Teaching Family Therapy

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The teaching of family therapy has been the subject of serious scrutiny since the onset of training and accreditation many years ago, yet there are relatively few attempts to apply what we know about systems and the ways they change family therapy teaching as a two-way process. It is as though family therapy teachers were preoccupied with the content of what should be taught, and were not able to direct their attention to the process by which people learned.The authors began by describing the way they conceptualize the "learning context" which sets the frame for all the teaching they do. Then they discuss the process of setting up a family therapy course, e.g. "What is the best way to negotiate with a training officer to set up a course in a local area?". The book then moves to creating the course syllabus, and some of the practical problems-from lateness to mechanical failures-of getting the course off the ground.The family therapy courses being described are generic courses which cover all the major schools of thought from Structuralist to Strategic to systemic to Constructivist approaches. The unique contribution of this book is the many carefully crafted exercises which form the heart of the teaching/learning experience. Each exercise is designed to teach particular content, such as "enactment", or "circular questioning", which is related to a particular family therapy approach, yet the exercise is also designed with the learning context in mind and it pays attention to the ongoing relationship between teacher and student to maximize the learning which can take place.

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CHAPTER 1. Teaching systemic thinking

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The participants in the teaching-learning system are: organising tutor - supervisor - teacher - course participant. They can be considered as a system when feedback about expectations is communicated between the different subgroups. What is more implicit than explicit at the outset of this process, is that the expectations of all members of the system cannot be met without giving and receiving feedback.

We see the interaction between the people at these different levels as identifying the boundaries of the teaching-learning-system.

The people are:

I The Supervisor or Course Organising Tutor

II The Teachers

III The Course Participants

IV The Agency Context or Course Participants Colleagues

We have chosen certain punctuations or phases in the life of the course to show how the co-evolutionary feedback process facilitates learning.

The initial phase includes the negotiations between an institution and the teachers to teach the course. A supervisor and a teacher begin to prepare the course outline and syllabus. When the applicants are offered and accept a place on the course, the teacher/course participants system comes into being.

 

CHAPTER 2. Systematic teaching preparation

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In this section we hope to show how to generalize from the issues identified and discussed in Chapter 1 as these issues are specific to our Tavistock Course experience.

We are aware that some of the content may seem repetitive but want to show how similar content has different meaning when placed in particular context.

Systematic teaching preparation requires a teacher to attend to the following:

Goals for an Introductory Training might be for the teacher “to disseminate as much detailed information as possible’’ and for the course participant “to take away as much detailed information as possible”.

On Introductory Courses participants want information but are not necessarily convinced of its value. Although this style of course is still available today, e.g., short term in-service courses, more course participants attend courses with more knowledge and request help to make the leap to put knowledge into practice. This has had a dramatic effect on the way teachers think and prepare.

Introductory Courses have had to be extended to cover the material: the increased commitment has led to requests from participants for qualifying certification. The professional bodies have responded with a serious attempt to administer the courses in order to sustain standards and ensure that clear objectives are met: this in turn has led to a demand for continued training. Job descriptions and requirements are being challenged and redefined.

 

CHAPTER 3. Teaching theory and skills practice

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We give below some general guide-lines for the use of role play, sculpting and video. These are universal modes of teaching and are integral to many of our exercises. We think they deserve special mention to enable teachers to maximise the learning possibilities of exercises.

It is important for trainees to get the feel of interviewing a family without the ethical problems of treating real clients as guinea pigs, yet giving them a chance of taking risks in trying out new ideas in a relatively safe context. We have come to see role play as not only a specific technique but also a general principle of teaching practice skills. It is an effective means for trainees to develop their skills and can often be far more involving than watching videotape of a real family. Course participants receive instant feedback either in their role as therapist or as a family member and realise what interventions they found helpful or unhelpful. We have found, however, that role play needs as careful thought and preparation as real therapy. On account of its central position in training, we have chosen to emphasise its format and offer some general guidelines to the teacher embarking on the use of role play in teaching.

 

CHAPTER 4. Structural family therapy teaching exercises

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Structural Family Therapy

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These exercises are almost exclusively based on the work of Minuchin as we would often start our teaching on family therapy models by studying the structural family therapy model via his writing and practice. In our experience, course participants find it easier to begin with this model as it often relates closely to their own current practice and the development of family therapy practice in this country - and then to move on to other models. A further point is that the theory and relevant skills associated with this model are clearly and simply presented in Minuchin’s writing.

Minuchin describes the structural family therapist’s task as the transformation of the family into a more effectively functioning group, rather than the manipulation of individual family members. He or she does this by becoming a part of the family system in various ways (joining and engaging) in order to understand the family structure. Minuchin’s model or family structure involves a model of the family as a set of sub-systems (parental sub-system, child sub-system) between which are boundaries, symbolic relationship markers which, if not present can lead to ineffective functioning or dysfunction. The development of a dysfunction is seen as the way a family maintains a balance or homoeostasis between its constituent parts, which might otherwise be threatened by disintegration at times of a need for developmental changes in the family system. Minuchin encourages therapists to develop visual representations of their observations of family structure in the form of maps.

 

Exercise 1: JOINING AND ENGAGING: STARTING OFF

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Minuchin considers it important for the family therapist to become a part of the family system in order to explore and experience for himself or herself the family structure which gives rise to the dysfunction. He calls this process joining and it is the means by which the therapist connects with or engages the family in the therapeutic process. He describes different positions of joining and we think it is important that course participants practise these different ways. Minuchin says that the therapist’s job as a healer requires him or her to be able to join a family in particular ways but he or she “must also have the skills to un-join, then rejoin in a differentiated way - and there’s the rub!” (Minuchin, 1982, p. 30).

In the introduction to this exercise with the group, it is important to clarify each of the joining positions, Minuchin’s rationale for joining in the broader context of his therapeutic model and some of the dilemmas raised by Minuchin in attempting these techniques. This is an easy exercise to organise and for trainees to execute competently. It presents good opportunity for complimenting people’s practice at a time when they may be feeling nervous about coming on a course.

 

Exercise 2: OBSERVING BOUNDARIES

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A theoretical introduction to Minuchin’s model of family structure and the notion of boundaries between family sub-systems is necessary to help people understand what they are looking for Minuchin presents this very clearly and participants generally find it easy to key into the idea of boundaries and will probably be able to make astute observations on the family quite quickly.

Aim: Understanding of family structure, particularly the notion of boundaries.

Task

1. The teacher can present information about a family e.g., mother and father with 16 year old girl and 12 year old school refusing boy. Mother is ambivalent about the school (implicitly supporting her son’s school refusal) whilst father is trying to get him back to school.

2. The group can be asked to take family roles and that of the therapist. The rest of the group is asked to observe.

3. The teacher interviews the family with a member of the group as co-therapist whilst the observers have the task of making notes about the family structure. They are particularly asked to look for interactions which indicate how relationships are organised into sub-systems. They might be given a few prompt questions such as:

 

Exercise 3: ILLUSTRATING THE HOMOEOSTATIC TENDENCIES OF A FAMILY SYSTEM

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Minuchin describes the family as a system striving for homoeostasis or balance amongst its constituent parts in the face of demands for change, for example the need for parents to behave differently towards their children as they grow up. The development of a dysfunction is seen as a product of the family striving to remain the same despite a need for change. For this reason families also resist therapeutic attempts to bring about change. This core concept is now referred to as homoeostatic tendencies within the system. This exercise gives participants an opportunity to see and experience the power of these homeo-static tendencies. They are usually surprised at how predictable the pattern becomes for them and has immediate effect on their perception of themselves as therapists.

Aim: Exploration of the homoeostatic tendencies of a family system.

Task

1. Some group members can devise a role play family. This should be an impromptu family group, not a case known to the group or the teacher.

2. Someone from the group is asked to enact a journalist who is writing an article about the family as follows:

 

Exercise 4: FAMILY STRUCTURE FROM DRAWINGS

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A pictorial representation of the family is static and represents a moment in time in family life. It is useful in helping trainees to observe and understand the structural components in a family as described by Minuchin. The expectation of artistic skill is limited!

The exercise is based on adapting and expanding the use of Kinetic Family Drawings (K. R D.). In this exercise, the clinical usefulness of drawings of the family is explored. We share the hope of the authors of K. E D, that drawings speak for themselves and in this sense, we feel able to adapt it to this context. Their interpretive manual is most useful.

This is an exercise which works well with a small group of up to 8 people and can best be organised by sitting around a table in the manner of a working party. You need to equip yourself with paper and coloured felt-tip pens, pencils, etc.

Aim: Understanding the family as a structure.

The Task

1. The group members can be asked to sit together around a table and are given the instruction, “Draw a picture of everyone in a family doing something”. They can be given the option of drawing their own family or a family they might be working with.

 

Exercise 5: MAPPING

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Minuchin encourages therapists to record their observations of family structure in the form of a map or visual symbolic representation of family structure using certain mapping conventions (Minuchin, 1982, p. 53). This exercise is usually offered near the beginning of a presentation of Structural Family Therapy since it is such a useful technique for clarifying thinking about family problems. It offers a perspective on the family at a particular moment in time and the direction for therapeutic intervention is indicated. It is most useful for case recording.

Aim: Introduction of the technique of mapping and its conventions. Task

1. The teacher can write up on the board (or use handout) Minuchin’s mapping conventions

2. At this point, the teacher has several choices:

(a) observe a family on tape;

(b) ask the group to present a family from case material;

(c) role play an impromptu family ;

(d) sculpt a family for observation.

3. In pairs or threes, the group can be asked to map the family according to Minuchin’s guidelines. The teacher can go from group to group offering help if it is needed.

 

Exercise 6: OBSERVING DYSFUNCTIONAL STRUCTURE ON VIDEOTAPE: DYSFUNCTIONS LUCKY DIP

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A dysfunction arises in a family system which is organised so as to resist the change required by an outside event. If they are able to observe dysfunctions on tape, it offers course participants the feeling of reality around the idea of dysfunctions - they can see them! The labelling of dysfunctional sub-systems helps course participants to give new meanings to relationships they observe in the system. This is the first step towards the restructuring process.

Aim: Identification of dysfunction in the family system.

Task

1. The teacher needs to prepare slips of paper with a dysfunction written on each one and put them into a hat or suitable receptacle. These dysfunctions should be ones the course participants might see on the videotape.

2. Each person chooses a slip of paper from the lucky dip.

3. The videotape can then be shown for about 10 minutes and the trainees can look for their dysfunction on the tape.

General discussion. The group can be asked if they can name dysfunctional relationships in families they are working with.

 

Exercise 7: RESTRUCTURING ROLE PLAY

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Restructuring is a general description of the technique of intervention used in structural family therapy; that is, the transformation of family structure so that the family can accommodate to change without the dysfunctions that lead to symptoms in one family member Teaching restructuring through role play gives meaning to theoretical ideas in structural change since course participants have the opportunity to see it in action. This exercise can have dramatic impact and may leave a considerable aftermath that should be taken into account by the teacher.

Aim: Skills practice of restructuring techniques.

Task

1. A member of the group can be asked to present a family they are currently working with.

2. The teacher or presenter can draw the family tree on the board.

3. The group can be divided into fours. One group can role play the family and the other groups can be teams of therapists.

4. Whilst the family is planning their role play, the therapist groups are asked to map the family and to plan how each therapist might intervene to restructure the family.

 

Exercise 8: IDENTIFYING UNBALANCING TECHNIQUES FROM ROLE PLAY

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This exercise usefully follows a theoretical presentation of unbalancing. It will be important to make a distinction between boundary-making and unbalancing. In boundary-making, the intention is to change family sub-system membership, whereas in unbalancing, the intention is to change the hierarchical relationship of members of a sub-system. This exercise will usually demonstrate not only unbalancing but also the effect of unbalancing. This may uncover all kinds of possibilities within the sub-systems that people in the group may want to address. For example, in a parent child sub-system, if you change the hierarchical arrangements, it may leave other members of the family more or less vulnerable. This exercise introduces an element of fun and play useful for lightening the group’s mood.

Aim: Skills practice of unbalancing techniques.

Task

1. The group can be divided into two to devise a therapeutic scenario to demonstrate one of the unbalancing techniques, for example creating affiliations or creating coalitions.

 

Exercise 9: PROMOTING ENACTMENT

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The task in this exercise is to help trainees to get a family to demonstrate how they relate to one another, in the context of the problem they have brought to therapy, usually as a prelude to suggesting different patterns of interaction which would be more functional to the family system. The demonstration from the teacher following a short theoretical presentation on enactment is a key component of this exercise since it enables course participants to make the link between theory and practice and experience the powerful effect of this technique. This is an exercise where people are able to intervene and see immediate results and it is therefore most encouraging for them.

Aim: Skills practice in promoting enactment.

Task

1. The teacher selects two members of the group to be a mother and father. The parents are given a script, e.g., a couple who disagree on the way they discipline their teenage son.

2. The teacher, together with a member of the group can act as therapist to promote an enactment between the parents, for example to ask the parents to demonstrate what happened when they asked their son to return home from a disco by 10 pm.

 

Exercise 10: FOCUSING

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One of the most difficult tasks is for people to become process-orientated rather than content-orientated in their work with families. This exercise asks course participants to limit their area of enquiry to a small area of content and to explore it within the context of a restructuring or unbalancing plan. The therapist in this exercise may be quite proficient at the task. However, there needs to be an illustration of how easy it is to go off course and, in that case, you might ask the role playing therapist to “do it wrong”.

Aim: Skills practice of focusing.

Task

1. The group can be asked to briefly (5 minutes) present a family.

2 The teacher and the group can together draw a map of the family and make a re-structuring or unbalancing plan.

3. The focus of the session is decided upon, i.e., the small area around which the therapist will question.

4. The family members can be selected for role play. The observing group are the therapists and are asked, in turn, to interview the family. The therapists will continue to interview for three minutes or until such time as one of the observing therapists think that the therapist has gone beyond the limit of the focus decided upon earlier. At this time, the therapist can change over.

 

Exercise 11: PRACTISING INTENSIFICATION

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It is essential that this exercise is prefaced by an explanation of Minuchin’s meaning of intensification by which he means amplifying or exaggerating a dysfunctional interaction as a challenge to the existing structure. There are a number of different methods that he describes, i.e., repetition of the message, repetition of isomorphic transactions, changing the time and resisting the family pull. These will need to be described beforehand and can all be practised within this exercise.

Aim: Skills practice of intensification.

Task

1. The group can be asked to present a family.

2. The group can be asked to map the family.

3. The group can make a restructuring plan.

4. The teacher can decide with the group what area to focus on for the interview.

5. The group can then plan the interview with the instruction that the therapist will attempt to restructure the family with the use of intensification techniques.

The role play can be set up and enacted. Everybody in the group needs to have a part in the role play in some form. It is helpful to have two therapists from the group working together. Should the therapist find it difficult to stay on task, alternative therapists could be substituted during the role play.

 

Exercise 12: COMPLEMENTARITY AS A SAVING GRACE

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When Minuchin talks about complementarity, he is particularly concerned about the battles that people get into within the family context. To illustrate this, he maintains that the therapist should be able to extend the family member’s view of their behaviour to see not only one interaction but “the whole dance”. This exercise is the first practice for participants to address disagreements between family members in such a way as to make them therapeutically useful.

Aim: Skills practice of complementarity.

Task

1. The group can be divided into threes; two family members and a therapist.

2. The two family members enact a disagreement and the task of the therapist is to intervene by expanding the context of the argument by, for example, including significant other family members in the questions.

The group can be asked for the three most useful responses from the therapists.

This exercise could be done with a whole family role play.

Reading

Minuchin, S. and Fishman, H. C (1981) Family Therapy Techniques. Harvard University Press, Cambridge, Mass.

 

Exercise 13: REFRAMING CRITICAL STATEMENTS

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Refraining refers to the therapist’s attempt to provide alternative explanations for the family problem other than that offered by the family. These usually refer to the function of the symptom in maintaining homoeostasis in the system. People find reframing a difficult skill to learn and the feedback we have received over the years is that trainees would always like more time to fully understand it. There is very little written on how to practise what is such a central activity in all the approaches and we therefore give it priority in our teaching. It is possible to prepare reframe statements before the session, but it is preferable to ask course participants to reframe their own ideas as this avoids them being stuck with the teacher’s solution and allows the teacher to help them to develop their own.

Aim: Skills practice of reframing.

Task

1. The group of any size but equal numbers can be asked to give examples of critical statements they have heard families make about their problems. These can be written up on a board or flip- chart.

 

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