Doing Family Therapy Chapter 3 PDF

CHAPTER 3 The Basic Seven What to Do When You Don’t Know What to Do process, patterns, and resistance are the core concepts that P roblems, form the heart of family therapy and the clinical work on which you can build your therapy approach and style. In this chapter, we look at the extensions of t...

CHAPTER 3 The Basic Seven What to Do When You Don’t Know What to Do process, patterns, and resistance are the core concepts that P roblems, form the heart of family therapy and the clinical work on which you can build your therapy approach and style. In this chapter, we look at the extensions of these four concepts and examine the Basic Seven: those elements that are the heart of the therapy session to which you can always return to keep you grounded. When you start to feel overwhelmed by content, when the family unravels problem after problem with no end in sight and shifts their burden directly onto your lap, or when the family is paralyzed by powerful emotions that evaporate whatever sense of hope you try to create, you need ways of refocusing and recentering. Recentering is the important word here. If you’ve ever learned meditation, you were probably told to focus on your breath or a one-word mantra. And you were also probably told that whenever you “caught” yourself lost in meddlesome thoughts, you didn’t need to feel concerned or guilty or worry about doing it right, but merely to stop and return to the breath or mantra. In the beginning, it was easy to wander off into the forest of your plans and worries—the argument you had with your husband that morning, the list of items you needed to get at the grocery store, the upcoming deadline on the report or paper you needed to do—without even being aware of it. And in the beginning, it probably seemed that you were returning to the mantra more than you 29 30 D O I N G F A M I LY T H E R A P Y were actually saying it. But if you kept it up long enough with practice, this changed; you were more able to stay with it before wandering off. So it is with family therapy. When you find yourself lost in the family—overwhelmed by words, questions, and emotions—don’t panic and don’t kick yourself for messing up. Simply keep in mind the basic skills outlined in this chapter for navigating the process, and get recentered. They can help you stay on track through the most difficult sessions. In the beginning, you may find yourself seemingly always going back, but with practice your forays into the thick of the family will increasingly go further. Even with a lot of experience, you’ll sometimes get overloaded, and it’s good to know you can always go back and start again. Once you feel comfortable with these basic skills, you can use them as the basis for improvisation. Mix and match them, the way a good chef mixes and matches her favorite ingredients, to create your own style, your unique approach to a particular problem or family. Figure 3.1 lists our Basic Seven. Now let’s walk through them one by one. 1. DETERMINE WHAT IS THE PROBLEM/ SEPARATE MEANS AND ENDS “I just haven’t been feeling myself lately.” “The teacher says my son is acting up in class, and he has been giving me a hard time at home. I wonder if you could talk to him and straighten him out.” 1. Determine What Is the Problem/Separate Means and Ends. 2. Think Adult. 3. Look for What’s Missing, Go Where They’re Not. 4. Block the Dysfunctional Patterns. 5. Track the Process. 6. Create an Experience, Apply the Brake. 7. Be Honest. FIGURE 3.1. The Basic Seven. The Basic Seven 31 “The judge ordered me to come here for counseling until you say I don’t have to. I don’t think I need to; it’s my ex-wife who’s the one with the problems.” “My husband and I agree that our daughter has a problem with her attitude, but personally, I think the real problem is that my husband is never home.” As mentioned in the last chapter there are a variety of ways of looking at problems. But the starting point and what you want to always return to is a clear understanding of just what the client is talking about and struggling with: What do “haven’t been feeling myself,” “acting up in class,” or “a problem with her attitude” mean? At face value, these are not solvable problems because the behaviors, emotions, and symptoms they indicate are vague and undefined, and so you ask. By helping clients become clearer and more precise about what they are saying, you are like that family physician who looks at your skin rash with a bright light and magnifying glass: as she moves from vague to more precise language, she becomes clearer and more precise about what she is thinking and feeling. This not only begins to bring the problem into the room and to create a clearer picture of what is wrong, but also helps you begin formulating a clear, positive vision of what the solution can be. Concrete language creates concrete problems and concrete solutions. But in addition to being clear about what the presenting problems are, you also need to be clear about who has which problem. Again, a primary motivator of people are problems, but what motivates them the most is their problems rather than someone else’s. Sometimes, especially when the client is a self-referred adult, the client in the room and the client with the problem are the same, and it’s all pretty simple: “I feel depressed; I’m here so you can help me”; “My kids are running all over me, I need to learn how to handle them better.” Other times, however, it’s not quite so easy. Often the only person with the problem is the person who is seeing a problem in someone else: the mother who thinks her son should work harder to get better grades, but the son thinks his grades are just fine; the father who thinks the mother should be more strict, but the mother feels she has a close relationship with her daughter and the father is just jealous; the wife who wants her husband to stop drinking so much, but he says that he only has a beer now and then, and it isn’t a problem for anyone but her. If only this other person would change and fix his or her problem, each says about the other, I would feel better. 32 D O I N G F A M I LY T H E R A P Y So when they all show up in your office, with everyone pointing the finger at someone else, it’s important to carefully pair problems and people. The mother and teacher who are having problems with the boy’s academics may be the only ones having problems; the boy and his father may not be. The man referred by the court doesn’t believe he has a problem, except with the court order itself; so far, the only person with a problem is the judge or probation officer. The father has a problem with his daughter, but the mother has more of a problem with the father. Whoever sees or feels the problem owns it and is ultimately responsible for solving it. When the problem behaviors seem obvious—the husband is falling down drunk every night, the little boy is failing every subject, the teenager is refusing to go to school—it’s easy for you to get caught up in everyone’s concern and to join forces with them in trying to convince the identified patient (IP), the one who everyone is pointing their fingers at, that a problem does exist. It’s an awkward role that you need to avoid. You are stepping out of the service role, rapidly becoming an enforcer, and the IP lumps you in with everyone else giving her a hard time and pressing a problem on her that she doesn’t feel she has. Rather than being a more neutral facilitator or potential advocate for her, she will instead respond to you with more and more resistance. Rather than wrestling with the IP over the problem, you can ask those who feel that there is a problem to come in together with the IP and use different words and a different emotional tone (thanks to you) about their worries and fears about the IP’s behavior, and see if this approach helps motivate the IP to look at the problem. If the person defining the problem—the probation officer, social service worker, teacher, or generally some other representative of an agency or institution—isn’t planning on being present at that first meeting, invite her to come in. “I’m concerned,” says the teacher, “that if you don’t settle down in class and pay attention, you’ll be left back.” “I’m worried,” says the mother, “that if you don’t stop arguing with me at home, you won’t behave well with your aunt and shouldn’t go to see her this summer.” “If you don’t get counseling to help you control your anger,” says the probation officer, “not only will you possibly be sentenced to jail time but you could lose custody of your daughter.” Your job here is to make sure the communication is clear, that the IP can understand the others’ concerns, and that the IP can explain why the problem is not his. Another approach to this conversation is to tap into his motivation by exploring with the IP any problem that he is concerned about: If you could have any change at home, school, or in your life, what would it be? This is where the boy, it turns out, is very upset that his mother The Basic Seven 33 seems to be spending all of her time with the new baby or he feels like his teacher is always on his back and never gives him credit for what he does well; where the man agrees that maybe he does have a problem with his temper, but he’s gotten a lot worse since he lost his job, and he feels like no one is willing to help him get into job training. You’re uncovering the problem under the problem, discerning and redefining the presenting problem as a bad solution. You now have a point of engagement and motivation for change, and since it often doesn’t matter where you start but rather that you start, you have a green light to go forward. But what if the IP won’t engage despite your efforts and absolutely states that there is no problem and that therapy is a waste of time? You leave the IP alone—thank the son for coming in—and help the remaining family members see what they can do next. You offer the mother an individual appointment to talk about parenting, and have her sign a release for you to talk to the teacher so that they can coordinate how they can better respond to the boy’s behavior. Tell the client that you’d be happy to tell the court that the IP doesn’t see a need for coming and that the probation officer needs to consider some other option. Tell the man that you’re not sure whether he has a drinking problem, that you’re always happy to refer to a substance abuse specialist for an evaluation, but suggest to the wife that she attend an Al-Anon meeting or offer to help her figure out what she can do if the drinking continues. Which brings us to the second half of our equation over determining what is the problem: separating means and ends. Therapy, for example, is never an end in itself, but a means to an end—a way to solve problems, but often one option among potentially many others. But the battle you often see in families over whose reality is right often includes battling over means—family therapy versus individual therapy, this therapist versus that therapist, or using time-outs versus logical consequences with the kids, cutting back on expenses versus getting a second job. The danger here is that the process of how to solve a problem often becomes the problem itself, with everyone losing sight of the ultimate goal. And what can happen within families can also happen within the larger community: social services pushes hard for parenting classes, the family refuses, and a power struggle ensues. Making the family comply replaces the original goal of finding ways to improve parenting in the home. One of your jobs and skills is cutting through and clarifying this confusing means-versus-ends dynamic. Your stance is one of stepping back from the fray, helping the family or community stay focused on the bigger goals, clarifying and sorting out the combination of problems 34 D O I N G F A M I LY T H E R A P Y that are part of the mix: the parents’ problem and the kid’s problem, the agency’s problem and the client’s problem, the husband’s problem and the wife’s problem. By defining, pairing, and drawing a line of responsibility around goals and problems, you avoid getting swept up in and overwhelmed like the family members (and community members) by the emotional jumble of overlapping problems and realities. From this clear position, you now have several interrelated and often sequential options: The first may be to step up and be that clarifying voice, mediating the conversation between the community and family, or the family members and each other, helping them focus on the ends while considering the strategies available. And if you are presented with several problems once family therapy begins, you have a few ways of tackling the bundle. One is to treat each problem separately: “Since this is what you seem most concerned about, in this session let’s talk about ways of using time-outs with Sam, and next week we can talk about that holiday depression that you’re worried about”; “Let’s work on deciding what to do about Chloe’s school behavior, and then we can work on some of those marital issues that you mentioned.” But because the family is a system, another option is to show the family how its process, patterns, and problems are connected: “Susan, you don’t like Jesse going out with his friends so much, and Jesse, you feel that Susan’s always involved with the kids and doesn’t want to spend time with you both alone. Maybe one problem dovetails into the other”; “John, you’re worried about Tom always provoking his younger brother, and Tom, you’re mad at your dad for ignoring you; I wonder if your bothering your brother is a way to let your dad know that you’re mad and get him to pay attention”; “Manuel, you are worried about Teresa’s not keeping up with her schoolwork. Teresa, you said that you are upset about your parents arguing so much. I’m wondering, Teresa, if the tension at home is making it hard for you to do your work.” This way of linking one problem to another helps the family members begin to see that their behaviors are not independent but interrelated, that one problem becomes an attempted solution to another, and that these actions and reactions create those dysfunctional patterns. If you can make this connection and sell the family on this perspective, you have a clear path for shifting the conversation from who has the problem to finding ways of breaking the pattern. This linking also builds on motivation: When each individual’s concerns are acknowledged rather than dismissed, the solution comes from solving the needs of both. Finally, rather than taking turns working on separate problems and linking problems, it is often possible to collapse several problems The Basic Seven 35 into one new one. Joseph, for example, is referred by the school for truancy and arrives at the first session with his parents. It is quickly revealed that the father has started gambling heavily again after years of restraint, and the mother reports that for the past 6 months she has been suffering from chronic back pain and that doctors have done little to help. Although on the surface you can look at these problems as separate, it is no coincidence, perhaps, that they have all erupted since the sudden death of Joseph’s 6-year-old sister of leukemia last year. In this light, it is useful to see that the family members’ problems are different responses to the grief that they each struggle with. By exploring and defining this underlying shared trauma, the seemingly separate problems become one, namely, the sadness and grief that each feels. With your support, the focus shifts from the specifics of their behaviors to unraveling the emotional knot of grief that both links and handicaps them. You in effect have replaced their old, worn-out, or overwhelming bundle of problems with a new perspective and new problem, which together can bring new energy and creativity to solving it. As we’ll discuss more fully in a few moments, you want to make sure that the family is on board with the new ways you are framing their problems, that, yes, they agree that there is a link between their shared grief and Joseph’s truancy, dad’s gambling, and mom’s back pain. To help sell your perspective, you can add psychoeducation—for example, talking about how common it is for those grieving to show a wide range of reactions—or point out how a problem has just been replicated in the room—that the parents, for example, have just given the children two contradictory messages no doubt similar to their polarized stance at home. And should you run into any resistance to your new frame for their problems, you can always backpedal and work on the problems separately until you can gather more evidence to convince the family that the connections exist. Being clear about who has what problem and separating means and ends are the starting points for developing a therapeutic contract. It is also what you can return to when you begin to feel overwhelmed by the variety of problems that the family presents or when the family fails to follow through on the treatment plan. 2. THINK ADULT As mentioned in our first chapter, what helps your family physician make quick treatment decisions is that she already has a repertoire of 36 D O I N G F A M I LY T H E R A P Y treatment maps at the ready for the common ailments that she treats. But she also often relies on something else to make her assessment and plan: She compares your state of health against “healthy” others, usually through various medical tests. Any results in your blood work, for example, that fall outside the normal range let her know that some possible underlying problems that she needs to address are afoot. Her reliance on matching her patients against these healthy standards that helps her can also help you. You too can assess the psychological health of family members by comparing their behaviors and skills against healthy standards. One of the best standards is Murray Bowen’s (1992) concept of self-differentiation and what we’re calling the adult. Here are some of the qualities of the adult stance (Gilbert, 1992; Taibbi, 2019):  An ability to be emotionally calm.  An ability to observe yourself in a relationship pattern and      make changes without expectations of the other. An ability to view others as anxious or fearful rather than malicious or manipulative. An ability to not react in kind to the anger or anxiety of others. An ability to make choices and be assertive even if doing so risks the approval or acceptance of others. An ability to focus more on your personal responsibility and behavior than on the behavior of the other. An ability to be thoughtful in decision making and to be able to solve problems as they arise. The theme here is clear: be deliberative, proactive, and rational, rather than reactive and emotional; keep your head down, focus on yourself and what you can do and believe, rather than on the other and what he is doing; have a compassionate view of others rather than a cynical one; take action to put problems to rest. This model intuitively makes sense; when you think about people you admire, no doubt many, if not all of these qualities, likely come to mind; it has a commonsense feel; it is what we would expect reasonable people to do. By comparing this model—what you hope to see—against what clients say and do, you, like the physician, have a quick way of detecting problems and uncovering what keeps clients from more successfully solving them. We are back to process—the how rather than the what—how clients run their lives and overall cope, rather than the what—the content of today’s specific problem. But when we’re comparing them to The Basic Seven 37 our adult model, we’re also looking at the other side of the same coin, not only what they do, but what they can’t do. Where do they struggle in the everyday running of their lives that gets in the way of their successfully living as “adults”? Just as we all have one or two coping styles that we rely on to navigate our lives, we also all tend to have one or two challenges, things that we can’t do, emotional and behavioral stuckpoints that are our emotional Achilles’ heels, that snag us and get in the way of our successfully solving our individual and relationship problems. If you think back over the ways that you or those close to you struggle in your relationships, no doubt you can identify stuckpoints, things you and or they seem to continually struggle with. Perhaps you are selfcritical and have a difficult time tolerating mistakes, or you are leery of any confrontation or conflict, and in general, get anxious around the strong emotions of others. Or your father has trouble regulating his emotions; he is quick to anger and has trouble reining it in. Or your grandmother is someone who can never let go of the past; she seems perpetually haunted by regret and guilt or grudges. Or you’ve seen in couples or families that you work with that they get stuck solving their problems because the communication quickly breaks down, they trigger each other’s emotional wounds, or they have differing visions or ideas of what it means to be a couple or family or of their goals for the future. These individual and relationship challenges are common; they again represent the faulty process that threads through our lives. And once again, this being process—this what can’t clients do, where do they get stuck running their lives, what is that gap between what they present and the adult model—you can step out of the flood of content and help clients and families to do the same. The parent, for example, who is afraid of conflict and instead accommodates his partner and children only needs to tackle this one problem—learning to step up and be assertive—to begin to change the dysfunctional patterns in the family. The teen who is self-critical and perfectionistic can sidestep all the ways her anxious brain is telling her that she needs to be ever more perfect, but instead, with your support and guidance understand that perfectionism is in fact her primary problem, rather than all that content in her head. Similarly, the couple who struggle to regulate their emotions and instead find themselves in constant emotional brawls need your help to realize that the problem is not the content of their current argument nor their differing realities, but their emotions themselves that they need to learn to rein in to move forward in their lives. By defining these difficulties and showing clients how 38 D O I N G F A M I LY T H E R A P Y they play out across their individual and relationship lives, you are teaching them not only the language and impact of process, but you are again simplifying theirs, and your, clinical challenge. By learning with your support and guidance to do what they can’t do, by acquiring the awareness and skills that enables them to become more self-differentiated, more “adult,” clients can step out of their childhood potholes, update their psychological software, and be better able to conduct their lives. And by thinking adult you have a simple yet effective gauge to understand not only where clients get stuck managing their problems, but have yet another way to avoid that easy trap of getting snared in the muck of facts and stories. 3. LOOK FOR WHAT’S MISSING, GO WHERE THEY’RE NOT There is a Sherlock Holmes story about a horse that’s stolen from a barn one night. Holmes declares to Watson that the key to the case is the barking dog. “But,” says Watson, “there was no barking dog.” “Precisely!” says Holmes. “The fact that the dog didn’t bark meant that whoever came that night was not a stranger, but someone who the dog knew well.” You too need to think like Holmes and be sensitive to what is not there. You are doing this on a macrolevel when you are thinking adult and uncovering what clients can’t do. But there is a microlevel at play as well where you are looking for what is missing as the session process unfolds—the father who doesn’t come to the appointment or isn’t engaging; the good things that Michael can do instead of only hearing about the bad things; being willing to talk about the time the mother was in jail or about the affair the wife had 3 years ago; anger; sadness; the oldest brother’s ongoing depression; laughter; physical affection— looking for all the things different members of the family can’t do, avoid, or aren’t aware of. Or looking for what they can’t quite say—the way the father mentions “problems” or “things in the past” or how the mother stops and shifts gears in midsentence—“And then he . . . but the teacher said”— and simply trails off. To be aware of this is to see language working as protection. To talk about “a problem” rather than specifically describing the behavior or situation is to put a protective glaze over the emotions, to use language to smooth over pain. To stop in midsentence and shift course is literally to “not go there.” The Basic Seven 39 But you want to go there. Why? Because this is often where the solutions to the family’s problems lie, outside their comfort zones, in those empty spaces, and embedded in these absent emotions and fragmented stories. This is where their anxiety lives and prevents them from making changes they need to make. And like the outsider, you are the one who can see what they cannot see—these blind spots or holes in the fabric of their relationships. Once you notice them, your job is to challenge and guide clients there. Ask the father, “What problems?”; “What things?” Ask the mother to go back and finish her sentence. Have the courage to ask the hard questions—“Are you thinking of getting divorced?” to poke holes in their narratives; “You said you felt worried but you never said that to your mother—why?”; to guide them to places that they seem to close the door on to create that deeper conversation—“How did you both feel and cope after your daughter died?”; to say what they don’t; to go where they are not. You are like the child in the story of the Emperor’s New Clothes, who dared to speak up and say what everyone else is afraid to say. By moving the family away from the familiar, by stirring the pot, by saying what they avoid saying, you not only fill in the blanks of their content, you assess their tolerance for anxiety, uncap new emotions, and provide them with a slightly different perspective of one another and even a small experience of change. How do you learn to see and hear what is missing, rather than only what is present? By training your eye, ear, and mind. As you listen to an audio recording or watch an interview on YouTube, for example, listen for what is not mentioned and for what is only vaguely said. As you watch a video recording, notice what the individuals and the family as a whole are not doing. When you hear emotions or see behaviors, ask yourself what would be the opposite or, like Sherlock Holmes, ask yourself what you would expect to see or hear that you’re not. With practice, what’s presented will become an automatic springboard for zeroing in on what’s not there—what can these individuals and families not do? And when you feel overwhelmed or unfocused in a session, look for what’s missing right there in the room—what is not being talked about, what emotions are being avoided, what secret is lying somewhere in the corner of the family’s past—or focus once again on the holes you may have already mapped out—the mother’s anger, the father’s sadness, the child’s inability to say what he feels. You are the change agent and guide. Step forward so the family can do the same. 40 D O I N G F A M I LY T H E R A P Y 4. BLOCK THE DYSFUNCTIONAL PATTERNS As already discussed, patterns are the heart of family therapy, the way of organizing what you see and the complement to what you don’t see. While what’s missing—unexpressed emotions, undiscussed secrets, and so forth—points to anxiety that feels too great for the family to handle—the dysfunctional patterns you see signal the family’s attempts at anxiety containment. So, in the initial session, you give the family the space to not only tell their stories but to allow the patterns to unfold: that mom repeatedly interrupts the daughter, the daughter snaps back, the father tells the daughter not to talk to her mother like that. The father observing his child playing with the toy house makes suggestions—to notice the toy dog at the corner of the table—and the child says that he doesn’t want to play with the house anymore. The elderly parents try and talk to their grown son about his seeming isolation and gaming addiction, and he always retorts by pointing out problems the couple used to have in their relationship. Once you figure out what the pattern is, your next step is clear: Block the pattern. It’s common for many clinicians new to family therapy to panic, worrying that they need to have a healthy pattern already at hand to replace the dysfunctional ones. Although using your treatment map and noticing what’s missing can give you a direction, even if you can’t think on your feet, by simply blocking the pattern you will force the family to do something different, and different is what you are looking for. So, you ask the mother to try to not interrupt her daughter or the father to stay out of their exchange. You ask the father to just watch what his son does in play, rather than making suggestions. Hold up your hands like a traffic cop when the parents begin to double-team their son with criticism yet again, and see what happens. While their first reaction is likely to be to ignore you, if you persist and continue to cut them off at the pass, the anxiety of the moment will push them to try a new and different way of relating. Blocking the pattern places them in the position of creating their change, which you can help them fine-tune over time. With your help, they begin to recognize the pattern themselves. Just as you can learn to look for what’s missing, you can also train yourself to notice patterns. Again, watch video recordings of sessions or movies, or even sit back and observe what you notice at a family gathering or a couple at a restaurant. The Basic Seven 41 5. TRACK THE PROCESS To keep you from getting lost in the details of content, to enable you to detect patterns, and to shape what unfolds, you want to track the process closely, and with your support help the family to do the same. Show how content and process run alongside each other: “I realize I keep asking the same question because I’m confused about what upset you so much about this situation”—and underscore when family members do the same—“I’m hesitating and fumbling because I’m afraid that if I say the wrong thing you’re going to get mad,” and also track when words, emotions, and intent are mismatched. Tracking is usually done with questions (“John, you’re talking about the good times of the past, but looking mighty sad. How are you feeling right here, right now?”) or statements (“Mary, I’m trying right now to offer a suggestion, and I feel like you’re ignoring me”). The client, be it one individual or the entire family, has to shift, and is forced to stop and think about what just happened and is happening right then. This shift in focus creates the opportunity for the family members to move from meaningless content to meaningful, honest content that fully incorporates the underlying emotions. The first time you point out these mismatches, clients will often resist you to reduce their anxiety. “I was listening,” Mary mumbles back, both denying the reality in the present and avoiding the confrontation. But if you stick with the process (“Did you just feel like I was scolding you?” said in a gentle voice) and help the client to stay focused on what’s happening in the present, cutting her off from slipping back into the same content, the client not only plows new emotional ground in her relationship with you but begins both to discriminate content from process and to learn to move between them. Finally, you want to track the process like a bloodhound to make sure that you and the family are staying in lockstep together. As we discussed earlier, you want to be certain there is an agreement when you suggest to the family that its problems are not separate and several but are connected and reducible to one or two core ones; and as we discuss in Chapter 5, this staying in lockstep is vital in the first session. What this means is that you don’t want to go forward unless the family is with you. You want to correct any blips in the process as they arise. So if you ask the father to try and just watch how his child plays and not make suggestions, but he continues to do so, you want to stop him right away and address it: “I was suggesting that you let Jacintha play on her own just to see better what she decides 42 D O I N G F A M I LY T H E R A P Y to do, but you seem to be having some trouble doing that. I’m wondering why.” Similarly, if you make an interpretation: “It sounds like your supervisor reminds you of your mother,” and the client makes a face, or “I’m wondering aloud whether Harold seems to be having trouble paying attention in school because he may have ADHD,” and you get back a weak, look-away, whatever “I guess so,” from the mother, you need to stop and find out what is happening. “You just made a face and it seems like you don’t agree. Tell me how you think about your supervisor differently.” “I’m thinking Harold may be at risk for ADHD because of your family history, but it seems like you’re thinking about this differently.” Catching these out-of-step moments allows you to repair missteps in the interaction and in the relationship. You can explore the problem under the problem of the father’s difficulty in leaving his daughter alone; you can explain to the client why there is a parallel between her reaction to her supervisor and her history with her mother; you can educate the mother about what ADHD means, or find out what about it bothers her the most. By catching these moments as they unfold, you are fixing the problem that is interfering with moving forward and implementing the treatment plan. If you let it go, miss or disregard the father’s continued interruption, the client’s facial expression, or the mother’s weak response, they may say at the end of the session that this was helpful, promise to do the homework you gave them, but then they will cancel the next appointment and tell you they’ll get back to you or show up and not have completed any of the homework. By tracking the process both you and the client can learn to tackle problems and derailments—the hurt feelings and the misunderstood comment, which are sources of resentment in the therapeutic and family relationships—directly and immediately as they unfold. The therapy stays on course, and the family sees how to confront problems quickly and effectively. By staying aware of and on the growth edge, you and the client can avoid creating and lapsing into your stale patterns of behavior that can bind anxiety and blunt the change making. Tracking the process requires the courage we talked about at the start. Your job is to always turn up the corners of content to see what lies underneath; to talk about the elephant in the room that no one wants to acknowledge; and to confront the client who too quickly dismisses your well thought out, well-grounded sage advice, interpretation, intervention, and diagnosis. You want to bring up what is missing, say aloud what they are possibly thinking, and ask the hard questions that they at the moment are afraid to ask. It seems easier to let it go, to The Basic Seven 43 rationalize that you can circle back “at a more appropriate time” later, or like the family, to deflect and focus on content—“So what did you do on your vacation?”—to relieve the building tension. Resist the urge to do this. Instead, stay with the process, move forward, and say what you see. 6. CREATE AN EXPERIENCE, APPLY THE BRAKE This mother is sitting alone across from you, and she is angry. For the last 6 months, her 11-year-old son has been driving her crazy: getting into fights at school, earning failing grades, and arguing with her all the time. She thinks the problem is the new kid in his class who he has been hanging around with. “Had anything happened 6 months ago?” you ask. “No,” she says, then hesitates. “Well,” she says matterof-factly, “his grandmother, my mother, died back during the summer, but she had been ill for a long time, and we all knew it was coming.” “Tell me about your mother,” you say. She begins to describe her, and as she does she becomes teary. “Do you miss her?” you ask quietly. The wall around her grief begins to break, and she quietly begins to sob for many minutes; you sit with her and wait. When she finally calms down and looks at you again, you ask, “Do you think your son feels the same way you do?” “I don’t know, I guess, but we never talk about it,” she responds. “I wonder,” you say, “if the way he has been acting is maybe connected to all this sadness and the way you both have been feeling.” At the urging of the schoolteacher, Jim brings in his 8-year-old daughter, Jenny, who has lately become moody and withdrawn. He is not so much concerned about why, but what he should do about it. He and his wife have been divorced for several years, but, Jim assures you, they continue to have a good relationship, and Jenny has handled it well. Jim has been steadily and recently dating a woman named Cathy. He swears that Jenny likes Cathy, though Jenny says little to anyone, including you. You ask Jenny to draw a picture of her family, and with some prodding she does. You show it to the father. There, clearly labeled in her 8-year-old scrawl, is a picture of her mother and father holding hands with a smiling Jenny standing right in the middle of them. It’s the classic marital argument. Lisa starts complaining about how Phil is always criticizing her, and Phil snaps back, saying that Lisa never follows through on what she agrees to do. Quickly they escalate, using sarcasm, making faces, yelling, and bringing up old wounds and stories of the past. You hold up your hands and ask them both to stop. You ask Lisa to turn her chair toward you and ask her to say 44 D O I N G F A M I LY T H E R A P Y more about what bothers her when Phil seems to be criticizing her. She becomes teary and says she feels pushed away and lonely, much like she felt when her father did the same thing when she was growing up. You talk briefly about the power of triggers from the past and ask her to tell Phil how she would like him to speak to her when he is frustrated. Identifying who and what is the problem tells you what you most need to focus on and fix and what the family’s expectations and goals are. The focus on process, patterns, and what’s missing helps you link what you see happening in the session with what goes on in the family’s life outside the session. This focus helps you formulate the nature of the problem and a possible solution and also helps the family see therapy as a viable and active means of changing the problem, rather than merely talking about it. All of these skills are essentially means to an end, creating experiences, our next skill set. Therapy is always experiential in that emotions are stirred, experienced, and often changed by the process itself. But what we’re talking about here is actively crafting those experiences rather than passively allowing them to unfold. By gently leading the mother into her grief, the telling of the story of her son and her mother flow together; only after she is emotionally aware of her grief can she consider it resting within her son as well. Similarly, the daughter’s picture expresses much more clearly than her words ever could, what she is struggling with, and hoping for. By breaking the couple’s pattern and doing what Phil could not do, namely giving Lisa a chance to openly talk and be heard without criticism or anger, a different and deeper and positive interaction was created right there in the room that you can then map out for them so that they can replicate it at home. This is what you do when you notice and then drill down into subtle wisps of emotion—when you ask the teen to finish her sentence rather than fading off, when you ask the father to say what he appreciates about his son to counter the criticism that he continually deals out. What you are doing in each of these examples is deliberately shifting the emotional climate in the room. It is said that one can’t solve a problem with the same emotion that fostered it or with the same consciousness that created it. Only by changing the emotional climate in the room is the family able to see what you see and fully absorb the new ideas you have to offer, which in turn can help them change their perceptions of the problem. And so, you want to create experiences and look for opportunities to do so as you track and shape the unfolding process, and this is what the family wants as well; they, like you, want to leave feeling differently from when they walked in. The general rule is that you want to The Basic Seven 45 fix feelings with feelings, drill down into those emotions, and counter with experiences to change the emotional climate. And, as we show in later chapters, if you can craft good experiences that stir new emotions, and in turn, create new perspectives, you provide here-and-now opportunities for healing, for change. To say you want to fix feelings with feelings also implies what you don’t want to do, namely, fix feelings with facts. If someone is emotional or talking about emotional issues, stay with the emotion, and resist the urge to lecture or provide explanations or information. Explanations and facts can smother the emotional experience; often they feel dismissive or unempathetic to clients. But that doesn’t mean that explanations don’t have their role to play within the session process. Although experience will most often take the lead and is where you want to go when you’re not sure where to go, explanation can be your ballast. Just as you want to toggle between process and content, you also want to toggle between experience and explanation. Experience, the close cousin of process, is the one that runs through the room intent on what happens; like questions, experience raises anxiety and energy. Explanation, the close cousin of content, like statements, helps smooth and soothe; it makes sense out of experience and emotions that have just unfolded and connects the experiential to the family’s problem and needs. Although experience raises anxiety to help the family break patterns and change the process in the room, without the calming presence of explanation, clients feel rattled and overwhelmed and are not likely to return. Explanation lowers the anxiety, puts the experience in a larger context, and allows clients to apply their experience to their everyday lives. This is what your family doctor does when she explains to you why she doesn’t believe the rash on your skin is anything to worry about and how the medication will help, or tells the frightened little boy that she is going to give him a shot in his arm, and it’s going to sting for a tiny minute, and then he can pick out which Band-Aid he wants to put on it. This is what you do in the first session when you talk to the family about what therapy can or cannot do regarding the problem or what the format will be for the session. Your skill involves learning to maximize experience, yet keep it from being overwhelming. Think of experience as the gas pedal and explanation as the brake. If you load on too many emotional experiences and let experience run too wild for too long, the family feels overwhelmed, shaky, fragmented, and frightened; everything is in shambles, they leave with their anxiety going through the roof. On the other hand, if you swing too far in the other direction, lay down 46 D O I N G F A M I LY T H E R A P Y too much explanation, smother emotions with facts rather than feelings, the client shuts down, the session doesn’t move, the family goes to sleep. Like its cousin content on a bad day, explanation washes over them, leaving them unchanged. Your challenge and skill comes in learning how to do this toggling. You may have guessed, for example, that the moment the mother mentioned the death of her mother that the grief may be trickling beneath the boy’s acting out. You could have cut to the chase and explained this to the mother, who most likely would have nodded her head, but emotionally disagreed and discounted what you were saying. Or, similarly, because the father wanted to know what to do to help his daughter, you could have quickly given him a list of behavioral things to try at home, just as you could have offered the couple a minilecture on communication. But you’re essentially mopping up when there’s nothing yet to mop up. Explain and debrief with the mom, the dad, or the couple after to help them process their experience while leaving its impact intact. But having said all this, there are times when you want to use explanation for its raw braking power. If you are moving too quickly and notice that the client’s anxiety is rising too high and creating resistance (for example, not paying attention, distracting, outright refusing to try what you suggest), you can use explanation about your intentions to slow things down: “Lisa, I’m asking you to look at me rather than Phil so that you can say what you think without getting distracted by his nonverbal behavior”; “Jim, I asked Jenny to draw a picture because it is usually easier for kids to say how they feel through art or play”; “Mrs. Johnson, I’m asking about your mother because I’m wondering how much the loss of his grandmother may be bothering your son even though he doesn’t talk about it. Often children’s sadness comes out as behavior problems.” Statements like these put a frame around the experience and make it just enough less threatening that you can continue to go forward. What we are circling around with all this talk about experience versus explanation and feelings versus facts is what we are always circling when doing therapy: modulating anxiety. There’s always the temptation, especially when you feel overwhelmed or frustrated, to pull on explanations like a blanket to dampen the fires of anxiety (yours and the family’s) before it gets out of control. But the better way to look at anxiety is to see it like a tightrope that you, and eventually the family, learn to walk across together. Creating experience is the walking, the challenge, and the goal, while explanations are the balancing pole that you hold in your hands and gently shift from side to side to stay upright and move along the wire. With practice as you move through The Basic Seven 47 experience, your skill in using the balancing pole increases; explanations become more and more part of the experience itself. 7. BE HONEST While creating experience is the end that the other skills help support, honesty is the central thread that runs through the other six skills and holds the therapeutic fabric together. Honesty keeps you moving in the right direction; it is the essential ingredient of leadership and your default position; it enables you to define problems, track the process, see the patterns, and go where they are not. When you fear that things have drifted off course, when you are not sure what is going on or what you are going to do, and when you feel confused and worry that you made a mistake (gulp!), being open and admitting this to the family— that we’ve moved off course, I’m feeling confused, I’m not sure what to say in response—keeps you responsible, matches content and process, models authenticity, and reduces the pressure to do it right or have all the answers. You are not giving up your leadership; you are merely telling the family that it’s time to regroup and check the map. For those new to family therapy, this stance can seem like a difficult one to take. It’s all too easy to feel that you need to have all the answers so the family doesn’t see you as incompetent; that if you say what you think, they’ll get angry or even more depressed and won’t be able to handle it. But remember that the beauty of family therapy is that you don’t have to work so hard, you don’t have to be the one to crack the case, to get something absolutely right. By changing the process and patterns, by asking the hard questions, you are changing the emotional climate, creating something new, solving the problem. If you have a question and don’t have the answer, don’t panic, you’re not alone. Throw it back to the family and ask them to figure it out with you. If you feel stuck, ask if they feel the same; see if anyone has any ideas. Family therapy has the potential to become good group therapy; your job is to guide the process and keep everyone on task. This is where your values, principles, and philosophy come into play. Mine tells me that it is better to show integrity and to match my words, actions, and emotions; that my honesty encourages others to be honest as well; and that supporting greater integrity and honesty is, when you think about it, what therapy is all about. There you have it, the basic seven of family therapy, the skills that can keep you on track and sane. Match them not only against your own conception of family therapy but against your personality and values. 48 D O I N G F A M I LY T H E R A P Y In the next four chapters, we explore how these basics are applied to the beginning, middle, and end stages of family therapy. L O O K I N G W I T H I N 1. It is easier to develop skills when you’re not under performance pressure. Increase your sensitivity to what’s missing by looking for it in others outside the clinical sessions. Sit back and watch what emerges over the next couple of staff meetings or consults with other therapists. Track your own emotions and behaviors: which are hard for you to show, feel, and see? Try showing, feeling, and seeing them, and watch what happens. 2. Try being honest outside the clinical room—not in a big way in the form of confession, but in a smaller form of staying attuned to your inner process as you interact with someone, matching your words and inner feelings. Undoubtedly you do this well already with certain people in your life (your daughter, your spouse, your best friend); try building courage with someone where it is less comfortable (a stranger, your supervisor, one of your parents). Be sure to pat yourself on the back for the effort, regardless of how you think it turns out. 3. Practice tracking the process. In a conversation, focus less on content and more on the process. When the other person trails off in a sentence, ask him to pick it up again and finish it. When he uses some abstract word, ask him to give you an example to make it more precise and concrete, and notice what happens emotionally. If he makes a face when you make a comment, ask the person about his reaction: “It seems like you don’t agree”; or “You’re getting quiet. Are you bored? Am I talking too much?” Again, the content is not important; focus instead on the process. 4. What are your emotional stuckpoints, what are the one or two things that are difficult for you to do? What do you need to help you overcome these difficulties?