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

Psychoanalytic Model (Object Relations)

Part 1: Assumptions and Assessment

Discuss the assumptions that the theory has about the following:

1. According to this theory, describe individual and family problems.

a. The basis of the theory is uncovering and interpreting unconscious impulses and defenses against them.

b. Self: Every human being longs to be appreciated.

i. If, as a child, a person is appreciated he develops healthfully. If not, then he spends his whole life seeking attention.

ii. Infantile dependence and an incomplete ego development are core problems. The fear-dictated flight from object relations is the deepest source of problems.

c. Family:

i. Children distort their perceptions by attributing the qualities of one person to someone else

ii. Projective identification—subject perceives an object as if it contained unwelcome elements of the subject’s personality AND evokes responses from the object that conform to those perceptions

1. Parents project anxiety-arousing aspects of themselves onto their children, but the children collude by behaving in a way that confirms it.

2. Intrapsychic conflict becomes externalized. Parent acts as superego and punishes the child for acting on the dictates of parental id.

3. Parents overreact because they are afraid of their own impulses

2. What relationship do the past and/or family of origin have with the present for individuals and family relationships?

a. If parents demonstrate appreciation children develop strong, self-confident personalities. This child will be secure, and able to love and stand alone as a center of initiative.

i. Environment does not have to be ideal; an average expectable environment with good-enough mothering is sufficient.

ii. The parents’ capacity to provide security for the baby’s developing ego depends on whether they themselves feel secure.

b. Early attachment between mother and child has been shown to be critical for healthy development. Close physical proximity and attachment to a single maternal object are necessary preconditions for healthy object relations in childhood and adulthood.

i. The infant needs a state of total merging and identification with the mother as a foundation for future growth of a strongly formed personal self.

c. If they do not, the desire for attention is suppressed but breaks through whenever there is a receptive audience. This child will be unhappy will spend his/her whole life seeking the attention he/she was denied.

d. Attachment between mother and child has been shown to be critical for healthy development:

i. Identification

ii. Transitional object

iii. Separation-individuation

iv. Introjections

v. Selfobject

vi. Mirrioring

vii. Idealization

3. What meanings do symptoms have in this theory?

a. Symptoms are attempts to cope with unconscious conflicts over sex and aggression

b. One important reasons for relationship problems is that children distort their perceptions by attributing the qualities of one person to someone else. Transference—called family projection process by Bowen.

c. Projective identification—a process whereby the subject perceives an object as if it contained unwelcome elements of the subject’s personality and evokes responses from the object that conform to those perceptions. Projective identification is interactional. Not only do parents project anxiety-arousing aspects of themselves onto their children, but the children collude by behaving in a way that confirms their parents’ fear.

i. Intrapsychic conflict becomes externalized, with the parent acting as a superego, punishing the child for acting on the dictates of the parental id. That’s one resons parents overreact: they’re afraid of their own impulses.

ii. Parents’ failure to accept that their children are separate beings can take extreme forms, leading to the most severe psychopathology.

1. We hide some of our own needs and feelings in order to win approval.

2. Children tend to suppress feelings that lead to rejection.

a. False-self—children behave as if they were perfect angels, pretending to be what they are not. In its most extreme form, a false self leads to schizoid behavior.

d. The presenting symptom may be symbolic of denied parental emotion.

i. A misbehaving child may be acting out his father’s repressed anger at his wife.

ii. A dependent child may be expressing his mother’s fear of leading her own independent life

iii. A bully may be counterphobically compensating for his father’s projected insecurity.

e. Pathological reactions may develop from invisible loyalties.

i. Unconscious commitments that children take on to help their families that are a detriment to their own well-being.

ii. A child may get sick to unite their parents in concern.

4. According to this theory, how does change occur?

a. Change works through insight, but insight does not cure. Families must expand their insight and come to accept the repressed parts of themselves and then work through and translate their insights into more productive ways of interacting

b. Old wounds and deep longing must be exposed , and a climate of trust and slow proceeding is necessary.

c. Once a trusting environment is established the family and therapist can work to stop projective identification and accept the previously split-off parts of their own egos.

d. Empathy is needed to create a “holding environment” for the family.

5. According to this theory, describe healthy individuals and families.

a. Healthy families have separation-individuation or differentiation. Autonomy is important in both individuals and families.

b. Healthy families members are free from unconscious constraint so that they’ll be able to interact with one another as healthy individuals.

c. Good family relations are acting ethically and consider other member’s welfare and interests.

6. Who are some of the primary figures in the development of the model(s) and what are their contributions?

a. Adelaide Johnson—explanation of superego lacunae.

i. Gaps in personal morality passed on by parents who do things like telling their children to lie about how old they are to save a couple of bucks at the movies

b. Erik Erikson—explored the sociological dimensions of ego psychology.

c. Henry Dicks—established the Family Psychiatric Unit at Tavistock Clinic in England

i. where social workers attempted to reconcile coupled referred by divorce courts in the 1940s.

d. Nathan Ackerman—stayed allied to the psychoanalytic view of family therapy and had many students come to study under him, including Salvador Minuchin.

7. Compare and contrast the assumptions of this model with the assumptions of one that we have already studied.

a. Common themes:

i. Between this theory and Bowenian is the importance of autonomy—differentiation of self or separation-individuation.

ii. Solving the symptom problem is not the focus of either, but rather what is causing it.

iii. Symptoms develop as a result of something wrong, not always in the person with the symptom.

b. Differences

i. Rather than focusing upon the process of arguments, psychoanalytic focuses upon the feelings underneath the argument.

ii. Rather than a child acting out, or developing asthma, to triangulate the couple and their problems , the acting out comes from the child acting out conscious or unconscious thoughts and insecurities from the parent.

iii. Change

Part 2: Clinical Application

Discuss the clinical application of the theory by answering the following:

1. What are the treatment goals for this approach? What outcomes are anticipated?

a. Primary goal of psychoanalytic therapy is to free family members from unconscious constraints so that they’ll be better able to interact with one another as healthy individuals.

i. When a family is motivated only for symptom relief, the therapist should support their decision to terminate.

b. Supporting defenses and clarifying communication rather than analyzing defenses and uncovering repressed impulses.

c. Easy answer is the goal of personality change.

d. Autonomy is major goal: through separation-individuation or ­differentiation

i. Adolescents and young adults may be treated separately from their families in order to help them become more independent.

e. Focus on letting each family member let go of one another in a way that allows individuals to be independent as well as related.

f. Insight is major goal—but the belief that insight cures is a myth. Insight is seen as necessary, but not sufficient for successful treatment. Insight must be worked through—translated into new and more productive ways of interacting.

2. What is the role of the therapist, and how does a therapist engage with the family?

a. Role of the therapist is to promote trust. Therapist works to build a climate of trust and proceeds slowly.

b. Therapist helps couples and families to break down the need to rely on projective identification and acknowledge and accept previously split-off parts of their own egos.

c. Therapist needs empathy to create a holding environment for the family.

3. What does assessment focus on?

a. Process of discovery is protracted and not only directed at the conscious thoughts and feelings, but also at fantasies and dreams.

b. 5 step strategy for formulating a hypothesis:

i. How does the family interact around the symptom, and how does the family interaction affect the symptom?

ii. What is the function of the current symptom?

iii. What disaster is feared in the family that keeps them from facing their conflicts more squarely?

iv. How is the current situation linked to past trauma?

v. How would the therapist summarize the focal conflict in a short, memorable statement?

4. Describe the preferred interventions.

a. Listening

i. Strenuous but silent—not trying to get a word in. Concentration on understanding, not solving. Change may come as a byproduct of understanding.

b. Empathy

i. When analytic therapists do intervene, they express empathy to build trust and to help families open up.

c. Interpretations

i. Clarifications of hidden aspects. Helping people to understand: why they got so angry; what do they want from each other; what do they expect.

ii. Rather than resolving the argument the therapist would explore the fears and longing beneath it.

d. Analytic Neutrality

i. Concentrate on understanding, not solving. Change may come through understanding but anxious involvement is withheld. Resist temptations to reassure, advise or confront families in favor of a sustained but silent immersion in their experience.

e. A psychoanalytic therapist is interested in helping partners understand their emotional reactions. Why did they get so angry? What do they want from each other? What did they expect? Where did these feelings come from?

i. Rather than try to resolve the argument, the analytic therapist would explore the fears and longings that lay underneath it.

5. What are the strengths and limitations of this approach?

a. If therapist make themselves too central to the process of breaking arguments and delving into the feelings beneath the argument, the power of family therapy is lost.

b. Interrupting defensive sparring to get to the hopes and fears that lie beneath it all is good, but unless these interrogatories are followed by unstructured interchanges among family members, these explorations may only produce the illusion of change as long as the therapist is present to act as detective and referee.

c. Pyschoanalytic therapist have resisted attempts to empirically support their works as symptom reduction isn’t the goal and cannot accurately serve as a measure of success.

6. Compare and contrast the clinical application of this model with one that we have already studied.

a. Common between Bowenian:

i. Awareness is important in both.

ii. FOO and childhood feelings/actions are of great importance.

iii. Therapist is not a problem solver, but helps to develop empathy and a safe environment for family.

b. Differences between Bowenian:

i. Rather than focuses on processes of family, focus is upon underlying thoughts, fears and the unconscious ego.

ii. Therapist does not ask questions to develop process understanding, but to help individuals understand the feelings behind their actions.

iii. Dates and family history is less of focus, but rather the attachment and autonomy of families.

iv. Few therapeutic exercises—focus upon accepting and resolving underlying issues.