Assessments in Family Therapy

Self-report scales

■ Cost effective to administer

■ Provide information on how family members evaluate their own functioning.

■ The Dyadic Adjustment Scale (DAD)
■ 32-item measure of marital quality and marital adjustment
■ Four subscales measure

• • marital satisfaction
• • cohesion
• • consensus
• • affective expression

■ The Family Environment Scale (FES) is a 90-item true/false measure assessing how family members perceive their family environment along the three domains of relationships, personal growth and system maintenance.

■ The Family Questionnaire (FQ)
o Brief measure of perceived criticism and overinvolvment.

■ The Family Assessment Device (FAD)
o 60-item scale that assesses the six dimensions of the McMaster Model of Family Functioning

• ■ Communications
• ■ problem solving
• ■ affective responsiveness
• ■ affective involvement
• ■ roles
• ■ behavior control

Interview-based family assessment instruments

■ More labor intensive and require rater training.

■ Provide an outside perspective on how a family functions compared to other families.

■ The Camberwell Family Interview o Requires extensive training
o Used to assess levels of criticism and overinvolvment.

■ The Five Minute Speech Sample o Method of assessing expressed emotion in relatives of patients with psychiatric disorders.

■ The McMaster Clinical Rating Scale (MCRS) o Based on a family interview conducted by a rater
o Assesses the same six dimensions of family functioning as the FAD in addition to assessing the overall health/pathology of a family.
o Inter-rater and test-retest reliability as well as concurrent and discriminative validity.
o Can take from 45 to 90 minutes depending on the experience of the rater.

Family Therapy for Childhood and Adolescent Disorders

■ Family Risk and Protective Factors
 o Childhood and adolescent behavior problems have been strongly and consistently linked to a number of family factors, such as conflict and aggression.
o Longitudinal studies show that ineffective parenting practices in childhood maintain antisocial behavior into adolescence.

■ Family based interventions for child behavioral problems
 o Various family therapy approaches specifically target the coercive family patterns maintaining behavior problems while at the same time bolstering protective factors in the family and other systems that have an impact on the child.

■ Engagement and Retention Therapy
 o One of family therapy’s major contributions is an increased focus on strategies for engaging difficult youth and their families in treatment

■ Parent Management Training
o Focusing on the parent in treatment
o Helping parents identify, observe, and react to the child’s problem behavior in new ways
o Applying social learning principles to increase parenting skills to shape the child’s behavior.
o Providing opportunities to practice new parenting skills and apply them in the home.

■ Functional Family Therapy
 o This model is based on the assumption that children’s behavior problems serve a function within the family system and are initiated and maintained by maladaptive interpersonal processes.
o Treatment targets change in these destructive interactional patterns and uses behavioral interventions to reinforce positive ways of responding and to establish more effective problem-solving

■ Multisystemic Therapy
 o Several different models have demonstrated efficacy and are generating evidence of effectiveness community-based replication studies.
o These therapies promote positive outcomes such as more pro-social peer relationships and family functioning, as well as reducing conduct problems.

Risk factors for and patterns of abuse

Recognizing sings of abuse
In the child:
o Sudden changes in behavior or school performance
o Not medical attention for problems brought to parents attention.
o Learning problems, difficulty concentrating, that cannot be attributed to specific disabilities.
o Tends to be watchful, expecting something to happen.
o Lacks adult supervision.
o Overly compliant, passive, or withdrawn.
o Comes to school or other activities early, stays late, does not want to go home.

The Parent:
o Shows little concern.
o Denise existence of, or blames the child, for problems at school or home.
o Asks teachers to use physical discipline.
o Describes child as bad or burdensome.
o Demanding high levels of academic and physical performance.
o Relies on child for care, attention, emotional needs.

Parent and Child:
o Do not look or touch each other.
o View of relationship is only negative.
o State they do not like each other.


Pattern of Abuse
Tension building 
o Anger builds.
o Poor communication.
o Victim feels the need to keep the abuser calm.
o Tension mounts.
o Victim constantly feels weary of abuser.
o Abuse (physical, emotional, or sexual) takes place.
Making up:
o Apology may be made.
o Promise of the last time.
o Victim blaming.
o Denial of abuse.
o Calm
o Abuser acts as if nothing has happened.
o Some promises may be met, during this time.
o Victim may believe the abuse is truly over.
o Abuser may give gifts to victim.

Adopting Parents

■ The idea of adoption has changed over the last few decades from a last resort to a natural option in creating a family.

■ With the ease of travel many adoptions are from outside the US, blending not only a new family but also cultures and races as well. (known as transracial and transcultural adoption).

■ Adoption occurs for many reasons, such as the wish to expand families or to provide a home for children in need.

• o Kinship adoption may include grandparents adopting the children of their children.
• o More single people of both genders are adopting today than ever before, as are gay and lesbian couples.

■ The Decision to Adopt

• o If the choice is motivated by infertility many issues can accompany the choice.

◆ Feeling of loss
◆ Feeling of giving up on a dream
◆ Anxiety and fear about making this decision
◆ Stress related to how to go about adoption, how society will impact their decision, how their families and support systems will react.

• o The paper work alone can be overwhelming
• o Stress may affect a marriage if couples have different coping skills or if one is more ready to adopt than the other.

■ Foster Children

• o Being able to provide the appropriate medical, emotional, or academic support for foster children with special needs.
• o Prepared to suffer the potential loss of the relationship if child is returned to home or adopted by another family.
• o Stress of how to handle the child’s biological parents and family.

■ Parenting Adopted Children
o Address children’s questions about their adoption, about birth parents, and be able to prepare child for questions by others about their adoption.
o Any parent has to be aware of changes in behaviors that indicate an emotional struggle, such as:

• ◆ Social withdrawal
• ◆ In attentiveness that affects productivity at home or school
• ◆ Anger outbursts and temper tantrums
• ◆ Attachment anxiety, fear of being alone
• ◆ Changes in eating or sleeping patterns.

■ Role of Family Therapists

• o Help the family understand the impact of adoption on the family and the child
• o Work with the children who may have a hard time talking to adoptive parents about the adoption fearing it might show a sign of disloyalty or being unappreciative.
• o Normalizing the feelings of wanting to learn about their biological parents and the reasons why they were put up for adoption.
• o Work with the biological children in the family giving them a place to explore their feelings about the adoption.
• o With the adjustment to new relationships, the family therapist can ensure positive communication and creating appropriate boundaries to benefit the children and strengthen the family.

SocialWorkExam.com offers online prep for NASW. Unlimited access to practice exams, case studies, simulations, video, audio, and flash cards 24/7.

■ The idea of adoption has changed over the last few decades from a last resort to a natural option in creating a family.

■ With the ease of travel many adoptions are from outside the US, blending not only a new family but also cultures and races as well. (known as transracial and transcultural adoption).

■ Adoption occurs for many reasons, such as the wish to expand families or to provide a home for children in need.

• o Kinship adoption may include grandparents adopting the children of their children.
• o More single people of both genders are adopting today than ever before, as are gay and lesbian couples.

■ The Decision to Adopt

• o If the choice is motivated by infertility many issues can accompany the choice.

◆ Feeling of loss
◆ Feeling of giving up on a dream
◆ Anxiety and fear about making this decision
◆ Stress related to how to go about adoption, how society will impact their decision, how their families and support systems will react.

• o The paper work alone can be overwhelming
• o Stress may affect a marriage if couples have different coping skills or if one is more ready to adopt than the other.

■ Foster Children

• o Being able to provide the appropriate medical, emotional, or academic support for foster children with special needs.
• o Prepared to suffer the potential loss of the relationship if child is returned to home or adopted by another family.
• o Stress of how to handle the child’s biological parents and family.

■ Parenting Adopted Children
o Address children’s questions about their adoption, about birth parents, and be able to prepare child for questions by others about their adoption.
o Any parent has to be aware of changes in behaviors that indicate an emotional struggle, such as:

• ◆ Social withdrawal
• ◆ In attentiveness that affects productivity at home or school
• ◆ Anger outbursts and temper tantrums
• ◆ Attachment anxiety, fear of being alone
• ◆ Changes in eating or sleeping patterns.

■ Role of Family Therapists

• o Help the family understand the impact of adoption on the family and the child
• o Work with the children who may have a hard time talking to adoptive parents about the adoption fearing it might show a sign of disloyalty or being unappreciative.
• o Normalizing the feelings of wanting to learn about their biological parents and the reasons why they were put up for adoption.
• o Work with the biological children in the family giving them a place to explore their feelings about the adoption.
• o With the adjustment to new relationships, the family therapist can ensure positive communication and creating appropriate boundaries to benefit the children and strengthen the family.

SocialWorkExam.com offers online prep for NASW. Unlimited access to practice exams, case studies, simulations, video, audio, and flash cards 24/7.

Adoption

Impact on Birth Parents

o Grieving the Loss of the Child. - Sense of loss.
- Loss of immediate life plans.
- Most struggle with the decision to place the child for adoption; those who decide to do so begin to plan for a great loss in their own lives with the hope that placing the child for adoption will result in a better life for their baby and for themselves.
- Trauma can be impacted by the process, lack of support, the behavior of the adoption agency, or level of communication with adopting family.
- Clients often express feelings of numbness, shock, and denial, as well as grief.

o Normalize these as typical reactions to loss. - An added struggle with this type of loss is the greater sense of privacy around it which may limit help from support systems who may not be informed.
- Due to the secrecy, this loss often lacks typical cultural rituals or ceremonies to gain closure.

o Grieving Other Losses. - Loss of parenting role.
- Feelings of loss may reoccur during holidays, anniversaries or birthday.
- Stress of pregnancy and adoption may take a toll on the partner/marital relationship.
- If client is young, this may also cause a significant issue in parental relationships.
- If young, the client my have to drop out of school.

o Guilt and Shame. - Societal values often show a lack of understanding over the circumstances leading up to adoption.
- Culturally, there is an association of shame with unplanned pregnancy.
- Client may express feelings of unworthiness.
- Clients who discuss their feelings with supportive friends, family, or counselors may more easily come to terms with their decision over time and be able to integrate the experience into their lives in a healthy way.

o Identity Issues. - Clients often ask themselves if they are “parents”.
- Some mothers may experience a sense of incompleteness after giving birth.
- Parent status is not acknowledged by society, family, or friends for those who give up children for adoption.
- The issue of being involved in the child’s life and how to integrate with the adoptive family is an important one.

o Long-Term Issues. - Feelings about the adoption may be life long, but varying in intensity.
- Some of the factors that have been found to be associated with longstanding grief include:
⋄ A birth parent's feeling that she was pressured into placing her child for adoption against her will
⋄ Feelings of guilt and shame regarding the placement
⋄ Lack of opportunity to express feelings about the placement
- For some birth parents, the ability to establish a successful marriage or long-term relationship may depend on the openness with which they can discuss their past experiences of birth and adoption placement.
- Some birth parents never tell their spouses or subsequent children of their earlier child.

Addiction treatment modalities

Outpatient Care

⋄ Techniques vary by clinician but typically include :

• o cognitive-behavioral therapy
• o problem-solving groups

⋄ Low success rate with heavily addicted individuals.
⋄ Moderate addicts may find that this level of treatment is enough to end their drug abuse problems.

12 Step Programs

⋄ Clients attend meetings.
⋄ Preferable after or in conjunction with some other form of drug treatment
⋄ There is the belief that they will never "recover" from their drug addiction.
⋄ This type of program may leave many feeling powerless (one of 12 steps is to accept powerlessness) over ever ending their battle with drug addiction.
⋄ This type of program may work for some, but has low success rate.


Inpatient Short-Term Rehabilitation

⋄ Substance abuse treatment that lasts typically for 30 days.
⋄ Overseen by medical professionals and trained counselors, often Certified Drug Addiction Specialist.
⋄ Goals are primarily physical stabilization, abstinence from all use, and lifestyle changes.
⋄ Primarily founded in a modified 12-step approach.


Inpatient Long-Term Rehabilitation

⋄ Inpatient long-term residential program is a 24 hour a day 7 days a week treatment.
⋄ Duration can be from several months to a year or more.
⋄ Residential treatment is conducted in non-clinical settings known as therapeutic communities.
⋄ May also include additional treatment strategies such as social education.


Methadone Maintenance Treatment

⋄ For clients with a dependence on heroin or other morphine like drugs.
⋄ Methadone decreases the feeling of pain and reduces emotional responses to withdrawal symptoms.
⋄ A dose typically suppresses an addict's symptoms for 24 hours.
⋄ Downside:

• o Clients are physically dependent on
• o They may find themselves using it for many years after they start treatment.
• o Methadone may be more difficult to withdrawal from than heroin.
• o Maintenance involves more time, pain, and expense than heroin withdrawal.

SocialWorkExam.com offers online prep for NASW. Unlimited access to practice exams, case studies, simulations, video, audio, and flash cards 24/7.

Adlerian Therapy

Adlerian Therapy

Adlerian Concepts

■ Basic Mistake- faulty, self defeating perceptions attitudes and beliefs, personal myths

■ Fictional Finalism- imagined central goal that gives direction to behavior and unity

■ Holism- study of humans as integrated beings

■ Insight- special form of self awareness

■ Style of Life- individual’s ways of thinking feeling and acting

■ Complexes

• Inferiority complex- normal feelings of incompetence exaggerated, feeling its impossible and hopeless to reach goals
• Superiority complex- very high opinion of self, bragging, quick to argues often

■ Organ Inferiority- everyone is born with some physical weakness, this motivates life choices

■ Aggression Drive- reaction to perceived helplessness or inferiority, lashing out against the inability to achieve or master

■ Masculine Protest- kids work to become independent from adults and people in power.

■ Perfection striving- people who are not neurotically bound to an inferiority complex spend their lives trying to meet fictional goals

• Elimination of perceived flaws
• “As if” philosophy
• Gives motivation and focus

■ Social responsibility and understanding of social issues
o Occupation tasks

• career
• self worth

o Societal tasks

• Creating friendships
• Social networks

o Love tasks

• Life partner

■ Positive and Goal Oriented Humanity
o People striving to overcome weakness to function productively
o Urge to contribute to society

Adlerian Therapy Process

■ The role of the client
 o Explore private logic- concepts about self, others and life
o Discover purposes of behavior or symptoms of basic mistakes associated with their coping.
o Learn how to correct faulty assumptions and conclusions

■ The Client Therapist Relationship
 o Based on mutual trust, respect, confidence and alignment of goals.
o Collaborative relationship
o Develop a therapeutic contract (goals for therapy)
o Emphasis of responsibility on client for his or her own behaviors


Techniques

■ Establish a therapeutic relationship
 o Therapists gets to know the client as a person
o Collaborate on goals for therapy
o Supportive therapist creates caring human connection
o Therapist work to make client feel deeply understood and accepted.
o Client focuses on what needs to change in therapy.

■ Explore the psychological dynamic operating in the client
 o Consists of a subjective interview
o Clients tells own story as expert on own life
o Therapists listens for cues to client’s coping and approach to life
o Objective interview ■ Family constellation
■ Early recollections
■ Personal priorities
■ Integration and summary

■ Encourage development of self understanding (insight into purpose)
 o Understanding motivates that operate in client’s life
o Client disclosure and therapist interpretation (open ended manner)
o Make unconscious into conscious
o Confront resistance to help client and therapist align
o Explore purposes of symptoms, feelings, behaviors and human difficulties or block

■ Help client make new choices (reorientation and reeducation)
 o Encouragement process
o Change and search for new possibilities
o Make a difference through change in behavior, attitude and perceptions.



SocialWorkExam.com offers online prep for NASW. Unlimited access to practice exams, case studies, simulations, video, audio, and flash cards 24/7.

The Impact of Developmental Disorders on Family Systems

Symptoms of Developmental Disorders

■ Aggression and perhaps violence

• o Work with family on behavioral issues, reinforcing appropriate behaviors.
• o Work with family on parental coping skills with difficult situations.

■ Alienation of parents, caregivers and authorities o Educate family on the symptoms of disorders and what to take as a symptom rather than a person attack.
o Processing how to handle isolation moments, what the client shares as input on how they would like to b addressed or left alone until ready to return to family participation.

■ Antisocial attitudes and actions o Insight and reality therapy with clients on what impact their behaviors have on the family- natural consequences.
o Make sure family has consistent discipline for inappropriate behaviors.

■ Behavioral and learning problems at school o Encourage family to be in close communication with school figures to prioritize school goals and continue strengths.

■ Cannot express trust, intimacy and affection o Educate clients on the realities of the disorder and behavioral symptoms.
o Work with families to process feelings in regard to having a loved family member who has not yet developed these essentials of relational interaction.

■ Lacks empathy, compassion and remorse o Parenting skills enhanced to encourage the education and modeling of these skills in the home to promote it within the client.

■ Needy and clingy, or pretends independence o Behavioral methods encouraged by all family members to make sure enabling is minimized and support for growth is promoted.

■ Withdrawal and perhaps depression or psychosis o Work with family to ensure the therapy treatment and medications are attended to