Genograms

As part of the program here at UNLV we meet with a supervisor twice a week for our practicum.  The practicum in which I am currently assigned requires that we make a "case presentation" every few weeks.  As part of this presentation we are required to have a basic genogram (which is basically a family tree).  While genograms are an integral part of Bowenian or Multigenerational Family Therapy, I have really found the technique to be very helpful in early session to bring out more information about the family--especially patterns and interplay between members.  Below is the cheat sheet I use for making genograms.

I Statements (and how to use/teach them) AND Reflective listening

In the early 1970s Thomas Gordon introduced a concept to the family sciences called "I statements: (Gordon, 1970).  It has since become a common and early starting point for couples/group therapy.  It's commonly taught as a way to improved communication and I've used it with my wife as well as clients with great success.  However, I was tricked this week.

We began by briefly introducing the concept of I-statements to a family while helping a family to structure a conversation.  First, the family members began by using I-statements to speak to each other through us (the co-therapists).  As this was progressing well, we then asked the family to move their chairs to face each other, and begin to use these I-statements to speak to each other.  The child then made a statement about his feelings about a disagreement.  The parent then responded with, "I thought I made it clear..."  It was about here that I jumped back in and mentioned the implications behind the statement.  (Being that if the child misunderstood differently the child is dumb because the parent made it easy to understand) It was at this point I realized that I needed to improved my teaching about using I-statements because all my rules had been followed...  So I'm going to work to improve that.



Burr, W.S., (1990).  Beyond i-statements in family communication.  Family Relations, 39(3), 266-273.


Gordon, T. (1970). Parent Effectiveness Training.  New York: Wyden.

Update:

It's been almost a year now since my first attempt get a family to use I statements in session.  They still try to trick me--but I expect it now.  I pretty much always provide people with a template:

"When ______________________________  I feel __________________________."
"When you stay at work until 10pm I feel like I'm not important."


"When you flirt with other women I feel like you don't care about me."
"When you ask me why I didn't take out the trash I feel like I'm never going to be good enough for you."



This exercise pairs very well with reflective listening:

First, one partner says how they feel. Then the other reflects it back.
A to B: "When you work until 10pm it makes me feel like you care more about work than me!"
B to A:"When I work until 10pm it makes you feel like I care more about work than you."
If it was not reflected back correctly, A corrects.

Once A has expressed his/her feelings entirely and B has reflected them, B begins to reflect feelings to A and A reflects them back

Reflective listening is really the ONLY way to ensure that communication and actual understanding is taking place.  Usually we listen to respond/defend.  Which really means we are not listening for understanding.  Why listen at all if not for understanding?

The 5 Love Languages

I've found (not like it was really a surprise my wife would say, I'm sure) that I like having very structured sessions in therapy.  I like lists and structuring just about everything--even if that means I plan to have no plan or structure a session to have no structure.  Does that even make sense?  

So cut to yesterday, a fellow student and I are preparing to go into a session with a couple (it's fairly standard practice here to go co-therapy with couples and families--we like the dynamics and also all need the relational hours) and we make an outline for things to cover in session.  We begin session and start with our list--but it just felt off to us.  We ask a few questions and we get down to an issue of communication and how each partner understands love.

So we began a brief psychoeducation process about the 5 Love Languages developed by Dr. Gary Chapman.    While it can be said that the 5 Love Languages are "pop-psychology", I believe there is a lot of truth to them.

 The basic gist of the 5 Love Languages is that people have different ways of expressing and understand emotions (love).  By this I mean that partner 1 may use a different method than partner 2, but also that partner 1 may express emotion in one way and understand it differently.  Though it seems pretty common that it is both expressed and understood the same way.  These five love languages are:

1. Words of Affirmation
1. Actions don't always speak louder than words.  If this is your love language, unsolicited compliments mean the world to you.  Hearing the words, "I love you," are important--hearing the reasons behind that love sends your spirits skyward.  Insults can leave you shattered and are not easily forgotten.
2. Quality Time
1. For those whose love language is spoken with Quality Time, nothing says, "I love you,:" like full, undivided attention.  Being there for this type of person is critical, but really being there--with the TV off, fork and knife down, and all chores and tasks on standby--makes you significant others feel truly special and loved.  Distractions, postponed dates, or the failure to listen can be especially hurtful.
3. Receiving Gifts
1. Don't mistake this love language for materialism; the receiver of gifts thrives on the love, thoughtfulness, and effort behind the gift.  If you speak this language, the perfect gift or gesture shows that you are known, you are cared for, and you are prized above whatever was sacrificed to bring the gift to you.  A missed birthday, anniversary, or a hasty, thoughtless gift would be disastrous--so would the absence of everyday gestures.
4. Acts of Service
1. Can vacuuming the floors really be an expression of love?  Absolutely!  Anything you do to easy the burden of responsibilities weighing on an "Acts of Service" person will speak volumes. The words he or she most want to hear: "Let me do that for you."  Laziness, broken commitments, and making more work for them tell speakers of this language their feelings don't matter.
5. Physical Touch
1. This language isn't all about the bedroom.  A person whose primary language is Physical Touch is, not surprisingly, very touchy.  Hugs, pats on the back, holding hands, and thoughtful touches on the arm, shoulder, or face--they can all be ways to show excitement, concern, care, and love.  Physical presence and accessibility are crucial, while neglect or abuse can be unforgivable  and destructive.

Discernment Counseling (working with couples who are leaning different ways on divorce)

Common Therapist Mistakes:

1. Pursue the distance to get them to try therapy
2. Hold back meaningful help unless they both want therapy
3. Launching half-hearted couples therapy

Overview of Discernment Counseling with Mixed Agenda Couples

1. Goal:  greater clarity and confidence in their decision making about divorcing, and better equipped to understand their prospects for reconciliation.
2. Make a clear distinction between discernment counseling and marital therapy.
3. Short term:  1-5 sessions.  Preferably weekly, but sometimes biweekly (makes it more intense)
4. Structure:  after assessment and agreement on doing discernment counseling, sessions consist of three parts:
1. brief check in with couple
2. separate conversations with each partner
3. brief summary/check-out at the end
5. Frame three paths:
1. stay married as it has been
2. move towards divorce
3. agree on a six-month reconciliation period with all-out effort in therapy (and using other resources) with divorce off the table--and then make a decision about the long term future.
6. Use different approaches with leaning-in and leaning-out partners (adapted by Doherty from Betty Carter)
1. Leaning out:  help them make a decision based on a more complex understanding of the marriage and own role in its problems
2. Leaning in: help them bring best self to the crisis, not making things worse, using it as a wake-up call to work on self.
7. Outcomes:  launching couples therapy and other help for six months, move towards divorce with better understanding and acceptance, or stay on hold for now.

Medical Family Therapy

My very first client was a transfer who had been coming into therapy for about a year.  It appeared that the client had been previously treated using a Solution-Focused framework.  While I very much subscribe to a Solution-focused ideology--it seemed less appropriate for this case.  One of the biggest critiques of Solution-Focused therapy is that it does not seem to appropriate address real and permanent problems--such as what my client is facing.  Upon discussing this with my practicum, my supervisor suggested (instructed) switching the model to a Medical Family Therapy model.  This was very exciting to me because it is a model we have not studied in our program and because it is something that I find very interesting and would like to go on to a PhD program that has some sort of MedFT program.  These are my findings in my dabblings with Medical Family Therapy.

What is Medical Family Therapy?

The following outline comes from lecture notes by Dr. Katherine Hertilein.

Medical Family Therapy refers to biopsychosocial (biological, psychological, social) treatment of individuals and families who are dealing with medical problems.  It actively encourages collaboration between therapists and other health professions.  It recognizes that there is a relationship with biology and family therapy.

Goals of MedFT

The two primary goals of Medical Family Therapy are increasing agency and communion.

1. Agency

Agency refers to the active involvement in and commitment to one's own care.  A sense of making personal choices in dealing with the illness and the health care system, both of which often contribute to a patient's feeling of passivity and lack of control.  This can involve:

         a. Helping a patient and family set limits on the amount of control an illness or disability has over their lives.  E.g. deciding to proceed with holiday celebrations despite the patients limited participation.

         b. Helping the family to negotiate for more information or better care arrangements with health professionals, hospitals, or insurance providers.

         c.  The therapist can promote agency of the patient in relation to other family members

                     1. Setting boundaries on family members' helpfulness

                     2. Teaching a family member to ask assertively for help

2. Communion

Emotional bonds are often frayed by illness, disability, and contact with the healthcare system.  There needs to be a sense of being cared for, loved, and supported by a community of family members, friends, and professionals.  Serious illness or disability is an existential crisis that can isolate people from those that who care for them, but the quality of the patient's social relationships appears to be the most powerful psychosocial factor in health and illness. One of the reasons for emphasizing medical "family" therapy is that serious illness and disability provide opportunities for resolving old conflicts and for forging new levels of health family bonding.  During the acute phase of an illness, family members may be emotionally available to each other in unaccustomed ways, but during the chronic phase, many families find that their sense of common purpose and common feeling deteriorates. One of the MedFT's important tasks is to help family members join together to cope with an illness, and to do so within the context of allowing the patient maximum feasibility and autonomy.  

Techniques

There are seven major themes to techniques in the MedFT model: 1. Recognize the biological dimension; 2. Solicit the illness story; 3. Respect defenses, remove blame, and accept unacceptable feelings; 4. Maintain communication; 5. Attend to developmental issues; 6. Increase a sense of agency in the patient & family; 7. Leave the door open for future contact.

1. Recognize the biological dimension

• Start with a focus on the patient
• The word "patient" has its own implications and depersonalization issues
• Use a psychoeducational approach to explain the difference between psychotherapy and other medical encounters
• Ask the physician to explain the patient's illness, its prognosis, and its possible course
• When there is ambiguity or disagreement about the diagnosis, maintain an open, exploratory stance
• Maintain humility about the possibility of biological change

2. Solicit the illness story

• Listen empathetically
• Taking a genogram to trace the course of their particular history with illness and loss
• As part of soliciting the illness story I have asked clients to first write a eulogy of their pre-loss life, and then second to write a birth announcement celebrating the new life.
• I suggested a rule to maintain a 3-1 positive to negative ratio (I wanted to keep the 5-1 Gottman ratio, but I wanted it to be hard not damn-near impossible)

3. Respect defenses, remove blame, and accept unacceptable feelings

• Accept Denial
• A common goal that I have seen from clients is to find a way to grieve the old self and accept the new self.  The eulogy/birth announcement previously mentioned helped to work towards this--however it was not enough.  
• After this I created (compiled) a handout about grief--largely from Kubler-Ross's 5 stages of grief.  After this psychoeducation I assigned an art therapy assignment.  At some point  I'll provide an example/template of some sort of this assignment but it consisted of an instruction to take a large sheet of paper (or 4 regular ones taped together) and draw a visual representation of all the things that have been lost as a result of the illness.  (This works well with any loss).  
• It can be a very challenged and powerful assignment.
• Externalize the illness
• I found this to combine very well with soliciting the illness story.  I've found that my client has a lot to say--and it seems of therapeutic importance that there is a chance provided to allow this to happen.  I'm skeptical of pushing clients beyond telling their story and venting frustrations--but this allow a refocus of these discussions into an externalized discussion.  Once the story is told, I believe they move on.
• Remove blame
• Normalize negative feelings

4. Maintain communication

• Between families and medical providers
• Among family members

5. Attend to developmental issues

• Out the illness in its place
• This means acknowledging the demands placed on a family by an illness, but not letting it run your life

6. Increase a sense of agency in the patient/family

• Emphasize the patient's input
• Bracket patient's unhealthy decisions
• Facilitate rather than advise

7. Leave the door open for future contact 

• Recognize the physician's ongoing involvement
• Provide patient follow-up

Along with these 7 techniques, these 9 steps from Patterson (1991) have proven to be very beneficial to me in working with Medical Family Therapy and chronic illness.

1. Balance illness with other family needs
2. Maintain clear boundaries
3. Develop communication and competence
4. Attributing positive meaning to situation
5. Maintaining flexibility
6. Maintaining family cohesiveness
7. Engaging in active coping efforts
8. Maintaining social supports
9. Developing collaborative relationships with professions