Family Therapy History, Theory, and Practice 6th Edition Gladding – Test Bank A+

Description

• In family therapy, there is a link between selecting treatment approaches and professional issues, such as ethical and legal factors
• Knowledge of ethical, legal, and professional issues can prevent clinical or personal actions that result in harm to families
• For family therapists to stay healthy, they must abide by ethical codes and legal statutes and practice according to the highest standards possible

Overview of Ethics in Family Therapy

• Ethics are moral principles from which individuals and social groups, such as families, determine rules for right conduct
• Relationship ethics refer to ethics in a family that are based on the principles of equitability and caring.
• equitability – everyone is entitled to have his or her interests and welfare considered in a way that is fair from a multilateral perspective
• caring – moral development and principles are centered in the social context of relationships and interdependency
• Early family therapy models stressed neutrality, rarely discussed ethical principles with clients, and believed theory and practice were ‘value free’
• Modern practitioners understand that all therapeutic decisions are related to values and cannot be ethically neutral
• Family therapists may face more ethical conflicts than other types of therapists due to the complexity of relationships and of meeting the needs of multiple individuals within the system

Ethics and Values

• Values are a ranking of an ordered set of choices from the most to the least preferable
• Values have four domains
• personal
• family
• political/social
• ultimate
• Effective family therapists closely examine their own values first
• ethical genograms help determine how one’s family of origin made tough ethical decisions
• examine the values of client families from a systemic view (i.e., how family members’ values affect the family as a whole) and negotiate with the family if values are far apart
• explore values associated with theories, processes, and outcomes selected
• using therapy as a means to promote personal values is unethical
• denying the role of values in selecting treatment approaches and outcomes can lead to clinical errors and possible harm to clients

How Do Values Influence Ethical Practice?

• All ethical decision making has, as its core, the values, beliefs, and preferences of individuals and groups
• “All values that deal with social rights and obligations inevitably surface in ethical decisions” (Doherty & Boss, 1991, p. 610)
• Action-oriented research focuses on finding solutions to problems such as abuse
• Family therapists are ethically bound to be honest and open with client families, clearly informing them of biases and values that impact clinical practices and outcomes

Guidelines for Making Ethical Decisions

• Family therapists must be aware of professional guidelines for making ethical decisions
• Five primary models and resources

1. Codes of ethics – guidelines developed by professional associations (e.g., AAMFT, IAMFC) to address issues confronting family therapists including:

• confidentiality
• responsibility to clients
• professional competence
• integrity
• assessment
• financial arrangements
• research and publications
• supervision
• public statements
• common ethical concerns include
• treating the entire family
• being current on new family therapy developments
• seeing one family member with the others present
• sharing values with clients
• few specific behavioral guidelines on what to do and how
• dual or multiple relationships can be problematic
• determining the best course of action from simply reading the code of ethics may be difficult for both beginning and experienced family therapists

1. Educational resources

• case histories relating to ethical dilemmas
• User’s Guide to the AAMFT Code of Ethics (AAMFT, 2001)
• The Family Journal
• ethical decision making process involves the following steps
• generate a continuum of alternative actions for the good of the family and to meet professional responsibilities
• evaluate and weigh the consequences of each
• make a tentative decision and consult with colleagues/supervisors
• implement the decision
• document the process

1. Professional consultation
   • consultation is the use of experts in an area to enhance one’s own knowledge and abilities

• internal consultation – talking with an expert where one works about an ethical matter
• outside consultation – conversations with a professional outside one’s agency or setting
• process consultation – conferring with an expert about the ethics or methods one is using with a family
• outcome consultation – focuses on the ethics of what the therapist and/or family hopes to accomplish
• formal consultation – input received from an expert through an appointment or structured meeting
• informal consultation – talking with an expert in the hallways at a professional therapy conference or some less structured way of interacting

1. Interaction with colleagues and supervisors

• provides opportunities for sharing of expertise and wisdom
• colleagues may be more accessible than consultants/ed. materials
• cost is inexpensive or free
• direct supervision by noncolleagues is effective and recommended
• family therapy supervision is different from individual therapy supervision
• focus on interpersonal as well as intrapersonal issues
• videotapes used to critique work
• one-way mirrors for live observation and/or supervision
• bug-in-the-ear supervision allows live communication with the therapist during sessions

1. Meta-ethical principles

• high level principles that guide ethical decision making
• autonomy – the right of individuals to make decisions and choices
• nonmaleficence – the avoidance of doing possible harm to a client through one’s actions
• beneficence­ – doing good and promoting the welfare of the client
• fidelity – being trustworthy, loyal, and keeping one’s promises
• justice – treating people equally

Common Ethical Concerns

• Confidentiality is the ethical and legal duty to fulfill a contract or promise to clients that the information revealed during therapy will be protected from unauthorized disclosure
  • Confidentiality issues should be conveyed to all family members in a written professional self-disclosure statement
• Confidentiality has limitations, including:
• if clients may inflict harm on themselves or others
• when the mental or physical health of a client(s) is called into question
• when child or elder abuse or neglect is suspected
• when clients give the therapist written permission to share information (e.g., with another professional)
• privileged communication is a client’s legal right that confidences originating in a therapeutic relationship will be safeguarded
• avoid talking about cases in public
• cell phones, e-mails, and faxes may not be secure
• office personnel must understand and abide by confidentiality requirements
• client information stored on computers should be password protected
• computers should be oriented so that unauthorized persons cannot view the screen
• client notes and records must be kept securely locked
• Gender issues
• gender of therapist and family members influence what issues are addressed in treatment
• gender sensitive issues may include
  • the balance of power between a husband and wife both financially and physically
  • the rules and roles played by members of different genders and how these are rewarded
  • what a shift in a family’s way of operating will mean to the functionality of the family as a while
• avoid implementing changes in gender-prescribed behaviors solely based on therapist values or beliefs
• failure to address emotional abuse or intimidation that is lethal to the life and functioning of the family is irresponsible
• Sex between a therapist and a family member
• sexual relations between a therapist and client are forbidden in the code of ethics of all family therapy associations
• if sexual behavior between a therapist and client is discovered, the person receiving the news should confront the accused professional with the evidence and file a written report to the appropriate association ethics and/or licensure/certification board
• ethics and licensure boards have the authority to investigate, receive testimony, make a decision, and determine appropriate consequences
• Theoretical techniques
• some theoretical approaches are controversial and should be used with discretion
• conscious deceit
• paradox
• neutrality when violence is occurring
• Multicultural therapy issues
• multicultural competence is necessary to insure therapists do not impose their values on families
• three potentially serious ethical errors in working with minority culture families

1. overemphasize similarities
2. overemphasize differences
3. make assumptions that either similarities or difference must be emphasized

• ‘culturally relevant perspective’ identifies what is culturally significant from the family’s perspective rather than from a prescribed cultural perspective that may not be relevant to a family
• Use of the Internet for online therapy
• useful to communicate with clients locally and around the world
• clients can email questions to a counselor and receive an email response within 24 to 72 hours for a predetermined fee
• hearing impaired clients or clients in remote areas can benefit from Internet based counseling
• introverted clients may benefit from web based counseling
• communication with families or family members in between sessions for guidance, to lower anxiety, or clarify issues
• ethical issues include:
• security issues
• possible breaches of confidentiality
• inability of therapists to either protect clients or warn others of potential danger
• inability of therapists to read nonverbal responses and clues
• potential for client misunderstanding of written communications
• client vulnerability due to incompetent therapists
• few existing guidelines for ethical practice (exception is Shaw & Shaw’s Ethical Intent Checklist to evaluate online counseling websites)

Addressing Unethical Behavior

• When unethical behavior is observed, the behavior should first be discussed directly with the person observed to have acted unethically
• If the problem is not resolved at this level, the family therapist should be reported to the appropriate national association (e.g., AAMFT, IAMFC) or licensure/certification board regulating the practice of family therapy
• If allegations about a family therapist are made through a client, options include:
• check with an attorney or ethics case manager
• encourage your client to file an ethics complaint with her or his professional association or licensure/certification board
• file a complaint yourself
• do nothing, if your professional code does not require you to report
• In addressing ethical violations, it can be traumatic for a client to come forward against a therapist

Legal Issues in Family Therapy

• Ethical issues often overlap with legal issues
• Important legal terms
• legal – law or the state of being lawful
• law – a body of rules recognized by a state or community as binding on its members
• liability – an obligation and responsibility one person has to another
• civil liability – results from lawsuit by a client against a therapist for professional malpractice (negligence) or gross negligence
• criminal liability – results from the commission of a crime by the therapist, such as failing to report child abuse, engaging in sexual relations with a client, or insurance fraud
• administrative liability – results when the therapist’s license to practice is threatened by an investigation from a board which has the power to suspend or revoke the license
• Differences between legal and therapeutic systems
• legal systems are concerned with gathering evidence based on facts
• therapy is more interested in processes and making changes
• attorneys spend more time gathering information and concentrating on content than therapists do
• legal systems rely on adversity
• therapeutic systems rely on cooperation
• attorneys focus on ‘winning’ cases for their clients, often discrediting or disproving evidence that contradicts their cases
• family therapists affirm family members and work towards equitable resolution of family issues
• in the legal system, each family member is represented by a different legal counselor
• family therapists work with the whole family to resolve internal disputes
• attorneys work with individuals
• AAMFT provides its members one free consultation per quarter with legal counsel to discuss legal and ethical practice issues
• Types of law
• common law – law that is derived from tradition and usage; accepting customs passed down from antiquity such as English law
• statutory law – laws passed by legislative bodies and signed by an authorized source; only valid in the jurisdiction in which they are passed
• administrative (regulatory) law – specialized regulations passed by authorized government agencies that pertain to certain specialty areas
• case law (court decisions) – law that is decided by decisions of courts at all levels from state to federal
• civil law – acts offensive to individuals; most applicable to family therapists
• criminal law – acts offensive to society in general
  family therapists must be aware of their duties and responsibilities in all areas of law and ethics

Legal Situations That Involve Family Therapists

• Family therapist may encounter a number of legal situations, for example, dealing with minors, mature minors, age of consent, emancipation, common law marriage, durable power of attorney, and custody issues

• Persons younger than the age of 18 years, who ordinarily cannot enter into binding legal contracts. Mature minors. Persons 16 years or older but younger than the age of 18 years who have demonstrated the ability and capacity to manage their affairs and to live wholly or partially independent of their parents or guardians.
• Age of consent. The age at or above which a person is considered to have the legal capacity to consent to sexual activity.
• Emancipated minors. Persons who are usually at least 16 years old and are considered adults for several purposes, including the ability to enter into a contract, rent an apartment, and consent to medical care. Emancipated minors include those who are self-supporting and not living at home, married, pregnant or a parent, in the military, and who have been declared emancipated by a court.
• Common-law marriages. Sometimes called de facto marriages or informal marriages, these are arrangements by which couples are considered legally married without a having undergone a ceremony or a received a license.
• Common law marriages receive the same legal treatment as other types of marriages, including the fact that the couple must go through a divorce to legally end the marriage.
• Durable power of attorney. An authorization to act on someone else’s behalf in a legal or business matter
• Custody. A legal term describing the relationship between a parent and a child, including the parent’s duty to care for the child and make decisions regarding the welfare of the child.

• Therapists may be called on to participate in some legal and legally related situations as expert witnesses, child custody evaluators, reporters of abuse, and court-ordered witnesses.

• Expert witness
• family therapists may be asked to testify in court about probable causes and recommendations in regard to family members
• essential for therapist to remain objective, establish credibility, speak from authority, and be specific
• courts are adversarial, with one side seeking to affirm the testimony of the expert witness and the other side working to discredit the expert witness’s testimony
• Child custody evaluator
• family therapists may be asked to determine what is in the best interest of a child when making child custody arrangements
• child custody evaluators represent the child and the court, not the parents
• duties may include home visits, testing, and conversations with the child
• requires a background and experience in child development, family systems, parenting skills, psychometrics, counseling, and witness testimony
• Reporter of abuse
• when reporting abuse, family therapists are breaking confidentiality
• abuse reporting is mandated in all states
• Child Abuse Prevention and Treatment Act of 1974 established mandated reporting for the greater good of society
• it is recommended that family therapists advise the family when they are obligated to report abuse and to explain the reporting process
• Court-ordered witness
• family therapists may be asked to testify in court on behalf of or against a family or family member
• if subpoenaed, it is recommended that family therapists immediately seek the advice of an attorney to avoid pressures to take sides and to avoid penalty or perjury situations

Issues of Law in Family Therapy

• Malpractice – failure to fulfill the requisite standard of care because of ‘omission’ (what should have been done, but was not done) or ‘commission’ (doing something that should not have been done)
• negligence must be proven for a malpractice suit to be brought forward
• common malpractice issues include:
• advertising – most states place legal limits on practice titles and only professionals who have met specified criteria may call themselves ‘licensed marriage and family therapists’
• record keeping – clinical records must be accurate, kept secure, and maintained for a specified length of time
• “in camera review” of clinical records is when an impartial party, usually a judge, reviews records and releases on pertinent parts of the clinical record
• liability insurance is essential to protect therapists financially from legal claims that they have mishandled family needs or members

• Managed care and the process of therapy
  • third party reimbursement for private practitioners have changed from the traditional ‘fee for service’ health care system to a ‘managed care’ health care system
  • managed care systems were created to address a perception of overutilization of benefits and little accountability within the health care industry
  • managed care has resulted in changes for private practitioners
• the number of practitioners available to see families
• the length of treatment authorized
• the types of treatment received
• compensation rates
  • in managed care systems, limits are placed on the amount and type of services provided by close monitoring of services and changing the nature of approved services
• utilization review requires practitioners to submit written justification for treatment and comprehensive treatment plans that are submit to review and approval
• services not previously authorized or approved are not reimbursed
• capitated contracts, an emerging managed care method, are service contracts in which practitioners (called providers) agree to provide treatment for a population for a per person per year fee
• due to a high demand to minimize the number of sessions available for reimbursement, brief therapy, solution-focused, narrative, and strategic family therapy approaches have become common
• providers must be skilled in drafting treatment plans, following them, and providing evidence of treatment effectiveness
• care pathway guidelines have been developed that provide timelines and guidelines which address the decision making process, clinical services offered, and the potential interactions among multidisciplinary health care professions

Professional Identification as a Family Therapist

• Who are marriage and family therapists?
• AAMFT research on MFTs in the United States in 2004
• over 50,000 licensed MFTs
• 30,000 MFT trainees working toward licensure or completing coursework
• two-thirds have masters degrees, one-third doctorates
• half of the professionals work exclusively in private practice
• one quarter work in institutional or organizational settings
• one quarter work in both
• two thirds work full time; 21% work part time
• most clients are seen during normal business hours
• 73% also see clients in the evenings
• one third see clients on weekends
• mean salary in 2004 was $46,573, compared to the overall mean of $43,000 for the general population
• income varies greatly due to the diversity of settings, and other factors such as age and experience
• mean age is 54
• 60% of licensed MFTs are women
• 91% are white
• Who seeks marriage and family therapy?
• majority are women
• ethnic distribution closely resembles the general population
• 80% white
• 9% black
• 10% Hispanic
• 4% Asian
• 1% Native American
• 10% other
• children are overrepresented in MFT caseloads
• average session length is 59 minutes
• two thirds of clients were in therapy for less than one year
• treatment approaches
• 33% use cognitive-behavioral approaches
• 10% use multi-systemic approaches
• 6% use psychodynamic approaches
• 5% use Bowen family therapy
• 5% use solution-focused therapy
• most common presenting problems
• mood disorders
• couple relationship problems
• family relationship problems
• anxiety disorders
• adjustment disorders

• Organizations associated with family therapy
  • professional associations
• establish standards for the profession, including ethical codes
• provide a means for address grievances involving practitioners or the profession in general
• provide a means for practitioners to communicate with one another through conferences and publications
• provide opportunities for continuing education to keep practitioners abreast of current practices and issues
  • American Association for Marriage and Family Therapy
• oldest and largest (23,000 members)
• established in 1942
• focus on accrediting educational programs (COAMFTE)
• focus on advocating for MFT licensure at the state level
• publishes professional literature and videotapes
• Journal of Marital and Family Therapy
• Family Therapy News
• lobbies for MFTs, including recognition of MFTs as ‘core’ mental health providers
• American Family Therapy Association
• founded by Murray Bowen in 1977
• 1,000 members
• objectives are
• advancing systemic theories and therapies
• promoting research and professional education
• disseminating information about family therapy
• fostering the cooperation of all professionals concerned with the needs of families
• promoting the science and practice of family therapy
• membership categories include
• charter
• clinical-teacher
• research
• distinguished
• foreign
• annual conference to share ideas and develop common interests
• Division 43 of the American Psychological Association: Family Psychology
• established to enable psychologists who worked with families to maintain their identity as psychologists
• concerned with the science, practice, public interest, and education of psychologists who work with families
• annual conference
• The Family Psychologist
• Journal of Family Psychology
• according to L’Abate (1992), family psychologists differ from family therapists in three areas

1. family psychology is interested in the whole functionality-dysfunctionality continuum, while family therapy is mainly concerned with dysfunctionality
2. family psychology focuses reductionistically on the relationship of the individual within the family, while family therapy focuses holistically on the family as a whole unit or system
3. family psychology stresses objective evaluation and primary and secondary prevention approaches, while family therapy stresses the subjective understanding of the family and sees therapy as one type of tertiary prevention

• not everyone agrees with L’Abate and there continues to be debate on the identify of family psychology

• International Association of Marriage and Family Counselors
• a division of the American Counseling Association
• regional and national conferences
• established national training standards (CACREP)
• The Family Journal: Counseling and Therapy for Couples and Families
• IAMFC Newsletter
• produces training videotapes and publishes books
• established standard to credential MFTs
• National Council on Family Relations
• established in 1939
• the oldest professional association dedicated to working with families
• focus on education
• focus on disseminating information on family history, family forms and functions, and family life in a variety of settings
• Journal of Marriage and the Family
• Journal of Family Theory and Review
• Family Relations: Interdisciplinary Journal of Applied Family Studies
• annual conference
• Education of family therapists
• professional identity is linked to one’s education
• educational programs and processes are regulated by accreditation bodies
• Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)
• Council on Accreditation of Counseling and Related Educational Programs (CACREP)
• issues in the education programs in family therapy
• professional ‘in-fighting’ for recognition among accreditation boards and professional groups
• some professional groups refuse to recognize other similar groups
• current programs tend to ignore controversial issues or issues that are hard to teach (e.g., divorce, substance abuse, homelessness, teen pregnancies, extramarital affairs, impact of HIV/AIDS on family life)
• Issues in professional identification
• practitioners have many choices for professional organizations and alignment
• each professional association has unique aspects or foci
• friction continues to exist among associations dedicated to family therapy

Key Terms

action-oriented research research that focuses on finding solutions to a problem, such as spouse abuse.

administrative (regulatory) law specialized regulations that pertain to certain specialty areas that are passed by authorized government agencies, for example, laws governing the use of federal land.

American Association for Marriage and Family Therapy (AAMFT) the oldest and largest (23,000 members) professional family therapy organization in the world and dedicated to increasing understanding, research and education in the field of marriage and family therapy, and ensuring that the public’s needs are met by trained practitioners.

American Family Therapy Academy (AFTA) a non-profit organization of “leading family therapy teachers, clinicians, program developers, researchers and social scientists, dedicated to advancing systemic thinking and practices for families in their ecological context.”

autonomy in ethics, the right of individuals to make decisions and choices.

beneficience the ethical principle of first do no harm to individuals and work in their best interest.

bug-in-the-ear supervision method a supervision model where the therapist working with a family receives messages from a supervisor through a telephone hookup device.

camera review where an impartial party, usually a judge, reviews a therapist’s records and releases only those portions that are relevant to the situation at hand in a court case.

caring the idea that moral development and principles are centered in the social context of relationships and interdependency.

case law (court decisions) the type of law decided by decisions of courts at all levels from state to federal.

child custody evaluator a family therapist who acts on behalf of a court to determine what is in the best interest of a child in a custody arrangement.

civil law that part of the law that pertains to acts offensive to individuals. Law involving family therapists pertains primarily to civil law—for example, divorce.

common law law derived from tradition and usage.

consultation the use of a neutral third party experts in an area to enhance one’s own knowledge and abilities in that area.

criminal law that part of the law that deals with acts offensive to society in general.

Division 43 of the American Psychological Association (APA): Family Psychology a division of the APA established to enable psychologists who worked with families to keep their identity as psychologists. The division’s mission is to expand both the study and the practice of family psychology, through education, research, and clinical practice.

dual (multiple) relationship a relationship that is not built on mutuality and where a therapist assumes a second role, for example, being a friend, business associate, lover, and so on.

equitability the proposition that everyone is entitled to have his or her welfare interests considered in a way that is fair from a multilateral perspective. Equitability is the basis for relationship ethics.

ethics the moral principles from which individuals and social groups, such as families, determine rules for right conduct. Families and society are governed by relationship ethics.

family therapy supervision a systemic type of supervision that includes a focus on interpersonal as well as intrapersonal issues.

fidelity the ethical prinicple of being trustworthy and keeping one’s promises.

International Association of Marriage and Family Counselors (IAMFC) a division within the American Counseling Association that promotes excellence in the practice of couples and family counseling by creating and disseminating publications and media products, providing a forum for exploration of family-related issues, involving a diverse group of dedicated professionals, and emphasizing collaborative efforts with other marriage and family counseling and therapy groups

justice the ethical principle of treating people equally.

law a body of rules recognized by a state or community as binding on its members.

legal the law or the state of being lawful.

liability a legal term dealing with obligation and responsibility. A liability may be civil, e.g., dealing with professional malpractic such as negligence; criminal, e.g., dealing with the committing of a crime; or administrative, e.g., investigation from a licensure board.

liability insurance insurance that protects therapists financially from legal claims that they have mishandled a clinical situation.

malpractice the failure to fulfill the requisite standard of care either because of omission (what should have been done, but was not done) or commission (doing something that should not have been done). In either case, negligence must be proved.

National Council on Family Relations the oldest professional association dedicated to working with families. It was established in 1939, and many of its members helped to create and support the AAMFT. Throughout its history, the NCFR has concentrated on education. Its membership is interdisciplinary and includes family life educators, sociologists, family researchers, and family therapists.

neutrality literally value free; some family therapies pride themselves on operating around a neutrality framework. Critics of such a framework claim that all therapy has moral and political values. A neutrality stance has deep ethical implications.

nonmaleficence the avoidance of doing possible harm to a client from clinical action.

privileged communication a client’s legal right, guaranteed by statute, that confidences originating in a therapeutic relationship will be safeguarded.

professional self-disclosure statement a statement given to the family by the therapist that outlines treatment conditions related to who will be involved, what will be discussed, the length and frequency of sessions, emergency numbers, information about confidentiality and exceptions to it, and fees.

records remembrances in the form of written notes from sessions with couples and families. Records are important for treatment purposes and as a defense for the therapist if he or she is accused of wrongdoing.

relationship ethics Boszormenyi-Nagy’s term for ethics in a family that are based on the principles of equitability and caring.

statutory law that group of laws passed by legislative bodies, such as state and national legislatures, and signed by an authorized source, such as a governor or the president.

Classroom Discussion

1. According to Fishman (1988), in family therapy, some therapists work from an individual therapeutic approach in the presence of the family, or they work with family members individually. This type of treatment raises a value and an ethical question because problems of the family in such an arrangement are not being viewed from their “context as a whole.” Discuss the ethical issues involved in this type of treatment and why it is not considered an effective and/or ethical approach to family therapy practice.

1. Codes of ethics are guidelines developed by professional organizations to address issues confronting marriage and family therapists. However, there are few specific behavioral guidelines on what to do and how. As a result, determining the best course of action from simply reading the code of ethics may be difficult for both beginning and experienced family therapists. How can codes of ethics best be used by practitioners to insure sound ethical practice and quality decision making?

1. How does the considerable in-fighting among professional association groups impact the profession of marriage and family therapy? What would you suggest as strategies to reduce or eliminate this “turfism?”

Multiple Choice Questions

1. Relationship ethics refer to ethics in a family that are based on the principles of:
2. values and culture
3. equitability and caring
4. behavior and values
5. mutuality and complementarity

1. There are five primary models and resources for making ethical decisions. They include all the following except:
2. educational resources
3. professional consultation
4. action-oriented research
5. codes of ethics

1. The ethical principle of _____ goes beyond the avoidance of doing possible harm to clients and includes doing good and promoting the welfare of the client.
2. autonomy
3. nonmaleficence
4. beneficence
5. fidelity

1. The responsibility for maintaining confidentiality lies with
2. the client
3. the therapist
4. both the client and the therapist
5. none of the above

1. Multicultural competence is necessary to insure therapists do not impose their values on families. One way to avoid serious ethical errors in working with minority culture families is the _____ perspective, which identifies what is culturally significant from the family’s perspective rather than from a prescribed cultural perspective that may not be relevant to a family.
2. gender
3. neutrality
4. culturally relevant
5. interactional

1. When unethical behavior is observed, the behavior should first be
2. discussed with the person observed to act unethically
3. reported to the appropriate professional association
4. reported to the appropriate licensure/certification board
5. all of the above

1. Marriage and family therapists may be called to provide testimony in court. One role in which family therapists are asked to testify about probable causes and recommendations in regard to family members is called:
2. child custody evaluator
3. expert witness
4. court ordered witness
5. court advocate

1. Failure to fulfill the requisite standard of care when providing therapy services can result in
2. an “in camera review”
3. a malpractice suit
4. nonmaleficence
5. dual or multiple relationships
6. Most marriage and family therapists in the United States practice
7. full time
8. part time
9. some time
10. seldom

1. Most marriage and family therapy clients are
2. men
3. women
4. childless couples
5. deviant families

1. Most marriage and family therapists have a
2. bachelors degree
3. masters degree
4. doctoral degree
5. medical degree

1. The most widely used treatment approach by marriage and family therapists is:
2. Bowen family therapy
3. psychodynamic approaches
4. cognitive-behavioral approaches
5. solution-focused approaches

1. The professional association that focuses on accrediting educational institutions and advocating for MFT licensure at the state level is:
2. AAMFT
3. AFTA
4. IAMFC
5. NCFR

1. What are the two accrediting bodies for marriage and family training programs?
2. COAMFTE and CACREP
3. COAFTA and NCFR
4. CORE and CACREP
5. CAPA and COAMFTE

1. _____ results from a lawsuit by a client against a therapist for professional malpractice (negligence) or gross negligence.
2. criminal liability
3. civil liability
4. administrative liability
5. no liability

True/False Questions

1. Sexual relations between a therapist and a family member are never allowed.

True ___ False ___

1. Internet counseling can be a useful therapeutic medium for many client types, especially for hearing impaired clients and clients in remote areas.

True ___ False ___

1. In the legal system, attorneys affirm family members and work towards equitable resolution of family issues.

True ___ False ___

1. Modern practitioners understand that all therapeutic decisions are related to values and therefore therapeutic practice must be ethically neutral.

True ___ False ___

1. In the ethical decision making process, the first step is to consult with colleagues or an ethics case manager.

True ___ False ___

1. Using experts in an area to enhance one’s own knowledge and abilities is known as consultation.

True ___ False ___

Chapter 7

The Process of Family Therapy

Chapter Overview

Common Factors in Therapy

• Four common curative elements in psychotherapy
• extratherapeutic factors
• therapy relationship
• expectancy, hope, and placebo factors
• model and technique factors

The Personhood of Family Therapists

• Personal characteristics of family therapists contribute to therapy success
• Personal therapy can help resolve negative family of origin experiences
• Major stressors for family therapists include
• listening to client family’s problems
• less time for one’s own family
• unrealistic expectations for one’s own family
• psychological distancing from one’s own family due to professional status
• Enhancers for family therapists include
• increased ability to solve one’s own family problems
• acceptance of personal responsibility of all family members in contributing to family dysfunction
• greater appreciation of one’s own family
• increased desire and ability to communicate effectively
• Successful family therapists appear to have artistic qualities, (i.e., they are intuitive and feeling oriented)

Common Problems of Beginning Family Therapists

• Due to inexperience, beginning family therapists often overemphasize and try and do too much, or they underemphasize and fail to make timely interventions that might help the family
• Overemphasis
• overemphasis on details
• two primary components of family therapy are content (details and facts) and process (how information is dealt with in an interaction)
• beginning therapists tend to focus more on content rather than process
• content is essential but does not tell the whole story
• process questions (how the family interacts) are often more revealing than content questions (what, where, and when)
• redirection is a technique that asks the family to attend to the process and affective components of their interactions
• overemphasis on making everyone happy
• beginning therapists often are overly concerned that families leave their offices in a ‘happy’ state
• based on a belief that competent therapists help families solve their problems
• beginning family therapists may lack confidence and may be uncomfortable with confrontation and/or friction/disharmony
• family discomfort is sometimes unavoidable and can be productive and motivate families to change old behaviors
• overemphasis on verbal expression
• verbal expressions to families can be very helpful but often are not remembered and may have limited impact over time
• it is what the family and family therapist do, as well as what is said, that makes a difference
• a variety of therapist tools must be used for maximum impact such as instructing, commenting, asking questions, modeling behavior, role plays, assigning homework outside of the session
• both verbal and nonverbal expressions are necessary
• overemphasis on coming to an early or too easy resolution
  • families often report feeling better after discussing their situation for a few sessions even though they have not actually changed it
  • quick and easy resolutions rarely succeed
  • family therapy is an ongoing process that will vary for each family and families must be advised regarding time frames and expectations
• overemphasis on dealing with one member of the family
• families tend to scapegoat one member as the cause of the family problem
• family therapists must view the family as a system and the problem as lying within the family system
• family therapists must see the family as the unit of treatment, rather than one member of the family
• a systemic approach helps family members become more aware of their actions and how they personally contribute to both family health and family dysfunction
• Underemphasis
• underemphasis on establishing structure
• for therapy to be successful, therapy sessions must be conducted differently than the way families normally conduct their family life
• the battle for structure refers to the struggle by the therapist to establish effective rules for therapy
• the therapist must win the battle for structure so that the family will have a different and more productive experience rather than running the therapy sessions in their own nonproductive ways
• family therapists can inform families about the conditions under which therapy will occur by using a written professional disclosure statement or informed consent brochure
• fees and payment schedules
• theoretical orientations
• treatment approaches
• rules about appointments
• how to contact the therapist
• confidentiality and limits to confidentiality
• therapist qualifications
• risks of therapy
• family therapists structure the room by arranging furniture
  • to make it easy for family interaction to take place
  • to allow for family members to move closer or farther away from each other as necessary during the session
• underemphasis on showing care and concern
• beginning therapists may treat families more like objects than persons, thus increasing the family’s anxiety about therapy
• beginning family therapists may appear rigid and distant due to a lack of confidence and experience
• effective family therapists are caring, open, sensitive, and show concern and empathy
• SOLER is an acronym which describes effective interactive skills for therapists
• S means facing the family squarely
• O means adopting an open posture that is nondefensive
• L means leaning forward to show interest
• E means making good eye contact when appropriate
• R means to relax and feel comfortable
• effective family therapists make self-disclosures and use self-effacing humor when appropriate
• underemphasis on engaging family members in the therapeutic process
• systemic therapy requires joining with all members of the system
• it is important to spend time with each person in the system
• rapport and cooperation are increased by acknowledging each person’s importance to the family
• underemphasis on letting the family work on its problems
  • effective family therapists help families become motivated to make changes
  • help families to win the battle for initiative (the family’s motivation to change) by increasing their hope and the possibilities for change
• underemphasis on attending to nonverbal family dynamics
• nonverbal cues, such as eye glances, hands folded across one’s body, seating arrangements give essential information about family dynamics
• ignoring nonverbal family processes gives an incomplete picture of the family and can limit change if not addressed

Appropriate Process

• Therapists who do not plan properly are likely to fail
• Because family systems are complex, conceptualizing, planning, and implementing interventions also are complex
• How to conduct family therapy should be based on one’s impression of the family, one’s theoretical position, and one’s clinical skills

Pre-session planning and tasks

• Family therapy begins with the first contact with the family
• The family member who initiates the contact may be the one most interested in change and most open to engaging in therapy
• Initial contact is best made with the therapist rather than a receptionist so the therapist can answer questions directly, determine who should attend, and how sessions will be conducted
• Essential data is collected during the initial contact
• Ideally, the initial appointment should be scheduled within 48 hours of the contact
• Intake information should be used to develop an initial hypothesis about the family dynamics, life cycle stage issues, ethnic/cultural background, and initial diagnosis of the family problem
• A DSM diagnosis of an individual family member may be indicated but does not substitute for a diagnosis of relational problems from a systemic perspective
• Family therapists investigate the possible linkages within the family such as what happened, why did it happen, what can be done about it and how?
• Family therapists use diagnostic information to come up with a ‘case conceptualization,’ which is a way to comprehend more thoroughly what is happening with the family members as well as the family as a whole
• Case conceptualization is part of the planning process which helps family therapists integrate theory with practice and come up with a treatment plan

Initial session(s)

• The first few therapy sessions may be the most critical in terms of success
• Most families withhold judgment about family therapy for a few sessions to give treatment a chance to work
• Critical factors are a combination of structuring (e.g., teaching, directing) behaviors and supportive (e.g., warmth, caring) behaviors by the therapist
• The unit of treatment (i.e., the couple, the family, inclusion of children) is dependent on the theoretical approach used and the comfort level of the therapist
• Children are most often included when the therapist is comfortable with children, children are quiet, when the presenting problem is child focused, and with single parent families
• Join the family: establishing rapport
• the first step in the initial session(s) is establishing a sense of comfort and trust with the family, a process called ‘joining’
• failure to join with everyone is a common reason for unsuccessful treatment outcomes
• Inquire about members’ perceptions of the family
• begin by finding out how each family member perceives the problem
• family members organize their thoughts and behaviors around a ‘frame’ or perception/opinion which results in predictable patterns of interaction around the problem
• knowing how family members frame the problem, person, or situation helps therapists to challenge the family to redefine their perceptions and develop new ways of responding
• Observe family patterns
• families have unique ‘personalities’ and characteristic ways of interacting, often referred to as the ‘family dance’
• the following questions help family therapists determine how families function together
• What is the outward appearance of the family?
• What is the cognitive functioning in the family?
• What repetitive, nonproductive sequences do you notice?
• What is the basic feeling state in the family and who carries it?
• What individual roles reinforce family resistances and what are the most prevalent family defenses?
• What subsystems are operative in this family?
• Who carries the power in the family?
• How are the family members differentiated from each other and what are the subgroup boundaries?
• What part of the family life cycle is the family experiencing and are the problem-solving methods stage appropriate?
• What are the evaluator’s own reactions to the family?
• Assess what needs to be done
• assessment is usually done informally, through observation, although diagnostic instruments are sometimes used
• the assessment process involves determining what can and what should change to improve family functioning
• Engender hope for change and overcome resistance
• help families see that things can get better
• identifying family strengths and assets helps families recognize their potential for improvement
• almost all families exhibit resistance to treatment in some way
• controlling sessions
• absent or silent members
• refusal to talk with each other
• hostility
• failure to do homework
• coming late to sessions
• challenging therapist competence
• denial
• rationalizing
• family therapists need to understand the nature of resistance and overcome it without alienating family members
• depending on theoretical orientation and how resistance is being used by the family (e.g., fear, defiance), interventions may be chosen to overcome, avoid, or use resistance to produce change
• creating boundaries for the family can increase safety and interaction
• reframing can give a positive and different interpretation to the family’s resistance
• family therapists also use the technique of paradox to give families permission to do what they were going to do anyway
• regardless of approach, resistance must be addressed in order for treatment to move forward positively

• Make a return appointment and give assignments
• at the end of the initial session, the family therapist should take the initiative in offering to see the family again
• if future sessions have been agreed to, the therapist may assign the family ‘homework’ or tasks to complete outside the session
• homework helps families behave and feel differently and gives them practice time, intensifies the relationship between the therapist and family, and helps the therapist see how the family members relate to one another
• homework assignments must be clear and clearly understood by the family
• tasks should be practiced in session first if time allows
• Record impressions of family session immediately
• if not recorded immediately, impressions of families may become difficult to recall and may be distorted over time
• clinical notes should be used to record both content and process oriented information
• clinical notes can
• be studied over time to better understand processes and trends
• offer a place to reflect and be objective
• serve as a reminder of what has already transpired, avoiding repetitiveness
• a unique way of writing clinical notes is to write them in the form of a letter to the family about what occurred in the session

Middle phase of treatment

• This is a ‘working’ stage in which family therapists push family members to make changes and breakthroughs
• involve peripheral members
• make sure all family members are involved in the process of therapy
• invite the least involved member to be an observer of the family
• using the technique of circular questioning, ask the least involved member to comment on the different interactions of other family members
• use the power of the entire family to physically and verbally insist on participation by reluctant members
• seek to connect family members
• link individuals with common generational interests and concerns (e.g., siblings)
• support coalitions formed for connection, closeness, and growth
• break up inappropriate coalitions formed against other family members
• establish contracts and promote quid pro quo relations
• promote the benefits of relationship changes through contracts (e.g., in return for doing chores, special privileges are granted) or quid pro quo (something for something) in which family members benefit from their interactions together
• emphasize some change within the family system
• help families understand the change process by helping them see their current situation, options for change, consequences of changing or not changing, and the skills and commitment needed
• emphasize that change is often slow and that ‘baby steps’ now can produce larger changes over time
• small changes are less threatening to families and give them time to get used to behaving differently
• reinforce family members for trying new behaviors
• the most simple way is to use brief, verbal acknowledgments such as ‘good’ or ‘nice work’
• a goal is for family members to learn to give each other reinforcement
• stay active as a therapist
• successful family therapists are mentally, verbally, and behaviorally active with their client families
• few approaches to family therapy are passive
• family therapists, as a rule, do not count on insight as a primary basis for change
• family therapists are actively involved in creating change opportunities for families and do not wait for insight or spontaneous remission of symptoms
• link family with appropriate outside systems
  • family therapy success can be enhanced through appropriate referral to outside agencies
  • do not wait until the end of therapy to make referrals
  • Boszormenyi-Nagy stresses that healing and growth for families take place best when the total context in which families operate is included in treatment
• focus on process
  • focus on process instead of just content tends to produce change
  • changes occur over time
  • families tend to make the easiest changes first
  • family therapists must continuously engage the family in the change process
• interject humor when appropriate
  • humor can help change family perceptions from seeing their situation as a tragedy which results in hopelessness and paralysis
  • using humor does not mean making fun of families but helping them have fun and gain a different perspective on their situation
  • Frank Pittman says “If we are fully imbedded in our comic perspective, then we can bear all the reality life has to offer.”
• look for evidence of change in the family
  • closely observe the family for signs of both obvious and subtle changes
  • point out changes the family does not readily notice or acknowledge
  • discovery of changes may signal moving to the termination stage of therapy

Termination

• although it can be at times difficult to pinpoint the exact time to end or change therapy, termination should be a planned for part of the therapy process
• termination usually occurs for one of the following reasons
• the course of treatment has come to a natural end and there has been improvement (i.e., the goals have been met)
• the couple or family’s problem exceeds the skills/competency of the therapist
• the couple or family are no longer benefiting from therapy
• the therapist must leave their employment, temporarily or permanently
• the client family can no longer afford treatment and no viable alternatives are available
• the termination process involves four steps
  • orientation
  • summarization
  • discussion of long-term goals
  • follow-up and relapse prevention
• termination can begin by reducing the frequency of sessions
• a three session termination procedure
  • setting the date
  • next-to-the-last session
  • final farewell session
• rituals and tasks can provide meaning to the termination process and provide a forum to celebrate changes
• termination is often premature, with 40% to 60% of families dropping out before therapy is finished
• regardless of when termination occurs in the therapeutic process, it should take into account progress made and skills that can be used later

An Example of Appropriate Process in Family Therapy

• Initial Sessions
• joining and establishing rapport with family are foci of treatment
• family dynamics observed in regard to power, boundaries, coalitions, roles, rules, and patterns of communication
• importance of typical day and early recollections also important
• therapist engenders hope that change can take place
• Middle Phase of Treatment
• therapist concentrates on helping family members become more aware of their behaviors and to reorient, or become more motivated and want to try new behaviors
• Areas of difficulty include:
  • changes in perceptions, beliefs, values, and goals
  • changes in the structure and organization of the family
  • changes in the skills and social behavior of family through teaching
  • changes in the way indirect and direct power are imployed
    • Termination
  • begun with mutual agreement
  • family members encouraged to project ahead and discuss how they might address future problems
  • follow-up treatment is scheduled

Key Terms

battle for initiative the struggle to get a family to become motivated to make needed changes.

battle for structure the struggle to establish the parameters under which family therapy is conducted.

boundaries the physical and psychological factors that separate people from one another and organize them.

captitated contract a managed care method of cutting costs in which providers agree to provide treatment for a per-person, per-year fee.

care pathway guidelines instructions and directions in the managed care arena that delineate specific timelines in which diagnosis, interventions, decision-making processes, clinical services, and the potential interactions among multidisciplinary health care professionals should occur.

case conceptualization a presession exercise where therapists ask themselves certain questions about couples or families they are going to see in order to form an initial impression of their future clients. This procedure helps them integrate theory with practice and come up with a treatment plan.

circular questioning a Milan technique of asking questions that focus attention on family connections and highlight differences among family members. Every question is framed so that it addresses differences in perception about events or relationships by various family members.

content the details and facts.

distancing the isolated separateness of family members from each other, either physically or psychologically.

enmeshment loss of autonomy due to overinvolvement of family members with each other, either physically or psychologically.

family dance the verbal and nonverbal way a family displays its personality.

fee-for-service health care system a system where clients pay for services, such as family therapy, either directly or indirectly through insurance, without being accountable to a third party for specific ways of making interventions.

homework tasks clients are given to do outside of therapy session. Marital and family therapies that are noted for giving homework assignments are behavioral, cognitive-behavioral, psychodynamic, systemic, structural,and postmodern approaches.

informed consent brochure a brochure that includes all the information in a self-disclosure statement about therapy as well as a place for clients to sign off that they understand the policies and procedures involved.

joining the process of “coupling” that occurs between the therapist and the family, leading to the development of the therapeutic system. A therapist meets, greets, and forms a bond with family members during the first session in a rapid but relaxed and authentic way and makes the family comfortable through social exchange with each member.

managed health care a wide range of techniques and structures that are connected with obtaining and paying for medical care, including therapy. The most common are preferred provider organizations (PPOs) and health maintenance organizations (HMOs).

paradox a form of treatment in which therapists give families permission to do what they were going to do anyway, thereby lowering family resistance to therapy and increasing the likelihood of change.

process how information is handled in a family or in therapy.

professional self-disclosure statement a statement given to the family by the therapist that outlines treatment conditions related to who will be involved, what will be discussed, the length and frequency of sessions, emergency numbers, information about confidentiality and exceptions to it, and fees.

quid pro quo literally, something for something.

redirection where the therapist asks the couple or family to attend to the process of their relationship instead of the content of it.

reframing a process in which a perception is changed by explaining a situation from a different context. Reframing is the art of attributing different meaning to behavior.

resistance anything a family does to oppose or impair progress in family therapy.

scapegoat a family member the family designates as the cause of its difficulties (i.e., the identified patient).

SOLAR an acroym, each letter of which stands for the way professional skills may be shown. S stands for facing the couple or family squarely, either in a metaphorical or literal manner. The O is a reminder to adopt an open posture that is nondefensive. L indicates that the therapist should lean forward toward the client family to show interest. E represents appropriate eye contact. R stands for relaxation.

structuring behavior a general term in family therapy for describing the activity of a therapist in teaching and directing.

subsystems smaller units of the system as a whole, usually composed of members in a family who because of age or function are logically grouped together, such as parents. They exist to carry out various family tasks.

supportive behavior a general term in family therapy for describing the giving of warmth and care by a therapist.

triangulating projecting interpersonal dyadic difficulties onto a third person or object (i.e., a scapegoat).

utilization review the process in managed health care by which a therapist submits a written justification for treatment along with a comprehensive treatment plan to a utilization reviewer for approval.

Classroom Discussion

1. Successful family therapists appear to have artistic qualities (i.e., they are intuitive and feeling oriented). Explain how having artistic qualities are advantageous and give some examples of how they might be effectively utilized in family therapy.

1. It is widely believed that therapists who do not plan properly are likely to fail. How can therapists blend the need to be flexible, creative, and spontaneous with the structure and rigidity which can be a part of the planning process?

1. Resistance is defined as anything a family does to oppose or impair progress in family therapy. Why is it so important that resistance be addressed in order for treatment to move forward positively? What are some ways of addressing resistance?

Multiple Choice Questions

1. Beginning family therapists often overemphasize and try and do too much. All the following are examples of overemphasis except:
2. details
3. verbal expression
4. dealing with one member of the family
5. establishing structure

1. SOLER is an acronym which describes effective interactive skills for therapists. In this acronym, the “R” stands for:
2. relax and feel comfortable
3. establish roles
4. reframe
5. respect the family

1. Critical factors in the success of the first few sessions are:
2. verbal and nonverbal behaviors
3. structuring and supportive behaviors
4. assessment and data collection
5. orientation and summarization

1. In family therapy, establishing a sense of comfort and trust with the family is called:
2. hypothesizing
3. circular questioning
4. joining
5. engendering hope

1. Almost all families exhibit resistance of some kind during treatment. Which of the following is/are not an example(s) of resistance:
2. hostility
3. failure to do homework
4. silence
5. none of the above

1. Involving peripheral members and pushing family members to make changes and breakthroughs is a characteristic of which phase of treatment?
2. initial
3. middle
4. termination
5. none of the above

1. Termination from treatment is often premature, with _____ of families dropping out before therapy is finished.
2. 10% to 25%
3. 20% to 40%
4. 40% to 60%
5. 60% to 65%

1. Third party reimbursement for private practitioners has changed over time from a _____ health care system to a _____ health care system.
2. managed care system; fee for service
3. capitated; utilization review
4. fee for service; managed care
5. preferred provider organization (PPO); health maintenance organization (HMO)

1. In managed care systems, submitting written justification for treatment and comprehensive treatment plans is called:
2. utilization review
3. capitation
4. fee for service
5. care pathway guidelines

1. One way therapists can inform families about the conditions under which therapy will occur is by using a(n):
2. treatment plan
3. paradox
4. clinical note
5. written professional disclosure statement

True/False Questions

1. A common problem of beginning family therapists is the tendency to try too hard to make everyone happy.

True ___ False ___

1. While being a family therapist can be stressful, it may also give therapists a greater appreciation of their own families.

True ___ False ___

1. Family therapy begins with the first session as opposed to the first few sessions.

True ___ False ___

1. Reframing can be used to give a positive and different interpretation to the family’s resistance.

True ___ False ___

1. A common problem of beginning family therapists is the tendency to ask more process questions than content questions.

True ___ False ___