Contextual Therapy for Family Health

Clinical Applications

Alexandra E. Schmidt Hulst, D. Scott Sibley

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781134853533
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This book provides readers with a compelling case for the inclusion of contextual therapy in comprehensive healthcare settings by presenting its applications to individual and family health across the lifespan. Part I gives an overview of contextual therapy, including case conceptualization, assessment, intervention, and supervision. Part II provides specific recommendations for incorporating contextual therapy in diverse and multidisciplinary settings. Case studies illustrate how concepts such as justice, loyalty, and balanced giving and receiving influence families' adjustment to chronic illnesses and mental health disorders. Accounting for the trend toward increased collaboration between providers in traditional mental health and medical settings, this book will empower clinicians to expand their current range of assessment methods, intervention techniques, and supervision experiences

PART I


AN ORIENTATION TO CONTEXTUAL THEORY AND SKILLS

Chapter 1


The Theory Behind the Practice

Before learning how to use a set of tools, it is important to know what the tools are used for and how they address a problem. Although the current system of healthcare includes many treatments and techniques to improve patients’ health, we propose that contextual therapy offers a unique array of tools to promote healing in a variety of dimensions. Before we can learn how to use them, however, we need to develop a rationale for why and when contextual therapy interventions could be included as part of comprehensive healthcare.

IN DEFENSE OF ASSUMPTIONS

By definition, assumptions are expectations that are accepted to be true without having proof. These suppositions serve as the foundation for a set of beliefs that guide the way we think, behave, and feel. Although problems arise when we adhere too strongly to our assumptions without exploring alternative ideas, equally serious problems emerge when we don’t recognize the existence of our assumptions and how those impact our life and the lives of those around us. As the author and biochemist Isaac Asimov (n.d.) wisely reminded, “Your assumptions are your windows on the world. Scrub them off every once in a while, or the light won’t come in.” Notice that he did not say to get rid of all your assumptions, but to be aware of them and to consider clarifying and refining your perspective every so often so you are seeing with clearer vision.

According to Boszormenyi-Nagy and Krasner (1986), the foundation of contextual therapy is formed by two core assumptions. First, the model assumes that the consequences of any one person’s decisions or actions affect the lives of all those who are connected with him or her. This conviction places this model of individual, couple, and family therapy squarely within the realm of models grounded in general systems theory, which acknowledge that a change in any one part of a system inevitably reverberates throughout the rest of the system. In other words, we do not live our lives in a vacuum. Rather, clinicians guided by a contextual framework recognize how patterns and shifts in various systems, both large and small, influence individuals’ unique experiences and forever alter that system as a whole.

For example, the diagnosis of a chronic illness such as diabetes impacts other people in that person’s social network, including family members, coworkers, and friends. Likewise, a decision made by an insurance company about which medications will be covered trickles down to impact the very individuals who receive benefits from that insurance provider. The insurance system also intersects with other social and environmental systems influencing individuals’ experiences within the healthcare system. These systems, whether individual families or complex healthcare systems, are composed of more than just a set of objects or individuals (Gray, Duhl, & Rizzo, 1969). Rather, a comprehensive understanding of these systems accounts for both (1) individual characteristics of those who make up the system and (2) the interrelationships between individual patients, family members, healthcare providers, healthcare policy decision-makers, and more.

The second assumption, according to Boszormenyi-Nagy and Krasner (1986), is that satisfying, fulfilling relationships include responsible consideration of and accountability for other people within the relationships we form. In other words, contextual therapy proposes that, contrary to popular belief, we are, in fact, accountable for how our decisions affect others. In the contextual view, responsibility for how we affect others is beneficial for their well-being, as well as for our own. Boszormenyi-Nagy and Krasner (1986) wrote, “Context implies consequences that flow from person to person, from generation to generation, and from one system to its successive system” (p. 8). As system members and individuals, we are not immune from acknowledging the ripple effects of our actions. Our relationships have significance in past, present, and future interconnectedness, regardless of whether members maintain active contact or not.

Research supports this assumption. The 75-year long Grant Study, run by Harvard University, demonstrated a crucial ingredient for a healthy, satisfying life: fulfilling intimate relationships with others (Itkowiz, 2016). Dr. Robert Waldinger, the current director of the study, has described the health benefits of rich intimate relationships by saying, “Good, close relationships seem to buffer us from some of the slings and arrows of getting old.” At its core, this second assumption of contextual therapy reminds us as clinicians that relationships are significant for every single patient. For some readers, this may seem intuitive, and for others, unfamiliar.

How might your own practice change if you were to assume that, no matter how close or estranged, every family member of your patients is invaluably important to understanding how best to keep them healthy? What if you were to assume that encouraging your patients to consider how they affect others around them is good for their health? Unfortunately, we often accept too quickly and change the subject when a patient says, “I have not spoken to my mother in 5 years, and I do not want to talk about it” or “It does not really matter what I do. My husband does not care anyways.” Contextual therapy beckons us to take a closer look at these relationships that seem strained or one-sided. The reality is that whether this patient recognizes the relationship as currently significant or not, past dynamics and meanings attached to events influence day-to-day functioning and medical decision-making. This we cannot afford to ignore.

These basic assumptions provide the foundation for core values specific to contextual therapy. As we introduced during the prologue of this book, contextual therapy clearly emphasizes concepts such as justice, fairness, loyalty, and trustworthiness. The emphasis on these values helps distinguish contextual therapy from other approaches to individual and relational psychotherapy. Here, we will briefly describe the major ideas associated with these values. Throughout the rest of this book, we will connect these key values to individual and family health experiences.

LOVE, TRUST, AND LOYALTY

One of the hallmarks of the contextual model is a recognition that throughout the course of a lifetime, each of us experiences violations of love, trust, and loyalty within relationships. We may become disappointed, jaded, or angry when our relationships do not provide the security and safety we seek. For many patients, these relational violations are at the very forefront of both physical and mental health symptom development and their decision to seek treatment in the first place. A clinician working from a contextual framework listens astutely and recognizes within the narrative presented by patients the various relational violations that have occurred and continue to occur. For clinicians guided by contextual therapy, love, trust, and loyalty are binding ingredients that preserve relationships and keep them vibrant and alive.

As a transgenerational model of family health, contextual therapy closely attends to the impact of family interactions across multiple generations on individual functionality and development of health symptoms. Relationships are divided up into two kinds: vertical relationships such as those hierarchical connections between parents and children, and horizontal relationships such as those non-hierarchical connections between siblings and romantic partners. Specific attention is paid to how patterns of behavior in vertical relationships between parents and children shape individuals’ beliefs about love, trustworthiness, and loyalty. As eloquently explained by Johnson (2013), “We instinctively know that there is no other experience that will have more of an impact on our lives—our happiness and health—than our success at loving and being loved” (p. 3). We learn how to give and receive love in our families of origin, and these experiences of love (or the lack thereof) are often at the heart of many of the times of great joy and times of great pain that families experience.

For instance, some families must address parental issues manifested in the perceived favoritism of one child over another. This preference for showing love to one sibling over another can cause great friction within family relationships, and parents may struggle with determining how to give and receive love in ways that are tailored to each child’s preferences and needs. This can lead to troubles between siblings, born out of hurt feelings, questions about self-worth, and dashed expectations. As explained by Boszormenyi-Nagy (1987):

Family members may question each other’s capacity for loving. One may claim that the other uses the word “love” to mean selfish receiving while he himself means giving or give-and-take of emotional exchanges. Further, people’s preferences may be divided between loving and being loved—between being the subject or the object of love. (p. 85)

As we will discuss more in the next chapter, contextual clinicians hold an essential belief that relationships are most satisfactory when they allow us to be both the subject and the object of love. Although individuals may have preferences for giving or receiving care, a balance between the two is essential for sustainable growth.

Love, however, is not the whole story. Western societies may disseminate the belief that love can cure all relational ailments, but trust comprises a substantial piece of the puzzle (Hargrave & Pfitzer, 2003). For the seasoned clinician, issues revolving around trust are present within many of the conversations we have with our patients.

Although there are a myriad number of actions, big or small, that may damage individuals’ experiences of love, trust, and loyalty within their family relationships, one particularly damaging example can be found in parental infidelity (Schmidt, Green, Sibley, & Prouty, 2015). Children can be haunted for years by the past decision-making of their parents, especially if they considered their parents’ actions unjust and relationally unethical. For instance, Schmidt et al. (2015) found that adult children who had knowledge of their father’s involvement in infidelity reported being less trusting and loyal in their own relationship with their current romantic partner. Just as we learn how to give and receive love in our families of origin, we also learn what it means to earn trust and show others that we trust them.

In some cases, discovery of infidelity can lead couples to separate or divorce with multi-systemic consequences (e.g., Amato, 2010). Regardless of parents’ diligence in working to manage the fall-out, a separation and divorce inevitably change family relationships and introduce the need for significant adjustment. Research has clearly indicated that parental conflict and divorce can have a moderate impact on children and their ability to succeed in their future romantic relationships (e.g., Amato & DeBoer, 2001; Cui, Fincham, & Durtschi, 2011; Segrin, Taylor, & Altman, 2005; Rhoades et al., 2012). According to Amato (2010), “Research during the last decade continued to show that children with divorced parents, compared with children with continuously married parents, score lower on a variety of emotional, behavioral, social, health, and academic outcomes, on average” (p. 653). It is also important to note that there are protective factors—rejection sensitivity and maternal warmth, to name a couple—that help ameliorate some of the negative effects of divorce on children and adolescents and promote resiliency (Luecken, Hagan, Wolchik, Sandler, & Tein, 2017; Schaun & Vögele, 2016). As a model that places significant value on addressing violations of love, trust, and loyalty (such as those associated with infidelity and parental divorce), contextual therapy provides a framework for how to help families maintain a focus on health and well-being during times of emotional distress.

Loyalty encompasses one’s sense of obligation and connection to those who have earned love and care, either by nature of their own offering of love and care or by nature of the relationship (e.g. parent and child). In a sense, it guides how individuals choose to consider, “What do I want to do?” and “What is best for us?” According to Goldenthal (1996), loyalty is not actually something that parents need to qualify for from their children. Instead, members of each generation are naturally drawn toward the desire of being loyal to previous generations.

Contextual therapists assume that if a loyalty connection between generations is not hard-wired in, it is so universally prevalent that the potential for the development of loyalty must be so wired. We speak of being loyal as opposed to feeling loyal to emphasize that loyalty involves action, not just emotion. Loyalty is not something the parents need to earn from their offspring. (p. 74)

Even in cases in which children strive to be psychologically different than their parents, there seems to remain an innate desire to be loyal to their parental figures. Loyalty can take a variety of forms, such as maintaining family routines and traditions, following in the footsteps of a parent’s career, adopting similar coping or conflict resolution strategies, or defending a parent’s actions to someone expressing criticism. There are also times when a child may feel caught between two (or more) loved ones, feeling torn between relationships and how to demonstrate loyalty; not surprisingly, this pattern often emerges in families where parents are engaged in significant conflict with each other or other family members. As clinicians, we have found that it is helpful to guide clients through considering which aspects of loyalty are helpful (e.g. carrying out a favorite holiday tradition) and which may be harmful (e.g. following in the footsteps of a parent’s alcoholism) rather than using a black-and-white approach with loyalty exploration.

FAIR AND SQUARE

Unique to the contextual model is the emphasis placed on fairness, which guides the flow of giving and taking that occurs within relationships. Although many people seem to have an attitude that “Life is unfair, so you should learn to accept it,” our contextual lens guides us to believe that relationships can, and should be, guided by a sense of ethics steeped in a human desire for fairness. To have healthy, whole relationships, we should strive for balanced, fair justice. This means that we are accountable for a fairness that ensures that all members’ needs, both for giving and receiving, are met. Although this may initially sound naïve and trite, we propose that this balanced giving and receiving is absolutely essential for having sustainable, trustworthy relationships. Van der Meiden et al. (2017) described the balance of giving and receiving as a key indicator for the quality of family life.

How do we know when a relationship is guided by fairness? What is perceived as fair differs across couples and families, which makes this a concept that is difficult to define. Perhaps the best way to describe a relationship as fair, in the contextual sense, is one that promotes a balance of giving and taking, which creates a culture of loyalty to one another and trust that all members’ needs will be met over time. Fairness helps individuals to give more freely of themselves and to ask more clearly and confidently for what they need in relationships (Dankoski & Deacon, 2000).

When we speak of a balance in giving and taking, this does not mean a quid pro quo “I did something nice for you, now you do something nice for me” arrangement. Rather, relationships become generally balanced throughout the passage of time as both parties demonstrate a commitment to caring for each other. In the contextual framework, individuals are both obligated to demonstrate care for others and entitled to receive care from others. When we trust someone, we believe that they will “pay us back” eventually, and we don’t feel the need to keep score diligently and set a deadline on when this kind deed must be repaid. Trust is maintained when others hold up their end of this unspoken deal and return love and care to us as we have shown to them.

Relat...