Deliberate Practice exercise 2.pdf

Building the Therapeutic Alliance: Establishing Bonds and Joining the System Preparations for Exercise 2 1. Read the instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form and the Deliberate Practice Diary Form at https://www.apa.org/pubs/books/deliberate-practice-systemic-fami...

Building the Therapeutic Alliance: Establishing Bonds and Joining the System Preparations for Exercise 2 1. Read the instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form and the Deliberate Practice Diary Form at https://www.apa.org/pubs/books/deliberate-practice-systemic-family-therapy (see the “Clinician and Practitioner Resources” tab; also available in Appendixes A and B, respectively). Systemic Context for Exercise 2 Systemic therapists work with individuals, couples, and families and approach each from a systemic perspective. For this particular systemic skill, you will need five trainees: one therapist and four clients. We have provided some case context before each client prompt. This context will come in the form of underlined text that first states the type of relationship followed by additional background information (e.g., “Family—father and adolescent daughter”). Please make sure a trainee in the role of a client reads the underlined text out loud before each client prompt. If there are more trainees available than there are client roles designated in a particular prompt, then one or more trainees can sit out and observe the role-play of that particular prompt. We encourage trainees in client roles to rotate who will be reading a client statement and who will be observing so that everyone has a chance to participate in the exercise. https://doi.org/10.1037/0000301–004 Deliberate Practice in Systemic Family Therapy, by A. J. Blow, R. B. Seedall, D. L. Miller, T. Rousmaniere, and A. Vaz Copyright © 2023 by the American Psychological Association. All rights reserved. 37 EXERCISE 2 38 Deliberate Practice Exercises for Systemic Family Therapy Skills Skill Description Skill Difficulty Level: Beginner The therapeutic alliance (also referred to as the therapeutic relationship) is a core component of successful therapy, and the strength of the alliance, especially early in therapy, is a robust predictor of positive change. Although the therapeutic alliance has been described in a variety of ways, we focus on Bordin’s (1979) pantheoretical conceptualization of it as composed of three distinct content dimensions: tasks, goals, and bonds. The first of these dimensions, tasks, targets therapist and client agreement on the process and structure of therapy. The second dimension, goals, refers to client and therapist consensus on the preferred outcomes for therapy. The bonds dimension captures the empathetic connection between therapist and client. When working with couples and families, the skills of the alliance quickly become complex as the therapist operationalizes each component of the alliance with each member of the system. This skill focuses on the bonds of the alliance. The goal of this skill is to train therapists to establish bonds by connecting in a positive way with all members of the client system. The bonds component of the systemic alliance consists of the emotional connection between the therapist and each member of the system. To form bonds with a system, the therapist needs to be able to convey an attitude of acceptance for each system member and a respect for their ways of being in the world. The family therapist should attempt to engage each system member by forming a bond with them individually but should not force anyone to speak or make any member unnecessarily uncomfortable. The therapist needs to have especially strong bonds with members of the system who are highly influential in the change process as well as system members who have the power to sabotage the system’s engagement in treatment altogether. Skilled therapists can form initial bonds in minutes, but these are truly deepened over several therapy sessions. The skilled therapist will also be able to form bonds with each member of the system, even though they each have different views of their situation. To form genuine connections with each member of the system, the therapist approaches each member with positive relational qualities, such as empathy, warmth, kindness, curiosity, compassion, humor, concern, caring, acceptance, and understanding. This relating is free of negative relational qualities such as judgment, rudeness, impatience, and disapproval. It is important to note that in forming bonds with individuals in a system, the therapist does not have to agree with their behavior or point of view, and the therapist avoids the appearance of taking sides or favoring one system member over another. SKILL CRITERIA FOR EXERCISE 2 1. Explicitly convey that you are listening to each system member’s unique view of the problem or session content. 2. With each system member, identify and reflect relevant emotions or meaning in a warm, understanding, and accepting way. 3. (a) Seek feedback from the system members on their experience of you and the therapy process. or (b) Suggest the therapist or therapy process as a place for healing or change. Building the Therapeutic Alliance: Establishing Bonds and Joining the System Examples of Establishing Bonds and Joining the System Example 1 An adolescent son and mother—the mother is concerned about her son’s behaviors. SON: [frustrated] We’re here today because my mom is always nagging and yelling at me. She doesn’t let up. THERAPIST: As I listen to you (Criterion 1), I hear you saying that you see your mom as nagging you a lot, and this frustrates you and is causing distress (Criterion 2). What do you think about what I just said (Criterion 3A)? MOTHER: [smiling] I never thought I would grow old and be called a nag! I am just trying to keep things organized in our home. THERAPIST: I hear (Criterion 1) you say that you have really good intentions about your requests of your son, and you are shocked to hear that you have become the “old nag” [smiles]. (Criterion 2) What is it like for you to be talking about this here today in therapy? (Criterion 3A) Example 2 A lesbian couple—the partners discuss a lack of closeness in their relationship and fears of infidelity. PARTNER 1: [accusing] I would feel so much happier in this relationship if I did not have to worry all the time about whether she is going to be faithful to our relationship every time she leaves on a business trip. THERAPIST: I hear that you have concerns (Criterion 1) every time she leaves on a business trip that she would do something that would be really threatening to your relationship. It must be scary for you to be home alone and have to worry about that all of the time. (Criterion 2) How does what I said sound to you? (Criterion 3A) PARTNER 2: [defensive] This is a difficult topic for me, as I am doing nothing wrong. I have never cheated on her, and I have no plans in the future. Even when I reassure her, nothing seems to help. I am not sure what to do any more. THERAPIST: Thank you for sharing your perspective. (Criterion 1) It is a difficult situation for you as well but for different reasons. You are feeling frustrated that you have tried to reassure her but nothing seems to help. (Criterion 2) Are you OK with continuing to use therapy as a place to explore these differences between the two of you? (Criterion 3B) Example 3 A mother, father, and two young children—the father complains about general chaos in the family home. FATHER: [overwhelmed] I keep trying to have us sit at the table every night, but it normally ends up like a circus. I wish she (wife) would be more supportive, and I wish the kids would listen to me. THERAPIST: I am hearing you have been making strong efforts to implement family rituals and, in this case, eating dinner as a family. (Criterion 1) But you are feeling defeated 39 40 Deliberate Practice Exercises for Systemic Family Therapy Skills because not everyone is on board with the plan, and this is leading to further tensions. (Criterion 2) How do you feel about using the therapy process to explore further about how things get off track? (Criterion 3B) THERAPIST: [To Child 1] How do you see the mealtime situation? CHILD 1: [quietly] I like eating together at the table, but Dad is often yelling, and when that happens I prefer to leave and go to my room and finish dinner on my own. THERAPIST: I hear that you have a different experience of meals than your dad and that you are also experiencing tension but that is different to what your dad experiences. (Criterion 1) It sounds so lonely for you to have to eat on your own in your room. (Criterion 2) How about we use therapy as a way to solve this problem so that you don’t have to argue about this so much? How does this sound? (Criterion 3B) Building the Therapeutic Alliance: Establishing Bonds and Joining the System INSTRUCTIONS FOR EXERCISE 2 Step 1: Role-Play and Feedback • The client reads the underlined text aloud before each client prompt. • The client says the first beginner client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provides brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (see Appendix A) and decides whether to make the exercise easier or harder or to repeat the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then rotate roles and start over, repeating this exercise until each trainee has had a chance to act as the therapist. 41 42 Deliberate Practice Exercises for Systemic Family Therapy Skills ➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses. BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Beginner Client Statement 1 Individual—the client is distressed about a recent breakup of a dating relationship they had hoped would be long term. [Sad] I am here to see you because my boyfriend broke up with me 2 weeks ago. I am crying every day and have found myself wanting to stalk him to find out if he is dating someone else already. Beginner Client Statement 2 A mother, father, two adolescents (ages 15 and 17)—the family is having major disagreements about curfew, which has caused a lot of arguing. FATHER: [Matter-of-factly] We are here to see you today because the kids—or, should I say, young adults—will not keep curfew. I am tired of all of the yelling that results, and it is interfering with my work. MOTHER: [Annoyed] If he (dad) would help out a little, I think that I would not have to yell so much. I need his support in enforcing the curfew. Beginner Client Statement 3 Heterosexual couple—the female partner is worried they are drifting apart and made the appointment; the male partner is reluctant to be in the session. FEMALE PARTNER: [Accusing, anxious] Our relationship has been falling apart for a long time now. He never pays attention to me and seems obsessed with his soccer league. I am very worried that we are not going to make it. MALE PARTNER: [In disbelief] I’m not sure what I am doing here. This is going to be a complete disaster. Beginner Client Statement 4 A foreign-born couple—they have lived in the United States for 3 years and came so that one partner could obtain their degree. PARTNER 1: [Exasperated] We came to the United States to study. We have never been to therapy before, but I felt like it was urgent because she seems so depressed, sleeping most of the day. She is also angry with me all the time. I feel helpless. PARTNER 2: [Unhappy] The USA is a terrible place. I am not sure what we are doing here. This therapy stuff is not going to help. Beginner Client Statement 5 Stepfamily (biological father, stepdad, and two adolescent daughters, ages 13 and 16)—the family has been fighting since the father came out as gay, left his wife, and partnered with a new man (the stepdad). STEPDAD: [Calmly] I am the one who insisted on therapy. I have been to see someone before, and it really helped me. OLDEST DAUGHTER: [To stepdad, disapproving] I am also glad we are here. Things are so much more tense since you moved in. Assess and adjust the difficulty before moving to the next difficulty level (see Step 3 in the exercise instructions). Building the Therapeutic Alliance: Establishing Bonds and Joining the System INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Intermediate Client Statement 1 An individual client—this person is distressed about a recent breakup of a dating relationship they had hoped would be long term. [Distressed] The main feeling I have is despair. I have reached out to my friends to help me with this breakup, but they are out having fun and going to bars. I am just not into that scene. Intermediate Client Statement 2 A mother, father, two adolescents (ages 15 and 17)—the family is having major disagreements about curfew, which has caused a lot of arguing. ADOLESCENT 1: [Intensely] Mom and dad keep on making out like we are criminals. We are not, and now they are forcing us to come to therapy. ADOLESCENT 2: [Tired] I am also tired of the fighting in our house. I would be willing to come to therapy if I could see how it would help. Intermediate Client Statement 3 A heterosexual couple—the female partner is worried they are drifting apart and made the appointment; the male partner is reluctant to be in session. FEMALE PARTNER: [Resentful] Not only are we drifting apart, but we don’t kiss as often as we used to. I also have a ton of stuff going on at work, and he is oblivious to my situation. MALE PARTNER: [Defensively] She comes here and she raises all of these issues, but she never tries to talk to me at home. I am much more available than she thinks. Intermediate Client Statement 4 A foreign-born couple—they have lived in the United States for 3 years and came so that one partner could obtain a degree. PARTNER 1: [Depressed] Coming to the United States was a way for me to secure an international degree so that my family would be happy. Now it seems that the person I love the most is unhappy and angry all of the time. Sometimes I just want to take a drink and zone out in front of the TV. PARTNER 2: [Upset] He never has any time for me. Because I don’t have a work visa, I have to stay at home all day long. He is gone doing his study thing all day long, hanging out with his new friends, and having a good time. I am just stagnating. Intermediate Client Statement 5 Stepfamily (biological father, stepdad, and three adolescent daughters, ages 13, 15, and 16)—the family has been fighting since the father came out as gay, left his wife, and partnered with a new man (the stepdad). FATHER: [Expressive] I have never been to therapy before, but I thought we should give it a try. When I invited Ben (stepdad) to move in, I thought we would be a big happy family. Boy, was I wrong . . . MIDDLE DAUGHTER: [Shut down] I don’t have anything to say. Assess and adjust the difficulty before moving to the next difficulty level (see Step 3 in the exercise instructions). 43 44 Deliberate Practice Exercises for Systemic Family Therapy Skills ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Advanced Client Statement 1 Individual—the client is distressed about a recent breakup of a dating relationship they had hoped would be long term. [Crying] I feel so alone in the world. I had really thought that this relationship was going to work out. [Sobbing] I can’t believe he broke up with me the day after he said he loved me. Advanced Client Statement 2 Mother, father, two adolescents (15 and 17)—the family is having major disagreements about curfew, which has been causing a lot of arguing. FATHER: [Deliberately] I feel I work so hard every day to allow the family to have what they want, but sometimes it seems I am being taken advantage of. ADOLESCENT 1: [Angry] Dad, that’s ridiculous—it’s not always about you. MOTHER: [To dad, concerned] We do say how much we appreciate you, but you seem checked out so much of the time. Advanced Client Statement 3 Heterosexual couple—the female partner is worried they are drifting apart and made the appointment; the male partner is reluctant to be in session. FEMALE PARTNER: [To partner, appreciative] Thank you for coming today. I really want our relationship to work, and I want both of us to be happy. MALE PARTNER: [Taking her hand, warmly] I want things to work out as well. Advanced Client Statement 4 Foreign-born couple—the couple has lived in the United States for 3 years; they came so that one partner could obtain their degree. PARTNER 1: [Exasperated] Sometimes it seems pointless. Maybe we should just get a divorce. PARTNER 2: [To partner, anxiously] You are always going to extremes. I love you and we are here to work on things. Please don’t make any rash decisions. Advanced Client Statement 5 Stepfamily (biological father, stepdad, and three adolescent daughters, ages 13, 15, and 16)—the family has been fighting since the father came out as gay, left his wife, and partnered with a new man (the stepdad). YOUNGEST DAUGHTER: [Tears in her eyes, speaking to whole family] I really miss Mom, but I love all of you as well. We can’t go back to the way things were. Can we all just try a little harder? Assess and adjust the difficulty here (see Step 3 in the exercise instructions). If appropriate, follow the instructions to make the exercise even more challenging (see Appendix A). Building the Therapeutic Alliance: Establishing Bonds and Joining the System Example Therapist Responses: Building the Therapeutic Alliance: Establishing Bonds and Joining the System Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses! EXAMPLE RESPONSES TO BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Example Response to Beginner Client Statement 1 It sounds like you are going through a very difficult time after the end of your relationship. (Criterion 1) It is a very painful experience to live through, (Criterion 2) and I’m here to help you work through these feelings. (Criterion 3B) Example Response to Beginner Client Statement 2 [To father] It sounds like your family has been going through some stress as your children grow up. (Criteria 1 and 2) While stress during this time is normal, I want to hear more about your experiences as a parent and also about the things that are stressing you out at work. How do you feel about sharing that with me? (Criterion 3A) [To mother] I am hearing that from your point of view, (Criterion 1) there are frustrations about the division of labor in the home. (Criterion 2) It sounds like you are also stressed out and are needing support. (Criterion 2) What would it be like to work on this in therapy? (Criterion 3B) Example Response to Beginner Client Statement 3 [To female partner] I hear that you are really worried about your relationship (Criteria 1 and 2) because it is not in a place where you are happy with how things are going. (Criterion 2) This is a difficult situation to deal with, (Criterion 2) and I am pleased you have come to therapy to work on the problems you are facing. (Criterion 3B) [To male partner] It sounds to me that you were not too excited about coming into therapy. (Criterion 1) It is a big commitment to make to work on your relationship, and I admire you for giving therapy a try. (Criterion 2) I am pleased you came today to give it a try—although there are no guarantees, I have seen many relationships strengthened through couple therapy. (Criterion 3B) Example Response to Beginner Client Statement 4 [To male partner] Thank you for sharing that. (Criterion 1) Even though it is strange to talk to someone about personal problems, I will do my best to make this a comfortable experience for you. (Criterion 2) It sounds like you are really worried about your wife (Criteria 1 and 2) and you are not sure what to do. We can work on this in therapy. (Criterion 3B) [To female partner] I really appreciate you sharing your point of view. (Criterion 1) It is a big step coming to therapy, and I know that it is a really awkward place at first. (Criterion 2) I also realize that you are really far from home living in a foreign country, and I know that can be a challenging experience. (Criterion 2) You have said you have questions about therapy. I want to give you my reassurance that I am here to help you as best as I am able. (Criterion 3B) Example Response to Beginner Client Statement 5 [To stepdad] It is always good to hear that your past experiences in therapy were helpful. (Criterion 1) It takes good leadership to bring your family into therapy, (Criterion 2) and I believe that I will be able to help with some of the issues you are dealing with. (Criterion 3B) [To oldest daughter] Thank you for coming and for your engagement in the process. (Criterion 1) It sounds like your family has been through some transitions that have created tension. I can tell that you are eager to resolve these issues (Criterion 2) and I am here to help. (Criterion 3B) 45 46 Deliberate Practice Exercises for Systemic Family Therapy Skills EXAMPLE RESPONSES TO INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Example Response to Intermediate Client Statement 1 I hear that you are going through a lot of changes after this breakup. (Criterion 1) It has been very painful for you, and you feel alone. (Criterion 2) How do you feel about working together as you process this loss in your life? (Criterion 3A) Example Response to Intermediate Client Statement 2 [To both adolescents] It sounds like you have both been under a lot of stress with the ongoing fighting in your home. (Criteria 1 and 2) I admire you both for being here today and value hearing your voices and perspectives. (Criterion 1) I know that therapy can seem like a chore, (Criterion 2) but I want to reassure you both that I am here to support your points of view as well as those of your parents. (Criterion 3B) Example Response to Intermediate Client Statement 3 [To female partner] I can hear the sadness in your voice when you talk about your relationship drifting apart. (Criteria 1 and 2) It sounds like you also feel unnoticed regarding other stress you are facing. (Criterion 2) I am pleased you are willing to discuss this in therapy. (Criterion 3B) [To male partner] I hear what you are saying in that a lot of what you have heard today was new to you (Criterion 1) and you wish she would have shared more at home. This has understandably made you defensive even though when I listen to her, she wants to make your relationship stronger. (Criterion 2) I believe therapy will be able to help with that, and I hope you will stick with the process. (Criterion 3B) Example Response to Intermediate Client Statement 4 [To Partner 1] What I am hearing you say (Criterion 1) is that you came to the United States to improve the lives of your family, and it hurts you deeply to see your wife in such distress. (Criterion 2) I think you will find that turning to therapy for help was a good decision. (Criterion 3B) [To Partner 2] I am hearing you say (Criterion 1) that you are feeling neglected and alone. You came with your husband to the United States, but now you are feeling left out and that you are not doing anything meaningful with your life. (Criterion 2) I am hoping that therapy will be a place to work this out. (Criterion 3B) Example Response to Intermediate Client Statement 5 [To family] I am hearing dad say that even though his intentions were good about Ben moving in, it has not gone as well as he hoped. (Criterion 1) [To dad] I hope you are not beating yourself up over this; stress in stepfamilies is normal and with some work we can improve the situation. (Criteria 2 and 3) [To middle daughter] It’s fine that you don’t have anything to say. (Criterion 1) I am just pleased that you are here today to work on some problems your family is facing. (Criteria 2 and 3B) Your input is important, so anytime you want to say something, I will be here to listen. (Criterion 1) Building the Therapeutic Alliance: Establishing Bonds and Joining the System EXAMPLE RESPONSES TO ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Example Response to Advanced Client Statement 1 I hear that this breakup is bringing up so many sad feelings now. (Criteria 1 and 2) What he did is confusing, and I am sure that contributes to how much it hurts right now. (Criterion 2) This is a safe place to get all of those feelings out. (Criterion 3B) Example Response to Advanced Client Statement 2 [To family] I keep hearing how much stress your family is going through right now. (Criteria 1 and 2) You all have busy lives, and everyone wants to be heard and seen. I want to assure each one of you that I am here to support each one of you. I know that may sound difficult [laughs], (Criterion 2) but when working with families, it is possible because I am here for the well-being of the whole family. Does that make sense? (Criterion 3A) Example Response to Advanced Client Statement 3 [To couple] It makes me so happy to see (Criterion 1) the two of you connect in that way. That was a special moment of care and love, and it seems like (Criterion 2) we need to work together to create more of those in here—but most importantly, in your daily relationship. (Criterion 3B) Example Response to Advanced Client Statement 4 [To couple] I hear your frustrations that when things are not going well you want to bail out of the relationship. (Criterion 1) I have been listening closely to both of you today, and I have heard both of you say that you love each other and want this to work out. (Criterion 2) I invite you both to commit to a time in therapy, maybe 3 months, and then reevaluate things at that time. (Criterion 3B) Does that sound OK? (Criterion 3A) Example Response to Advanced Client Statement 5 [To youngest daughter] Thank you so much for sharing. (Criterion 1) You have been through a lot, and I admire your courage in sharing your feelings with the whole group. (Criterion 2) [To family] I am willing to help you work at this if you can commit to it as well. (Criterion 3B) 47