Family Counseling Notes

Presenting Problem

  • Definition: The reason a family seeks counseling, as identified by the family members themselves.
    • It's an issue, specific event, or series of events that have caused changes in thoughts, feelings, or external consequences, leading to emotional pain.
    • Family members may have differing perspectives on the presenting problem.

Identified Patient

  • Definition: The family member whose behavior or mental state is the primary concern, motivating the family to seek help.
    • This member may be acting out (behavioral issues with consequences) or acting in (internalizing, seeking mental care).
    • Important for insurance purposes to identify the patient, their diagnosis, and the services provided.

Launching

  • Definition: The stage when young adult children leave home.
    • This significantly impacts family dynamics.

Family Counseling Assessment Process

  • Why Now?:
    • Determine the urgency and recent events prompting the family to seek immediate help.
    • Explore previous attempts by the family to address the issues.
  • Family Goals for Counseling:
    • Identify individual goals, which may be contradictory.
  • History of Presenting Problems and Identified Patient:
    • Track the problem's evolution, changes, and improvements over time.
  • History of Nuclear Family
  • History of Extended Family:
    • Inquire about the history of mental health issues or other relevant patterns.
  • Social Supports:
    • Assess the family's connectedness to friends and other support networks.
    • Determine if they are socially isolated.

Nuclear Family

  • Definition: two parents and their direct children (biological, adopted, or stepchildren).

Extended Family

Function of Family

  • Producing children
  • Socializing children
    • Teaching social norms, expectations, relationships, gender roles, and information about societal systems.
  • Unit of economic cooperation
  • Significant roles:
    • Wife, husband, parents, children, sibling.
    • Provides a source of intimacy, security, stability, and protection.

Psychological Roles and Characteristics

  • Sense of mutual commitment (time, energy, money).
    • Dedication of time and energy to serve the greater good of the family system.
  • Sense of history and continuity.
    • Sharing stories, family folklore, inside jokes, family trips, and important events to create stability.
  • A potential for and expectation of long-lasting relationships.
    • Commitment for the long haul, through thick and thin.
  • Extensive and intense relationships.
    • Multidimensional and intense emotions.
  • Responsibility for the welfare of each other.
    • Parents caring for children and children caring for each other and their parents as they age.

Recent Societal Changes

  • Smaller families / fewer kids.
  • Increase in single-parent households.
  • Rate of divorce on the rise.
  • Advancements in medical fields.
  • Less necessity for a double-parent household.
  • Increase in grown children living at home with parents (boomerang children).
    • Due to economic factors.
  • Increase in older adults living alone.

Family Life Cycle

  1. The Unattached Young Adult Leaving Home
    • Overview: Young adults leave the family and venture out on their own.
    • Erikson’s Stage: Intimacy vs. isolation.
    • Major Developmental Task: Creating and maintaining an identity separate from the family of origin.
  2. Joining of Families Through Marriage or Committed Partnership
    • Major Developmental Task: Adjusting to the new demands inherent in the new living situation with a partner or spouse.
      • Adjusting (moving in with one another).
    • Features of the Stage:
      • Conflict, compromise, negotiating roles and rules.
  3. Families with Young Children
    • Overview: Couples accept a new person into their dyad.
    • Complexity: Multiple stages of development combining (family cycle, couple cycle, individual cycle for each adult, child cycle, cycle for family of origin for each partner).
    • Major Developmental Task: Renegotiating roles, rules, and relationships.
  4. Families with School-Age Children
    • Overview: Parents allow for more independence, which can create feelings of protectiveness and anxiety.
    • Erikson’s Stage:
      • Generativity versus stagnation.
        • Am I going to continue to build something through my children, career, or will I feel overwhelmed by parenting
    • Major Developmental Task: Building a legacy to leave behind.
  5. Families with Teenagers
    • A difficult time for parents to provide enough space for teens to explore their independence while maintaining appropriate closeness and boundaries to ensure the child's safety.
    • How to allow them to grow and mature while still maintaining closeness and enforcing boundaries.
  6. Launching
    • Empty Nest Syndrome:
      • Grown children are leaving the household, and parents are renegotiating their relationship with their spouse/partner.
      • For 18 years, the relationship was defined by raising kids, and now it's not.
    • Boomerang children:
      • Grown children who have been launched (left) and then return home to live with their parents.
  7. The Family Later in Life
    • Parents shifting their focus to retirement, bucket lists, and reflecting on lives.
    • Sandwich generation:
      • When parents are simultaneously caregivers for their children and their aging parents.

Grief and Stages of Grief and Loss

  • Elizabeth Kubler-Ross
    • Stages: denial, anger, bargaining, depression, acceptance.
      • These can shift/do not need to be in this order/do not operate in stages/NOT sequential, don’t need to experience all of them to reach acceptance.

New Grief

  • Orzo
    • Crisis, unity, upheaval, resolution, renewal.

Helping Children Process Grief

  • Honesty
    • Avoid euphemisms (down below); be clear that this is a permanent change and the person will not be back.
    • Avoid specific details, especially in the case of a traumatic death.
    • Telling a child that grandpa just went to sleep is unhelpful and causes more damage to the child.

Other Losses

  • Ambiguous Loss: A loss where the circumstances are making it difficult to grieve.
    • Examples: Miscarriage, loss of job, infertility, disability, missing person, loss of relationship due to dementia, undetermined cause of death.
  • Complicated grief: Often applying to deaths by suicide or homicide.
    • Involves a mix of anger along with common intense sadness that accompanies grief.
  • Prolonged Grief Disorder: new to the DSM-5 |||| needs to be at least a year long
    • Consists of identity disruption, a sense of disbelief about death, avoidance of reminders, and intense emotional pain.

Types of Assessments

  • Birds Eye View: Quantitative AND qualitative method
  • Family Adaptability and Cohesion Evaluation Scale (FACES)
    • Assesses 3 dimensions of marital and family systems.
      • Cohesion (how bonded/connected is the family).
      • Flexibility.
      • Communication.
    • Each member fills out the assessment scale twice: Once for how dynamic is now AND once for how they WANT the dynamic to be.
      • Current function / ideal function.. The gap between the two is a measure of family satisfaction.
        Family Assessment Measure (FAM)
    • Assesses 7 dimensions of family systems.
      • Task accomplishment.
      • Role performance.
      • Communication.
      • Affective expression - How are different emotions expressed throughout.
      • Involvement.
      • Control.
      • Values.
      • Norms.
    • Assesses at 3 different levels.
      • Within the whole family.
      • Various dyads.
      • Individual functioning.
    • Answered on a scale: Dyadic scale, Self-rating scale, General scale.
      Genograms
    • 3 - generation family tree.. Complete with names, birth / death dates, other notations as desired.
    • Can be helpful for individual and families to detect and understand patterns that take place across different generations as well as cultural values and historical contexts of problems.
    • Key Concept: Intergenerational Transmission.
      • The expectations, teachings, and influences passed down from generation to generation.
      • They help make us who we are and explain why we believe certain things and behave certain ways.
      • Not everyone has access to this kind of information equally (adoption, marginalized communities).
        The Lifestyle Questionnaire
    • Each individual family member completes it.
    • Asks for subjective descriptions of each family member such as who is the smartest, who is most easygoing, who is the loudest, who is a leader.

Family Sculpting

  • Technique where therapist instructs an individual family member to position, or “sculpt” people together in the way that they view the family.
    • Utilize different props/chairs/furniture to symbolize different positions in the family.
    • Props may be used to symbolize position within families.
    • Can also create a “sculpture” of how they would like to see the family change.

Family Scripting

  • Technique where a therapist asks family members to identify the typical interaction patterns in order to define what a normal script is for that family.
    • Once identified, therapist can ask what purpose the script plays, how it benefits certain family members, and how it may be detrimental to other family members.

Family Play Therapy

  • Family Puppet Shows:
    • Counselor can see how the family interacts, what the major themes of the story are, and how they decide who does what.
  • Family Build-A-House:
    • Therapist observes who takes on the leadership roles, how decisions are made, and how the family communicates and solves problems.
  • Family Aquarium:
    • Therapist observe the process among family members, assessing roles, interaction, problem-solving patterns, and methods of communication.
  • Family Play Genograms:
    • Family members choose miniatures to represent each member of the family including themselves. Therapists then ask each member to deceive what item they chose and why.

Bronfenbrenner’s Ecological Systems Theory

  • Microsystem - immediate environment
    • Closest more immediate environment to child
    • Direct interactions with family, friends, teachers
    • EX. child's relationship with their parents / teachers influence on their learning
  • Mesosystem - connections
    • The interactions between different elements of microsystem
    • Represents how relationship in the microsystem influence each other
    • EX. parent-teacher conference affects child's academic performance
  • Exosystem - indirect environment
    • Systems, environments that individual does not directly interact with, but are still impacted by
    • Local government / city councils
    • Child wont be on the council, but still will be affected
    • EX. a parents stressful workplace affecting their mood at home, influencing / impacting child
  • Macrosystem - Social and Cultural Values
    • Dominate values, morals, and traditions within culture
    • Family religious beliefs / culture beliefs
    • “Wearing makeup at a certain age is not allowed” - the parents beliefs impacting the child
  • Chronosystem - changes over time
    • Dimension of time affecting development
    • Idea of launching
    • Turns around the age of 18 - big impact on child leaving
    • EX. teenagers development being influenced by rise of social media

Origins of Family Counseling

  • Influenced by early psychiatrists who observed that children hospitalized for mental health diagnoses would get worse when they would return home
  • Key Figures:
    • Gregory Bateson: applies concepts of biological systems theory to human groups, especially the family
    • Murray Bowen: Developer of systemic therapy
    • Salvador Minuchin: developer of structural family therapy
    • Carl Whitaker and Virginia Satir: developers of experiential family therapy

Family Dynamics

  • Any repeating patterns of how family members interact with each other
  • When the family interacts, and dynamics get created:
    • the family system becomes greater than the sum of its parts
    • Family System > sum of its parts.
    • Suggests that something new gets created in that process.
    • Not inherently positive or negative (can be either).
    • Stem from reactions.
    • Counselors focus on these dynamics and patterns rather than the connect of a particular argument

Family Systems Approach (cont.)

  • Family systems counselors: Focus on identifying the family system and dynamics rather than individual diagnosis or psychopathology
  • Family Subsystems: part or units of a system that form smaller systems of their own (parents, spouses, siblings, sisters, brothers, ect.)
    • Family subsystems are fixed, their membership do not change.
      • Parents - always the parents, won't change (biologically).
      • Siblings - won't (biologically) jump up to parent subsystem.
    • 2 types of subsystems:
      • Alliances: certain types of subsystems that form and reform for specific purposes and fulfill family needs in a way that is beneficial to all family members.
        • Beneficial to all family members, Fulfil family needs that impacts all members.
        • Both parents form an alliance to take care of aging parents and also beneficial to kids because they get to see their grandparents more often.
      • Coalitions: a subsystem formed to exclude or oppose one or more family members.
        • Purposely leaving out someone.
        • Leaving out one parent, or leaving out one child

Linear Causation

  • A → B
    • One specific event (event A) happens and it directly leads to/causes the outcome (event B).
    • Cause and effect.
    • EX. parent yells at a child, and the child becomes sad → parents yelling CAUSED child to become sad.

Circular Causation

  • Interactions feed upon themselves creating feedback loops
    • A affects B → B affects A → A reacts to B again…
    • A child acts out in school → The parent gets frustrated and becomes stricter → The child feels misunderstood and acts out more → The parent reacts even more harshly

Feedback Loops

  • Cycles of behavior that become increasingly less functional and more disruptive
  • Circular causation that leads to feedback loops

Equilibrium

  • A balance among a system that allows the parts to stay together
    • Does not necessarily mean it is “good” for the family or specific family members

Homeostasis

  • The process by which equilibrium is maintained
  • Family systems counselors work to prevent family’s homeostatic mechanism from disrupting efforts to resolve conflict while also facilitating a new homeostatic correction to bring about more effective conflict resolution
    • Ex. storming out/walking away from argument = helping to achieve equilibrium
    • System goes through homeostasis with the goal to maintain equilibrium

Family Rules

  • Emerge from the interactions, feedback loops, and homeostatic corrections
  • Rules are unspoken and unwritten and are often not directly observable
  • Understood by family even if not voiced
    • EX. my family rules: ask mom about going out/making plans.

First Order Change

  • Involves a change in behavior only
  • May involve doing more of whatever is already not working
  • May involve the opposite of what has not worked
  • Usually ineffective

Second Order Change

  • Involves a change in family rules and dynamics.
  • Preferable to first-order change
  • Changing family rules ⇒ changing underlying assumptions ⇒ becomes more difficult to recreate the patterns that created the problem.

Second Order Cybernetics

  • A term that refers to the process by which the counselor “joins with” or becomes part of the family system
  • Counselors need to join the system but also need to avoid falling into the same family dynamic and rules that underlie the family’s problems
  • Key Assumption: The presenting problem serves some sort of function for the family (equilibrium)
    • This function is not a “conscious” decision that any one family member is making
    • Counselor would normally not openly share this function with the family
    • EX. liz being so focused on Emma’s needs and Christina’s issues distracts her from her marital distress with Mark, therefore potentially preventing the family from going through another divorce

Stressors

  • Any event that requires change within a family
  • Can be internal or external to the system
    • External stressors: Natural disasters - hurricane
  • How families respond is impacted by their resources:
    • Financial, Emotional, Social
      • Social resources: friendships, connections to social services

Bowenian Theory

  • Families would be observed in lab for up to 3 years
    • Helps examine families and help them examine themselves
    • Understanding individuals within their families and the roles each member plays in the family

Emotional Fusion

  • Term for when 2 members of the family are closely (too closely) emotionally interconnected
    * To the point where they put their own needs aside because they are worried how it may impact someone else .. in order to maintain the relationship harmony
    * Tend to be more REACTIVE than proactive
    * Reactive - reacting to whats happening around me, not focused on what i need and want
    * EX. resorted to a means she knew her mom would not be able to ignore (self harm)

Differentiation of Self

  • (essentially opposite of emotional fusion)
    • Able to make choices for myself relatively easy without dependence of how others may feel.
    • Seen at the goal for an individual's “healthy” emotional function
      Triangles
    • 2 family members are having conlfict with eachother, so a 3rd member is pulled in to lessen the tension between the original 2
    • Goal : trying to get the 3rd person to side with one of them / other times less attention focused and instead focused on outside

Triangle vs. coalition

*   Coalition - always dysfunctional always 2 against 1

Drama Triangle
* When family members get stuck in these certain roles … it becomes messy
* You're stuck in these roles → prevent to take accountability
* Alwaysss the rescue: emotional fusion
* Victim and pro .. : never taking accoutnabliity

Nuclear Family Emotional Process

  • Maritial Conflict: Parents primarirly
  • Dysfunction in on Spouse
  • Impairment in one or more children:
    • Symptoms: emotional, physical, mental, financial
      Emotional Distance
    • In order to protect from the tension, intensity, anxiety

Family Projection

  • We have certain fears or anxieties that are not actually there but we project them onto the family
    • EX. conflict among the parents relationship, they may project this conflict onto another family subsystem
    • EX. fear or anxieties that the parents may have ABOUT the child, they become hypervigilant and look out for signs and cues about it
      • Interpret child's behavior or project on to the child the fears of anxiety

Cutoffs

  • (ghosting, boundaries)
    • Cutting off or ending a relationship
      • Physically or emotionally or BOTH

Multigenerational Transmission Process

Structural Family Counseling

  • Founded by Salvador Minuchin
    • Arose a method of intervention with low-income “multi problem” families
    • Applied multigenerational
    • Focus: on the structure of the family
  • Key Concepts
    • Boundaries
    • Coalitions and triangles
    • Hierarchies
    • Questioning family assumptions (method structural family counselors use in their work)
    • Enactments (method structural family counselors use in their work)

Boundaries

  • Reflection of family rules for managing the physical and emotional distance among members, between groups of family members, and between the family as a whole
    • Through repeated interactions, families develop rules about closeness and distance at all levels within and outside the family system
    • Boundaries that apply at all levels of the family (nuclear ect.)
    • Influenced by lots of different factors: Culture - What is considered functional in some cultures may be dysfunctional in others
  • Reflection questions about boundaries:
    • Are there both public and private spaces in your home? Or do visitors have free range?
    • Do family members close/lock doors? Under what context?
    • Is it alright to talk about family dynamics to other people not a part of the family?
    • Do family members tell each other everything that happens to them?
    • Are there times children known not to disturb their parents
    • Do you tell one of your siblings or partner more than you tell other family members?
  • Types of Boundaries: (spectrum) ideal: middle zone between the two below

Diffuse Boundaries

  • When boundaries are so easily crossed (or nonexistent) that members have difficulty knowing where one member stops and where one begins
    • White board cleaner mixed with water example.
    • Leads to meshed relationships (so close together they are merged)
    • Issues: members of the family are not able to develop their own individual identities
    • Key indicator: if there's a family member that speaks on BEHALF of other members

Rigid Boundaries

  • The boundaries the family has established that are so strict, intense, and impossible to cross that members have a hard time connecting with each other
    • Leads to: disengaged relationships
    • Issues: individuals not able to develop their own identities
    • Especially in children → not enough interaction with siblings, parents, friends to see how they are responding to them and to learn how to socialize and become a part of the community
  • IDEAL: clear boundaries leading to flexible relationships (Minuchin)
    • Idea of parentification of child, that the child doesn't feel like they need to take the role of a parent
    • This is especially important between generations, at they allow parents and children to be close without confusing who is responsible for what
    • Minuchin: believed that when boundaries fall at either extreme of the continuum (diffuse|rigid), they impede family adaptability to stress, exacerbate symptoms, and require intervention

Coalitions and Triangles

  • Coalitions: negative subsystems between 2+ members

    • Dysfunctional
    • 3+ is triangle (bringing in the 3rd person)
    • Minuchin believed that triangles are a normal part of family lives and only become dysfunctional when they cross generations (both parents and a child) and become rigid
    • To address dysfunctional triangles, Minuchin recommended strengthening the boundary between the parental and child subsystems
    • Alliances fulfil family needs in a way that is beneficial to all family members
    • Coalitions are negative subsystems between any two (or more) family members
    • When coalition occurs among three family members, it is called a triangle
    • A triangle involves bringing in a third person into a distressed dyad which puts pressure on that person (often this person that becomes the identified patient)

  • Structural Approach:

    • Intent to dissolve problems rather than reflect
    • Seeks to deal with triangles and coalitions by focusing the family away from the identified patient, strengthening the boundary around the parental subsystem, and addressing the distress in the parents’ dyadic relationship with the intent to resolve than deflect this distress.

Hierarchies

  • Generational boundaries assumed to lead to more of a functional family dynamic
    • Good thing, can be helpful for families
    • Clear boundaries between generations (parents and children) lead to parents assuming parental responsibilities and children not stepping into their parenting roles, while both generations continue to interact with one another
    • Structural family counseling aims to strengthen these generational hierarchies as another way of getting the identified patient out of the parent’s relationship

Questioning Family Assumptions

  • Similar to how individual counselors may utilize confrontation to challenge a client’s belief using questions, structural family counselors question the family’s assumptions
    • EX: emma is actually able to function independently as any other 4-year old so the counselor questions the family’s assumption that Liz needs to spend so much of her time, energy, and focus on assisting Emma

Enactments

  • Technique frequently utilized by Structural family counselors that allows the family to practice corrective interactions which, one experienced in the counselor's office, can be recreated and practiced at home.
  • 3 steps: Tracking, Enacting, Redirecting

Experiential Family Counseling

  • General overview of experiential :
    • Approach founded by carl whitaker and virginia satir (lady from videos we’ve watched)
    • Idea of creating some sort of experience that happens IN THE PRESENT MOMENT (in the counseling moment)
      • Here and now
      • Here, in the room - with the family and counselor
    • Less interested in diving into the past
    • Emotional connection to the experiences
    • Places emphasis on the “here-and-now” in the room among counselor and family members
      • Targets the emotional layer of behavior and cognition
      • Encourages family members to actively experience their emotions in the counseling room (not just reviewing their feelings after they have happened)
      • Change starts by noticing rather than doing something differently (if we are not aware of our own emotions and reactions, we will not be able to change them)

Difference Between Structural and Experiential Family Counseling

  • Experiential pays attention to both individual persons AND the family as a whole
    * It does not make the assumption that changing family dynamics will automatically change the mental health of its members
    * A change in one family member is likely to reverberate throughout the family system, perhaps creating change in other family members and the family system as a whole

Role Flexibility

  • Term used to describe the process whereby family members can assume and change multiple roles as needed
    • This ability familial flexibility and the family's ability to adapt to stress
    • EX. family consisting of working father and SAHM: the mans job became too mentally damaging and could no longer work there and support family SO…. mom went out to find a job to help provide for the fam

Whitaker’s Symbolic Experiential Family Counseling

  • Emphasizes the need for the counselor to be fully present and empathic with clients in the moment
    • Utilizes the therapy space to gently perturb the family system, use compassion, playfulness, and humor to guide family members toward new options for relation to themselves and each other

Virginia Satir’s Family Growth Model

  • Role Of Counselor:

    • To provide the family with the experience of emotional warmth in communication and direct them toward expressing emotional warmth when interacting with each other
      • Focused on nurturance as well as empathy within the family
    • To alleviate the lack of validation and intimacy within families
      Counselors help family members assume congruent stances, teach them to empathize with each other, and encourage or amplify enough crises that it becomes possible to alter the family system in such a way that members are forced to change

Enactments

  • Satir utilized a specific type of enactment where the counselor asks family members to imagine what other members felt at the time when a frustration occurred and then to reenact the situation accounting for how others felt Survival Triad
    • Involved two parents and an infant, the infant’s survival being dependent upon the parents’ nurturing
    • The nurturing one receives as an infant within the survival triad determines the “stance” one takes in communication throughout life
      • Determines an infant's later communication stance far more than the biological connection between the adults and the infant of how many adults are in the home.

Communication Stances

  • Congruent Stance: involves the consideration of self, others, and the context in which the communication occurs
    • Resulting from: an infant that is sufficiently nurtured within the survival triad
    • Results in: an adult that is versatile, able to tolerate conflict, and able to express themselves in a way that considers everyone's feelings as well as the situation
      *Communicates directly with empathy
  • 4 DEFENSIVE STANCES: Attends to self and the context in which communication occurs, but does not attend to the feelings of others
    Attends to the context in which communication occurs while ignoring the subjective needs of themselves AND other family members

Other Family Approaches

Adlerian Family Counseling

  • Key Concepts: Teleology, The 4 goals of misbehavior, Birth order

Teleology

  • The belief that all of our behaviors are goal-directed and therefore serve a purpose for each of us
    * This belief directly impacts how adlerian family counseling conceptualizes children's misbehavior within family systems
    4 Functions / Goals of Misbehavior Attention: Children have very limited power and influence in our society, Children do things in search of power

Revenge

  • Children have the desire to hurt their parents back when they feel hurt or angry Display of inadequacy - Being inadequate at something lets you off the hook and lowers peoples expectations First born, Middle child, Youngest

CBT TFA Model

  • thoughts, feelings, actions (same as the cognitive triad)
    Shows different people have different emphasis in these triangles that can create their own triangles

Reality Therapy

  • Emphasizes the need for clients to identify what they can control and what is outside of their contro
    WDEP Model: Enabling clinicians and clients to break down their problems by having them identify what they want and what they are doing to get what they want, evaluate what they are actually currently doing to get what they want (and whether or not it is working), and then develop a new plan for getting what they want wants, doing, evaluate, plan

Postmodern Theories

  • Narrative, Feminist… knowledge is socially constructed, we should explore the experiences and social context (environment) or individuals and groups (including families)

Narrative Family Counseling

  • Meaning: Counselors focus more on what meaning families are making from their situation rather than their thoughts, feelings, or behaviors
  • Family Narrative: The family's interpretation of their experience and how this interpretation impacts their functioning
    Dominant Culture: The ideas, values, beliefs, knowledge, norms, and customs commonly accepted as representative of the majority of a society’s members intervetions: Exteralizating Conversations and Empowering the Family to Re-wrote their Narrative

Feminist Family Counseling

  • Emerged in the 1980’s as women family counselors began to examine original family counseling theories and how they were created by men and not sufficiently consider female perspective and the larger social context gendered experiences as well as by ethnicity, race, age, SES, sexual orientation, ect