Family Therapy NCE

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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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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