The phases of treatment, education, generalization and termination in family therapy PDF

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In the treatment and education phases,the family therapist tries to get family members to engage in newbehaviors. To the extent that the family and therapist have successfully completed the Therapy and Induction phase, family members should not experience any emotional or relationship dynamics that ...

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THE PHASES OF TREATMENT, EDUCATION, GENERALIZATION AND TERMINATION IN FAMILY THERAPY

The treatment and education phases In The Treatment and Education Phases, the work of the family therapist changes to “fit" the behavior into the dynamics of the family, and the therapist may assume that mistakes or mistakes occur in carrying it out due to decoding/coding problems, rather than due to an underlying dynamic. Although no less important than previous stages of intervention, at the time of treatment and education family members generally rely on the therapist's motivation and skills, and are eager to behave in ways that support their more positive motivational structure. The new attributions and cognitions of family members are relatively fragile and have to rely on the behavioral changes that are consistent with them. Therefore, the task of family therapists is to encourage family members to carry out those behaviors that are useful for the functions of their interpersonal dynamics and, at the same time, that are consistent with the new therapeutic framework attributional. Expectations of efficacy in the treatment and education phases Albert Bandura's "self-efficacy model" (Bandura, 1977) has highlighted the cognitive elements of behavior change efforts. He points out that an appropriate conceptualization for any model of behavior change is the distinction between an expectation of results and an expectation of effectiveness. In an expectation of outcomes, a patient evaluates the likelihood that a given change in behavior will produce the desired outcome. For example, family members might wonder how setting aside half an hour for a talk about ways to spend time together could lessen symptoms of crime or marital problems. Expectations of effectiveness address the question of whether a given individual perceives himself capable of carrying out a particular behavior, even if it entails a high expectation of the results. For example, a family might realize that families "should communicate better," but have little confidence that they are able to do so. The situation is further complicated by the recognition that family members may have interests of effectiveness with respect to themselves or other family members. To summarize globally, Bandura's review of the literature on psychotherapy leads him to conclude that the more direct the experience of performing the behavior, the greater the patient's effectiveness. Therefore, Bandura's formulation provides a cognitive-behavioral explanation for what has long been the emphasis of family therapy on the practice of new behaviors within sessions (Alexander and Barton, 1995; Gurman, Kniskern and Pinsof, 1986).

In the treatment and education phases, the family therapist tries to get family members to engage in new behaviors. To the extent that the family and therapist have successfully completed the Therapy and Induction phase, family members should not experience any emotional or relationship dynamics that prevent them from acquiring and carrying out a new behavior. On the contrary, family therapists may assume that the transition from the treatment and education phases does not require the manipulation of the thoughts and feelings of family members, but the presentation of information. Problem cognitions in the treatment and education phases Cognition Problem: "This Won't Work" This type of statement reflects the lack of confidence of family members that a given intervention will produce the result they want (expectation of results). Family therapists need to recognize that family members will need to experience how behavior change can benefit them (persuasion being less effective than actually performing the behavior in the session) and how to obtain the affective and attributional benefits in the process signaled by the family therapist. Cognition problem: "I/he/she can't do that" Expressions such as this reflect the feelings of family members that they are unable to carry out the behavior (expectation of effectiveness). This kind of limitation can usually be overcome by using processes such as reinforcement by successive approximations or modeling new behavior, along with reassuring words that new behavior always feels clumsy: carrying out a new behavior usually requires remembering a sequence of steps, clumsily; and the person is so focused on his own apprehensions that he often forgets the fact that no one else is judging him harshly, and may not even realize the effort. Again, family therapists may need to provide these reassuring words to people during the process of learning the new behavior. Cognition Problem: "This Isn't Fair" Much of the technology of behavior change in family therapy resembles traditional behavior therapy, which is considered by many people to be an "economy" of exchanging efforts for rewards of some kind. Thus, people can create complex configurations of what they consider equitable: the relationship between a person's perceptions of the efforts made associated with their experience of rewards given by others ("Walster, Walster, and Berscheid, 1978). Family therapists should recognize that not only are the appetitive qualities of the enhancer found in the eyes of the viewer, but that people compare their booster rate to their expectations. These expectations of reinforcement will depend on dimensions such as the perceived status or motivation of the other person. When family therapists help families fine-tune their negotiations during communication training or behavioral

contract, a final process being included is to help family members reach their perceptions of equity. The perception of equity will be important to maintain the exchange of reinforcements, as well as the subsequent experience of positive affect. In general, the problem cognitions associated with the treatment and education phases are related to the obstacles to acquiring or carrying out a new behavior, and are not supposed to be driven by the dynamics of therapeutic resistance or homeostasis of the family system. However, one of the implications of the Intervention Anatomy Model is that if family members continue to have difficulty implementing new behaviors, therapists should suspect that the new behavior is likely to be inconsistent with the Assessment and Understanding phase. The therapist needs to revisit the activities of this phase to make sure that the new behavior is a timely match with the family's properties. For example, a mother who constantly teases or interferes with negotiations between a father and a child may be feeling "excluded" from the family. Conversely, a family therapist's first hypothesis about a family member's refusal to even attempt new behavior, or a family member's continued inability to understand the mechanics of a new behavior, and with second to feeling resentment, will be the signs that the family therapist may have to perform some retribution or reframe work with that member. The sequence of the phases of the Anatomy Model of the Intervention suggests that if a therapist has successfully completed the Therapy and Induction phase, then the apparent difficulties of the family members in carrying out new behaviors are probably related to the expectations of results and efficacy. If these difficulties become obstacles or appear to contribute to the weakening of relationships between the therapist and the family or between family members, then the family therapist should return to the functions of Assessment and Understanding and Therapy and Induction. Decoding the problem cognitions in The Treatment and Education Phases Decoding the problems in The Treatment and Education Phases lies in understanding the obstacles to family members's new behaviors. Typically, therapists who are being effective in structuring new family experiences will find themselves solely providing information about what family members should do next, and creating pathways for those family members to carry out the new behavior. Bandura's (1977) distinction between acquiring and carrying out new behavior is useful: acquisition issues refer to a person's ability to incorporate a new behavior into their repertoire, while questions of performing new behavior refer to whether an interpersonal environment is supporting the expression of such behavior. Therefore, family therapists need to make an assessment of what are the obstacles to learning to carry out new behaviors and propose educational and communication strategies to make behavior change possible.

The family therapist should encourage the family to carry out the new behaviors. Observing this process will show the family therapist what problems the family might be having, as well as how to improve the effectiveness of family members for the new way of behaving. The difficulty elements of the process will provide the family therapist with live opportunities to understand what additional information family members need. This process should reveal to the therapist differences between motivations and feedback on the performance. Coding problem cognitions in The Treatment and Education Phases Research suggests that the therapist should codify the direction families should take during the treatment and education phases (Alexander, Barton, Schiavo, and Parsons, 1976). Therapists should have the ability to be managers, that is, to be able to direct the behavior of family members with instructions, promptings, etc. The family therapist should express these instructions with an aura of selfconfidence, improving family members' feeling (expectations of outcomes) that new ways of behaving will benefit them. The therapist's communication to family members needs to be clear, so they can understand what they need to do as well as how well they are doing. Finally, family therapist-to-family talks need to have a clear organization and structure, optimizing the ability of their members to focus on what they should do and when they should do it. Again, once the resistance issues addressed in earlier stages of the intervention are absent, coding the family therapist into The Treatment and Education Phases is a combination of good salesman and good teacher skills. Communications from family therapists about what family members should do need to be very active presentations of clearly organized information, delivered at a pace that allows family members to practice the new behavior and receive feedback. Public strategy in the treatment and education phases The public objectives of the treatment and education phases are to make explicit those elements of behavior change that are consistent with the processes of positive reinforcement and to build an interpersonal environment of support. Family therapist activities model processes such as asking for clarity, providing encouragement, stimulating behavior, and other indicators of group processes with interpersonal effectiveness (Alexander et al., 1983; Alexander and Parsons, 1982). At the same time, the therapist encourages the implementation, by oneself, of new ways of behaving, reinforcing successive approaches to the target behavior(s) (Fleischman, Home and Arthur, 1983). At the same time that the family therapist stimulates behavioral action, the process of stimulation, reinforcement and offering metacommunication feedback provides effectiveness to family members. In addition, they have direct experience of acting. The family therapist will increase expectations of desirable outcomes when he or

she points out to family members the attributions and positive affective experiences that come from trying new ways of relating to other members. The private strategy in the treatment and education phases The private objectives of The Treatment and Education Phases are to monitor whether the fact that family members carry out the behaviors suggests that they do not need to revisit the Evaluation and Understanding phases or the Therapy and Induction phases. Family therapists need to assess the inability of family members to carry out the new behavior change and judge whether there is resistance that requires additional therapeutic inductions, or whether carrying out the new behavior is compatible with the dynamics of the family relationship. As therapists give feedback to family members on their performance on the task, aside from basic attention to feedback on performance, therapists will be pointing out how this performance supports the positive attributions (and affect) created by therapy and induction phase interventions. Similarly, family therapists will reassure family members that the implementation of new behaviors will result in their interpersonal roles being fulfilled — as discovered in the Assessment and Understanding phase. The generalization and completion phases In global terms, the phases of generalization and termination occur when the family and the family therapist mutually agree to terminate the services being provided (Alexander, Barton, Waldron and Mas, 1983). Typically, this decision is made because the therapist and the family agree that the therapist has achieved some clinical goals. In addition to having achieved some clinical criteria of success, the family therapist judges whether the family will be able to maintain the benefits achieved in the therapy process. We need to make a point about the conventional end elements of the therapy process. Mental health professionals are used to thinking that their services are fairly well defined. Some of these boundaries highlight the final moments of the intervention, or serve as markers for when the therapist's work is finished. Most of the problems that therapists deal with are aimed at prescribing a fairly wellestablished dose (such as in a support group with a scheduled resume), or that it depends on the patient's subjective assessment that they don't need the service (as in someone who solves the ambivalence of staying in a relationship) , or that it reaches some well-defined clinical goal (an agoraphobe is able to shop and feels comfortable away from home). In these circumstances, both the provider and the consumer have some potential markers that indicate when and on what basis to consider the termination of services. In addition to deciding when it is appropriate to end treatment, family therapists need to assess their own and the patient's confidence that the patient can maintain

therapeutic benefits after the end of the intervention. This assessment has to see whether the environment of family members is likely to support the exchange rates instilled in family members. For example, some spouses may feel threatened or unhappy with changes in assertiveness of the other partner who has been treated individually. Or, members in a community will shun a person who has been hospitalized with a psychotic episode. Considering these issues means that the therapist has to anticipate the patient's "ecology" and determine if he or she is prepared for sources of resistance (or lack of support) to therapeutic gains that could be imposed on the family members' natural environment. Some types of conduct offer more severe repercussions or penalties in the event of relapse than others. For example, patients who have been treated for problems of violence or sexual abuse against others pose a great risk, not only to themselves, but to others, if the patient has even a single known manifestation of that problem. The family therapist has to consider the consequences of relapse for the individual as well as for the community of which he or she is a part. Decisions about the termination of services are important and deserve considerable important attention from family therapists. Both the therapist and the families have to evaluate the progress of the treatment process and then make predictions about the future course of events. Problem cognitions in The Generalization and Termination Phases In general, cognitive problems in the generalization and termination phases occur because family members attribute responsibility for change inappropriately; because they lack knowledge of change; or because they may still show small vestiges of resistance. Cognition problem: "We owe everything to the therapist" Family members who have this belief will not have a sense of effectiveness in being able to solve their own problems. As long as family members believe that the therapist is responsible, it will not be possible to recognize positive developments in their own affection or in their perceptions regarding other family members or with respect to themselves. Thus, when the therapist is no longer present, the family is likely to return to their duties, affection, and characteristic interactions. Family therapists need to monitor the attributions of family members to determine whether they properly perceive themselves as the source of motivation and resources for positive change, as well as as the source of positive affect. Family members should end family therapy with a feeling that they have been largely responsible for many of their earnings. If families were left with the feeling that all the positive changes were the result of the professional's strength, it would be expected that it would lead them to maintain some kind of emotional and

practical dependence on the professional, and they would be faced with their needs to confidently solve problems at the end of services. Cognition problem: "Small failures mean our profits have vanished" In people with problems, the negative elements of their experience are inappropriately generalized to situations in which they do not apply (Beck, 1972; Lewinshon, 1974; Seligman, 1975). Family members should be encouraged to think of setbacks and setbacks as developmental nuisances associated with change, rather than as indicators that all is lost. Family therapists need to consider the impact on the patient in the event that they have the naïve thought that termination of treatment means that they will not experience any problems in the future. For most intervention models, positive change is not the same as a major personality reorganization. Patients should probably realize that many of their style tendencies, daily mishaps, and temptations will be the same as before. For most people, it is also likely that the process of change has been very short compared to the largest area and history of their lives. Just as it would not be therapeutic for a patient to be pessimistic about the opportunities for maintaining positive changes, or to feel anxious and guilty about failure, families should probably realize that new ways of thinking, behaving, and feeling require some attention and maintenance. Cognition problem: "He/she is only changing for the reward" This type of attribution can take place with behavioral intervention strategies. Family members may believe that tangible reinforcements are responsible for changes, or in other words, the locus of control is attributed to circumstances external to the person. This statement can imply pessimism about the possibility of maintenance, or worse, discredit the motivation of an individual (reinforced) who is making a great effort to change. It also happens that if the reinforcement program is too rich, a family member may come to believe that the reason for their behavior is not the non-tangible aspect of the impact of some positive relationship, or the increase in competition, but the beneficial properties of some medicine or the appetitive quality of some stimulus. This phenomenon is known as the "effect of over justification" (Lepper and Greene, 1978). If people are rewarded for something they would like to do for other reasons, they have a harder time attributing the positive value to their own resources or character. Decoding the Cognitions Problem in The Generalization and Termination Phases Being near the end of the family therapy process, family members will supposedly be outspoken about unfinished aspects of Therapy and Induction and Treatment and Education. These complaints about the unfinished aspects do not pose problems for the therapist. In general, the types of decoding problems faced by the therapist in the generalization and termination phases are exploring predictors of

later problems that would have a profound impact on family membe...