Issues
◦ Extra-marital Relations
◦ Alcoholism/Drug Abuse
◦ Incarceration
◦ Incest
◦ Sexual Abuse/Violence
Special Contracts: treating unmarried couples; lesbian or gay male couples; or co-habitating
couples serving as custodial parents
20. A. Stable Unsatisfactory Situation
Unresolved conflicts and power-plays result in chronic fatigue and tension:
1. Individual Symptoms (ie. depression, drug abuse, phobias, failure) or
2. Symptomatic Interactions (abuse, bickering/apathy, sexual dysfunction)
B. Marital Crisis
1. “Trigger event” (ie. death in family, job change)
2. Precipitating event (ie. Extra-marital affair
21. Demetrios Peratsakis, LPC 21
A. Crisis Event Typically, the reason for seeking treatment is clear, such as when a crisis erupts in the individual or couple’s life
“triggered” by some precipitating event such as a death in family or job change.
1. It may come through the disclosure or discovery of a major breach of the couple contract: an affair; incest; desire for separation or divorce; desire
to change gender or sexual orientation; incarceration; or a unilateral decision that results in a major change in couple’s finances or life-style, ie.
pregnancy; permitting in-law or friend to move in; new job requiring relocation.
Therapist’s Job: a) stabilize the crisis and implement an immediate, short-term plan of action; b) implement supports by the partner; consider
ancillary counseling (individual, group or family); c) push off final decisions about the fate of the relationship, if possible. If not, consider a
“structured separation”, then determine interest in repair of the relationship or separation.
2. Trauma or life-changing event may befall one partner: rape; victim of a crime; death of a loved one; job loss; major illness or health related loss
Therapist’s Job: first stabilize the crisis and implement an immediate, short-term plan of action. Then determine interest in repair of the relationship
B. Stable Unsatisfactory Situation In a “stable unsatisfying” relationship however, the couple has accommodated to change, albeit in
an unhealthy or dissatisfying way. The imperative for change may be less defined and pose a challenge to deduce, including by the partners:
1. Has an illness or symptom worsened or become manifest in a more vulnerable member, such as a child?
2. Has pressure been brought to the couple from the outside, such as by the school, the court or by one’s job?
3. Has an underlying “secret”, such as incest or spousal abuse , been finally discovered or revealed?
4. Has some major shift alignments occurred such as the birth of a child or a teenager beginning the process of leaving home?
5. Is there a surreptitious plan by one of the partners to escape the relationship?
Unresolved conflicts and power-plays result in chronic fatigue and tension, either as Individual Symptoms (ie. depression, drug abuse, phobias,
failure) or Symptomatic Interactions (abuse, bickering/apathy, sexual dysfunction). Typical Presenting Problems include
◦ Sound relationship but block in communication or cooperation
◦ Pattern of bickering and fighting or lack of trust due to great hurt or betrayal/Mutual caring but lack of passion and “zing”
◦ Re-marriage or blended family problems/Complaint about Family of Origin or In-laws (triangulation; intrusion; immaturity in partner)
◦ Sexual dysfunction
◦ Dysfunction in One Partner (ie. depression, phobias)
Therapist’s Job: a) explore what has changed (“Why now?”) b) push the dead-lock and disengage and re-direct the power-play; alternatively create
a crisis c) push off final decisions about the fate of the relationship, but force an “interim” direction toward repair or separation.
22. Conflict is always about Power, influence and control within the relationship system:
Tend to occur around issues of money, work, sex, children, chores, and “in-laws”. Determines style of communication and how
love, caring, anger, and other emotions are expressed and understood
Determines style of decision-making and problem-solving;
Defines level of trust for meeting or not meeting needs;
Establishes rules for interdependence and independence and for distance and closeness between members (attachment/mutual
accommodation; affection/expressing and experiencing love)
Defines roles, or positions, taken or assigned: reciprocal, interactive patterns of behavior (typically from the Family of Origin,
thereby possessing an intergenerational quality) that the individual is expected to maintain. They are relatively enduring
(permanent) and acquire “moral character” and have ‘status’, thereby determining placement on the power hierarchy.
Chronic conflict is a stalemate, a power-play that breeds tension and duress: “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).
Faulty remedies ingrain the stalemate and result in feelings of hopelessness:
Failed Remedies: previous counseling, mediation, consultation with attorney, legal separations
Power-less Power: One partner becomes dysfunctional, fails or becomes the Identified Patient (I.P.)
Equal but Separate: solo activities, hobbies or individual interests; mutual or solo acts of defiance, selfishness, or betrayal
Combat: fighting, forcing, hurting, beating, withholding, stealing, etc. often involving outside groups (triangulation) such as the
police, the courts or spouse abuse programs/shelters
Alliances, Coalitions, Collusions and Triangles/Triangulation: patterns of adding power or deflecting anxiety through the
inclusion of a third-party, such as friends, family, children or extra-marital affairs or relationships
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23. Begin here or here
1. Tell me about your relationship and how it began?
2. What brings you to see me? or What do you see as the pain in the relationship/marriage? (Symptom)
3. What happens when this problem occurs? (Underlying Dysfunctional Interaction/Pattern)*
* Note how the unresolved conflict manifests itself. How does the Power-play play-out?
Descriptors & History (collected as presented or needed
over the first few sessions)
1. Partners: Brief description of partners/partnership, including names; ages/DOBs;
occupations/work histories; educational background; race, religion and cultural factors; Family of
Origin 3-generation data; physical appearances; history of relationship, including children,
previous “marriages”, separations, “divorces”, etc. ;illnesses/medical conditions;
income/finances; resources, including transportation, home ownership/rental arrangements; major
family cut-offs
2. History: Brief history of relationship including onset and chronology of couple events;
family of origin, extended family and partner’s family; friends and other sources of stress and
support; re-locations, neighborhood/landlord issues
3. Process: Explore what happens with differences, problems and conflicts; inquire as to how
the couple make decisions, who participates and how; explore issues of attraction and mate
selection, parenting styles, individual and couple ways of dealing with anger, grief and so on.
Joining and agreement to work toward separation or repair of the relationship
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24. Couple counseling is nothing more than getting two people to work effectively together as a team. Hurt and
betrayal must be mended and success in some joint achievement experienced.
1. Disengage and re-direct the inherent power-play
◦ Obtain commitment to work as a team (push off final decisions about the fate of the relationship)
◦ Implement a truce and exchange “acts of good faith”
◦ Turn the dyad’s energies toward a common purpose, goal or problem
2. Effective Teamwork
◦ Obstacles to effective team-work
Power-plays: over-powering (bullying) or under-powering to get one’s way or ends met
Traumatizing: wounding the partner or self-mutilation; picking the scabs off trauma
Alliances, Coalitions, Collusions, Triangulation
◦ Supports to effective team-work
Conflict-resolution skills: planning for outcome, decision-making, problem-solving
Forgiveness/Repairing Trust: tenderness, affection, appreciation and respect
Experiencing success working as a team
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25. 1. Sets appointment, cancels/no-shows; sets appointment, cancels/no-shows
2. Spouse/Partner sets appointment, partner refuses to attend
3. One sets appointment, then sabotages their partner’s participation
4. Both attend, one sees a problem, one does not
5. Both attend, both agree that one partner is the problem (identified patient/I.P.)
6. Both attend, agenda moves to Individual Counseling (I/C) or child focus (F/C)
7. Both attend, one begins to No-show (leaving therapist with partner/spouse)
8. Both attend, one drops a “bomb” (ie. sexual affair, drug abuse, major illness)
9. Both attend, one discloses their desire to separate or divorce
10. Both attend, one or both unclear on commitment (separate or remaining together)
11. Both attend, one or both continually triangulate the therapist
12. Both attend, the agenda and goal of therapy continually changes or vacillates
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