Essential Skills in Family Therapy: Book Summary

In the third edition of the book Essential Skills in Family Therapy: From the First Interview to Termination , authors JoEllen Patterson, Lee Williams, Todd Edwards, Larry Chamow, and Claudia Grauf-Grounds explore various disorders, trauma, psychosis, family issues, couple issues, spirituality, somatization, and personality issues. The is categorized into 13 chapters that discuss topics such as preparations to become a family therapist, the initial interview, assessment guidelines, treatment planning, required skills and treatments for family therapy, and helping families and children respectively. They also discuss helping older adults and their caregivers, therapy focused on couples, helping families with mentally ill individuals, the issue of being stuck, and the relevant issues for beginning therapists respectively. The present paper summarizes the chapters before reflecting on the major points of the book 

Chapter 1 & 2 

In the first chapter, the authors focus on new therapists in which they highlight several points. For instance, they note that beginning counselors usually feel insecure and inadequate regarding their abilities mainly due to lack of experience. Specifically, beginning therapists doubt their ability to assist clients, are concerned about harming clients, and question their ability to be therapists. Therapists can address these concerns by accepting their anxieties and recognizing that it is a normal experience, not a demonstration of inability. In particular, new therapists usually interpret unrelated feelings such as being overwhelmed or fatigue as potential demonstrations of their inability to be counselors. It is also worth noting that therapists should develop therapeutic associations with their clients, as this is their main role and can help them address the concerns they feel when beginning. Positive relationships with clients are therapeutic because the therapist does not do anything to establish a good relationship. Besides, many therapists trust their relational skills, which they can use during the initial encounters. 

Other measures that new therapists can use to address the initial concerns include avoiding panicking, sharing their thoughts with experienced counselors and supervisors instead of feeling incompetent, learning from their early experiences, and identifying the source of their fears. It is essential to locate the origins of the concerns because some of them may be due to unrealistic expectations or distorted thoughts. Such sources result in critical self-talk or attempt to be perfect, which the therapists should reflect on to identify any unrealistic performance demands that exceed their training level. Reflection is essential because new therapists start feeling confident about their work and skills after practicing for about 700 hours. The concerns can also reduce after about three months of practice but after 700 hours, the therapist will have adequate experiences that allow them to become more confident even though they may experience doubts. The authors demonstrate that doubts occur naturally and therapists will experience them periodically when helping clients. 

The authors also emphasize the importance of therapists increasing their knowledge about the biological component owing to the role of biological processes in several mental illnesses. Family therapists select an appropriate intervention using a specific theoretical model and should evaluate the required treatment for the presented issue. Nevertheless, sometimes the presenting issue is not within the family therapy domain, requires extra skills possessed by other psychology experts, or requires the therapist to collaborate with a health care expert from another field. In particular, practitioners must be aware of the evaluation, intervention, and pharmacology of the presenting problem by collaborating with different intervention groups and multidisciplinary intervention strategies concerning the biopsychosocial model. In turn, this requires therapists to find ways of collaborating with different experts in the healthcare field, as they may need to consult physicians and other experts to establish an active interdisciplinary team. 

The authors also demonstrate how therapists learn therapeutic skills. In particular, therapists learn through three phases in which they start by learning basic skills before conceptualizing cases and identifying their role in creating a therapeutic relationship. The first phase usually entails mixed emotions such as irritation because of not serving a client, joy for being a therapist, and increased anxiety levels. However, the first phase allows them to practice and learn essential competencies. In the second phase, the therapists start recognizing the needs of different clients and the required solutions in addition to the different factors that affect the effectiveness of the therapy. In the final phase, the therapist is competent enough to know their role in interventions. 

In the second chapter, the authors focus on initial interview preparations by discussing family expectations about therapy, family anxieties, factors that influence clients to seek therapy, and their preparedness level for interventions. The authors show that crises compel families to seek therapeutic assistance. In particular, members of a single-family usually have different views about the need to seek assistance about an issue. The family only initiates the therapy after exhausting their resources for tackling issues and after being desperate for a solution. Consequently, the therapist must attend to the potential issues by listening and paraphrasing various views, evaluating the critical level of the issue, and considering the issues that fall under the therapeutic scope of practices. Listening carefully during the initial interview is particularly important because it helps the therapist to identify secrets concerning the family. Awareness of these truths is essential because it enables the therapist to offer appropriate responses to help clients view the importance of therapy in resolving the issue or deciding if clients require a different intervention. This is critical because some issues concern the biomedical domain or include additional problems such as substance abuse or suicide risk, which may require the clinician to possess appropriate training or seek assistance from other fields to address the issue adequately. 

The authors highlight that clients usually initiate the contact to assess the ability of the therapist to help them address the issue they are facing. In particular, new clients are usually concerned about how caring or empathetic the therapist is and if the therapist can help them solve the issue. However, clients do not usually ask directly when seeking answers to such questions. Rather, they assess the speed at which therapists return their calls or how well the therapist can learn from brief descriptions of the issue. Thus, how well the therapist responds to the client offer answers to the client concerns. For example, if the therapist discusses the required fees more than attending to the client explanations, then the client may get the impression that the therapist values finances more than client issues. In turn, the client may never attend the first session. Consequently, the therapist should demonstrate confidence and empathy during initial encounters with the client to set the basis for future interactions. Therapists must understand the people they are communicating with such as the identity of those making calls and the reason for deciding to make the first step. The initial content of the call should focus on relevant and essential issues and information. For example, therapists should acquire information about the primary issue and evaluate its effect using scores such as moderate, crisis, or severe. Besides, the therapist should determine whether the issue is chronic or a recent occurrence, the initial responses of the family to address the problem and if there was an intervention previously. Seeking such relevant information lays the foundation of the entire engagement with the family and facilitates the participation of all members of the family. 

Regarding attending therapy sessions, the authors demonstrate that therapists must not compel all members to be involved in all sessions. Rather, the therapist must ensure that all involved members understand the importance of including members who are considered irrelevant to the issue even though it would be helpful if all involved people participate. Still, the therapist must gain insights into the family to identify those who want to attend sessions and the reasons for attending in addition to those who hesitate. It is also vital to identify family members who the problem affects the most and their availability for face-to-face interactions. Gaining insights into the family members to identify the willing and unwilling members is essential. The authors also caution that it may be inappropriate to involve all age groups. In particular, while the therapist must form a relationship with all family members, each member does not need to attend all sessions. The basic information acquired initially helps the therapist develop a theory that can be altered after obtaining more information initially and during the treatment process. 

Chapter 3 & 4 

The authors continue with the initial interview topic in the third chapter in which they demonstrate that the initial interview begins when the therapist develops connections to join with clients. Establishing a connection is considered a key focus during the first session and its success affects future sessions. Specifically, clients expect to connect with the therapist securely before sharing their secrets. Ignoring this step can be destructive throughout the entire therapy process because clients will hesitate when it comes to sharing information or can terminate the treatment. In particular, successful connections with the client occurs when the therapist instils a sense of care, respect and understanding towards the client. 

However, connecting with the client is a process that starts when welcoming clients and requires the therapist to be fully attentive. For instance, when the client arrives for the first time, the therapist should ensure that the client feels at ease by engaging in social discussion. Listening to the client carefully and responding to their questions respectfully throughout the therapy process also helps in establishing a connection. In particular, the therapist is encouraged to discuss administrative matters including confidentiality, information sharing, and the presence or absence of recording such as videotaping during the initial interview. Other techniques to facilitate connections include leaning forward, direct eye contact, and reflective listening. These measures demonstrate a caring attitude to the client. However, the authors caution that establishing a connection involves more than the aforementioned techniques because factors such as the compassion, experiences, attitudes, and personality of the therapist are also relevant. Therapists must also be careful about their features because aspects such as biases against specific people based on religion, status, sexual orientation, ethnicity, or race can hinder their ability to develop an effective relationship with the client. Thus, the therapist must be vigilant about those features and ensure that they do not interfere with relationship building. 

Fee management must also be discussed in which the therapist ascertains client anticipations and determine the therapeutic objectives. Discussing the issue of fees can be challenging and demanding because of confusion about valuing the therapy in monetary terms in which most therapists experience unease feelings regarding charging the client while helping them. Nevertheless, since the therapeutic association has a business element, the ability of the therapist to deal with such issues increase with experience. The therapist must still ensure that discussions about fees are direct, factual, and clear. They must also be sensitive to the customary fee in their geographic area and avoid working outside customary fee ranges. Other important considerations include payment forms, payment time, and any extra costs for non-attendance or late cancellation. It is essential to discuss fee issues as this helps the therapist to clarify the role of the family in the therapy. 

The therapists should also explore client expectations about the goals of the therapy and explore ways of accomplishing those objectives. This is essential because clients vary in the way they express their goals. For example, some start directly and express their objectives while others offer extended narrations, which usually requires the therapist to establish objectives from those narrations. Besides, family members may have different views about the objective of seeking therapy and the therapist must take time to listen to individual views. The therapist must also identify any differences between the goals of the client and the therapeutic objectives. 

The initial interview also involves the therapist evaluating motivation to identify whether there is a need to increase the desire to engage in the intervention and establish personal credibility. In particular, behaviors such as reluctance to pay the agreed fees demonstrate low motivation for the treatment as most clients consider free services as less helpful. Fees act as encouragement to ensure clients use the therapy service effectively. Nevertheless, clients are usually motivated to seek help for different reasons. Therapists can determine the client motivation when describing client goals for the treatment. The responses of the clients about their objectives helps the therapist identify unmotivated and motivated clients. In particular, clients who describe their issues are motivated while those who state that someone else compelled them to seek assistance may present motivation issues during treatment. 

In the fourth chapter, the authors offer details about the need to formulate a general plan for assessment in which the therapist explores existing issues, tried resolutions, and identify coexisting stressful events. These elements are usually obtained during the initial assessment phases. After obtaining the basic information, the therapist explores other relevant matters such as possible harmful issues such as sexual, emotional, or physical abuse and family violence and a discussion of the duty to warn. Other elements to be included in the plan include concomitant biological issues. However, obtaining comprehensive information is not always possible for all clients due to the reluctance of some clients to offer the necessary data before trusting the therapist. An assessment plan is vital because it helps the therapist identify client elements that may hinder effective therapy. 

The initial interview also offers opportunities for the therapist to explore psychosocial matters by examining spirituality, belief system, cognition and mood, and behavior as well as exploring the extended couple or family system with the related outside systems. Psychosocial topics are relevant because of their effect on the client. The therapist should also evaluate family associations in the community and in the wider social contexts, which is vital because family members reside in a larger social system comprising of neighborhoods, a network of friends, work settings, and schools. Others include healthcare services, social service organizations, and the courts. Thus, assessing the wider context allows the therapist to identify the way other factors beyond the immediate family affect the client. For example, systems in the wider social context can offer useful resources or support, which affect family functioning positively. Families can also obtain instrumental or emotional support from friends and extended family. In particular, assessments showing that clients lack adequate support can offer an opportunity to develop a positive support network. 

Furthermore, the therapist should organize additional information in the wider social context in terms of suicide rates based on demographics with a comparison of factors such as the effect of residing in inner areas of the city, economic status, physical diseases, fortune reversal, mental issues, alcoholism, recent grief, childhood loss, ethnicity, sex, and age. Assessing these issues helps the therapist to be aware of the potential issue of harm. It is particularly useful to examine the factors and warning indications about suicide to ensure that the therapist identifies the potential for suicide attempts among clients. Other elements to be reviewed entail any attempted suicides besides suicides attempts in the family including relatives. The therapist should also identify data related to warning signs for suicide. Nevertheless, such assessments require the therapist to focus on details and possess the required training to understand specific risk factors. 

The therapist should also review disruptions in the marriage such as divorce. Such assessments help to uncover potential commitment issues and the functioning of the family. Besides, the disruptions affect partners differently and assessing them allows the therapist to identify the partner that suffered the most from the divorce. It will also uncover the partner who requires more assistance after the divorce. Besides reviewing marriage disruptions together with external systems is also useful in understanding interpersonal and individual dynamics in the family. For example, the therapist can examine the relationship between the clients and their workmates and friends, to learn how members interact. 

The authors also present an assessment model for alcohol use disorder. Assessing these aspects is essential because of its effect on relationships and suicide risk. In particular, if the wider social context is characterized by alcoholism, then the therapist can anticipate adverse effects such as alienation and isolation. Alcoholism is also a contributing factor to other forms of abuse such as family violence and child abuse. Generally, the therapist should conduct a thorough assessment to identify the relevant factors within the family system and across the wider social context where the family resides. Such an assessment helps the therapist uncover different factors and their influence on the client. 

Chapter 5 & 6 

In the fifth chapter, the authors discuss potential difficulties that therapists can face when developing a focused intervention. The first difficulty concerns the challenge of formulating structure during the initial two sessions due to regular crises and chaotic family life. It is, thus, essential for the therapist to play an active role in establishing the structure immediately when interacting with clients for the first time. In particular, the therapist should lead and guide the client throughout the therapy process by formulating the structure in which the therapy format is identified including the rules to be followed by participants. Another issue concerns failing to implement session agendas. The challenge hinders the formulation of a therapeutic plan since each session is turned into a discussion about addressing the existing chaos without time for addressing the major issues cohesively. For example, the therapist may focus on addressing issues of client self-harm throughout the session rather than set adequate time for assessing the situation and formulating a therapy plan. Consequently, the therapist may take the wrong path by considering these immediate issues as the core issues to be addressed. Such a focus leads to more problems such as non-attendance and reduced motivation, which hampers the therapeutic process. 

Another difficulty is the need to deal with every issue. In particular, after conducting assessments during the initial interview, the therapist usually possesses a list of relevant issues and think that all the issues must be addressed. The authors recommend that rather than focusing on addressing each issue that emerges, the therapist should work on a single intervention plan to address critical issues identified during the initial interview. Specifically, the therapist should prioritize issues to ensure that they focus on crisis and safety issues first before attending to other issues. The therapist can even re-evaluate the issues to work with the family to prioritize relevant ones only since the intervention plan should focus on 2-3 issues. It is also worth noting that therapists who do not maintain fidelity to a single intervention plan and the major issues may have underlying issues such as inadequate theoretical orientation. The authors emphasize that all therapists must have adequate skills in the relevant theoretical model to be in a position to deal with large data volumes and work with different families. The model aids in identifying relevant data and issues to allow the therapy to focus on critical issues only. Therapists lacking skills in relevant theoretical models are usually overwhelmed by the data they receive from clients as they are forced to use individual experiences to understand the data. 

The authors also discuss proven processes and the reasons for the therapists to possess a single theoretical framework to guide the selection of intervention approaches. Specifically, the authors demonstrate that therapists should be knowledgeable in different theoretical models as this helps them to integrate theoretical ideas that they can use to make decisions during the treatment. A therapist can also use detailed therapy plans to document client data; develop a genogram; state the key issue, tried the solution, and the views of the family regarding the desired results; identify the history of the key issue; assess the biopsychosocial system; and develop the hypotheses by restating the issue, formulating goals, and identifying interventions. The therapist should also identify additional needs such as the required collaboration or referral and document them in the plan. The therapist may need to collaborate with a multidisciplinary health care team or refer patients for psychological examination or psychopharmacological treatment. The authors also emphasize that therapists must know about the common psychotropic drugs for various mental issues such as psychotic problems, OCD, bipolar disorder, anxiety, and depression to ensure effective treatment. They also stress that regular assessment concerning the treatment effectiveness is the key to evidence-based intervention. 

In chapter six, the authors caution against rushing into the treatment part before developing a relationship with the client. They also demonstrate that the effectiveness of the therapy relies on a strong and reliable relationship between the therapist and the client. Other factors such as a reliable theoretical framework or intervention approaches cannot produce positive therapeutic results if the therapist and the client have a poor relationship. In particular, therapists who face challenges when beginning the practice usually ignore the step of connecting with clients to establish a meaningful relationship by focusing on the need to implement a therapeutic intervention. Nevertheless, the problem should concern the initial training that focused their attention on proven therapeutic models. The authors recommend that new therapists should first connect with their clients by understanding their stories, communicating empathy to clients, and demonstrating interest in the client’s narration. 

The authors also review the essential counseling skills in which they discuss the time for and the time to avoid self-disclosure. An emphasis is placed on trust in which the authors argue that clients trust the therapist first before they can interact fully. Specifically, clients want the therapist to work with them, assist them, and be honest. Therapists are advised to avoid disclosing information about themselves unless it is necessary to help the client. Besides, the therapist must state their status clearly concerning their practice. For example, they must ensure that the client knows that the therapist is being supervised, on training, or is working in a team. Such disclosures enhance trust. Nevertheless, only the client is allowed to self-disclose throughout the therapeutic process since the therapy content concerns the client. While the therapist places the welfare of the client first, he or she may engage in self-disclosure in the context of the treatment process. Factors such as the established relationship, the client age, credibility of the therapist, effect on clients, and the type of information to be disclosed affect the self-disclosure level. Regarding self-disclosure, therapists are advised to follow five guidelines including normalization; reframing; lineal, reflexive, strategic, and secular questioning; support provision, confrontation, and pacing; and addressing the crisis. 

The book also emphasizes the importance of psychoeducation, which is a form of written and verbal information regarding common issues in families. For instance, the therapist can offer handouts covering specific topics, direct clients to reliable internet resources, and suggest a list of self-help printed materials. These resources help families gain insights into the relevant issues. It also highlights the unique skills that therapists require to deliver a relational or systemic intervention in family and couple therapy. The authors explain genogram in addition to competencies such as improving communication skills, agency and being personally responsible, help mobilization, and interrupting adverse interactional patterns. These skills are needed to develop communion or a sense of belonging. However, therapists must practice careful listening to identify relevant concepts and patterns. Genograms are particularly useful because they help therapists to create a visual depiction of various family members and the relationship between members in terms of age, generation, and gender. Counselors are also advised to consider other factors such as the anxiety levels of clients, the timing of the intervention, and the content and process of the intervention to ensure the selection of an appropriate intervention. Therapists can also use these factors as a self-assessment tool to review their skills concerning operating in a family therapy domain, assessing and intervening, and forming a therapeutic association. Using the tool, the therapist can consider the focus of the intervention, the effectiveness of the intervention, when to apply it, and ways of evaluating and managing anxiety in sessions. 

Chapter 7 & 8 

In chapter seven, the authors detail the family lifecycle stages. They stress that authors must be aware of the development stages in a family to ensure that they engage in proper assessment and implement appropriate interventions, particularly for issues affecting adolescents and children. Specifically, six stages encompass relevant emotional mental processes and development roles in each stage. The stages include leaving home, marriage, and presence of young children in the family, presence of adolescents in the family, moving on after launching children, and later life. Owing to the lack of a specific sequence through which families develop, the authors suggest that rather than focusing on sequential development when using the family lifecycle, therapists should focus on ways clients address transitions between stages. The transitions are particularly important because they also involve changes in diverse aspects such as relational, mental, behavioral, and emotional. They may also involve significant levels of fear and pain, which necessitates the therapist to be careful during assessments to avoid trivializing issues. The family lifecycle also demonstrates that issues in families arise mainly during a transition from one stage to another. Using the developmental stages, therapists must understand events at individual transitional phases to identify presenting issues and understand family predicaments fully. Proper use of the model allows therapists to address chaotic emotions in the family, which contributes to the development of a positive working relationship. 

The authors also explain challenges facing families with young children including issues related to shared expectations and responsibility, safety, and space. They show that issues among couples are dominant when they have young children mainly due to the response of the couples to a new child. Specifically, some couples usually neglect their young children after lacking adequate resources to care for the child. However, couples that embrace the new child and have the needed resources to care for the child do so by neglecting other demands altogether including the relationship between the couples. Such couples are prone to suffer from independence issues in a later stage, which can lead to depression or distress in the marriage. In particular, issues arise due to the need to balance financial, household, and childrearing needs. The issues can be severe for those who bear a child outside marriage. Other issues that can arise during this stage entail gender problems regarding roles, space, expectations, shared responsibility, and safety. Assessment at this stage usually focuses on the couples and the child with an emphasis on attachment matters. 

The authors also highlight issues and challenges involved in families with school-going children in which they discuss the importance of establishing connections with schools. While challenges at this stage are similar to those for families with young children, families at this stage interact with the wider social context such as schools and sports. Children at this stage also have peers, who the therapist must consider in addition to schools when assessing issues. Other relevant people such as cousins, uncles, aunts, and grandparents are also considered concerning boundary issues. Some of the issues that may arise among children at this stage entail self-esteem issues, negative or positive emotions regarding learning, and peer relationship issues. Such issues require the collaboration between parents, the therapist, and the school stakeholders such as teachers to help the child become competent in specific domains such as music, art, or sports. 

The authors also review the unique challenges posed by adolescents to families, the required skills to deal with adolescents, and the effect of technology on adolescents. In particular, they suggest that families must be flexible to transition from this stage given that competing family needs converge at this phase. For instance, adolescents have the flexibility to move and start establishing important relationships outside the family. The behavioral decisions may also conflict with family values, which can lead to issues. The role of the therapist at this stage is to ensure that the family adapts positively. The authors also discuss disruptions and transitions in the family such as the graduation of children, divorce, and children leaving the home. They also explore mediation aspects related to the assessment of child custody and discuss the topic of families with single parents and the role and effect of stepparents. The authors also demonstrate the matter of the presence of older adults and parents in chapter eight. They argue that the society does not focus much on the mental issues affecting older adults due to the stigmatization issues. The stigma also prevents the seniors from seeking therapeutic assistance even though effective interventions exist. 

In particular, families can also care for the handicapped or older members. Handicapped seniors may find it challenging to solve normal issues, experience memory and executive function issues, and engage or fulfil daily activities. As a result, feelings of isolation and beliefs among older adults that they are a burden may emerge. In such situations, family members play an important role in helping seniors live normally. The family can help by driving seniors to attend appointments or managing their finances. Nevertheless, such families face challenges such as a lack of awareness regarding ways of dealing with older adults, particularly among daughters and wives. Others include the role of family members, family authority issues, and new responsibilities. Caregivers must also balance their lives and caring for older adults. In turn, this may result in a build-up of emotions and mental problems among the caregivers due to burnout. In such situations, therapists assist clients by offering alternatives options such as placement and identifying the needs of the clients. 

There is also a discussion of treatment and evaluation required for older adults to address issues such as depression and anxiety, improve social interactions, CBT application, and facilitate healthy life practices such as exercise. Others include managing loss, disability, and decline. The authors identify the struggles therapist go through when interacting with older adults due to factors such as generational values that the client, clinic, and therapist possess in addition to ageism. In particular, ageism issues such as beliefs regarding normal psychological issues among older adults and the age of older adults prevents them from seeking therapy and adversely affect expectations about the results of interventions. Specifically, older adults think that therapy works only for young people. Other challenges entail accessibility problems and a lack of awareness regarding mental health services. The authors suggest that when dealing with older adults, the therapist should focus on a systems orientation by working collaboratively with caregivers, treatment providers, and family members to ensure that they understand the different relationships involving older clients. The therapist needs to help older adults establish a social support network involving family members, friends, and social activities. The support network is important because it allows older adults to deal with mental issues positively. The network also reduces loneliness and increases positive feelings. 

The authors also explore end-of-life topics in which they suggest resources for counselors, caregivers, and clients in addition to approaches for supporting the grieving, ensure that caregiving families are functioning, and empowering families. The authors also discuss evidenced practices for older adults, the role of music, and the required modalities for dealing with older adults. For instance, they recommend that therapists can use public resources such as the Alzheimer’s Association and the National Institute on aging to assist families with older adults. They can also use dignity therapy and caregiver family therapy for caregivers. 

Chapter 9 & 10 

The authors explore how to work with couples in the ninth chapter in which they highlight the importance of understanding the distinctiveness of couple therapy to enhance effective therapy. Some of the difficulties that counselors might face include managing a three-person association, the ambivalence of one partner regarding relationship continuity, and identifying and altering negative interactional behavior among the partners. Others include shifting the partners from blaming each other to focusing on the required changes they should make, the need to strengthen cohesion among partners, identifying existing mental issues among partners, and helping partners manage emotions. 

Another important topic concerns the role of individual therapy in place of couple counseling. The authors emphasize that therapists must develop empathetic associations with individual partners without judging them regarding their individual views on the presenting issue. Specifically, the therapist can still be empathetic to partners without inclining to one of them. Developing individual relationships with each partner establishes an initial bond that encourages interest in the therapy. However, the empathetic relationship must be developed early or during the first interaction. This early association affects the three-person relationship because a partner may feel unattended and interrupt the session. It is recommended that the therapist make it clear that each partner will have a chance. It is not advisable to interact with each partner separately because couple therapy requires the attendance of both partners. In particular, counselors should consider the couple as a single entity to focus on without focusing on either partner during the intervention. 

Ensuring success when dealing with couples entail the therapist using alternative languages than what the couple is presenting as this ensures that both sides understand their expressions and their position. The author state that the therapist can act as the translator for the couples with a focus on understanding the presenting issue and creating new ways for partners to understand each other. However, it is essential to educate the couples about ways of dealing with conflicts and communicate effectively besides teaching them about techniques for understanding each other such as the five love languages. This is useful because it enables partners to understand each other’s language. In turn, this requires that partners commit themselves to the relationship. For example, the therapist can encourage the couple to prioritize the relationship and engage in activities that led to their first love. Nevertheless, the therapist should explore the impact of other factors such as the family of each partner, their religious affiliations, and cultural values to identify the positive or negative effect of the factors on the couples. These factors are relevant because they affect gender roles and association with extended families. 

According to the authors, each family unit has its techniques of communicating and disagreeing. These techniques ensure continuity and enhance stability since the couple uses them to ensure that everything stays the same and to decrease anxiety, as each partner understand their boundaries. The authors also emphasize that each partner of the dyad needs in couple therapy must focus on their behavior in which the role of the therapist is to strengthen behaviors that enhance caring and cohesion in partners. In particular, couples attending the therapy do so after the conflict has eroded their relationship, which may result in partners distancing from each other. The work of the therapist in such situations is to provide behavioral assignments to the couples that aim at developing the ability of the partners to care for each other and bond together. The therapist may also need to conduct psychotherapy conjointly with couple therapy sometimes, which is important because it allows the therapist to focus on a single unit or the couple. For instance, the therapist can orchestrate new behaviors among couples by teaching the couple new skills. It may also be necessary to introduce emotion management skills to prevent differences from escalating. The authors also discuss relevant matters such as divorce, separation, sexual difficulties, pornography, infidelity, and domestic violence. They emphasize the importance of fostering trust through effective and open communication as one of the ways of addressing the aforementioned matters. 

The authors also examine the mental illness issue within families in chapter 10. They show the stubbornness of mental illnesses in families in which families seek treatment only after struggling for years and using many resources. They also identify factors that affect families with members suffering from mental illnesses, namely high levels of stressful life events, inadequate social support, poverty, and loneliness. These factors worsen the family situation. They demonstrate that the mental illness incidence is about a fifth of people at a given time in nearly 1/25 of the population suffering from chronic mental disorders. Consequently, while mental disorders are severe with more and fewer symptoms over time, they persist. The authors also demonstrate that mental disorders are significant stressors in families. Therapists can deal with families having such stressors through emphasizing a strong sense of family identity, common values and beliefs, and closeness in addition to understanding individual diagnosis and evaluation. In particular, family stress or family cohesion worsen or improve the situation of people suffering from a mental illness in the family. 

Counselors should also consider that mental disorders have a genetic element that results in a generation of families suffering a specific disorder. Therapists should familiarize themselves with the genetic knowledge underlying the relevant mental issues they anticipate dealing with to be able to identify them early instead of waiting for symptoms to emerge. The focus should be on preventing the illnesses from emerging or detecting the illness before it worsens. Owing to the genetic component of mental illnesses, it is also important for the therapist to understand the effect of a family and the environment on the illnesses. 

Besides, even though the therapist must ensure that members of a family understand that they are not the source of a specific mental issue, the client behavior can worsen or ease symptom presentation. Specifically, factors in the family such as critical attitudes, hostility, and over-involvement can result in a relapse. The role of the family therapist when dealing with families with a member suffering from mental illness is to consult for the family and obtain the relevant data that can be used in combination with the intervention. It is also essential for therapists to seek information from different sources to develop optimal treatments for clients. The authors identify dominant mental illnesses in families, namely anxiety issues, impulse control problems, mood disorders, and substance use issues. When addressing these mental issues, therapists are advised to focus on a holistic context in which the therapists consider the family deficits and strengths, emotional issues, social factors, and the main symptoms. The therapist should also familiarize themselves with symptoms of other relevant disorders such as somatization and psychotic problems even if they may be unable to offer the required interventions. Identifying these signs can help the therapist to refer clients to specialists for further assessment. 

Other useful statistics are that 60 percent of people suffering from anxiety seek assistance while about 90 percent of people suffering from mood problems seek help. However, only 40 percent of those suffering from substance use problems and impulse control issues seek assistance. Factors such as minority status, low education, marital status, gender, age, and the onset of the illness affect treatment-seeking behavior. In particular, minorities, married individuals, men, and the elderly do not seek treatment in most cases. 

Chapter 11 

The authors also examine ways therapists can address therapeutic impasses due to resistance to change. Therapists should expect these situations since their work involves helping clients adopt new ways of life. While all clients will be reluctant to change at some point, they vary in terms of what they resist exactly, which therapists should strive to understand. Dealing with reluctance among clients may entail identifying external factors that hinder change such as transportation issues, inadequate time due to work, or inadequate financial resources. These factors inhibit the therapy process. Resistance to change should be regarded as a normal occurrence in which the therapists must possess the relevant theoretical model while considering the client objectives for seeking treatment to be able to understand the resistance. The therapist should also convince the client to consider the effect of their behaviors such as alcoholism on the presenting problem. Therapists can also offer emotional support to clients while acknowledging how change can be challenging as this enables clients to consider potential growth areas. 

The authors also detail ways counselors can address the lack of clear conceptualization, issues related to therapists hesitating to intervene, mismatches in timing, and differences in agenda. In particular, disharmony between the client objectives and the therapist objectives may cause resistance, which can be demonstrated when clients hesitate to follow the guidelines of the therapist. Such issues usually emerge when therapists focus on individual agendas rather than establish a positive association with clients. Consequently, the therapist must demonstrate to the client clearly about the desired change and consider the timing of the therapy. Specifically, the therapists should discuss with the client when to focus on specific activities and those involved throughout the treatment process. Therapists can also address mismatch issues by evaluating the views of the clients regarding the progress of the therapy regularly to identify if adjustments are required. It is also important for therapists to understand how clients respond to their direct suggestions. Dealing with clients who resist such suggestions may entail identifying the underlying reasons for the resistance and an alternative approach to circumvent the resistance. The therapist can also use paradoxical treatment when clients are non-compliant. Sometimes the therapist may not intervene, particularly when clients talk without clarity. The issue emerges mainly due to inexperience and anxiety on the part of the therapist concerning dealing with client problems. Addressing the issues entail using the clinical reasoning procedure to familiarize with the main issues and focus on the required treatment. Unclear understanding regarding ways of conceptualization cases on the part of the therapy can also result in problems during therapy. In particular, the therapist may heavily focus on client data rather than the treatment process. Therapists may also be less consistent regarding how they apply theory to issues, which is particularly prevalent among beginning therapists. New therapists usually rush to apply their new knowledge, which can result in the use of an irrelevant approach. Addressing these issues involve commenting during client interactions to stay focused, using the relevant theoretical approach to describe the required therapy domain for specific clients, and setting clear objectives with the client during initial sessions and selecting appropriate theoretical models to help in achieving the objectives. 

The authors also demonstrate that therapists can deal with impasses by addressing unrealistic expectations regarding what they can change. Unrealistic expectations cause resistance to change in which both clients and therapists think that the clients must change for their lives to ensure improvements. Nevertheless, therapists must understand that things such as personality and temperament may not change significantly. Rather than attempting hard to change even when change cannot occur, both parties must think realistically about what can change and what cannot change. Besides, therapists must assist clients to understand what to accept as reality and what to change. Regarding things that cannot change, the therapist should help clients learn ways of managing the issue to cope as this helps to address distressing feelings. Psychoeducation can be very helpful for these situations as the therapist can use it to alleviate adverse attributions that clients may direct towards themselves. 

Another problem that can emerge during the treatment process entails issues on the part of the therapist interfering with the intervention. The issues emerge when therapists focus more on the techniques they know than on the therapeutic association. The issue also concerns the countertransference idea in which the therapist brings interpersonal material into the therapeutic association. The interpersonal material mainly involves personal behaviors, feelings, and thoughts from the therapist’s past life. Counselors can deal with the behaviors that disrupt intervention by normalizing individual responses during the treatment, establishing a working association with the client, and reviewing and clarifying the role of the client regarding the intervention. The therapist must also set and acknowledge clear boundaries about the intervention and consult with peers when countertransference issues emerge. 

The authors also discuss approaches that therapists can use to address non-attendance and cancellation. They state that counselors can gain useful information about the problems. In particular, therapists are advised to interpret the problems relationally by contacting the client to understand the reasons behind non-attendance or cancellation to clarify any misunderstandings regarding the therapist’s policy on the issues. Therapists should understand that clients might have emergencies that prevent them from attending sessions. However, some clients communicate their discomforts about the therapeutic process through non-attendance. For such cases, the therapists should re-assess the therapeutic relationship, identify whether the therapeutic objectives are being met, and determine whether to end the association. It is also important to understand that underlying issues such as family abandonment issues or those suffering from avoidant personality or borderline disorders are vulnerable to non-attendance issues. Clients may also feel that the therapist validates some members more than others and decide to cancel appointments to demonstrate their displeasure indirectly. Thus, the therapist must assess the stability of the therapeutic relationship regularly to determine the treatment progress. It is also important for therapists to strive to understand the reason for non-attendance and ways of managing the issue. 

Additionally, the authors emphasize that therapists should cope with hidden issues and deal with clients whom they have a poor relationship with or those they dislike sometimes. In particular, the issue of confidentiality emerges when dealing with more than one client in a single session. In such cases, therapists should address confidentiality issues. The authors suggest that therapists need to manage relevant information appropriately to avoid causing problems during the intervention. However, it is essential to use the relevant theoretical model and highlight the importance of maintaining the therapeutic relationship when managing secrets. Sometimes the therapist dislikes certain clients who challenge their credibility or due to countertransference. The authors warn that disliking clients is harmful as it undermines the therapeutic process. They suggest that therapists should identify the underlying issue about their dislike behavior and remain objective towards the client throughout the therapy process. Other suggested measures include focusing on the strengths of the client, positively framing negative attributes, becoming more empathetic for clients, and seeking supervisory assistance. 

Final Assignment 

The covered topics will affect my practice in different ways. For example, the book demonstrates the importance of considering the biopsychosocial approach to client assessment and treatment to facilitate a holistic focus. I believe it is essential to consider the approach at the beginning before starting the treatment to identify the relevant social, mental, and biological aspects of the client’s case. The biopsychosocial model is relevant because presenting problems do not arise in a vacuum. Rather, several factors interact with each in diverse ways involving the client and the surrounding environment (Hawkins et al., 2019). Consequently, the model will affect my practice by highlighting the importance of assessing numerous and diverse elements of the client’s life. Besides, the family is a large unit consisting of different members with different views and understanding. Sometimes, clients may resist the therapist’s attempt to discuss their social life while others may think that the work of the therapist is to address the problem without considering the effect of the environment or other factors on the presenting problem. Such situations require the counselor to find ways of persuading clients to cooperate and offer the required information needed to make proper decisions regarding the treatment. Therefore, it is vital to possess the required interviewing skills to facilitate the collection of relevant data. 

Besides, while the initial sessions are crucial, it can be difficult for a new counselor to understand exactly what to do. Besides, the theoretical models learned may not always be effective in real-world settings since the counselor may be required to combine different techniques to glean the required data initially while establishing a reliable therapeutic relationship. Consequently, the book’s discussion and suggestions regarding what beginning therapists should do clarify various ways in which therapists can conduct sessions. Another essential component from the book concerns the role of culture. Specifically, therapists should anticipate dealing with clients from diverse backgrounds. Cultural attitudes, beliefs, and value in which clients reside can affect their behavior and feelings. Indeed, the therapist also has individual backgrounds, but the book demonstrates that the client is the focus of the therapist. Thus, everything should be understood from the client’s perspective and that the therapist should understand clients as products of their environment. This environment offers them spiritual and cultural backgrounds, a strong identity, and teaches them how to relate with family members and society. 

Mental issues affect people differently based on their spiritual, cultural, and ethnic backgrounds. Owing to this background, the therapist must be knowledgeable about the ethnic, cultural, and spiritual aspects of client problems to ensure the selection of an appropriate treatment approach. In particular, the assessment and treatment approaches should be structured in a way that respects the client background. Studies show that culturally competent therapists achieve positive treatment responses (Damashek et al., 2011). Therefore, cultural competence is an essential skill in addressing client issues and needs to facilitate recovery. Therapists must still strive to establish effective relationships with clients to build confidence and trust. 

Thus, implementing best practices in treatment planning in practice and personal life entails being sensitive to the cultural and individual views of the client, practicing authentic empathy, respecting the client, demonstrating friendliness, and practicing acceptance. In particular, it is vital to acknowledge and examine the way culture, ethnicity, and spirituality affects the relationship between the client and the therapist (Kopelowicz et al., 2012). Being sensitive to the client background enables therapists to explore the way personal biases, experiences, and beliefs influence how they define client problems. Implementing treatment while valuing this sensitivity also allows therapists to understand the context of the client problem and its role in the treatment process. Consequently, before initiating any treatment, counselors should be aware of the client background to facilitate an effective therapeutic process. The therapist must question the way personal views shape and perpetuate interactions with clients, treatment planning, intervention decisions, and the therapeutic approach. In short, sensitivity to client background entails understanding different views and the way the views interact throughout the therapeutic process with a consideration of the therapist views, client views, family views, the treatment approach, and the society. 

Another best practice is to ensure that there is a clear understanding regarding the way the therapist’s status and role affect the therapeutic relationship. While some contexts require therapists to be experts, the clients may sometimes see them differently based on initial impressions. Thus, the therapist must explore ways in which such dynamics in therapy influence the therapeutic process with clients. For example, the therapist should consider the effect of client views on the process and on the trust level in the therapeutic association to identify and address any issues at the beginning of the therapeutic process. Besides, the therapist should offer clients adequate opportunities to express their views, needs, and experiences. The therapist should also practice within the limits of their competence. In turn, this requires therapists to explore themselves, engage in self-reflection, and think critically or even seek supervision to gain insights into their therapeutic capacity and limitations about the offered services, the served clients, and addressed issues based on their training. 

Implementing effective treatment requires that the therapist can evaluate the client accurately to facilitate the provision of appropriate interventions within the available expertise. Besides, therapists cannot be effective if they have inadequate knowledge regarding the importance of establishing therapeutic relationships with clients, different client issues that can emerge, and the therapeutic process. Thus, ensuring the provision of competent client care entails respecting clients, taking time to understand the views of the client regarding the presenting issue, and recognizing how client background influences care. It also involves acknowledging the difference in power between the therapist and the client, demonstrating empathy by expressing the importance of individual client concerns, and eliciting client fears and concerns regarding the treatment, and developing trust and therapeutic relationship with the client. It is also essential to ensure that assessment is conducted periodically to guide treatment planning as this helps in addressing challenging and complex issues in family therapy. It also helps to focus the therapy on key areas during distractions, enables therapists to understand when clients are resisting their efforts, and reduces confusion and frustration since the therapist can categorize and delimit complexities in families. 

Several issues can arise with clients when applying treatment planning. For example, being insensitive to the background of the client may result in interventions that do not address problems concerning culture, ethnic heritage, and spiritual beliefs (Kopelowicz et al., 2012). Besides, culturally unaware therapists may not understand the way their backgrounds such as attitudes, values, and beliefs affect client impressions. Thus, insensitivity to the client background may cause the therapist to impose personal experiences on clients, which may adversely affect treatment outcomes. Beginning counselors can also find it challenging to navigate the various family issues due to lack of experience and may end up harming family relationships. Indeed, numerous therapists can conduct effective family therapy well. However, challenges arise when the therapist applies an individualistic approach to family sessions. Doing so may harm the clients. Compared to traditional one-on-one therapy, effective family therapy focuses on systemic interactions between family members to identify the way relationship dynamics perpetuate issues and the required steps that members can take to address the issues. 

Specifically, family therapy requires the counselor to focus on the family system, not the indicators of the issue. Failure to do so may result in some members being reactive or feeling left out, which may interfere with the entire treatment process. Effective family therapy entails identifying the underlying factors driving the presenting issues and ensuring that all family members make the necessary changes without blaming each other (Oruche et al., 2013). Focusing on individual members as the source of the presenting issue will certainly result in termination and they may never come back. Specifically, some families seek therapy hoping that the therapist will agree that a specific member is the source of the problem. However, therapists must avoid siding with some members as this adversely affects the treatment process. Rather, the therapist should act as the mediator whom family members trust to guide the session when conflicts arise and develop positive associations between members. Each participating member should understand that the counselor understands diverse viewpoints and shapes sessions actively (Nanninga et al., 2016). Besides, family therapy cannot involve just one member of the family because only one part of the issue will be heard, which may polarize the family. 

Other issues such as ensuring consistency during the therapeutic process may be problematic due to challenges such as transportation, the need to involve family members in the intervention, and conflicts between family members. Factors such as members of the family experiencing individual mental health problems and high-stress levels in the family can also impede engagement and attendance (Oruche et al., 2013). Studies also show that client expectations of treatment can interfere with their full engagement in treatment as some may consider the therapeutic process as too demanding or time-consuming (Nanninga et al., 2016). These issues highlight the importance of familiarizing with treatment barriers as this facilitates the creation of adequate measures to serve client needs. In particular, the therapist is responsible for addressing client needs and must ensure that challenges to proper treatment are identified and addressed. 

References  

Damashek, A., Bard, D., & Hecht, D. (2011). Provider Cultural Competency, Client Satisfaction, and Engagement in Home-Based Programs to Treat Child Abuse and Neglect. Child Maltreatment , 17 (1), 56–66. https://doi.org/10.1177/1077559511423570 

Hawkins, J. M., McPhee, D. P., & Brown, C. C. (2019). Incorporating Biopsychosocial-Spiritual Resources in Emotionally Focused Couple Therapy. Contemporary Family Therapy , 42 (3), 217–227. https://doi.org/10.1007/s10591-019-09523-8 

Kopelowicz, A., Zarate, R., Wallace, C. J., Liberman, R. P., Lopez, S. R., & Mintz, J. (2012). The ability of multifamily groups to improve treatment adherence in Mexican Americans with schizophrenia. Archives of General Psychiatry , 69 (3), 265–273. https://doi.org/10.1001/archgenpsychiatry.2011.135 

Nanninga, M., Jansen, D. E. M. C., Kazdin, A. E., Knorth, E. J., & Reijneveld, S. A. (2016). Psychometric properties of the Barriers to Treatment Participation Scale–Expectancies. Psychological Assessment , 28 (8), 898–907. https://doi.org/10.1037/pas0000229 

Oruche, U. M., Downs, S., Holloway, E., Draucker, C., & Aalsma, M. (2013). Barriers and facilitators to treatment participation by adolescents in a community mental health clinic. Journal of Psychiatric and Mental Health Nursing , 21 (3), 241–248. https://doi.org/10.1111/jpm.12076