Tuesday, October 27, 2009

Minuchin's Structural Family Therapy

Minuchin’s Structural Family Therapy
Sliver Article

It may sound superfluous to say that I learned my most important lesson about Structural Family Therapy from Salvatore Minuchin, but it’s true. When I was first introduced to family therapy in the ’70’s, Families and Family Therapy was my first textbook. Minuchin’s book was my primer for entering the field. I devoured that book.
Throughout my career, I have had a hobby of having authors inscribe the books they write. Attending a Minuchin workshop gave me the opportunity to have him inscribe my copy of Families and Family Therapy. When he was finally alone, I approached him and he was pleased to honor my request to write in my book.
As he was signing his name, I started talking about how meaningful the book had been to me when I started doing family therapy. As he finished inscribing, my last comment was that Families and Family Therapy had been my bible entering the field. He closed the book, handed it back to me, smiled and said, “I hope it isn’t any more.”
I walked away somewhat stunned. Minuchin had ditzed his own book. At first I wasn’t sure what to do with his comment. On reflection, I realized what he was saying. Structural Family Therapy, as put forth in Families and Family Therapy was written as an introductory text book. It describes a simple model of understanding the family and techniques to intervene. A family therapist should develop beyond techniques. A family therapist needs to integrate all the techniques. At some point a therapist stops using techniques and is able to be with the clients.
So if you, like me, started your career with the building blocks of structural family therapy and it was your basic outline for doing therapy, I hope it isn’t any more.

Saturday, September 26, 2009

My book interview on the Faith Middleton show (CPBN)

In February of 2009, I was interviewed by Faith Middleton, a WNPR radio show host of the two-time Peabody Award-winning Faith Middleton Show who has been widely recognized for fostering insightful, thought-provoking conversation, about my book Bedlam.

Listen to the interview

Monday, August 17, 2009

Blind Date

I remember one particular referral phone call I received from a woman. She began by asking if she could make an appointment with me. Before I gave her an appointment, I asked her why she needed to see me. It took several minutes before she was wiling to talk, but then she started sharing a multitude of problems. First of all, she was actively suicidal. Second, she was consuming huge amounts of alcohol on a daily basis. Third, her husband had left her and she was totally overwhelmed by her children and household demands.

After she finished providing the highlights of her difficulties, we had a good talk about what she really needed in order to address the problems she faced. She finally agreed that meeting with me for an hour a week would not begin to handle her problems. We started talking about other resources. I gave her a number of referrals, including a variety of social service agencies which could be helpful with her situation. By the time we ended the phone call, I had significantly helped her and I had not even met with her.

In my opinion, I would have been cheating her if I had given her an appointment. I never could have addressed the seriousness of her problems in a one hour a week format without putting her at risk. She needed more than I had to give. I believe this was an ethical and responsible clinical decision, although probably not a popular one among clinicians.

Carl Whitaker was concerned with how therapists went about scheduling initial appointments. He thought the idea that anyone could call you up and tell you what insurance they carried and receive an appointment was ludicrous. He compared it to the blind date.

An individual you've never met calls you up and asks if they can make an appointment to talk. They want to come into your space and reveal intimate details of their life. Without knowing anything else, other than their insurance carrier, many therapists proceed with scheduling the appointment. Carl considered this a dangerous gamble. By calling it the "blind date," he emphasized the risk that goes with making the first appointments with clients.

If you thought of it as a blind date you would be more suspicious. You'd want to find out what you were getting into. You would ask about the person and why they want to meet you. In fact, most people would set up the first meeting in a public place, which would be safer than letting them enter your space.

Carl felt that the first phone call should be used to screen, negotiate and assure the therapist that the appointment is a good decision. He sometimes spent forty-five minutes to an hour on the first phone call. He would ask questions about who they were and ask them to describe their problems. He wanted to know why they wanted to see him. He believed that once you meet with families the first time, you have accepted some level of responsibility for them. If you are not the right therapist, it is better to provide appropriate referrals and avoid the meeting.

Carl had two beliefs he used to support his actions. First, most families rarely sit together and talk about their issues. When an entire family talks about their issues for the first time, there can be immense pressure. This pressure was one of the major reasons Carl referred to his work as the family crucible approach. When the family finally sits together, it heats things up and makes things happen.

Second, knowing this, Carl believed when the family first calls and tells you who can attend the therapy, they will offer only enough of the puzzle to maintain homeostasis. Their initial phone call will reflect a desire to have you change the scapegoat. He suggested that the family was like a puzzle. When they called up for the first session, they would offer you some of the pieces. He would challenge the situation by trying to determine how many of the pieces of the puzzle were needed to solve the problem. He insisted that all the relevant family members attend. If the teenager or the father were not available, he believed that they knew better and that he would agree with them by refusing to meet with the family. Their reluctance to attend signaled Whitaker that they did not believe in change. Awareness that the family will offer you just enough to not change is a motivator to use the initial phone call to get more help from the family. Once they have come in for the first meeting, in later sessions, it is more difficult to increase the size of the system.

Drugs, Children and D.A.R.E.

I am a strong supporter of DARE. If one child, who is on the fence about drugs is tipped in the way of abstinence, I believe it is worth the effort and money. The Dare program does a great job of educating youth about drugs. It gives the children the opportunity to see the drugs so they know what to watch out for. Dare educates them about the effects of the various drugs and the problems that accompany them. However, I do have one recommendation on how to improve DARE.

The DARE program tells children that drugs and alcohol are bad and people who use substances are bad. I believe this is all too simplistic, even for children. When children see people drinking and laughing, or it is their parent that is using substances, or it is their physician that gives them drugs, the 'substances are bad' message is counter to their experience. A parent is not necessarily bad because they drink or use drugs. To differentiate between describing a parent's behavior as bad versus saying that the parent is bad, is a fine point, but an important one to make for children. Anyone working with youth knows that once they catch you in a lie, you have lost them. They will not listen to the rest of the message.

Children who are exposed to people drinking or doing drugs may see a vast array of emotions and behavior. The unpredictability of people's reaction to substances exposes children to rage and violence, as well as laughing and silliness. Finally, we know that today, one cannot necessarily trust all the medications the doctor gives you. Drugs and alcohol are complicated enough for adults, how can we expect our children to understand them. So what can we tell our children about substances?

When I was young, I was given a profound message. I can remember sitting in my kitchen while my mother talked about heroin. She told me that if I tried drugs, I would love them. I would love them so much that I would give up everything for them. I would give up my money, my health, my family, She convinced that that if I tried heroin, I would love it so much that I would give up my integrity and even my life. I understood what she was saying I understood how much power love would have over me. I found this much scarier than being told "drugs" were bad. Bad is often attractive. Bad would have aroused my curiosity. If I had been told they were bad, I could have been much more interested in finding out more or experimenting.

So if you are interested in giving children a strong message about drugs consider telling them that they will love using drugs and alcohol. They may love them to death.

Sunday, August 16, 2009

Suicide: Impact on student therapists

I applaud the recent interest in trauma. There are articles and trainings everywhere on how to help our clients with trauma. My concern is that so little is done to prepare student therapists for trauma. If you are in the psychotherapy business for any length of time, you are going to have losses, failures and deaths. Yet, our students appear unprepared. I have supervised students from most of the mental health disciplines. Not once have I met a student who had received any training on how to handle a successful suicide.

I believe it is our duty to prepare students for tragic eventualities. Let me suggest the following interventions:

First, we need to warn our students that they will lose clients. The awareness of this helps prepare them. We need to tell them before it happens.

Second, our clients are important to us. We care about them and offer communicative intimacy to them. They have shared their lives with us, so losing them is traumatic. Students should be encouraged to treat these losses as a trauma. Therefore, trauma interventions are appropriate. Students frequently tell me that they are discouraged from talking about treatment losses. When I was an intern and a client died, there were meetings to discuss the death, but interns were not allowed to attend. Our students should be encouraged to talk about their losses. Treatment teams need to provide time to debrief and students should not be excluded.

Third, after a successful suicide, clinicians need to distinguish between who is responsible for the suicide versus what were the contributing factors. To this end, I encourage reminiscing after a loss. I encourage therapists to review all their interactions. What did the therapist say? What did the client say? Did they miss anything? What could they have done differently that might have made a difference? What could have been done to avoid the suicide? Upon completion of this review, students are usually able to make a determination that the client is solely responsible for the death. Did the student contribute, miss something important not say the right thing? Maybe but that does not make them responsible for the suicide. Having completed a review of the case, including time to process all the interactions, most students will accept that they provided support, attention, guidance and caring interventions. They can accept that their actions were those of a reasonable clinician and that short of following the client home, they could not have prevented the suicide.

Finally, I want my students to feel more prepared for potential suicides. I ask them to provide a report on the characteristics of clients before suicide. By reviewing the characteristics of these clients, they lern how impossible it is to correctly predict which clients will be successful with suicide attempts. This knowledge helps students understand what is known about suicide and represents their only defense for this clinical situation.

I suspect that one of the major reasons that therapists have a short career span, burn out and leave the field, is because they are never trained on how to handle trauma. It is our duty as supervisors and clinicians to help prepare students for one of the most difficult professional problems they will face.