Post on 10-Apr-2018
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` A psychotherapy that involves family members in
addition to the identified patient, and/or explicitly
attends to the interactions among family members
(Pinsof and Wyne 1995).
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1. Meanings are in words.
2. Communication is a verbal process.
3. Telling is communicating.
4. Communication will solve all our problems.5. Communication is a good thing.
6. The more communication, the better.
7. Communication can break down.
8. Communication is a natural ability.
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` The diagnostic family interview is an invaluable
tool to assist the psychiatrist in the development of
diagnostic and therapeutic goals.
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` The diagnostic interview can take place as the
initial contact with the family, regardless of the
nature of the presenting problem; it can be part of
the comprehensive assessment of a symptomaticchild or adult; or it can occur when therapeutic
efforts of any type are partially or totally
ineffective.
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` The goals of clinicians vary and may include:
I dentifying family and individual variables t hat may
play t he decisive role in shaping t he behavior of a problematic family member.
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Assessing t he adequacy of family functioning,
structure, and development according to t he family life
cycle; and
Conducting an initial family treatment session, w hen
t he necessity of suc h course has been recognized by
t he family or by t he referral source.
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The clinician acts as a host to t he family according to
t he prevailing customs.
The family is put at ease by engaging in mutual
introductions, asking t he family to introduce
t hemselves by name, matc hing t he names wit h
family members, and inviting t hem to make
t hemselves comfortable.
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3.The family should be provided wit h adequate seating,
preferably in a conversational living room
arrangement, and wit h play material, table, and c hairs
for young c hildren.
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` Z ilbac h (1986) recommends t hat t he clinician crouc h
down to establish eye ± to ± eye contact wit h young
c hildren and be alert to t he possibility t hat some young
c hildren may be afraid of handshakes or physical
touc hing.
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` A few minutes may be spent in small talk, inquiring.
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The clinician asks t he family to describe t he problem
t hat has prompted t he clinical contact.
The initial inquiry may be directed to t he fat her, in
recognition of t he often tenuous motivation of many
fat hers to attend t he t herapeutic setting, or to t he
mot her, as t he person w ho may be most
knowledgeable about t he family life and problems.
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The t herapist should t hen inquire about t he views of
different family members on problematic areas in t he
family.
The t herapist should observe carefully t he family¶s
relatively unconstrained nonverbal behavior.
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The exploration of family structure t hroug h observation
of family interactions provides t he clinician wit h
valuable clues, including t he level of differentiation,
boundary formation, and boundary flexibility of different
family subsystems and family members.
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The clinician is particularly interested in t he functional
adequacy of different family subsystems. The common
family subsystems include t he:
x marital ± parental
x parent ± c hild; and
x siblings subsystems
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` Grandparental involvement, very common in certain
et hnic and socioeconomic groups, would provide
additional subsystems of grandparent ± parent and
grandparent ± grandc hild.
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` For the initial session, all members of the
household and significant others should be
invited; these include young children, toddlers,
and infants, who are an important source of diagnostic data about the family.
x Simple statements such as ³I¶d like to meet you all,
include the little ones´ can readily communicate the
clinician¶s goal.
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` The clinician should avoid any lengthy phone discussion
to justify the participation of all family members because
a prolonged explanation based on general assumptions
may make the therapist appear as if he or she lacks
confidence.` The diagnostics interview preferably should be
scheduled for 90 minutes to allow a systematic
evaluation of the family in an unhurried fashion.
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` The assessment of family structure should include the
determination of the characteristics constellations of
family conflicts, patterns of contr ol, clarity of
parental authority and generational boundaries,
expression of feelings, and family rigidity, includingthe brittleness of family defenses.
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` The assessment of family functioning should include the
exploration of instrumental ± adaptive functions of the
family, geared toward enhanced adaptation and problem
resolution, as well as their expressive ± integrative
function, addressing the expression of affect andprovision of comfort.
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` The diagnostic family interview can be extended into
interviews with family subgroups, such as parents or
children, or with one child for exploration of other
important information that may not be readily shared in a
conjoint session.
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x Establish structure in the interview to counter the
common tendency of dysfunctional families toward
chaos, a high level of blame, and silencing of the
members.
x Maintain objectivity, avoid side taking or prematureclosure of topics, and elicit the views of all family
members.
x Address the transactional patterns that are clearly
burdensome to many family members and thereforemore amenable to change (Gordon and Davidson
1981).
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x Understand role of different family members within
the family unit.
x Uncover the explicit and implicit rules that govern
family interaction.
x Determine the family¶s problem ± solving behavior.
x Understand the nature of boundaries, splits,
alliances, and coalition formations in the family.
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x Assess the level of concordance between the
developmental and chronological stages of the
family.
x Assess the concordance between the value system
of the family and the surrounding community.
x Help the families transcend the repetitive, immediate,
and trivial problems and recognize the underlying
patterns and main issues.
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` A significant goal of t he family diagnostic interview
is to help the family recognize and
acknowledge its strengths as a family and the
assets of family members, particularly t h
e index patient.
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` When the diagnostic family interview is part of an
overall comprehensive evaluation, it is best to
delay the therapeutic recommendation until the
closing conference.
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` Under other circumstances, the family diagnostic
interview should be closed by highlighting the
points of convergence among the problems of
the index patient, the information gathered fromthe different family members, the transactional
patterns in the family system, and the referral
inf ormation.
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` An experienced family therapist attempts to
highlight the family¶s assets, knowing well that the
family is aware of its conflictual interactions and
relationships but barely cognizant of those assetsthat are the key to therapeutic success.
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` An inexperienced family therapist tends to focus
on family problems to reveal his or her
observational acumen; this may inadvertently
make the family feel severely disturbed anddiscouraged.
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` Significant experiences in the past may influence
family orientation and mythology and directly or
indirectly relate to the family problems.
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` Such information includes the early death or
suicide of a grandparent when a parent was very
young, significant financial losses, or other eventsthat were traumatic for the family.
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` The gradual unfolding of historical information in
the family session is an important aspect of the
family interview and generally reveals theaffectively charged and dynamically significant
past experiences of the family.
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` The contracting phase is an important step prior to
initiating formal family therapy.
` I t refers to agreed ± on issues and goals for
treatment between t h
e t h
erapist and t h
e family.
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` Later on, the goals can be expanded to include
the disagreement between the parents, such as in
their views on child rearing or on other issues.
`
Many treatment failures are due to inadequatecontracting between the family and the therapist.
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` The problems of contracting include covert
disagreement between the therapist and the
family, within the family, or between the family and
referral sources (e.g., the Department of Human
Services or the court system).
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` What to look for?
x Projective identification
x Unresolved grief
x
Clarity of ego boundaries and capacity for intimacy/separateness
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` What to think about?
x Internal processes within individual family members
shape family interactions.
x Family member¶s motivations, conflicts, defenses
and relationships from the past, currently influence
present relationships.
x Gaining change occurs through family members
gaining conscious insight into previously
unconscious processes generating problems infamily relationships.
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` What to do?
x Opening emotional expression in the family
relationships.
x Clarifying communications.
x Encouraging family members to speak from the ³I´
position.
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x Interpretation of unconscious conflicts to resolve
projective processes, cutoff relationships, and
difficulties in modulating closeness and distance in
the family relationships.
x Psychodynamic techniques, such as doubling androle reversal.
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x Therapeutic rituals to facilitate developmental
transitions and grief over losses.
x Family genograms.
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` What to look for?
x Contrasting the particular family structure with that
³normal´ to the culture and developmental stage in
terms of:
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x Organization (structure)
x Rules (sequences of action)
x Roles that shape the family members¶ actions
x Boundaries
x Hierarchy of power
x Alliances
x Coalitions
x Verbal and nonverbal behavioral sequences
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` What to think about?
Presenting problem results from a family structure
out of alignment with the culture and the
developmental stage of the family.
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` What to do?
x Actively shift the family structure
x IN session enactments
x Out ± of ± session homework assignments
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` What to look for?
x Here ± and ± now context of the problem
x Who, what, when, where, and how people are
involved in trying to solve the problem
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` What to think about?
x ³The solution becomes the problem´
x Difficult life ± cycle transitions give birth to clinical
problems when people persist in old coping
strategies but relational and communication
processes need to change to meet new life contexts.
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` What to do?
x Psychoeducation
x Direct behavioral assignments to adopt new problem
± solving strategies
x Defiance ± based, paradoxical interventions
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x Relational conflict due to a paucity of relational skills
x Relational conflict due to interpretive errors based on
family assumptions or cognitive distortions
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` What to think about?
x Each member of the family is assumed to be doing
his or her best to cope with the behavioral
contingencies perceived at that point in time, given
the practical and emotional restraints experienced.
x Family members need to learn cognitive and
behavioral principles of learning.
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x Family members need to gain skills needed:
x To reinforce desired behaviors;
x To eliminate reinforcement of undesired behaviors;
x To modify faulty assumptions and interpretations about other family member¶s actions;
x To learn skills for communicating clearly and effectively.
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` What to do?
x Conduct psychoeducation about the presenting
problem.
x Conduct skill training in empathic listening
expressing positive feelings and speaking negative
communications respectfully.
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x Conduct training in a problem ± solving and conflict ±
resolution skills.
x Teach operant conditioning strategies for behavior
shaping with children.
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x Teach principles for contingency contracting to
replace coercive and blaming behaviors with
contracts specifying what each family member
agrees to perform.
x Teach family members to utilize behavioral
observation and thought diaries in out ± of session
assignments to track patterns of thoughts, feelings
and behaviors that generate symptoms.
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` What to look for?
x Listen for exact usage of language expresses as
metaphors, stories and beliefs.
x Listen for first ± person narratives from the family
members¶ lived ± experiences that imbue with
meaning such abstractions as ³love´, ³trust´ and
other important language of relationships.
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x Note exceptions, or unique outcomes, when
problems might have occurred but surprisingly did
not.
x Note what is happening at times when problems are
absent.
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` What to think of?
x The limits of a person¶s language constitute the limits
of his or her experiential world.
x Narratives, or stories, are the basic units of human
experience.
x A canon of personal narratives shapes the meaning
each family attributes to his or her experience.
x Narratives of identity, about which one is as a family
member, strongly influence family interactions.
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x Family conflicts emerge:
x When lack of narrative skills makes their experiences
unintelligible to others;
x When the available narratives preclude ways of relating other
than conflictual ones;x When specific words or expressions hold very different
meanings for different family members due to the personal
narratives with which they are associated;
x When family members become positioned relationally such
that they cannot hear, tell, and/or expand their stories in
conversation.
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` What to do?
x Focus on creating a dialogue in which important
personal narratives can be safely expressed, heard,
and reflected upon by family members.
x Ask questions that elicit forgotten, or unnoticed,
narratives of family life that open better possibilities
for solving problems that the current narratives that
have dominated the family dialogue.
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x Engage family members in an inquiry of:
x What is happening in family interactions when problems are
being solved successfully and symptoms are not occurring?
x Skills, practical knowledge, competencies and resources of
the family that can be brought to bear upon the problem.
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Family Demographics & History
Case Conceptualization &
Treatment planning
Family Therapy Process
Intake Interview
Session 1 Session 6Session 2 - 5
Building Working
Alliances
Free drawing task
Combining strategic
FPT with art
Family mural art
task
Use of art
tasks
Rebuilding family
connectedness
Termination