Doing Family Therapy (4th Edition) PDF

DOING FAMILY THERAPY Also by Robert Taibbi Doing Couple Therapy: Craft and Creativity in Work with Intimate Partners, Second Edition Doing Family Therapy Craft and Creativity in Clinical Practice F O U R T H E D I T I O N Robert Taibbi THE GUILFORD PRESS New York  London Copyright © 2022...

DOING FAMILY THERAPY Also by Robert Taibbi Doing Couple Therapy: Craft and Creativity in Work with Intimate Partners, Second Edition Doing Family Therapy Craft and Creativity in Clinical Practice F O U R T H E D I T I O N Robert Taibbi THE GUILFORD PRESS New York  London Copyright © 2022 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number: 9 8 7 6 5 4 3 2 1 The author has checked with sources believed to be reliable in efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the author, nor the editors and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources. Library of Congress Cataloging-in-Publication Data Names: Taibbi, Robert, author. Title: Doing family therapy : craft and creativity in clinical practice / Robert Taibbi. Description: Fourth edition. | New York : The Guilford Press, [2022] | Includes bibliographical references and index. Identifiers: LCCN 2021035977 | ISBN 9781462549214 (paperback) | ISBN 9781462549221 (cloth) Subjects: LCSH: Family psychotherapy. Classification: LCC RC488.5 .T33 2022 | DDC 616.89/156—dc23 LC record available at https://lccn.loc.gov/2021035977 About the Author Robert Taibbi, LCSW, is an experienced clinician, supervisor, and clinical director who has been practicing almost 50 years. He is the author of numerous books, including Doing Couple Therapy, Second Edition, as well as over 300 magazine and journal articles, and writes a column titled “Fixing Families” for Psychology Today online. Mr. Taibbi provides training both nationally and internationally in couple therapy, family therapy, brief therapy, and clinical supervision. He has a private practice in Charlottesville, Virginia. v Preface I write this on the heels of completing this new edition, I’m left A swith an appreciation and a memory. The appreciation is that those times in our lives when we are able to step back, measure, and reflect on where we are and where we have been are precious. Sometimes life events or transitions—­a change of jobs, a move, a loss, such as a divorce or death—­bring these moments to us. For me, the writing of this book has provided such an opportunity. This book and I are like two old friends that have aged together over the past 25-­plus years. The writing of this edition is an occasion for this book and me to catch up with each other. I’m grateful for having this experience. The memory: When I was 6 or 7 years old, I decided I wanted to write a book. So, I picked one of the books I enjoyed—­a book on astronomy with wonderful illustrations of the planets—­and copied pages from that book. Obviously, I really wasn’t writing a book, but in some ways, I was: I decided what pages to copy, I wrote them in my own handwriting. It was my childish attempt to craft something of my own out of what was available to me at that time in my life. But isn’t this what we all do, what the families that we see do? Don't we, they, copy our culture’s and our parents’ lives and then choose and try to change them to make them our own? Isn’t this what we are doing when we are doing family therapy—­helping families cast the characters vii viii Preface in their stories in a different light, redefine the conflict, change the ending and moral of the story they tell themselves—­to make it their own and, by doing so, change themselves? So, what have I changed in this new edition? What have I noticed most in my reflection? Several things: One is my continuing fascination with process—­the movement, the unfolding of our lives, the how rather than the what. In particular, over the past several years I’ve been interested in where and how people get stuck in the running of their lives, what they can’t do that gets in the way of their solving their problems, reaching their dreams. I’ve also had a deeper appreciation of both the limits and strengths of what our “talking cure” can and cannot do: that the power of therapy and the only power we have to help others come from what we say and do, our words and gestures, right there and then within a session. I’ve given more attention in the book to the process of shaping the crucial initial sessions with clients. I’ve also added sidebars, called “Drilling Down,” that highlight some of the common challenges facing new clinicians. What emerges from this awareness is a curiosity about the ways we might craft and choreograph our sessions—­t herapy as performance—­to change the emotional climate in the room, to help clients think and feel differently when they walk out than when they walked in, to create those corrective emotional experiences for clients that lead to real change. Linked to this idea is the notion that while we want to be ourselves in therapy—­doing our form of therapy that reflects our own skills and style—­we also need to be aware of and deliberate with how we need to be with each client—­what we need to do and not do to avoid stirring resistance and instead create safety and trust. Finally, all this gets distilled into a sharper focus on shaping the microprocess—­being aware of what we choose to say and do (and how and when we do it) to challenge the family sitting in front of us while remaining connected to them. All these concepts and elements you will find within these pages. But there is also much that is the same, not only in terms of content, but also in terms of assumptions and beliefs—­that therapy is a pragmatic sport; that there are many paths to the same destination, and the challenge is to find the one that fits both your and the family’s expectations; that not only are families always doing the best they can, but so are we. That life is ultimately about discovery, and discovery only comes about with both honesty and courage. Preface ix And finally, what I said before I want to say again: That I am thankful to all who have been generous with their comments—­social workers, psychologists, and counselors in workshops who remember using my book in graduate school; professors who have brought this book into the classroom year after year; readers across the country and across the world who sent me emails; all who have been kind enough to tell me how the book has shaped their clinical work in some small way. My humble gratitude to you all. Contents CHAPTER 1. Family Therapy: Welcome to Oz CHAPTER 2. Core Concepts: Problems, Process, 16 CHAPTER 3. The Basic Seven: What to Do When You Don’t Know What to Do 29 CHAPTER 4. In the Beginning: Great Expectations 49 CHAPTER 5. In the Beginning: Running the Sessions 83 CHAPTER 6. The Middle Stage: Are We There Yet? 116 CHAPTER 7. Endings: Enough Already? 141 CHAPTER 8. Jack Has a Problem: Kids in the Family 156 CHAPTER 9. Jack: The Story Continues— 187 CHAPTER 10. Maggie: It’s Not about Food— 205 Patterns, and Resistance Working with the Parents Adolescents and the Family xi 1 xii Contents Helping Maggie: Unraveling Adolescence 242 Getting to the Core: Couple Work 270 CHAPTER 13. The Power of One: Individual Work 301 CHAPTER 14. Staying Sane: Survival Tips for Therapists 324 References  341 Index  343 CHAPTER 11. CHAPTER 12. in Family Therapy in a Family Context DOING FAMILY THERAPY CHAPTER 1 Family Therapy Welcome to Oz intake sheet says “parent conflict.” You’re braced for your T heappointment. And here they come into your office. A maybe 8-year- old is taking the lead, followed by the “teen,” maybe 16, who is texting on her phone as she lumbers in. Next is mom who, to your surprise, is carrying a car seat with a baby in it. “Hi,” says Mom as she shakes her free hand. “And this is ­Ronnie and Carly. And I’m Cindy.” “Glad to meet you.” “So sorry about the baby. Babysitter canceled at the last minute, and Steve, my husband, just called and said that he has to work overtime—­ something about someone not showing up or something.” She takes a deep sigh. “Been quite a day. The good news is the baby is sleeping.” That is good news, you think. Carly flops herself in the single chair and is still working her phone. Mom settles on the couch with the baby on the floor next to her, and Ronnie, for some reason, is starting to prowl around the room—­ touching books on the bookshelf, picking up the coaster on the coffee table. “Carly, put your phone away while we’re talking to the doctor.” Carly rolls her eyes and, while still holding on to the phone, moves it to her lap. “So, good to meet you all. Ronnie, could you do me a favor and maybe go sit next to your mom?” 1 2 D oing F a m ily T her a py “Come here, Ronnie. Do like the lady says. Come sit next to me,” she says as she pats the couch cushion. “So,” you say to Carly, “did you and your mom talk about coming here today?” Carly is staring at her phone and mumbles, “I got nothing to say. This is her idea, ask her.” “This is our problem, doc. This is what is driving me and Steve crazy, this attitude! Carly, I said lose the phone!” Carly pushes the phone to the side of the chair, but is still looking at it. Ronnie is now bending over and poking at the baby’s cheek. Really? “Ronnie, leave the baby alone. You’ll wake her up.” Ronnie stops for a nanosecond that shifts his poking to the baby’s chest. “Ronnie, stop, you’ll wake her up!” The baby wakes up, and not only wakes up but starts crying, actually screaming . . . loud! “I’m so sorry,” says Mom, clearly frazzled. “I need to take her outside and settle her down. Ronnie come with me. Maybe the doctor can talk to Carly alone for a few minutes.” Good idea, you think. Mom picks up the car seat with the baby and tugs at Ronnie, who begins to follow her out. They close the door behind them. “Well,” you say, “a lot of commotion. So, do you mind if you and I talk together for a few minutes?” “Like I said,” says Carly, “I got nothing to talk about.” And she picks up her phone. SWEPT AWAY Welcome to family therapy. This, of course, is one of a family therapist’s worst nightmares. The family that breaks out the guns and knives before you even get to introduce yourself. The family that stages a mutiny and gangs up on you: “Do you have children?”; “Are you telling me that I should let him run around ‘til 3:00 in the morning?”; “We tried being nice, we tried being tough, but it doesn’t help”; “You don’t understand, young lady, I have bad nerves.” And worst of all, perhaps, the family that just won’t talk. Individual therapy always seems easier. One-on-one, no distractions, the quiet intimacy of the therapeutic relationship. As you listen deeply, soaking in both what is said and not said, the client’s internal Family Therapy 3 world, layer by layer, slowly unfolds. The vulnerable and fearful are named, and by naming are known. Couple therapy offers a different challenge and requires a different skill set. Here, like a tightrope walker, you’re always struggling to maintain balance in the room, moving within the triangle of relationships. You want to make sure that Tom doesn’t feel left out or that Kate doesn’t feel you are taking her husband’s side. But there can be waves of intimacy, where partners are stepping out from behind their walls, where you seem not to be in the room, but, of course, it is only because you are there that they can step out at all. If you do your job well, family therapy too can create these same powerful experiences, but getting there can seem particularly tough at times. Like Dorothy in The Wizard of Oz, you’re swept up and suddenly dropped into a realm that seems strange, bewildering, and intimidating. Even though it’s your office, you’re the outsider. Four or five people talking at once, each wanting your attention, each testing the limits (“I want to go to the bathroom”; “Can I go get a Coke from the machine?”), and if you are doing telemedicine over a computer, it’s even worse—­ someone literally does walk off to get that Coke or coffee or go to the bathroom and doesn’t come back. Everyone is talking at once, blaming someone else or waiting for you to blame them, or expecting you to tell them what to do to fix the problem 5 minutes after they sit down. A group of people with their own history, culture, and language. Secret signals—­the biting of a lip, a quiet laugh, the shaking of a head, the clenching of a fist—that suggest pools of stored resentments, private grudges, and painful conflicts touched off by the most innocent of questions; a chain reaction that can spiral out of control before you have a chance to glance up from your notes or catch your breath. That’s how it seems to go in family therapy; so much can speed by outside your control or even your awareness. The sigh that hung in the air and seemed so poignant in individual therapy is now quickly swallowed up by the stepfather’s smirk. The intimate conversation between the caring but frightened mother and her lonely and awkward adolescent daughter suddenly dissolves when the 4-year-old decides she’s sick and feels like she’s going to throw up right there and then. Instead of being a guiding sage, you’re more often like a traffic cop stuck in the middle of a busy intersection doing your best to keep the verbal traffic flowing—“Hold on, Dad,” you say, holding up your hand, “let Sara finish”; “Okay, Dad,” now beckoning him on, “what did you want to say?” And then there are the stories—­he said . . . , she said . . . , they said . . . , today, last Friday, 30 years ago. Stories of the past, stories about 4 D oing F a m ily T her a py people long dead yet strangely alive and powerful, stories of hurt, and stories that show just how bad things can get or how good they can be. That 50-pound heap of facts that partners in couple therapy will each dump in your lap to make their case to you that the other guy is the crazy one can now in family therapy feel like 500 pounds, all of it falling on your head at once, enough to quickly drown even the best family therapist. OF LEADERSHIP, PRAGMATISM, AND COURAGE Family therapy is not for the weakhearted; even if you’re a seasoned therapist, it can feel like you are flying by the seat of your pants at times. To be able to navigate the family therapy terrain, and be both grounded and creative, requires an interlocking of three qualities: leadership, pragmatism, and courage; without them family therapy never gets off the ground, and the family leaves the session feeling more hopeless about change and therapy itself. Let’s break them down: Leadership Lacking the built-in intimacy of individual therapy or the greater control and easier focus of couple therapy, family therapy requires that you step up and actively guide the process throughout the session. You can’t afford to sit on your hands, nod your head, and simply ask, “And how does that make you feel?” If you allow an argument to go on and on, or permit one family member to dominate the conversation, the other family members will interpret your passivity as permission to continue doing what they are doing and your silence as condoning their stance. What they will have accomplished by the end of the session is what they could have done at home for free, and they will leave feeling the same way they did when they came in—­miserable and angry—and conclude that therapy is a waste of their time and money. Although some clients you meet have had experience with therapy before, many have not—their only frame of reference may be stories they heard from a friend or relative, a television show, or more often from their experience with their family doctor. There they walk in, describe their concerns, are quickly examined, asked a bunch of questions, and the session ends 20 minutes later with a diagnosis and prescription; there’s no “Oh, I’m sorry, we’re unfortunately out of time. How’s the same time next week?” So creating the expectations and setting the tone start with you. You are the role model and the coach; you, Family Therapy 5 as the outsider, are the one who can see in which new direction the family needs to go or can go and the one who can guide them toward it. And as you do this, they will simultaneously begin to understand what family therapy—­and your style of family therapy—­is all about. As the process unfolds in the room, you shape it—­pulling and prodding at some comments or emotions, while choosing to let others fall away. To help offset the performance pressure this responsibility may understandably create, realize that your success and failure as a family therapist come less from knowing what exactly to do at each step along the way and more from your willingness to push family members out of the behavioral and emotional comfort zones that fill their lives and hold their problems in place. Your most basic of goals is often to just bring change in some form into the system itself—­by challenging families to approach rather than avoid their anxiety—­and then steering them through the change process. And while you are doing this, it’s your leadership that allows them, paradoxically, to feel safe because there is someone there who is in charge and able to calm the chaos in the room and in their minds. They learn to see that if they stick it out and get through their minefield of fear about the unknown, good things can be found on the other side. Your leadership is the rudder that steers the therapy ship. Pragmatism Family members often come in believing that they are right, or that you will tell them who is right, or that you will have the right answer, all good reasons to feel pressure to deliver. But the problem with right is not only that it implies a wrong, which implies mistakes that (as most people believe) you should avoid, but that holding onto right can also get in the way of successfully solving problems. If you want to be right, you need to live alone, but if you live in a relationship, you need to give it up. Easier said than done. The families that focus on who and what is right get stuck in their same dysfunctional patterns and comfort zones, get caught battling over means, and lose sight of ends. And if you focus on doing right, you will become tentative and this, in turn, will undermine your leadership. Good therapy and a good life are both pragmatic sports. Creativity is about experimenting; success comes from trying and doing and seeing what happens next. In place of that common phrase “ready, aim, fire,” think ready, fire, aim. Give a homework assignment, and from the results decide what needs to be done next. Make an interpretation, and 6 D oing F a m ily T her a py when it falls flat, back up and try a different approach. Family therapy requires a trial-and-error, do-and-fine-tune, acceptable-­risk mind-set. Change begins not with a criterion of what is right but with the criteria of what is different and seeing what works. By doing this with families they can hopefully begin to do this with themselves. By assuring families that the best they can do is to only do the best they can do right now, by adopting an attitude of flexibility and a willingness to try, you lead them into bringing change into their lives, and help them override their fear of mistakes or their rigid mind-set of right. You and the family become free to be creative and proactive, rather than reactive, cautious, and potentially stuck. Courage While few of us would list therapy up there among the world’s most dangerous professions, in many ways it is. The journey into one’s inner worlds can be just as perilous as any in our outer ones. It’s no surprise that clients often talk about feeling as though they are perched at the edge of a cliff or that there is a bomb inside of them ready to explode—­ their sense of danger is absolutely real. It’s fear and anxiety, after all—not foolishness or ignorance—­that usually keep our lives stuck and stagnant. In families, each member’s fears interlock with those of the others, compounding and making any change ever more difficult. Courage is the antidote and what powers your leadership and pragmatism. Without it, there is no leadership or pragmatism. Being courageous isn’t the same as being impulsive. It doesn’t mean that you take foolish chances, but instead that you can approach rather than avoid your and the family’s anxiety. It may mean confronting the mother who appears so fragile and makes others, including you, believe that she can’t handle confrontation, or asking a child about the terrible things that happened to her without getting lost in your own grief and anger, or saying nothing at all so that the person across from you can finally say what he has been holding back for a long time. It means moving against the family’s natural inertia, asking the hard questions and raising the thorny issues that no one wants to talk about, resisting all the pressure you feel inside to fix people, take sides, and do everything right. This is the everyday courage that doing therapy demands: pushing yourself to use your theory and skills creatively, mindfully. The courage of not only putting your philosophy into practice, but of helping others to define, refine, and eventually live theirs. It’s acknowledging Family Therapy 7 both the gift of seeing much of your own life in the lives of others and the danger of becoming confused over who you are trying to help. It is the willingness to try something to move ahead, even if you aren’t exactly sure where it will lead. It’s the simple courage of honesty. Good therapy requires control but is not controlling, constantly facing the unpredictable while constantly predicting that the unpredictable will come, fostering intimacy while keeping clear limits on that intimacy, and being committed but being willing to stop when it seems an end has been reached or will never come. Good therapy is a seeming hodgepodge of contradictions and qualifiers that require that you walk a thin line between too little and too much, between reaching out and holding back. Courage is the stuff that glues the contradictions together, keeps you steady on the line, and gets you moving until the skill, knowledge, and self-trust can take over. Without it, the families you see are penned in, confined to the narrow range of your own comfort; with it, they can begin to experience their lives in a new way. These three qualities then determine the success of your work with families. We explore them in myriad forms as we survey the landscape of family therapy together. THEORY: SOMETHING TO HOLD ON TO If the triad of leadership, pragmatism, and courage form the core and challenge of doing family therapy, if they together become the ballast that can keep you emotionally upright and steady, you also need to be rooted in a particular theory that works for you. While too many theories can overwhelm you and the wrong kind can constrict you, if you have none, you are set adrift in a vast ocean of facts and observations. A theory of therapy gives you something to hold on to. It can be as simple or complex as you like, and what a theory says is less important than what it gives you and allows you to do. Theories fulfill several important functions. First, they are by definition, tools for organizing. They are the pegboard on which we hang what we see and hear; they show us where to look and what to listen for. Events that once seemed random are now seen as connected. A father’s hunting trip with his son is no longer just a family folktale, but when hung on the theory is an example of role modeling, an attempt to resolve and repair some split from the past, or yet another way of avoiding growing tension within the marriage. A daughter’s unexpected running away from home is not the ridiculous ending to a 8 D oing F a m ily T her a py stupid argument about shoes, but an understandable, even predictable way of coping with undisclosed sexual abuse, a response to the father’s life-­draining depression, or part of the larger cycle of addiction. With your theory as a lens, behavior and words suddenly have meaning and merit. Seemingly unrelated events and reactions are now linked to a larger family process, a deeper layer of problems that not only explain what has happened, but tell what can happen in the future. Most important, your theory can provide a road map for changing it. With the organization that theory provides comes an increase in your sense of control, that shaping of the session process. Think back to your first interviews with families, couples, or even individuals. In the middle of them, you probably felt swamped by the tidal wave of facts and emotions coming at you, and no doubt left the session bleary-­eyed and exhausted. With a theory’s ability to help us bundle facts together and dismiss others entirely, anxiety that potentially can make us ineffective is reduced. When we fear becoming overwhelmed in the process of the session—­by the conflicting stories about what happened last Thursday, the building emotions of dad’s anger, or mom’s sadness—­we can lean on our theory to tell us what to ask or do to gather the information we need. As we read the intake sheet, we use our theory to help us start filling in the blanks, formulating a hypothesis that we can take into the initial session with us. The theory becomes then not only a tool but a support, an internal security blanket, a place you can always return home to. With it, you have the courage to walk into the unfamiliar world of the family; you will feel prepared, rather than confused and apprehensive. Theory not only helps you, but it helps your clients as well. Through the filter of your theory, old behaviors are suddenly seen with new eyes. Neutral words replace those laden with anger and blame: “I can understand, Ms. Smith, why you are feeling frustrated, but Davon isn’t just trying to give you a hard time. He is hyperactive, and it is harder for him to sit still than it is for Shameka”; “Did you all see what just happened? Mom, you made a suggestion, Dad, you disagreed, you both start to argue, and Mary whines as a way to distract you and get you to stop. This pattern is one that you all easily fall into, and it can automatically sweep you up. Every family has patterns, and this is one of yours.” By seeing their problem in such a new light, by “reframing” the problem, and by talking to themselves with different words, the family discovers ways out of the psychological and emotional mental ruts in which they were constantly spinning. New, more creative solutions Family Therapy 9 become possible: “My son isn’t a bad kid who needs to be punished, but has a biochemical disorder that makes it hard for him to do certain things”; “I’m not really going crazy, I just need to talk to someone about my sadness”; “Our relationship isn’t lousy simply because we’re both stubborn, but because our needs over the years have changed.” The theory opens new doors to the solving of problems, the process of healing. Although research, evidence-­based approaches, and sensitivity to the subtle but important aspects of human dynamics always need to be considered to bring high-­quality services to those you work with, you must be careful not to dismiss another important ingredient in the process: namely, you. There is enough research that shows it is within the fine connections between therapist and client that effective therapy takes place. Choose a theory that is effective and proven, but also choose one that best fits you. This means that you shouldn’t just settle on a particular theory just because it’s what you were exposed to in school. You shouldn’t choose one because it intellectually appeals to you, is popular with your colleagues, or even seems to work with certain problems. The best theory for you is the theory that meets you halfway. It should fit your personality, strengths, and personal philosophy: your assumptions, values, and notions of what life is and the role that people and problems play in it. When there’s that kind of a match—a close fitting of the basic you and the theory you embrace—­it supports you rather than you supporting it. It underscores your instincts and intuitions. Rather than feeling constricted or constrained, you feel empowered. TREATMENT MAPS With theory as a foundation, you can build your own treatment maps. Like a road map, your treatment map can help you see options for the clinical journey ahead, and can lay out for you an overall direction so you can hit the ground running and avoid having to start from scratch with each and every family. It is when you set out and begin driving the route that you sometimes find blocked roads or detours and the need to change course. It is having such maps at the ready that enables your family doctor to develop a diagnosis and hand off a prescription to you in 20 minutes. If you show her a rash on your arm and she inspects it and 10 D oing F a m ily T her a py D RILLING D OW N  Starting Out If you are a novice therapist or even a more experienced therapist new to family therapy, doing family therapy can seem like a complicated and at times overwhelming world. As Willy Wonka said, “So much to do, so little time.” What’s often difficult is navigating not only what is unfolding in the room, but also what is going on in your own head. You want to be analytical—­to bring to the effort that outside perspective of someone who can see what the family can’t see simply because they are in the middle of it all. You want to be able to offer the skills that you have and they may not; you want to help them navigate their lives better. And you want to be compassionate (you’re dealing with people, after all, and not doing computer repair), while at the same time not get swept up and lose yourself in their emotions. Hard stuff. So, you have anxiety. You can understandably get flooded by content. It’s normal at these early stages of your career or in your work with families to focus on “you know what you don’t know.” You are most sensitive to your seeming inadequacies—­what you can’t do, can’t figure out in the heat of the session, and the ways you are struggling to connect the dots and say the right thing. You have a deep fear that the family will see you the way you feel all too often—that you are faking it, a phony—and it is only a matter of time before they realize this. Take a deep breath. You’re struggling with rational anxiety. You’re moving into uncharted territory. You are understandably hypersensitive to your own performance. How to manage this? This is about talking yourself off the ledge. A few ideas may help: „ Realize that all this will get better. Your anxiety is coming from being new at this work, and with experience and practice it will, despite what your anxiety is telling you, get easier. „ Get support. While so many other occupations have other colleagues ready to step in and bail you out, therapy is a solo act, which makes this job so difficult. But you are not a solo act; hopefully, you have a supportive supervisor and colleagues who can help you navigate through this. „ Create realistic expectations for yourself. My experience with new clinicians is that by personality they are often hardwired Family Therapy 11 to be self-­critical. If you are, practice stepping back and being kinder to yourself; recognize and challenge those old childhood tapes about how you need to be. „ Realize what clients are wanting from a therapist. The good news, which incorporates all of the above, is that clients usually don’t see you as you see you; their expectations are more modest than your own. What they are often looking for and what they most appreciate is not the immediate fixer person, but someone who helps them feel safe, who is a caring listener, who shows empathy and concern, and who can ask the hard questions they are afraid to ask themselves. You don’t need to be the wizard, but someone who joins them in their struggle and points them in a new direction. asks, “When did you first notice this? Does it itch? Were you outside in the last few days? Have you eaten anything unusual? Have you had a fever?,” she is marching through her handful of possible options, eliminating routes. Once she decides you have contact dermatitis, probably from being in the woods over the weekend, her map tells her the next steps—the two or three medications that will work. She chooses one and tells you that if it doesn’t start to clear up in 3 days, you need to give her a call. You want to be like the physician, and have at the ready, based on your theory, your clinical orientation, and your experience, clinical maps for treating the common problems you are most likely to see—­depression, various types of anxiety, common parenting issues, couples and affairs, anger management issues, and addictions. When a parent says at the initial phone contact that her daughter is struggling with binge eating, you already have a beginning framework for treatment in mind: You know what questions to ask and what feedback you want to give in the initial sessions; you’re already considering what other professionals you need to bring in as supports; you know your overall focus and goals and whether you need to discuss medication or what family members you want to include. Like theory, your maps will help you avoid getting flooded by too much content, enabling you, as it does for the family physician, to shape and manage the process. Equally important, like your physician, you can lay out for the client in the first session exactly what you plan to do or not do, offering the client not only a clear sense of the next steps, but relief. 12 D oing F a m ily T her a py BOOK GOALS AND OVERVIEW This book is not meant to be a survey course in family therapy theories nor, though slanted toward a structural and cognitive-­behavioral approach, meant to offer an in-depth presentation of any particular model. Instead, think of it as a guidebook of sorts on core family therapy concepts, skills, and tools that can hopefully help you—­whether you’re new to the therapy field or a seasoned practitioner new to family therapy—­feel less overwhelmed or intimidated, more empowered and grounded. Along the way, you’ll hopefully learn how to think like a family therapist, as well as begin to develop your style of family therapy. Which is the other goal of this book: While theory is important, you don’t want to obsess about following the chapter and verse of any particular one, but instead incorporate your personality and creativity into your thinking. If staying anchored means learning to rely on a basic core of concepts, staying creative means realizing that there isn’t only one approach to any family, but several, that the best family therapy you can do is one that utilizes your professional and personal strengths. This is the pragmatism that we’ve been talking about, and it is this individualized approach to family therapy that we’ll be focusing on together. In our opening chapters we look at various lenses through which to view what the family presents, what the family needs, what you have to offer. Through case examples, we’ll look at the multiple ways of tackling a family’s concerns, so you can learn how to map out those alternative routes that not only keep you and the family moving forward when a particular path seems blocked, but also take into account your skills and the family’s resources. This book is divided into three sections. In Chapters 2–7, we map out the terrain of family therapy; basic skills that keep you afloat; obstacles and dangers that can keep you and/or the family from moving forward and solving problems; and the ways to handle them in the beginning, middle, and end stages of treatment. With these chapters as a foundation, we look in Chapters 8–13 at a variety of cases, problems, and clinical formats. Here’s where we talk about applying the basic skills, developing treatment maps, and exploring clinical options to help you begin to sort out your preferences and style. Through this process, you’ll learn to think creatively and make use of your intuitions. Finally, in Chapter 14, we discuss some practical tips for dealing with the pressures of the work, especially in agency settings, ways of staying emotionally healthy over the long haul, and ways of managing Family Therapy 13 the daily wear and tear of the work. We also step back and explore work in the larger context of your everyday living, the role of work and therapy in the light of your beliefs and values, what it means to have a calling, and what it takes to have integrity. Let’s begin our journey. L O O K I N G W I T H I N At the end of each chapter, you will find several exercises and questions that can help you see how the concepts of the chapter may apply to your personal and professional life; help you further define your strengths, skills, and values; and help you incorporate the material into your practice. It may be tempting to just read and not do the exercises, but try to give some time to them. If, after starting, an exercise seems redundant or irrelevant, go ahead and move on to the next. But if the exercise stirs your curiosity, or better yet, your anxiety, give it a try. You have nothing to lose, and you may be surprised at what you find. 1. Here are some questions to help you uncover some of your own core beliefs, philosophies, and values. Try writing down the answers to as many as catch your interest. See if you can develop a short, concise personal statement about life, values, and work. „ What is the most important thing in life? (Trust the first thing that „ „ „ „ „ „ „ „ „ „ comes to your mind.) What is the purpose of life? What is the purpose of your life? What can only you give, create, do? What is the meaning of relationships, of families? What is our responsibility toward others? Why do relationships change? How much can people change? How do we know when change is necessary? What are the limits of relationships? When should relationships end? What does commitment mean? What is the relationship between doing for yourself and doing for others? What does it mean to love someone or something? What should parents most teach their children? What are the limits of parents’ responsibility and involvement? What is the role of emotions in our lives? What is the purpose of work? How much of our life is controlled by our past? 14 D oing F a m ily T her a py 2. Here’s a short imagery exercise. Go to a quiet place for a few minutes where you know you won’t be disturbed. Sit comfortably in your chair. Take a few deep breaths, and for a few moments just concentrate on your breathing. Begin to feel relaxed. See if you can envision a meadow in your mind’s eye. It is a bright, warm, sunny day; the grass is green, flowers are in bloom, and the air smells sweet with their fragrance, a slight breeze blows. And there you see yourself, walking along, feeling relaxed, the sun warm on your back. As you are walking, you see ahead of you the edge of a wood. You decide to walk toward it. As you approach the wood, you begin to hear in the breeze the sound of a name, the name of a person of the same sex as you. As you near the edge of the wood and peer into the darkness of the trees, you are aware that someone is there in the shadows, the person whose name you heard. You become curious, you begin to wonder who this person is, what he or she is like. Then you listen and can tell that this person is coming toward you. A person emerges from the trees. Notice how he or she looks and imagine yourself starting a conversation with this person. Imagine asking all the questions that you are curious about, finding out all you want to know that will tell you just what this person is like. Take as much time as you need to talk to this person. When your conversation is over, the person waves good-bye and walks back into the wood. You turn around and begin to walk back toward the meadow, thinking about all that you have just heard. When your fantasy feels over, just sit for a few minutes and relax. It is important to hold within ourselves (and help create for families) a vision of what we can be. This imagery exercise is designed to get you in touch with your ideal self. This may have been easy for you to do, or you may have had some difficulty. Perhaps you had sensations or recalled memories or heard the dialogue, but had trouble creating the images. Don’t be concerned. You can try again another time, and will probably have a different response. Be aware of the person you saw, not only his or her appearance but his or her personal qualities, dreams, and attitudes toward others and life. Notice the gap between the way you see yourself now and the person you imagined. Is there anything that surprised you? Is there a particular quality that you would most like to develop? What would it take to do it? Family Therapy 15 3. You don’t need to take karate lessons or Outward Bound courses to increase your sense of courage. Simply begin by taking small risks, not just in your work but elsewhere in your life. Practice approaching your fear: walk up to that neighbor on your block who you’ve seen a few times and start a conversation, ask a question in a group even though you know it sounds foolish, try something physically different even though you feel clumsy or know you’re not good at it. Avoid telling lies for a couple of days and see what happens. A half dozen times during the week, as you become aware of approaching the edges of your anxiety, go forward, do whatever is scary, and then pat yourself on the back. The goal is not to be without fear, but to be able to act despite it. 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 oing F a m ily T her a py 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 oing F a m ily T her a py 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 oing F a m ily T her a py 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 . .