9. Goals of Clients - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Attachment and mutual nurturing can be compromised when individuals develop defensive and competitive feelings in areas where there was collaboration or at least, deference to the other person's primacy.  The classic stereotype of ownership for a heterosexual couple may be that wives "own" the daily child rearing needs and the household functioning including cooking and cleaning, while husbands "own" the finances, are responsible to make income, make the "big" decisions, take care of the cars, and barbeque occasionally!  If wives question their expenditures on sports tickets and hunting gear, they have invaded the men's domain.  If husbands suggest adding more extra-curricular activities to children's schedule, they are usurping women's realm.  Surprise, hurt, and anger at being challenged harms intimacy between them, which may bring them to therapy.  Orathinkal and Vansteenwegen (2006) uses the concept of territory to describe how individuals in relationships may arrange realms of influence and control, and how they compete with each other.  They assert that individuals' sense of territory often extends to other aspects of their physical, emotional, social and intellectual lives.  "It could be described as that area of an individual's life which he/she experiences as his/her own, in which he/she exerts control, takes initiative, has expertise, or accepts responsibility… A territory is any area that an individual feels a sense of ownership about and seeks to own, be it a particular object, an idea, time, privileges, privacy or anything else that holds an individual's fancy to such a degree that one seeks to own it. The need to have things for oneself or to own things is called territorial need. Within a marriage the partners need a number of exclusive ownerships. A healthy ownership is an important factor in a relationship. The term ''territoriality'' refers to the inclination towards this ownership" (page 29)
 
Therapy from this perspective may not directly deal with intimacy issues between individuals.  Motivations or intentions and feelings or emotions are also not the focus of this approach.  Territory oriented therapy is more concerned with regulating behaviors, functions or tasks (page 43).  Issues where territory is relevant include:

Attention- an appeal to get the complete attention of the partner

Privacy retreat or refuge-island- the area where an individual goes to get away and wherein one can stay with his/her own feelings or thoughts without being disturbed by the partner.

Useful objects- each partner likes to be the ''owner'' of particular things, not juristic but psychological ownership.

One's own thoughts and feelings- partners have the need to be the ''owners'' of their own private thoughts and feelings, and not be forced to share them.

Body- with feeling of ownership of his/her body and good feelings about it, then he/she can share the body and bodily pleasures with another.

Action territories- assigning or sharing tasks so that each have a certain number of territories only for themselves, that one is responsible for.

Control versus execution of the territory- someone who is responsible for a task has control over the task and is the owner. The executioner is the one who does the task.  Problems often occur when the ownership and the execution of a task is ''split up" (page 29-31).

Individuals may attempt to expand the boundaries of their territories and thus, intrude on other's territories.  The other person may respond by asserting his or her territory.  If the other persons fail to assert his or her territory and lose it, he or she may respond with hostility.   Hostility does not restore the territory or is it otherwise productive.  Instead, hostility destroys the territory of another.  The result is often two individuals with lost territories and mutual resentment.  Territory oriented therapy, instead of focusing on feelings addresses how to restore or create secure mutually acceptable territories for both individuals.  Individuals, couples, or families may present their issues in terms of territories or in terms of emotional needs.  Or, there may be some other perspective, each with their implicit set of goals. The therapist needs to discover which goals are relevant to each client, which may be the same as those of the therapist.  Sometimes, they are not.  Coming to therapy itself implies some goal or goals that the individual or each partner or family member holds, but they may not be shared goals.  Individuals may present therapeutic goals that duplicate with their goals in life.  "Emotionally Focused Therapy and Adlerian therapists both share the idea that each individual operates with a specific goal or set of goals in mind, and these drive behavioral  strivings... all behavior has a goal, which may be facilitative or destructive to the relationship.  These are based on their subjective perceptions (or private logic), which color their construction of reality (lifestyle).  This teleological or goal-directed approach allows therapists to look for the personal meaning to a person's (or a couple's) behavioral interaction.  Thus, understanding of the client's goal via movement is a key to unlocking the couple's conflict… Similarly, EFT theorists view the goals of a couple's behavior as driven toward meeting the basic attachment needs (security and exploration of the environment) in order to fulfill their potential in life" (Peluso and Macintosh, 2007, page 256).

The therapist needs to clarify what are the personal goals of each individual, each partner or family member in addition to what are the different goals between the individual, couple, or family and the therapist.  Only then can the therapy establish a consensus about what are appropriate goals.  It is imperative to find out and discuss whether the goals of one partner or family member are the same as the other partner or family members and what it means to therapy.  One individual may be trying to save the marriage or relationship, while the other person is "trying" therapy.  In individual therapy, a person comparably may have a similar dynamic of conflicted motivations.  The first partner or family member is already invested in the relationship and invested in the therapy.  The second partner or other family member may be invested in the relationship or not, but as yet has not invested in the therapy.  In another situation, one partner is ready to leave and seeing if there is any reason to stay together, while the other partner is willing to do anything to keep the relationship together.  Individuals may hold their investment or goals in therapy a secret from both their partners or family members and the therapist.  The therapist should not assume that both partners or all family members are invested in sustaining the relationship or the therapy process.  Nor assume that both or all are willing to be vulnerable, want better communication, and reveal feelings and thoughts.  The therapist should directly ask each individual about personal goals and investment in therapy.  The therapist can then use clinical judgment to determine the candidness of their replies.  Processing the difference in goals may need to be the first task of therapy.  For individual therapy, that may be clarifying conflicting motivations.  There may be an inherent and untenable power inequity in the therapy if the goals do not match.  The less invested partner or family member may manipulate his or her partner or other family members and the therapy itself with the threat of withdrawing from therapy.  The therapist needs to address both the differences in investment and the implicit control one partner or family member (or a compelling motivation) may have or the therapeutic process may be compromised.  

To a certain degree, when therapy proceeds along the lines that clients anticipate, it tends to be more productive.  Estrada and Holmes (1999) found that "couples who reported the most marital satisfaction were those who indicated they had participated actively in therapy, collaborated with the therapist, and tended to comply on homework assignments… results suggest that success in marital therapy depends on couples' active involvement and compliance in therapy (page 152)."  Bowman and Fine (2000) explored what were helpful and unhelpful aspects in couple therapy.  These may be used as guides or goals for the therapeutic process.

Helpful Aspects
Therapeutic Atmosphere seemed to be an essential component of a satisfying therapy experience…

1. Trust in the Therapist.  The following sub-themes were associated with trust:
Validation, supportiveness, and nonjudgment…

Genuine interest and caring…

Transparency of the therapist… willingness of the therapist to share his or her perceptions and understandings about the partners' issues contributed to the establishment of trust.

2. Safety in Session Structure.  Safety in sessions was associated with two subthemes.
Session rules.  Having some ground rules related to listening, and a prohibition of verbal abuse.

Closure.  This was accomplished when… therapists checked out whether it was okay to continue talking about an issue… a safe closure was achieved by the therapist "carefully choreographing the discussion so that (the clients) would be able to leave the session in a positive frame of mind.

3. Client Choice.  Participants… seemed to find a nonimpositional orientation helpful.  Subthemes included
Clients find their own answers… rather than imposing answers on them.

Clients determine session focus… rather than having to stick to a predetermined plan.

Clients do not have to adopt a particular world view or approach.

Clients feel no pressure to respond in particular ways or to arrive at particular outcomes.

4. Equal treatment of Both Partners… participants seemed to value their therapists' abilities to work in ways that permitted both partners to feel heard and acknowledged.
Both partners feel heard… therapists actively intervened to make sure that both partners had a chance to talk.

Both partners feel acknowledged… being recognized as unique individuals with unique experiences of therapy

5. Therapist Refocused Session… helpful when their therapists refocused the session on "core" issues discussion strayed too far afield.

6. Therapy Context as Special Time to Focus on Relationship (page 300-01)

Ideas and Information
Some of the most meaningful impacts of couple therapy for all participants were the development of new ways of looking at and doing things. Four themes related to the generation of ideas and information emerged.

1. Coming to a New Understanding About the Relationship.
Learning more about each other and seeing each other in a different light.

Understanding underlying issues.

New understanding about communication and couple interactions…. Communication was helped when their therapists shared personal examples from their own relationships to illustrate potential problem-solving strategies.

2. Seeing Self in a New Light… experiences in couple therapy had helped them develop new, more positive pictures of themselves as individuals… when their therapist asked… questions about… current ideas and behaviors in light of some of their family of origin experiences.

3. New Ideas about Gender… develop new ideas about gender that helped them see themselves and their partners differently.

4. Making Links Between Sessions (page 301-03).

Estrada and Holmes (1999) found twelve effective ingredient categories emerged from the sorting of clients' statements.  The 12 effective ingredient categories in descending order of frequency were:

1. Therapist moderates and controls discussion.

2. Therapist facilitates communication.

3. Therapist increases awareness of personal patterns.

4. Therapist reflects and provides feedback.

5. Therapist provides safe environment.

6. Structure of therapy

7. Therapist as an objective third party.

8. Therapist encourages participation.

9. Therapist is empathic.

10. Therapist helps in resolving problems.

11. Therapist challenges couple.

12. Therapist asks questions. (page 155-56)

There is significant overlap between Estrada and Holmes' list of effective ingredients and Bowman and Fine's list of Helpful Aspects.  However, Bowman and Fine's list of Unhelpful Aspects has a different tone than Estrada and Holmes' list of ineffective ingredients.

Therapeutic Atmosphere
1. Unequal Treatment of Partner

2. Therapist Talks When Clients Wants to Talk

3. The Term "Therapy"

4. One-Hour Session is Too Short… feeling constrained by… the 1 hour session format and the length of time it takes to "get into things" each session

Ideas and Information
Not Enough Bridge Between Therapy and Life. (page 303-004)

The five ineffective categories in descending order of frequency were (Estrada and Holmes):
1. Wasting time in therapy.

2. Therapist techniques are unclear.

3. Therapist does not help in resolving issues.

4. Therapist is not acting empathically.

5. Being unfocused in therapy (page 155-56).

Thomas et al (2005) state that clients prefer an active therapist, which tends to positively affect outcomes.  Letting individuals, couples, or families lead the therapy runs an inherent risk of them merely duplicating the previous dysfunction that brought them to therapy in the first place.  If they feel that they are out of control, they often want someone… and that someone being the therapist to take control.  Allowing for individual, couple, or family dynamics to be revealed is useful but not to the point that it spirals out of control.  If it devolves to toxicity in front of the therapist, it can cause the individual, couple, or family to be even more despairing.  They may think, "Even the professional can't stop this dysfunction."  An active therapist often creates the essential rapport with the client for change.  "…a pattern of heightened therapist activity in family/couple therapy has a particular and profound impact on the therapist–client relationship.  The alliance can, especially in long-term work, become a pivotal focus for promoting change.  By actively structuring the sessions, the therapist is given a unique opportunity to use this special relationship to help a couple reshape their behaviors and work together to make changes that are deep rooted and significant… findings… suggest that therapist activity during sessions (e.g., demonstrating behaviors such as moderating conversation or reducing negativity) is associated with more positive outcomes for clients" (page 20-21).

The therapist would probably benefit from taking and combining the aspects and categories listed above and recommended by others to set as goals of the therapy process to guide the work.  Bowman and Fine found that clients associate effective moments in therapy with therapists who facilitated the development of their own goals, rather than determining the client's goals for them (page 305).  They speculate that aspects of the therapeutic relationship (i.e., trustworthiness of the therapist, genuine interest, caring, safety in the session, nonimposition, and so on) may cross all approaches to therapy, and may be more fundamental to successful therapy than the approach used (page 307).  Estrada and Holmes found that especially in the beginning of therapy, couples' expectations are for therapists to create a safe environment and to be active, structured, and focused in therapy (page 158).  Couples have clear expectations and do not favor wasting time and unclear and unfocused therapists.  Clients have expectations about what and how therapy should be.  When expectations are met or exceeded, they develop greater hope.  Getting feedback from clients about what is working or not working in the process helps therapy and helps develop better rapport, collaboration, and involvement in the therapy (page 160).  

The art of therapy may be about accepting client's goals and expectations, collaboratively working towards them, while expanding or converting them to goals and expectations that the therapist believes will be the most beneficial.  This may involve addressing and achieving instrumental or territorial goals to serve attachment and intimacy goals.  It may involve processing family-of-origin experiences to deconstruct and adapt current dysfunctional communication.  It may mean improving communication skills to facilitate clear healthy relationship boundaries.  It may mean working on boundaries to reduce emotional reactivity.  It may mean cross-cultural work to aid in conflict resolution.  The sophisticated expert therapist may quickly intuit that individuals, couples, and families' expectations of and goals for therapy are expressions of deeper issues or routed in other problems.  Rather than dismissing client's goals and expectations, the skilled therapist joins with clients and help them achieve their goals and expectations, but often in ways unanticipated or even uncomfortable for clients.  Such expert and skilled work is truly attentive and respectful of clients and their needs from the most superficial and the most deeply hidden.  When the therapist is intimately connected to the deeper emotions and issues of clients, then individuals, couples, and families are more likely to get what they fundamentally need.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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