Category: Research Papers by Terri Fisher, LMFT

Research Paper by Terri Fisher

Abstract

This paper discusses the history of opioid addiction.  Historical content includes recorded information pertinent to current trends.  The impact on the individual, family, and society is also included.  Relevant societal and cultural issues are discussed as they relate to opioid addictions.  Intergenerational patterns as they relate to opioid use and perseveration of its use are included.  It concludes with the effective use of family therapy to overcome opioid addiction.

The History of Opioid Use

Brownstein (1993) quotes Homer as he describes opium in The Odyssey; “Presently she cast a drug into the wine of which they drank to lull all pain and anger and bring forgetfulness of every sorrow” (p. 5391).  This reference to opium dates back to the ninth century B.C.  Opium and its derivatives have a long and infamous history throughout the centuries.  It is now included in the drug category of Opioid in the DSM-V (2014).  Heroin is also another opioid substance included within the category.

Opium comes from “opos or the Greek word for juice” (Brownstein, 1993, p. 5391).  In fact, the juice or liquid comes from the unripe seedpods of the opium poppy after the pod is broken.  Duarte (2005) indicates that opioid drug derivatives “have been called narcotics, hypoanalgesics and narcoanalgesics, which are inadequate terms for including other sleep-inducing drugs” (p. 2).  Additionally, opioids produce a feeling of euphoria.  Sumerians, who lived in the part of the world that is now Iraq, used to call opium “gil, the word for joy, and the poppy hul gil, plant of joy” (Brownstein, 1993, p. 5391).

Other historical references are noted in Egyptian tombs in the 15th century B.C. Duarte (2005) notes, “The Ebers Papyrus describes a blend of substances, among which opium, were effectively used to sedate children” (p. 2).  Even as late as the 1980s, physicians were prescribing paregoric which contained opium as a way to alleviate the symptoms of colic and other chronic digestive conditions in young children (Juurlink and Dhalla, 2012).  This application was also noted in the Ebers Papyrus as “a remedy to prevent the excessive crying of children” (Brownstein, 1993, p. 5391).

Duartes (2005) notes several references to the drug in Greek and Roman historical accounts of their Gods.  Additionally, this translated to the Arab world in the ninth century where opium was used to treat a variety of ailments and as a form of anesthesia during surgical procedures.  According to Duartes (2005), “During the Golden period of the Muslim civilization, Arabs have mastered India Ocean trade and have introduced opium in India and then in China, where it was called o-fu-yung” (p. 4).  In China, opium was widely used as a way to control diarrhea for over one thousand years.

According to Duartes (2005), a Swiss physician named Paracelsus, “reintroduced opium for medical use in Western Europe” (p. 4).  This occurred during the fifteenth century.  Brownstein (1993) credits a German pharmacist assistant by the name of Sertuner for isolating the active ingredient of Opium.  In 1806, “Sertuner isolated the active ingredient in opium and named it morphine after the god of dreams, Morpheus” (p. 5391).  These results were published in the Journal of Pharmacie where he reported the discovery of an acid called meconic acid” (Duarte, 2005, p. 4).  Sertuner decided that he should test the new drug morphine on himself to discover its active properties.  This is one of the most articulated references to the addictive properties of morphine: “I consider it my duty to call the attention to the terrible effects of this new substance, so that a calamity may be prevented” (p. 4).  Unfortunately, Sertuner’s plea was not heard.

The government of China was also alarmed by this drug.  China became so concerned about the effects of opioid drugs that it attempted to limit trade related to opioid drugs.  This was to stem the tide in coastal provinces where entire adult populations became dependent on the drug.   Juurlink and Dhalla (2012) elaborate, “Government officials became so concerned not only about public health but also about the impact of opium use on the economy.  Their attempts to limit the opium trade eventually led to the Opium Wars (1839-1842 and 1856-1860), both of which were won by Britain” (p. 394).

The American civil war contains some of the first wide spread uses of opioids.  Duarte (2005) notes, “The American Civil War has created major opportunities for the massive use both of oral opium and subcutaneous morphine in soldiers wounded in combat and, as a consequence, there were records of several cases of physical dependence generating a social problem for the US” (p. 6).  These same concerns were noted with British soldiers fighting in the Crimean War and Prussian soldiers in the 1870 war between France and Germany.

Concepts such as tolerance, psychological and physical dependence, including addiction were not widely discussed in the twentieth century (Duarte, 2005).  It was during this time that a withdrawal syndrome was discussed to describe the discontinuation of the drug.  It was at this time that “Addiction was defined by the World Health Organization as a state of periodic or chronic intoxication, noxious to individuals and society, produced by the repeated use of a drug” (p. 6).  The harmful effects of the drug had been previously noted by Sertuner.  Society seems to pursue that which is unhealthy once it is discovered despite the evidence that cautions against that pursuit.

Kreek and Vocci (2002) bring to light the mortality aspect of the drug.  This has been chronicled since the 1940s.  This set the stage for research that could stop the trend.  Additionally, “a resurgence of heroin addiction in the 1960s prompted clinical researchers to search for a long acting, orally active opiate agonist that was capable of reducing or eliminating withdrawal signs and symptoms, reducing drug craving, and normalizing physiological function” (p. 94).  This research lead to the development of methadone and other synthetic opioids.

In 1939, “meperdine, the first totally synthetic opioid, was introduced, starting a series of phenylpiperidine-derived drugs (Duarte, 2005, p. 7).  This research was also being conducted in Germany.  During World War II, methadone was first synthesized to combat the effects of opioid drug addictions with soldiers.  Other synthesized drugs followed during the fifties and sixties.  According to Kreek and Vocci (2002), “The Nixon White House supported the expansion of methadone treatment and worked with the FDA to develop the 1971 regulations governing the use of methadone in the treatment of heroin addiction” (p. 95).  This was followed by the 1974 act passed by the U.S. Congress, which established the Narcotic Addict Treatment Act.  This act “required annual registration of physicians and treatment centers, and specified treatment standards were the responsibility of Health, Education, and Welfare” (p. 95).

The Modern Day Scam

During the 1960s and 1970s, the use of opioids was still wide spread in cases of acute conditions, at the end of life, and for postoperative patients (Juurlink and Dhalla, 2012).  It was during the late 1980s that widespread use of opioids for the use of noncancerous and non-acute conditions became common practice.  “It was not until the late 1980s and, in particular, the 1990s that opioids became a commonplace element of therapy for patients with chronic pain” (p. 394).  This also prompted research into new opioid formulations that became known as Oxycodone, which was quickly followed by OxyContin.

Perhaps one of the most interesting results of these new drug formulations is with the promotional activities related to the release of OxyContin in 1996.  OxyContin is a sustained release version of Oxycodone.  Upon its introduction, the product was vigorously marketed as a safe and effective way to help patients manage pain.  It was also touted as having very low addictive properties.  Van Zee (2009) notes, “The promotion and marketing of OxyContin occurred during a recent trend in the liberalization of the use of opioids in the treatment of pain, particularly for chronic non-cancer related pain” (p. 221).  In fact, Purdue Pharma, the company which produces OxyContin, “conducted more than 40 national pain-management and speaker-training conferences at resorts in Florida, Arizona, and California . . . physicians, pharmacists, and nurses attended these all-expense paid symposia where they were recruited and trained by Purdue national speaker bureau” (p. 221).  Over five thousand of these professionals were trained to teach their cohort about this new and safe drug.  These medical professionals were picked based on research noting the areas in which opioids were being widely prescribed.

This massive training effort was also supported by an increase in sales staff (Van Zee, 2009).  Massive incentive bonuses were paid to its doubled sales force.  A physician list of over 94,000 doctors was generated.  The sales staff was then instructed to deliver patient starter coupons to the physicians.  These coupons “provided patients with a free limited-time prescription for a 7 to 30 day supply” (p. 222).  Van Zee states, “By 2003, nearly half of all physicians prescribing OxyContin were primary care physicians” (p. 222).   This represented a shift in the treatment of pain from surgical, pain monitoring, and emergency physicians to primary care physicians; the primary work force in managed care systems.

A societal shift occurred that created a market that previously had not existed.  Van Zee (2009) notes that during this time Purdue Pharma executives continued to claim the safety and efficacy of OxyContin.  In fact, “Purdue claimed that the risk of addiction from OxyContin was extremely small” (p. 223).  Sertuner may have disagreed if he would have been alive to discuss the merits of opioids.  In 2007, “Three company executives pled guilty to criminal charges of misbranding OxyContin by claiming that it was less addictive and less subject to abuse and diversion than other opioids, and will pay $634 million in fines” (p. 223).  This seems a very small price to pay when compared to the effects the drug had and continues to have on family, societal, financial, and ecological concerns.

According to McHugh, DeVito, Dodd, Carroll, Potter, Greenfield, Connery, and Weiss (2013), “The number of opioid prescriptions and the abuse rate of prescription opioids have increased greatly in recent years . . . consistent with these new trends, mortality rates, societal costs, and treatment seeking related to prescription opioid use disorders have increased substantially” (p. 38).  This is a societal patterns as well as an addiction pattern.  Lewis (2014) notes that patterns of use create addictions.  In fact, the very act of going to the doctor monthly, having your pain level monitored, leaving with your handy prescription of legally acquired drugs, then going to the pharmacy where you provide the financial reimbursement for your drug of choice is similar to the drug seeking activities of any individual who regularly seeks out his dealer, makes a time and place for the meet, handles the financial transaction, then leaves with her drug.  The first difference in the pattern lies in the shift from non-acceptable to acceptable behavior.  The second lies with an insurance company that helps pay for the drug.

Vulnerable Populations

Few question their doctor; after all, he/she took the Hippocratic Oath that provides for ethical treatment.  Your own doctor would not allow you to be treated in a harmful manner.  We are brought up to culturally accept the direction of a physician.  Women may be particularly sensitive to the role of a doctor.  Other factors also add to the gender difference such as a pregnancy, a situation that includes domestic violence, or a woman who is homeless.  Heil, Jones, Arria, Kaltenbach, Coyle, Fischer, Stine, Selby, and Martin (2011) state, “Licit and illicit opioid dependence during pregnancy is often complicated by a multitude of other factors, including low socioeconomic status, poor nutrition, lack of parental care, family instability, interpersonal violence, homelessness, psychological problems, and other drug use” (p. 199).

Another population of individuals that is particularly vulnerable to opioid addiction is the elderly.  Lofwall, Brooner, Bigelow, Kindbom, and Strain (2005) state, “The continuing shift to an older age distribution in the United States will significantly impact the entire health care system including substance abuse treatment services . . . substance use problems are frequently overlooked and are often associated with significant medical and psychiatric morbidity and mortality, and among older adults (age 60 and over) have been declared an invisible epidemic by the Substance Abuse and Mental Health Services Administration” (p. 265).

Lofwall, et al., (2005) note, “Consistent with previous studies of psychiatric comorbidity in opioid dependent samples study participants had high rates of many lifetime and current psychiatric diagnoses compared to general-population samples” (p. 270).  This begs the question of how effective we are as a society in providing psychological and medical treatments concurrently.  As individuals move through life stages and change, do we provide a level of care that addresses the needs of individuals in relation to their family stages?  MGoldrick, Carter, and Garcia-Preto (2011) state, “In families where addictions and AIDS have led to parents being unable to take care of their children, grandparents may continue to be caretakers way past midlife” (p. 249).  The long terms effects established by ineffective patterns create a generation of elderly individuals who are particularly vulnerable to the stressors in life.  In a managed care system that gives perhaps ten minutes to discuss a plethora of needs, it would be easy to prescribe a pill that has a history of helping relieve both physical and emotional pain without solving the underlying issues.  This creates a pattern of societal demands, which creates epic failure to address needs adequately.

Conclusion

Research clearly shows that addressing needs from a systemic perspective, and incorporating family concerns, has a measurable impact when dealing with opioid addiction.  Comisky (2013) elaborates, “Opioid addicted parents within methadone treatment who underwent a family focused intervention reduced their level of opioid use, improved their coping skills, and held more family meetings to discuss family fun” (p. 90).  In fact, including the family provides the stability for each member to heal together without the trauma of separation.  Rowe and Liddle (2003) state, “Process research focuses on the nature and sequences that determine important change events in family therapy, or those interventions that lead to successful resolution of problems or relational shifts within the family” (p. 105).  Addressing the needs of families who have members with opioid addictions should include a process that focuses on the patterns and behaviors that created intergenerational patterns of dysfunction.  It should also provide support for the resiliency of the family to withstand societal pressures while honoring the family as a unit that can heal.

References

Brownstein, M.J. (1993). A brief history of opiates, opioid peptides, and opioid receptors. Procedures of National Academy of Science, 90, 5391-5393.

Comisky, C.M. (2013). A 3 year national longitudinal study comparing drug treatment outcomes for opioid users with and without children in their custodial care at intake. Journal of Substance Abuse Treatment, 44, 90-96.

Duarte, D.F. (2005). Opium and opioids: A brief history. Revista Brasileira de Anestesiologia, 55(1), 1-11.

Heil, S.H., Jones, H.E., Arria, A., Kaltenbach, K., Coyle, M., Fischer, G., Stine, S., Selby, P., and Martin, P.R. (2011). Unintended pregnancy in opioid-abusing women, Journal of Substance Abuse Treatment, 40, 199-202.

Juurlink, D.N., and Dhalla, I.A. (2012). Dependence and addiction during chronic opioid therapy. Journal of Medical Toxicology, 8, 393-399.

Kreek, M.J., and Vocci, F.J. (2002). History and current status of opioid maintenance treatments: Blending conference session. Journal of Substance Abuse Treatment, 23, 93-105.

Lewis, T.F. (2014). Substance Abuse and Addiction Treatment. Upper Saddle River: NJ: Pearson Education.

Lofwall, M.R., Brooner, R.K., Bigelow, G.E., Kindbom, K., and Strain, E.C. (2005). Characteristics of older opioid maintenance patients. Journal of Substance Abuse Treatment, 28, 265-272.

McGoldrick, M., Carter, B., and Garcia-Preto, N. (2011). The expanded family life cycle: Individual, family, and social perspectives (4th ed). Boston, MA: Pearson Education, Inc.

McHugh. R.K., DeVito, E.E., Dodd, D., Carroll, K.M., Potter, J.S., Greenfield, S.F., Connery, H.S., and Weiss, R.D. (2013). Gender differences in a clinical trial for prescription opioid dependence. Journal of Substance Abuse Treatment, 45, 38-43.

Rowe, C.L., and Liddle, H.A. (2003). Substance Abuse. Journal of Marital and Family Therapy, 29(1), 97-120.

Van Zee, A. (2009). The promotion and marketing of OxyContin: Commercial triumph, public health tragedy. American Journal of Public Health, 99(2), 221-227.

Research Paper by Terri Fisher

Jay Haley originally started his research with the Mental Research Institute (MRI) in Palo Alto, California, where he developed a model known as Strategic Family Therapy. This model represents a combination of his work at the Mental Research Institute in Palo Alto California and his work with Salvador Minuchin. A model know as Brief Strategic Family Therapy was also developed to represent adherence to basic strategic techniques which seek to only solve the problem initially presented. Both of his approaches are brief in nature and use general systems theory along with cybernetic theories (Gehart, 2014). General systems theory and cybernetics are often used interchangeably (Becvar and Becvar, 2009). In fact, there are many similarities. Both seek to understand how rules within relationships affect behavior. Additionally, both seek to observe the function of the system or family in terms of interactional patterns which create boundaries, stability, and change. Cybernetics looks more at the question of how relationships are affected by change within the observer status. First order cybernetics views change from an observational perspective. Change occurs similar to a teacher providing directions to a class. Specifics are defined, then the students complete their assignments. Second order change occurs when the teacher joins the student in their learning experience. Rather than providing an outline and sending the students to complete the task, the teacher joins with the students with thoughtful questions that promote discussion. Through the discussion, the students apply material and reach self-directed conclusions.

Change occurs through the use of interventions which include reframing, directives, enactments, paradoxical interventions, and most importantly, the therapist-client relationship. Fraser, Solovey, Grove, Lee, and Greene (2012) suggest that the relationship between the therapist and family system is integral to both the joining process and the intervention phase of therapy. Additionally, the success of interventions may depend on the therapists’ ability to engage with the family and join in the family system. This relationship supports the possibility of intrinsic second order change.

In the case of one client, Anne, Strategic Family Therapy may provide relief from the family’s difficult and challenging life circumstances. This family is comprised of a mom who is 48, her two adult children ages 21 and 18, and the baby of one of the children. Mom works two jobs to support the family. She reports feeling in pain, tired, and not feeling good for a long time. Her mother is sick. She has a brother, however; he will not assist with the mother’s care. The mom feels like a “mess” including her clothes. She constantly thinks about her problems and doesn’t engage in her social or church activities anymore. Her two adult children do not work and continue to live at home with her and the baby.

Robbins, Alexander, and Turner (2000) describe reframing as a way to interrupt negative interactional patterns while supporting and eliciting positive feedback from the family system. Through the process of elicit and describe, the therapist is able to gently ask questions that relate to specific and noticeable sequences that may be damaging family relational patterns. An example with Anne would be to elicit how she feels about what is happening with her family. She may describe that she is overwhelmed and unable to manage the multiple life circumstances. A reframe may be to suggest that Anne must love her family dearly to take on the total responsibility for the family by herself. This promotes acknowledgement of her circumstances, her desire to be a good mom while also allowing opportunities to acknowledge how challenging her position is. This also promotes discussion from other family members about how they may see how they are helping. Specifics are then elicited from members about what they are contributing. These nuggets of promise promote self-directed opportunities for goal setting.

Muir, Schwartz, and Szapocznik (2004) describe the reframing process as culturally sensitive to the immediate needs of the family in session. Strategic therapy techniques including reframing have also been proven to meet the unique needs of Cuban, Mexican, Caribbean, and Puerto Rican Hispanic cultures. Additionally, this research has been extended to African American families. Long term outcomes have also been evaluated with Strategic Family Therapy. Santisteban, et al., (2006) discovered that outcomes with Hispanic families demonstrated continued improvement one year post study.

Research also indicates that strategic therapy techniques promote empowerment and support the natural flow of the family system (Amini and Woolley, 2011). The use of directives are unique and often paradoxical interventions. Directives are culturally sensitive as the therapist is only asking the family system to do what they currently do, and to just adjust a minimal factor. For example, in the case of Anne, a directive may be to continue to complain about her pain factors every day. The therapist would elicit from Anne when during the day she generally complains the most. The directive would be to ask Anne to change the time of the day she normally complains about the pain. This may also be extended to incorporate who she complains to. If she generally complains to her brother, Anne would be asked to complain to her adult daughter with the baby. This minor shift alters the patterns of interaction while concurrently changing the focus of the interaction.

Haley stressed the importance of being aware of the smallest indicators of feedback such as small facial movements. This awareness provides opportunities to reflect on the effectiveness of interventions in order to promote change (Karam, Blow, Sprenkle, and Davis, 2015). In the case of Anne, paying close attention to small changes such as body language and position allows the therapist to understand what topics are affecting family members. Enactments are then able to be used to essentially rewind the interaction and focus on the interactions within the movement. For example, if the daughter with her baby shifted away from Anne during the discussion of the directive, the therapist may ask permission to discuss the experience of the daughter. The family would be asked to enact the interaction again in order to focus attention on the discomfort of the situation. Gentle and thoughtful questions would be generated to elicit information that is specific to the body language and verbal interactions. The family would be asked to reflect on what has happened and generate possibilities for the action. This would then be followed up with reframes that elicit the nature of the interactions while supporting the members within the process.

Lebowitz, Dolberger, Nortov, and Omer (2012) suggest that this family may have adults with “adult entitled dependence” (p. 90). Adult entitled dependence (AED) is a growing and global phenomena. Lebowitz, et al., (2012) cite studies in Japan, Italy, Germany, England, Greece, Spain, and France that show adults living with their parents. This causes parental complaints similar to Anne. One of the ways to assist in this dilemma is the use of techniques used in Strategic Family Therapy.

According to Lebowitz, et al., (2012) the use of systems theory to interrupt the negative interactional patterns promotes change within the family. Techniques that can be learned just by Anne have shown promise in alleviating stress from the parent. In fact, use of these systemic techniques demonstrated more accountability for the adult children at the end of the study.

Strengths of Strategic Family Therapy include its ability to translate into homes and in group settings (Henggeler and Sheidow, 2012). Studies show that the model performs well and respects the family system throughout the phases of therapy. These phases include joining, intervention, and termination. Another strength is that it is able to be brief. Brief Strategic Family Therapy shares all the similarities of its regular counterpart. The exception lies in its very defined and specific session tasks. Brevity is helpful for low socio-economic families who may not have the time to devote to a lengthy period of therapy. It also is beneficial for insurance companies who seek to provide benefits but have limited dollars.

Limitations of the use of Strategic Family Therapy include the lack of research pertaining to cultural adaptations with global populations (Henggeler and Sheidow, 2012). Strategic Family Therapy has a broad base of applied studies with people of Hispanic origins. The origins are limited to primarily Caribbean, Puerto Rican, Mexican American, and Cuban American populations. Additionally, the research only extends to African Americans with the southeastern United States. There is currently no translation into Caribbean and African Americans or Hispanic populations that do not have some level of acculturation within the United States. Additionally, research has not extended into other continents with African, Asian, or European populations.

Research does indicate that within the above mentioned populations that have undergone extensive research, the model is ethically sound. The American Association for Marriage and Family Therapists (AAMFT, 2016) suggests that therapist use models that align with the values and beliefs of the family. Additionally, that therapists are mindful of the imbalance of power within the therapeutic relationship. As such, respectful and empowering processes should be used when working with families of all cultural and diverse backgrounds.

References

AAMFT. (2016). Code of ethics. Retrieved September 4th, 2016, from Web site: http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx

Amini, R.L., and Woolley, S.R. (2011). First-session competency: The brief strategic therapy scale-1. Journal of Marital and Family Therapy, 37(2), 209-222.

Becvar, D.S., and Becvar, R.J. (2009). Family therapy: A systemic integration (7th ed). Boston: Pearson.

Fraser, J.S., Solovey, A.D., Grove, D., Lee, M.O., and Greene, G.J. (2012). Integrative families and systems treatment: A middle path toward integrating common and specific factors in evidence-based family therapy. Journal of Marital and Family Therapy, 38(3), 515-528.

Gehart, D. (2014). Mastering competencies in family therapy: A practical approach to clinical case documentation. Belmont, CA: Brooks/Cole.

Henggeler, S.W., and Sheidow, A.J. (2012). Empirically supported family-based treatments for conduct disorder and delinquency in adolescents. Journal of Marital and Family Therapy, 38(1), 30-58.

Karam, E.A., Blow, A.J., Sprenkle, D.H., and Davis, S.D. (2015). Strengthening the systemic ties that bind: Integrating common factors into marriage and family therapy curricula. Journal of Marital and Family Therapy, 41(2), 136-149.

Lebowitz, E., Dolberger, D., Nortov, E., and Omer, H. (2012). Parent training in nonviolent resistance for adult entitled dependence. Family Process, 51(1), 90-106.

Muir, J.A., Schwartz, S.J., and Szapocznik, J. (2004). A program of research with Hispanic and African American families: Three decades of intervention development and testing influenced by the changing cultural context of Miami. Journal of Marital and Family Therapy, 30(3), 285-303.

Robbins, M.S., Alexander, J.F., and Turner, C.W. (2000). Disrupting defensive family interaction in family therapy with delinquent adolescents. Journal of Family Psychology, 14(4), 688-701.

Santisteban, D.A., Suarez-Morales, L., Robbins, M.S., and Szapocznik, J. (2006). Brief strategic family therapy: Lessons learned in efficacy research and challenges to blending research and practice. Family Process, 45(2), 259-271.

by Terri Fisher

Abstract

This brief paper analyzes narrative therapy within a professional construct. The basic premises are discussed and compared with structural therapy including change and role of the therapist. Brief descriptions of applied studies are also included to demonstrate ethical and professional efficacy. A conclusion describes the position of the author.

Narrative Therapy vs. Structural Therapy

Metaphors describe part of the context of Narrative Therapy. White (2007) suggests that metaphors provide a way for individuals to describe and present the problem that is occurring in their lives. In doing so, they are able to find meaning and value for the problem. The process of finding a theory from which to practice is similar to the process of entering this PhD program. It is a rollercoaster of dips, turns, drops, loops, and changes in speed that propel one through a journey that is exhilarating and exhausting at the same time. Some people have described the process of therapy in the same way.

Narrative therapy began with discussions between Michael White and David Epston in the early 1990s (Wallis, Burns, and Capdevila, 2011) It was a natural progression from the scope of practice which discussed how people told stories and described their lives. It is a strength based theory which believes that individuals are the experts on their lives. It is a practice that evolves through discourses between client and therapist. Consequently, it is led by the client. The therapist acts as a safari guide to assist the client. As a guide, the therapist provides the options and maps which take the client where she wants to go in order to find the things she values most.

This practice is in stark contrast to other more directive approaches such as structural therapy. Structural therapy is conducted with a therapist who directly intervenes and coaches the individual and family members to interact in different ways (Minuchin, 1974). It provides specific instructions and assignments which promote change through direct relational interactions. Change is possible in both methods. Narrative therapy is client directed change whereas structural therapy is therapist directed change.

The role of the therapist is also different in these two methods. Narrative therapists act as guides to provide support and be with the client in her journey of self-discovery (Bertrando, 2011). The therapist walks with the client in her journey in an empathetic and empowering stance. Conversely, structural therapists act as the orchestra conductor (Minuchin, 1974). The therapist has the score and directs each member to play according to her preferences. These preferences are based on experience and knowledge related to what works well and how the final piece should sound. Each therapeutic role provides opportunities for change to occur although one is directive and the other collaborative.

Narrative therapy assumes that the problem is created and expressed because of discourses that are not intrinsic to the person. The individual begins to experience chaos and confusion as she attempts to map a destination where she does not want to go. Externalizing conversations are a process by which an individual may begin to view herself as separate from the problem (Vetere and Dallos, 2008). In a sense, the problem becomes the problem rather than the individual being the problem. Separation from the problem provides opportunities for the individual to see herself as under the influence of a problem rather than the problem itself.

As an individual becomes more expert in her life, the influence of the problem becomes tenuous. This new identity forms within the construct of individual values and beliefs that align more with how she sees herself (Wallis, Burns, and Capdevilla, 2011). These more salient views promote a separation from the dominant discourses that have influenced her. The old discourses were not inherently a part of what she valued. Consequently, as the newer and more inherent constructs form, she is able to align herself with those views that inherently fit. Thus, the problem is further removed from her.

Landscapes of change begin to form through the process of scaffolding. Butler and Bird (2000) describe scaffolding as a process in which incremental goals are self-initiated and tried on for fit. These incremental goals are discovered as the individual begins to find her own unique outcomes. These unique outcomes are the times that already occur when the problem has less hold on the individual. Often, she has been unable to see the unique outcomes due to the influence of the problem. Detecting the unique outcomes provides hope while offering opportunities to describe valuable moments of relief. Goals within the scaffolding framework are then constructed and practiced. Through this practice, the individual is able to manage and tweak differences to create more unique outcomes of personal and self-directed success.

In a study by Miller and Forrest (2009) the ethics of narrative therapy were compared with the American Counseling Association (ACA) code of ethics. Two case studies were reviewed. The therapists in these studies used narrative therapy. One of the cases involved a family. Miller and Forrest (2009) describe that the ACA code of ethics requires the therapist to define the client. In this specific case involving abuse, the therapist was clear to differentiate the roles of family therapist and individual therapist. Describing and clarifying this information at every session promotes opportunities for adjustment within the therapeutic relationship.

Another study by Chan, Ngai, and Wong (2012) tested the use of narrative therapy in a case with a woman struggling with substance abuse. This study served as a pilot program for a hospital in Hong Kong. Through the use of externalization, scaffolding, proximal development, the use of photographs, and distancing tasks, the woman was able to gradually reduce her substance use to the point of no use. This hospital served as a rehabilitation center in Hong Kong.

Narrative therapy resonates with me personally and professionally. Coming from a background of problem saturated stories, it was liberating to finally understand that I was not a problem, the problem is the problem. From a professional view, it is not my nature to direct and tell people what to do. As a Marriage and Family Therapist, I am able to use directive methods, such as structural family therapy, to provide direction and relief for families who are struggling. Insurance companies are becoming more directive as to how long a family may be in therapy. There may not be time for self-guided approaches. In cases where immediate change is necessary, such as domestic violence situations, directive methods provide specific and direct change in the moment within relational constructs.

Given the time and option, narrative therapy resonates within my psyche. It provides the opportunity to value and appreciate the individual and family position. It takes into consideration the cultural beliefs and values which are intrinsically healthy and productive. Additionally, it provides the context for client centered conversations where families and individuals are able to explore and relate to difficult and challenging life circumstances. These challenges are often found in dominant discourses that may not be the beliefs and values of the individuals. Consequently, families are able to examine these discourses and decide what value they have. In this process, they create a roller coaster of events and experiences which eventually end at the destination of their choice.

References

Bertrando, P. (2011). A theory of clinical practice: the cognitive and the narrative. Journal of Family Therapy, 33, 153-167.

Butler, M.H., and Bird, M.H. (2000). Narrative and interactional process for preventing harmful struggle in therapy: An integrative model. Journal of Marital and Family Therapy, 26(2), 123-142.

Chan, C., Ngai, K.H., and Wong, C.K. (2012). Using photographs in narrative therapy to externalize the problem: A substance abuse case. Journal of Systemic Therapies, 31(2), 1-20.

Miller, P., and Forrest, A.W. (2009). Ethics of Narrative Therapy. The Family Journal, 17(2), 156-159.

Minuchin, S. (1974). Families & family therapy. Cambridge, MA: Harvard University Press.

Vetere, A., and Dallos, R. (2008). Systemic therapy and attachment narratives. Journal of Family Therapy, 30, 374-385.

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Research Paper by Terri Fisher

Abstract

A concise description of Gottman Method Couples Therapy, including therapeutic goals, the change process, main interventions, and ethical and legal considerations will be presented. An evaluation of the strengths and limitations of the approach along with a discussion of cultural applications will follow. The method will be applied to the case of Nora and Sam. A conceptualization of techniques and interventions will be discussed. Finally, Gottman Method Couples Therapy will be briefly applied to two other clients. Concise Description of Gottman Method Couples Therapy.

Gottman Method Couples Therapy

The Gottman Method Couples Therapy is based on over forty years of research observing couples and applying these data to specific techniques and interventions (Gottman and Gottman, 2015). This has led to concepts such as the Sound Relationship House (Gottman (2011), the four horsemen of the apocalypse (Kimberly and Werner-Wilson, 2013), and the seven building blocks of the Sound Relationship House (Gottman, 2011).

These catch phrases provide a way to distinguish Gottman (1999) from other therapy modalities. They are the tip of Gottman’s research iceberg. Gottman’s assumptions create an integrative perspective. It is a combination of observing and quantifying affect and emotions (Driver and Gottman, 2004) along with using specific and tested interventions in order to facilitate change (Gottman and Gottman, 2015). The major goal of the therapy is to properly assess each partner, develop a treatment plan to address each area, and then use specific interventions in order to facilitate healthier interactional patterns between the partners (Gottman and Gottman, 2015). An additional goal is to help the couple develop healthier attachment patterns which create a stronger relationship.

Change comes about as each partner begins to understand the other’s point of view (Madhyastha, Hamaker, and Gottman, 2011). The Gottman/Rappoport intervention provides opportunities for each partner to practice using I statements to describe what he or she wants, needs, or feels. Following this, the other partner reflects this back. The speaking partner then confirms the partner correctly heard the information or repeats back the initial statement and thoughts about the statement. After successful completion, the partners then shift listener/speaker positions and repeat the process (Gottman and Gottman, 2015).

Change also occurs in the dream within conflict intervention (Gottman and Gottman, 2015). During this intervention, the couple discusses a topic in which they are experiencing gridlock. Gridlock occurs when partners are unable to appreciate the aspirations behind specific conflicts. Research has demonstrated that when couples begin to understand each other’s dreams, they are able to more effectively discuss subjects without becoming gridlocked (Gottman, 2011).

Additional change occurs with the aftermath of a fight intervention. Research indicates all couples fight (Gottman and Levenson, 2002). Assisting couples to come back together after a fight provides opportunities for healing and awareness. This promotes the building of the Sound Relationship House. This intervention is similar to the Gottman/Rapoport intervention. It adds the component of identifying triggers, taking responsibility, understanding the feelings, and supporting each other’s perceptions. For other change promoting interventions that are not within the scope of this application, refer to the reference list.

Ethical and legal considerations include knowing when to counsel couples together and when to separate partners. Friend, Bradley, Thatcher, and Gottman (2011) have demonstrated through research the use of situational and characterological types of intimate partner violence (IPV). With situational violence, research has shown it is more helpful to counsel partners together (Gottman and Gottman, 2015; Gottman, 2011, Friend, et al., 2011; and Madhyastha, et al., 2011). With characterological violence, this same research demonstrates that separating the partners provides a safer space for the partner who is the recipient of the violence.

This position is also supported by the ethical code of the American Association for Marriage and Family Therapists (AAMFT, 2016). Additionally, all therapists who work with couples should be aware of who the client is and adhere to treatment modalities that are congruent with ethical standards of care.

Evaluation of Strengths and Limitations of Gottman Method Couples Therapy

Gottman Method Couples Therapy has been proven to be effective when working with couples from low socio-economic status and low income structures involved in IPV. In a study by Bradley, Drummey, Gottman, and Gottman (2014), a sample of 115 heterosexual couples who met the above criteria participated in a group program based on the Gottman Sound Relationship House program. Couples were randomly assigned to either the control group that used normal couple therapy methods, or to the treatment group that used Gottman Method Couples Therapy. The couples who were in the Gottman group showed fewer aggressive behaviors than the control group. This progress continued through the eighteen month follow-up period.

Another study by Bermudez and Stinson (2011) used the Gottman Marital Conflict Scale to test its effectiveness among the Latino population. Conflict avoidance and unity in a marriage were other areas tested. Gender along with culture was also used as variable in this study. The participants included 191 married couples in the Houston and Dallas Texas area who had lived in the United States for a time periods from one year to fifty-eight years. Sixty-seven percent of the participants were born outside of the United States. The countries of origin included Mexico, Central America, and South America. The findings were that women, whether born in or out of the United States, showed the same style of relationships. Conversely, men born out of the United States demonstrated less unity in couple relationships than men who were born in the United States. These data showed similar findings with other studies conducted with non-Latino populations.

The previous study notes an important limitation with the Gottman Marital Conflict Scale method. Latino men are often stereotyped as being volatile or avoidant. Recognizing the language used in the scale and understanding that culture may provide stability in patterns are important considerations.

Example of Clinical Application

In the case of Nora and Sam, the issues of trust and betrayal are important considerations. The Sound Relationship House provides a strong base for couples who are not in extreme distress (Gottman, 2011). Couples who have experienced betrayal, distrust, and power imbalances require additional assistance to recreate the foundation within the Sound Relationship House. Gottman (2011) describes that loyalty, trust, and balance may be rebuilt by using specific and proven techniques that will rebuild those powerful linking emotions.

First, a specific couple assessment interview is used to obtain information that guides interventions. Following the couple interview, each partner is interviewed separately. This provides each partner an opportunity to tell their story. It also allows for each partner to discuss any issues related to IPV that may be critical to safety and welfare.

The couple’s issues would be conceptualized through the interview and assessment process. Next, Interventions start that are specifically geared to the needs of the couple. One intervention that would be helpful with Nora and Sam is the stress reducing conversation. It is clear there is stress in this relationship. Teaching the couple to manage conversations in a way to reduce this would be helpful. The four horsemen would also be discussed and framed within the context of relationship building. Flooding and self-soothing exercises would be taught, demonstrated, and practiced in order to assist the couple to understand what is happening while also promoting each other in the relationship. This intervention would be used as a way to assist the couple to learn to soothe each other in the process of healing and building trust.

The building rituals of connection intervention would be used to assist the couple to move towards each other instead of away from each other. This helps build connection and healthy attachment. Fondness and admiration interventions would also be used concurrently to promote better ways to connect with each other. This is generally lacking in relationships where there is betrayal.

The dreams within conflict intervention and Gottman/Rapoport interventions would be used to assist each to understand individual pain. Both partners have suffered distance and isolation. Providing opportunities while supporting each member is critical in promoting healing and reconnection (Gottman and Gottman, 2015). Treatment concludes when the goals specified through the assessment process have been completed.

Clinical Applications for Other Clients and Issues

Gottman Method Couple Therapy would be appropriate to assist families who are in discord. Hedenbro, Shapiro, and Gottman (2006) suggest that helping parents come together creates better harmony within family systems. This position is also supported by Minuchin (1974). Aligning parental subsystems promotes healthy boundaries and creates more safety and security with children.

This method would also help individuals who have chronic health issues and who are in long term relationships. Gottman and Gottman (2015) provide case studies related to work and research involving individuals from the gay and lesbian communities. Much of this research has been conducted to determine the efficacy of Gottman Method Couples Therapy related to issues pertinent within that community.

Conclusion

The Gottman Couple Therapy Method provides an ethical base from which to work with Nora and Sam. It is a method that is based on forty years of research. Research continues in order to refine and add to the vast base of empirically proven interventions. Issues such as IPV, parenting, building and rebuilding trust, culturally sensitive practices, low socio economic couples, attachment patterns, and other relevant topics continue to be researched in order to provide a comprehensive and integrative format. This format will continue to evolve in order to represent current findings while providing evidence based practices for couples.

References

AAMFT. (2016). Code of Ethics. Retrieved August 20, 2016, from Web site: http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx

Bermudez, J.M., and Stinson, M.A. (2011). Redefining conflict resolution styles for Latino couples: Examining the role of gender and culture. Journal of Feminist Family Therapy, 23, 71-87.

Bradley, R.P., Drummey, K., Gottman, J.M., and Gottman, J.S. (2014). Treating couples who mutually exhibit violence or aggression: Reducing behaviors that show a susceptibility for violence. Journal of Family Violence, 29, 549-558.

Driver, J.L., and Gottman, J.M. (2004). Daily marital interactions and positive affect during marital conflict among newlywed couples. Family Process, 43(3), 301-314.

Friend, D.J., Bradley, R.P., Thatcher, R., and Gottman, J.M. (2011). Typologies of intimate partner violence: Evaluation of a screening instrument for differentiation. Journal of Family Violence, 26, 551-563.

Gottman, J.S., and Gottman, J.M. (2015). 10 principles for doing effective couples therapy. NY: Norton.

Gottman, J.M. (2011). The science of trust. NY: Norton.

Gottman, J.M., and Levenson, R.W. (2002). A two-factor model for predicting when a couple will divorce: Exploratory analyses using a 14-year longitudinal data. Family Process, 41(1), 83-95.

Hedenbro, M., Shapiro, A.F., and Gottman, J.M. (2006). Play with me at my speed: Describing differences in the tempo of parent-infant interactions in the Lausanne triadic play paradigm in two cultures. Family Process, 45(4), 485-300.

Madhyastha, T.M., Hamaker, E.L., and Gottman, J.M. (2011). Investigating spousal influence using moment-to-moment affect data from marital conflict. Journal of Family Psychology, 25(2), 292-300.