2. Treatment Plans & Goals - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Mirror Mirror… Reflections of Self-Esteem in Relationships and Therapy
Chapter 2: TREATMENT PLAN & GOALS
by Ronald Mah





The therapist incorporates the individual, couple, or family's goals into the therapy, but simultaneously holds additional goals.  Bert has his goals.  Terry has her goals.  And, they have goals in common- at least, they profess to have joint aspirations for their ongoing co-parenting relationship.  Each therapeutic orientation has implicit strategies for therapy based on the conceptual foundations of the therapy.  Such goals more or less match up with client goals or must be brought into sync somehow with the therapist's strategy in the work.  The Satir model has set four meta-goals as its positively directional focus for change. These are:

1. Raising the self-esteem of the clients.  Self-esteem is considered as one's own judgment, or experience, of one's own value.

2. Helping clients to be their own choice makers.  Satir encouraged people to consider at least three choices in any situation.  She wanted to empower people to become their own choice makers.  At the mechanistic, reductionist level of viewing humanity, we often find ourselves at one or the other end of a polarity: right or wrong, good or bad, for example.  The Satir model, in simple terms, tries to avoid dilemmas such as "either/or" choices and advocates looking at one's situation in terms of three or more possibilities.  The model also advocates a more integrative view instead of "either/or" thinking.  Choices are not only decisions about one's actions; they include different responses to unmet expectations instead of a person's usual reactions.

3. Helping clients to be more responsible.  Responsibility includes being in charge of one's internal experiences, not only one's behavior.  The main focus here often is being responsible for one's own feelings. This includes being in charge of them, managing them, and enjoying them.  With the help of the written works of such authors as Damasio (1999), Le Doux (1996), and Pert (1997), the responsibility of individuals could move deeper inside towards the molecular level of responsibility and change.  The Satir model is open to such possibilities in its therapeutic work.

4. Helping clients become congruent.  Congruence is a state of internal and external harmony.  It is a sense of calmness, wholeness, peace, and tranquility.  Congruence is a state therapists are encouraged to be in during their therapy sessions.  It is a sense of empowerment, which means that the individual is not controlled or triggered negatively by the outside world, but responds to the world from a state of internal harmony with one's deepest Self, as well as with others and within the context of the situation (Banmen, 2002, page 11-12).

Meta-goals guide the overall process of therapy.  The therapist facilitates the individual, couple, or family developing their positively directional goals within the conceptualization of the therapy's change process.  "These goals need to include the whole person, not only one aspect of life such as behavior or feelings.  In Satir model terms, goals need to include changes in behavior, feelings, feelings about feelings, perceptions, expectations, and yearnings…"  As theorists have evolved Satir's model, Banmen (2002, page 12) describes it as "best described as positively directional goal focused and transformational change based."  This means change at multiple levels of the individual as noted in the Personal Iceberg Metaphor: behavior, coping, feelings, feelings about feelings, perceptions, expectations, yearnings, and self (Banmen, 2002, page 10).

"Satir's iceberg model a person's behavior is the tip of the iceberg and at the water line is the person's coping stance.  She maintains that becoming familiar with one's under the waterline, bulk of the iceberg is the path to becoming congruent.  She described three levels of congruence.  The first level under the waterline to become aware of and familiar with is one's feelings, expectations, perceptions and yearnings.  The second level is awareness, acceptance and experience, the knowledge of self-wholeness.  The third level is of spirituality and universality" (Caflisch, 2010).

The therapist needs to look beneath the coping stance or waterline (or behind the mirror, so to speak) towards the deeper values held by the individual, couple, or family.  The therapy reveals that all manners of rules about feelings, perceptions, and assumptions come from the family-of-origin.  That would include both Terry and Bert's experiences from each family-of-origin.  Parents give messages that define the self-worth of children into adulthood in the next generation.  Members of the same family may vary in how they hold family rules.  However, overall the family rules guide, set boundaries, and determine socialization.  Family rules may also create a closed family system characterized by members who:

Are guarded with each other

Are hostile

Feel powerless and controlled and are passive

Are inflexible in their views and behaviors

Wear a façade of indifference toward each other

Problematic behaviors or symptoms occur when the rules constrict a family member's self-esteem and sense of emotional or psychic survival.  Especially relevant to relationship functioning are family rules about which feelings may be expressed and which are off limits, including possibly against asking for what the individual wants.  From such rules, the individual may enter adulthood thinking he or she cannot verbalize what one feels, am allowed only certain feelings to feel, cannot ask for what he or she desires, but instead only ask for what others expect him or her to ask for.  An individual often operates from old family rules inappropriate for current needs of the relationship.  The therapist should help individuals examine whether archaic family rules have stymied relationship productivity and consider developing new guidelines for functioning.  "Satir believed that it was important not to throw out the rule because most likely it had been based on some original wisdom, rather to move the rule from 'compulsion to choices' (Satir et al., 1991, p.307).  Satir would then lead her client through three stages of transformation.  Changing the shoulds to cans, the nevers to sometimes, and the third step is to expand the 'I can' into three possibilities of what the person can do" (Caflisch, 2010).  

The leadership of the therapist is critical to any transformative process for the individual, couple, or family.  The therapist sets the tone and context for individuals to develop safer and accepting perceptions of each other or others.  This is often inherently difficult in conflictual relationships.  It is further intensified when there has already been a formal marital failure as exists in Terry and Bert's post-divorce co-parenting relationship.  Some relationships have comparable or even more negative intensity despite not being formally separated.  There may be years of dysfunction as was in their case.  Terry and Bert had tried couple therapy prior to getting divorced.  The negative tone between them had not been interrupted, and subsequent degeneration of the relationship lead to final dissolution.  It had not been safe for either of them in their prior therapy.  The context of therapy needs to be safe enough and stable enough for the individual, couple, or family to experience it as different enough from their strained interactions.  If the therapist can create a sense of security in therapy, partners or family members can explore the possibility of better individual and relationship satisfaction.  In family therapy, it is often unsafe for children or teens to reveal their true feelings and thoughts for fear of retribution when they return home.  This continues to compromise the family relationship.  And possibly, for relationships outside of therapy.  It is "a primary task of the therapist is to provide a secure base that makes safe exploration possible" (Heene et al., 2005, page 435).  

The therapist puts out expectations and queries that prompt the individual, couple, or family to consider different perspectives from their internal operational models.  Terry may be challenged to see how Bert's behavior may not be about control, but about a sincere desire to have a quality relationship with the children.  Bert might be guided to see how Terry has anxiety about the children's well-being rather than being out to hurt him.  The therapy may show them how their respective behaviors to win or dominate, rather than supporting the children's health teach them a dysfunctional relationship model that they will replicate to their detriment in adult intimate relationships.  One way or another depending on therapeutic orientation and personal style, the therapist questions their memories and expectations of previous attachment figures.  How does Terry remind Bert of his mother?  How might Bert's stoicism feel like her father's emotional disconnection to Terry?  The therapist further encourages continued exploration that allows for integration of new information and experiences into entrenched operational expectations and values from the family-of-origin.  The older model tends to be stable and not amenable to adaptation whether or not it is effective in the current relationship.  In evaluating his or her experiences, the individual tends to have a confirmation bias favoring the older model.  Either or both Terry and Bert unconsciously anticipate and experience the vulnerability they endured as children with each other, whether or not it is actually the other person's intentions.  The therapist may ask a direct question such as, "I know it probably feels the same, but is it really the same?  Are you as helpless as before?"  The therapist constantly must balance cognitive and rational processes with possible attachment issues in addition to the interactive process between the individual and others, between partners, or among family members.  

The relational behaviors or interactions between people can be problem-solved and adapted with sound communications training, but only if individual vulnerabilities are simultaneously addressed.  Direct work on the communication process with Terry and Bert must include dealing with two additional "members" in therapy: Terry's vulnerability and Bert's vulnerability.  Otherwise, a person may be emotionally triggered and feel threatened by the communication training process and become unexpectedly resistant, if not outright hostile.  Communication-oriented therapy invariably promotes revealing ones sensitive emotions.  For example, Bert's lifetime of avoiding vulnerability by being defiantly angry cannot be easily bypassed.  Activated to defend him or herself and ready to fight, the futility of the relationship is duplicated in the therapeutic relationship.  Bert is as likely to become infuriated at and fight the therapist as rage at Terry, if the therapist has not helped him explore his habitual reactions.  "…we try to teach the couples who come to see us that it is impossible to fight and explore at the same time.  The immediate job, as we see it, is to try to open up a clear and present space that might eventually facilitate a growing ability… to move or 'bridge' (see Pizer, 1992, 1998) from fight mode to reflection, from the binds of a 'relational (k)not' (Pizer, 2003) or negation of one another to mutual recognition (Benjamin, 1995) and gaining perspective (Coates, 1998; Fonagy and Target, 1998)" (Pizer and Pizer, 2006, page 73-74).

Assessment and conceptualization of client issues are the initial explorations of therapy.  While they serve the therapist beginning understanding of the individual, couple, or family, they also deepen self-understanding.  Exploration leads to the therapist specific goals for therapy that may or may not be explicitly negotiated with the partners.  Initial goals for Terry and Bert may be to lessen pain, improve self-esteem, recognize communication stances, recognize family-of-origin communication and behavior patterns, improve communication skills- leveling (congruent communication), growth/maturation.  Therapy often critically emphasizes facilitating greater awareness of how the individual, couple, or family communicate with another or each other.  By gaining greater awareness of their communication dynamics, individuals such as Terry and Bert hopefully improve understanding of personal unique interactive patterns.  With greater awareness comes the possibility of altering dysfunctional communication processes.  This serves the relationship in developing greater intimacy and functioning.  The individual with problematic communication often assume incorrectly that the effect on the recipient is exactly what the sender intended the message to convey.  As a result, "It is important to address overtly these internal assumptions early in the therapy process to set the stage for acceptance of the efforts of partners while working toward creating more effective communication patterns in the relationship (Weeks and Treat 2001)" (Parr et al., 2008, page 167-68).  Sometimes, the recipient incorrectly assumes that what he or she feels is what the sender wanted him or her to feel as a result of the communication.  Negative outcomes from another's messages are assumed to be intentional, which causes anxious individuals to have difficulty trusting one another or any other person.

Individuals often self-identify as having poor communication dynamics with resulting personal depression.  Or, depression may be identified as contributing to poor communication.  Relationship problems can cycle repeatedly with communication problems as a key element.   The therapist should attempt to interrupt the problematic communication and ineffective conflict.  This often requires teaching individuals of the relationship among poor communication, depressive symptoms, and relationship distress.  Heene (2005, page 434) recommended in addition to improving insight about harmful patterns underlying relationship dynamics, that "the implementation of communication training can be an important component for long-term maintenance of progress, improving their repertoire of effective interpersonal behavior."  Communication training can be done with homework, established programs, videos, and literature in addition to work in therapy.  When approaching how to work with the individual, couple, or family, the therapist should aware of implications of open congruent communication on the status quo of individual, couple, or family's values.  The therapist should return "the therapeutic power to the couple by inviting them to decide which of the possible solutions and aspects of culture they prefer" or to the individual or to the family.  The therapist consciously and/or unconsciously may be promoting change as the individual, couple, or family desires or as he, she, or they desires personally or professionally.  For example, "In a sense the therapist can also be seen as 'pushing the gender line' by encouraging couples to consciously pick and choose gender patterns that work for them at this particular point in time rather than developing them by default (Maciel et al., 2009, page 21).  Egalitarian-based communication values may be incongruent with internalized cultural models of the individual, one or both partners, or some or all family members.  The therapist should be beware of making cultural assumptions as to what the individual, couple, or family wants or can tolerate with communication and the relationship.  

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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