The Art + Science of Therapy, Part 4: Connecting Therapy Work to Model

Topics covered:  A review of concepts covered in previous masterclasses in the series (throughout); the common factors that make therapy work; specific factors related to the therapist and systemic work; the role of theoretical model, a conversation on couples therapy, the therapists’ influences and integration. Length: 1 hr, 11 min.



About Dr. Anna Lynn Schooley

Dr. Schooley returns for part four of her series on the art and science of therapy as craft. She is an unofficial "faculty" member here, in RTN. 

Dr. Schooley is a professor of marriage and family therapy for Capella University, as well as a licensed mental health counselor, licensed marriage and family therapist, and qualified supervisor in the state of Florida. Additionally, she is an AAMFT-approved supervisor and supervisor for supervisors.


Class Notes


* Note:  Not all resources are linked in the notes/transcript, but there is a comprehensive list of links at the bottom of this page.


Overview

This is fourth masterclass in her series on the art and science of therapy as craft.  The first three masterclasses are:

Part 1:  Foundational Skills

Part 2:  Crafting Questions

Part 3:  How to Get and Stay Focused In Your Sessions

In this masterclass, Dr. Schooley discusses how theoretical model (in general) relates to our therapy work.
 

KEY TAKE-AWAYS

A brief review:  We've chatted about micro schools/nano skills--the the tiny little behaviors that when you select them create a therapy session. In middle range, mezzo skills, are the models themselves--the actual concepts. Then, at the highest, macro level, are the common factors (Sprenkle & Blow).

Common Factors

  • Extratherapeutic factors:  The things that the clients bring.
  • Therapist effects:  For example,  strong alliance, being consistent with client expectations, etc.
  • Therapeutic relationship factors: The client’s perception of the alliance--trust, caring involvement, which is all the joining stuff.
  • Expectancy, or placebo factors:  Helping clients become hopeful; the client believing in the credibility the treatment (which the therapist may or may not
  • have a lot of effect on).
  • Nonspecific treatment variable factors:  Clients’ cognitive mastery, emotional experiencing, etc.

Common Factors specific to Marriage and Family Therapy/Systemic Work

  1. The relational conceptualization: Keeping the entire system in mind.
  2. The expanded direct treatment system: Involving more people in therapy than the “identified patient.”
  3. The expanded therapeutic alliance: Joining with every member of the system, subsystems (Minuchin, Structural Family Therapy), and the family as a whole.  The difference between having them in the room as consults, and involving them in the therapeutic process.  Including people and larger systems who are not in the room, or represented in the room.

Common Factors: Therapist Effects

  1. Creating a strong alliance
  2. Offering activity that is consistent with clients’ expectations and preferences
  3. Creating new ways of approaching problems
  4. Suggesting credible ways of learning adaptive skills
  5. Being personally well-integrated
  6. Privileging the clients’ experiences

Model

  • The model is what directs the six therapist effects..
  • The model that you pick has only a 15% effect on the outcome of therapy. All the rest of it, 85%, is due to factors other than model (Duncan and Miller).
  • But what's interesting based on common factors is that the model is one of the things that the therapist actually has agency over. That’s our influence.

Choosing our model

  • Should we choose based on personal fit?

Solution-Focused, for example:
To really be completely grounded in solution focused, It takes a lot of work. It takes a lot of reviewing of your language. This is true of all the models by the way, I mean, but solution focus is one of those that's so popular that everybody thinks. It's so easy because there's only four questions.  I sa,  if there's only four questions that means there's all this other stuff you have to have on board that you already believe in these assumptions that you already subscribe to fully in order to get away with only four questions.

SFBT and trance

Lee Shiltz starts his session with a trance induction:
“It's really great to meet you, and I'm sure that I know that I'm gonna do my very best for you today, And, I'm certain that you're gonna do your very best today.”

He puts clients in a specific place to be ready. Then his very first question is, “What would be good for us to talk about today?”

Everything that comes from this man's mouth is solution oriented in a very specific way.


"The best model to use is the one you actually know how to do."


It takes time to know how to do it. You have to do a lot of reading of your model.

  • Read the founders.
  • Read case studies, where people have used the model; particularly, case studies where they give you transcripts.
  • Find a supervisor who knows and can supervise from the model you want to learn.

Work clean (Eddie Marrero)

  • Working to the very best that you can.

  • Getting rid your idiosyncrasies and things that are not useful, that are not related to the common factors.

  • Be faithful to a model.

  • It really doesn't matter what model you use, according to common factors. It's whether you do it well.

Picking a model based on the client

  • Pick one that fits the client’s language

  • Make sure you know it!

Examples of personal integration

  • Parenting

    • Dr. Schooley’s influence as a supervisor of supervision (for Ili).

    • My (Ili’s) professor using his theory during a situation when his daughter was afraid, and how he turned it around. She ended up laughing.

Therapy is not something you do, it's what you become.

Common factors, cont.

  • They are the factors that make therapy effective, according to what we currently know.

  • They show up in all therapeutic models.
     

Ways we get sloppy, or how to avoid sloppiness

  • No longer summarizing and validating

  • The small summaries have to be in client language. Say it back to them in their words.

  • The grand summary is where two things happen: Reframing, and what you summarize is informed by your model.

    For example, the MRI (Mental Research Institute) therapist is going to summarize the interactional cycle, and the failed solution attempts.  

The Structural therapist is going to be summarizing the enactment and what they saw there and will get curious about what worked and what didn't.

The Bowen therapist is going to summarize the interactions based on triangles and triangulation and cut-offs.

Your summary is what you pick out from what the client says. It should be informed by your model, because if it isn’t, you're not working clean.

  • Check your work by recording and transcribing your sessions.

Ask yourself, “Where did my model show up in this session?” “Where would I have liked it to have been clearer?”

  • Practice

    • Therapy is “performance.” Practice is walking around in your everyday life talking to the checkout person at the grocery store, your friends on the phone, your your children, your spouse, etc.

    • Watching TV:
      What would you ask, or how would you summarize what they just said?
      What are you noticing? Does it relate to a model?

    • How would you summarize?

How do you summarize based on a model, if you are integrative?

  • Integrative means that you're taking multiple models, and you're blending them together with a common philosophy.

  • What is your “default model?”

  • Before you even know anything about what's going on. How do you start and what model is informing that?

Listen to your tapes or look at your transcript, and figure out: What did the client do or say that prompted you to flip to this other model?

If you are flipping to a model, know enough about it to do it well.

  • What does the model tell you to do?

  • What is the next concept?

  • The Grand Central Station metaphor: Commit to going somewhere!

  • For most models, you have to set up the big ideas.

Setting up the big ideas
There's a series of questions or a series of assessments that you need to do in order for the big ideas to be successful. You can't walk in the door and say “Hi! I'm Dr. Schooley, and what's your miracle? It won’t work.

  • Know the concepts, but also know how to set them up so that they're successful

You don’t have to “marry” any one model.

I suggest folks have at least three models of different types, like Bowen, Structural, and Solution-Focused, for example. They are sufficiently different. They look at the world from sufficiently different positions, so if one model isn't working, you can shift to a different one.

Progressing in a model

You need to channel the founder, to a certain extent, until you make the model your own, and I think that is something that will happen naturally.

Improvisation and Mastery
Dalí, for example, learned from the masters, and he learned how to reproduce the masters. Then, he developed his own style.

What the originator did was completely spontaneous and improvised. But, we have to learn it note by note, until we learn how to improvise.

Therapy is all improvised action.

If the client says to you, “I think the problem is I keep getting kidnapped by aliens.” You say yes, I can see how that would be a problem. I could see how that'd be inconvenient. And, you know, they don't eat the same food we do, so you probably get really hungry when that happens, right?”

Humoring vs.  joining their world

  • Get into their world right.  
  • “Putting your foot wrong” is simply a way for you to course-correct, by asking a different question.
  • There are no mistakes, only opportunities. (A mantra for life!)

Philosophical underpinnings of systemic models

Four major systems theories:

  • Cybernetics (Bateson)
  • Social Constructionism (Foucault)
  • General/Natural Systems Theory (Van Bertalanffy)
  • Communication Theory

Foundational philosophies of psychodynamic theories (Carl Rogers)

  • Unconditional positive regard
  • Genuineness
  • Person-centered

Lessons on the history of MFT

  • Stepping away from psychodynamic theories

  • Echoes of Rogerian principles

Tips on Integration

“Packaged” Integrative Systemic Models

  • Internal Family Systems (Schwartz)

  • Metaframeworks

  • Emotionally-Focused Therapy

  • You can use integrative theories, without creating your own integration.
  • If you are going to create your own integration, write a paper on it, for your own understanding of your integrative model.
     

The founders of systemic theories took ideas from other fields and applied them to
families, couples, and human systems.

A conversation on couples therapy, certifications, and practicing within a model

There's nothing to say that you can't practice a model, but you can’t call yourself an “EFT therapist,” for example, without being certified.

So why can't we say we're a couples therapist and use Bowen, and use Metaframeworks, or use the the model that informs our work?

Couples work is very different from family work.

The book, Family Therapy Review: Contrasting Contemporary Models, includes one scenario and thirty five different therapists, all from different models, talking about how they would do the first session. Family therapists would say, of course, we would do the couple's work right with the family. Couples therapist would definitely carve out the couple to do it.

Again, your model dictates how you do therapy.

Couple therapy models are moving into offering family therapy conceptualizations.

But I think that there are things happening around couples therapy that are making it feel like it's becoming its own discipline, and I think couples therapist have to figure out where they want to stay, and what to pursue in terms of model.

Dr. Schooley’s example of “landing” on her preferred model for couples therapy, after exploring new, exclusively couple-oriented models.

If we're really thoughtful about our work, we must go through that process. I am in that process now. I don't want to do Gottman. I'm not sure that I want to become EFT certified. So, I've landed on the fact that I wrote my own theory for my dissertation. I will use my theory with couples. I will use the things that I know that work with couples.


Whether you're a family therapist, or an individually oriented therapist, or if you work with couples, there's a lot of information out there. There's even a lot of pressure, I think, related to public perception about certifications, etc., with couples therapy.

A lot of therapists go with the trend, but take some time to think about:

  • What works best for you?

  • Who are you as a therapist?

Learning, and integrating new experiences into our work

Example of interns practicing Child-Centered Play Therapy, and how its principles have showed up in my (Ili’s) daily interactions.

Clinical Supervision

  • One supervisee presents a case, then the supervisor and the supervisees apply many different models to the case.

    • Every model will assess/pay attention to different things.
    • The assessment leads to the intervention.
    • In order to find the intervention, you must pick one model.

Tip:  Think about your case from several different models. Not because you're going to pursue them, but because you look at it from all these different other ways, and when you come back to it, you have a new perspective.


Bateson: The person who says that they don't have an epistemology just has a bad epistemology.


More Tips:

  • Know your philosophy.
  • Work clean.
  • Know what you believe, at least for the moment.
  • Could you answer, if someone stopped you while you were doing therapy, and asked, “What model are you drawing from?”
  • Do post-hoc analysis of your work.
  • You have to know the rules really, really well in order to break them properly.--Dalai Lama
  • How do you assess your own work and outcomes?
  • What do clients actually do that’s different?
  • Thinking vs. doing

Two things to know about a model

   1.  How you're going to manage the client's problem talk.

  • Do you flip the script and become solution oriented?

  • Do you track an interactional cycle to understand how it happens in sequence?

  • Do you look at it as identifying what the boundaries are between subsystems?

   2.  How to solicit the talk you need to have to do the model.

What kind of talk does the model have to solicit to do the work?  

For example, “What's different about the way you solicit that is Contextual?

From the Common Factors perspective:

  • What are the skills necessary for the relational conceptualization?

    • Conceptualization that it's not just happening for the individual.

    • Whatever is going on is happening within relationships, in between people.

    • It’s not a problem in me or a problem in you. It's a problem in the relationship between.

    • Always thinking in terms of what's going on in the relationship between all these different players.

  • Expanded Treatment System
    • You know you look at the genogram, and can we invite everybody?
    • Whitaker: If three generations of the family didn't show up, he would decline to meet the family.
    • From his perspective if he didn't have the whole system in the room, to see how all the parts were moving in relationship to each other, he could not make an appropriate assessment.
    • The expanded direct treatment system means that you're going to want the entire system, or as much of it as you can get.
    • If things aren't progressing, you either need to add more people or get rid of people.

The power of having the person in the room
While it's all fine and good for me to say: So, Ili what would your mom say?
The fact is, if I get mom in the room and ask her the question, there’s a 95% chance that there's going to be enough of a subtle difference that it's going to make a difference to you as the client.

The origins of family therapy and the intergenerational work--that actual conversation, or that actual listening happening in real time, you can't replace it.

Example from This American Life:

  • The story of a journalist whose Dad and uncle have not spoken to each other for decades.
  • Just one piece of information changes everything.


So, if you don't get people in the room and ask the questions that get the story, you don't have the data you need for people to have a different understanding of their world. That's the magic.

  • Most of the time, like with journalists, we trip over this. It's not what we know we were gonna find that well, but I will always find something.
  • I know it's there, but I don't know what it is.
  • I don't know when it's gonna come out.
  • I don't know what question is going to “blow things up.”

Something will pop up!

  • Assessing through your model and having the firm belief that there's something there.
  • I'm confident in the process.

The expanded therapeutic alliance

  • If you're alone in the room, and you have eleven people in the room, you have to figure out how to validate and empathize every single person's perception.

  • Solicit their perception to manage their problem talk and solicit the data that's pertinent to your model.

  • Also, holding the system as a whole, and allowing people to feel “Wow! The therapist is really with me and with us.”

Final Notes

Jeff Cotton says:

  • What is your goal for the session?

  • What is your intention for the session? And, that intention should be from your model.

  • How does your goal for the session, that is, your intention, sit with their goals and expectations?


RESOURCES

Resources on Common Factors:

Common Factors and Our Sacred Models

The Role of The Therapist In Common Factors

Common Factors Across Theories of Marriage and Family Therapy

Book on Common Factors:  Common Factors in Couple and Family Therapy

Resources on theories:

Duncan and Miller: The Heart and Soul of Change:  Delivering What Works In Therapy

Structural Family Therapy:  Families and Family Therapy

Contextual Therapy; Ili's suggested book:  Truth, Trust, and Relationships

Bowen Family Systems:  Family Therapy In Clinical Practice

Internal Family Systems Therapy, Richard Schwartz

Mental Research Institute Systemic Model:  The Tactics of Change

Steps to An Ecology of Mind, Gregory Bateson

Lee Shilts (search his name on scholar.google.com, for articles)

Maps of Narrative Practice, Michael White

1001 Solution Focused Questions

Metaframeworks: Transcending the Models of Family Therapy

Family Therapy Review: Contrasting Contemporary Models

For fun:

Bossy Pants, Tina Fey

Recommendation:

This American Life podcast

Episode mentioned in this masterclass:  Episode 597: Segment, Uncle's Keeper