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296 PROCESSES IN FAMILY THERAPY Where families face a diffi cult dilemma, a perspective on the validity of each course of action may be presented as a split message, as in the fol- lowing example: I’m struck by the fact that there are two different ways of looking at this thing. On the one hand you could say, this problem has been with us for too long. Its really time now to plan a way out of this mess no matter what it takes. On the other hand, you could say, changing our situation. Taking on this problem. Trying to agree on a plan. And then trying to follow through is going to lead to more fi ghting, more confl ict, more hassle. It’s just not worth it. Let’s pull out now to avoid further disappointment. These are two different viewpoints. Both are valid. Between now and the next session you may wish to think about each of these different positions. Where factions within the family or network hold polarised viewpoints and are unable to reach a consensus because they believe that one view is right and the other is wrong, then presenting multiple perspectives may help them see that all viewpoints have some validity and that the central therapeutic task is to fi nd a shared perspective that helps resolve the prob- lem (rather than the right answer or the one true perspective). The team were impressed by the strength with which each of you hold your differing viewpoints on how best to tackle this problem. They were, however, divided in their views. Half of the team, like you Mrs ABC thought that this is a situation that requires a softly, softly approach, because they know that in the past ABC has responded to this and so may do so again. The other half of the team took your approach Mr ABC. They believed that a strict, fi rm but fair approach was called for. They feared the worst if the problem was not nipped in the bud. However, there was a consensus among all of us, that whichever approach you go for in the end that you will need to agree on it or it will be very confusing for your child, DEF. With refl ecting team practice, during a break towards the end of the ses- sion, the family are invited to observe the team refl ecting on the interview that has just occurred between the family and the therapist. The refl ec- tions may offer comment on the problem, explanations for it and possible solutions. In refl ecting team practice it is important to use the clients’ own language and avoid jargon; to frame comments respectfully and empa- thetically; and to highlight family strengths that may contribute to a solu- tion. Here are some refl ections from such practice where a family have a child with a chronic illness: (Team member 1) One thing that went through my mind when I was listening to that conversation is how committed everyone is solving this problem that, on the face of it, seems overwhelming. (Team member 2) It occurred to me how brave ABC was being. Really brave. Having this chronic illness, but just hanging in there and keeping going. That really stood out for me. The idea that being brave and keeping going are the way to do it. INTERVENTIONS FOR BEHAVIOUR, BELIEFS AND CONTEXTS 297 (Team member 3) I felt like I could see DEF’s point of view very clearly. You know. The idea that sometimes it easier just to turn off. Tune out. As a sort of survival thing. Like, if you let yourself worry about this sort of stuff all the time, then it would be too much. (Team member 4) I was struck by how GHI explained her sense of exhaustion and then linking that to the really busy schedule she has. And then linking that back to the demands of caring for a child with a chronic illness. In all that I was hearing a need for sharing the load a bit more. (Team-member 1) Another thing that was really clear to me was the idea that there is a better way to do things. I think that was an idea mentioned by everyone especially ABC. I think these were the main themes that came up for us today. Will we leave it there? The invitation is now for ABC, DEF and GHI to discuss and refl ect on our comments. To see what fi ts and what doesn’t. Ok? Externalising Problems and Building on Exceptions With externalising problems and building on exceptions the overall aim is to help clients fi rst separate out the problem from the person; identify the effects of the problem on the person; identify and amplify situations in which the person was able to modify or avoid the problem including recent pre-therapy changes; develop a self-narrative that centralises these competencies; empower the person who has overcome the problem to let other network members know about these competencies and support their development; and develop a personal narrative that links the current life exceptions to clients’ past and future. This resource-based approach to therapy has been pioneered by narrative (Freedman & Combs, 1996) and solution-focused (Miller et al., 1996) therapists. It is common when externalising the problem with childen to give the problem a name so that it is personifi ed. For example, with soiling, the problem may be named Sneaky Poo (following Michael White’s practice); with covert problems, Mr Mischief; with aggression, the Hammerman; or with compulsions, Tidy Checker. Here is an example of a line of question- ing that aims to externalise a child’s diffi culties in controlling aggression and build on exceptions: Let us call the force that makes you hit people you care about the Hammerman, OK? What age were you when you fi rst noticed the Hammerman was affecting your life? Did the Hammerman make things between you and your mum/dad/brother/sister/ friends/teachers, better or worse? Tell me about a time when the Hammerman was trying to make things between you and your mum/dad/brother/sister/friends/teachers go wrong, and you stopped him? How did you stop the Hammerman, that one time? Who was there? 298 PROCESSES IN FAMILY THERAPY What happened before you beat him? How did you beat him? How did you feel afterwards? What happened then? You beat the Hammerman that one time. Were there others? Because you have beaten the Hammerman, what does that say about you as a person? Does it say that you are becoming strong? Grown-up? Smarter? Would you be interested in noticing over the next week how you will beat the Hammerman again? Will you come back and tell me the story about how you beat him again? When you beat him again, you will receive a certifi cate for beating the Hammerman and copies of this will be sent to a list of people you think should know about your victory. Will you think about who should be on that list? With adults, it may be less developmentally appropriate to personify problems, although often people do. For example, Churchill referred to depression as his ‘Black Dog’. The following line of questioning is addressed to an adult with depression and makes use of pre-session changes (which are quite common) as a way of identifying exceptions: When did you fi rst notice depression was coming into your life? How long have you been fi ghting against depression? How has depression been affecting your relationships with your husband/wife/son/ daughter/friends/people at work? What feeds depression? What starves depression? If 10 means you are really winning the fi ght against depression and 1 means you are losing, right now much are you winning? When you called for an appointment a week ago, how much were you winning on this 10-point scale? You say you are winning more now than a week ago. You have moved from 2 up to 4 on this 10-point scale. What have you been doing to beat depression? Take one incident when you noticed you were beating depression last week. Talk me through it as if I was looking at a video. Who was there? What happened before during and after this fi ght with depression? You beat depression that time, what does that say about you as a person? Does it mean that you are powerful? That you have stamina? That you are a survivor? INTERVENTIONS FOR BEHAVIOUR, BELIEFS AND CONTEXTS 299 Would you be interested in noticing over the next week how you will overcome depression again? Will you come back and tell me how you overcame depression again? Who in your family or circle of friends could be on your team in this fi ght against depression? Will you think about how we could connect with them. Maybe we could invite them to a session, when you have had a number of victories and they could listen to your story and offer their congratulations? When clients begin to show change and master their problems, lines of ques- tioning such as the following, drawn for the work of Michael White (1995), help clients consolidate new personal narratives and belief systems about themselves and their competence in managing their problems. This line of questioning links the exception to the person’s past and into their future. If I were watching you earlier in your life, what do you think I would have seen that would have helped me to understand how you were able recently to beat depression? What does this tell you and I about what you have wanted for your life? If you were to keep these ideas in mind over the next while, how might they have an effect on your life? If you found yourself taking new steps towards your preferred view of yourself as a person, what would we see? How would these actions confi rm your preferred view of yourself ? What difference would this confi rmation make to how you lived your life. Of all those people who know you, who might be best placed to throw light on how you developed these ideas and practices? INTERVENTIONS THAT FOCUS ON HISTORICAL, CONTEXTUAL AND CONSTITUTIONAL FACTORS Interventions that aim to modify the impact of historical, contextual and constitutional predisposing factors or mobilise protective factors within these areas include the following: • addressing family-of-origin issues • addressing contextual issues • addressing constitutional factors. Addressing Family-of-origin Issues Where parents or spouses have diffi culty making progress in marital or family therapy by altering problem-maintaining behaviour patterns or 300 PROCESSES IN FAMILY THERAPY the belief systems that directly underpin these in response to interven- tions listed in the right-hand and middle column of Table 9.1, it may be the case that unresolved family-of-origin issues are preventing them form making progress. These issues may include the following: Major family-of-origin stresses 1. bereavements 2. separations 3. child abuse 4. social disadvantage 5. institutional upbringing. Family-of-origin parents–child problems 1. insecure attachment 2. authoritarian parenting 3. permissive parenting 4. neglectful parenting 5. inconsistent parental discipline 6. lack of stimulation 7. scap egoat i ng 8. triangulation. Family-of-origin parental problems 1. parental psychological problems 2. parental drug or alcohol abuse 3. parental criminality 4. marital discord or violence 5. family disorganisation. In such instances, it may be worth exploring transgenerational patterns, scripts and myths to help clients understand how relationship habits from their family of origin are infl uencing their current life situation. In some instances, it may be necessary to help clients access, express and integrate emotions that underpin destructive relationship habits. In others, it may be valuable to coach clients to reconnect with parents from whom they have become cut-off, so they can become free of triangulation in their families of origin and so stop replicating this in their families of procre- ation. Typically this work, which has the potential to address core identity issues and painful unresolved feelings, is done in sessions attended by couples or individuals, without their children being present. Exploring Clients may be invited to explore transgenerational patterns, scripts and myths relevant to their diffi culties in making therapeutic progress in a INTERVENTIONS FOR BEHAVIOUR, BELIEFS AND CONTEXTS 301 wide variety of ways. Genogram construction, which was described in Chapter 7, is a useful starting point. Once the genogram is fully drawn, the client may be invited to begin exploring family-of-origin issues, rel- evant to resolving the presenting problem with lines of questioning like that presented below. This approach draws on the ideas and practices of transgenerational family therapy (Kerr, 2003; Nelson, 2003; Nichols, 2003; Roberto-Forman, 2002), object relations-based family therapy (Savage- Scharff & Bagini, 2002; Savage-Scharf & Scharf, 2003), approaches to fam- ily therapy that have their roots in attachment theory (Johnson, 2003a; Byng-Hall, 1995), and experiential family therapy (Volker, 2003). I have noticed that no matter how hard you try to make sense of this problem and tackle it in a sensible way, you end up in diffi culty. You have a way that you would like your relationships to be with your partner and children, but you just can’t seem to get your relationships with them to work like that. Something is blocking you. One possibility is that you are carrying relationship habits from your family of origin in the back of your mind, and any time you are under stress you fall into these old habits. Would you like to explore this possibility? The advantages of this type of exploration is that it may help you pinpoint some part of your past that is getting in the way of you living your life as you would like in the present. The disadvantage is that it may take time and effort and lead nowhere or to discoveries you would rather not have made. So are you sure this is still something you would like to explore? Look at your genogram and think about what have been the most important relationships in your life? What relationship habits did you learn from these relationships? In these relationships how did you learn to live with giving and receiving care and support? Tell me how your parents and siblings received and gave support to each other? In these relationships, what did you learn about the way people should communicate with each other in families. How should parents and children or mothers and fathers talk to each other? Tell me how your parents and siblings talked to each other about important issues? In these relationships how did you learn to deal with leading and following, the whole issue of managing power? Tell me about who was in charge in your family of origin and how others fi tted in around this? In your family of origin, how did you learn to deal with confl ict? What happened when your parents or siblings didn’t agree about an important issue? What about triangles. Did people get stuck in triangles in your family of origin? Was anyone piggy in the middle between your parents or two other people? Did you and your siblings fall into two camps, backing your mum or your dad in some triangle situations? 302 PROCESSES IN FAMILY THERAPY Are you still involved in a triangle in your family of origin? Who have you stayed close to? Who have you cut off? Have you ever tried to reconnect from your cut-off parent? What are you avoiding by being cut off – what is the disaster you guess would happen if you spoke intimately with the person from whom you are cut off? What does this exploration tell you about the possible relationship habits you have learned from your parents, siblings and other family members? When you try to do the sensible thing in solving the problem you have with your partner and children and that brought you into therapy, how do these relationship habits interfere with this? Do you think that there are situations in which you can control the urge to follow through on these relationship habits you have received from your parents, sibling and other family members? What is it about these situations that allows you to break these chains, these destructive relationship habits? Would you like to explore ways of weakening their infl uence on you? Before making this decision, I am inviting you to look at the downside of changing your relationship habits. One big problem is this: if you change the relationship habits you learned from your parents, you may be being disloyal to them. What are the consequences of that for you and for your relationship with them? Lines of questioning such as this, conducted over a number of sessions, may lead in some instances to a realisation that family-of-origin issues are interfering with effective problem solving in the family of procreation. They may also lead clients to want to change these. Awareness of destruc- tive relationship habits learned in the family of origin is rarely enough to liberate clients from slavishly following these habits when under stress. Re-experiencing One way to help clients weaken these relationship habits is create a context within which they can remember and re-experience the highly emotional situations in which they learned them, and integrate these forgotten and destructive experiences into their conscious narrative about themselves. Clients may be invited within therapy sessions, to close their eyes and visualise their memories of specifi c situations in which they learned spe- cifi c relationship habits and tolerate experiencing the intense negative affect that accompanies such visualisation experiences. Clients may be invited to verbalise the self-protective emotionally charged responses that they would have liked to have made in these situations to their parents or caregivers, within therapy sessions. Such responses may be made to a visualised im- age of their caregiver or to an empty chair, symbolising their caregiver or INTERVENTIONS FOR BEHAVIOUR, BELIEFS AND CONTEXTS 303 parent. In addition, clients may be invited to write (but not send) detailed letters to their parents or caregivers expressing in graphic emotional terms how diffi cult they found their challenging early life experiences in which they learned their destructive relationship habits. These processes of re-ex- periencing and responding differently to early formative experiences helps clients to gain control over their destructive relationship habits. Reconnecting A further technique that helps clients to break free from inadvertently slipping into destructive relationship habits, is to coach them to reconnect with parents from whom they have cut off. This type of work typically follows accessing, expressing and integrating emotions that underpin destructive relationship habits. In this type of coaching, clients are invited to prepare a plan of a series of visits with the parent from whom they are cut off and talk with them in an adult-to-adult mode, and avoid slipping into their old relationship pattern of distancing and cutting-off from the parent. Initially in these visits, conversation may focus on neutral top- ics. However, greatest therapeutic gains tend to be made where clients can tell their parents in an adult manner, how the parent’s behaviour hurt, saddened or angered the client as a child and how this led to a long period of distancing and cut off, which the client would like to end and eventually replace with a less destructive relationship. Sometimes, clients fi nd making such statements easier if they write them out with coaching from their therapists. In other instances, clients’ parents may be invited into sessions, so that the therapist can facilitate clients making this type of statement and their parents hearing them. In many instances, clients’ parents mention the circumstances and constraints that led them to hurt or sadden or anger the client and a process of mutual understanding and forgiveness is set in train. Of course, this is not always possible. Addressing Contextual Issues Where families have diffi culty making progress in therapy by alter- ing problem-maintaining behaviour patterns or the belief systems that directly underpin these in response to interventions listed in the right- hand and middle column of Table 9.1, it may be the case that factors in the family’s wider social context are preventing them from making prog- ress. These factors include issues requiring role change such as lifecycle transitions and home–work role strain; lack of social support; recent loss experiences, such as bereavement, parental separation, illness or injury, unemployment, moving house or moving schools; recent bullying; recent child abuse; poverty; or ongoing secret romantic affairs. A range of inter- ventions may be considered for managing these various contextual pre- disposing factors. These include: 304 PROCESSES IN FAMILY THERAPY • changing roles • building support • managing stresses • mourning losses • home–school liaison meetings • network meetings • child protection • advocacy • exploring secrets. Changing Roles During lifecycle transitions or when home–work role strain occurs, these factors can underpin problem-maintaining beliefs and behaviour patterns, and so facilitating changes in family members’ roles may be appropriate. For example, when fathers are absent from family life, though work demands, separation or divorce, children are at risk for developing problems and when fathers are involved in family therapy, the outcome has been shown to be more favourable (Carr, 1997). Thus, one of the most useful role change tasks is to invite fathers to become more centrally involved in therapy and in family life. Where fathers are unavailable during offi ce hours, it is worth- while making special arrangements to schedule at least a couple of fam- ily sessions that are convenient for the father. Where parents are separated or divorced, it is particularly important to arrange some sessions with the non-custodial parent, since it is important that both parents adopt the same approach in understanding and managing the child’s diffi culties. In families presenting with child-focused problems and in which fa- thers are peripheral to childcare, one role change task that may be useful is to invite fathers to provide their children with an apprenticeship to help them mature and develop skills required for adulthood. Here is an ex- ample of offering such an invitation in families where boys present with emotional or conduct problems: When boys have diffi culty learning to be brave and deal with fear. When boys have problems learning to cope with sadness. Or where lads have a hard time learning to control their tempers and their aggression, they need to do an apprenticeship in how to be a self-controlled young man. So, I am wondering how you might provide your son with this apprenticeship he needs. Would you be able to set aside a half an hour each day in which he tells you what he has been doing or in which you both do something that he would like to do? The other side of this is that, when he sticks to the rules, praise comes from you and when he steps over the line he would be answerable to you. How would that be for you and for everyone else in the family? Building Support In many instances, families referred for therapy lack social support and this underpins problem-maintaining beliefs and behaviour patterns. This INTERVENTIONS FOR BEHAVIOUR, BELIEFS AND CONTEXTS 305 defi cit can be addressed immediately in family therapy by providing a fo- rum where clients may confi de their views and feelings about their prob- lem situation. Clients experience support when therapists relate to them in a way that is empathic, warm and genuine, and in a way that fi ts with their communication style and ability. So it is important to use language that clients can understand easily, especially when talking to young chil- dren or people from ethnic groups which differ from that of the thera- pists. Some families require no more than the additional social support afforded by regular therapy sessions to meet their needs in this area. However, other families, particularly those with chronic problems may need a more sustained input. In some such instances, it may be possible to refer clients to self-help support groups where others with similar prob- lems meet and provide mutual support. Some such groups provide infor- mation, ongoing weekly support, and in some instances arrange summer camps for children or special events for adults. Using a multiple family therapy format (described in Chapter 6) for chronic problems, like psy- chosis or chronic eating disorders, allows clients to obtain support from other families in similar circumstances. Where nuclear families have become disconnected from their extended families and immediate community, it may be suggested that they invite members of their extended families and networks to sessions to begin to form supportive relationships with them. For children, particularly those who have become embroiled in coer- cive problem-maintaining interaction patterns, an important intervention is to train parents in providing their children with support. Parents may be coached in joint sessions with their children in how to do this. The guidelines for supportive play set out in Table 9.6 are fi rst explained. Next, the therapist models inviting the child to select a play activity and engag- ing in child-led play, while positively commenting on the child’s activity, praising the child regularly and avoiding commands and teaching. Then the parent is invited to copy the therapist’s activity and feedback is given to parents on what they are doing well and what they need to do more of. Finally, the parent and child are invited to complete a 20-minute daily episode of child-led play to increase the amount of support the child ex- periences form the parent. In families with older children and teenagers where parents and chil- dren have become embroiled in coercive interaction patterns, a parent and youngster may be invited to schedule special time together, in which the child selects an activity in which the parent agrees to participate. This may increase the sense of support that the youngster experiences. Rituals for Mourning Losses Bereavement, parental separation, illness, injury, unemployment, moving house or moving schools are all loss experiences. Loss is an inevitable, [...]... incidents are 322 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS Murray is Sandra’s first and only child Sandra and Tony have a passionate relationship Sandra’s mother devoted her life (after the divorce) to raising the children and held that being a parent is the central value in life Murray wishes his needs for care and stimulation to be met by his mother Sandra is devoted to Murray and wants... frenulum, extensive facial bruising and burn marks from an electric heater on his arm Sandra,the Family strengths: Sandra accepts responsibility, and shows remorse Sandra and Tony are open to learning parenting skills Murray 6m Living together for 18 m Sandra 20y The grandparents have no contact with Tony, Sandra or Murray Tony’s four siblings are married with children and live in another district There... of 328 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS assessment procedures is presented in Table 10.1 The schedule includes provision for assessment of all relevant family subsystems, the wider professional network and the use of sample therapy sessions to determine the family s capacity to use marital and family therapy sessions to learn Table 10.1 Schedule for a comprehensive family. .. a family assessment has been conducted to give feedback on whether or not the family therapy service judge the family to be suitable for family treatment Assessment The first aim of family assessment is to construct three-column formulations, like those presented in Figures 10.2 and 10.3, of the abusive process and exceptions to it The second aim is to assess the family s capacity to benefit from family- based... goals and therapy plan Without a shared view, opportunities for using available resources effectively and synergistically may be lost Instead members of the family and network may inadvertently drift into problem-maintaining behaviour patterns When convening a network meeting, particularly where difficulties have developed in the coordination and delivery of therapy and other 308 PROCESSES IN FAMILY THERAPY. .. child suspects deception Destructive family secrets, such as those concerning family violence, often maintain 310 PROCESSES IN FAMILY THERAPY problems by cutting the family off from people or agencies in the community that may be able to help the family When the therapist is offered a secret in confidence by a family member, the secret and the confidence are accepted and respected as a confused plea for... for Sandra that makes her happy Sandra wants to deepen her relationship with Tony Sandra believes that being a good parent is central to identity as a person Sandra believes that under the right circumstances she can meet her child’s needs Murray cries and Sandra, who is tired, tries to sooth him Sandra asks Tony for help and he supports her This reduces Sandra’s sense of exhaustion, frustration and. .. one’s own death; and acceptance (Walsh & McGoldrick, 2004) These processes, which are central to the grieving process, occur as family members change their belief systems and mental models of the world so as to accommodate the loss The grieving process is complete when family members have developed a mental model of family life and a belief system that contains the lost member as part of family history... control her sense of frustration and anger Sandra asks Tony for help and support He argues with her and Murray becomes more upset and cries even more This increases Sandra’s senseof exhaustion, frustration and anger Sandra continues to try unucessfully to sooth Murray, whose crying persists Eventually she is verbally and physically violent to him She feels remorse and vows to try harder to be good... Such rituals may allow family members to alter their belief system and to accept the loss into their cognitive model of the family This change in the belief system then frees the INTERVENTIONS FOR BEHAVIOUR, BELIEFS AND CONTEXTS 307 family to break out of the cycle of interaction that includes the stuck member’s grief response and the family s reaction to it For example, the husband and two daughters of . coordination and delivery of therapy and other 308 PROCESSES IN FAMILY THERAPY services, set clear goals. Such goals typically include clarifying or refi ning the formulation and agreeing on roles and. experiences. Loss is an inevitable, 3 06 PROCESSES IN FAMILY THERAPY uncontrollable and painful aspect of the family lifecycle. In adjusting to loss, distinct processes or overlapping stages have. Systemic Family Therapy Manual. University of Leeds: Leeds Family Therapy & Research Centre. Available at http://www.psyc.leeds.ac.uk/research/lftrc/ index.htm Part III FAMILY THERAPY PRACTICE