A Systems-Crisis Approach to Family Treatment

This paper presents a model which integrates a wide range of possible interventions using family treatment and provides a method of differential decision making with regard to the intervention to be used in a given case. The model uses an ecological perspective and draws on concepts from general systems theory and crisis theory. A number of case examples are provided to demonstrate how the model has been applied in a clinical setting.     

Dialectical Behavior Therapy

SUMMARY

This chapter provides an overview of Dialectical Behavior Therapy (DBT), an evidence-based outpatient treatment developed for suicidal women with borderline personality disorder (BPD), and since adapted for other settings and populations. The chapter introduces the biosocial theory of the etiology of BPD and how DBT addresses each aspect of the disorder. It further describes the theoretical foundations of DBT in behaviorism, Zen and dialectics. The reader learns about DBT structures of treatment and what client behaviors are targeted in each stage of treatment. Finally, the chapter uses a clinical case example to illustrate how a therapist would get started with a new client using DBT.     

Treatment Choices in a Managed Care Environment: A Multi-Disciplinary Exploration

This article reports the results of an exploratory study to determine how managed care is influencing mental health practice from an inter-disciplinary perspective. Using two case vignettes, respondents were asked about how they would classify presenting problems and treatment strategies within the context of two scenarios: (1) managed care and its limitations, and (2) fee-for-service/private pay. Findings suggest that managed care has a significant influence on case assessment and treatment planning across the mental health disciplines. Although respondents did not favor adjusting treatment approaches to meet managed care expectations, they nevertheless did so. Findings also substantiate managed care's negative impact on earnings and job satisfaction. These preliminary results begin to address discipline-related cost effectiveness from the perspective of practitioner treatment choices and preferences and highlight the perceived incompatibility between preferred practice and the dictates of managed care.     

THERAPIST-CONDUCTED CONSULTATION: USING CLIENTS AS CONSULTANTS TO THEIR OWN THERAPY

Using qualitative research methodology, the authors developed an in-session therapeutic procedure called the therapist-conducted consultation (TCC) which is designed to enhance the therapist-client collaborative relationship. In the TCC, the therapist and client(s) relinquish their traditional roles and discuss the client's treatment. During this process, clients are invited to (a) share their perspective of treatment, (b) assess whether treatment is meeting their goals, and (c) suggest how treatment could change to improve their experience. The three-stage model of the TCC that resulted from the research is presented with a case example.     

When the going gets rough ... difficult points in treatment: Identification,exploration and working through (panel)

This paper is a summarized report of a panel presentation made by three analysts on the topic of resolving difficult points in the treatment of three of their patients through the understanding of countertransference and transference issues. The first analyst presented a case in which a stalemate was broken by addressing three different kinds of countertransference. The second presenter addressed an impasse in the treatment of her drug addicted male patient which was caused by positive transference and countertransference. The third analyst discussed the resolution of a critical point in the third year of treatment of a female patient which was uncovered by addressing the parameter of appointment scheduling. The candor and honesty of these presentations takes the reader into the heart of practice issues and illustrates how stalemates are resolved and treatment deepened. Audience reaction indicated that more such presentations which illustrate how analysts really work would be welcome.     

Therapists’ Assessment and Treatment of Internet Infidelity Cases

In this study, we investigated through an Internet survey of 508 practicing marriage and family therapists which treatment decisions varied by gender of the client and background variables of therapists. The subjects responded to several typical Internet infidelity scenarios. We varied the gender of the person initiating the infidelity for half of one sample. We also asked the family therapy participants to respond to how they might assess and treat each presenting problem. They also evaluated problem severity, prognosis of the case, number of sessions necessary for treatment, and the extent to which a therapist would focus individually or relationally. Results indicate that there were differences in how therapists assessed and treated clients based on client gender, therapists’ age, therapists’ gender, how religious therapists reported they were, and the extent of therapists’ personal experience with infidelity.     

Separation-individuation and speech and language development in the psychotherapy of an atypical child

Children with psychiatric disorders often experience speech and language problems, however, the association between the two is not fully understood. The literature lacks explorative case examples to suggest how attention to language and speech difficulties may serve as a vehicle for diagnosis and intervention. A case study is presented to examine psychother-apeutic techniques and activities to improve psychic structuring and attendant communication skills in a child. Speech and language concepts and the affect induced by the child in the therapist serve as major organizers to demonstrate how therapy proceeds within Mahler's stages of separation-individuation.The treatment of the child occurred during a Post-Master's Fellowship Program at the Institute of Living, Dept. of Child Psychiatry under the supervision of Michael Hayes, M.S.W. Ms. Streit is in private practice, but currently on leave in Adelaide, Australia.     

How Routine Patient‐Centered Monitoring Relates to Therapeutic Gains in Family Therapy: A Single‐Case Study

As routine outcome monitoring systems develop, questions emerge about how therapists incorporate feedback into their practice, and how this relates to therapeutic gains. A case of covert grief was monitored in each session with the Personal Questionnaire and the Helpful Aspects of Therapy instruments. At 4 months follow‐up, the Change Interview was administered. Individualized items facilitated access to the private views and needs of each member, which was useful for case formulation and ongoing personalization of the intervention. Qualitative feedback of treatment experiences helped therapists confirm the impacts of interventions, monitor therapeutic alliance, reformulate clinical hypothesis, and plan sessions. Therapists followed a critical triangulation process to decide the clinical meaning of feedback, according to his/her intervention model, expertise, and case‐specific context.     

"THE STORY" OF A DEATH: THERAPEUTIC CONSIDERATIONS WITH BEREAVED FAMILIES

Facilitating and listening to bereaved families tell "The Story" of their loss is an important component of therapeutic work with bereaved families. Following a discussion of the general functions of stories, the authors use a variety of case examples to illustrate how "The Story" can be used as an assessment device, as an initial intervention, and as a gauge of the progress of treatment. Family stories of loss are conceptualized as constructions, and the emphasis is on how individual and family context affect and are affected by these stories. Throughout the paper, particular attention is paid to ways stories canbe useful for children in families.     

Projection and Misperception in Couples Treatment

Projective identification is discussed as an interpersonal mechanism involved in distortions of perceptions and communications. Several case illustrations are presented to show how this mechanism manifests itself in relatively healthy, though neurotic, couples. A treatment approach based on correction of the perceptual distortions is suggested as a model for short-term counseling with such couples.     

Long Distance Psychoanalysis

This article describes a psychoanalytic treatment that was conducted, in large part, by telephone. In this case, the dilemma of how to make contact with a schizoid patient without intruding intensifies when treatment shifts to the phone. The patient's dissociated feelings of dependence are enacted in the transference-countertransference dynamic. A holding environment is re-established, enabling dissociated experience to be integrated. The telephone's simultaneous separateness and connection provide a transitional space in which to work on ambivalence about dependency. The patient moves from communicating through dissociative projections, enactments and physical contact toward verbal symbolic communication.     

Mitchell's Relational Conflict Model: An Analysis of Its Usefulness in Clinical Social Work

This article examines the relational conflict model developed by Stephen A. Mitchell. The main concepts of Mitchell's relational conflict model are discussed, particularly early patterns of connection to parental figures and the interactive treatment approach to understanding and changing those relational patterns. The model is contrasted with classical drive and developmental arrest theories in the psychodynamic treatment of psychopathology. We explain how Mitchell's model, in keeping with a social work perspective, takes into consideration the social, cultural, and environmental factors as well as the intrapsychic. We discuss how patterns of relating are reworked throughout the life course, and we explore the potential for individual agency in constructing new patterns of relating. We also highlight the social constructivist aspects of Mitchell's approach which are congruent with current contemporary trends in social work theory. A case vignette is presented to illustrate the viability of this model for clinical social work practice.     

The importance of volitional narrative in treatment: An ethnographic case study in a work progran

The revised theory of the model of human occupation expands the concept of volition to include volitional narrative. This paper focuses on the application of this theory of volition to a client's experience in a work program. This ethnographic case study describes the volitional narrative and life world of one client who attended the occupational therapy work based program. For fifteen months the client was the subject of narrative interviews, participant observation, videotapes and telephone contacts. The findings will illustrate how knowledge of a client's volitional narrative and life world can shed critical light on understanding treatment conflicts. Finally, the discussion will underscore how important it is for work based programs to be designed to encourage therapists to adapt their treatment approaches to maximize the opportunities to seek out the client's volitional narratives and to create meaningful experiences that are consistent with the client's life world.     

USING SOCIAL NETWORK INTERVENTIONS TO IMPROVE MENTALLY ILL CLIENTS’ WELL-BEING

This paper reviews empirical evidence showing that the structures of the social networks of mentally ill clients influence both their well-being and their use of mental health services. Network interventions that might help clients better address network-related problems, and might help their families improve relationships and prevent caretaker’s burn-out are presented. A case illustration will demonstrate how practitioners can assess a client’s social network, involve the client’s family in treatment, evaluate that treatment, and select tailored interventions. This case will emphasize both how practitioners can help a client restructure her network, and the complementary roles of formal and informal networks. The author shows practitioners how to match clients’ initial network structures to interventions and desired outcomes. Practitioners can thus help clients modify their social networks, increase the use of preventive services, and improve their well-being. Dr. Pinto has been supported by a training grant from the National Institute of Mental Health (732MH19139, Behavioral Sciences Research in HIV Infection; Principal Investigator, Anke A. Ehrhardt, Ph.D.) at the HIV Center for Clinical Behavioral Studies for Clinical and Behavioral Studies.     

A spiritual framework in incest survivors treatment

Through an examination of recent incest treatment development, this article emphasizes the theoretical concept of integration within the treatment process for female adult incest survivors. Spirituality as a therapeutic foundation is discussed with examples of therapeutic techniques. A case study illustrates the psycho-spiritual process of treating a 29-year-old female incest survivor and describes how self-integration has helped this client heal from trauma and change her worldview. Significant outcomes of treatment include the client's gaining of self-awareness and freeing herself from emotional blindness. The recommended practice framework includes a three-step healing process of building alliance with the client in a safe environment, disputing faulty religious assumptions in a learning process, and affirming the needs for reconnection and continuous spiritual support.     

Teaching Trauma Theory and Practice in MSW Programs: A Clinically Focused,Case-Based Method

Social workers provide much of the mental health treatment in the United States, and, given the ubiquity of trauma, most clinical social workers will provide treatment to trauma survivors during their careers. Therefore, trauma theory and practice must be included in MSW curricula and taught as a clinical course. This paper suggests that experienced clinician instructors teach trauma theory and practice classes using a case-based method. Bringing case material into the classroom helps prepare students for the complexities and challenges of treating survivors of trauma. To demonstrate how cases can help students connect theory to practice, the paper presents the treatment of a Central African asylum seeker recovering from trauma. The case emphasizes the centrality of the therapeutic relationship and illustrates the use of several evidence-supported trauma interventions along with core principles of social work practice. Finally, the paper suggests that social work educators consider developing a structured method of integrating cases into the trauma curriculum.     

Attachment‐Based Family Therapy With a 13‐Year‐Old Girl Presenting With High Risk for Suicide

This article describes the application of Attachment‐Based Family Therapy (ABFT) to the treatment of a 13‐year‐old female adolescent presenting with high risk of suicide, complicated by a history of depression and sexual trauma. The article begins with an overview of ABFT, including (a) how attachment theory guides treatment; (b) the structure of the clinical model; and (c) the data that provide empirical support. A case example is then presented that exemplifies the primary clinical procedures used to reach therapeutic goals in ABFT, including attachment repair and autonomy/competence promotion. Weekly changes in suicide ideation and depression scores are presented. The article concludes with a discussion about implications for family‐based treatment of suicidal youth.     

Integrative module-based family therapy: application and training

The field of marriage and family therapy is currently at a crossroads. The challenge for contemporary therapists is how to incorporate the wisdom of previous models with the accountability that comes from evidence-based practice. The Integrative Module-Based Family Therapy treatment model provides a formalized series of steps that clinicians can use in their case planning and implementation. It is based on nine clinically relevant modules for assessment and intervention that are consistent with current best practices and empirically supported treatments. It thus meets the need for a structured family therapy practice and training approach that is respectful of the "art" of family therapy while still adhering to the principles of the "science" of evidence-based treatment.     

Sociologists on trial: Theoretical competition and juror reasoning

This paper examines the work of sociologists as expert witnesses and how sociological theory is used in criminal trials. The study describes how alternative sociological theories were propounded by sociologist expert witnesses and used by competing lawyers to establish the correct understanding of the case. The paper indicates that the sociological testimony was relevant to the deliberations and verdicts and details how the judge’s and jurors’ practical treatment of the law and evidence reconciled the adversaries’ mutually exclusive, partisan positions and the theoretical bases for those positions.