Breaking the race barrier

Through the reflective process of analyzing one's own feelings and reactions to the ethnic minority patient, the white therapist develops an inner clarity that serves as a resource to cope with the unique conflicts one must confront in interracial practice. Only when the therapist has come to some resolution of his or her own feelings about the plight of ethnic minorities in this country can this acumen develop. Although the therapeutic skills applied in psychotherapy with ethnic minorities are in no way different from overall therapeutic skills, certain techniques may be especially useful in interracial practice. For instance, a discussion of the meaning of race and ethnicity in the relationship may curtail racial distortion, prevent stereotyping, and lead to the creation of a therapeutic alliance. When dealing with transference and countertransference issues, the therapist must be particularly attentive to the representation of these same distortions and stereotypes. Formulating clinical problems from dual perspectives, theoretical and sociocultural, is an arduous, but necessary task. Finally, the white therapist must be able to view ethnic minority patients as individuals. Although these patients cope with special problems which must be acknowledged and dealt with in therapy, the therapist must realize there is a common ground on which to communicate. On this common ground, therapists discover the foundation of interracial clinical practice is the ability to accept and respect their patients and themselves as individuals who may have similar anxieties, problems, experiences, and goals. It is through the recognition and sharing of the fundamental human bond that ethnic and racial differences, which may have detrimental effects on interpersonal relationships, are transcended.     

Thinking About the Emotional Interaction of Therapist and Family

The emotional interaction of therapist and family has been difficult to explore within the field of systemic family therapy. This paper looks at ways of thinking about this process. As a starting point, I take some feelings I had with three families in the course of therapy. These are used to illustrate some concepts from analytic therapy which address the emotional interaction of therapist and family. The kind of theoretical space and guidance offered within systemic family therapy is then explored, and it seems that the Milan frame gives some space for thinking about the process but offers little guidance as to exactly how this might be done. This is a paper about practice, though it's primarily a theoretical discussion. There is no aim of establishing a ‘correct’ way of understanding the emotional interaction of therapist and family.     

Beginning Struggles with Families*

Beginning treatment with families is marked by a sense of struggle between the family and the therapist. The family is seen as testing the therapist and as asking through their behavior questions about the therapeutic process. The therapist is advised to focus intently on the beginning interviews, working toward the point where the family relaxes and decides on an intuitive level to enter therapy. The major hurdle is in dealing with the family's anxiety as the therapist attempts to shift the focus from the individual patient to the family as a whole. Strategy in establishing this shift is outlined     

Therapy of the Expectant Family: The Foetus as a Force to be Reckoned With

Over the past 30 years, there has been increasing recognition that pregnancy constitutes a crisis, not only for the pregnant woman, but also for the expectant father and siblings. The tasks facing the “expectant family” and the associated stresses are outlined. Expectant families present when one or more members find the stresses overwhelming, and a range of presenting problems is described. Guidelines for the therapist working with the expectant family are developed, highlighting the importance of acknowledging the existence of the foetus as a “family member” who can already exert a powerful influence on family system dynamics.     

Intervening in Family Systems with Observer Messages*

This article presents an approach to family therapy in which a group of observers becomes part of a therapeutic team by introducing strategic messages into the sessions. The observers, who operate from behind a two-way mirror, are thus able to effect change in both the family system and the therapeutic system consisting of family and therapist. Messages are described in terms of five components: function, target, timing, content, and delivery. Some guidelines for effective team functioning are given and three examples illustrate the approach. Finally, implications for training are discussed.     

Engaging Fathers in Family Therapy with Violent Adolescents

Violent behavior in adolescents can often signal profound distress or pain arising from family conflicts, hostile marital separations, sudden losses and other family turmoil. By circumventing blame the therapist engages the family in a constructive process that allows adolescents to change and grow and parents to share pain and sorrow about their own issues and responsibilities for their children. This re‐establishes healthy generational boundaries, produces a clearer co‐parenting alliance (e.g. after divorce) and creates sibling support. This paper describes an experiential approach, for working with violent adolescents in family therapy influenced by the pioneer work of Satir and Whitaker. It integrates systemic and developmental theories linking the presenting problem to relevant family events. The therapist: (1) explores adolescent development in the family and social context; (2) establishes a therapeutic alliance through understanding the interpersonal context for violent behavior, and (3) re‐directs negative actions into positive connections with family members. Segments of family therapy sessions with two adolescent boys and their families from different cultural backgrounds illustrate the impact of paternal absence for adolescent well‐being and the need to actively engage fathers in family therapy. Mario, the father's ‘tumor’, and Juan with his despairing violence are two problematic adolescents brought to therapy because of their aggressive behavior at home and/or in the school. The paper describes how to give them a different voice and build a therapeutic alliance with the family.     

Therapeutic Process as a Means to Navigate Impasse? Reflections on a Complex Case of Crosscultural Adolescent Family Therapy

This article explores the process of family therapy with a Turkish‐speaking single‐parent family with four children in which suicidal behaviour and family violence have become the norm. The following example describes a pivotal experience early within my career as a family therapist. The universality of first, being a beginner family therapist, and second, receiving a referral of a daunting, difficult case has led me to share my experience here. Central to this article is the focus on therapeutic process as a means to navigate beyond impasse. It is my hope that those who read this article will consider taking the risk to prioritise the therapeutic relationship, even when anxiety about ‘doing something’ to fix the problems is high.     

Projective Identification: A Request for Relationship

Projective identification is commonly recognized as a primitive defense. In group work with ego-impaired preadolescent boys with significant environmental deficits, projective identification is used to communicate a need for a relationship previously unavailable to them. These boys project unwanted aspects of themselves in order to have them contained by the therapist. They induce feelings in the therapist in order to share their internal experience. As the feelings are modified by the therapist and reintrojected by the boys, the boys receive the parenting they missed and are able to form more stable attachments.     

Affective disorders

Unipolar depressive disorders are especially common among persons presenting with marital and family problems, rendering their impact on the treatment of marital and family problems of interest to every marriage and family therapist. The current paper describes empirically based decision making rules for determining who may benefit most from marital and family therapy interventions. Using well-controlled outcome research, it is concluded that both marital therapy and parenting interventions can play an important role in the treatment of many but not all depressed persons. Predictors of treatment response are discussed and recent epidemiological research is used to examine the size of the population that may respond especially well to marital therapy. Future directions for research are suggested and public policy implications are discussed.     

Lost in Translation? Embracing the Challenges of Working With Families From a Refugee Background

This article describes the difficulties a mainstream family therapy service experienced in working with families from a refugee background. The experience of six therapists and five bicultural workers, who are also the referring agents, was captured in focus groups, and the reflections that emerged shaped a four‐part approach for working with families from a refugee background. Live consultation, either by the family therapist or bicultural worker, is suggested as a way to marry the expertise of family therapists who are not cultural ‘insiders’ with the ‘lived experience’ and cultural expertise of bicultural support workers. The process of reflecting on therapeutic failure resulted in several principles for working therapeu‐tically with families with a history of refugee trauma, unmet resettlement needs and family relationship challenges. These include maintaining a flexible approach to therapy, ascertaining a clear understanding of the referral context, defining an explicit therapeutic contract from the first session, being mindful of the important role that language plays and terminating therapy if it is contra‐indicated.     

The RELATionship Evaluation (RELATE) with therapist-assisted interpretation: short-term effects on premarital relationships

This study assessed participant satisfaction with two interpretation formats and the effects of taking the RELATionship Evaluation (RELATE) on single young adults' premarital relationships. Thirty-nine engaged or seriously dating couples were assigned to one of three groups: (a) those who took RELATE and interpreted the results themselves, (b) those who took RELATE and participated in an interpretation session with a therapist, or (c) a control group. Results showed that taking RELATE with therapist assistance had a significant positive effect on perceived relationship satisfaction, commitment, opinions about marriage, feelings about marriage, and readiness for marriage. Positive effects also included increased awareness of strengths and challenges, improved couple communication, and the expectation of the prevention of future relationship problems. Taking RELATE without therapist assistance produced a small initial drop in relationship satisfaction followed by a marked improvement over time. Both genders approved of two interpretation formats-self-interpretation and therapist-assisted interpretation-with males slightly preferring therapist assistance. These results add to the literature on the usefulness of brief assessment techniques as effective interventions with premarital couples.     

The ‘Not to be Opened’ Letter: Family Secrets,Hidden Knowledge and Violate Prohibitions

This paper presents a view of family secrets that is informed by their broader biological and cultural context. Two particular perspectives are employed. First, Bateson's biologically-based concept of ‘sacred knowledge’ is extended to apply to human cultural practices, such as the ban on certain forms of intergenerational instruction. Second, the anthropological concept of ‘taboo’, as expressed in cultural practices, myth and folklore, is used to provide insight into the mixture of awe and disgust which surrounds secrets, and into the possibilities for both positive and negative outcomes when prohibitions are violated. From these complementary viewpoints, the author explores why family secrets arouse such intensely polarised feelings in helping professionals as well as in family members, and suggests more morally neutral frames within which therapists might view secretkeeping behaviour. A case illustration is used to illustrate potential problems with the assumption that secret knowledge should always be shared across generational bound-aries. Finally, the ‘not to be opened’ letter is introduced as a therapeutic option in cases where the clients and/or the therapist are unclear about the wisdom of revealing a particular secret.     

Juvenile anorexia nervosa: family therapy's natural niche

Juvenile Anorexia Nervosa (AN) is a severe problem both in terms of presenting symptomatology and its tendency toward chronicity. Researchers have consistently shown that family-based approaches are superior to individual approaches for the treatment of juvenile AN. This article addresses the capacity deficit of trained family therapists to treat this disease. The author reviews the effectiveness of Structural Family Therapy as a treatment of juvenile AN and the essential concepts and skills required by the family therapist to treat this disorder. The concepts of therapeutic crisis induction, enactment, and therapeutic intensity are discussed in detail. Recommendations are made for future research.     

Family Therapy with Adolescents: Giving Up The Struggle

This paper examines problems in adolescence from the perspective of a power struggle between parent(s) and teenager. The structural approach of Minuchin and the strategic approaches of Haley, Madanes, and the Mental Research Institute (M.R.I.) are considered in relation to the significance they attribute to power and power struggles in families with adolescents. It is argued that the M.R.I. approach has certain therapeutic advantages for working with problematic adolescents, primarily because of its focus on understanding and intervening in the power struggle itself. A focus on the power struggle as the ‘problem’ reminds the therapist of the circular nature of parent-adolescent interactions. This awareness assists the therapist to design indirect interventions that are less likely to become absorbed into this vicious cycle. It also encourages a therapeutic stance that prevents the therapist from becoming involved in a power struggle with family members.     

Family therapy and terminal illness

Abstract

This article describes the experience of a family therapist working in a family with an adolescent child suffering from a terminal illness. This work was undertaken in the framework of the Mexican Institute of Social Security.

In dealing with patents afflicted with incurable diseases such as renal deficiency, osteosarcoma or leukemia, which will eventally lead to death, it is important to know about the successive stages in this progression from life to death and to understand them. Some authors have studied in general the reactions of the dying and their families. Kubler-Ross (1970) reports denial, resentment, bargaining, depression and acceptance; Eric Lindemann (1944) mentions pain, anxiety, tension and guilt as the main components of mourning.

Psychotherapy with the terminal patient and their family is intimately concerned with the separation process, which is always accompanied by anxiety; this can become so acute that it feels like death or total annihilation. The family responds in many ways to this anxiety, but will often not express these feelings; the therapist has to try to discover at which stage of mourning the family has arrived. This is even more important where the patient is an adolescent who has no hope of achieving his longing to live. It is important that we are dealing here with anticipatory mourning, which can prevent serious reactions following bereavement. Great care is required in uncovering feelings of hostility, anger, fear, repulsion and frustration. The patient too must be encouraged to express his feelings; this will relieve tension, and make it easier for the family to accept the reality of what is going to happen.

It is important to keep the family informed about the medical requirements of the treatment. These should be explained very clearly, so that all members understand, accept and cooperate in such tasks as ensuring attendance at out-patient consultations, laboratory investigations and taking the medicine prescribed. We find that often only one member of the family, usually the mother, carries the whole responsibility of caring for the patient. All these matters need to be discussed with the whole family, together with such matters as the patient's school attendance, any problems of family relationships, and plans for the future. The worker needs to help family members to continue their personal growth and development while understanding this crisis, which might otherwise arrest them.

Treatment should not be rigidly planned at the start; as in all psychotherapies, it is necessary to make an initial evaluation of the degree of function and dysfunction in the family. This appraisal is made by exploring family problems, areas of conflict and the resources which are mobilized to support the system. In this process the worker collects all the elements which enable him to get a picture, free from his own technical preferences, so that the data can be integrated, taking into account the opinions of experts on structural family therapy, triaxial or psychodynamic views among others.

In the case I shall describe, we used a combination of theories and techniques, mainly derived from systems theory and psychoanalysis. A purist attitude was not adopted, because our main aim was to find what was of most immediate benefit to patient and family.     

Child-Oriented Family Therapy Outcome Research: Comparisons Between Brief Family Therapy and an Alternative Treatment

This paper is concerned with outcome research in child-oriented family therapy. Nine investigations comparing brief family therapy with an alternative treatment were critically reviewed. All of the studies were vulnerable to criticisms on design and methodological grounds. Problem areas included: specification of therapeutic techniques, confounding of therapeutic variables, equivalence of therapist factors, measurement of outcome, adequacy of measures and appropriate use of control groups. All studies concluded that childhood problems could be treated successfully with brief family therapy techniques. However, in the light of the design problems listed above, these conclusions should be treated tentatively.     

Live Consultation Without A One-Way Screen†

This article is about a method of teamwork in which both the therapist and the consultant are present in the same room as the family. It distinguishes between the therapeutic team of consultant and therapist and the therapeutic system of consultant, therapist and family. It outlines some particular advantages and disadvantages which are present when working in the same room as the family and emphasises the importance of the careful preparation and maintenance of the therapeutic team if its creative potential for the family is to be fulfilled.     

Countertransference,resistance and frame management in the psychotherapy of a 15 year old anorexic and her mother

Countertransference is a rich source of understanding of client dynamics but can be difficult to detect. A case vignette is used to illustrate how changes in the arrangements of therapy should be viewed as red flags alerting the therapist to possible countertransference. By paying careful attention to the client's derivative response to the therapist's agreeing to a request for a change in appointment times, the therapist was able to understand the unconscious motive behind the request, as well as her own countertransference reasons for participating in the resistance expressed in the request. When, based on this under-standing, the therapist was then able to hold to the framework and maintain the previous appointment schedule, this furthered the treatment by providing a model for introjection and by promoting understanding rather than acting out. In complicated therapy situations where treatment of more than one family member by a single therapist is indicated, such careful attention to the framework and to the client's derivative response to the therapist's interventions is particularly important.An earlier version of this paper was presented before the Annual Conference of the Washington State Society for Clinical Social Work on May 14, 1984.     

La metafora: the power of metaphors and creative resources in working systemically with families and children with autism—a conversation with Carmine Saccu

Metaphors are valuable tools of expression, which give meaning to situations and allow the spontaneous processing of feelings and emotions. As therapists, we can support clients to develop and create their individual metaphor to explain their own meaning of experiences or communicate their perception of problems. Creativity provides us with a rich landscape to explore, expand, and enrich ourselves as therapists and consequently our clients. As systemic therapists, we are responsible for the co-creation of a human process, which has at its core safety in allowing expression, connection, and movement. Through a respectful and curious approach, we can develop pathways to tap organically into our ‘creative selves’ while reaching into our clients' creativity and selves as catalysts for connection and positive change. Creative resources and therapies have been successfully used in psychotherapy to enhance the mental and emotional well-being of children, particularly children with autism who have limited verbal capacity or who are non-verbal. These children also wish to be understood in expressing their thoughts and feelings; however, they use other methods of communication – sometimes obvious, sometimes not. Therefore, it is important that a therapist can access diverse ways to support the child through this process. The creative use of animals in therapy neutralises spaces, eliciting calm, safety, and healing. This is particularly the case when working with this group of children. This paper is derived from my conversation with an elder statesman of the family therapy profession, Professor Carmine Saccu. He is a jovial master storyteller who craftfully communicates via metaphors. Through creative means, play, and humour, he has developed a remarkably unique way of working with children, especially non-verbal children with autism. He uses his canine, co-therapist Mafalda, as a powerful resource and intervention strategy to safely elicit engagement and connection in the therapeutic space.