Creating our Environment

"...one if the most important principles of groups is that the group is a miniature world - whatever environment we create in the group reflects the way we have chosen to live..."

Love's Executioner by Irvin Yalom

Stages of Change & SFBT

"...clients can actually be in any stage of change when presenting for counseling and still be stuck.  Using specific techniques employed in the SFBT model, therapists can assist the client through the processes of change which will ultimately result in them entering the next stage of change."

Pre-contemplation, Preparation & Action Stages:  Talk therapy has been found to be more effective (such as the Miracle Question of SFBT)

Action Stage:  Behavioral techniques such as compliments, cluing and stimulus control are encouraged.

From Solution Focused Brief Therapy by B.P. Kelch & A. Demmit

what's going on in the family?

"But for Claudia, the experience was different.  Since we have moved away from her and her problems, she looked different:  more alert, more curious, and relieved.  She was quickly composing herself and hearing every word." 

"I'm pretty clear on what's going on with Claudia and I'd like to get away from her for a while.  Can you talk about the family as a whole?"

(Claudia is the teenage daughter in a family therapy session with greats Whitaker and Napier)

From the Family Crucible

Essential Relationship Factors

Rogers asserted that the therapist ability to be empathic and congruent and to accept the clients unconditionally were not only essential but sufficient conditions for therapeutic gains.

From The role of the therapeutic alliance in psychotherapy in Journal of Consulting and Clinical Psychology by A.Q. Horvath & L. Luborsky (1993).

Our Childhood Story and Attachment to Our Children

As a result of interviewing the mothers of the children in the study, Main found a strong correlation between how a mother describes her relationships with her parents during her childhood and the pattern of attachment her child now has with her.  Whereas the mother of a secure infant is able to talk freely and with feeling about her childhood, the mother of an insecure infant is not. 

In this part of the study an interviewer asks the mother for a description of her early relationships and attachment-related events and for her sense of the way these relationships and events affected her personality.  In considering results, as much or more attention is paid to the way a mother tells her story and deals with probing questions about it as to the historical material she describes.   

At the simplest level, it was found that a mother of a secure infant is likely to report having had a reasonably happy childhood and to show herself able to talk about it readily and in detail, giving due place to such unhappy events as may have occurred as well as to the happy ones.   

By contrast, a mother of an insecure infant is likely to respond to the enquiry in one of two different ways.  One, shown by mothers of anxious resistant children, is to describe a difficult unhappy relationship with her own mother about which she is still clearly disturbed and in which she is still entangled mentally, and, should her mother be still alive, it is evident that she is entangled with her in reality as well.  The other, shown by mothers of anxious avoidant children, is to claim in a generalized matter-of-fact way that she had a happy childhood, but not only is she unable to give any supporting detail but may refer to episodes pointing in an opposite direction.  Frequently such a mother will insist that she can remember nothing about her childhood nor how she was treated.  Thus the strong impression of clinicians, that a mother who had a happy childhood is likely to have a child who shows a secure attachment to her, and that an unhappy childhood, more or less cloaked by an inability to recall, makes for difficulties, is clearly supported. 

Nevertheless a second finding, no less interesting and one of especial relevance here, arises from a study of the exceptions to the rule.  These are the mothers who describe having had a very unhappy childhood but who nonetheless have children showing secure attachment to them.  A characteristic of each of these mothers, which distinguishes them from mothers of insecure infants, is that despite describing much rejection and unhappiness during childhood, and perhaps tearful whilst doing so, each is able to tell her story in a fluent and coherent way, in which such positive aspects of her experiences as there were are given a due place and appear to have been integrated with all the negative ones.  In their capacity for balance they resemble the other mothers of secure infants.  It seemed to the interviewers and those assessing the transcripts that these exceptional mothers had thought much about their unhappy earlier experiences and how it had affected them in the long term, and also about why their parents might have treated them as they had.  In fact, they seemed to have come to terms with their experience. 

By contrast, the mothers of children whose pattern of attachment to them was insecure and who also described an unhappy childhood did so with neither fluency nor coherence: contradictions abounded and went unnoticed.  Moreover, it was a mother who claimed an inability to recall her childhood and who did so both repeatedly and strongly who was a mother whose child was insecure in his relation to her.  In further examination of the data it has been found that all these correlations also hold true for fathers. 

In light of these findings Main and her colleagues conclude that free access to, and the coherent organization of information relevant to attachment play a determining role in the development of a secure personality in adult life.  For someone who had a happy childhood no obstacles are likely to prevent free access to both the emotional and the cognitive aspects of such information.  For someone who suffered much unhappiness or whose parents forbade him or her to notice or to remember adverse events, access is painful and difficult, and without help may indeed be impossible.  Nevertheless, however she may accomplish it, when a woman manages either to retain or to regain access to such unhappy memories and reprocess them in such a way that she can come to terms with them, she is found to be no less able to respond to her child's attachment behaviour so that he develops a secure attachment to her than a woman whose childhood was a happy one.  This is a finding to give great encouragement to the many therapists who for long have sought to help mothers in just this kind of way.

A Secure Base:  Parent-Child Attachment and Healthy Human Development by John Bowlby


Ahhh! the implications...

Narrative Exposure Therapy (NET)

Working in South Los Angeles where most students are exposed to multiple traumatic events and half endorse traumatic stress, depressive and anxiety symptoms in the clinical range, I wondered what is done in war-torn countries to treat trauma?  Because addressing this through individual or small group (6-8 students) interventions by mental health professionals seems burdensome and unfeasible.

Apparently, TEN years ago a short-term intervention to reduce PTSD symptoms among civilians living in low-income and war-torn countries was developed and shows very positive and sustained outcomes among adults AND children.  

Further, "both mental health professionals and lay counsellors can deliver NET....[a] study demonstrated how lay counsellors recruited from the local area and trained to deliver NET had results equivalent in efficacy to trials in which NET was delivered by mental health professionals...The lay counsellors who provided both types of therapy were recruited from the local community and were trained for six weeks." 

As if all that were not interesting enough, NET aims to create an autobiographical account of a traumatized persons life - with details, coherence, organization, order, the good and bad - which may not only be effective in reducing PTSD symptoms.  Given what we know about the nature of a parents narrative of their childhood being a good predictor of the quality of attachment security with their children, NET may also prove to be effective in increasing attachment security between traumatized parents and children (which we know is a mediator and moderator of PTSD development) - that will be my next research question...

Attached is an abstract and excerpt from an article that describes the research evidence and steps in conducting Narrative Exposure Therapy (NET).

ABSTRACT

Individuals who have experienced multiple traumatic events over long periods as a result of war, conflict and organised violence, may represent a unique group amongst PTSD patients in terms of psychological and neurobiological sequelae. 

Narrative Exposure Therapy (NET) is a short-term therapy for individuals who have PTSD symptoms as a result of these types of traumatic experiences. 

Originally developed for use in low income countries, it has since been used to treat asylum seekers and refugees in high-income settings. 

The treatment involves emotional exposure to the memories of traumatic events and the reorganisation of these memories into a coherent chronological narrative. 

This review of all the currently available literature investigates the effectiveness of NET in treatment trials of adults and also of KIDNET, an adapted version for children. Results from treatment trials in adults have demonstrated the superiority of NET in reducing PTSD symptoms compared with other therapeutic approaches. 

Most trials demonstrated that further improvements had been made at follow-up suggesting sustained change. 

Treatment trials of KIDNET have shown its effectiveness in reducing PTSD amongst children. 

Emerging evidence suggests that NET is an effective treatment for PTSD in individuals who have been traumatised by conflict and organised violence, even in settings that remain volatile and insecure.

Conducting NET

NET is a manualised treatment. The patient first undergoes psychoeducation in which the theoretical underpinnings of PTSD and the process of NET and rationale for treatment are explained. Psychoeducation about how avoidance of reminders of traumatic events is a key feature of PTSD, and the impact of this on inhibiting treatment, is provided. Once informed consent has been obtained, the therapy can begin. Sessions are usually 60–120 min in length and ideally occur in close succession preferably with one or more sessions per week and a maximum of a fortnight between sessions.

In the first session the patient constructs the ‘lifeline’. This is a physical representation of their life using a rope, beginning at birth and ending at the present day, with a section of the rope left uncoiled representing the future. The patient then briefly goes through their life, in chronological order, placing a symbol (e.g. flowers of different shapes and sizes) on the line to represent happy events and a different symbol (e.g. stones) for sad or frightening events. The therapist's role is to ensure the correct chronology of these events. The lifeline is useful in establishing the therapeutic relationship and in providing an indication of the number of sessions that may be necessary to address all traumatic events (although some events may only be disclosed later in therapy).

Following this session, subsequent sessions are dedicated to the narration of the person's life, in chronological order, with particular focus on and attention to the traumatic events. Periods between events are described in brief to contextualise the traumatic events within the individual's life and produce a coherent narrative. On approaching a traumatic incident, the focus is on contextual information, firstly establishing what life was generally like at that time (where was the person living, what were they doing, what was a typical day) and then narrowing this down as precisely as possible to what happened when the event occurred. The traumatic events are then narrated in great detail, gently resisting the patient's attempt to hurry through or avoid emotional engagement with the memory. 

The patient then slowly narrates their traumatic experience in chronological order, as they experienced it at the time. They are encouraged to describe all sensory modalities along with their thoughts and feelings. The aim of NET is to connect the hot memories into the corresponding information held within the cold memory for the event and so the patient must be emotionally involved in the narration but must also put these experiences into words, constantly integrating the contextual information. At the same time as the narration of the traumatic event progresses, the patient's current physical, emotional and cognitive reactions are observed and verbalised. The therapist continually guides the patient back and forth between what is happening for the patient at the time of the narration (present time) and what occurred at the time of the event.  One of the aims of the therapy is for the person to be emotionally exposed to the memory of the event for sufficient time that habituation occurs and their emotional response to the memory is diminished over the course of therapy. However, this is unlikely to occur within a single session. The session ends at a safe point in the narrative, at the end of a traumatic event, once the therapist has ensured that the patient's arousal has diminished and that their emotional state is improved. The events in the period after the traumatic incident are narrated to help the patient place the episode in context.

The narrative as described in the session is written up by the therapist between sessions, this provides an opportunity for the therapist to ensure they have fully understood the details and chronology of the events described and therefore highlights areas in the story which do not seem as coherent and possibly need further exploration at the next session.

At the beginning of the next session the narrative from the previous session is read to the patient to ensure accuracy, once again expose the patient to memories of the event, elicit further information and promote integration of the hot and cold memories. Usually the patient notices a reduced physiological and affective reaction from the first session, although several sessions may be necessary for habituation to occur for severely traumatic events. 

At the end of the re-reading of the narrative, the period between this event and the next traumatic event is briefly narrated, before moving forward to the next traumatic episode, which is again narrated in intricate detail. This process continues until all stressful events have been narrated and the affective responses to the memories have reduced. At this point, the patient and therapist will have created a testimony of the person's life from birth to the present day, with a detailed narration of the traumatic events. 

At the end of the therapy some time is spent discussing hopes and aspirations for the future, following which all parties who have been involved in the therapy (including the patient, therapist and interpreter) sign the completed testimony. The patient receives a copy of this for their own private records and the authors report that it is common to find patients sharing their testimonies with others including lawyers and human rights organizations.

Pearls from The Family Crucible

Because a family comes into the therapy with such a sense of failure, it is important to show that they are unconsciously 'up to something' that is basically constructive.

Napier & Whitaker, 1978, p. 32

We try to keep the right balance of pushing and waiting, and sometimes we err in one direction or another.  

Napier & Whitaker, 1978, p. 99

Good old transferences...we therapists being stupid about it, flattering ourselves that the patient is really reacting in the beginning to us...but we are deluding ourselves if we think that the patient isn't always struggling with subtle and largely invisible ghosts and images out of the past.

Napier & Whitaker, 1978, p. 107

She felt pressured by her parents, and the [individual] therapy felt like more pressure.

Napier & Whitaker, 1978

There is another maxim:  the therapist will project his own family system onto the family he is treating.

Napier & Whitaker, 1978, p. 183

We gotta do our own family of origin work.  We gotta address the tendency toward co-dependence in our field.  The opposite of co-dependence is self-care.  We can find a happier medium between being other-centered and being self-centered - in extremes either is problematic, in balance - well that's called living well.