Brief Therapy With Couples and Families in Crisis

Robert Taibbi

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781351847711
• Topic: Psychologie
• Subtopic: Santé mentale en psychologie

As the average length of therapy shortens, clinicians need a resource to lead them step-by-step through the goals and process of the opening sessions of brief therapy as well as clear treatment maps for the most common presenting problems. This resource helps clinicians do just that and more, including doing a quick assessment and isolating and addressing the underlying emotional wounds that prevent families and couples from solving problems on their own. Readers will not only learn how to "think brief," they will also discover how to navigate the session process in an interactive and action-oriented way, even with clients who are in high-pressure, crisis situations.

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1 The Landscape of Brief

Anne leaves a voice mail message. She just discovered that her husband Bill has been having an affair for the past six months, and he in fact admitted so last night. She is understandably distressed and would like an appointment as soon as possible, and Bill, though reluctant, has agreed to come in.

The couple is in crisis. While Anne and Bill are struggling with infidelity, they could have just as easily been reeling from a bigger-than-usual argument that resulted in the police being called. For families, crises may come in the form of parents learning that their 10-year-old son just got suspended from school for pushing a teacher, or that their 15-year-old daughter is pregnant. Their emotions are high and they want to be seen quickly. They need help putting out the fire.

This is what this book about—how to put out the emotional fire and effectively help those couples and families who come to you in crisis, using a brief treatment model. Our approach will be two-pronged. One is using tools and techniques to calm the emotional waters and put the couple’s or family’s presenting problems to rest. This is about hitting the ground running, demonstrating leadership, successfully shaping the content and process in those crucial opening sessions.

But we also want to go beyond simple crisis intervention, and our other focus, and larger focus on this book, is to help couples and families leave treatment not just feeling better, but with the awareness and tools they need to successfully manage future problems on their own. To do this you need to quickly diagnose the source of their problems and crises, repair the faulty infrastructure and teach them the communication and emotional skills that they lack. And to do this within a brief model demands an action- and process-oriented behavioral approach, one that keeps the clients in lockstep with you throughout. This is what we plan to provide.

But in order to get our bearings, let’s begin by exploring in this chapter the broad landscape of brief therapy and the dynamics of those in crisis.

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Brief World

You might be considering a brief model for a number of reasons. Perhaps you work in a setting where this is the clinical norm: a walk-in community clinic where crisis work is the bulk of what you do, or a community agency where there is always a strong demand for services, where waiting lists are common and where there may be a cap on the number of sessions that clients can receive. Or perhaps you want to be more flexible in your overall approach, your own clinical style already leans towards a short-term approach, and you are looking for new ideas and techniques that will enable you do such work better.

Or brief work may be less of a choice and more a reality, you realize, of how long clients stay. You’re not alone if you think this way. When we look at the statistics of those in therapy, it turns out that most clients come to therapy once (Phillips, 1985) and the average length of treatment is five to eight sessions (Cooper, 2011). In spite of any cherished images we may have of the inward journey of therapy, the unraveling of the past and the unconscious, the reality check is that, in fact, most couples and families are in brief therapy. Both their expectations and actual involvement often limit you to a fairly short window of treatment. Crises only increase the challenge. You have to work fast, effectively and efficiently, in order to quell their high emotions, making sure that each and every session counts. If you don’t—if your pace doesn’t match their expectations—they’re likely not coming back.

Thinking Brief

Imagine that you wake up one morning with a huge rash on your arm. Quickly you go on the internet, open up WebMD and begin looking at an array of ghastly pictures of various types of rashes—one from Africa that actually can rapidly spread mayhem all over your body and looks exactly like the rash on your arm, and another that is a form of Lyme disease that you remember your mother having many summers ago, which caused her much pain and months to recover from. Now you’re feeling a bit panicky. You call your family doctor who (big relief!) schedules you for 2:00. Just having the appointment helps you calm down.

You show up a bit early, still worrying. In comes your doctor to the exam room, and what does she do? She asks you what is bothering you. You show her your arm. She looks at the rash under a magnifying glass. She asks you an assortment of questions—when did this start, does it itch, did you try any treatments on your own, have you been in the woods lately, has it gotten worse? She says she’d like to do some blood work to rule out any possible underlying infection, but she doubts that the case. It looks to her like simple contact dermatitis, probably some exposure from your hike last weekend. She gives you a sample of skin cream that you need to apply three times a day for the next five days. In the meantime, she will see what the blood work shows, and if the medication doesn’t seem to be working in the next three days, you are to give her a call.

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Do you feel better when you walk out of her office 15 minutes later? Absolutely! Why? Because you imagined that you had that rare African rash or your mother’s Lyme disease, and she assures you it is neither. You have the prescription—something to do and try—which gives you a sense of control and relief. You feel more settled; you have a new perspective—this is fixable—and you’re not dealing with this on your own.

If you’re doing brief therapy with couples and families in crisis, you want to be like your doctor—assess quickly, counter and change the couples’ or families’ worse-case expectations, and provide a clear action-oriented plan that helps them feel that they are in good hands. And what the doctor does in 15 minutes you have 50 minutes to accomplish. Not bad.

But what are we exactly talking about when we talk about brief therapy and how is it different from longer-term models? It’s less about time and more about how you think; namely, about being clear and decisive. Here is an overview of the basic elements of the brief model that we will be working from and discussing more fully in later chapters.

Focus on the Present Rather Than the Past

The psychodynamic tradition has made the exploring of a client’s past and the unraveling core issues the foundation for treatment. In brief therapy your focus is on the present—the here and now, fixing the problems the clients present. Though you may dip into the past as part of an initial assessment, or address the past when pertinent issues arise, the present is your therapeutic footprint and arena.

Focus on Patterns and Behaviors Rather Than Insight

The psychodynamic deconstruction of the past seeks to provide clients with insights into their history that can help them better navigate the present. This is where the unconscious becomes conscious, where a clinician’s interpretation hits its mark and creates an “Aha” experience or “breakthrough” for the client.

While clients in brief therapy can certainly have an “Aha” experience, insights are replaced with clients’ recognition of patterns—the ways they act and react to each in other in set ways, enabling them to move from a “who has the problem” mindset to realize how natural human instincts and brain processes contribute the problems they are struggling with. Patterns are essentially problems in motion, and the goal becomes replacing dysfunctional patterns with healthier ones.

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Alongside pattern recognition, and in contrast to most psychodynamic approaches, your focus is on planned behavioral change—stopping and reshaping the dysfunctional patterns, communicating in new ways, helping clients step outside of their comfort zones to increase their behavioral and emotional range. While many clients’ attitudes are that they need to feel better before they can do anything different, your message to them is the opposite: that while you can’t directly control how you feel, you can control what you do; if you keep doing the same thing, you will keep feeling the same way. This is where behavioral homework assignments become the means of putting treatment into everyday practice.

Focus on Process Rather Than Content

Most couples and families come to therapy essentially speaking a different language than that of the brief therapy clinician. Clients are usually speaking the language of content—the blow-by-blow argument over what the dog did and didn’t do, what his brother really said at Christmas, how the spouse wasn’t “tuning out” but “listening,” how much debt in dollars and cents he put on the credit card—all important to each in presenting and defending his own version of reality. And as emotions rise, so too does the content.

Just as they erroneously believe that they need to feel better before they can act, their emotional brain is erroneously telling them they need to do a better job of lining up their facts in order to win an argument. While they believe that the issue in the room is about whose reality is right, the real issue, your issue, is about what keeps the couple or family from successfully solving their problems on their own. And that is about process—how they talk and manage their emotions—not content and facts.

But this is not what the couple or family expects from you. They expect you to enter into the sorting and sifting of facts. They are trying to drag you into the weeds of their stories so you can, at best, be an arbitrator and pass judgment on who is right after all or, if not, at least be a mediator and find a factual path out of their mess. You are neither. Instead, you want to focus on and speak to them about process—help them see that how they talk and problem-solve is more important than what they talk about. Help them see how the interactional dance unfolds in the room and how listening and problem-solving fall apart. Assess what missing skills or negative emotions keep them from moving forward. Make them curious about what gets in the way of their running their lives more effectively. While the content is ever-changing, the process is generally always the same. It is not the content, you say, that is faulty, but the process that carries the content.

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Staying in Lockstep Throughout

This focus on process also means that you are always aware of what is unfolding moment by moment in the room. Good therapists are naturally attuned to this, but because you are dealing with crises in a limited amount of time, and because each session is critical, the need is greater and your focus needs to be sharper to ensure that the couple or family are always in lockstep with you. As you present your assessment, make an interpretation, educate them about the dynamics and recommend a course of action, you are always looking for solid agreement. This is what your doctor does after she explains to you why she believes you have contact dermatitis; she is looking for agreement—verbally or non-verbally—before marching ahead with a treatment plan. If she senses any objection—that you make a face, you become passive or you say “yes, but”—she is likely to stop and ask what are your hesitations or questions.

You always want to do the same. If you don’t, and if the couple or family is not fully on board with your assessment or treatment, they will disregard it and not do what you suggest, or not return. You need track the process at each step along the way.

Focus on Specific Concrete Goals Rather Than Personality Overhaul

Because couples and families are in crisis and your time is limited, and because you’re focusing on problem-solving specific issues rather than historical deconstruction, you are not expecting to overhaul personalities. That said, by focusing on the overall how of process, rather than the specific what of content, these new skills and behavioral changes can ripple out and affect other areas of clients’ everyday lives. You are not only repairing this problem and this relationship but also enabling clients to carry these new skills and perspectives into other present and future relationships.

Focus on Rapid Assessment

While you will continue to assess and reassess as a means of fine-tuning treatment, the bulk of your assessment, like that of your doctor, occurs in the first session. Why? Because, like your doctor, you want to reduce the crisis, and the angst and anxiety that comes with it, by providing clear feedback and beginning treatment by the end of the first session. To this you need to be active and clear.

Focus on Having Treatment Maps in Place

Your family doctor is able to be efficient because she mentally has linked the common medical problems she sees with specific tried-and-true treatments. In order to hit the ground running, you want to do the same: mentally have your own treatment maps at the ready for common couple and family problems. While such maps, like all maps, are not the same as actually walking the terrain, they do provide you with a preliminary plan, a starting point for your assessment and treatment goals and tasks.

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So when Anne leaves her message about Bill’s affair, or a parent calls about her daughter’s unexpected pregnancy, you are already mentally moving ahead and placing the problem within your clinical orientation, thinking about what information you need to gather in the first session, mentally sorting through your clinical repertoire of tools and techniques. Your treatment planning, in effect, begins even before your first contact with a client.

Focus on Changing the Emotional Climate

While behavioral change is the meat and potatoes of treatment, you also want to change the emotional climate, calm those emotional waters in the first session to ensure that the couple or family feels different when they walk out than when they walked in. If they don’t—if they feel much the same as when they walked in—they are likely to dismiss you and your therapy and not return. While your feedback and treatment plan will do most of the heavy lifting in this area, you are looking for opportunities to change the emotional climate in the room throughout the session. We’ll be talking about specific ways of doing this in Chapter 5.

The theme running throughout these points is clear—that a brief treatment model requires setting clear boundaries on the scope of treatment and making those first sessions focused, specific, and action-oriented so clients know what to do to relieve their anxiety and their problems. This will be our focus throughout.

When Not to Do Brief Therapy

Jake comes to therapy with his partner Teresa. Teresa has a history of anorexia, and though she had been stable for many years, the stress of having their first child has taken its toll and caused Teresa to relapse. Jake is frightened by her rapid loss of weight and frustrated at seeing the little she eats and the restrictive food patterns she has fallen back into. Jake believes she needs to go into residential treatment, but Teresa, not wanting to be separated from the baby, continually swears she will do better; in spite of her efforts, however, she is making no progress.

While a sizeable majority of couples and families usually come to therapy in some form of crisis and need crisis stabilization, not all such clients are appropriate for a brief therapy approach to treatment. While Jake and Teresa may benefit from having a safe place to discuss their worries, perspectives and possible options, it is obvious to you that Teresa does indeed need either residential treatment or ongoing intensive outpatient treatment if she is to pull out of her relapse. Offering a limited number of sessions is an unrealistic and inappropriate level of treatment and is unethical.

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Similarly, there are other such individuals who may be in a relationship crisis but also need ongoing or intensive support: those with psychotic disorders or with undiagnosed or untreated bipolar disorder; those wi...

Table of contents

• Cover Page
• Brief Therapy With Couples and Families in Crisis
• Title
• Copyright
• Contents
• 1 The Landscape of Brief
• 2 Core Concepts
• 3 Treatment Maps for Common Couple Problems
• 4 Treatment Maps for Common Family Problems
• 5 First Session Goals
• 6 First Session Process
• 7 Second Session and Beyond
• 8 Couple and Family Therapy Techniques and Tools
• 9 Integrating the Brief Approach Into Your Own Therapeutic Style
• Index