#51 – Beginning Family Work – Part 2

Is This CBT?

Yes, by using cognitions to help change behavior in a therapeutic setting…were it so simple….

Part of my introductory training in mental health work, way back when, involved watching the Gloria Tapes three times along with a half dozen other young staffers of the Everett (Wa.) Drug Abuse Council’s clinical arm, named Karma Clinic. That name itself was about five years out of date, but in ways so was the small timber and industrial port city, one that was comfortable within itself.     

Gloria’s problems were conventional issues of anxiety, depression, relationships, and none with behavior. A pleasant and earnest woman in her 30’s, she would have been rated somewhere in the moderate to mild, 51 – 70 range on the CGAS scale. She had consented to be interviewed by three psychotherapy titans of the time, including Carl Rogers, Fritz Perls, and Albert Ellis.

Rogers was a manifestly kind and gentle man who represented the humanistic, “client-centered” approach that itself came to be known as Rogerian Therapy. That school’s clinical focus was on self-actualization, the realization toward fulfillment of one’s potentials. Perls was the somewhat theatric and more widely known proponent of GestaltTherapy, a school that focuses on one’s experience and insights as they emerge in the here-and-now, enhancing self-and-other awareness.  Ellis was the founder of Rational Emotive Therapy. That school’s clinical focus is on self-defeating thoughts and feelings, challenging their rationality, and helping the client replace them with healthier, more productive beliefs and behaviors. As a representation of the growing, coalescing clinical world at the time, the Gloria Tapes would have been more complete had they included Virginia Satir, both as a representative female therapist and as an advocate for the family approach to mental health, one that promotes mutually supportive and enhancing relationships for their clientele, in some part as a conduit toward behavior change.

The three professionals had very different approaches and left plenty of discussion material for us beginners. In her summary exit interview, Gloria said she felt most comfortable with Rogers, but would have chosen Perls. She got less from Ellis, but then again, his approach was less gravitational than those of his two magnetic peers (albeit those two were vastly different from each other) and would likely need more time to become fully engaged. Of the three, Ellis was the one toward whom I instinctively gravitated, not so much concerning his focus but for his more centrist approach to problem definition, clinical formulation, and creative solutions.

All through the 40 + years following those ‘Gloria’  staff sessions, et. al., identifying my work by a specific school of therapy never really occurred to me.  What got done is what got done, all along reasonably effective, the process grew and was best at the end, et.al.

Two years before retiring and in need of a few CEU credits before what turned out to be a last recertification, a flyer advertised a six-hour Friday workshop by Don Michenbaum on CBT. The topic itself was not of particular interest. At that time, my incorrect belief was that CBT entailed a collection of specific behavioral treatments from which clinician could choose. I didn’t do that.  The attraction was Michenbaum himself, a forerunning clinician and researcher in the field of behavioral therapies since the late 60’s, a cut below the more iconic three above. This would be like seeing Tony Bennet on a farewell tour.

Arriving at the hospital conference hall about 15 minutes late, I took a copy of the program manuscript and sat in one of the back seats. Michenbaum was well into his introductory remarks, walking back and forth across the stage. His delivery was an almost reverent overview of his specialty, then interspersed by a raspy, acerbic patter that for all the world sounded like a 1950’s Catskills comic, an odd, amusing, maybe even endearing combo that also raised questions about just what this day might possibly bring. A disappointing CEU conference could feel like an eternity, and then Friday evening travel out of the city could be long and jangly. But then, this would be the six credits needed. Maybe with a quizzical look, I continued to read through the manuscript. 

Some fifteen absorbing minutes later, I laid the document down, a bit stunned. What he outlined was what I did. I’d had virtually no idea. This 75-ish character, expertly knowledgable, maybe eccentric, out there roaming the stage, presenting his information and periodically veering into this vernacular was my role model…really? But then his show went into a live, Gloria-type interview. Buddy Hackett disappeared, and his inner therapist led his client, coincidently or not a 35-ish single female, through a beautifully done, compacted initial session replete with engagement, problem identification, tentative clinical formulation, conceptually broad suggestions, and a clear mutual appreciation to conclude. I walked out at the end with a clinical identity, supposing better late than never.

An excellent synopsis of CBT that closely resembles what Michenbaum presented is an article published by the American Psychiatric Association’s Psychological Tools section pertaining to PTSD treatment entitled “What Is Cognitive Behavior Therapy”, available via google.

Continuation on Language Shaping in Session

As stated in the last post, language shaping as a clinical tool involves two functional dynamics. The first is the intent to directly aid the client, in this instance here by facilitating clinical comfort, maintaining a clarity of roles, and preserving trust. The second function is to provide a model of interaction that can be experienced as more engaging, running less risk of being off-putting or  disengaging, and probably more of benefit to the parents.

In a way, psychotherapeutic style can be seen as being bipolar (the graphic type), one pole being directive and the other collegial. The directive style relies on unilateral expertise to develop a truth and apply their authority on remedy. The collegial style works more toward mutual discovery to understand, and include trial and error among recommended treatments. Typically, the inquiring style of the ‘expert’ is structured by the ‘who, what, when, where, why, or how’ questioning paradigm to uncover what one thinks, feels, and or does. The collegial approach is essentially “let’s explore this together”. While never much for extorting authority (despite having been a lieutenant in the army), the gravitation toward the peak of the collegial pole took time. Conduciveness to family therapy, if for no other reason than that the collegial style lends itself as a model for more effective resolution skills and solution processes within the family itself.

The following short compilation of phrases were accumulated over the first ten years or so of the practice. My first private practice clinical consultant, a conventional clinical psychiatrist and consultant with forty years experience, had an unusual combination of a personal austerity and a heightened sensitivity to other’s struggles. He modeled this humanist tone outlined here by using the first three phrases on this list as regular part of his repertoire. The rest were either adopted from hearing someone else or occurred spontaneously. Noticing a positive impact within a client, the new line was field tested, generally using the dictum ‘if something worked once, take note; if something worked twice, there’s a pattern; and if three times, the item is probably a keeper’… until proven otherwise.

Also take into account that the interpretation of spoken words can be seen as a combination of  given meanings and the personality of the conveyor. Particularly in the first half dozen sessions, clients young and old alike can find the atmosphere intrinsically intimidating to one degree or another. Beginning therapy can generate vulnerability when the delving person is essentially an unknown, even if highly recommended. Knowing the words to use is important. Knowing how you as the therapist come across using those words is equally as important if not more so. Particularly if being an unknown entity to the ‘other’, modulating some kinds of probes or critiques by a beckoning preface can reduce self-protective resistance on the part of the client, even dissipate it altogether, and help foster a growth of trust, both of the therapist and within oneself.

Cultivating The Clinician Role 

“I’m interested in understanding…..” rather than just “what…” or “how…” or the more potentially more vexing “why…”.

“I’m interested in learning more about (your feelings, thoughts, behavior, etc)” rather than ‘tell me why” or “…what”, or “…how”

“You did the work”, in response to ‘you’ve helped me so much’ when reviewing changes that have occurred

Clarifying Role Boundaries

“I work for you…”

“My job is to work myself out of a job.”

“I may have helped, but you did the work”.

Preserving Trust

When time allows toward the end of a session, on occasion randomly ask “Do you have any (other) questions you’d like to ask me?”

“How are you feeling about this process so far?.”   Some speaker years ago said that ‘super-clinicians’ are in part defined by the willingness to encourage honest feedback from clients about themselves. This line was used effectively, again on occasion, after the first few sessions of a case settling into the process and a certain comfort established in the room, particularly with complicated or evidently difficult cases.

Wading Into Difficult Waters

“I might be wrong here, but I think what’s happening here is….”

“There may be no answer to my question here, but…….”

“This will be a difficult question, but I’ll help you with it”.  Infrequent, but used particularly in a family setting, providing both direct clinical help and, in a way, parental modeling.

“Unsolicited advice is usually worse than no advice at all, so, this may be pushing things, but I’d like to suggest that…” or something along those lines. Parents in particular might remember this one, and thereafter perhaps be more judicious with their feedback to the children.

“I’m having a hard time making sense out of this, so please help me…”

Acknowledging differing opinions

“…but you understand what I’m saying – you may not agree, but you get my point of view, right?” Again used infrequently, this was usually employed with adolescents

“Right or wrong, good or bad….” When offering an arguable point of view….

Second Half of Session 4 – Family Game

Following the individual inputs and around-the-room discussions about what each participating family member wanted to see improved, the second half of the session was having the family play a game together. The game of choice was Jenga, chosen for its simplicity, being well under under thirty minutes to play, and options of approach. 

For the uninitiated, Jenga is a block construction activity that uses 54 wooden pieces,  

all 3” x  1” x  1/2”. The classic game is to build a 3” x 3” tower as tall as possible. A level is usually made of either one or two pieces, starting with two, then crossed in the middle by one, then another two, etc. The skill is to maintain balance as the tower grows. Imbalance leads the tower to crash, a cute paradigm in this clinical setting that remained unspoken.

An interesting facet of Jenga is that playing the game can be either a competition or a collaboration. As a competition, everyone is on their own. Each player works to avoid being the one who causes the stack to fall. A handful of times among the few families that chose this approach, one of the children, usually an elementary aged boy, may try to set up the following player, often a parent, to be the ‘loser’ with an odd placement that poses a balancing problem. If the parent then crashes the tower, the joy can be truly funny.

As a cooperative enterprise, the group’s interest is to see how high the stack can be built. The goal of this particular game is to use all the blocks and still have a standing tower. What I would tell all families at the beginning is that building a tower of thirty-six levels can theoretically be done but is very difficult to do. Most families gravitated toward that route and cooperated with suggestions and rooting for others.

Aside from that implicit nudge toward the cooperative approach, I remained a neutral observer insofar as the game was concerned. The clinical purpose of the family game was to gather more information about the individuals, their individual relationships, roles, habits, and demonstrated values. As the final part of the formal assessment, I also viewed the family game as an opportunity to interact more informally with them. The byproduct would hopefully be enhancing the engagement process by joining them a bit. While clinical suggestions based on evident problems could have been done, to me the rubric of ‘unsolicited advice being worse than no advice at all’ prevailed. The next session, which starts with “what can I do for you today” would begin the treatment per se and all suggestions thereafter in the session could be deemed as overtly solicited.

This family game exercise was done some 350 – 400 times over the years. Very early on, one family of four did accomplish the goal of a 36-level stack. The pride they had in doing so was palpable. The ten year old client himself laid down that final stick, ever so carefully because of the slight but potentially deadly teetering up top. Knowing this sounds like saccharine theatrics, the father had his arm around the kid’s shoulder on the way out. Given the family’s presenting issues, that father’s gesture was meaningful in and of itself.

At the time, I didn’t give credit due to this exercise. As a result, almost nothing in the way of descriptions or notes were written afterwards. And I have no record of who that family was, what were their presetting problems their family structure, or the clinical outcome. Only the accomplishment and the distinct memory remained.The difficulty of finishing with a standing tower is demonstrated by the fact that this success would never be replicated in the office by anyone. Thirty-six is a tough make. 

With very few excerptions, the families left the office relaxed, so this somewhat lengthy assessment process finished on a fitter note. 

Only one out of the 55 cases experiencing this fourth session dropped out at that point afterward. Going into session five, 54 of 58 continued.

One of the regrets in hindsight was not collecting data about how families chose to approach the game, family make-up, pre and post CGAS status, other characteristics, etc.

Lastly, the value of repetition is that norms get established over time. The positive abnormals can be confidently reinforced based on data, and the troubled abnormals can be addressed on a similar basis.