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NCE – FAMILY THERAPY STUFF

TWO ORGANIZATIONS TO REMEMBER 

  1. AAMFT –American Association for Marriage and Family Therapy. Philosophically believe that MFT is a separate profession.
  2. ACA – IAMFC (Subdivision of ACA). Philosophically believes that it is a subspeciality, after getting general knowledge & experience.

OVERVIEW OF FAMILY THERAPY

  1. 1937 Nathan Ackerman, MD (Analytic Child Psychologist) “The family as a Social and Emotional Unit”. The grandfather of family therapy and founder of psychoanalytic family therapy.

    1. Used Freudian psychodynamic principles. (dream analysis, life history, transference, catharsis).
    2. Linear Causality (Cause/effect Model) Psychoanalytic family therapy stresses one thing causes another.
    3. Object relations – something a child wants to bond with to meet its needs. Intrapsychic conflicts from one’s family of origin continue to affect the individual relationship with his/her spouse and children.
  2. Analytic Object Relations Therapy Expert James Framo – This factor gets in the way of people changing because they have parental introjects.

    1. Introjection happens when you incorporate a parent’s attitude as your own. Introjects are imprints or memories of the past that are generally based on unresolved issues with parent
    2. Splitting – occurs when young child turns an object into all good and all bad and internalizes this perception. If not resolved, individual will review people as all good or all bad or will see same person as either all good or all bad.
  3. 1965 – Virginia Satir (Conjoint Family Therapy) the therapist joins with the family to improve family functioning. This means the family works with two or more family members.

    1. Delineated four patterns or styles of dysfunctional communication that exist when families experience stress
      • Placator – please everybody in family. People pleaser
      • Blamer – insists all is everyone else’s fault
      • Super Reasonable Analyzer – detached and calm, intellectualization.
      • Detractor – removed and talks about things that are totally irrelevant.
    2. Virginia Satir & Carl Wittaker – Experiential Family Counselors or Experientialists.
  4. Collaborative & Concurrent Family Therapy – popular cause initially insurance companies won’t pay for couple / family therapy…

    1. Collaborative Therapy – each family member sees a different therapist and occasionally they convene to take look at the situation.
    2. Concurrent Family Therapy – one therapist sees everybody individually.
  5. Network Family Therapy – People from the outside such as neighbors and colleagues are brought into the therapy sessions.

  6. Multiple Family / Couple’s Therapy approach – resembles group therapy and the treatment audience is actually made up of several couples/families.

    1. The family is the identified patient.  Goal is to address an unhealthy homeostais
    2. homeostasis – family interacts in ways that keep things in balance and maintain the status quo. They are naturally resistant to change.
    3. Most therapies rely on circular feedback. Individual relies on linear.
      • Linear – you are afraid of animals young attacked by dog.
      • Circular – You impact other members in a family but their behavior also influences you
  7. Murray Bowen – a client was functioning appropriately in hospital but regresses in home. According to those believe in family model it works better than treating a single client.  What they believe…

    1. When relationship between family members changes, symptoms go away.
    2. Interpersonal and not intrapsychic
    3. Look at the dysfunctional family system….
    4. Family is client – pathology is in family.
  8. Double Bond Hypothesis – 1954 by Gregory Bateson. Family members are sometimes placed in a no-win situation.  Person who is recipient of double bind receives two mutually exclusive person and cannot respond appropriately.  Can lead to schizophrenic behavior.

  9. Family System Theory – The family is an open system since people can leave and enter freely. Three key hints.

    1. Equifinality – similar outcomes can occur in family from different origins. Family can achieve similar goals in different ways.
    2. Equipotentiality – same processes can produce markedly different results.
    3. Focusing on the Past too much in counseling and therapy – genetic fallacy.
    4. Feedback comes from the theory of cybernetics – a system uses feedback to stay same or correct itself. A process that the family uses to adjust itself.
      1. Negative – family goes back to way it was in past. Remains and keeps same
      2. Positive – family forced to change and cannot stay in previous state.

Major Schools of Thought

Behavioral Family Therapy & CBT Therapy

  1. Behavioral family therapists use interventions quite often based on BF Skinner’s Operant Conditioning stuff below r/t this section….
    • Positive Reinforcement.
    • Punishment
    • Charting
    • Extinction
    • Premack Principle
    • Systematic Desensitization
    • Social Learning Theory.
    • Sensate Focus.
  2. CBT Therapists – Would rely on Albert Ellis’s or Aaron T. Beck’s reframing. Dysfunctional behavior is learned and can be unlearned.  Focus on thinking processes and cognitive distortions.
  • FOR EXAMPLE – QUID PRO QUO contracts. This phrase means something for something.  Is used to get two people to engage in a comparable and functional behavior.
  1. IMPORTANT PEOPLE HERE:
    • Gerald Patterson – behavioral theories to families often in 1960’s. Taught families to utilize these things with families.
    • Neil Jackson – also family behavioral approach. Used a lot.
    • Richard Stuart – Also pioneer in behavioral family therapy. Good families and marriages thrived on this something for something quid pro quo concept.
  2. Criticisms of This: are the systems that mimic what goes on in an individual session using these same modalities.  Focus on the individual rather than the family session. Since it violates the rules of family therapy and therefore often criticized by family therapists. Too mechanistic and simplistic.  Ignore Family dynamics and emotions…

Family Systems Theory

  1. (Ludwig Von Bertolanthy all living elements are connected.). All living elements are connected. Need to look at an entire system to understand a human or animal’s behavior.
    1. Likes Circular causality and focuses on insight more than behavior.
    2. Murray Bowen born 1913 and died in October 1990.
    3. First family division director at NIMH.
  1. A single therapist is used for the entire family but would have each family member talk to the therapist to ward off argument.
  2. Differentiation – or “being yourself” is the goal for each individual.
  3. Family Projection Process – We each have a level of differentiation that matches our family. Called this.
  4. Created theory in 1950’s after examining triangles.
    1. When things going well we operate in dyads – two’s
    2. When anxiety builds, third party builds, someone enters to support someone. This rarely helps and causes further problems.
    3. Murray sez de-triangulation is vital.
    4. Goal to respond not merely react to family system.
  5. Going Home Again Technique
    1. Individual in treatment literally returns home to family of origin to better understand the family.
    2. “Extended Family Systems Theory Approach”. – Murray sometimes people in beyond the immediate family. Considered to be an in-depth model of treatment.
  1. Birth Order Important.
  2. Disturbed behavior transmitted from one generation to the next. Called mult-generational transmition, or multigenerational therapy.
  3. Used Genograms quite a bit. Helps grasp family patterns and history in a pictoral family tree assessment.
  4. Effective but difficult to research.

Structural Family Therapy

  1. Structural FamIs an action oriented approach created by Salvador Minutchen. Every family has a structure and organization.  Dr. Mnuchin retired in 1996 and he lives with his family in Boston Mnuchin focuses on parent child relationships rather than on the three generational model proposed by Boeing area Punty is also associated with the structural model
  2. Minutchen born 1921 received medical training in Argentina. Came to U.S. in 1950 has training in Psychoanalysis.  Families of Slums, book he wrote.  Is the spokesman for family therapy in the 60’s.
  3. Altering family structure/organization is critical.
  4. Two basic problems with disfunctional families.
    1. Family members are emeshed/chaotic, very closely connected.
    2. Family members are disengaged/isolated.
  5. Family is a multibodied organism with three key subsets
    1. Marital spousal system – husb/wife interactions
    2. Parental subsystem – parental interaction with kids
    3. Sibling subsystem – interaction amongst siblings.
  6. Boundaries are critical, loosen or establish these.
    1. Healthy boundaries – firm yet flexible.
    2. Dysfunctional families –
      1. Rigid boundaries – families disengage
      2. Diffuse boundaries – everyone is in everyone else’s business.
  7. What does a structural family therapist do?
    1. Relies on a number of critical steps
    2. FIRST – inital session counselor is joining, same wavelength. Everyone met and greeted and has social exchange with each member.
    3. TRACKING used, this is a person-centered approach, (reflecting/attending/open-ended questions).
    4. MIMESIS – copying behaviors of someone to seem more like them. Aligning self with that particular person.
    5. REFRAMING- used to change the perception that a client has about him/her self.
    6. INTENSITY –  intensity is achieved when you repeat a message again and again are do you change the distance between family members intensity can also occur if the counselor encourages a family interaction to go beyond the time that the discussion would normally occur sometimes intensity has been referred to as putting pressure on the family the extra time can create nurturing or produce a higher level of conflict to help the family get to a new level of functioning

Strategic Marriage and Family Therapy 

  1.  WHO IS JAY HALEY?  Ok moving right along I’m going to discuss Jay Haleys strategic marriage and family therapy.   Haley came to the mental research Institute in Palo Alto California in 1962 this approach is also known as the problem-solving model.  initially Haley was not trained in counseling psychology psychiatry our social work his degree was in arts and communication in 1967 he became the director of the well-known Philadelphia child guidance clinic in 1976 he created the family therapy Institute.
  2. This paradigm has a number of interesting caveats…..
    1. you should always see the entire family if possible
    2. Use a second Therapist if you can or a team of therapists behind a one-way mirror as consultants
    3. assume that the first session must be successful in order to perform successful therapy
    4. during that crucial first session trailing gauge every family member
    5. during that first session re-define the problem as that other family not the identified patient initially let the family discuss the problem don’t you get involved is the counselors
    6. give a directive at the end of the session another words give the family in assignment or a prescription that focuses on a single goal paradoxes used a lot in this model hence a client who has panic attacks is instructed not to try to stop them but rather to hold onto them and even intensify them yes you heard me correctly the therapist prescribed the problem to the client as a homework assignment often without an explanation

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NCE – Assessment Section

FIRST, You need to know some things about assessing and/or estimating attributes of the client….(i.e. appraisal)

Testing – now 7% of job as a teacher. 20-37% of a high school counselor’s work.

A Test is simply a systematic way of assessing a sample behavior.  Select the appropriate test format. The manner in which the test items are presented.  Should consider the following.

  1. Objective or Subjective Test?
    1. Scoring procedure is specific.
    2. Essay for example will based on subjective impression.
  2. Free response items or Recognition Items.
    1. Free response items – can respond however you choose.
    2. Recognition Items – forced choice items.
    3. ABCD Structure – multipoint item
    4. Likert Scales are considered multi-point recognition items
    5. Agree/Disagree item – dichotomous recognition item.
  3. Normative or Ipsative Measure
    1. Normative each item independent of all other items. You can legitimately compare various people who have taken the test.  (i.e. I.Q. or MMPI)
    2. Ipsative – person being tested needs to compare items with each other. Occupational preference surveys.  You cannot legitimately two or more people who have taken a ipsative measure.  Strengths/weaknesses within a specific person.
  4. Speed versus Power Tests –
    1. Speed test – keyboarding test. Timed and assesses accuracy.
    2. Power Test – not timed. Achievement Test is a power test.  Level of difficulty of individual taking the test. Nobody can receive perfect score ideally.
  5. Maximum / typical Performance Measure –
    1. Maximum – assesses best possible performance (Achievement Test)
    2. Typical – A typical or characteristic performance (Interest Inventory)
  6. Spiral versus Cyclical –
    1. Spiral -items get more and more difficult.
    2. Cyclical – several sections each of which is spiral in nature.
  7. Vertical versus horizontal
    1. Vertical -different forms of the test for various age groups / grade levels.
    2. Horizontal – measures various factors at once.
  8. Test battery to describe the situation where we administer a group of tests to the same person. Can be combined into a profile.   More accurate than merely assessing the individual with a single measure.
  9. Parallel Forms / Equivalent Forms –
    1. Test has various versions that all measure the same thing.
    2. Parallel Forms – each person takes different version of test.

NEXT, you should be concern with the quality of the test.  How good is it?  There are two things to consider.  Most critical issue is validity & Second is reliability.

  1. Validity – does test measures what it purports to measure.
    1. Content validity – extent that the test samples the behavior that it is supposed to.
    2. Construct validity – refers to the extent that a test measures an abstract trait, construct, or psychological notion.
  • Criterion-Related Validity – test is correlated with an outside criterion (i.e. a standard).
    • Concurrent Validity – A job test might be compared to an actual score on an actual job performance.
    • Predictive Validity – predict future behavior. (GRE scores).
  1. Face validity – does it look like it is testing what it is supposed to.
  1. Reliability – refers to whether a test will consistently yield the same results. Does the score remain stable over repeated measures.
    1. Experts often assert that the quality of a test is determined by validity and reliability. A reliable test is not always valid.  However, a valid test will always be reliable.
    2. Test-Retest Reliability – simply test same group using same measure 2x and correlate to see if consistent.
  • Equivalent Forms Reliability – to equivalent forms of same test administered to same pop and correlated.
  1. Split-Half Method – examiners take whole test and split it in half with two tests. And a correlation made between two halves of the test.
  2. Interrater reliability – with subjective tests. You take the test and then have two independent raters grade it and see if scores are similar.
  3. Reliability coefficient can tell you if it is reliable.
    • 00 is perfect reliability in the test. Happens with physical measure
    • Coefficient .90 or +.90 is considered really good in a psych test.
      • .90 is accurate
      • .10 is d/t error

Intelligence Testing

  1. Francis Gaulton – intelligence is a unitary factor that was normally distributed like height or weight (Bell shaped curve). 1869 he chose 197 men who achieved fame.  It was 300x more likely that famous person would have a famous relative.  Gaulton felt it was a product of genetics.  ½ cousin Charles Darwin.
  2. Charles Spearman – 1904 British psychologist postulated a 2 factor theory of intelligence, (G & S Factors)
  3. Louis Thurston – intelligence is a series of factors, primary abilities. Used factor analysis to develop these.
  4. P. Gilford – 120 elements add up to intelligence. Best remembered for dimension of convergent and divergent thinking
  5. Raymond B. Katell – two forms of intelligence. Fluid intelligence and crystalized.
    1. Fluid – dependent on nervous system and the ability to solve complex novel problems.
    2. Crystalized – application of fluid to education. Is the ability to use facts.
  6. James McKean Katel – mental test coined in 1890. First person to use psychological tests to predict academic performance.
  7. FIRST INTELLIGENCE TEST – Alfred Binet French psychologist & French doctor Theodore Simone in 1905. Revisions occurred in 1908 and 1911. The first test was named the Binet Simone scale.
    1. In 1904 the French government wanted to discriminate normal Parisian children from those who were mentally deficient.
    2. Teacher’s could not be trusted to make this distinction.
    3. Dull children could be separated from the others and placed in a simplified curriculum….
    4. Used the concept of age-related tasks.
    5. Binet never believed his tests measured intelligence.
  8. Intelligence Quotient – IQ is divided computed us Wilhelm Stern’s formula
    1. Mental Age / Chronological age x 100 = IQ.
    2. This is know as a ratio IQ.
    3. oday prefer deviation IQ. Compare obtained IQ against a normative sample
  9. Louis Turman – 1916 adapted for American Usage. Stanford Binet. Updated in 1937 and again in 1960 and 1986 the MA/CA no longer used.  Not called IQ.  Now called SAS “Standard Age Score” at this time.   Since 2003 the standford Binet intelligence scale 5th edition, has been used and can be administered ages 2-85 and beyond.  The current version created by Gale H. Royd uses 10 subtests.  5 verbal subtests and five nonverbal subtests.  Mean is 100 and SD is 15.  One small controversy remains.  The old Form LM is till the best test for measuring ability of gifted individuals.
  10. Weschler Scales – Mean score is 100 SD is 15. David Weschler first published in 1939 Weschler Bellevue.  Grew in popularity for adults.
    1. WAIS-3 most popular adult intelligence test in the world. 14 sub-tests. 7 verbal subtests and 7 performance subtests.  Verbal IQ / Performance IQ and full IQ.
    2. WISC-IV – for children is used for ages 6-16 11 months. Takes 50-70 minutes. Six verbal subtests and subtests.
  11. WIPSI-3 Weschler preschool and primary scale of intelligence revised for ages 2/6mths – 7/3mths. Takes 1.5 hours.  Wipsi is long, can administer over two sessions.  The rationale is that children at this age have difficulty concentrating for long periods of time.
  12. Infant and Preschool IQ tests – useful to pick up mental retardation. Predictive validity is extremely poor of IQ-
    1. Denver Developmental Screening Test 2
    2. Bailey Scale of Infant Development (BSIDII) – most widely used. 1-42m
    3. FTII Fagan test of infant intelligence.
    4. Tests given before age 7 do not correlate well with tests later in life.
  13. Group IQ tests – not as accurate as individual tests. Began in 1917 Army Alpha and Army Beta testing recruits during WW2. In WW2 the Army general classification test AGCT test.  Armed forces qualification tests.  Used frequently in schools.
    1. PROS – don’t need special training to give. Give to many people.
    2. CONS – Not as accurate
  14. Asian Americans score highest then European Americans, then Hispanic Americans and at the bottom African Americans.
    1. Some feel any IQ test should be a culturally fair test. (eliminate BIAS)
    2. Culture fair tests do not predict academic performance as well
    3. ake them culture free…take problems on test and make them problems that would not depend on knowledge of any culture.
  15. Heated debate in social science has been over racial differences in IQ. Arthur Jensen had social science community arguing back and forth when publishing 1969 article which states that blacks scored 11-15 points lower than whites and this can be due to genetics.  Robert Williams created the BITCH test “Black Intelligence Test of Cultural Homogenity”.  Any black inner-city child that a duce and a quarter is a Buick Electra 225.  How many high IQ kids would answer this question.
  16. SOMPA – System of Multicultural Pluralistic Assessment. Eliminate Culture from tests and create culture-free tests.  Some say you can eliminate culture from an exam.  Proponents of these test remind us that they tell us nothing about our makeup.  They are good predictors of success in life.
  17. The FLYNN Effect – IQ tests worldwide are going up. We are unsure whether it is because of better nutrition, earlier maturation.  Or increase practice of video games.

Personality Testing

 MMPI – Minnesota Multiphasic Personality Inventory (MMPI-2)

  1. First published in 1943 by Hathaway and McKinnley extent of emotional disturbance and helps with diagnosis using 567 true/false questions.
  2. 10 clinical scales –
    • Hypochondriasis – Concern about health.
    • Depression
    • Hysteria – use of physical/mental symptoms to avoid symptoms
    • Psychopathic Deviante
    • Masculinity/Feminity
    • Paranoia – suspicious
    • Psychasthenia – excessive worry or guilt
    • Schizophrenia
    • Hypomania – overlyactive
    • Social Introversion – Shy

Myers Briggs Type Indicator – Based on Carl Jung theory of types four bipolar scales which result in four letter type.

  1. Exam hint. Myers Briggs a theory based inventory since it Is based on a theory. MMPI is a criterion based inventory since it compares a person taking it to a criterion group.
  2. Self-report inventories like MBTI more accurate than projective tests. Projective test shows neutral stimuli and asked to interpret, (ink blot).

Other Misc Personality Things….

  1. Rorschach inkblot test – Association Projective test, ink blot test…what does the blot bring to mind. Most popular ink blot measure for ages 3 and up.  By Herman Rorschach using 10 ink blot cards.
  2. Construction Projective Test – TAT Thematic Apperception Test. Person being tested is asked to describe make up or construct about a picture on a card.  The picture is ambiguous.  Created by Henry Murray and Christina Morgan in 1935.  Orignally based on needs pressed theory today you can utilize psychoanalytic.
  3. Expressive Projective Test – draw a person or house/tree/person test. Bender Gestalt test, a test of organicity and screens for brain damage.
  4. Arrangement Projective Test – place pictures in a sequence and discuss why in this order. Sentence completion test.  Difficult to hide things here….

Interest & Aptitude testing

  • Interest Inventory – Occupational and Educational Interests. Students younger than the 10th grade show instability in interests and the interests may not be that valid.  It is very easy to give untruthful responses on these.  Strong Interest Inventory (SII) Based on Holland’s six types. Most famous.
    1. Ask people who are happy and successful for three years what they like.
    2. When a person’s profile matches this, then a particular profession might be appropriate.
    3. Self-directed Search (SDS) administered by self and scored self.
    4. Fairly reliable and nonthreatening.
  • Aptitude Test – measure an inherited capability rather than what you have learned.
    1. ACT/SAT/GRE – examples
    2. Great aptitude must have superb predictability.
    3. GATB – assesses 9-12 students and adults on pen and pencil
  • Achievement test – what have you learned and are primarily used in educational settings. National Counseling Examination. GRE….Some books call GRE tests that measure aptitutde and achievement both.  Some tests cross this fine line.
  • STANDARD ERROR OF MEASUREMENT (SEM) How accurate or inaccurate a test is. The Standard Error is a measurement of the variation in a single person’s score of he/she would take test again.
    1. EXAMPLE IQ TEST STANDARD IQ ERROR +/- 3.
    2. YOU GET 100
    3. 68% YOU FALL BETWEEN 97-103.
    4. SMALLER PERCENT OF TIME YOUR SCORE WILL BE HIGHER/LOWER
    5. INACCURATE TO SAY THAT BOB SMARTER THAN NANCY IF ONE IS AT 100 and ONE AT 102.
    6. AKA CONFIDENCE LIMIUTS OF THE TEST.

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OCD Treatment Approaches

PAPER ONE

Abstract

This paper reviews the two treatment approaches to Obsessive Compulsive Disorder (OCD) described in Chapter thirteen of our Orvashel, et al, (2001) textbook.  Family Systems Therapy and Cognitive Behavioral Therapy Methods are described and contrasted.

This assignment focuses on a case study in chapter thirteen of our Orvashel, et al, (2001) textbook.   In this case study, we learn about a 12-year-old, 6th grader by the name of Jack, who lives with his parents and younger 9-year-old sister.  He has been referred for outpatient services for a worsening of OCD symptoms over the last several months.  While Jack was diagnosed approximately three years ago, his ability to cope with OCD has become increasingly problematic.   In an assigned video this week we hear an OCD sufferer describe the fears associated with it as a mental torture in which you realize the irrationality of your thoughts and actions, but feel compelled toward them nonetheless (Mayo Clinic, 2008).  This insight provides a useful starting point for understanding Jack’s symptoms.   As a result of his OCD, Jack has experienced difficulty in several areas of his life.  His relationship with others has become strained, and ability to participate in home and school-related tasks is suffering.

CBT and Exposure Therapy

In our textbook’s hypothetical case scenario, the therapist utilizes a CBT approach coupled with exposure therapy.   From this perspective, a neurobehavioral case conceptualization describes Jack’s OCD as a byproduct of individual vulnerabilities and environmental factors (Orvashel, et al, 2001).  Jack’s OCD is reinforced by his perceived understanding of the contingent relationship between his obsessive fears and the compulsive reactions he uses to cope.

Naturally, regardless of what method a therapist might use, psycho-education is an essential starting point.  While this family has been dealing with this for quite some time, it is important to make sure that they are interpreting his behaviors and symptoms correctly.  I like the textbook’s description of these behaviors and thoughts in utilizing a computer language with terms such as “bad microchip” and “re-programming” (Orvashel, et al, 2001).  This psychoeducational process should provide Jack with an overview of the therapy process and its purpose to “reprogram” and learn to talk back to his thoughts so they can no longer control him.

Before initiating exposure and response interventions, the therapist will need to create  a hierarchical list of anxiety-provoking situations with Jack.  This hierarchical list could then be utilized to expose Jack to these anxiety producing situations.  The goal in doing so, the goal would be to provide Jack an opportunity to utilize CBT coping methods as an alternative to his compulsive habits.  These CBT coping methods can include, for example, relaxation methods or a cognitively based “talking-back” (Orvashel, et al, 2001, p279) technique.   Including exposure-related at home, with the guidance and participation of his parents, can allow further habituation to occur.  While these technique’s don’t cure OCD, they are successful in decreasing anxieties and overcoming his compulsions.

Family Systems Therapy

An alternate case conceptualization of Jack’s OCD can involve an examination of any areas of familial dysfunction.  This model might useful if family characteristics are observed during treatment that indicates family therapy is warranted.  Orvashel, et al, (2001) state that oftentimes familial dysfunction

References

MayoClinic [Screen Name] (2008, May 13) New treatment for kids with obsessive compulsive disorder-Mayo Clinic. Retrieved from:  http://www.youtube.com/watch?v=OcXn3m3M-U0
Orvaschel, H., Faust, J., & Hersen, M. (Eds.). (2001). Handbook of conceptualization  and treatment of child psychopathology.  Oxford, UL: Elsevier LTD.

PAPER TWO

This assignment focuses on a case study in chapter thirteen of our Orvashel, et al, (2001) textbook.   In this case study, we learn about a 12-year-old, 6th grader by the name of Jack, who lives with his parents and younger 9-year-old sister.  He has been referred for outpatient services for a worsening of OCD symptoms over the last several months.  While Jack was diagnosed approximately three years ago, his ability to cope with OCD has become increasingly problematic.   In an assigned video this week we hear an OCD sufferer describe the fears associated with it as a mental torture in which you realize the irrationality of your thoughts and actions, but feel compelled toward them nonetheless (Mayo Clinic, 2008).  This insight provides a useful starting point for understanding Jack’s symptoms.   As a result of his OCD, Jack has experienced difficulty in several areas of his life.  His relationship with others has become strained, and ability to participate in home and school-related tasks is suffering.

CBT and Exposure Therapy

In our textbook’s hypothetical case scenario, the therapist utilizes a CBT approach coupled with exposure therapy.   From this perspective, a neurobehavioral case conceptualization describes Jack’s OCD as a byproduct of individual vulnerabilities and environmental factors (Orvashel, et al, 2001).  Jack’s OCD is reinforced by his perceived understanding of the contingent relationship between his obsessive fears and the compulsive reactions he uses to cope.

Naturally, regardless of what method a therapist might use, psycho-education is an essential starting point.  While this family has been dealing with this for quite some time, it is important to make sure that they are interpreting his behaviors and symptoms correctly.  I like the textbook’s description of these behaviors and thoughts in utilizing a computer language with terms such as “bad microchip” and “re-programming” (Orvashel, et al, 2001).  This psychoeducational process should provide Jack with an overview of the therapy process and its purpose to “reprogram” and learn to talk back to his thoughts so they can no longer control him.

Before initiating exposure and response interventions, the therapist will need to create  a hierarchical list of anxiety-provoking situations with Jack.  This hierarchical list could then be utilized to expose Jack to these anxiety-producing situations.  The goal in doing so, the goal would be to provide Jack an opportunity to utilize CBT coping methods as an alternative to his compulsive habits.  These CBT coping methods can include, for example, relaxation methods or a cognitively based “talking-back” (Orvashel, et al, 2001, p279) technique.   Including exposure-related at home, with the guidance and participation of his parents, can allow further habituation to occur.  While these technique’s don’t cure OCD, they are successful in decreasing anxieties and overcoming his compulsions.

Family Systems Therapy

An alternate case conceptualization of Jack’s OCD can involve an examination of any areas of familial dysfunction.  This model might be useful if family characteristics are observed during treatment that indicates family therapy is warranted.  Orvashel, et al, (2001) state that oftentimes, familial dysfunction until the therapist notes that Jack fails to progress through treatment successful and suffers an array of setbacks (p283).   For example, if one of Jack’s parents worried excessive and tends to enable him.  This might involve acknowledging and agreeing with his obsessive worries, and helping him avoid feared items while facilitating compulsions.  As an alternative, other symptoms indicative of a family dysfunction can be if jack’s illness somehow draws attention to other family issues, such as marital disharmony.

In such cases, it would be necessary to involve the entire family in treatment.   This might involving teaching Jack and his parents about alternative CBT-oriented coping methods.  This would allow the parents to model healthier methods of coping with anxiety so they can work together on exposure-related homework interventions.   Addressing how Jack’s OCD behaviors fit within the larger family system would also be essential.   How does the family adapt to these behaviors, and what purpose does Jack’s OCD serve in maintaining the interpersonal homeostasis?

Comparing Therapy Methods

When utilizing CBT to treat OCD in childhood, individualized psychopathology is the focus.   The case conceptualization is based on a nature versus nurture, neurobiological perspective.   Jack obsessions and compulsions are the focus of therapy in this instance.  The treatment response is to focus on exposure therapy with homework assignments that build on these efforts.   The family’s inclusion in therapy is limited to any facilitative efforts they might engage in at home to help Jack utilize alternative CBT coping methods.

In contrast the family systems perspective, looks at how Jack OCD fits within the larger family system.  Rather than focusing on individualized psychopathology, the concern is familial dysfunction.  Addressing how families adjust to Jack’s OCD, and greater issues in home environment influence his progress in therapy are the key issues.

Ideally, I would think both these perspectives are best when utilized in tandem.  Regarding CBT, I would be interested in learning it in depth in the future since it is used so frequently throughout the therapy field.  Regarding family systems therapy, I would be very interested in developing solid clinical judgments that can allow me to see the bigger picture.  To be honest, I think both perspectives are very pertinent and it would be a disservice to exclude either one.

References

MayoClinic [Screen Name] (2008, May 13) New treatment for kids with obsessive compulsive disorder-Mayo Clinic. Retrieved from:  http://www.youtube.com/watch?v=OcXn3m3M-U0
Orvaschel, H., Faust, J., & Hersen, M. (Eds.). (2001). Handbook of conceptualization  and treatment of child psychopathology.  Oxford, UL: Elsevier LTD.

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MCC662 – Child’s Communication Needs

A child’s play is an intrinsically motivated, nonliteral and imaginative activity that provides them with a nonverbal mode of communication while facilitating development (Landreth, 2002; VanFleet, et al, 2010).  Children are strongly motivated to engage in activities that capture their attention and reflect their inner world.  As a therapist, play therapy allows us a view of a child’s beliefs, feelings, intentions, and perceptions (VanFleet, et al, 2010). The therapist’s role is to establish a relationship with children through play and create a safe environment that is accepting, respectful, and sensitive to their needs, (Play Therapy, Basics for Beginning Students, 2006).   In doing so, it is important for a therapist to adjust his interventions to suit a child’s unique needs.  Communication must be adapted to a child’s developmental needs, cultural perspective, and life experiences (Landreth, 2002; VanFleet, et al, 2010).  Below, I provide an overview of how every child’s needs might vary and how to adapt accordingly.

Variations in a Child’s Needs

Landreth, (2002) utilizes the metaphors of molasses vs. popcorn, and orchid vs. mushroom, to describe the varied approaches children display to life’s problems (p50).  Understanding a child’s unique developmental, sociocultural, and interpersonal needs essential in order to adapt effectively.   Understanding how a child’s needs can vary is a first step to contextualizing observations during therapy.   What follows are just a two examples.

Variation in Stages of Play

Children can be observed displaying stages of play during therapy.  VanFleet, et al, (2010) discuss stages of play that include: (1) warming up, (2) aggression, (3) regression, and (4) mastery.  These stages are a convenient assessment of a child’s progress while in therapy (VanFleet, et al, 2010).  In contrast, Landreth, (2002) mentions stages with an emotive focus that include observable stages represent the gradual development of greater self-awareness.

Systems Theory & Ecological Perspectives

Other variations in a child’s needs can be understood from a systems theory and ecological perspective (Metcalf, 2011; VanFleet, et al, 2010).  From a systems theory perspective problems are reflective of the home environment.   A complex web of interpersonal relationships in a child’s home often has a circular causality, which influences the child in complex ways (Metcalf, 2011).  Adding to this insight is an ecological model of human development (VanFleet, et al, 2010).  This ecological model describes children as embedded within an immediate family, community, neighborhood, as well as culture (VanFleet, et al, 2010).  These contexts further complicate the nature of each child’s unique and highly varied needs (Gil & Drewes, 2005).

Diagnoses & Presenting Problems

The discussion board posts this week are convenient examples of how children often bring complex issues to therapy.   Diagnoses such as PTSD, ADHD, and autism, each present with unique challenges for a therapist during play therapy.  Complex issues such as severe neglect or sexual abuse often require a multidimensional approach in which one singular intervention is rarely sufficient (VanFleet, et al, 2010).

Adapting to a Child’s Needs

Molasses vs. Popcorn

Adapting to a child’s needs is no simple matter in light of all the ways it can vary from individual to individual.   Since play is a form of communication, adapting a child’s unique needs is essential so this can be possible.   Landreth, (2002) provides an excellent example in his utilization of the popcorn and molasses metaphor to indicate varied energy levels present in play therapy.  VanFleet, et al, (2010) discuss two cases that are excellent example of the molasses and popcorn metaphor found in Landreth (2002).  In one case, VanFleet, et al, (2010) share the story of a nine-year-old boy with ADHD who would around in therapy like popcorn.  Therapists captured his attention and intrinsic motivation by providing physically engaging activities he enjoyed (VanFleet, et al, 2010).  Directive play interventions decreased his impulsivity (VanFleet, et al, 2010).

In contrast, VanFleet, et la, (2010) also discuss another case of a boy about the same age with PTSD who had grown up in a domestic violence situation.  With symptoms of hypervigilance, night terrors, depression, and explosive anger, he was brought to therapy (VanFleet, et al, 2010).  Initially, he refused to talk and played alone in a corner.  The therapist was patient and let him move at his own pace.  Nondirective Child-Centered Therapy was utilized in which the therapy provided a safe, accepting presence (VanFleet, et al, 2010).

Guiding Principles

The above examples are a convenient illustration of how I might respond to varied levels of energy in play therapy.   The underlying goal in any interventions would be to provide an environment in which a child can engage a play-oriented communicative exchange with the therapist.  With a goal of providing a non-judgmental and accepting presence, it would be my goal to respect the child’s own self-actualizing tendencies (Landreth, 2002).  Allowing the child to lead the way, would mean being in tune with their needs and patiently following along with adaptations necessary to maintain a therapeutic environment (Landreth, 2002).

Expected Challenges

I have worked as a C.N.A. and Psych Tech for about 13 years.  In this span of time, I am frequently assigned to a patients on a 1:1 basis for safety purposes.  Based on this background, I have noticed the greatest difficulty with adolescents and children who are defiant and oppositional.  In the context of my position, I am required to set limits, so the patient adheres the rules of the acute care units while maintaining safety.

Setting aside my roles as mother and health care worker, are required in the play therapy context.   This would present the greatest challenge for me personally.  The nature of a play therapist’s interaction with children is based on an attitude of respect and acceptance.  Providing these qualities requires an awareness of how I am present with the child from moment to moment.  The intentionality and self-awareness underlying all this, would be essential in order to be fully present and provide a child unconditional validation.

References

Gil, E., & Drewes, A. A. (2005). Cultural issues in play therapy. New York: Guilford Press.

Landreth, G. (2002) Play therapy: The art of the relationship (3rd Ed.). New York, NY: Oxford University Press.

Metcalf, L, (2011). Marriage and family therapy: A practice oriented approach. New York: Springer Publishing Company

Play Therapy: Basics for Beginning Students [Video file]. (2006). Microtraining Associates.  Retrieved September 10, 2015, from Academic Video Online: Premium.

VanFleet, R., Sywulak, A. E., & Sniscak, C. C. (2010). Child-centered play therapy. New York: Guilford Press.

 

 

 

 

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MCC 662 – Play Therapy

In therapy, we give to others based on who we are, and not what we know.  Landreth, (2002), asserts this is especially true for when working with children.   Creating a therapeutic atmosphere, displays of personal courage, and self-understanding, are important for therapists when working with children (Landreth, 2002).   Below, I describe each of these qualities and discuss areas in need of improvement.

Personal Assessment

Creating a Therapeutic Atmosphere.

The adult-child relationship that exists in the context of play therapy is unique in every child’s experience (Landreth, 2002).  Rarely experienced with adults, child therapists engage in a playful interaction that is not “verbally bound” (Landreth, 2002, p96).  Child therapists display a genuine sensitivity and interest in a child’s thoughts and feelings.  Landreth’s (2002) description of the respect and sensitivity required in play therapy, reminds of Marsha Linehan’s concept of emotional validation.  When a child’s perspective is met with validation, they allowed experience acceptance, understanding, and a sense of legitimacy (Linehan, 1997).  Rather than managing or correcting a client’s feelings, a child therapist should seek to respect the validity of this experience from the child’s viewpoint (Linehan, 1997).  The intentionality required to provide this therapeutic atmosphere, requires a great amount of awareness (Landreth, 2002).

When I consider all that is required to provide this therapeutic environment, there are several areas of improvement that come to mind.  As a mother, letting go of “mommy-mode” will be a challenge as I adopt the child therapist’s perspective.   The disciplinary and limit setting elements of motherhood would need to take a back seat.  Additionally, as someone who tends to process things verbally, letting go of this mode of interaction for a play-oriented one, would be a new experience for me.  One key strength I bring is an appreciation of validation, as a critical element in all therapy (Linehan, 1997).  I feel my current profession, has provided me many opportunities to develop this basic skill.

Personal Courage.

Landreth (2002), discusses several personality characteristics essential for a child therapist.  When reviewing these characteristics, I thought personal courage presented the biggest challenge for me personally.   Landreth (2002), describes it as a willingness to admit our mistakes and shortcomings (p102).  This concept is similar to Brene Brown’s (2006), notion of vulnerability which she defines as a willingness be truly seen by risking exposure.   This sort of personal courage goes against one’s natural psychological defenses against hurt or shame (Brown, 2006).  Acting as a child therapist out of personal courage requires a non-defensive expressiveness.  On the one hand, I do have much patience, and am fairly secure in acknowledging my shortcomings (Landreth, 2002).  These qualities can help me display personal courage in my interactions with children during therapy.  On the other hand, I do believe a high degree of self-awareness and mindfulness is required.  This requires an amount of self-care that is currently hard to sustain, as a night-shift worker.   Hopefully, with a different work schedule in my future career, this could be remedied somewhat.

Therapeutic Self-Understanding.

An awareness of our “motivations, blind spots, and biases” (Landreth, 2002, p103), is critical for any therapist.  As Landreth, (2002) notes, the values and ideals underlying these issues are integral to who we are, and we should be aware of them for this reason.  Since we give to others on the basis of who we are, it is our responsibility to understand how these issues can impede or promote our efforts.   While I do consider myself to be a highly self-aware individual as a lifelong self-help junkie, this quality still presents a challenge.  The idea that my personal motivations or biases could enter a play therapy setting makes me cringe somewhat. The best solution is to make personal growth and self-care is a priority.  This would allow me to gain a awareness of how I become an integral part of the therapeutic relationship so I can act more proactively.

Plan for Improvement

As I read through the above descriptions of three essential qualities, I realize  improvement is unlikely to occur overnight.   As a student therapist, I believe personal development should be an ongoing concern.  The following goals can help me develop these essential skills for working with children in therapy.

  1. Goal One: Seek Opportunities to Work with Children.   While this class can provide a vital foundation of knowledge to begin working with children, experience is essential.   I need to seek opportunities to work with children, in order to better understand how to be of a therapeutic benefit in this community.  This can include seeking work-related opportunities, volunteering, and choosing my internship placement carefully.
  2. Goal Two: Be Mindful of How You Respond to Others’ Emotions. The therapeutic environment child therapist’s seek to create provides clients with a unique respectful and validating experience.  Being mindful of how I choose to “attend” to the emotions and thoughts of all children in my life is a good start.  How do I take time to listen and acknowledged the grain of truth in my sons’ feelings and thoughts?  Do I rush to correct any misperception without listening?   Considerations such as these, can help me understand how realistically develop this unique way of relating to children and adolescents.
  3. Goal Three: Display Personal Courage in Conversations with Sons.  My oldest son is 15 and lately I’ve found the personal dynamic between us changing.  He is very bright and observant, and can at times bring up issues that touch upon my own mistakes and shortcomings.  While he doesn’t do so in a disrespectful way, I find I may react with occasional twinges of defensiveness.  I’ve currently practiced, the vulnerability that is integral to personal courage in these conversations.  This effort has taught me what Landreth (2002) says about how we give to children on the basis of who we are and not our internal knowledge bank.
  4. Goal Four: Journal Regularly & Seek Therapy As Needed.  Prior to entering this program, I had been in therapy for about five years.  I still remain in contact with my therapist, and as needed, I may still visit her from time to time throughout my career.  I believe self-understanding requires commitment in the form of adequate self-care coupled with time for reflection.  I enjoy journaling and blogging, and these efforts have provided great insight into myself.  I will continue doing these things in order to promote greater self-understanding in my new role as a therapist.

References

Landreth, G. (2002) Play therapy: The art of the relationship (3rd Ed.). New York, NY: Oxford University Press.

Linehan, M. (1997).  Validation and psychotherapy. Washington, D.C.: American Psychological Association.

Brown, B. (2006). Shame resilience theory: A grounded theory study on women and shame. Families in society: The journal of contemporary social services,87(1), 43-52.

 

 

 

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Studying for the NCE – Behavioral Therapies – A Closer Look

For the second part of this paper, an article will be reviewed that is titled: “Behavioral Couple Therapy:  Building a Secure Base for Therapeutic Integration” (Gurman, 2013).   This article begins with a historical overview of how individual and couples-oriented behavioral therapies have developed.  At the conclusion of this paper, are comments on how Integrative Behavioral Couple’s Therapy can help a practitioner provide a secure base for couples.

A Historical Perspective

n an effort to dispel a historically negative caricature of behavioral therapy Gurman (2013) provides a historical review of behavioral therapy’s course of development.  According to Gurman (2013), despite the historical distrust of this method, approximately 80% of all couple and family therapists now utilize it (p115).   Next is a review of Gurman’s (2013) description of behavioral therapy’s development and application.

Individual Behavioral Therapy

Behavioral therapy’s origins begin with Pavlov’s classical condition and Skinners operant conditioning models.  During individual behavioral therapy’s first wave of development in the 50’s and 60’s, efforts were being undertaken to address the deficits of psychoanalysis (Gurman, 2013).  The stimulus-response learning perspectives of early behavioral therapy were nonetheless criticized as emphasizing first-order changes and a mechanistic in orientation (Gurman, 2013).  Bandura’s social learning theory introduced behavioral therapy’s second wave of development (Gurman, 2013).  In an effort to address a wider range of difficulties, cognitive variables were incorporated with behavioral therapy methods.   Finally during behavioral therapy’s third wave of development cognitive behavioral approaches were applied to an ever increasingly range of issues.  The influences of eastern thought and Buddhist practices were then integrated into many third wave therapies, including Acceptance and Commitment Therapy, and DBT (Gurnman, 2013).  In reaction to the early first-wave behavioral therapies, these third wave CBT therapies emphasized a holistic perspective that considers the importance of context.

Behavioral Couple’s Therapy (BCT).

Interestingly, the development of Behavioral Couples Therapy (BCT) followed a similar path as its individualized variant.  During its first wave of development Gurnman, (2013) describes Operant-Interpersonal Treatment for Marital Discord (OMIT, and Traditional Behavioral Couple Therapy (TBCT).  OMIT, closely resembling early forms of individual behavioral therapy and focuses on each partner’s responsibility.  OMIT focuses on changing behavior with techniques that include techniques and marital token economies, and Quid Pro Quo Contracts (Gurnman, 2013).  TBCT, also a first wave couples behavioral therapy, includes a rewards vs. cost perspective.   Skill development became the focus for TBCT, based on the notion that “nastiness begets nastiness” (Gurnman, 2013, 119).   Since Gotmann’s research has confirmed the uselessness of these early interventions, BCT has developed well beyond its historical origins.

Cognitive-Behavioral Couple’s Therapy (CBCT) constitutes the second wave of BCT’s evolution and development (Gurnman, 2013).   With this perspective the emphasis on skills training was now considered too limiting.  Internal psychological process including automatic thoughts and schemas gained attention in BCT’s ongoing development.  Internal belief structures, and each partner’s attachment history, gained new attention through CBCT.

Integrative Behavioral Couple’s Therapy (IBCT)– The Third Wave

Gurnman, (2013) concludes his paper with a description of BCT’s third wave approach: Integrative Behavioral Couple’s Therapy.  IBCT is a unique form of behavioral therapy that appreciates individual differences and facilitates empathy (Gurnman, 2013).  Central to this approach is non-judgmental perspective in which a holistic analysis is given priority.  The context of a given situation, is important in understanding why behaviors and interactions persist.  In IBCT, context refers to “the term used for changeable steams of events that can exert an organizing influence on behavior” (Gurnman, 2013).  Understanding the function and purpose of behavioral patterns means examining context.  This requires a close examining of a early child experiences, attachment histories and recurrent core themes or patterns in a relationship.

Unlike the earlier forms of Behavioral Couple’s Therapy (BCT) in its third wave of development, insights have been incorporated to address effectively Gotmann’s perpetual problems (Gurnman, 2013).   Functional analysis is useful in explaining how the effects of context and the causal historical underpinnings of ongoing interpersonal relationship patterns.  Techniques and skills taught therapy, can provide a secure and safe place to discuss issue openly during a session.  For example, carefully wording one’s words, by using “I” to discuss one’s feelings and “it” to describe problems in a neutral third-part context are convenient examples (Gurnman, 2013).   Other unique interventions include tolerance-building, which involves a process of learning to find new experiential meaning in the midst of ongoing unsolvable conflicts.  This technique is quite intriguing since it reflects an insight of the Gottman’s regarding masters and disasters and how they take in life experiences.

IBCT – Providing a Secure Base

In conclusion, I would like to make a few comments on IBCT and its ability to provide a secure base during therapy (Gurnman, 2013).  While earlier versions of BCT involve interventions that involve directly modifying thoughts and behaviors, IBCT utilizes a new approach (Gurnman, 2013).  The goal in IBCT appears to involve linking individual experiences with relational ones in an order for the couple to understand each other better.  A mutual understanding of context, provides for the development of more adaptive interactions, and greater empathy.  As a result, alongside pragmatic behavioral changes, are deeper insights that allow partners to develop a greater appreciation for one another.

Underlying this transformation, I’m quite intrigued by how Gurnman (2013) describes the therapist’s role in this process.  As Gurnman (2013) states, rather than micromanaging clients’ behavior, the therapist is watching ongoing functional patterns throughout therapy, and allowing this to play-out.  Gurnman, (2013), describes therapists as barometers, who are wholly present, maintaining a non-defensive and mindful stance throughout sessions.   From this perspective, Gurnman (2013) states that the functional analysis is enriched with the underlying meaning and affective functions of behaviors.  By “wondering aloud” (Gurnman, 2013, p133), within a safe environment, the therapist can introduce these insights to couples in session.

Finally, Gurnman (2013) concludes his article with the following comment:  “The therapist’s emotional resonance to such implicit experiences can greatly facilitate the identification of controlling variables in the couple’s problem themes” (p133).   This insight reflects a comment by Dr. Heitler in the assigned “Angry Couple” video (Holland & Schein, 1995).  In this video, we see Dr. Heitler becoming frustrated at one point during therapy with this angry couple.  She uses this emotional reaction, as a way of understanding and facilitating the variables that underlying their ongoing conflicts (Holland & Scheiin, 1995).  I had great appreciation for how Dr. Heitler was able to remain present and non-defensive throughout this process.  She used this emotional reaction as a guidepost for her interventional techniques (Holland & Schein, 1995).

References

Gurman, A. S. (2013). Behavioral couple therapy: Building a secure base for therapeutic integration. Family Process, 52(1), 115-138. doi:10.1111/famp.12014
Holland, J. (Director & Schein, L. (Producer. (1995).  The Angry Couple [Video File].
Psychotherapy.net. Retrieved November 11, 2015, from The Psychotherapy.net Collection.
Lebow, J. (2006, Sep). FROM RESEARCH TO PRACTICE, scoreboard for couples therapies. Psychotherapy Networker, 30 Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/233324408   ?accountid=28125

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Studying for the NCE – Personal Lesson about the Binuclear Family

Ahrons, et al, (2006), describe the binuclear family as a concept that helps normalize a broken home situation in a healthy way.  This term refers to situations in which one family member lives in two homes as the result of divorce. (Ahrons, et al, 2006).  Since nobody in my extended family has ever divorced, my experience with binuclear situation is very limited.   For this reason, I find it interesting that unresolved conflict is the norm in a binuclear family situation.   Upon learning this fact, I’ve stopped to examine my personal beliefs about conflict.  In my family of origin, conflict is conceived of in a highly negative manner.  My parents are college professors who tend to “lead” with their intellect.  As a result emotions take a back seat and issues were “discussed” calmly.   This typical manner of handling issues stands in stark contrast to shows such as “Rosanne”, which my mother always hated.  According to here, it was off putting because everybody was rude to one another.   To this day, as a result of those experiences, I tend to have difficulty with conflict.

Ahrons, et al, (2006) describe conflict as a component of the nuclear family, which must be normalized.  Rather than defining it in highly negative terms, Ahrons, et al, (2006) see it as an issue to manage.  Improving communication styles, examining boundaries and establishing roles are just a few ways in which the therapist can help a families manage conflict more effectively

Most Rewarding Challenges

Helping a family getting unstuck from dysfunctional patterns of interaction would be especially rewarding to me.  This starts as the family learns to see the situation differently by taking time to consider all perspectives of a situation in a therapy session together.   With this understanding in place, this video introduces the concept of a limited partnership that involves a redefinition of the co-parenting relationship (Ahrons, et al, 2006).  Small changes such as developing clear boundaries and roles can make big differences for children.

Most Difficult Challenges

The therapist in this video cautions against allowing our beliefs and values to enter the therapeutic situation (Ahrons, et al, 2006).  Self-awareness is critical in order to prevent imposing our beliefs upon others.   As I’ve stated earlier, I have a problem dealing with conflict.  In a previous position, I worked in a law office with several family law attorneys.  As the individual responsible for preparing many of the legal documents, I often found myself in the middle of conflict.  Family therapy situations such as the one in this video wouldn’t be overwhelming to me.   However, in families with greater levels of dysfunction and conflict, I might become overwhelmed.   The therapist in this video makes a point of noting that beginning therapists often become anxious with so many people in the room together who don’t get along (Ahron, et al, 2006).  This may become me, especially if you add addiction and domestic violence to a situation.

Handling Difficult Challenges

As a therapy student, I don’t think avoiding difficult situations would be the best option.  Working on developing the skills necessary to address these issues effectively would be the best route to take.   I need  to educate myself on issues I have little experience with, such as addiction.  Finally, I will need practice on learning how to manage conflicts in the directive manner as described in this video (Ahrons, et al, 2006).

References

Ahrons, C. R., Graumann, P., Lerner, S., & PsychotherapistResources.com. (2006). Making divorce work: A clinical approach to the binuclear family (Instructor’s version. ed.). San Francisco, CA: Psychotherapy.net

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Studying for the NCE – Family Secrets

In a video Dr. Imber-Black (Family Secrets, 2006), defines secrets as information which is withheld from someone that produces distress and shame as well as create symptoms of dysfunction in a family.  Keeping secrets requires a degree of heightened tension and anxiety.  Communication is less open and individuals are less emotionally present.  For the secret-keeper a feeling of shame perpetuates the secrete and an anxious worry that “if you knew you wouldn’t love me anymore” pervades their thinking  (Family Secrets, 2006).  In contrast the person unaware of this secret, exists in the family as an outsider within the system.  At some level they are aware of this fact and that there is a problem, but they feel they are not supposed to notice. (Family Secrets, 2006).  In addition to worry and confusion, individuals left in the dark begin to doubt their own intuitions.  Over time, family secrets develop into a systemic problems that affect many generations.  Imber-Black (Family Secrets, 2006), describes relationships as booby-trapped, waiting to explode symptomatically as a result of the ongoing secrecy.  Triangles, betrayal, and hidden-alliances as just a few symptoms of secrecy in families that can develop over time (Family Secrets, 2006).  In the end, nobody is able to live as a whole individual in full acknowledgment of the truth (Family Secrets, 2006). In time boundaries are laid down in which those who know and don’t know become divided (Family Secrets, 2006).  Symptoms of these secrets are maintained and supported by efforts as by family members to maintain secrecy for the sake of a systemic homeostasis.

Secrets Supporting Symptoms

Imber-Black states that “knowing, but acting like you don’t know and pretending you are what you are not” are key components of secret keeping (Family Secrets, 2006).  With this in mind, what exactly is meant by Imber-Black’s assertion that “secrets support symptoms” (Family Secrets, 2006)?  The maintenance of family secrets requires a concerted and coordinated effort by everyone in the family.   These efforts can involve the closed communication systems, rigid boundaries and emotional distance.   By keeping a secret, the family is able to maintain homeostasis, although change is unable to happen for the better.  For this reason, I am in agreement with Imber-Black’s therapeutic stance regarding the Reiger family secrets.  While Imber-Black is supportive of whatever decision the family makes, and allows them to move at their own pace, she makes her position clear (Family Secrets, 2006).   Secrets restrict the free flow of information, harming everyone involved.  The secret keeper, is left with distress and shame and unable to live life outside this reality (Family Secrets, 2006).  At the same time, this secret violates a person’s right to know, and “affects their ability to freely [process all information] about their lives” (Family Secrets, 2006)

Understanding The Positive Outcome

What factors attributed to a positive outcome in this particular case?  Not all  instances of revealing family secrets, are likely to go as well as they did within the Reiger family.   Fortunately several important factors were working in their favor.  Firstly, I feel it helps that Dr. Imber-Black was the therapist.  As an individual who has studied, written, and researched extensively on this issue, she was able to delineate several symptoms of family secrecy in the video.   Additionally, I do feel it helps that some time has pasted since the tragic circumstances of Jerry’s death.   The emotions surrounding these events are a bit “less raw”.   I also think the strength of Ray and Liz’s marriage helped them work through this issue together.  They appeared willing to listen and support each other throughout this process.  Finally, while Liz’s parents and Jerry’s family had strong opinions about their marriage at the time, fortunately they were able to move past these issues.  It seems they were open-minded enough to see things from Galen’s viewpoint, and how this secrecy was a dis-service to him.

In cases where things do not go very well, I would expect to see a family divided, as a result of this new information.  The mourning of a lost relationship is strangely similar to a death “of sorts” as family members stopped communicating.  The end result is a long process of  “radical acceptance” and “forgiveness” in order to begin moving forward.  The toughest thing in such cases is the realization that you can only have control over your own actions and behavior.

I greatly appreciated the fact that the instructor included this video.  I struggled with the hypothetical ethical scenarios several weeks ago that touched on this very subject.  Having this information in hand, provides a useful perspective with which to better clarify one’s understanding of the systemic effects of secrecy.

References

Family Secrets: Implications for Theory and Therapy [Video file]. (2006).Psychotherapy.net.

Retrieved October 15, 2015, from The Psychotherapy.net Collection.

Imber-Black, E. (1999). The Secret Life of Families: Making Decisions about Secrets:  when Keeping Secrets Can Harm You, when Keeping Secrets Can Heal You–and  how to Know the Difference. Bantam Dell Publishing Group.

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Studying for the NCE – Gottmans

Abstract

This paper provides a review of an assigned video titled, “Building Trust, Love and Loyalty in Relationships”.   It is a videotaped lecture of John & Jill Gottman, who have devoted their work to understanding relationships.

Question One: “What do these therapists identify as the key ingredients to promoting successful marriages?”

The assigned video this week, we hear John and Julie Gottman discuss the results of almost 30 years of research on marriage.  According to their studies, approximately 69% of all conflicts in a relationship are unsolvable and a byproduct of temperamental differences and lifestyle preferences (Building Trust, Love and Loyalty in Relationships, 2013).   Based on their research they could predict with 90% accuracy the status of a relationship in five years time (Building Trust, Love and Loyalty in Relationships, 2013).   The key to their predictive accuracy lies in examining how the couple handles conflict.   He describes these couples that have participated in his studies as falling within two general categories:  masters and disasters.  The disaster couples become more visibly agitated during conflict. In fact, these disaster couples often display signs that the relationship is doomed in what John Gottman describes as “The Four Horseman of The Apocalypse” (Building Trust, Love and Loyalty in Relationships, 2013).   During a conflict, disaster couples engage in finger pointing, defensiveness, contempt, and stonewalling (Building Trust, Love and Loyalty in Relationships, 2013).  In contrast, master couples are able to maintain calm during conflict, and display empathy, interest, and respect.  The key to long-term success in such cases is an attitude of appreciation and respect even through ongoing conflict.   Criticisms handled with an attitude of pointing toward rather than away.  Describing gently what one wants and how one feels then prevents defensiveness, and the other individual is able to respond with listening and acceptance.   Over time, these couples develop an appreciation and respect and learn to look at their lives together in terms of what they have to be grateful for.

Question Two:  “Do you think that it is possible to build healthy marriages in a counseling session?”

At one point in the video Julie Gottman, describes a counseling session with a couple from Alabama.  In a session, she describes how the wife shares something pivotal, about how her father kidnapped her at night as a young child after divorcing her mother.  As a result of the trauma associated with being separated from her mother, she vowed that she would never let anyone control her again.  This insight was pivotal for the couple, and helped her husband understand why she was always so controlling.  After describing this story, Julie Gottman discusses how this pertains to their theory of marriage.  The uppermost levels of their marriage theory pertain to the notions of shared meaning.  Understanding the perspectives at which the other person is able to take in life experiences is critical.  Are you able to honor and appreciate their meaning system, and how their life experiences and actions reflect this?   Examples, such as this, provided by the Gottman’s show how effective their theory of marriage has served their efforts as therapists.  I do believe that it is possible to build healthy marriage in counseling sessions, given that the couple is motivated and willing to work on the relationship.    Insights such as what is provided in the Gottman’s theory of marriage, when coupled with pragmatic changes can transform the quality of a relationship.

Question Three: “For you as a counselor, what do you view as obstacles or difficulties in conducting successful marriage counseling?”

One key obstacle to conducting successful marriage counseling is if each individual entered with divergent long-term views of the relationship.  If one couple was much less motivated than the other to work on the relationship, there would be limitations to the degree of success.    Other obstacles and difficulties to marriage counseling would include severe mental illness and substance abuse.  Finally, histories of abuse and/or trauma during childhood may complicated the degree of success in marriage counseling, unless these past events were worked through first.

Question Four: “Do any of the issues that are presented differ for same sex couples vs. heterosexual couples?”

In the assigned video, Dr. Gottman didn’t find any significant differences between heterosexual and homosexual couples.  For example, regarding the issue of stonewalling, both lesbian and gay couples, appeared to engage in this behavior equally (Building Trust, Love and Loyalty in Relationships, 2013).  It is important to note, that the Gottmans’ research was based on a laboratory study.  The couples spent weekends in a camera-equipped apartment and observations were isolated to this context.  I do firmly, believe differences between same sex and heterosexual couples would have been observed, if real-world behavioral analysis could have occurred.  For example, Patterson, et al, (2009) briefly mentions challenges unique to same-sex couples including: prejudice, same-couple composition, lack of social-support.   Examining the couples, contend with issues such as these may provide unique insights not found in the Gottman’s studies.

Question Five: “Share one (or more) new insights into marriage counseling that you learned from this video.”

From this video series, I learned that my hubby and I are actually doing very well.  We displayed several ongoing habits common in the Master couples, described by Gottman.  The biggest insight that stuck with me, from this personal perspective was their description of the three love stages.  In the final stage of love, commitment appears to reflect a feeling of gratitude, which involves the fourth level of perspective taking from their marriage theory.   The rose-colored glasses notion involving seeing the best in your partner related to this idea.  It also pertained to how one choose to take in the experience of life, were you seeking for things to be grateful for or criticize?  As I understand it, this final stage of commitment is a feeling of gratitude that permeates all things that transpire between a couple.  Underlying this insight is the simple realization that it is how I’m looking at something and not just what I’m looking at, that is critical.  This video gave me a renewed appreciation for my marriage and the life I’ve created with my husband.

 

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Studying for the NCE – CBT Family Therapy Defined

Metcalf (2011) states that CBT family therapy is based on Albert Bandura’s social learning theory.   Behavioral origins include skinner’s operant conditioning and Pavlov’s classical conditioning.  From this perspective, the cognitive processes people utilize are important when trying to understand how they make sense of their reality.  The behavioral influences provide insight on how beliefs and behaviors are observed and replicated in families.  With all this in mind, change occurs in CBT family therapy when new ways of thinking and interaction are allowed to occur.   This therapy is a present-oriented approach requires a direct and active role of therapists.

One Concept:  Invalidating Environment

Metcalf (2011) spends quite a bit of time discussing Dialectical Behavioral Therapy, a model designed originally by Marsha Linehan, for patients with Borderline Personality Disorder.  A key theoretical concept in DBT is the invalidating environment.  This concept is based on the biopsychosocial model, which asserts mental health is a byproduct of individual vulnerabilities and environmental factors.   According to Linehan, invalidating environments are situations in which a person’s private experiences are met with disapproval and rejected.  Metcalf, (2011) states that in an invalidating environment a person is made to feel they should “not feel what [they] feel” (p97) or think what they think.  Understanding how invalidating environments affect a child’s emotional development is an important insight for parents.

Strengths of CBT

Strengths of CBT include its focus on the present alongside the direct and active role therapists take on when utilizing this model.  I also appreciate that CBT provides both insight and pragmatic solutions for families.  These factors allow this theory to be used in many contexts and even brief therapy.

References

Metcalf, L, (2011). Marriage and family therapy: A practice oriented approach. New York: Springer Publishing Company

 

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