Crisis Intervention & Management Module

Module Sections:

Introduction

Course Introduction

Welcome!

This therapeutic skills module is focused on developing skills associated with crisis intervention and management. Throughout the module we will ask you to reflect on a variety of concepts in your “journal”; answer survey questions; and finally, to explore “resources” for further study.

The structure of this module will guide your exploration of crisis management issues that arise in your work with families. The module is structured to accomplish the following:

  1. Explore the scope of the crisis management in HBFT
  2. Establish a common ground of terminology and interact with a family vignette
  3. Develop a unified framework for exploring crisis management throughout the process of therapy
  4. Examine examples of effective strategies and techniques to therapeutically address family crises
  5. Apply the unified framework to the family vignette introduced in an earlier section

At the conclusion of the module there are important evaluations to provide the partners with feedback regarding the content of the module and your navigation of the website. We hope this module is informative and relevant to your clinical work. We look forward to this shared experience. Thanks for participating!


Module Objectives

Through this module you will be able to:

  • Define crisis and family crisis
  • Determine the differences among four types of family crisis
  • Identify the common characteristics and dynamics of family crisis experiences
  • Assess a family’s needs, resiliencies, resources and meanings associated with a crisis
  • Identify therapist roles in “framing” the family crisis
  • Identify the interactions among crisis interventions and the phases of family therapy
  • Determine appropriate treatment strategies to use within each phase of therapy
  • Assess the progress of crisis intervention efforts

Scope of the Issue

The stresses families experience are common experience and a normative part of family life. The interacting changes occurring for each member and the family as a whole, produces stress and requires a level of personal and relational adaptation. While family stress is common, the members’ ability to understand and respond to that stress varies depending upon a number of important variables.

Antonovsky and Sourani (2003) performed a study exploring the levels of stress and a family’s ability to address that stress. They examined two variables relating to a family’s efforts to address stress: family sense of coherence and family adaptability. Family sense of coherence captures the multiple ways each member understands the stress and the degree to which the meaning of the stress is shared by the members. Family adaptation reflects the ability of the family members to respond to stress and achieve a degree of well-being, satisfaction, and perceived manageability.


Pre-Test

Click the link to respond to the following survey:


Establishing a Common Ground

Defining Crisis

As clinicians with different training backgrounds, the language we use to understand our work is often different from one clinician to another. This section will explore those differences and establish a common understanding of the concepts addressed in this and subsequent modules. Speaking the same language will help us collaborate more effectively with one another. This section provides information to support a common language while asking you to consider how you conceptualize information.

Journal- Recall a family you recently helped during a time of crisis.

Defining crises depends upon where you look. A crisis can be identified in several ways:

  • An event, circumstance or issue (e.g., death in the family, job loss, violent event)
  • The process by which an issue is handled can become the crisis (e.g., frustration, hopelessness in response to failed attempts to resolve issues)
  • A family’s experience of limited resiliency or resources (e.g., continual decline in functioning and accumulated effects of multiple crises)
  • A single crisis may be embedded in a larger pattern of recurring crises occurring over time (e.g., crisis-->helper interventions-->repair-->period of calm-->repeated crisis).

Theory & Phases of Therapy

Your preferred theory guides your work with families. It is important to think about how you apply your theory to the various phases of therapy.

Joining – Rapport Building

  • Getting to know the family and each of the members
  • Building a level of mutual trust and respect as the foundation for subsequent work

Assessment and Diagnosis

  • Family readiness to change is reflected in the combination of each member’s readiness
  • Moving to subsequent phases depends in part on your assessment of readiness
  • Work at and with the motivation level of each member
  • Acknowledge members’ efforts to affect the circumstances within the family

Contracting – Goal Setting and Treatment Planning

  • Each member needs to “buy-in” to treatment and contracting provides the opportunity for each to suggest her/his goals and expectations for treatment
  • Identify points of disagreement and the possibilities for compromise to accomplish shared goals

Termination

  • Determine what the family needs to know as early as possible in treatment which prepares them to finish treatment
  • Termination suggests that the child and the family are familiar with and demonstrate healthy responses to the reverberating effects of conflicts within the family. A family that is ready for termination develops the self-efficacy and practical strategies needed to consistently manage the effects of the SED on all members including the child.

Journal- Crises occur at various phase in the course of therapy. How do family crises impact the therapy process?


Factors Influencing Understanding of Crises

Numerous potential issues influence that understanding (e.g., age, gender, member’s relationship to I.P., family secrets, substance abuse, domestic violence, family resources). Each person involved in the experience determines the answer to this question based on the perspective of the event or circumstances and its impact. Those involved could include:

  • Family members
  • Extended family
  • Neighbors
  • Case workers
  • SRS
  • Other systems (e.g., courts, medical personnel, religious leaders)
  • Therapists

The role of the therapist is to examine the crisis from each of these perspectives. The family’s ability to manage a crisis depends, in large part, on the consistency of the various views about the crisis. The following questions can help guide the therapist to determine the varying perspectives:

  • Does each person define the crisis event in a similar way?
  • Does each person understand the other’s experience of the crisis event?

Journal- How does the therapist handle multiple perspectives about the same event or circumstance?


Family Functioning is Comprised During a Crisis

A families ability to adapt and adjust to new circumstances and factor new information into effective decision-making is dependent upon the members’:

  • Ability to maintain a degree of stability and predictability
  • Experienced empowerment
  • Access to various support systems with each other and with those outside of the family
  • Perceived level of safety

Differentiating Stress from Crisis

Stress and crisis are often mistaken as synonymous with each other (Kagan & Schlosberg, 1989; Kazak, 2003). Recognizing the differences can enable the family and the therapist to prioritize the management of each.

Stress is…

  • …a change in the family’s steady state
  • …present in all families in varying degrees

A crisis is…

  • …a disturbance in the equilibrium that is so overwhelming, or
  • …pressure that is so severe, or
  • …change that is so acute that the family system is blocked, immobilized, and incapacitated.

When a family is in a crisis state, it ceases to function adequately. Personal and family boundaries tend to be compromised, roles addressing specific tasks no longer provide the expected results, and family members psychologically or physiologically function at sub-optimal levels.


Goals of Crisis Intervention

Initial crisis interventions focus establishing the following:

  • Stabilization of members and the family as a whole
  • Mitigation of the signs and symptoms
  • Restoration of an adaptive level of member and family functioning

Family therapy utilizes the resulting stability to address the factors that influenced the family to experience the stressor as a crisis.

Unique Factors of Crisis Intervention in HBFT

Boyd-Franklin and Bry (Boyd-Franklin & Bry, 2000) remind us that…

  • “Families referred for home-based family therapy often, as a common feature, function in ‘crisis mode’…” (p. 58)
  • “Home-based sessions can be used to support and enhance skills needed in daily life.” (p. 78)

Family Crises & Family Therapy Model

Types of Family Crises

Frank Pittman (1988) delineates the differences between various types of crises and the implications of those differences on crisis management. The following is a list of the four types of family crises:

  • “Bolt-from-the-blue” crisis involves the unexpectable event occurring outside of the individual and family system (e.g., fire, war, illness, accident)
  • Developmental crisis reflects the responses to normal, mostly universal, stages of development. Interventions generally focus on normalization of family members’ thoughts and feelings. (e.g., baby’s birth, first steps, first day at school, puberty, driver’s license, adventures)
  • Structural crisis arises from problems of the family structure involving repeated, patterned responses to relieve symptoms. Efforts result in intermittent exacerbations rather than resolutions to the problem structure. Families experiencing this type of crisis appear resistant to change. (i.e., the events may change but the family’s repeated responses remain the same)
  • Caretaker crisis occurs when a caretaker’s efforts prevent family changes and usurps family efforts to resolve issues. (i.e., the function of the caretaker actually prevents the family from developing the abilities needed to make change)

Family Therapy Model Conceptualizations of Family Crises

Each model of family therapy makes varying assumptions about focus of the family issue and the appropriate place to focus treatment. The following examples describe differing conceptualizations and subsequent treatment priorities:

  • Structural – This model focuses on the family structure reflecting the family functioning within and in response to the crisis. Treatment focuses on making adjustments to the family subsystems, boundaries, hierarchies, and member roles.
  • Cognitive-behavioral – This model examines the distorted thinking and cognitive schemas informing the family members’ views of the crisis and their awareness of their available resources and abilities. Also assesses factors reinforcing the family’s repeated crisis experiences.
  • Solution-focused – This model asks the family to envision and articulate a preferred view of their life when the crisis does not exist. Then treatment focuses on repeating that preferred experience.
  • Bowen – This model equips the family members with specific ways to detriangle, access and utilize emotional and cognitive processes, and establish each member’s greater differentiation of self. These tasks become resources for handling crises in deliberate, responsive ways rather than through heightened reactivity.

Journal- As you examine a family crisis, what model(s) inform your assessment?


Crisis Management

Unique Features of Crisis Management

  • Crisis management takes a meta-view of the crisis examining the processes and contexts in which crises are embedded
  • Family therapy addresses the processes that foster recurrent family crises
  • Family therapy addresses the family vulnerabilities while accessing the family resiliencies and resources

Impact of Crisis Management on Therapists

Exposure to family distress and despair impacts therapists’…

  • Level of energy
  • Level of creativity
  • Level of perceived empowerment
  • Level of effectiveness

Providing therapy to families in perpetual crisis often tempts therapists to work harder than the family. When therapy is dependent upon the therapist’s work, families have difficulty discovering the abilities and resources needed to resolve the crisis on their own.

Recommendations for Therapists

  • Seek supportive supervision
  • “…not only an investment in the personal and professional development of family therapists, but it has a direct link to clinical outcome.” (Boyd-Franklin & Bry, 2000, p. 202)
  • Foster relationships with multidisciplinary teams of helpers who compliment each others’ work with the family and mitigate the isolation home-based family therapists often experience.
  • Seek ongoing training experiences that familiarize you with the most current best practices available for providing effective home-based family therapy.
  • Engage in personal family work

“The family worker who is able to address painful issues in his/her own family will be better able to work with the extreme pain and despair in chronic, crisis-oriented families. Given the intense emotional climate of families in perpetual crisis, practitioners must be capable of feeling their own emotions and keeping themselves free enough to both understand their position in family-practitioner interactions and intervene in the turmoil around them.” (Kagan & Schlosberg, 1989, p. 68)


Family Needs & Understanding a Stressor Event

Assessing Family Needs

  • Consider the following questions that aid in exploring the varying aspects of family stress and crises (McCubbin & Patterson, 1982):
  • What happened or has been happening in this family? Why is this a crisis now? (Event)
  • What does the crisis mean to the members of this family? (Members’ Perceptions)
  • What instrumental, emotional, and relational resources are available to the family to address the crisis? (Family Resources)
  • What has moved the family experience beyond stress to the level of a crisis? (Stress/Crisis)
  • Is this impact of this crisis compounded by previous unresolved stresses or crises? (Pile-up)

Understanding a Stressor Event

Epstein and Schlesinger (2000) describe the multiple dimensions of stressor events. Identification of these dimensions enables the therapist to develop a more complete picture of the family’s experience and the meaning they attribute to the stressor.

  1. Internal or external to the relationship
  2. Suddenness of onset
  3. Whether or not the event was expected
  4. Degree of ambiguity about onset and characteristics
  5. Severity
  6. Duration
  7. Degree to which family members choose to be exposed to the stressor
  8. How many members are directly effected?

“It is not the stressor itself that places pressure on a couple or family and its members to adapt, but rather the ‘hardships’ associated with the stressor.” (p. 293)


ABC-X Model

Family Crisis ABC-X Model

The original ABC-X Model (Hill, 1958) was developed to reveal the multiple components involved in a family crisis.

  • The event can be any issue, circumstance, or occurrence.
  • The family resources encompass the individual emotions and physical abilities, family cohesion, responsiveness, financial, and other physical resources.
  • Members’ perceptions of the event represent their objective, cultural, and subjective interpretations of the meaning of the event.
  • Crisis arises when the resources and members’ perceptions interact with the family’s experience of the event. The interactions either mediate or exacerbate the impact the members’ experiences of the increased stress associated with the event.

Resources and perceptions chart

Journal- How does the interaction of the resources and perceptions advance the stress of the family to the point of becoming a crisis?

Pittman (1987) notes that a “crisis results when an event comes to bear upon a system and requires change outside of the system’s usual repertoire.” (p. 4) In other words, stress has become so great exceeding the family’s abilities to adequately respond and cope.

Issues to Address When Examining Crises

  • Achieve member safety through de-escalation and specific prevention strategies
  • Determine the chronicity of the crisis
  • Situational or enduring crises
  • Determine impact and extent of crisis on member functioning at home, school, work, community involvement
  • Identify family and member previous attempts to address crisis

Journal- Think of one family you have worked with who appeared to move from one crisis to the next are there patterns of responding that maintain that movement from one crisis to the next?


Double ABC-X Model

The Double ABC-X Model (McCubbin & Patterson, 1982) addresses when the family experiences a crisis as a new event. The original cycle is perpetuated, not based on a new event, but resulting from the family’s residual stress, or pile up, occurring from the original event in the family system. The range of a family’s adaptation to and management of this crisis:

  • Families tending toward the left end of the continuum tend to adequately manage the stress or crisis and allow for the growth and development of the individual members and the adjustments in the family system
  • Families tending toward the right end of the continuum tend to experience an increased experience of stress and crisis often hampering growth and development and perpetuating cycles of crisis.

Crisis Management

Identifying Coping Skills

The goal of crisis management is directed at assisting the family in developing the resources and perceptions needed to handle stresses as they arise and, therefore, prevent pile up.

  • Improved coping occurs when:
    • There is a degree of immediate relief with the intention of bringing about long-term solutions
    • The use of strategies familiar to the family provides entrée to explore new, innovative strategies
    • Focus on symptom relief points to the existence of and the need for problem relief
  • Management implies the reduction of reactive responses making room for a family’s increased self-advocacy and use of effective coping responses

Identifying Resources

The identification of resources involves using & strengthening existing resources while discovering new ones. Family resources include:

  • Member resources: characteristics of individual family members (self-esteem, knowledge, skills available)
  • Family system resources: internal attributes of the family unit (cohesion, adaptability, communication)
  • Social support and community resources: people or institutions outside the family (mental health professionals, extended family, school, church, mentors)

Family Eco-Map

A family eco-map (Lindblad-Goldberg, Dore, & Stern, 1998, p. 104-107) provides an assessment tool to examine the needs of families by mapping the major systems involved with a family and the relationship with those systems. The eco-map provides a visual organization while interviewing the family and gathering information about contextual influences. The eco-map:

  • …is an information and assessment gathering tool.
  • …demonstrates the flow of resources and energy.
  • …depicts the nurturing or conflictual relationships between the family and other systems.

Eco-maps identify connections with a descriptive word or by drawing different kinds of lines to demonstrate the nature of the relationship.

Eco-Map Legend

  • Solid thick line- strong connection that contributes to and supports family coping
  • Dashed line- tenuous connection that is experienced as limited support or the depletion of member energy and resources
  • Cross-marked line- conflictual relationship that increases family stress and depletes family coping ability
  • Arrows- direction of flow of energy or resources

Eco Map


Crisis Management

Identifying Perceptions

  • Members maintain varying views of danger and security
  • Understanding members’ perceptions indicate how the family as a whole makes sense of the situation including the stressor event, pile-up, and resources available for meeting increased demands
  • Comparing member perceptions enables the therapist to assess the degree of congruity among members and highlighting areas of overlap
  • Perceptions will provide the therapist with a sense of the family’s reliance on maintaining crises and their readiness for change

Source of Vulnerability and Resilience

Families cope with stress in a variety of ways. When stress rises to the level of a crisis for a family, therapists examine the family interactional patterns to determine the evidences of family and family member vulnerability and resilience:

  • Nature vs. nurture interact and contribute factors to people’s experiences of stressful events and circumstances.
    • Genetic factors include each family member’s…
      • Temperament - ways of processing experiences and defining self in the world
      • Personality – tendencies toward depression, impulsivity, aggressiveness, passivity, etc.
      • Intelligence – ability to understand experiences and feelings
  • Environmental factors represent each family member’s engagement with varying contexts using…
    • Social skills – interacting with others and relationships
    • Self-esteem – feelings about oneself, own identity
    • Attachments – early experiences of bonding with caregivers
    • Family system dynamics – attach/distance, straying/connecting, rigidity/flexibility

Assessing the “Family’s Pattern” Crisis-Proneness

Various researchers have offered descriptions of the families who appear to experience repeated or constant crises. Each suggests examining the pattern of crisis as the focus of assessment and subsequent intervention.

  • Hill (1958) described families who displayed a crisis-proneness. He noted that events are experienced with greater frequency and severity. The family members more frequently define events as crises, appear to lack the “crisis-meeting resources,” and fail to learn from past crises.
  • Bell (1963) described families in perpetual crises as crisis-oriented families who feel“ trapped between the need for change and the need to protect current patterns, roles, and organization… They experience the stability of chaos or patterned crises.” (p. 38)
  • The following cycles contribute to current family patterns:
    • Transgenerational cycles involving the ways loss, abandonment, trauma, family emotional process are managed and have been passed down through the generations
    • Personal cycles involving conditions such as PTSD, depression, and anxiety
    • Interactional cycles involving family conflict/violence, cohesion/adaptability, and family emotional process
  • The meaning of time varies for different families suggesting recommendations for responsive therapeutic approaches
    • Chaotic families most often view time as eventful. Therapy must attempt to slow down events, involve clear contracts, and specify time limits.
    • Rigid families most often view time as arrested. Therapy must mobilize time and events by stimulating a crisis or no change.
  • A real crisis puts family members into acute grief, whereas for families in perpetual crisis, grief is blocked to protect self from facing difficult issues.

Resilience

Individual and Family Resilience

Walsh (1998) describes the strengths-based therapeutic process that searches for evidences of existing family resilience and ways to support the development of resilient processes.

  • Resilience is the process of adapting well in the face of adversity, trauma, threats, or even significant sources of stress. Sources of stress include: family and relationship problems, serious health problems, and workplace and financial stressors. Resilience means ‘bouncing back’ from difficult experiences.
  • Resilience is not a trait that people have or do not have. It involves behaviors, thoughts, and actions that can be learned and developed in anyone.
  • Resilience is a set of qualities that fosters a process of successful adaptation and transformation despite risk and adversity.

Factors in Resilience

Therapy should identify, support, and further develop the factors that lead to individual and family resiliencies. Those factors include:

  • Caring and supportive relationships within and outside the family
  • Relationships that create love and trust, provide role models, and offer encouragement and reassurance
  • Capacity to make realistic plans and take steps to carry them out
  • A positive view of self and confidence in personal strengths and abilities
  • Skills in communication and problem-solving
  • Capacity to manage strong feelings and impulses

Hernandez Family Vignette

Joe and Carmen Hernandez are 47 and 46 years of age respectively. They are second generation Americans with ties to Puerto Rico. They report a close relationship with their families although they are not able to visit very often. The Hernandez family lives in south central Kansas.

Joe and Carmen have a strong marital relationship and have endured many challenges to their marriage. They were married as teenagers and their son was born during the first year of their marriage. Carmen was 16 and Joe was 17 when their son John was born. They report that their families were influential in helping them to finish high school and care for their son. Carmen gave birth to their daughter Mary 3 years later and the twins, Carmelita and Angela were born 3 years after Mary. The children are now 20, 17, and 14. Following high school, Joe worked full time and excelled in the computer classes he took at the local community college. He completed his degree in computer programming and has been steadily employed throughout their marriage. Carmen is also employed at the local hospital in the billing department. The family members report caring very much for one another and believe they are going through “growing pains” and believe therapy will help them to get back on track as a family. They report a strong support system with their extended families, work relationships, and church.

The family has sought home-based family therapy services due to problems with their 17-year old daughter Mary. Therapy is no stranger to this family and they are seeking therapy services now because of the positive interactions it helped create about 8 years ago. As a child, Mary was diagnosed with ADHD and depression. After many years of stability, Mary has become inconsistent with her medication and Mr. and Mrs. Hernandez report that they believe she has become involved in gang-related activities. She was recently arrested for burglary and subsequently resisting arrest. She is also behind academically and is not expected to graduate high school on time. Carmen and Mary report being close even during difficult times but have been struggling over the last 3 months. Mary also expresses resentment regarding the attempts by her brother John to “control her.” She reports that John follows her and shows up when she is with her friends. John reports being worried about her and you notice he has become very attentive to his mother over the last three sessions.

Throughout your work with the Hernandez family you notice that Carmen appears to be in much pain, very tired, and seems to have less energy each time you see the family. Carmen contacted the therapist for an emergency session. During this session with the family, Carmen reveals that she has been diagnosed with ovarian cancer. Carmen expects to have surgery next week. She expresses concerns that Mary has become increasingly aggressive since her mother’s diagnosis; the twins are spending more time with their friends; and John wants to move back into the house. Joe is not present for the session and Carmen reports he has not wanted to talk about her illness. Carmen is fearful of what the future will hold for her family and how they will cope with her illness and the subsequent treatment she believes will follow her surgery. She is hoping the therapist can help the family talk about the cancer and adapt to the changes to come.


Forming a Unified Framework

Theoretical Foundation

This section explores the systemic and contextual dimensions of change processes. With an awareness of individuals' and family's resiliencies and vulnerabilities, we will examine the adaptations necessary at various phases of therapy.

Personal Theoretical Foundation

  • As therapists work with families, there is a theoretical foundation that guides your work
  • As you revisit your foundation, continue to think about the Hernandez family and how you apply your theory to your work
    • Consider the cultural similarities and differences within the process of therapy
    • Consider the phase of therapy when the crisis occurs
  • Your theoretical foundation informs each phase of the therapy process

Phases Addressing Crisis Intervention

Phases of Crisis Intervention

Joining

Joining entails the development of a relationship with and a commitment to each member of the family. Establishing a clear understanding of the members’ multiple perspectives of the crisis fosters therapist connection with and responsiveness to the whole family.

Assessment

Establishment of an accurate assessment entails an understanding the type of crisis the family has faced. Next, the therapist determines the individual and family resources and perceptions associated with the crisis and the family’s ability to manage and adapt to the crisis. Finally, the assessment includes a consideration of the individual member and family resiliencies and vulnerabilities.

Contracting

Contracting involves the obtaining of, not only family consent, but also the “buy-in” necessary to collaboratively address the crisis with the family members. Goals are focused on accomplishing both short-term relief while placing the priority on long-term, sustainable solutions that moderate the effects of stressors.

Interventions

Effective interventions provide opportunities to highlight larger patterns of family crisis responses. Interventions also identify available resources, explore alternative perceptions, foster improved individual and family resiliencies, and minimize individual and family vulnerabilities.

Termination

A family is ready for termination when they manage and adapt to a crisis effectively, generalize learning and coping to other stressful issues, discover and behaviorally demonstrate alternative narratives that do not incorporate crisis-perpetuating patterns, and express reduced fears or concerns about handling stressful situations.


Impact of Crisis

Multilevel Impact of Crisis

Crises impact families at multiple levels and in varying degrees (Boss, 2002; Boyd-Franklin & Bry, 2000):

  • The individual members’
    • Personal experiences of the crises
    • Cognitive, emotional, and physical resources informing the individuals’ perceptions
    • The formation of personal perceptions of the experiences
    • Behavioral responses to the crises
  • The whole family
    • The interactions between the members responding and/or contributing to the crises
    • The level of congruity between member perceptions of the crises
    • The family resources available to respond to the crises
    • The family responses to the crises including level of management, coping, and adaptation to changes
  • Intergenerational context
    • Interactional patterns reflecting responses to crises are often passed down and used by subsequent generations. The intergenerational resources and perceptions available to families include:
      • Cognitive and emotional processes
      • Family loyalties, values, and beliefs
  • Cultural context
    • Interactional patterns among family members, other systems, clinician, etc. impacting perceptions of crisis, coping strategies, resources

Systematic Approach to Individual and Family Crisis

  • Development of a unified framework guides the process of therapy with families in crisis.
  • The framework attends to the dynamic interplay between the multiple levels of families including: the individuals, the family, and the larger social and historical contexts.
  • The framework can be used for assessing individual and family coping by identifying individual and family vulnerabilities and resiliencies.

Circumplex Model

The Circumplex Model (Olson, 1993; Olson, Sprenkle, & Russell, 1979) provides ranges for two variables focusing on family processes. Healthy families strike a reasonable balance on each range that can vary from one family to the next.

  • Family cohesion reflects the degree to which family members experience emotional bonding. Optimal functioning occurs as a family strikes a balance between member separateness and togetherness.
  • Family adaptability indicates a family’s ability to adapt to meet challenges. Ranging from rigid to chaotic, families demonstrate the degree to which they are able to adjust family structure, rules, and roles. Optimal functioning occurs as a family strikes a balance between stability and change.

Family Life Cycle

Plotting a Family Through the Life Cycle

The levels of adaptability and cohesion within a family change as the individuals and the family as a whole develops through time (Olson, 1993). Note the changing levels of family cohesion and flexibility that occur to meet the changing demands of various experiences associated with relationship formation and member entry into the family.

Adaptability Cohision Chart

Journal- Revisit you client family by considering the Circumplex Model. Consider the family’s current levels of cohesion and flexibility. (How might these levels have changed since the family faced the current crisis?)


Using Strategies and Techniques

Approaches to Family Therapy

Approaches to Family Therapy

Cognitive-Behavioral Approach to Family Therapy (Dattilio, 2000)

A cognitive-behavioral approach considers the family schemata of the system. This approach seeks to understand the varying family members’ beliefs about the issues they face together. The subsequent strategies and techniques attempt to address those beliefs and bring them in line with healthy and productive ways the family can address their problems. Dattilio (2000) cites the work of Miller, Keitner, Epstein, Bishop, and Ryan (1993) describing a series of steps addressing members’ thoughts and behaviors. The following list provides modified strategies and techniques:

  1. Define the current problem or crisis.
  2. Actively and directively introduce the change that will take place.
  3. Explore the family history and intergenerational patterns.
  4. Examine ways that intergenerational schemata are present in the current family system.
  5. Assess the automatic thoughts and behaviors that each of the members currently enact as they attempt to address the problem.
  6. Discuss the automatic thoughts and behaviors that contribute to the current interaction patterns. Explore members’ options for alternative behaviors.
  7. Develop a behavioral contract that provides measurable goals and expectations for the new schemata and corresponding alternate behaviors.
  8. Assist the members to develop communication skills to facilitate the new behaviors and interactions between members.
  9. Address ways the new skills and interactions can be generalized to address future issues and crises.

Intergenerational/Strategic Approach (Kagan & Schlosberg, 1989)

Kagan and Schlosberg (1989) address the work with families that have experienced repeated crises. They address the needs of working with family interactions that are embedded in cycles of crises that make work with a current issue even more difficult. They suggest that the therapist must follow the “clues to the basic patterns” (p. 43). They suggest examining the intergenerational aspects of a crisis. By viewing the current crisis through an intergenerational lens, the therapist can address the family’s current status within in a larger frame that can help to inform the family members’ current responses.

Generally, families who have experienced repeated crises appear to be resistant to change and anyone who suggests that they should change. Integration of a strategic approach assumes that resistance is a normal and adaptive response to the prospect of change. Furthermore, the family’s resistance is better understood as a preservative effort that defines and protects the family despite the unresolved outcome of such efforts. Kagan and Schlosberg suggest discussing the functional aspects of the resistance with the family. By exploring the varied ways the resistance serves the family, the therapist signals a respect for their concerns and perceived vulnerabilities. Continued discussions can help the family to discover the varied ways that their efforts actually maintain the cycle of crises. Making the cycle overt, the family will have a better opportunity of changing those patterns.


Applying the Framework

Hernandesz Family Vignette

In this section, you will explore ways to navigate the phases of therapy using the unified framework to integrate theory and practice.

You will explore how your theory informs each phase of your work with the Hernandez family. Then you will be asked to identify how each phase intervenes with the family to help them manages the crisis.

Vignette - Hernandez Family

Joe and Carmen Hernandez are 47 and 46 years of age respectively. They are second generation Americans with ties to Puerto Rico. They report a close relationship with their families although they are not able to visit very often. The Hernandez family lives in south central Kansas.

Joe and Carmen have a strong marital relationship and have endured many challenges to their marriage. They were married as teenagers and their son was born during the first year of their marriage. Carmen was 16 and Joe was 17 when their son John was born. They report that their families were influential in helping them to finish high school and care for their son. Carmen gave birth to their daughter Mary 3 years later and the twins, Carmelita and Angela were born 3 years after Mary. The children are now 20, 17, and 14. Following high school, Joe worked full time and excelled in the computer classes he took at the local community college. He completed his degree in computer programming and has been steadily employed throughout their marriage. Carmen is also employed at the local hospital in the billing department. The family members report caring very much for one another and believe they are going through “growing pains” and believe therapy will help them to get back on track as a family. They report a strong support system with their extended families, work relationships, and church.

The family has sought home-based family therapy services due to problems with their 17-year old daughter Mary. Therapy is no stranger to this family and they are seeking therapy services now because of the positive interactions it helped create about 8 years ago. As a child, Mary was diagnosed with ADHD and depression. After many years of stability, Mary has become inconsistent with her medication and Mr. and Mrs. Hernandez report that they believe she has become involved in gang-related activities. She was recently arrested for burglary and subsequently resisting arrest. She is also behind academically and is not expected to graduate high school on time. Carmen and Mary report being close even during difficult times but have been struggling over the last 3 months. Mary also expresses resentment regarding the attempts by her brother John to “control her.” She reports that John follows her and shows up when she is with her friends. John reports being worried about her and you notice he has become very attentive to his mother over the last three sessions.


A Closer Look: Hernandez Family Vignette

Application of Vignette

Throughout your work with the Hernandez family you notice that Carmen appears to be in much pain, very tired, and seems to have less energy each time you see the family. Carmen contacted the therapist for an emergency session. During this session with the family, Carmen reveals that she has been diagnosed with ovarian cancer. Carmen expects to have surgery next week. She expresses concerns that Mary has become increasingly aggressive since her mother’s diagnosis; the twins are spending more time with their friends; and John wants to move back into the house. Joe is not present for the session and Carmen reports he has not wanted to talk about her illness. Carmen is fearful of what the future will hold for her family and how they will cope with her illness and the subsequent treatment she believes will follow her surgery. She is hoping the therapist can help the family talk about the cancer and adapt to the changes to come.

Consider the Hernandez family’s current crisis associated with Carmen’s recent diagnosis. Note that the information is limited to the details presented in the vignette, however, hypotheses and possible steps may reasonably be suggested using the components from the unified framework presented in the previous section.

Using the core questions for each phase of therapy, consider ways of connecting with the members and subsequent therapeutic work.

Phases of Crisis Intervention


Connecting using the Phases of Therapy

Joining

Joining entails the development of a relationship with and a commitment to each member of the family. Establishing a clear understanding of the members’ multiple perspectives of the crisis fosters therapist connection with and responsiveness to the whole family.

During your visit you increasingly notice that each member has developed varying perspectives about this current crisis. Joining with this family will require an approach that acknowledges each person’s understanding about the cancer diagnosis and its personal impact. Mom may struggle shifting focus on her medical management while attempting to juggle the demands of work and home and the most recent issues concerning her daughter’s behavior. Dad’s absence may make it difficult to personally join with him, however, efforts made during treatment to ask each member to hypothesize on Dad’s experiences and perceptions may provide him a voice. Mary, Carmelita, and Angela may resent being present in treatment since they tend to naturally seek relationships outside of the family. Inquiring about each one’s reaction to the news of hearing about mom’s cancer may generate an opportunity for each to express their thoughts and experiences as well as feelings of personal vulnerability. Your explicit expression of your intentions to provide a respectful space for each one to share while valuing the others’ experiences can invite this family to think about the crisis as something they share. Additional overt efforts to address the cultural implications of family togetherness coupled with the stresses of assimilating into the present context would invite members to share their views and efforts to do this.

Assessment

Establishment of an accurate assessment entails an understanding the type of crisis the family has faced. Next, the therapist determines the individual and family resources and perceptions associated with the crisis and the family’s ability to manage and adapt to the crisis. Finally, the assessment includes a consideration of the individual member and family resiliencies and vulnerabilities.

While Carmen and Jo have historically had a strong relationship, a shift has occurred in which they have become emotionally disconnected from each other. While family cohesion has been a hallmark of this family’s interactions with each other, assessment of their adaptability would explore the possible ongoing developmental crisis associated with their responses to the three adolescents’ would need to be explored. Mom’s diagnosis appears to have been a bolt-from-the-blue crisis that has simultaneously occurred and resulting in a pile up of stressors.

Contracting

Contracting involves the obtaining of, not only family consent, but also the “buy-in” necessary to collaboratively address the crisis with the family members. Goals are focused on accomplishing both short-term relief while placing the priority on long-term, sustainable solutions that moderate the effects of stressors.

Therapeutic focus on short-term relief combined with long-term direction would entail addressing the stresses associated with learning of a potentially fatal diagnosis while attending to the family’s efforts to adjust to the adolescents’ developmental tasks. The contract would need to incorporate goals that involve family members in substantive ways to support mom while addressing personal feelings and growing concerns. Additional goals would address ways the family can acknowledge the adolescent efforts to individuate while experiencing increased emotional connections and improving family support. Helping this family to acknowledge and adjust to the co-occurring developmental and bolt-from-the-blue crises could enable members to identify ways to address the current crisis within the context of the ongoing struggles they have faced.

Interventions

Effective interventions provide opportunities to highlight larger patterns of family crisis responses. Interventions also identify available resources, explore alternative perceptions, foster improved individual and family resiliencies, and minimize individual and family vulnerabilities.

Each intervention would need to suggest ways to address current issue while exploring ways to generalize the skills and efforts to be applied to other issues and circumstances. Use of the family’s unique and cultural history to inform the development of interventions will provide them with the connections to their broader values and expectations while acknowledging their available strengths and resiliencies. Integrating changes within their cultural frames of reference will provide basis for achieving sustainable change.

Termination

A family is ready for termination when they manage and adapt to a crisis effectively, generalize learning and coping to other stressful issues, discover and behaviorally demonstrate alternative narratives that do not incorporate crisis-perpetuating patterns, and express reduced fears or concerns about handling stressful situations.

Termination can effectively occur when the family members consistently demonstrate a level of cohesion and adaptation that addresses support for mom’s condition and while adjusting to the ongoing member developmental changes.


Post Test

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