Doing Family Therapy PDF - Core Concepts

CHAPTER 2 Core Concepts Problems, Process, Patterns, and Resistance are we doing when we are doing family therapy? In this chapW hat ter we try to answer that question by looking at the core concepts of family therapy: problems, process, patterns, and resistance. Think of them as different but oft...

CHAPTER 2 Core Concepts Problems, Process, Patterns, and Resistance are we doing when we are doing family therapy? In this chapW hat ter we try to answer that question by looking at the core concepts of family therapy: problems, process, patterns, and resistance. Think of them as different but often overlapping, interlocking, and interchanging lenses through which we can view the client’s outer and inner worlds and what we do in therapy. Together they form a core of what family therapy is about. Let’s take them one by one. PROBLEMS What motivates families to seek out therapy? Problems they can’t solve on their own—the child who won’t sleep; battles over money; the grief over a miscarriage; or the worry about the sister who lives in the basement, rarely comes out, and seems massively depressed. And we go into action: defining, deconstructing, reframing, redefining, and hopefully, ultimately helping to solve the problems that clients most want to fix. But problems are never what they seem. Even at first glance what would be a problem everyone would define—say, a flat tire—may seem overwhelming to a couple scrambling to get the laboring mom to the 16 Core Concepts 17 hospital as quickly as possible, while the businessman smiles, knowing he’s found the perfect excuse to miss the meeting he’s been dreading. This is the nature of problems; they are uniquely our own, handpicked, and labeled so by our psychology. They are truly in the eye of the beholder. What seems initially difficult about family therapy is that the family members are offering competing problems for your attention, each with different owners and levels of severity. While your job is not to sift through all the evidence, you do want to sort out who owns what problem (mom is worried about Tim’s grades; Tim and dad are not), and present some new perspectives to replace the family’s old wornout ones that keep them from moving forward. Here are some lenses that you can try on and try out when sizing up problems. Your Clinical Theory As mentioned earlier, your clinical theory shapes what you see and redefines presenting problems into something else. If you follow a structural approach, the model will direct you to look at the difference between the ideal family structure—a strong hierarchy, parents working together—and how the family presents. Presenting problems are set within this frame. If, on the other hand, you are using, say, a multisystemic approach with a teen, you will be looking at the extrafamilial systems in which the family is embedded and ways of moving away from those that are negative influences and strengthening the positive ones. By offering the family your outsider perspective—this new lens—you stir new questions, new emotions, and, ideally, new motivation and hope. Learning Problems versus Problems about Learning These terms were developed by Ekstein and Wallerstein (1958) in their seminal book The Teaching and Learning of Psychotherapy. Basically, they said client problems can be boiled down to one of two types: learning problems and problems about learning. Learning problems have to do with skills: I have never raised a baby and have no idea of how to diaper one. This is clearly a skill problem, but so is good communication, or learning how to create a budget to manage money, or having specific tools to control one’s anxiety or anger. Once someone shows you how to do it and you practice it, the problem goes away. 18 D O I N G F A M I LY T H E R A P Y Problems about learning, on the other hand, are those situations in which I have the skill—that I’m a good parent and know how to raise my kids—but my emotions override what I know and create the “problem.” Every time my teenage son acts defiant, puts his hands on his hips, and gives me that “look,” I forget everything I know I should do, and instead feel like wringing his neck. So, say Ekstein and Wallerstein, we need to sort out at the top whether a client’s problem is a learning problem or a problem about learning. Is this family struggling over money because they don’t know how to set up that budget or balance a checkbook, or is it about emotions and control: that the dad emotionally acts out by going on spending sprees, or that the argument isn’t about how to pay off the credit card but is really about who decides what should and should not be charged on it? As we’ll be emphasizing, you do not need to have the answers to these questions, you instead know to ask the questions. Start by asking yourself: skill or emotion? With this question, you have a quick and handy assessment tool, as well as a way of helping families understand where their problems may lie. Problems as Bad Solutions This is our next way of thinking about problems: Because of the tight relationship between problems and their owners, what often seems, especially to outsiders, a problem, is often a bad solution to another problem beneath. Sam’s wife may think Sam has a drinking problem because he drinks a quart of Jack Daniels every night, but Sam, most likely, doesn’t think he has a problem. For Sam, his drinking is a solution, albeit not a particularly good one perhaps, to another problem: that he is depressed, or worries about his business going bankrupt, or that he’s preoccupied with some trauma of the past, or that his relationship is on the rocks. Similarly, we can also look at the spending spree, the teen who runs away from home, and the angry outburst that results in the police being called as bad solutions. The assumption here is that people are most often doing the best they can at any given moment, however dysfunctional it may seem to you or other family members. For a family therapist, it means asking yourself, “If this problem is a bad solution, what’s the underlying problem?” Again, your job isn’t to have the answer. Instead, you pose the question to the family: Ask Sam how he thinks about his drinking differently from how his wife does, and see what he says. Core Concepts 19 Problems Arising from Childhood Wounds and Outmoded, Limiting Coping Styles Problems as bad solutions and problems about learning neatly fold into our last way of thinking about problems: those arising from worn-out coping styles and their origin in childhood wounds. Here’s the concept: Regardless of our parents’ best intentions, we all walk out of our childhood with some emotional wounds. If my father, for example, was critical of me, I became sensitive to criticism; if my mother was depressed, preoccupied with her own problems, or lacked mothering skills, I often didn’t get the attention I needed and became sensitive to feeling abandoned and neglected; if my sister got all the glory and my parents never noticed my accomplishments, I’m sensitive to not being appreciated. Generally, our wounds and sensitivities are one or two of a handful: feeling criticized, neglected, micromanaged, not appreciated, not heard, and feeling dismissed. As a child our ways of coping with these injuries and unmet needs were limited; we weren’t able as a 6-year-old to initiate an adult problem-solving discussion with our parents about our gripes, our wounds. Instead, we relied—based on personality, how our siblings were coping, what our parents modeled—on one of three basic options to cope: withdraw, be good (always do what we thought others expected of us), or become angry and defiant. Other childhood coping models, such as attachment styles and trauma-informed models, provide similar insights. Susan Johnson (2019), for example, uses the lenses of anxious and avoidant attachment styles to help her frame the common pattern-making she sees in couples and families as well as to guide her treatment plans. Trauma-informed models (Hodas, 2006) explain the ways trauma in children makes them prone to depression, anxiety, physical problems, and incarceration in later life. What these models have in common are the belief and awareness that these early coping styles and survival skills, such as hypervigilance or fight responses, being good or withdrawing, as well as our lingering emotional wounds, continue to shape our adult lives; the Buddhist phrase How you do anything is how you do everything perhaps most aptly summarizes this notion. They provide use with another lens that helps us see everyday problems arising from both the triggering of childhood wounds and the activation of old coping styles that are now like old software in a new computer—too inflexible for the larger, more complex adult world. 20 D O I N G F A M I LY T H E R A P Y But these models also share the belief that these coping styles can change, and changing them is one of the primary goals of therapy. To help clients do this, we need to not only be aware of how they “do everything”—how their coping styles infiltrate their lives and problems—but also be aware of how we need to be—what we need to not do to avoid triggering old wounds, what skills we need to teach, such as emotional regulation, or what environment we need to create, such as one of safety, so that clients lower their anxiety and learn to trust. By consciously and proactively shaping the session process and the therapeutic relationship, our goals become ones of creating those corrective emotional experiences that clients need to heal their childhood wounds. Problems Arising from Larger Societal Changes You lose your job during an economic recession. You lose your grandparent or uncle to the virus during a pandemic. You lose your house to a wildfire or hurricane. These devastating events arise not from the past or family dynamics, but from social and natural forces outside your control. There is no clear cause and effect; who becomes a victim seems arbitrary. And because these problems are outside your control, because there seems to be no rhyme or reason to who is victimized, the trauma is all the greater. This is another side of our work: helping families when these life events occur and cripple or shatter their lives. They turn to you because they can’t make sense of what has happened, or they worry about the impact on their children or what to say to them to help them feel better. These are difficult situations because, like them, you realize that there is nothing that they have done wrong, no underlying problem that they need to fix. So, what you help them with is what they can control—applying for new jobs, gathering information about what the insurance company will cover, finding out what government resources they are eligible for. But what you are most helping them with is grief—loss in whatever form for them it takes—and as part of the grief process help them make some sense of what has happened, help them stay connected to their emotions so they don’t escape from them through anger, blaming, or self-criticism. And for those who have suffered emotional childhood wounds, who already see the world as unsafe and their lives and others as enemies rather than supports, who see whatever has happened as more evidence for their negative worldview, you can help them separate the past from the present, help them realize that the past doesn’t Core Concepts 21 automatically translate into the present even though it feels that way, and that, although not everything is under their control, some things are, and you want to help them sort out the difference. We use different lenses for understanding problems. See what lenses you may want to keep, which ones to possibly throw out, which ones seem to best fit your family, and which ones resonate with you most that help you make sense of the why and how of life’s problems. PROCESS Process and content: the flow of water versus the water itself; the act of complaining versus the complaints themselves; the act of saying you’re sorry versus what you say about why you are sorry. The unfolding of emotion and language and behavior versus whatever the emotion, language, and behavior are about. Process and content are two sides of the same coin that make up therapy and form the whole of what happens in the room, and you, like a movie director, pan in and out, back and forth between them: Now focusing on content (“What did the doctor say?”; “What is dad’s specific worry about Karen’s dating?”); now focusing on the process (how dad is dominating the conversation, how mom always sounds hesitant, or how the family changes the subject when you bring up the grandfather). But process and content are not only the essential components of therapy but of everyday life. Content provides the structure for an endless array of events and situations that make up our lives. Most are neutral, some we deem positive, some negative, but all, as mentioned, are in the eyes of the beholder. The negative ones—the ones that trigger old wounds, that raise anxiety, that exhaust our skill set—we label as problems, and problems by definition need to be fixed or solved and are what bring families into our offices. Because families are so often consumed by the event or the situation, they focus on content. They come armed with facts and stories, the narrative that makes up their “reality,” and they argue in the session over whose reality is right—who said what, and was it on Tuesday or Wednesday. And as they become more emotional, they instinctively load on more facts—out come the text messages, what grandpa said on the phone, dragging out yet again Christmas 2016 as an example of. . . . If they sort out whose facts or whose content is right, then, they believe, the problem is at least halfway solved. And that is why they’re there—they are looking to you to be the judge, to hear their stories, to sort and sift through this truckload of content. They are looking 22 D O I N G F A M I LY T H E R A P Y to you to decide right then whose reality is the correct one, who really has the problem, who is screwed up and needs therapy. And if that isn’t challenging enough, there is not just one or two problems, but usually many: Jimmy struggles with attention-deficit/hyperactivity disorder (ADHD), dad is drinking too much, mom is depressed, grandma broke her hip, and they can’t afford the rent. All these problems and content and arguments about realities are dumped on your lap. But while they’re thinking and talking the language of content— the what—you want to think and talk about the language of process— the how, the Buddhist how, you do everything. We’re back to childhood wounds, outmoded coping styles, and problems about learning. The umbrella for all this is faulty process—their emotional reactions, the limits of their skills, and their underlying perceptions and assumptions and how they put them into play. These are the real culprits, the underlying “it” that most often creates and keeps the problem alive. The content is a moving target because life’s problems are always around the corner, but it is this faulty process, this old software—process as problems in motion—that are undermining the successful running of their lives and are most likely enacted there in the session right before your eyes. The way that a mother dismisses her partner’s stated desire in the session for more sex is identical to the way she dismisses her daughter’s concerns for having her own room; the way the teenager turns her chair away from you and stares at the ceiling is the same shutdown response she gives her parents when they ask who is the friend she is going to the concert with. You want to focus on process, because if you can help them recognize and change their process they can better handle whatever content life may throw at them. Not only do they avoid the arguments about whose reality is right, nor merely put to rest the current problem-ofthe-week, they learn the skills and develop the strengths to solve the problems yet to be. And by focusing on process, not only do you avoid getting lost in the weeds of facts, but the stack of 20 problems that the family has dropped on your lap to fix are now reduced to just a few. Your challenge is to make all this process, the how rather than the what, the priority at the start. Yes, you want to allow each person in the first session to present his “opening statements” to get things off his chest and actively listen to build rapport, but you want to resist the pressure to judge and arbitrate. This is where your leadership, theory, and treatment maps need to kick in. If you just listen and not lead, if you have no mental map to help you sort out what is and isn’t important out of all the facts coming at you (“And you said your dog’s name is . . . what was that again?”), you will get lost in the world of details, Core Concepts 23 and worse, you’ll likely begin to feel like the family—overwhelmed and reactive. Instead, you want to mentally push aside all that content, focus on the ways they respond to each other, and notice how their emotions derail their communication and ability to solve the problem. What you see becomes a microdemonstration of how they emotionally and behaviorally navigate their larger world. One of your goals is to teach them to think like you, to see what you see but they usually cannot, to help them shift from the language of content to that of process. You are already doing this in the first session by what you choose to focus on. If you get too caught up in detailed questions about facts—What exactly did grandma say on the phone? How do you know that Jake was late for school on Tuesday?— you’re training the family to think that this content is important for you to know, that these details matter. They’ll be ready at the next session to give you a verbal transcript of the phone conversation; they will have noticed the exact time Jake left the house. Instead, you want to direct their attention to what is unfolding: “Can you tell that you are getting upset?”; “Does this feel like a power struggle?”; “Do you notice how sad Megan looks even though she sounds angry?”; “I’m wondering if this is what happens at home.” A helpful metaphor for helping families understand process is to describe how having a conversation is like driving a car. There are two skills required in driving a car. The first is knowing where you want to go before you set out. Before you start a conversation, decide what is the one thing—the content—you most want the other person to understand (for example, that it feels disrespectful to me when you look through text messages while I am talking); the one problem you want to solve (for example, to come up with a chore list for the children). The second skill is keeping the car on the road—the process—and this is where most families get into trouble. Within minutes they are no longer talking about text messages or the chore list, but are getting angry and talking about that Christmas 2016 again, the time Sally lied, who decides whether chores are important at all. The conversation has gone off the road and into a ditch. When this happens in the session, you want to initially wait and see if the family can get the car back on the road: “We don’t need to talk about Christmas 2016 again right now,” says the dad, “let me explain why privacy about my phone is important to me.” If they can’t—if Christmas 2016 rapidly spirals off into your mother, your stupid brother, that time you did such and such—step in and change the process by pointing out the process: “Hold on, everyone. Can you tell that this conversation is going nowhere, that the car has gone off the 24 D O I N G F A M I LY T H E R A P Y road and getting stuck in a ditch?” Their first response will likely be to ignore you, say yes, but then continue where they left off. You’ll need to be persistent and point out the process repeatedly until they can begin to do it on their own. The family is understandably wanting you to help them fix the problems “out there” in their lives, but you have no control over what they do out there. What you can only control, influence, and shape is what is unfolding “right here, right now” during the session. Your influence and power are limited to what you do and say and can create in the room within the microprocess of interactions between you and your clients. And that is often enough, because in the broad scheme you assume elements of the client’s world, and problems are encapsulated in the patterns and interactions that take place before you. This is all you can work with and have available to work with: exploring what is under the wife’s dismissive tone or encouraging her husband to speak up even though his instincts are to remain silent and nod his head, talking gently to the teen about how she feels when questions are lobbed at her. This is where your skills are concentrated and applied: changing the conversation, unearthing new emotions, defining the intention behind the behavior, and the worry behind the anger. Everything else—whether the client follows your advice, pays the rent, or controls his temper with the kids at home—is out of your immediate control. Your challenge is to shape the time, space, and interactions in the immediacy of the moment to create something new. By doing this and by teaching families to do the same—to recognize when the process is breaking down, to have the skills and courage to change it right there and then—they too learn that life happens in the present, and that while they can’t control the other guy, they can control what they say and do next, and by doing so they too can change the quality of their interactions and relationships. This is often a difficult perspective to absorb and, at times, to maintain. When we feel frustrated or overwhelmed and flooded with content, we need to remind ourselves of both the limits and focus of our power and that our work of doing therapy lies in shaping what unfolds right now. PATTERNS If the faulty process is problems in motion, it is also the raw material of patterns. Patterns are the process solidified and set into anxietybinding shapes, chunks of predictable interactions. Like process, some Core Concepts 25 patterns are positive (supportive, anxiety reducing) whereas others are dysfunctional (interactions that invariably get stuck in the emotional mud rather than move along a path of understanding, problem solving, and compassion). A core belief of systems theory is that the patterns are always more powerful than the individuals; the patterns create their momentum and autopilot response. As Susan Johnson, the creator of emotionally focused therapy says, it’s not the other guy who is the enemy, it’s the pattern between them. Just as families are understandably prone to see content and not process, they are also inclined to focus on unilateral behaviors—“Eric fights all the time,” “My husband is always yelling at me”—or if clients do link events, they’re usually individual, sequential ones—Johnny starts to complain, then he wails, then he starts kicking, then he falls on the floor, rather than the horizontal, interactional, bouncing-off-eachother patterns you are looking for. You have two basic ways of finding these patterns. One is to ask “What happens next?” questions that help the client map the patterns for you: “So, after Johnny starts to complain, what do you generally do? And when he wails, what do you do then?” By doing this, both you and the client can see the ping-pong of moves, the connection between the behavior of one and the behavior of the other. Generally, the pattern continues until there is a shift in emotion (the mother swats Johnny and he starts to cry, or the mother stomps into her bedroom and slams the door), setting off a new pattern of reconciliation. The other way of detecting patterns is to see them as they unfold in the room. Mom tells Susan to sit up straight, Susan slumps even more; Dad tells Susan to listen to her mother, Susan snaps at her father; mom shrugs and looks away; Susan sits up a bit, slumps again, and it’s over. This pattern may be repeated with different content: Mom asking Susan to tell what happened yesterday, Susan saying there’s nothing to tell, dad scolding Susan, and so on. If the pattern isn’t automatically reenacted there in the room, ask them to enact for you what happens at home. Ask dad and his daughter to discuss right now a curfew time, ask mom and her son to negotiate a chore list, and watch what unfolds. As it does, you can begin to point out the pattern you see, in a calm, nonaccusatory way: “It’s interesting. I notice that when Susan does , you, Mom, always do , and then, Dad, you seem to do .” You’re introducing the family to how their reactions have become set. By thinking and looking in terms of patterns, you cognitively move away from the swamp of content details and help the family do the same. Rather than arguing over whether it was Tuesday or Wednesday, 26 D O I N G F A M I LY T H E R A P Y with your help they can begin to see that the conversation is going nowhere and that they are falling back yet again into the same emotional potholes of evidence and blame. The key to making things better lies in helping them realize when they are falling into their patterns, learning to get themselves out, and coaching them toward moving in a more positive direction. RESISTANCE Problems and a family’s resistance seem to go hand in hand in the clinical literature, although different theoretical models place a varying emphasis and slant on it. Traditional psychoanalytic models, for example, assume resistance is not only part of the work but, in fact, the focus, while behavioral approaches tend to talk little about it (Anderson & Stewart, 1983). Apart from the either/or camps is the notion that resistance makes sense, in that clients are likely to always have mixed emotions about stepping outside their comfort zones, adapting new perspectives, or even engaging in the therapeutic process itself. If we assume that people are always doing their best—that by walking into your office and giving up their time and money at least some part of them is desiring change and the solving of a problem— here are, for your consideration, four basic sources of “resistance,” all of which tie into our core concepts. The cause and solution also all happen to fall onto your lap:  No agreed-upon problem. If there is unclarity or disagreement about what the actual presenting problem is (social services believes the parents need couple therapy, the couple feels that social services is just harassing them), and if the ends and means are tangled (social services orders therapy, but the couple would rather talk to their minister or grandmother), the clients aren’t motivated and seem resistant.  Faulty expectations regarding the process. Clients cannot help but have expectations about therapy—about what the therapist will do (listen, give advice, decide who is right), the focus (see my child rather than the family), what will occur in a session (ask about my past, listen to my story, ask a lot of questions)—or about the length of treatment (two sessions rather than 2 months). If therapists don’t meet these expectations or are not able to change them quickly, the family is likely not to return.  Poor pacing. This is also about process and often pragmatism. You give a family a homework assignment (for example, for the parents to create a reward chart for a child’s behavior), and they show up next Core Concepts 27 week without having done it. This seems like resistance. But maybe they didn’t understand how to do it, or felt it was too overwhelming, or didn’t understand how it would help their child do better in school. The clinician is moving too fast and making too many assumptions, and the parents are having trouble learning the skills, feel overwhelmed, and need more support or information.  Replicating a family role. Here is what we mentioned earlier, namely, the therapist creating roadblocks by unintentionally igniting emotional wounds (for example, he comes on too strong with a teen and is seen by the teen much like the teen’s pushy father; the therapist works too hard to rescue the family and fix all the problems, and everyone becomes passive). The therapist in these situations has become inducted into the system. Rather than being an outside change agent, she is caught up in a role that ultimately maintains dysfunction and that interferes with the family learning new skills. What these sources have in common is that they are all about you and what you are doing or not doing. The clients’ seeming resistance is their bad solution to another problem in the therapeutic relationship or process that you’re not addressing. By keeping these four sources in mind when clients dig in their heels and don’t follow through, you can uncover the problem under the problem and address it. So back to our opening question: What are we doing when we are doing family therapy? What we are doing is toggling among these four core concepts: 1. Focusing on process. The how rather than just the what—not just so that we don’t get overwhelmed by the family’s content, but also to begin to help families see the process—how they respond, what they can and can’t do—and understand that it is the medium for change. 2. Defining patterns. Stopping dysfunctional ones and helping families do the same, so that they break out of patterns’ grip and take conscious action to move in a more positive direction. 3. Approaching the stated problems through a new lens. Our perspective, like that of the family physician’s, allows us to step out of the content, begin to define and deconstruct the problem, and give ourselves and offer the family a foothold in understanding it. 4. Resistance. Believing that families are doing the best they can, and it is our job to clear obstacles that arise along the way that prevent them from moving forward. 28 D O I N G F A M I LY T H E R A P Y So here you have the core concepts that form the foundation for family therapy and upon which everything else is built. In the chapters ahead, we look at the skills and techniques that you need to put these concepts into operation. L O O K I N G W I T H I N 1. When you look back over your past, what emotional wounds have you incurred? What are you most sensitive to in your relationships with others? Are there any themes (for example, “I always wind up feeling . . . ”)? How do you cope when these wounds are triggered? How do you tend to cope with stress overall? 2. Are there certain problems that you struggle with due to a lack of skills? Does this occur in therapy when handling emotional situations—the aggressive clients, for example—simply because you don’t know the skills involved in responding to such people? Are there other persistent problems in your life that could be improved by learning the skills to adequately tackle them? 3. Being able to shift between process and content is a matter of practice. In nontherapeutic situations—talking to a friend, for example— see if you can practice switching between both modes. When watching a movie, see if you can identify each mode. 4. Are there problems under your problems? One good way of sorting this out is by asking yourself the “five whys.” Initially developed by Toyota as a way of drilling down to automobile manufacturing problems, you can apply this practice to problems in your personal life. Write out the problem, ask yourself why, and see what answer comes up next. Then ask why again, and see what arises. Continue through the five whys, but feel free to go even deeper. 5. How have societal changes beyond your control affected your life? What has been its impact? How has it changed your perspective on the world?