3. Interventions - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Communication oriented therapy might begin with a discussion of communication.  "Some points that would be useful to discuss include:
 
(1) the role of the speaker;

(2) the role of the listener;

(3) the use of non-verbals;

(4) the metacommunication aspect of each message conveyed in conversations that are more about the messenger than the message; and

(5) specific issues related to each couple's unique communication patterns." (Parr et al., 2008, page 168-69).  

While the overall introduction to therapeutic goals and processes can be important, the therapist needs to adeptly translate principles into behaviors for the individual, couple, or family.  "The couple's experience within the treatment relationship must be operationalized by the therapist's offering of training in specific skills.  After all, the 'goodenough' mother does not just provide herself as an empathic object, she also provides crayons and paper.  The therapeutic efficacy of the couple therapist's activity relies on the therapist's provision of tools that are made available to the couple for their own use" (Pizer and Pizer, 2006, page 85).  The therapist provides both models and education within therapy.  The therapist creates the working space for individuals to explore new ways of existing and being with each other.  Giving dynamic interpretations and specific tools involves working from inside out and from outside in.  "For example, we have found it enormously beneficial to intervene in the heat of an argument with the simple reminder:  'It is impossible to fight and explore at the same time; the choice is yours.'"  This intervention presents a potentially new concept to clients that may calm an eruption between partners or among family members and set a workable reference point.  At opportune times, individuals can be taught to take ownership of communication and use "feelings" statements.  Receptive and reflective listening are noted and reinforced in sessions.  Accusatory statements that blame- often starting with "You" and defensive attitudes that forestall mutual understanding are discouraged.  The therapist is wise to recognize "that well-worn habits of mind, and tightly cinched relational (k)nots, are difficult to undo," which requires that therapist will "seek to establish new patterns of communication.  We assign concrete exercises that we tailor to each individual couple for them to attempt, first with our help in a session, and then for repeated practice during the interim week at home" (Pizer and Pizer, 2006, page 85).  

Other interventions may include a family life chronology (family map or genogram) to uncover family patterns of relating and community values.  For Terry and Bert, the therapist may uncover abuse in Terry's family, with a distant and blaming father through the family-of-origin exploration.  Exploration of Bert's family may find a powerful but emotionally distant father and a compliant mother that have shaped Bert's values and behaviors with Terry.  Coaching healthier communication skills in session may focus individuals on their interactions verbally and non-verbally: body language, tone of voice, facial expressions, etc.).  The therapist may direct the individual to the feedback that they gain by attending to feelings in his or her body.  Sculpting may be used to exaggerate a stance taken by an individual.  Sculpting creates an external picture or sculpt of an internal process such as a feeling, experience, or perception.  It uses body postures and spacing as a demonstration of relationship patterns of communication, power, closeness, and distance.  Used in group therapy, it can be adapted to individual or couple therapy.  The therapist or client can give his or her interpretation of what has happened between individuals by getting them to assume specific body positions and expressions reflecting his or her perception.  Or, may have the individual client or the therapist him or herself may take positions.  This may allow the one or another to gain a more objective view, creating the possibility for new awareness.  The therapist may use communication principles and interact intuitively or use more structured interventions with the individual, couple, or family.  For example, "One simple but powerful tool is the Listening Exercise.  The couple is instructed to take turns in the roles of Speaker and Listener.  The Speaker takes three to five minutes to elaborate without interruption from the partner on a particular topic of personal importance.  The Speaker may choose a worry, a memory, an area of need or a wish, or simply an experience of being in the day.  The Listener is asked to reiterate what he or she heard the Speaker say—not a rote and identical repetition, not an editorial or critical judgment, and not an effort to fix whatever it is, but just a rendering of what the Listener heard the Speaker communicating about him- or herself.  After each member of the couple has had a chance to play both roles, we may ask of each, 'What did you find more difficult, to speak or to listen?'  'Did you feel heard?'  'Was there anything missing for you?'  'How do you feel now?'  After providing a time for both listeners' personal responses to the material they heard, we explore together the internal and interactive obstacles to speaking freely and intimately and listening receptively and reflectively" (Pizer and Pizer page 85-86)

Gestalt work, doubling, or other strong therapeutic prompts for verbal practice may prove beneficial.  The individual can be asked to complete a statement such as, "I value you (the partner or the person in his or her relationship if not in therapy) for _______," with a series of comments or descriptions.  The therapist can make suggestions for the individual to try out.  The therapist might prompt for the individual to repeat, "I value you for caring about my sports."  If the individual balks at trying it out, the therapist tells him or her to say it anyway and then to make an adaptation to make it accurate.  For example, the individual may say to the partner (or about the person in the relationship), "I value you for caring about my sports.  Uh… no, I value you for letting me have my sports.  Yeah, that's right."  As the therapist offers one fill-in after another, he or she uses his or her therapeutic instincts to slow down and let the individual express freely.  This technique may connect the individual to deeper feelings that he or she may be able to communicate openly for the first time.  Another gestalt technique would be to use the "empty chair" to symbolically "speak" to an important persona from the family-of-origin, or to have parts of the individual converse dialectically.  For example, the therapist may have Terry move from one chair to another and speak from two personas.  Starting in one chair, she speaks first as the hopeful more conciliatory Terry, and then moves to another chair to speak as the more intolerant and angry Terry.  At clinically opportune times, the therapist tells Terry to switch from one persona to another to respond to what is said.  The therapist may use another version of the empty chair to have Bert have a discussion with the Terry persona he is afraid that she will be, or possibly the one he would like Terry to be.  The therapist may use physical touch between partners or family members, which is an extremely powerful non-verbal communication to interrupt emotionally disconnected discussion.  If appropriate with partners or family members, they can be told to first hold hands or sit together with arms and legs intertwined, and then given permission to continue arguing.  The empathic connection from physical non-sexual intimacy may increase congruence between feelings and verbalization.

TERMINATION
The individual, couple, or family is ready to terminate therapy when they feel able to continue to grow on their own.  The individual, couple, or family had operated wearing various masks that obscured communication.  Personal communication between individuals needs to be congruent- what Satir calls "leveling."  Leveling occurs when the person's words match with facial expressions, body language, tone, and other non-verbal communication.  The individual can honestly apologize to another, the partner, or family member for behavior or actions, but not for his or her existence.  This may be related to the individual resolving long-held grief or loss from the family-of-origin, other prior experiences, and earlier in the relationship.  There may be incongruence between feelings and thought, feelings and behavior, or thought and behavior.  The individual may love and yet hate a parent.  He or she may deeply desire something, but be also repulsed by his or her desire.  The individual may want to be independent but seek dependence.  Individual work in therapy may be necessary to help him or her become congruent before a relationship, the couple or family can be connected.  Individuals may be challenged to connect because of having different family-of-origin rules and models and different perspectives and ways of feeling and thinking.  However, if they practice leveling with one another or others, their communication congruent with internal processes can promote connection.  Sincere internal to external consistency communicates differences that can be tolerated and perhaps, appreciated.  For an individual to be congruent within oneself, he or she has to be self-aware, be aware and respectful of how others perceive him or her, make choices and express needs, anxiety, fears, and hopes in tune with inner values.  He or she then can free him or herself from past dysfunctional inappropriate family-of-origin values, rules, and models.  Disagreements become less or not about ones worth, but a difference of opinion between two worthy people.  The individual who is congruent develops healthy self-esteem.  He or she becomes more likely to promote and enable the self-esteem of his or her partner, and create functional intimate couples.  Termination of therapy is indicated when the individual, partners, or family members are individually congruent and congruent as a couple or family.  Getting two individuals such a Terry and Bert in sync with their joint desire to raise healthy children is a monumental achievement.  For Terry and Bert, that means being congruent as a co-parenting partnership but not as a happily-ever-after re-unified couple.  

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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