family therapy concepts process and practice phần 10 potx

552 RESEARCH AND RESOURCES Letters to Facilitate Role Change Letters can be used explicitly to facilitate changes in family members’ roles. Brian, a 17-year-old boy, was referred with headaches, which were interfering with his study and sports. The headaches occurred when he overheard his parents arguing. His parents, resolved their differences through loud and dramatic arguments in which crockery was occasion- ally broken. As part of therapy I helped the parents, Sharon and Trevor, compose the following letter, which they read to Brian and asked him to keep it on the notice board in his room as a reminder that the arguments were a sign of their commitment to each other rather than impending divorce. Brian We know that you have been worrying about us arguing. We are sorry that the worry causes you to have headaches. We want you to stop worrying so your headaches will go away. We want you to know that when we argue, this does not mean that we are going to separate. It means that we have different opinions and we need to talk about that. Arguing is a sign that we care about each other. We need to argue with each other from time to time. If you don’t like the sound of us arguing we will not be offended if you listen to your iPod or go out for a walk. Thank you for worrying about us but now you deserve a break from it. Love Mum and Dad Letters from Imaginary Authors Occasionally, I have enlisted the aid of imaginary authors in the treat- ment of children. Bozz is one of my favourite. He is an expert at help- ing youngsters boss their Hammermen about. When children have temper control diffi culties and routine behavioural control programmes have not worked or the parents oppose such approaches, the aggressive impulses are personifi ed as the Hammerman, or some other character. The child is then given advice on how to control the Hammerman from Bozz, a fi cti- tious character with whom they fi nd it easy to identify. They are encour- aged to develop a correspondence with him. Below is a letter from Bozz to Tom, an eight-year-old boy referred with temper control problems. This is just one part of an ongoing correspondence, which lasted six weeks. The use of imaginary authors like Bozz allows the therapists to adopt a posi- tion where they can comment to the youngster and the parents about the correspondence their child is having with Bozz. PROFESSIONAL RESOURCES 553 Dear Tom I know that you want to keep the Hammerman from getting you into trouble. So here is what you can do. You can take him down to the end of the garden every morning at 8.15 before school and every evening at 4.00 and get him to whack the tennis ball against the wall until he’s too tired to do any more. If he tries to get you into trouble with your sister say to him Hammerman hold it! If you can’t control him, ask your mum if you can go down to the end of the garden and let Hammerman whack the ball up against the wall. Write and tell me how you got on. Bozz Parables The use of parables, myths and fairy tales to help people fi nd solutions to problems of living is a custom that has its roots in the oral storytelling tradition. Within the family therapy fi eld, Milton Erickson has played a major part in the integration of this ancient tradition into modern clinical practice (Haley, 1973). The key to using parables in a clinical situation is to take the salient elements of the client’s situation and build them into a story which arrives at a conclusion that offers the client an avenue for pro- ductive change rather than a painful cul-de-sac. The story is a metaphor for the client’s dilemma, a metaphor that offers a solution. Such stories may be sent to clients as letters. The story below was sent to, Sabina, a seven-year-old girl who was referred because of recurrent nightmares in which she dreamt that her house was being burgled and her parents as- saulted. The nightmares followed an actual burglary of the family’s shop, over which they lived. The girl dealt with the nightmares by climbing onto the end of her parents bed when she awoke at night. She tried not to wake them and distracted herself by thinking of something other than the nightmares. During the day she refused to talk about the nightmares or the burglary. To some degree, her parents encouraged this process of denial. Sabina was in the Brownies and was learning about fi rst aid when she was referred. Here is the letter and story I sent her. Dear Sabina I really liked the pictures you did today. They gave me a clear idea of the sort of stuff you have been seeing in your dreams. I like the way you draw. Just to say thank you, here is the story I told you today. If some of the words are too hard just ask your mum or dad and they will let you know what they mean. See you in two weeks. Bye now. Alan Carr The Two Brownies Two brownies were on an adventure in the woods. They decided to have a race. They were both the same height and looked alike except that one had blond hair like yours 554 RESEARCH AND RESOURCES and one had dark hair. While they were racing they both tripped over the same branch at the same time and each of them cut their knee. The cuts hurt a lot and both girls felt like crying. The dark haired girl tried to stop herself from crying and her leg hurt more. The blond girl allowed herself to cry and felt relieved. The crying made her knee hurt less. Both girls went to the stream and bathed their cuts. Both girls had small fi rst-aid kits in their pockets. The dark haired girl put a bandage from her kit on her cut straightaway. The blond girl could have done this also but she did not. She let the air get at her cut. Both girls went home for tea. After tea they went to bed. The dark haired girl couldn’t sleep because the cut hurt so much. She turned on the light. She took off the bandage and noticed that the cut had become infected. It was all yellow with pus. The dark haired girl washed the cut quickly and put on another bandage over the pus. The blond girl woke in the middle of the night because her knee was hurting her. She woke her mum and her mum helped her bathe the cut in hot water to draw the pus out. This was painful, but she knew it would make her better. Three days later her cut was healed. But her friend was still wearing a bandage. Her knee still had pus in it. She still woke up in the middle of the night with the pain. THE END This story I sent Sabina took account of her interest in fi rst aid and racing. A physical trauma (cutting her knee) was used as a metaphor for the psycholog- ical trauma she had suffered (being burgled). The story included one course of action taken by the dark haired girl which resembled the pattern of coping she had adopted. It also contained an alternative. This other more adaptive route was taken by the blond girl; the girl whose hair was the same colour as Sabina’s. This detail was included to make it easy for Sabina to identify with her. The story reframed Sabina’s dilemma from ‘How can I distract myself from memories of the robbery and get rid of these nightmares so I can feel good?’ to ‘How can I squeeze all of this psychological pus out of my mind so the wound will heal?’. This reframing offered a new avenue for coping. Unfi nished Business Where adults have been hurt or traumatised during childhood by their par- ents or others and these issues remain unresolved; or where family mem- bers have suffered bereavement and left many important things unsaid, they may be invited to write letters as a way of resolving their unfi nished business. It is important that clients make a private time and place to write such letters; that they vividly imagine the other person and their feelings towards them as they write; that they express themselves in a spontane- ous emotive way without mentally editing what they write; and that they know that they will never send the letter they write to the person they are writing to. These types of letters allow clients to re-experience strong emotions that have not been fully processed and to alter the way they view their relationship to those to whom they write. The letters may be read aloud with full emotional expression in therapy sessions to enhance the degree to which they facilitate processing unresolved emotional states. PROFESSIONAL RESOURCES 555 TRAINING EXERCISES The following series of fi ve exercises offer trainers and trainees a way of developing the family therapy skills described in Chapters 7, 8 and 9. They are designed to be used over fi ve or six half-day practical workshops. These workshops are most usefully run after the group of therapists in training have read and attended classes on Chapters 1–9 and Chapter 18. Exercise 1 – Intake Interviewing Ex 1. Setting up the Exercise Required reading for this exercise is Chapters 7 and 8. To set up the exercise, invite the class to separate into a (role-play) family of four members and a therapy team (of 2–8 members). If there are more than 12 in the class, divide the class into a role-play family and a number of teams with about four members on each team. Just before the interview, randomly select one of the teams to conduct the interview and invite the other teams to be spectators. Ask the family and team to take 20 minutes to prepare for the exercise, in separate rooms if possible. Then run the exercise for about 40 minutes. Bring refreshments (coffee, tea, soft drinks) into the session, but do not take a 20-minute break as this will cause the family to de-role, which will greatly reduce the value of the debriefi ng. Then do the post-session de- briefi ng for no more than 40 minutes. If you schedule two hours, and stick strictly to this time schedule of 20 minute preparation – 40 minutes inter- viewing – and 40 minutes debriefi ng, you can let the class off 20 minutes early! If you break after the role-play, the debriefi ng will not work because the role-play family will have de-roled during the break. Ask the family to get into role and ask the team to plan who will do the different parts of the interview. It’s a better learning experience if as many members of the team as is practical take a turn at interviewing. However, advise the therapy team that there is no need to redo introduc- tions each time a new team member takes on the therapist role, since this lengthens the exercise unnecessarily. Let the group role-playing the fam- ily know that the therapist will change a few times in the session and at these transitions, to save time, the family should remain ‘frozen’ until the new therapist takes over the interviewing. Ask the family to pretend all the interviewing is done by a single person. In setting up the exercise don’t get sidetracked into talking about the value of the exercise, how ‘fake’ it is, etc. Once the role-play element of the exercise beings, it takes on a life of its own. During the planning stage of the exercise, check in with the family and the team from time to time to make sure they have understood the brief- ing and are completing the process of getting into role and planning the interview. 556 RESEARCH AND RESOURCES During the interview stage of the exercise, intervene as little as pos- sible. However, it may be appropriate from time to time, to say ‘freeze’ as a signal that the family will pretend that time has frozen, and to use this interlude to offer ‘live supervision’ to the therapist and team on how to proceed. When the therapist and team are ‘back on track’, say ‘unfreeze’ and the therapist and family can pick up the interview where they left off. Ex 1. Brief for the Family Four people take on the roles of the family members: June is the mother, Martin is the father, Mary is the daughter and Frank is the son. (Of course you may use more ethnically appropriate names if you decide to conduct this exercise role-playing a family from another culture.) Try to complete the process of getting into role in 20 minutes. Use the skeleton roles be- low to get in role and decide among yourselves the patterns of interac- tion within which the problem occurs and the exceptional circumstances where it does not. Also develop and discuss beliefs that family members have that underpin these two different types of episodes. Then develop an imaginary family history and genogram in which there are predis- posing factors or events that explain where family member’s beliefs came from historically and also within the wider community in which the fam- ily have lived and are currently living. When I facilitate this exercise with clinical psychology postgraduates at UCD, Dublin, I usually suggest the family has moved from London in the UK to Dublin in Ireland, because this is a cultural transition most postgraduates understand. However, it would be fi ne to conduct the exer- cise modelling it on a Polish family moving to Coventry, an Indian family moving to Washington, or a Maori family moving to Sydney. In this family, the mother, June, is overwhelmed by demands of making family life work in the new town and country to which she has recently moved. She misses her own family of origin but sticks by the decision to move to this new town and country because it is best for the family’s fi nan- cial viability. June is very concerned about Mary. She also wishes Martin was less consumed by his work. June has certain character strengths and skills which need to be elaborated and discussed with the family as you are getting into your roles. In this family the father, Martin, is swamped by responsibilities of a new job and there is latitude for you to make this job whatever you wish, for example, a manager; a computer programmer; a scientist; a physician; a waiter; a builder; or a train driver. It’s good to choose a job you know a bit about so you can get into role more easily. Martin is good at his job and has other character strengths and skills which need to be elaborated and discussed with the family as you are getting into your roles. You wish that you had more time to spend at home, that things were happier at home, PROFESSIONAL RESOURCES 557 that June was more available to you, and that Mary would get a grip on the situation and put her best foot forward. Mary, the daughter, is a 13 year old who misses the home town and coun- try which she has recently left, her friends, her school, and her extended family, especially those people in her extended family with whom she had regular contact. You will have to make all this up to create a credible role. Mary is miserable and gets headaches very frequently, usually in re- sponse to specifi c triggering events. Mary also has certain strengths and skills. Work out what these are and discuss them with the role-play family as you are all getting into role. You worry about your mother, whom you have heard crying alone in the evenings when your father is still at work. Frank, the son, is a tough survivor who mixes well and has adapted to living in this country, despite the move from another country and the fact that he has left friends, sports and his favourite school behind. You are on the football team in your new home town. You are also in karate classes and other activities. You have good friends on the street where you now live. You are having a good time. You are aware that Mary is not adjust- ing as well as you are, but your main focus is on keeping your new life working well and getting praise from your dad who thinks you are doing well. In the interview, the team will sit behind the therapist. You – the family – are invited to pretend that the team is invisible. If the interviewer wants to briefl y ask for help from the team to refocus the interview or for another interviewer to take over, he or she may say ‘freeze’ to ask you – the family – to stay frozen in time for a minute until he or she says ‘unfreeze’. This device will allow the therapist to consult with the team and supervisor or make transitions with a minimum of fuss. The therapist will use this device as little as possible. Also, pretend that you are being interviewed by the same therapist all the time. This eliminates the very time consum- ing need for introducing yourself to each new team member who takes on the therapist role. You may fi nd that you want to discuss the value of the exercise with your trainer or to giggle about the role play. Ignore these tendencies as they will prevent you form getting the most out of the exercise. You will fi nd that once the exercise gets going, it takes on a life of its own. Ex 1. Brief for the Team Convene a pre-session team meeting and read this letter. Dear Colleague Re: Mary O’Byrne. Age 13 years. I should be grateful if you would see this 13-year-old girl. Her mother has brought her to the surgery frequently over the past six months. The main complaints are headaches and depression. The girl did not respond to antidepressants. Things seem 558 RESEARCH AND RESOURCES to be getting worse. The family are originally from abroad and moved here, in the past year. Please assess and advise. Yours Sincerely Dr B. Goode Plan and conduct an intake interview with the whole family. In the inter- view, the therapist(s) must achieve the following goals: • form a good working alliance • construct a pattern of interaction around the problem (either head- aches or depression or both) • bring forth the beliefs of family members underpinning this pattern of interaction • link these beliefs to predisposing factors, which you may fi nd through doing a genogram • construct a pattern of interaction which occurs in exceptional circum- stances where the problem does not occur • bring forth the positive beliefs underpinning this • link these positive beliefs to predisposing factors • make a therapy plan • feed back the problem and exception formulations to the family and offer a contract for therapy for four further sessions. Take 20 minutes to work out your interview plan using the material in Chapters 7 and 8. You will need to form preliminary three-column hypotheses and sets of questions to help you construct the pattern of in- teraction around the problem and exception and the beliefs underpinning these. You will also need to do a genogram and family history to fi nd out the predisposing contextual factors. Take 40 minutes to conduct the interview. Different parts of the inter- view may be conducted by different team members. Try to arrange for everyone to have a turn. In the interview, the team should sit behind the therapist. The family have been briefed to pretend that the team are in- visible. If the interviewer wants to briefl y ask for help from the team or supervisor to refocus the interview or for another interviewer to take over he or she may say ‘freeze’ to ask the family to stay frozen in time until he or she says ‘unfreeze’. Use this device as little as possible. When a new team member takes on the therapist role, do not do introductions again. The family have been briefed to pretend that the entire interview is done by a single therapist. You may fi nd that you want to discuss the value of the exercise with your trainer or to giggle about the role-play. Ignore these tendencies as they will prevent you form getting the most out of the exercise. You will fi nd that once the exercise gets going, it takes on a life of its own. PROFESSIONAL RESOURCES 559 Ex 1. Debriefi ng Routine When the 40-minute role-play family interview is completed, the trainer may use the following debriefi ng routine. Invite the family and team to bring refreshments (coffee, tea, soft drinks) into the session, but not to take a 20-minute break, since this will cause the family to de-role and so reduce the value of the debriefi ng. Ask everyone in the role-play family to stay in role and focus on their experience of having been in the session. Then invite each family member to describe how they feel in role right now, how they feel about their relationships with each family member, the therapist and the team. Ask them each to describe the events in the session that made them feel good, hopeful, cooperative with the therapist, and attached to family members. Also ask them which events made them feel bad, hopeless, resistant to the therapist and alienated from family members. If members of the role-play family move out of role and com- ment ‘intellectually’ on the therapy, ask them to postpone de-roling until the experiences of the family have been described ‘in role’ by all role- playing family members. When all experiences of the family have been described ‘in role’ by all role-playing family members, ask the therapy team what they have learned from this account. Then ask the role-playing family members the same question. The sorts of lessons may include the following: • some things therapists do improve the therapeutic alliance and others do not • empathic statements and periodic summarising strengthen the thera- peutic alliance • neutrality can be lost from time to time, but it can be regained • organising the interview so there is a fair distribution of talk time for all participants can help increase neutrality • children can fi nd aspects of family therapy diffi cult • parents can fi nd aspects of therapy diffi cult • detailed hypothesis-driven curious questioning can be reassuring for parents • aimless interviewing can be distressing for parents • structuring the session so it has a beginning, middle and end is reas- suring for all involved. Ask the therapists who did the interviewing to self-rate the degree to which they believe they achieved each of following goals on a 10-point scale from 1 ϭ didn’t achieve this goal, to 10 ϭ achieve this goal well: • formed a good working alliance • constructed a pattern of interaction around the problem • brought forth the beliefs underpinning this 560 RESEARCH AND RESOURCES • linked these to predisposing factors • constructed a pattern of interaction which occurs in exceptional circumstances where the problem does not occur • brought forth the positive beliefs underpinning this • linked these to predisposing factors • made a therapy plan • fed back the problem and exception formulations to the family and offered a contract for therapy. Help interviewing therapists to avoid self-criticism. Say something like this: ‘All of us in this kind of work are overly self-critical. But it is of little value when we are learning interviewing skills. So can you let us all know which of the things you set out to achieve did you actually achieve.’ If the self-ratings are fair, there is no need to ask others to make rating. How- ever, if the ratings are way out of line, ask other members of the group to remember aspects of the session which showed that the session tasks (listed above) were achieved and to offer fairer ratings. If you video the session, then you can ask members of the class as homework to review the tape to fi nd evidence of having achieved session goals and show these to the class next week. Exercise 2 – Enactment and Boundary Making Ex 2. Setting up the Exercise Required reading for this exercise is Chapters 3 and 9. To conduct this exercise it is best if the class have completed exercise 1 in which three- column formulations of the presenting problem and exceptions to it were constructed and a treatment contract was established. If this exercise is at- tempted without the class having done exercise 1, the supervisor/trainer must brief the role-play family and the team more extensively by provid- ing them with three-column formulations of the problem and exception. Follow the same general procedures for this setting up this exercise as for exercise 1. This includes: • 20 minutes for preparation, 40 minutes for role-playing, and 40 min- utes for debriefi ng • inviting the family and team to prepare in separate areas or rooms • suggesting that a number of team members take turns at conducting therapy • explaining the freeze/unfreeze device as outlined for exercise 1 • avoiding getting sidetracked into discussing the value of the exercise • during the planning phase of the exercise, checking in with the family and the team periodically to make sure they are completing the pro- cess of getting into role and planning the interview correctly PROFESSIONAL RESOURCES 561 • during the interview stage of the exercise, intervening as little as pos- sible, and using the freeze/unfreeze device to do so. Ex 2. Brief for the Family Four people take on the roles of the family, as for exercise 1. Try to com- plete the process of getting into role in 20 minutes. Use the skeleton roles below to get in role. In this exercise, assume that you are attending your second session. In the fi rst session, the therapist (and team) asked about the presenting problem, the pattern of interaction around it, the beliefs underpinning it and explored possible predisposing factors by constructing a genogram with you. At the end of the fi rst session, the therapist (and team) offered a three-column formulation of the presenting problem (Mary’s headaches and low mood) and exceptions to it. Your family accepted the formulation and agreed to a treatment contract for four further sessions to resolve the presenting problems. When getting into role, discuss what your impressions of the last ses- sion were, your memories of your relationship with the therapist and the explanation of the problems that emerged from the session. Then discuss what you will say has occurred between the fi rst and second sessions. Imagine if you really were this family what would have gone on during this intersession interval. In the role-play part of the exercise, the therapist will invite the family to participate in certain tasks within the session, such as discussing how to resolve the presenting problems. As a family, try to cooperate with the task, but also try to follow these role prescriptions. If you are role-playing the mother, June, start off by working coopera- tively with your husband but gradually move towards siding with your daughter, when she expresses feelings of loss and sadness at leaving her home town and country to come and live here in this town, or when your partner seems unreasonable or unsympathetic to your position. You feel lonely and overwhelmed in this new town and country. You are distraught by your daughter’s condition. You miss the way your partner used to be when you lived back home. If you are role-playing the father, Martin, start off by working coopera- tively with your wife but gradually move towards siding with your son, when he says things about just getting on with life or when your partner seems unreasonable or unsympathetic. You are exhausted from working long hours and trying to get established in your new job. Things at work are very demanding, but you know you can do the job well, and in time the pressure at work will subside. When you come home you are disap- pointed that your wife is not more supportive. You also wish she would sort out Mary’s problems instead of making them worse, by being so sub- tly critical of the move to this country. [...]... 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The. the family and the team from time to time to make sure they have understood the brief- ing and are completing the process of getting into role and planning the interview. 556 RESEARCH AND RESOURCES During