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About the Treatments

Anxiety
Family and Couple Therapies

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Techniques of Family Therapy: Systems (Contextual) Theory

 

One assumption of this framework is that “environment does not simply create experience; people also create their own environment in a changing world”.   This means that humans are active contributors of their own development, that is, individuals play an active role in their own development.

People construct what they know on the basis of their perceptions of relations between their actions and events, and not simply the events themselves; their previous belief systems; and the meaning that these events hold for their own well-being.

For example, children with different temperamental attributes, emotional states, psychological adjustment, or experiential histories formulate very different appraisals and interpretations of identical interpersonal situations, for example, the same marital conflict scenario.

 

That said, an example involving an acorn that’s dropped onto a forest floor which will meet its needs for growth into a pine tree if, and only if, the biological makeup of the acorn has sufficient health to grow with the sustenance that seems plentiful.

Used in assessment and treatment of a family of individuals by determining first how needs are met in the dyads, and then how the family functions as a whole. Below is a hypothetical example of family therapy using the constructs of need assessment and interaction of a family of four.  Although simplistic, the following example demonstrates the elements of system theory and its use in family therapy.

 

The different dyads in a family of four, two parents and two children, son and daughter, are as follows:  Father –son, father-daughter, mother-son, mother-daughter, and mother-father

Assessment of family dynamics starts with a description:  This is an upper-middleclass family living in Boston, Dad is a successful business man, quiet, has a lot of interests. e.g. traveling to his hunting and fishing destinations for long stretches of time, using his strenuous and demanding work schedule shows a workaholic and one who’s  seldom home for family events because he spends most of his time at his office or on his trips. The son can only recall a few instances of outdoor activities with his father.

 

The mother is a stay-at-home mom, very emotional and gets little attention from her quiet husband that does little with the family but spends a lot of time for himself. She once threatened that she’d leave him if he didn’t stop being a workaholic and not spend time at home. He got better at first, but fell back into his old patterns.

 

Communication with his children was empty of real emotional and personal involvement.  He was a quiet man that kept busy in the outside world, he expresses few positive emotions in the presence of the children.  Both children become drug addicts, and every time the daughter has to be hospitalized Dad becomes very attentive and emotional/worried even frantic about his daughter’s wellbeing. Otherwise, she left to live on the west coast with her boyfriend and still had crises with suicide ideation. Her brother is the one that is afraid for her, calls her to talk.

 

The son started using at 13 and was addicted to cocaine and alcohol for 17 years, with private rehab and hospitalizations experiences.  It was a near death combination of drugs and alcohol which got his father’s attention. The son is the identified client.

 

The dynamics of this family is analyzed by needs assessment in each dyad, to understand how needs fulfillment is different between child –mother, child-father, and mother-father.

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  1. Ask the daughter and son how they perceive who “mom and dad” are. What are they like?

  2. Dad is seen as only being available when his child becomes self-destructive which then leads to active planning for rehab by the father, showing his love to his son when at rehab, more show of love and

  3. What does your sister want from Dad that’s different from what son wants from him?

  4. Now a young adult and in therapy, the son has more insight that father’s love is not accessible until a crisis. He realized why he put himself in danger when using drugs. To be normal and satisfied does not bring about a nurturing relationship with the father.

  5. The daughter has lost hope in his ability to love her, so she’s moved away from her family altogether, although her brother still actively shows his love and support to her.

 

A synopsis of this dynamic is this: This is an example of the analysis and family therapy without the presence of the other family members.The individual therapy is the same for this young drug abuser because the therapist gathers family information used to obtain many of his emotional and behaviorally dangerous choices.Clearly, the family structure of unmet needs in each child, mother, and perhaps even father who ventures out of the family for fulfillment.

 

The crux of the therapy for this son is to understand how he perceives his father’s behavior towards him, his sister and his mother.He can now understand the anger although the son still cannot be openly enraged, he can now be openly disappointed and frustrated that his father would not invest in his first business venture.The only time he was honest with himself is once in therapy when he expressed rage that if it were for himself, he’d stop at nothing to get his wish whether that be for hunting excursions, etc which is what he wants. But not for his son.He would not trust the son’s judgment about the business and he rejected his son’s asking for money that would be a business loan to be paid back. But that release is kept in check in this family system because the son has a 17-year history of acting out when he becomes explosive and dangerous to himself, so they detach from one another instead. Many interpersonal relationships with guys and females are tinged with the father-son relationship.These are explored as well. This is a case about dangerous drug use and now abstaining. The therapy draws on the character that he developed in that system, his personality, how he treats females, how he treats men he works with, how he experiences himself and who is really is, and then he quietly expresses his underlying passion or perfectionism that runs his life.

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Couple Therapy: A very effective Cognitive-Behavioral Therapy modality using the Couple Questionnaire, an extensive questionnaire that elicits needs and expectations of fulfillment of every aspect of the relationship, past and present. This questionnaire is completed and kept private until therapy begins. They are not to discuss it out of the therapy sessions and the therapist is the moderator throughout the treatment.

 

The completed forms are kept in their clinical file and the topics are broad enough to provide clinical work for up to six months at which time the relationship becomes viable or it begins to fall apart.  The questionnaire is extensive and helps the couple to open their heart and mind to the material that each shares with the other.

 

The questionnaire starts with the marital history, length, number of children and their age, were there other marriages, how long have they lived together, are they engaged to be married? And they each describe other children from different marriages or intimate relationship.

 

The therapist can be a moderator but also acts as a therapist examining the psychological underpinnings of behavior, and the answers to why he or she is acting that way.  It’s during the times of conflict about what one partner as disclosed that the therapist expands or explains what the partner is trying to say or show.  The reasons why they fight are explained with the answers that they share with one another. They both learn about each other’s good side and bad side. 

 

For example, one partner habitually smoked marijuana which disturbed the wife.  The husband became reclusive when he was high and went to a room in the house separate from her.

 

Sampling the material from the questionnaire are topics, such as, the couple openly discussing –

-the qualities that initially attracted him or her to the partner,

-four negative concerns they initially had in the relationship,

-five present positive attributes of your partner,

-five present negative attributes of your partner, and so forth. 

-It identifies the present state of the relationship and whether she or he needed more or less from partner attributes. For example, need for kindness, etc.

-Which partner spends most time conducting the following activities in and out of the home, e.g. cleaning the house, auto maintenance, etc.?

-The couple identifies emotions after an argument, if they’re mild versus severe.

-List five expectations or dreams you had about relationships before you met your partner?

 

You can well imagine that at times during the marital therapy, one or both require an individual session to work on a personal problem that is inhibiting positive growth in the couple work.  They are informed that the individual session is private and their information is not shared when resume the couple work. Sometimes the content of individual work is something the person is hiding due to shame for fear which is better understood and then shared in couple work.

 

Overall this is the most efficacious CBT couple strategy I’ve experienced in my practice. Interestingly, I state that this therapy is useful for engaged people who want to test out the relationships potential.  One case was a couple that had already planned their wedding and by the end of the questionnaire they both decided that they would not marry because what they learned of each other led them to feel that they would never truly love each other and the marriage would fail.  They weren’t angry, they just felt like it couldn’t work, that their needs would not be met. They thanked me for the insights that they believe lead to having made a choice to separate on good terms.  

Pink Sofa

Behavior Theories

 

In the 1970’s Brooklyn College of City University of New York (CUNY) became the epicenter of animal research.  After the building of Henry James Hall, a who’s who of scientists were lured to a building accommodating spacious and well-equipped labs, each scientist had his own.  A graduate (M.A. or Ph.D. candidate) could not get an Experimental Psychology degree without being affiliated with a laboratory. The competition was keen to become a research assistant accepted by a famous scientist, e.g. Anthony Sclafani, known as “Tony”, Martin Deutsch whose name appears in most Introductory Psychology texts, and others. I had the good fortune to be accepted by Dr. Chin C. Lee whose interest in animal aggression became a focus of my two-year experimentation with aggression, and serendipitously, after an advanced degree in Developmental Psychology, the lifespan study of humans, began a lifetime of interest in the understanding of aggression in humans.

 

You would like to think that the study of behavior began with children, but it did not. Theories of children’s maladaptive behavior were studied in the 1920s and 1930s.  The findings showed that over time children have behavior problems, as infants they could display poor sleeping or finicky appetite mostly because the baby adjusting to the level of sleeping or eating depending on their appetite and tastes. As toddlers, aggression is first seen during play.  Each child wants the toy and the aggressive child wins; this can reinforce using aggression again and again, until the wise parent says “No, that’s not nice”.   The mother must intervene consistently with “No, that’s not nice” until the toddler or preschooler understands and can control her/his behavior.

 

It all began in research laboratories where behavior was defined as a pure science of stimulus-response, like, something in the environment (stimulus) causes a boy to start a fight (response).  Let’s say that a classmate teased a boy for failing a test, the boy’s feelings were hurt so he hit him in the playground. Because hitting (aggression) is not allowed, he is punished with having to apologize to his victim. Another example of a common problem in oppositional behavior in children is procrastinating on school mornings because they don’t like school (or so they say).

 

Behavior theories applied to children is a 20th century approach has a common sense approach that something in the environment is causing a reaction from the child. Or-just as likely- a environmental response is needed for the child to behave.  Behavior theory needs the psychologist to find the cause of the behavior problem by looking at the child’s environment, e.g. having siblings, a father that drinks, mother that is “mean” and unfeeling, love and acceptance are not expressed, by assessing what the child has learned from rewards and punishments by responses of parents, teachers, peers, etc.).  Good behavior theory uses elements of Freud’s theory of psychoanalysis to explain complex behaviors driven by some internal cause, rather than an external cause. A drunk father cannot pay attention or show caring to his son, so the child learns to misbehave to get his attention.  As children grow older with the drunk father, it is usually an internal cause that has fostered maladaptive behavior over time, depending on how sensitive the child is.

 

Animal research used experimental control to study the Stimulus (cause) and Response connection.   From the simplistic regimen of stimulus and response in animal studies, we learn several things.  If I deprive 20 mice of food for 12 hours, I will quickly train these mice to push a lever that delivers food; he will also learn not to push the other lever that does not deliver food.  Once we have controlled for food deprivation, bar pressing occurs because hunger (from deprivation) is a powerful reinforcer. 

 

Humans being complex, causes that are psychologically driven because of experience are harder to measure.  The boy learning what love is from a drunk father will have difficulties expressing love towards a person that loves him because the likelihood of being loved is not defined.  How could he know what behavior will result in being love.

 

It is my opinion that children that are disobedient and oppositional can only be successfully treated by Behavior Modification therapy, mainly because the oppositional child is developmentally immature displayed in their impulsivity.  The following is needed: Noncompliance must be defined, rational for treating noncompliance, important aspects of deviant parent-child interactions to find the cause of noncompliance.  This is accomplished by first interviewing the parents to study the dynamics of the family system and childrearing perspectives. Parent self-report scales are generally used.

 

Unfortunately, many parents whose child is oppositional may prove to have had a poor relationship with their parents, such that the dynamics of the family-of-origin was not a good learning experience. But many of those parents invested with love for their child will follow the regimen that will help their child to become a healthy social individual.   Next is the collection of observational data, the child individually and then the child with the parents to obtain the dynamics of how parent-child interact.  With this information a behavior plan will be written by the psychologist, parents will be trained with the behavior plan, data entry charts are provided as they use the plan of rewards and punishments to record the outcome.

 

The child in therapy displays maladaptive behavior that stand in the way of controlling behaviors at home or school as stated on the behavior plan which can cause a crisis from essentially being told that ‘behaviors that are no longer allowed will result in loss of reward or punishment’ and ‘behavior that is acceptable will result in a reward’.

At times, parent training is recommended for families that are clearly dysfunctional.

 

The goal of behavior therapy is to construct a world where impulses must be curtailed, and the drive towards rewards must be stronger than the drive to get negative attention.  Loving, patient, and consistent parents can make an impact on their troubled child.

 

Play Therapy (Used from preschool to adolescence)

 

Play therapy stems from psychoanalytic thinking based on Freudian and Neo-Freudian theories. In play behavior we have the seeds of both problem and solution.  In reality although play therapy approaches take longer to achieve, it makes sense that the child must find answers to those emotions, thoughts, and behavior that are grossly wrong for becoming a contributing member of society which will take more time than correcting a behavior. The length of therapy is based on the extent of psychological damage, the worst scenario is sexually or physically abused children that have no clue what is normal, acceptable behavior.

 

Through play which is not controlled, the child will express themselves by freely telling stories, which symbolically give details of bad and good, and at time acting out “having a melt down” to push away the therapy situation by showing she or he is in control (when in fact their life has been one of no control when they were younger or the present. 

 

The therapeutic alliance is very important in play therapy because a “safe haven” must be created in the environment between child and therapist. This means that trust must be attained in order for a child to open up. The therapist must be peaceful, observant to take the lead, symbolic or otherwise from the child.  Useful play therapy gives a child time, even if no constructive play is possible.  A six-year-old sexually abused child spent 40 minutes of the 45 minute  session screaming and writhing on the floor to my stoic, quiet, nonconverational method of allowing this child to express all her indescribable emotions that she had stored from three years of horrendous sexual abuse from the age of three. She was one of three children; shortly after her mother gave up custody of her, but her adoption was her reward.

 

Listening more and talking less is an ideal strategy, especially early in therapy when the child is learning who you are.  Note that, at times, a parent can sabotage the alliance by a child-like competition with the (a parental casualty is at fault here) and may explain the child’s insecurity because in her family, her mother has child-like needs and isn’t mature enough to care for her child.

The alliance between the parents and therapist must also be rendered with trust.  Empathy goes a long way when the mother herself has never experienced love and security.  The message I give is always the same to this population, that is, that the love of their child now is motivation enough which demonstrates a good strong loving spirit. Forgiveness used when there have been parenting deficiencies is very healthy and can override anger from past damage. The therapist can facilitate this heart-rending repair of the parent- child bond.

 

Cognitive-Behavioral Therapy for Impulsive Children

 

My comment on the use of CBT for impulsive children is meant more for its informational than my clinical use of it.  Theoretically CBT can be used for oppositional defiant disorder, conduct disordered children, Learning Disabled children, and children with attention-deficit-hyperactivity disorder (ADHD). It seems counterintuitive to plan process of problem solving in the populations of children mentioned here that are diagnosed with disorders where children do not have the capacity to plan, agree to problem solving techniques.  Maladjusted children lack social problem-solving skills. Essentially the therapist creates self-instructional procedures and the child reads them out loud which we assume will become a cognitive product. 

 

Example: “Let’s see, what am I supposed to do?”

            “I have to look for all the” possibilities

            “I better concentrate and focus in, and think only of what I’m doing right now”

            “I think it’s this one…”

            “Hey, not bad.  I really did a good job”

 

Or “Oh, I made a mistake. Next time I’ll try to go slower and concentrate more and maybe I’ll get the right answer”

 

Although it appears that it’s social learning, it may work for some children. The repetition of the script may help some children focus on the task. Problem-solving self-statements may engage children that are oppositional, attention-deficit, or generally impulsive because it slows down the steps to follow.

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