Family Therapy Concepts 1

By Chris Lobsinger

2013

Family Therapy Concepts 1

• This four hour workshop is meet to introduce to participants some of the basic ideas and components that are associated with a body of knowledge referred to as Family therapy• In order to present a more congruently

it will be following the Leeds Systemic Family Therapy Model as laid out in the Leeds Systemic c Family Therapy Manual, Ms Helen Pote et al 2000

Basic concepts of System theory

• In the world of systems therapy, linear causality does not exist. Instead we find an emphasis on reciprocity, recursion, and shared responsibility

• A and B exist in the context of a relationship in which each influences the other and both are equally cause and effect of each other behaviour

Basic concepts of System theory• Over time, A and b establish patterns

characteristic of their particular relationship• Our perspective is holistic, and our focus is

on the process, or context, that gives meaning to events instead of only on the individual or the events in isolation. Our focus is also present centred, we examine here-and now interactions rather than look to history for antecedents causes.” (Leeds Systemic c Family Therapy Manual, Ms Helen Pote et al 2000)

Models of Family Therapy1. What is marriage and family therapy?

• Marriage and family therapists practice a unique profession. Family therapy began as a breakaway movement from psychiatry in the 1950's

• Marriage and family therapists may see individuals, couples, families, and/or groups, yet they retain their interactional perspective regardless of the configuration of clients

• Marriage and family therapists take an interactional perspective, and build on client strengths, rather than assumed pathology

What is the philosophy of family therapy?

• Each family operates on the basis of predictable patterns of interactions• patterns of behaviour being passed and

replicated from generation to generation• Family members are always affected by

one another's issues. 91): “• (Distant Education for Family Therapy

Counselling and Supervising -http://www.dmrtk.jgytf.u-szeged.hu/phare/eng/main.htm)

Some classifications of family therapy• Behavioural Family Therapy • Bowen theory • Brief Therapy: MRI • Contextual Therapy • Eriscksonian Family Therapy • Focal Family Therapy • Milan Systemic Therapy • Family Psychoeducational Therapy • Strategic Therapy • Structural Therapy

Types of Family Therapy

• Structural Family Therapy (Minuchin, 1974, Colapinto, 1991)• Conjoint Family Therapy (Satir, 1967)• Contextual Therapy (Boszormenyi-

Nagy, 1991)• Strategic Therapy (Madanes, 1981)• Brief Therapy• Milan Systemic Therapy (Boscolo et al,

1987)• Narrative Therapy (Freedman, Combs,

1996)

• “It is important to note that Family therapy is probably a misnomer. When family therapy is built on the assumption of systems theory, amore appropriate label would probably be relationship therapy.”• Family Therapy a systemic integration 3rd

edition Dorthy Becvar and Raphael Becvar, 1988 p12

• *Another alternative is the term systemic therapy

Contrasting individual and family Therapy

• Individual therapy Family Therapy• Asks why Asks what• Linear Cause and effect Reciprocal causality• Subjective/objective Dualism Holistic• Either/or Dichotomies Dialectical• Value-free Science

Subjective/Perceptual• Deterministic/Reactive Freedom of

Choice/Proactive• Laws & Law like External reality Patterns• Historical Focus Here-and now focus• Individualistic Relational• Reductionistic Contextual• Absolutistic Relativistic

CyberneticEpistemology/Systems Epistemology

• Metaphors of pattern Metaphors of

Material• Cybernetics Physics

• Mind Body• Communication Energy

• Biological World Physical• Organization of whole Ingredients

of whole• Qualitative analysis Quantitative

Analysis• Mechanistic Explanation Vitalistic

Explanation

Systems Focus

• In working systemically the central focus should be upon the system rather than the individual• The system may usefully be thought of

as the household or a wider family system, and may include friends, people in institutions (school, work, church)• A consistent view is that these

difficulties do not arise within individuals but in the relationships, interactions and language that develop between individuals

Systems Focus

• Rock and dog• Definition of a system• Environment-systems-subsystems• Open and closed system• Wholeness

• Boundary The interface between the system

and its environment is called the boundary of the system

Boundary The interface between the system and its environment is called the boundary of the system

Circularity• Patterns of behaviour develop within systems,

which are repetitive and circular in nature and also constantly evolving. Behaviour and beliefs that are perceived as difficulties will also therefore develop in a circular fashion

Punctuation

“Disagreement about how to punctuate the sequence of events is at the root of countless relationship struggles

Pursue/Distance

Connections and Patterns • In understanding relationships and

difficulties within systems it will be important for the therapist to consider the connections between circular patterns of behaviour• The process of therapy should enable

family members to consider these connections from new and/or different perspectives• All communication provides direct access

to world views and world views reflect processed structure.

Connections and Patterns

• Structure is like a snap shot of process

• Process is like making a movie basic on the structure

• Structure and process seen as communication reflect world view

Symmetrical and complementary interaction• Symmetrical interaction is characterised by

equality and the minimization of difference• complementary interaction is based on the

maximization of difference• Rigid symmetrical or complementary

patterns may be problematic• Meta- complementary – A lets or forces B to

be in charge• Pseudo-symmetry – A lets or forces B to be

symmetrical• Triangulation

Triangulation

Narratives and Language

• Behaviours and beliefs form the basis of stories or narratives

• The language that is used to describe these narratives and the interactions between individuals constructs the reality of their everyday lives

• At times when stories lived and stories told are incongruous change

Constructivism• This is the idea that people form

autonomous meaning systems and will interpret and make sense of information from this frame of reference• People cannot make assumptions about

what meaning will be attributed to the information they offer/contribute to others• Thus there is only the possibility of

perturbing other people’s meaning systems

Reality• Direct experience of reality (naïve reality) what

you see is what you get.

Constructivism• No direct experience of reality (constructivism)

The map is not the territory

Social constructivism

Social constructivism - elephant and the blind men

Map is the territory

Social Constructionism

• Relevant is the idea that meaning is created in the social interactions that take place between people and is thus context dependent and constantly changing

• this takes precedence over the concept of a single external reality

Cultural Context

• The therapist should consider the importance of context, in relation to the cultural meanings and narratives

• The relationship between these narratives, the therapeutic relationship and its context

• The family should be an important consideration at the point of referral and throughout the therapy

Power• The therapist should take a reflexive stance in

relation to the power differentials that exist within the therapeutic relationship, and within the family relationships

• No powerlessness

• No Power in a (Batesonian sense)

• Victim in oppressor, oppressor in victim

Co-constructed therapy

• In therapeutic interactions reality is co-constructed between the therapist (and team) and the people with whom they meet• They form part of the same system,

and share responsibility for change and the process of therapy• Particular attention should thus be

paid to the contributions that all members of the therapeutic system make in the process of change

Self-reflexivity• The therapist should aim to apply systemic

thinking to themselves and thus reject any thinking about families and their processes that does not also apply to therapists and therapy• Self-reflexivity focuses especially on the

effect of the therapy process on the therapist• In order to use self-reflexivity it will be

necessary for the therapist to be alert to their own constructions, functioning and prejudices so that they can use their self effectively with the family

Strengths and solutions• The therapist should take a non-pathologising,

positive view of the family system

• A family system that enters the therapeutic system should be considered as a system that owns a wealth of strengths and solutions in the face of difficult situations

• It is important for the therapist to recognise that there is a multi-versa of possibilities available for each family in the process of change

• The therapist can facilitate this process by attending to the strengths and solutions in the stories that the family system brings to therapy

Models of therapeutic changeFeed back - System

• In a system where a transformation occurs, there are inputs and outputs. The inputs are the result of the environment influence on the system, and the outputs are the influence of the system on the environment. Input and output are separated by duration of time, as in before and after. Or past and present

Feed back loop• In every feedback loop, as the name suggests,

information about the result of the transformation or an action is sent back to the input of the system in the form of input data

• If these new data facilitate and accelerate the transformation in the same direction as the proceeding results, they are positive feedback

• If the new data produce a result in the opposite direction to previous results, they are negative feedback

“An appropriate Fiction for behavioural Science”• Some one needs to provide a fiction for the

behavioural sciences that would work like the elegant fiction upon which physics was built-its Newtonian Particle. The idea of a recursive network with feedback structure provides a useful fiction behavioural science. (The Aesthetics of change Bradford Keeny the Guildford press New York London 1983)

Positive and negative feedback• Positive feedback leads to divergent behaviour

Positive and negative feedback

• positive feedback loop left to itself can lead only to the destruction of the system, through explosion or through the blocking of all its functions• Negative feedback leads to adaptive, or

goal-seeking behaviour: sustaining the same level, temperature, concentration, speed, direction

• In a negative loop every variation toward a plus triggers a correction toward the minus, and vice versa. There is tight control; the system oscillates around an ideal equilibrium that it never attains. A thermostat or a water tank equipped with a float are simple examples of regulation by negative feedback

Deviation amplifying feed back (positive feed back) • If the family system is to function

effectively; it must be able to encourage desirable changes in behaviour and to adapt to changes in the family members as they grow older. The positive feed back loop provides the necessary mechanism

• Difference that makes a difference• News of difference• Sameness and difference - stability and

change

Prescribed practices as in line with the Leeds model• The prescribed practices described below are

things that would not be included in a routine therapy session. It may be that on one or two occasions it is appropriate to use one of these approaches; however they must be used within a systemic framework that is, using the guiding principles outlined at the start of this manual

Advice

• As a systemic therapist you would not usually offer direct advice to the family about their interactions or the difficulties they are experiencing

• advice may be appropriate in helping the family work towards their goals, advice may be offered in a non-directive or reflexive manner. Options should be presented as choices about which the family can make their own decisions

Interpretation

• Psychodynamic interpretations about the meaning of symptoms or interactions in relation to individual or trauma would not be usual for systemic therapists

• Rather, meanings are explored in relational and interactional terms between members of the system

Un-transparent/closed practice • Therapists should not remain closed about

their working practices, ways of thinking and understanding the difficulties

• They should try to remain transparent by explaining their practices at the beginning of therapy, and during therapy as appropriate

Therapist monologues

• In the co-created process of therapy therapists should not find themselves lecturing or using long monologues in their interactions with the family

• The process should be more like a sharing of ideas between therapist and family, and between family members

Consistently siding with one person• In taking a neutral stance therapists should not

find themselves consistently siding with one person in the family

Working in the transference

• Therapists should be paying attention to the relational and engagement issues between themselves and the family with which they are working but they should not use the relational aspects between themselves and the family

Inattention to use of language

• Therapists should not be inattentive to the use of language used by the family

• They should pay attention to the both the words and phrases used, and the meanings attributed to these

Reflections

• Therapist’s simple reflections of the points or phrases that are used by the family should be kept to a minimum. Reflections may be used to enhance engagement and to develop the family’s sense of being listened to and understood, but when used, reflections should be followed by questions, and increased curiosity about the issues presented

Polarised position• Therapists should avoid taking a position which is

polarised from that of the family, or a position which is likely to escalate to a polarised position

• The therapeutic team can enable the therapist to achieve this by presenting the multiple perspectives from which the family situation can be understood

Sticking in one time frame

• Therapists should not stick in one time frame, but move the focus of their questions and discussion between the past, present and future

Agreeing/not challenging ideas

• Therapists should not be in a continual state of agreement with the family’s ideas

• They should remain curious and challenging about the nature and content of these ideas, in order to introduce new unexplored possibilities and ideas

Ignoring information that contradicts hypothesis • Therapists should not ignore, or minimise

information presented by the family which contradicts their own ideas and hypotheses

Dismissing ideas

• The ideas presented by the family about the difficulties with which they are struggling, or the process of therapy itself should not be dismissed by the therapist

Inappropriate affect

• The therapist’s affect should match that of the family, and would be considered inappropriate if it remained dissimilar from family for an extended period of time

• One example might be if the family were feeling optimistic about change and the progress they were making, and the therapist remained pessimistic

Ignoring family affect

• Therapists should pay attention to the affect that the family is showing in the session, and not ignore strong expressions of affect during the sessions

• This may be particularly relevant when a member of the family shows distress during the meeting, either by sad or angry behaviour

Ignoring difference

• Therapists should not ignore issues of difference between themselves and the family or within the family

Family Therapy concepts Part II Chris Lobsinger 2013

Plan of development

• Assessment

• Overview of specific goals

• Pre-therapy

• Initial sessions

• Middle-sessions

• End- sessions

Assessment Performa family

• Demographic Information• Genogram / Ecogram /timeline• Migration and trauma history• Referral information• Needs assessment• Family Structure/process• Change• Cultural formulation

6. Family Structure/Process

• The way in which activities within the home are organized along gender, generational lines and roles • The connections which partners maintain with their

network of friends and relatives• Partners attitudes towards their children• The way in which the family members perceive the

connection between the individual and the world (e.g. Autonomy of the individual or the individual in relation to family and generations/ in relation to culture - dominant/non-dominant)• Coalitions, alliances, boundaries, hierarchy within the

nuclear and extended families)• Communication and behavior patterns • Role and relationships clarity • Strengths (eg., coping mechanisms)

Convening Sessions

In deciding whom to invite to the firsts session

• Who is living in the household?

• Who else is mentioned as important members of the family system?

• Recent family life events, that may affect attendance e.g. childbirth / separation.

• Is further information required from referrers before therapy can commence?

Convening Sessions

• What professional systems are involved with the family? In relation to:

• i. The presenting issues.

• ii. Other issues, such as child protection.

• Would it be helpful to initiate a professional / network meeting prior to the therapy commencing?

Before the initial session discuss the therapy.

• Team working

• Attendance issues, who will be coming, how to get there, and

• ambivalence about attending.

• Therapist’s interest in hearing everyone’s ideas

• Confidentiality

Pre-therapy preparation

• Construct a genogram and ecogram from referral information

• Summarize the main themes from the referral

• Consider the recent life events of the family

• Consider difficulties which may arise around engagement and how to address these

Pre-therapy preparation

• Consider broader system issues, and define who is in the network

• Brainstorm themes/hypotheses/formulations which may be relevant to the family

Genograms

• All members of the family system, including adopted/fostered members

• Delineation of the household

• All members of the wider system

• Dates of birth

• Deaths, with dates

Genograms

• Partnerships and marriages, with dates

• Separations and divorces, with dates

• Pregnancies, miscarriages, and terminations, with dates

• Occupations / Schooling

• Any information that is missing from the referral information should be noted and enquired about during the initial session of therapy.

The Ecomap

• 1) includes the major systems that are a part of the family's life;

• 1) includes the major systems that are a part of the family's life;

• 3) portrays an overview of the family in their situation by, picturing the important nurturant or conflict connections between the family and their world;

The Ecomap

• 4) demonstrates the flow of resources or the lack and deprivations;

• 5) highlights the nature of the interfaces and indicates conflict for mediation and resources to be identified and mobilized.

Goals during initial session

• Outline Therapy Boundaries & Structure

• Engage and Involve all family members

• Gather and Clarify Information

• Establish Goals and Objectives of Therapy

Goals during middle sessions

• Develop and Monitor Engagement

• Gather Information and Focus Discussion

• Identify & Explore Beliefs

• Work towards change at the level of beliefs and behaviors

• Return to Objectives and Goals of Therapy

Goals during ending sessions • 1.Gather Information and Focus Discussion

• 2. Continue to work towards change at the

level of behaviors and beliefs

• 3. Develop family understanding about behaviors and beliefs

• 4. Secure Collaborative Decision re: Ending

• 5. Review the process of therapy

Pre-therapy preparation• Construct a genogram from referral information

• Summarise the main themes from the referral

• Consider the recent life events of the family

• Consider difficulties which may arise around engagement and how to address these

• Consider broader system issues, and define who is in the network

• Brainstorm themes/hypotheses/formulations which may be relevant to the family

Pre & Post Session Preparation

• Summary of the main themes from previous session• Information which requires clarification from previous session• Between session contact the therapist has had with the

family/wider system• The current formulation/themes/hypothesis of the issues with

which the family are bringing• Ways forward for the current session which are being

considered• Any team – therapist issues which need to be addressed

• Any family – family/team issues which need to be addressed

• CONSIDER THE 6. FAMILY STRUCTURE/PROCESS

Goals during initial session

• Outline Therapy Boundaries & Structure

• Engage and Involve all family members

• Gather and Clarify Information

• Establish Goals and Objectives of Therapy

Outline Therapy Boundaries & Structure

• IntroductionsThe therapist should introduce himself or herself as a team member and explain the role and context within which they work (the team and the centre).

• Team workingThe therapist should explain that they work as part of a team, and that the team’s role is to generate ideas and help the therapist understand the family / system.

• The confidentiality of any information discussed in the session should be outlined. Specific statements about the boundaries of confidentiality should be made in relation to other systems.

• Structure of the session Information should be given on the length of the meeting, the breaks, and the use of team feedback through messages or reflecting teams. Explain that during the break,

Confidentiality

• Structure of therapy Explain that if the family/team decide to meet again, that the meetings will be decided together by the family / team in accordance with their needs and wishes.

• Questions Time should then be spent giving the family an opportunity to ask questions and meet the team. Agreement to proceed with videoing should be confirmed, and the family informed that the video will now be switched on.

Engage and Involve all family members

•Supportive environment Initially it is very important for the therapist to provide a warm, supportive and empathic environment, to increase trust and rapport and to build the therapeutic relationship

• Hear from everyone: Therapists should try to hear from all members of the system/family, initially connecting with them all at an individual level, and assessing the level of contribution they feel they are able to make to the discussion

• Neutrality: The therapist is trying not only to hear everyone’s views but also to establish their interest in different perspectives that may be held within the system.

Gather and Clarify Information

• The concept of therapy• The system• The presenting difficulties or issues• Solutions and successes to date

Attention should be paid to collecting information in a circular manner. Although it will be appropriate to ask linear questions in collecting information, especially at this early stage of therapy, circularity can be maintained by linking multiple linear questions between family members in a circular way.

Establish Goals and Objectives of Therapy

• The therapist should consider with the system what are their goals and objectives for therapy

• The establishment of goals should be achieved in a way which expresses the Possibility of Change, and should convey the expectation that change is possible, and likely to occur

Post-session

• Review of main interventions and family’s response

• Ideas for future sessions, themes/issues to follow up,

• E.g. narrative prompts, unexplored areas, facts to check

• Feedback to therapist of team observations• Therapist’s reflections on issues evoked for

them by the session• Review of important information shared, e.g.

life events, elements of genogram• CONSIDER THE 6. FAMILY

STRUCTURE/PROCESS

Case notes

• All written records should be non-pejorative, legible, dated, signed, with no abbreviations. Alterations and Corrections should be clearly marked and signed. Case notes should include:• Family information sheet & Genogram/ecogram-

ecomap• Referral information/letter• All other written communications to and from

the centre• Record of attendance• Sessions notes• Notes on telephone contacts to and from the

centre

Session notes

Session notes should include :• Date and number of session• Who attended therapy• Therapist/Team member names• Main themes of the session – including

key language used by family• Team observations – clearly labelled

as impressions• Record of interventions• Key points/ideas/decisions to follow up

in later sessions

Middle sessions

Basic Structure for a session

• Pre-session

• Session

• Message

• End session

• Post session

Goals during middle sessions

• beliefs and behaviors Develop and Monitor Engagement

• Gather Information and Focus Discussion

• Identify & Explore Beliefs

• Work towards change at the level of

• Return to Objectives and Goals of Therapy

Develop engagement

• The therapist should pay particular attention to developing a co-constructed therapeutic relationship. In addition to attending to the three aspects of engagement from the initial meeting (supportive environment/hearing from everyone/neutrality), attention should be paid to:• Creating and offering choices about the

process of therapy• Resolving issues in the family-therapist-team

system as they arise. This will require therapists to allow sufficient time for team discussions pre and post sessions and time within sessions to discuss the process of therapy with families and any concerns or questions they have in relation to this.

Gather information & focus discussionThe therapist plays a role in developing this discussion

to develop themes and keep the discussion focused. Information may often focus on the following topics:

• The presenting difficulties or issues: Therapists’ should be collecting this information in a manner that enables circular descriptions of behavior to develop

• The family and wider system: The therapist will still gather information about the family and wider system as is necessary to understand the information and stories being presented by the family

• Solutions & Successes: The focus on the successes and solutions available to the family should be steadily increasing throughout therapy

Identify & explore beliefs

• The therapist should identify and explore the family’s thoughts, beliefs, myths or attitudes, which may be contributing to their dilemmas and difficulties

• Circular questions which build up circular descriptions of behavior can also be used to explore the beliefs and assumptions which lie behind those behaviors

Identify & explore beliefsTherapists should explore the family’s beliefs in relation

to:

The presenting difficulties.• E.g. What ideas has your wife come up with to explain

the behavior John is showing?

Relationships within the family and with the wider system.

• E.g. Who feels it is most important to keep liaising with the school over this issue?

Solutions that have been tried or hypothesized• E.g. What gave you the confidence to keep going with

this new idea?

Identify & explore beliefs

Successes in all areas of family life and relationships to the wider system

• E.g. Would that be judged as a success in your family?

Therapy process, beliefs about therapy• E.g. What led to your decision not to bring the

children to today’s meeting?

Family behavior during therapy• E.g. Jill is looking distressed, what do you think

was so upsetting for her in talking about the difficulties you are experiencing?

Work towards change at the level of beliefs and behaviours

Challenge existing patterns and assumptions:• To move with the family to a position where they

are able to query their own beliefs, perceptions and feelings• Th: How would your Nan explain the times when

you and your mum do get on well together?• John: Well she says we are alright when we stop

and listen, sometimes we can just bite off each other’s heads you see, over nothing, when no-one has really done anything wrong

Work towards change at the level of beliefs and behavioursProvide distance between the family and the problem:

• Providing distance to try and free the family from the pressure of the difficulties, so that they are more able to consider and reflect upon them. Alternative perspective circular questions and those aimed at looking at possible futures can often be helpful in achieving this

Externalize• That is to give the problem an external, objective reality

outside of the person. This can be useful in mobilizing the family’s resources to unite in working towards solutions and new ways of thinking which challenge the difficulties.

• Externalization means to put something outside of its original borders, especially to put a human function outside of the human body. The opposite of externalization is internalization

Reframing – Virginia Satir

• Reframing is altering the meaning or value of something, by altering its context or description • Reframing is a powerful change

stratagem. It changes our perceptions, and this may then affect our actions. But does changing our symbolic representation of the real world actually change anything in the real world itself?

Reframing – Virginia Satir

• A classic example of a reframe by Virginia Satir concerns a father who complains at the stubbornness of his daughter.• There are situations where she will need

stubbornness, to protect herself or achieve something. Reframing switches to a context that makes the stubbornness relevant. • It is from the father himself that she has

learned to be stubborn. By forcing the father to equate his own stubbornness with hers, this creates a context in which he either has to recognize the value of her stubbornness, or deny the value of his own

Open up new stories/explanations

Either by facilitating the family’s evolution of new ideas and narratives, or by the introduction of these ideas by the therapist. All family members will have stories about their lives, the lives of other family members, and the life of the family. Exploration of neglected information may open up the development of stories which are more helpful to the family in coping with their concerns. Information which is neglected often concerns:

• Successes• Solutions• Exceptions• Alternative views from the network• Other strengths

Elicit solutions

• It will be helpful to gather information from the family about solutions for the difficulties that they have tried or would consider useful

• Ideas generated by them are usually most helpful and linear questions are often used to develop an overview of solutions that the family have tried or thought of

• Amplify change: In order to maximize the change or potential change that is occurring throughout the course of therapy it will be important for the therapist to focus on statements the family present about progress

• Enhance mastery: To encourage the family to gain a sense of mastery or control over their situation, their thoughts, feelings and behaviors. This should enable the family members to take responsibility for their own roles and actions, and for the process of change

Introduce therapist/team ideas

• May include the therapist sharing their ideas and hypothesis about the family, individual, or difficulties, for a variety of reasons. Including:

• Normalize difficulties

• Move the family to new ideas

• Connect family’s ideas

• Suggest ways to organize the discussion, e.g. Enactments

Linear questioning

• Direct linear questions can often be useful in gathering information from the system and clarifying information given, especially at the beginning of therapy

Circular Questions

Circular questions are aimed at looking at difference and therefore are a way of introducing new information into the system. They are effective at illuminating the interconnectedness of the family sub-systems and ideas

Statements

Statements are used by the therapist for 3 main functions:

• To clarify and acknowledge a communication from the family

• To comment on the position or emotional state of a member of the family

• To introduce therapist/team ideas, directly or in the form of a reflecting team.

• In using statements therapists should ensure that they are not of long duration, and do not become therapist monologues

Positive connotation

• From the Milan systemic group, a complex paradoxical reframing technique which includes all family members and the system itself

• Each family member's contribution to the problem is reframed as an effort to solve problems and help meet the family's needs

Metaphor

• A figure of speech in which a word or phrase that ordinarily designates one thing is used to designate another, thus making an implicit comparison, as in “a sea of troubles” or “All the world's a stage” (Shakespeare)

Narrative description

• Utilizing the interactional dynamics of family therapy, people can deconstruct oppressive and debilitating perspectives, replace them with liberating and legitimizing stories, and develop a framework of meaning and direction

THE MIRACLE QUESTION Steve De Shazer

• "If you go to bed tonight and when you awake in the morning a miracle has occurred overnight and everything is going well in your marriage, then how would you know (or indeed how would any on else know, like a relative or a friend?......Note: because your are asleep you won't know that there has been a miracle) ...what will be different?...What will you see? What will you be hearing, doing, feeling? What are you going to notice if the problem is no longer there, what is it that is different about the situation that demonstrates to you that the problems has been replaced by solutions?....what else?....

Tasks• Noticing tasks• Between now and next time we meet, we would like you to

observe , so that you can describe to us next time what happens in your family that you want to continue to have happen (De Shazer and Molnar 1984)

• Writing tasks• Counting tasks• Using a piece of string, count the ( to tie knots in) number of

time that you compliment someone in your family between now and the next time we meet.

• Playing tasks• Hugs without warning• E.G. Given to each participate secretly the job to give a

family member a hug without warning.• Turn taking tasks• E.G. Planning a family activity

• Naming the dilemma• Change pattern• Proscribe problem• Counter paradoxes:• Therapeutic double binds.• For example the family was warned

against• premature change. The family feels more

acceptable and un-blamed for how• they are while at the same time challenged

to change. • The belief is that you can’t give a direct

prescription

Reported responses

Return to objectives and goals of Therapy

The therapist should return to the issues of goals for therapy as therapy progresses:

• If goals seemed unclear during the initial stages of therapy, it may take some time and thought with the family for them to consider the areas they want to change in therapy, or to find priorities for change.

• If goals are achieved, so that goals can be renegotiated, perhaps for change at a wider system level, or a decision to move towards the end of therapy is made

• If goals change due to changing circumstances for the family

Goals during end sessions

• Gather Information and Focus Discussion

• Continue to work towards change at the level of behaviors and beliefs

• Develop family understanding about behaviors and beliefs

• Secure Collaborative Decision re: Ending

• Review the process of therapy

Gather information & focus discussion

• The Presenting difficulties or issues

• Solutions and Successes to date

• The System / Wider system

Continue to work towards change at the level of behaviour and beliefsIt is more common in end sessions for the focus to be

on the following methods:• Amplifying change: In order to maximize the

change or potential change that is occurring throughout the course of therapy it will be important for the therapist to focus on statements the family present about progress

• Enhancing mastery: To encourage the family to gain a sense of mastery or control over their situation, their thoughts, feelings and behaviors

• Challenging existing patterns and assumptions: To move with the family to a position where they are able to query their own beliefs, perceptions and feelings

• Reframing: Reframe some of the constraining ideas presented by the family. Relabelling in a positive way, ideas and descriptions given by family members, in a manner which is consistent with their realities

Developing new stories and explanations

• Successes & Solutions

• Strengths

• Exceptions

• Alternative views from the network

Develop family understanding about behaviours and beliefs

As therapy ends it will be important for the therapist to work with the family to develop and encourage their understanding of the process of the development of difficulties. Underlying family interactional patterns.

• Motivations for assumptions, behaviors and feelings.

• Understanding of a family member’s reactions to other’s behaviors

Collaborative ending decision

The timing of ending is not always obvious and in aiming to make the ending process a collaborative process the therapist and therapy team should be alert to a number of signals in sessions:

• Positive feedback from the family: the family situation or the issues they presented are reported as improved or improving

• Negative feedback from the therapy: The family report dissatisfaction about the therapy, or the progress they are making

• Therapist notices changes: Missed sessions by the family. Changes in the level of engagement in therapy. Therapist notices positive changes in the way the family are interacting during sessions

The team should consider the following issues and then gather the family’s views on these:

• Whether the family might feel it was appropriate to end therapy, do they feel they have achieved what they set out to achieve?• How might the family prefer to end therapy, would

they like a follow up appointment or would they like to re-contact the team if necessary?• Might the family feel it would be important to

engineer systems of support, before therapy ends?• With whom should the team share information

about the therapy and what has been achieved, e.g. referrer, school.• A useful and engaging way of saying goodbye to

the family

Once this information has been shared decisions should be reached about:

• When therapy will end.

• What follow up arrangements will be made.

• What the family might do if difficulties should arise again.

• Who will be contacted post therapy

Review the process of therapy

• It will be helpful for the therapist to invite the family to review the process of therapy.

• What has been gained/lost for the family through therapy?

• Any misunderstandings not addressed during therapy should be clarified and addressed.

• Reasons for therapist’s behaviors and procedures used.

• What might the family do differently if future difficulties arise?