Becoming a Marriage and Family Therapist

From Classroom to Consulting Room

Eugene Mead

• Publisher: Wiley-Blackwell
• Year: 2012
• Print ISBN: 9780470027370, 9780470027363
• eBook ISBN: 9781118323403
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Becoming a Marriage and Family Therapist is a practical "how to" guide designed to help trainee therapists successfully bridge the gap between classroom and consulting room. Readers will learn how to apply empirically-based methods to the core tasks of therapy in order to improve competency, establish effective supervision, and deliver successful client outcomes.

• A practical guide to improving competency across the core tasks of therapy, based on over 40 years of observation and teaching by an internationally acclaimed author
• Presents treatment protocols that show how to apply therapy task guidelines to a range of empirically-supported marriage and family treatments
• Provides extended coverage on assessing and beginning treatment with crisis areas such as suicidal ideation, and family violence with children, elders, and spouses
• Suggests how supervisors can support trainees in dealing with crisis and other challenging areas, to build competence and successful delivery

Part 1

Chapter 1

Becoming a Competent Marriage and Family Therapist

Introduction

This book is designed to help you make the transition from the classroom to the consulting room. In the classroom you have developed verbal and theoretical knowledge of how to do therapy. In the consulting room you will begin to change your verbal-theoretical knowledge into experiential knowledge. In the classroom you learned to respond to verbal descriptions of client behaviors. In the consulting room you will learn to respond to actual client behaviors in real time. You will begin to feel the responsibility of attempting to help clients deal with the complexities of their lives. Meeting clients for the first time is both exciting and frightening. In this effort you will not be alone. You will have the support and guidance of your supervisor who is an experienced therapist. Therefore, this text is also for supervisors. It will help supervisors provide the support and guidance new therapists need as they work to become competent therapists.

As a new therapist your goal is to become a competent entry-level therapist. Wampold (2001) stated that competent therapists have successful client outcomes. Therefore, your goal should be to help clients achieve their therapy goals. Your supervisor's goals are to help you become a competent therapist while safeguarding the welfare of your clients. How can you help clients to have successful outcomes? Successful therapy appears to be a function of four factors that appear to be common to all models of therapy (Lambert & Barley, 2002).

The Role of Common Factors in Therapy Outcomes

Research over the past twenty years has found that about 80 percent of clients who undergo psychotherapy are better off than those who do not (Lambert & Barley, 2002). Research has also found that about 40–50 percent of couples and families who complete marital or family therapy have successful outcomes (Shadish & Baldwin, 2002). Why marital and family therapy should be found to be less successful than individual therapy is not known. One could speculate that the difficulty of building and maintaining multiple alliances in families may be a contributory factor (Blow, Sprenkle, & Davis, 2007).

When individual therapy models are compared with each other none of the models have been found to be more efficacious than any other (Lambert & Barley, 2002). The same is true for marriage and family therapy models. When they are compared head-to-head, no marriage or family therapy model is superior (Shadish & Baldwin, 2002, 2005).

There are a few noteworthy exceptions in which specific treatments have been found to be effective for specific classes of problems (Lambert & Barley, 2002). For example, exposure treatments for anxiety, avoidance, and rituals have been found to be superior to other forms of treatment (Lambert, 1992). Similarly, exposure techniques appear to play a significant role in the treatment of panic disorder with agoraphobia (Craske, 1999; Michelson & Marchione, 1991). Also there is considerable support for cognitive behavioral therapy (CBT) as an effective treatment for depression (Clark, Beck, & Alford, 1999). However, even in these specific treatments the common factors appear to play an important part.

Common factors contributions to successful client outcomes

According to the common factors literature there are four factors that make up the variance in therapy outcomes (Hubble, Duncan, & Miller, 1999; Sprenkle, Blow, & Dickey, 1999). The four factors are (1) the alliance, (2) what the clients bring to therapy, (3) the placebo effect, and (4) the treatment techniques. The alliance is the relationship between the clients and the therapist and makes up 30 percent of the therapy outcome variance. What the clients bring to therapy makes up approximately 40 percent of the variance (Lambert & Barley, 2002) and includes their presenting problems, their readiness to change, their social skills, and their support systems (Asay & Lambert, 1999). The third factor is the client's expectations for a successful outcome, what some call the placebo effect of coming to therapy and makes up 15 percent of the outcome variance (Lambert & Barley, 2002). The fourth factor treatment techniques employed by the therapist are embodied in the therapy model used by the therapist. Therapist techniques are used to maintain the therapeutic conversation between the therapist and the clients (Frank & Frank, 1991, 2004). Treatment techniques are believed to make up the final 15 percent of the outcome variance. These four factors appear to be common to all models of therapy and seem to account for successful client outcomes in both individual psychotherapy (Lambert & Barley, 2002) and in marriage and family therapy (Sprenkle et al., 1999).

Two of these factors, what the clients bring to therapy and the placebo effect, appear to be primarily client factors and not directly open to manipulation by you the therapist. The remaining two factors, the alliance and therapy techniques are factors that you can influence.

Here I will deal with each of the common factors independently although in practice they are difficult to differentiate. For example, the placebo effect may contribute initially to the client's trust in you thus facilitating the development of the alliance. Building and maintaining the alliance is related to how you employ the treatment techniques (Blow et al., 2007). It is difficult to differentiate the role of the treatment techniques from procedures that build the alliance. The alliance is said to consist of three elements, the clients' trust in the therapist, the clients' agreement with the therapist on the goals of therapy, and the clients' agreement about the techniques needed to achieve their goals (Bordin, 1979). So, at the same time that you are working collaboratively with the clients to clarify and establish their goals they will begin to trust you. As you communicate respect and empathy and exercise care concerning their safety in the sessions, the clients come to trust that you are on their side, both as individuals and as a couple or family. In this way two of the elements of the alliance are being forged, first, agreement on goals and second, trust in you as their therapist. Next you will propose a treatment plan tailored to fit the clients' needs and goals. If the clients agree that the treatment is appropriate to help them achieve their goals then the third element of the alliance is being constructed which is agreement on the treatment methods or therapy model. Finally, the treatment model serves as a structure for a continuing conversation about the clients' problems, needs, and goals while they formulate their solutions and change their behaviors and relationships (Frank & Frank, 1991, 2004). Thus, while treatment techniques have been found to contribute only 15 percent to the outcome variance, that 15 percent is not trivial.

Although the factors labeled “what the clients bring to therapy” and “client expectations” do not appear to be open to direct manipulation by you as a therapist there are potentially several ways you can influence the clients' perceptions of the alliance. These will be discussed at length in this chapter. Perhaps what is more important is that the delivery of the therapy techniques and the skill with which they are delivered is directly under your control. It has been shown that therapist's vary in their therapy delivering skill (Luborsky et al., 1986) suggesting that therapists can learn how to deliver therapy more effectively. By improving your skills in delivering therapy, you will increase the probability that your clients will have successful outcomes (Blow et al., 2007).

The Therapeutic Alliance

As stated above, the therapy alliance has been found to account for approximately 30 percent of the total outcome variance (Asay & Lambert, 1999). The alliance consists of three factors: (a) the clients' trust in, or bonding with, the therapist; (b) agreement between clients and therapist on the therapy goals; and (c) the clients' agreement with the tasks in the treatment plan (Bordin, 1979; Heatherington & Freidlander, 1990; Johnson & Talitman, 1997; Pinsof & Catherall, 1986). As a therapist you make a positive contribution to the therapy alliance by: (a) communicating respect, caring, and empathy (see Chapter 2); (b) helping clients clarify and establish their goals (see Chapter 3); (c) establishing treatment plans tailored to those goals (Chapter 3); and (d) dealing effectively with breaches in the alliance.

In individual psychotherapy you only need to be concerned with the alliance the client makes with you as the therapist. In family therapy you must be concerned about the alliance each family member makes with you (Friedlander, Escudero, & Heatherington, 2006; Pinsof, 1995). Family members may vary in their goals for therapy. Therefore, each family member will form her or his own alliance with the therapist. When family members' differ in their alliance with the therapist, the alliance is said to be split (Beck, Friedlander, & Escudero, 2006; Thomas, Werner-Wilson, & Murphy; 2005). Pinsof and Catherall (1986) were the first to define a split alliance. Split alliances occur when one member of the family rates the alliance with the therapist high and another member of the family rates the alliance low. Split alliances may lead to clients deciding to withdraw from therapy before they have reached their goals.

The probable causes of split alliances

In family therapy there may be as many goals for coming to and for staying in therapy as there are family members in the room (Friedlander, Escudero, & Heatherington, 2006). Family members have already formed alliances between each other before they come to therapy. Alliances between family members are what Friedlander and colleagues (2006) call family allegiances and what Garfield (2004) calls family loyalty. Family members may vary in their sense of family unity from total enmeshment to wondering whether or not they intend to remain in the family. It should come as no surprise then that the alliances they form with the therapist vary (Friedlander Friedlander, Escudero, & Heatherington, 2006; Symonds & Horvath, 2004).

The causes of split alliances are not yet well understood. The family power structure may be one factor in split alliances. Differential power may be a function of differences in physical size and development or in role differences between partners and between parents and children. The power hierarchy in the family may make some members vulnerable to other members in terms of psychological and physical aggression and even abuse (see Chapter 2). Therefore, some family members will be motivated to avoid family therapy and others may be motivated to come in self-defense. You will need to be sensitive to the power issues and be prepared to provide for the safety of each family member. Power differences may also occur between family members based on gender, race, education, and control of family finances.

There appears to be support for the idea that gender influences alliances however, the results are not consistent. Quinn, Dotson, and Jordon (1997) found that wives' scores on an alliance scale predicted outcome while the husbands' scores did not. On the other hand, Symonds and Horvath (2004) found that the relationship with the outcome was greater when the male's alliance was stronger. They also found that the relationship between alliance and outcome was greater when both partners agreed on the strength of the alliance and when the strength of the alliance increased over the course of treatment. Knobloch-Fedders, Pinsof, and Mann (2004) found that individual psychological symptoms in the couple did not predict alliance formation. Similarly Mamodhoussen, Wright, Tremblay, and Poitras-Wright (2005) found that psychiatric symptoms did not predict the alliance but marital adjustment did. In both studies husband's greater marital distress was a predictor of poor alliance. In the Knobloch-Fedders study women's marital distress at intake and reports of family-of-origin issues predicted the tendency for a split alliance. However, in the Mamodhoussen study the husband's marital adjustment and wife's psychiatric symptoms were associated with split alliances.

Family secrets are another source of alliance difficulties in family therapy (Friedlander et al., 2006). Some family members fear that the secrets will come out while others worry that they will not. In these circumstances the issue of safety in the therapy sessions is a serious issue for family members and therefore for the therapist. As a therapist you must address concerns about safety in the therapy system from the beginning of therapy starting with the initial phone call (See Chapter 3).

It is likely that the therapist will be working with split alliances when spouses or family members have mixed motives, are concerned about differential power, and are concerned about family secrets. Heatherington and Friedlander (1990) and others (Mamodhoussen et al., 2005; Symonds & Horvath, 2004) have empirically verified the existence of split alliances between family members and the therapist. Symonds and Horvath found strong correlations between alliance and outcome when the partners agreed on the strength of the alliance and when the strength of the alliance increased from Session 1 to Session 3. Similarly, Safran, Muran, Samstag, and Stevens (2002) found evidence in individual psychotherapy that alliance predicts positive outcomes if found to be about average, as measured by alliance assessment instruments, or if the scores increase over the course of treatment.

Johnson, Wright, and Ketring (2002) found that in family therapy the alliance scores for family members predicted changes in psychiatric symptom distress for mothers, fathers, and adolescents. Agreement with the therapist on the therapy tasks domain of the alliance was the greatest predictor of the outcome for both mothers and adolescents while agreement on the therapy goals domain was greatest for fathers. Beck et al. (2006) also looked at alliances in families in a qualitative study with four cases. Interestingly, they found direct measures of split alliances with the therapist in only two of the four cases. In the study Beck et al. (2006) found that most of the problems centered on the lack of agreement between family members on goals for being in therapy, rather than disagreeing with the therapist on therapy goals. In two of the cases, which included husbands and fathers, most of the conflict appeared to be between spouses.

It seems clear that as a therapist you will need to guard against forming reciprocal emotional triangles with either partner (Bowen, 1978; Rait, 1998; Thomas et al., 2005). Triangles that form between you and any family member or groups of family members – such as aligning with the parents against an adolescent – seems to have the potential to form rifts in the alliances. In addition, negativity or defensiveness on your part in response to client negativity may be harmful to the client-therapist alliance.

Detecting rifts in the alliance

Client confrontation of the therapist and client withdrawal from the therapist or the treatment program often signal a rupture in the alliance (Safran & Muran,1996; Safran et al., 2002). Confrontation is observed when the client openly expresses hostility or anger toward you or the therapy process. The far more frequent signal of a rupture is client withdrawal. The client may withdraw from you, the therapy process, or from her or his own emotional processes. Examples of withdrawal include passivity or refusal to talk and coming late or missing sessions. There can be, of course, a mix of ways of expressing alliance rupture in which the client manifests angry or hostile withdrawal.

It would appear that a split alliance in couple or family therapy should be treated as a therapeutic rupture (Friedlander, Escudero, & Heatherington, 2006; Pinsof, 1995). In family therapy one family member may confront you or attack the therapy process while another family member may experience you or the process as positive and helpful. In a split alliance one family member may withdraw from the therapy process, from you, or from interaction with the other family members.

When there is a split alliance two factors are said to determine the strength of the split (Pinsof, 1994). The first is the intensity of the negative alliance of one family member balanced against the degree of positivity in another family member. The second factor is the power of the subsystem, such as the parental subsystem, to influence whether or not family members keep coming to therapy. For example, your strong positive alliance with an adolescent son may not be sufficient to balance a negative alliance with the parents. Pinsof (1994) suggests that you need to...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• List of Figures, Tables, and Boxes
• About the Author
• Foreword
• Acknowledgments
• Part 1
• Part 2: Protocols for Selected Models of Marriage and Family Therapy
• Appendix A
• Appendix B
• Appendix C
• Appendix D
• Appendix E
• Appendix F
• Appendix G
• Appendix H
• Appendix I
• Appendix J
• Appendix K
• References
• Index