Case Report—Loyalty, Legacy, and Ledger: Contextual Therapy in a Patient with a Family History of Ovarian Cancer

A client's emotional experiences and reactions to those experiences are influenced by his/her family of origin and direct or indirect interactions with various family members. Contextual therapists propose that a client's satisfaction with a relationship depends on the equity of his/her emotional interactions with family members. When relationships are inequitable, trust between individuals disintegrates. In order to reestablish trust in a relationship, a balance of interests must be restored. If not, imbalances may be passed down to future generations. A case of a woman with a family history of ovarian cancer is reviewed with the principles of contextual therapy in mind. In her family, several legacies have resulted in unbalanced relationships between family members that lead to difficulty in establishing trust within the genetic counseling session.     

Virginia Satir’s Family Camp Experiment: An Intentional Growth Community Still in Process

In 1976, Virginia Satir began Satir Family Camp (SFC) with therapists and their personal families. Initially, it was a context for the family to experience Satir’s concepts and techniques so that the family system would change along with the therapist. The training of therapists is no longer a significant part of camp; relationships with self, family, friends, and the community is now the main focal point. The process and governance of the camp is presented along with a lengthy anecdote of an experiential family session. These two features—community function and personal/familial growth—inextricably work together to provide a validating environment that supports desired changes.     

Psychodynamic perspectives on teacher stress

Melanie Klein's concept of projective identification is now in common use by counsellors and psychotherapists. Julia Segal describes her own hypothesis about the way it works as well as her use of it in her practice, working as a counsellor for people with multiple sclerosis, members of their families and professionals working with them. When a person cannot bear to feel an emotional state they can evoke the feeling in someone else, not only a therapist or counsellor but also others within the family. Segal describes the way powerful emotions can be evoked in the counsellor; in particular the feeling that a certain idea cannot be shared with a client. She also describes working with clients who are on the receiving end of such projected feelings, sometimes evoked by illness within the family. She also points out that unresolved emotional states suffered in childhood can leave adults unable to bear certain feelings. If the feelings threaten to re-emerge in adulthood, perhaps triggered by their own children reaching a certain age, parents sometimes attempt to rid themselves of the emotional state by projective identification and in the process, evoke a version of the feelings in their own children. This may, for example, exert pressure on parents to divorce just as their own children reach the age they were when they themselves lost a parent.     

Family therapy and outcome: Relationships between therapist and family styles

This study examined therapeutic outcome for a group of 175 clinic families divided into levels of family competence and style, and, later, into seven clinical groupings. The division into these groups was based on the level of rated Competence and Style determined by using the Beavers Systems Model. Therapists also rated their level of Openness/Sharing Strategy, Power Differential, and Partnership with the family at the third session. Results indicate that more competent families who fared well in therapy had therapists who formed a partnership, disclosed strategy, and employed a minimal power differential with the family. The most disturbed families, and those with a Centrifugal style, did better with therapists employing a high power differential and lower levels of openness and partnership. The study also presented the distribution of individual diagnoses by family groups. Implications for family therapists, including the value of family assessment, are provided.     

Parent Training with Non-Traditional Families:

Although behavioral parent training has been shown to be effective with a variety of child behavior problems, this review notes that the adaptation and generalization of this treatment across family populations has not met with consistent success. The therapeutic need of families with diverse backgrounds and those facing interpersonal and intra-familial conflicts only recently has been raised by therapists. To promote effective and generalized treatment success across this population, some therapists recommend adjunctive or alternative treatment strategies that encompass the specific needs and characteristic make-up of a family. Several of the recommended adaptations that have been made are described in this review. Despite the therapeutic merit of many of these recommendations, it is concluded that little empirical information currently exists on the implementation of the various treatment adaptations. Recommendations are made to evaluate further clinical issues related to the needs of non-traditional and other non-middle class families.     

Family therapy with black families

Family therapy in Britain must develop to encompass the external reality of family life. Living in a racist society dominates the lives of all black families. Family therapists need to acknowledge and address this before intervening in the family system. This paper offers personal and professional experiences, confrontaion, structured exercises and general and specific principles for work with black families. Minimal and positive goals are advocated so that practitioners do not feel paralysed by the enormity of the task.     

Treating Parents and Children Together

SUMMARY

In this paper I look at two traditions of psychotherapy with children: family therapy {here considered in its common paradigm of systems theory and not in its diversity of approaches) and individual psychodynamically oriented child therapy. The author examines how, in these two modalities of treatment, the real world of the parent-child relationship, which remains mostly a world of women and children, tends to be left out in practice. Many family therapists “exclude” children from their sessions and concentrate on the marital relationship while child therapists “exclude” parents from the core of the therapeutic process. The issues for therapists and the consequences for adults and children in families in this com-partmentalization of services are examined within a feminist framework. The development which is advocated is for therapists to expose themselves fully to the world of the parent-child relationship as a fust step in reexamining their stereotypical views of motherhood and fatherhood which trap women in conflicted and potentially exploitative situations and do not consider that children actively construct their own relationships.     

A Single Intervention: A Visit to the Family

The following letter is reported unchanged except for disguised names. Concern with repairing disrupted relationships of adult members of a family with their own parents has been a matter of growing interest to a number of family therapists; Bowen (1), Boszormenyi-Nagy (2), and Framo (3), among others have stressed the importance of sending family members back to their families of origin. This report makes no effort to formulate the process in any particular theoretical framework (i.e., as reestablishing connectedness after an “emotional cut-off” or rebalancing a ledger of fairness, or whatever) but is intended only to illustrate the kind of outcome one may hope for in prescribing such a maneuver. It is offered simply as a clinical note. The letter needs little prefatory explication. Mr. Jack Newburgher had been a patient in psychoanalytic treatment for four years, with a quite successful outcome. On two occasions in the course of his therapy a joint session had been held with Mr. Newburgher and his wife, Muriel, when changes in his behavior had precipitated crises in the marital relationship. His therapy had terminated about two years before the visit referred to in the letter. Mr. Newburgher had called and asked for a joint consultation with Muriel about an acute family problem they were experiencing. Some — not all — of the background material was described, not nearly as coherently as it is reported in Muriel's letter, but in sufficient detail to make it plain that she was in distress about having to withdraw completely from her parents and that their family was in disarray as a consequence of her distress. The acuteness of the emotional disturbance, against a background of a lifelong adversary relationship between Muriel and her father and a history of ten years of illness on her fathers' part, suggested that the distress was the product of Muriel's anxiety and guilt over a decision to cut herself off completely from her parents. As a consequence, Muriel was urged to visit her family of origin, with the caveat that she might indeed discover them to be malignantly self-centered people indifferent to their effect on her and her family, but that she would at least have the gratification of having tried. The reference to “speaking French” was to the therapist having suggested that, on the other hand, she might find that her parents expressed their feelings in a different modality from her definitions of how feelings should be expressed, much as though their native tongue were French and she were insisting that they must speak to her in English.     

Cause and responsibility: towards an interactional understanding of blaming and 'neutrality' in family therapy

This paper aims to shed light on the ways in which 'neutrality' is both produced and resisted by socially competent actors in family therapy sessions. It draws upon recent and previous papers in this journal ( Stancombe and White, 1997; Stratton, 2003a, 2003b ), which highlight the importance of blame in therapeutic encounters. When families come to therapy, individual members frequently deliver competing accounts about the family troubles and who is to blame for them. This produces particular challenges for the therapist. We examine the practices of therapists in managing accountability in the session and in their own discussions. Family therapists operate with a professional ethic of neutrality, or multi-partiality. This paper is concerned with the linguistic strategies used by therapists to deal with overtly blaming accounts, how these strategies are responded to by family members in talk-in-interaction and how therapists go about crafting accountability-neutral versions. We show that the social and moral context of family work makes the therapist's job of communicating multi-partiality precarious. In producing accountability-neutral versions of families' troubles, therapists are forced to make practical-moral evaluations of competing versions of events. We conclude by arguing for a more explicit engagement with the moral nature of therapeutic practice.     

Manipulation of Verbal Behavior of Chronic Hospitalized Schizophrenics in a Group Therapy Situation

This paper describes a semistructured, time-limited model of group treatment for latency age children. The members, all of whom came from reconstituted families, had a variety of reactive, somatoform, and characterological problems. With help from the therapists, each member constructed his or her own genogram which was then discussed by the group as a whole. Because this format incorporated a technique for mapping family structure into a traditional model of children's group therapy, it focused the group's manifest communication on changing family roles and relationships, both as they had occurred in reality and as they were symbolically reenacted within the group process. Feelings of shame, guilt, anger, and loss were markedly ameliorated as the group members studied the structure of their extended families within an environment which encouraged normative peer interaction and progressive emotional development. A brief review of the recent literature on time-limited, theme centered groups for children is included to provide a context for understanding the group.     

Family therapy by default: developing useful fall‐back positions for therapists

This article looks at some of the effects on practitioners of the increasing complexity and variety of ideas within the family therapy field. In adopting the currently popular notion of ‘default position’ from information technology, I argue that therapists can easily feel that their work has a random quality to it. I examine how our own default positions can be based on force of habit, a quest for novelty or the effects of stress. Some suggestions are offered for how we can more accurately go about choosing ideas that will be of help to the families with which we work and to ourselves.     

Spatiality of the family's inner structure: choice of seat in family therapy

Many family therapists have observed that the family's choice of seat in the family therapy session provides information concerning the inner structure of the family. The purpose of this study was to study certain aspects of this observation. The selection of seats in family therapy sessions and the mutual distances between family members were investigated for 13 families. The inner structure of the family is described in terms of the existence of problematic relationships and the distribution and quality of power as assessed by the family therapists. The family members' selection of seats in the family therapy session was compared to the sitting order at meals, watching TV at home, and family drawings. It was found that the distance between the father and the patient (a son or daughter) and the location of the father and the mother in relation to each other in the family therapy are more related to the inner structure of the family than to situational factors.     

The Open Door: A Structural Approach to a Family With an Anorectic Child

This commentary on a videotape of an initial interview with a family of an anorectic girl demonstrates a set of therapeutic techniques based on a structural view of family organization and dysfunction. In the commentary, the interventions of the therapists are analyzed move by move throughout the session. The goal of the therapists is to assist the family to reorganize itself so that its dysfunctional structure will not support the symptom in the child. During the interview, they probe the characteristic interaction patterns of the family and engage with the family subsystems, making changes in the husband-wife relationship, the parent-child relationships, and the sibling relationships. The connection between the anorectic symptom and the structural organization of the family becomes clearer as the interview unfolds, with the result that the child's eating at the end seems incidental compared to the many changes in family relationships that precede it.     

Avoiding Colonizer Positions in the Therapy Room: Some Ideas About the Challenges of Dealing with the Dialectic of Misery and Resources in Families

Some authors have argued that certain acts of family therapists—despite their best intentions—may represent a form of colonizing the family. When acting as a colonizer, a therapist is understood as becoming overly responsible for the family and focusing too strongly on change. In so doing, the therapist disrespects the family's pace, and neglects their own resources for change. This paper aims to highlight the need for therapists to be hypersensitive both to the resources of families entering therapy as well as to the impact of prevailing ideologies on their own positioning in the session. The kind of sensitivity advocated here is dialectical in the sense that every family is understood as having potentials promoting dynamism, happiness, and well-being as well as potentials contributing to stagnation, unhappiness, and misery. In this article, using illustrations from clinical practice, we present some ideas for resisting the tendency by the therapist to assume a colonizing position as a professional solver of problems for families. Our main aim here is to redirect the therapist toward connecting with the family's suffering, as well as with the resource repertoire it has developed for navigating and negotiating its way through life.     

Sequential analysis as a method of feedback for family therapy process

Abstract

The purpose of this study was to examine the relationship between therapist verbal behavior and family cooperation and resistance during the second session of family therapy with juvenile delinquents. Sequential analysis was used to investigate the impact of one therapist's behavior on family resistance and cooperation in a sample of 12 families. The results of the sequential analysis revealed that therapist “support” and “teach” behaviors were associated with significant increases in the likelihood of family cooperation. The study provides an example of how sequential analysis can be used to inform family therapists about the impact of their behavior on families.     

Feeling like a good psychotherapist — Or a bad one: Critical incidents in psychotherapists' experiences

What makes a therapist feel competent or incompetent in a session, a concept related to the good — or bad — hour, is an implication of what the therapist believes is good therapy and therefore is trying to do — or believes is bad and therefore tries to avoid doing. In an attempt to infer covert processes in therapists, twenty-seven psychoanalytically-oriented psychotherapists furnished written accounts of sessions when they had felt like good — or bad — therapists. Accounts were analysed and interpreted to uncover the varieties of good and bad experiences and their grounds. Resistance and countertransference were found to be critical phenomena. When the therapist was able to cope with such complications, good feelings were generated, and when he was unable, bad ones — provided he became aware of this inability. If not, the therapist acted out patient-specific or unspecific countertransference feelings in ways that made him feel like a good therapist.     

Infant mental health home visiting therapists’ fidelity to the Michigan IMH-HV model in community practice settings

Implementation research suggests that fidelity to a therapeutic model is important for enhancing outcomes, yet can be difficult to achieve in community practice settings. Furthermore, few published studies have reported on characteristics of treatment fidelity. The present study examined fidelity to the Infant Mental Health Home Visiting (IMH-HV) model among 51 therapists with a range of experience practicing in community settings across the state of Michigan. IMH therapists completed fidelity checklists after every session with participating families to track use of 15 treatment strategies central to the IMH-HV model across the 12-month study period. Results indicated that the most commonly endorsed components utilized in home visits were developmental guidance and infant–parent psychotherapy, followed by the provision of emotional support. Use of IMH-HV components did not vary over time for the entire sample; however, patterns of strategies used showed somewhat more variability among more experienced therapists and when serving higher risk families. Findings demonstrate that IMH-HV therapists report a range of adherence to the model in community settings, with greatest fidelity to several model core components. Ongoing training in the flexible use of all core strategies may further enhance fidelity and contribute to positive outcomes for caregivers and their children receiving IMH-HV services.     

Countertransference revisited

A female patient of mine recounts her week. I listen with interest, waiting for her to arrive at particular conclusions. She has suffered a great deal and still does, but prefers not to dwell on it. My interest turns into patience as she continues to talk but circumvents her discontent. She is adroit at avoidance, but easily offended when I point such things out. "I'd better wait" I think. I grow more aware that I must encourage her digressions. I feel frustrated. Getting further and further away, she skirts the issue with supple grace, then strays off into tangentiality. I forget her point and lose my focus, then get down on myself. The opportunity is soon gone. I glance at the clock as her monologue drones on into banality. I grow more uninterested and distant. There is a subtle irritation to her voice; a whiney indecisive ring begins to pervade my consciousness. I home in on her mouth with aversion, watching apprehensively as this disgusting hole flaps tirelessly but says nothing. It looks carnivorous, voracious. Now she is unattractive, something I have noticed before. I forget who my next patient is. I think about the meal I will prepare for my wife this evening, then glance at the time once more. Then I am struck: Why am I looking at the clock? So soon? The session has just begun. I catch myself. What is going on in me, between us? I am detached, but why? Is she too feeling unattuned, disconnected? I am failing my patient. What is her experience of me? I lamentingly confess that I do not feel I have been listening to her, and wonder what has gone wrong between us. I ask her if she has noticed. We talk about our feelings, our impact on one another, why we had lost our sense of connection, what it means to us. I instantly feel more involved, rejuvenated, and she continues, this time with me present. Her mouth is no longer odious, but sincere and articulate. She is attractive and tender; I suddenly feel empathy and warmth toward her. We are now very close. I am moved. Time flies, the session is soon over; we do not want it to end.