08 Apr Why are marriage and family practitioners reluctant to embrace research and assessment in clinical practice? What do you think could be done to
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Chapter 17
- Why are marriage and family practitioners reluctant to embrace research and assessment in clinical practice? What do you think could be done to rectify this situation?
Chapter 18
- In cases of domestic violence, there are two major positions about responsibility and domestic violence which influence treatment options:
• both parties are equally responsible for the violence (conjoint or couples therapy)
• the perpetrator is unilaterally responsible for the violence (intimate justice theory and education)
Take a position and defend the appropriateness of each approach, including the necessary conditions for selecting each one.
Case Study Question: “Case Illustration: Seth’s Sexual Misconduct”
When the Scott family came into family therapy, they did so reluctantly and with a good deal of anger. Sara Scott was furious with her husband, Seth, for sexually abusing their 12-year-old daughter, Jenny. The abuse had been going on for almost a year, and it was purely by accident that Sara discovered it when she was talking with Jenny about growing up to be a woman. Seth was removed from the house immediately. He both apologized for his actions and begged to come back. Sara was having none of it. Jenny stated that she was still afraid of her father and would never forgive him for what he did to her.
This is your first meeting with the entire family.
What do you think you could accomplish in seeing them together? What would be your limitations? What would you need to be wary of? What type of treatment do you think you would ultimately recommend? Why?
Research and Assessment in Family Therapy
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Importance of Research and Assessment
Vitally interlinked with family therapy
Most of the pioneers in family therapy employed research-based procedures to evaluate and work with families.
In the 21st century, family therapy has become even more redefined in its research and focus on real-life context
The assessment of families is becoming stronger.
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Five Important Reasons for Research
Knowledge – informs therapists about phenomena
Confirmation and verification – demonstrates the efficacy of techniques and procedures
Accountability – provides means to show their services are grounded in science
Practicality – pays off in the long run
Uniqueness – way of distinguishing itself from other fields
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Research Findings in Family Therapy
Findings from research on family therapy indicate in general that most individuals and families improve when they receive couple and family therapy.
Contributions by Szapocznik:
Development of brief strategic family therapy
Formulation of structural ecosystems therapy
Development of the Strategic Family Systems Rating
Creation of one-person family therapy
Efficacy of individual, psychodynamic, and child therapy versus family therapy
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Two Types of Family Therapy Research
Quantitative
Grew out of the scientific traditions of physics, chemistry, and biology
Numbers
Qualitative
Rooted in the traditions of anthropology and sociology
Words or other means
Participatory evaluation research
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Difficulties in Family Therapy Research
Complexity of relationships within families
Time commitment needed to study the effects of family therapy
Getting families to participate in research projects
Ethical and regulatory standards
National Research Act
Belmont Report
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Research Design
The way in which research is designed affects results
Five categories of research design:
Exploratory: qualitative design used to better define issues
Descriptive: describes specific variables
Developmental: studies change over time
Experimental: adhere to classic “hard science methodologies, such as using hypotheses and dependent/independent variables
Correlational: studies degree of association between variables
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Sampling
Probability Samples: drawn from a known population with the possibility of calculating the likelihood of each case being included in the sample
Simple random sampling: each person in a population has an equal chance of being selected
Systematic random assignment: first family selected at random, then every nth family is automatically included
Stratified sample: random samples are drawn from different strata or groups of a population
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Sampling
Nonprobability samples: used when representation of a whole population is less important than the information itself
Convenience: using easy-to-access families
Snowball: asking participating individuals to refer other individuals
Purposive: choosing participants because they are believed to be representative of the study population
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Instrumentation
Self-report instruments
External validity (i.e., generalizability)
Construct validity (i.e., measuring what they report to measure)
Direct observational assessment (i.e., use of coders, raters, or judges)
Inter-rater reliability (degree to which raters agree on what they observe)
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Procedure
How families are studied
Many different methods for study families
Not neutral, as they reflect the epistemology of the investigator
Evidence-based research
Akin to outcome research
The available research evidence bearing on whether and why a treatment works (McMillan & Schumacher, 2014)
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Theory and Statistics
Well-designed research is based on questions that have usually arisen from a theory
Most family therapy is based on general systems theory
Statistically reported research needs to be clinically relevant and readable to practitioners as well as scientists (Gay et al., 2012)
Normal distribution is important when reporting statistics
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Validity
“The extent to which a measuring instrument measures what it was intended to measure” (Miller, 1986, p. 58)
Three main measures of validity:
Content: how well a measure taps the full range of dimensions or meaning of some underlying construct
Criterion: how well a measurement predicts or correlates with external criteria
Construct: how well a measure correlates with measures of similar construct
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Reliability
The consistency or dependency of a measure
Perfect reliability is expressed as a correlational coefficient of 1.00, which is seldom achieved.
An instrument can be reliable or consistent without being valid or accurate. However, an instrument cannot be valid or accurate without being reliable or consistent.
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Importance of Assessing Families
Assessment procedure – any method used to measure characteristics of people, programs, or objects.
Assessment is a vital part of family therapy
Through assessment therapists gain information that helps them diagnose and respond systematically and appropriately to families
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Dimensions of Assessing Families
Mostly based on a systemic approach
Questions asked in family therapy are generally focused on transactions and relationships
Fishman (1988) suggested four aspects of assessment for family therapists:
Contemporary developmental pressures on the family
History
Structure
Process
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Methods Used in Assessing Families
Informal Methods of Assessment
Couples Creativity Assessment Task (C-C A T)
Family Assessment Form
Direct Observation
Formal Methods of Assessment
More than 1,000 instruments are available to family therapists to assess families and couples
Cover such diverse areas as intimacy, power, parenthood, and adjustment
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Common Formal Assessment Instruments
Caring Days Inventory
Family of Origin
Locke-Wallace Marital Adjustment Scale
Myers-Briggs Type Inventory
Beavers-Timberlawn Family Evaluation Scales
Family Adaptability and Cohesion Scale
McMaster Family Assessment Device
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Working with Substance-Related Disorders, Domestic Violence, and Child Abuse
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Substance-Related Disorders and Families
A significant challenge to families and society
Substance-related disorders are even more destructive
Alcohol use disorders
Alcohol abuse – “problem pattern where drinking interferes with work, school, or home life” in addition to other difficulties with the law and society (Stanton, 1999, p. 1)
Alcohol dependency – person is unable to control his or her drinking behavior even after trying
Pseudo individuation / Pseudo self
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Manifestations of Substance-Related Disorders in Couples and Families (1 of 2)
Shielding of the substance-related abuser by nonabusing members of the couple or family
Denial
Expression of negative feelings
Deterioration
Focusing energy on the substance abuser
Misusing family resources
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Manifestations of Substance-Related Disorders in Couples and Families (2 of 2)
Assuming survival roles:
Enabler: spouse or other family member on whom the substance abuser is most dependent and who allows a substance abuser to continue and become worse
Family hero: an adult or oldest child who functions to provide self-worth for the family
Scapegoat: a child who attempts to distract the family focus away from the substance abuser by acting out in a disruptive manner
Lost child: child who suffers from rejection and loneliness and offers a substance abuser family relief
Family clown: often youngest family member who provides the family with humor and thus reduces tension
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Individual Manifestations
Children
May behave in confused ways about their self-identity and self-worth
Those who lives with at least one parent who is an abuser of alcohol are twice as likely to develop social and emotional problems
May feel less attached and bonded
Adults
May spend lots of time and energy attempting to resolve issues related to the dysfunctional nature of their families-of-origin.
May struggle in relationships
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Substance-Related Disorder and Treatment
Family treatments are among the most effective approaches for helping those with substance abuse problems.
It is helpful to engage concerned significant others (C S Os) in the treatment process.
Also, it is important to engage the most disengaged member of the family, possibly through a direct conversation
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Approaches to Treating Substance-Related Disorder Families After Engagement
Use the Community Reinforcement Approach (C R A)
Consider environmental influences – the theoretical basis for assessing is multisystemic therapy
Help with emotional, social, and vocational issues
Address feelings and defense mechanisms
Consider prominent theoretical approaches: structural-strategic, Bowen, behavioral, Adlerian, and multifamily therapies
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Prominent Theoretical Approaches
Structural-strategic
Bowen
Behavioral
Adlerian
Multifamily Therapies
Use of Community Resources and Prevention
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Domestic Violence and Families
“Aggression that takes place in intimate relationships, usually between adults” (Kemp, 1998, p. 225)
“The willful intimidation, assault, battery, sexual assault, and/or other abusive behavior perpetrated on one intimate partner on another (Cobia, Robinson, & Edwards, 2008, p. 248)
Can take many forms: physical, sexual, psychological, and economic
Battering – “violence which includes severe physical assault or risk of serious injury (Kemp, 1998, p. 225)
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Prevalence of Domestic Violence
“Approximately one-third of all married couples experience physical aggression” (Crespi & Howe, 2000, p. 6).
An estimated one half to two thirds of couples seeking marital therapy have had some incident of aggression in the last year (Schact et al., 2009).
Although some men are the victims of abuse and violence by their mates, the large majority of those assaulted each yea are women.
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Those Who Batter
Come in “all shapes, sizes, classes, races, and sexual orientation” (Almeida, 2000, p. 23)
Pit bulls – heart rate increases as they become verbally aggressive with their partners
Cobras – heart rate decreases as they become verbally aggressive
13% of all murders involve husbands killing their wives
1.3 million wives are severely beaten by their husbands each year (Cobia et al., 2008)
Relationship between alcohol intoxication and domestic violence
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Assessment of Domestic Violence
Barriers
Legal
Psychological
Difficult to determine level and prevalence of violence
Levels of violence
Common couple violence (C C V)
Severe abusive violence (S A V) or intimate partner violence
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Open Assessment
Often results in obtaining the most information
Blame is not a primary emphasis and the therapist emphasizes that the expression of violence in the family hurts the entire family
Focus centers on dynamics within the family associated with family relationships, such as emotional expression, handling of money, sexuality and social connections
“Detection rates are increased when women are questioned directly, specifically, and alone (Schacht et al., 2009, p. 48).
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Treating Domestic Violence: Conjoint Therapy (1 of 2)
Involves seeing the couple together
Assessment of safety required
Three conditions must be met:
Man’s participation must be voluntary
Special agreement about confidentiality must be established
An optimal therapeutic stance must be achieved (Bograd & Mederos, 1999, p. 296)
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Treating Domestic Violence: Conjoint Therapy (2 of 2)
Couple therapy may work if the following criteria are met:
Only a history of minor and infrequent psychological violence or abuse has occurred
No risk factors for lethality are present
The man admits and takes responsibility for abusive behavior and also demonstrates an ongoing commitment to contain his explosive feelings without blaming others or acting out
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Treating Domestic Violence: Intimate Justice
The theory encompasses three ethical dimensions and nine ethical concepts (Jory & Anderson, 1999, p. 350).
It is akin to solution-focused approaches and confronts disempowerment and abuses of power in a partnership while challenging internalized beliefs about how one should treat one’s partner (Jory et al. 1997).
Through knowledge and insight, both behavioral attitudes and behaviors in couples may be modified.
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Treating Domestic Violence: Educational Treatment
Educationally, programs based on intimate justice theory and C B T have been employed with domestic violence families
The Duluth model is one approach
A C B T model of treatment
Holds the premise that people learn violent behaviors because they are reinforced for them in cultural and social circles
People can unlearn these behaviors and learn new ones through cognitive-behavioral means, such as education
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Child Abuse and Neglect in Families
Child Abuse (acts of commission)
Child Neglect (acts of omission)
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Child Abuse and Neglect Statistics
“In 2010, child protective services (C P S) received more than 3.3 million reports for alleged maltreatment of nearly 6 million children” (Juhnke, Henderson, & Juhnke, 2013, p. 57).
Each year more than 1 million children are victims of child abuse (U. S. Department of Health and Human Services, 2004).
Abuse is seldom of one type.
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Effects of Child Abuse
Aggression
Delinquency
Suicide
Cognitive, academic, and psychological impairment
Less satisfaction with life and increased likelihood of behavioral, cognitive, and affective disorders
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Child Physical Abuse
Resides on a continuum from mild to severe physical contact
Severe physical child abuse
Skin injuries to physical traumas and death
Psychological consequences, from fearfulness to posttraumatic stress responses
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Childhood Sexual Abuse (1 of 2)
Includes the following:
Unwanted touching
Making sexual remarks
Voyeurism
Intercourse
Oral sex
Pornography
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Childhood Sexual Abuse (2 of 2)
Boys
Least reported
Most commonly done by perpetrators outside of the family
12% to 18% are sexually abused during childhood or adolescence
Girls
Most reported
Most commonly done by a person within the family
1 in 3 is sexually abused by age 18.
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Treating Child Abuse and Neglect (1 of 2)
Involves legal, developmental, and psychological issues
All states require mental health workers and other professional helpers to report child abuse and neglect.
“Failure to report child abuse usually constitutes unprofessional conduct that can lead to disciplinary action by a regulation board, possible conviction of a crime, and a civil lawsuit for damages (Leslie, 2004, p. 48).
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Treating Child Abuse and Neglect (2 of 2)
Family therapists must deal with many current and historical issues in working with child abuse
Important to concentrate on the following:
Assisting the abuser in learning how to delay acting impulsively
Helping the abuser and the abused family members to recognize and select alternatives other than violence
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Working with Adult Survivors of Abuse
Treat not only issues from childhood but also adult behaviors associated with the past events
Understand the context in which the abuse occurred
Realize that children are rarely abused in only one way
Treatment approaches may vary from Bowen-based family-of-origin work to behavioral interventions
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Working with Children Who have been Abused
A variety of treatments have been used
Very important to focus on the safety of children living in potentially violent environments
Important to draw up a safety plan during the early stages of therapy, and should include the following:
Hotline or local police number
Identified safe internal and external locations in case of violence
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