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A COUNSEI. I.ING INTER NSHIP ATTilE IJSYC IIOI.OGYDEP ARTME NTOF TilE JANEWAYcnu,nIIEALTII CENTER
WITH
ARES r:.ARC Ii STUDY ONCUENTS'ANDTIIERAPISTS' IJERCIW I'IONSOF SUCCESSIN FAMI LYTHERAPY
BY
RE1TYLO UKE NNEDY.R.Sr .,R.Ed.
A repor tsuhmltted to lhe SchoolofGraduateStud ies IIIpartl nlfulfillment
or
therequirementsforthedegreeor
MAsterofEducatio n
FRcully ofEducatlon MemorialUniversit y
or
NewfoundlandJuly.1994
St.John's Newf'oun d land
~uisit~ and BibltographicServices Branch 39/iW8IingIcnSl_
OIIan.QnIaro K1A 0N4
~b1~nauona1e Directiondesac9uisilion~at desselVicesbib hographiques
~~~K1A 0N4
THE AUTHOR HASGRANTED AN IRREVOCABLENON-EXCLUSIVE UCENCE ALLOWING THENATIONAL LIBRARY OFCANADA TO REPRODUCE,LOAN, DISTRIBUTEOR SElL COPIESOFInSJ1lERTHESISBY ANYMEANSANDIN ANYFORMOR FORMAT,MAKINGTIllS THESIS AVAILABLE TO INTERESTED PERSONS.
TIlE AurHOR RETAINSOWNERSHIP OF THECOPYRIGHTINInS!HER TIlESIS.NEITHERTIlE TI!ESISNOR SUBSTANTIAL EXTRACTSFROMIT MAYBEPRINTED OR OTHERWISE REPRODUCED WITHOUT mSIHER PERMISSION.
L'AUTEURAACCORDE ONELICENCE IRREVOCABLEET NONEXCLUSIVE PERMETTANTA LABIELlOTHEQUE NATIONALEDU CANADADE REPRODUIRE,PRETER, DISTRIBUER OU VENDREDES COPIESDE SA TIfESEDEQUELQUE MANIERE ET SOUSQUELQUE FORME QUE CE SOIT POURMETIRE DES EXEMPLAIRES DE CETTETIlESE ALADISPOSITIONDES PERSONNEINTERESSEES.
L'AtITEURCONSERVELAPROPRIETE DUDROITD'AtITEURQUI PROTEGE SA TIlESE.NI LA TIlESENI DES EXTRAITSSOOSTANTIELSDECELLE- CI NE DOlVENTETRE lMPRIMESOU AUTREMENTREPRODUITS SANSSON AUFORlSATION.
ISBN 0- 315-96050-7
Canada
TA8LEOF CONTENTS
ABSTRACT" .
ACK NOWLEDGEM ENTS .
LISTOFTABLES .
CHAPTER
IlATIONALEFORINTERNSHIP. Introduction .
Settingfor theInternship.. Supervision
Internship Goals,
Conclusion . II RES EARCHPROJECT
Introduction ...,
Purpose&Rationale. .
Research Ques tions Reviewof Literature. Methodology. Sample Instrument.. Design&Analysis . . Results..
iv
.1
...3
•Y ... . .•11 ..33 . ...35 .. 35 .. 36
.1R . . . .38
'6 .. '7 ..48 ....51 .51
Discussion
REFERENCES APPENCICES .
AppendixA: Family AssessmentDevice
... 58 .. 62 .... .... .... . . . .. . ... . 66 ... ..66 Appendi)!:n:Client Follow-upQuestionnaire
Aflpelldi)!: C:TherapistFollow-upQuestionnaire
...67 ..70 AppcndixD:Janeway ChildHealth CenterResearch ConsentForm..72
AppendixE:CHcntConsent Form. . ..73
Appendix F:Therapist ConsentFor m ..75
Appendix G:CopyrightPerm issionfortheFAD 76
AppendixII:GettingAlongwuhOthers-TeensSocialSkills Group.77 AppendixI:List of Rooks&ArluclesReadDuring Internship 78
I, Abstmcl
This reportconsists of twopans .Thefirslsectiondescribesall internship completed at 111ePsych ologyDep artm ent of theJanewayChild Health Center. Augu st1993toDecemb er1993.Itincludes: a compre he nsive report of the rationale for the internship:and a descriptionofthe selling.
supervision, goals and profession alactivitiesof theinternduring the intern shipplacement. Inaddit ion this reportdescribesa resear ch projcc ('011(\\1('1('11 duringtheinternship.Theresearch project studiedthe percepti ons ofclients' and the rapists'asit relat es10theoutcom e of family therapy.In ordertoasses.sthepercept ions of success. theFamily AssessmentDeviceanda resea rcher preparedfellow-upquestionnair efor theclientsand therapierswere administered.Overall results of this researchindicated thatclientsandthcreplstsCOIIl'IIT011theoutcome of family therap y.Thereisalsoclose agree ment on 111e a rcnsof improvementand the degree ofsuccess.Clientsrepo rt ed ahigh degreeof satisfaetionwith therapy,Theresultsof this studywillbeuseful informalionfOTclient s,therap ists,and the research setting forfuture plan ning and programmin gofffl11lily therapy services.
Acknowledgemenfs
Iwouldlike to thank Dr.LindaMoxley-Haegen forproviding excellent field supervision during this internship.Iamalsogratef ultothe staffofthe Janeway ChildHealthCenter andin particularthe Janeway PsychologyDepartment for shari ngtheirexpertisewith me.
Tothe families and childrenwho provided me with a rich and rewarding experience,Iexte nd my sincere thanks.
I wouldalsoliketothankDr.Ron Lehrfor (jis gu idance duringthe internship andthe write-upof this project.
Tomy friends,especially JudyFurlong-Mallard and Donna Mclenna n Ioffer manythan ksfortheirtireless supportand exper tise.
Tomyfamily,especially mymother Rose,forher uncondit ional love alwaysand tomymother-In-law Viviennefor herencourageme nt, I extend my sincere thanks.
Tomyhusband Patrickand mychildren Christine.Elizabeth , Patrick,andMichael a heartfelt thank-youfor yourenco uragement, support and love asIpursued this project. I love you.
111;Sreportisdedicatedtoall thefamiliesI have workedwithover the past severalyears,
v UslofTa bles
Table Tille I)age
TypeandFrequency of TestsAdministeredDuring 13 the Internship
Type andFrequencyof Activities10Develop
I.
FamilyTherapyProficiency
Type and Frequencyof Activities10Develop 21 Competency asIIPsychologist
TypeandFrequencyofActivitiesUsed10Develop 25 Group Counselling Skills
Typeand Frequent)'of ActivitiesParticipatedin10 31 DevelopPsychotherapyKnowledgeand Skills FamilyAssessmentDevice.StatisticalAnalysis of 53 Paired Differences
Percentageof ClientsShowingImprovement on the 54 SevenDimensionsof the FamilyAssessmentDevice Therapists'Perceptionsof Clients Successin 55 Percentages onSix Dimensionsof theFamily Assessment DeviceFollowing Therapy
Percentageof ClientsWhoPerceivedSuccesson
5.
SixDimensionsof The FamilyAssessmentDevice FollowingTb-rapy
10 AComparison ofClientsand TherapistsOverall 57 Rating ofTherapy Outcome.
11 Clents Ratlngsin Percentof OverallSatisfaction 58 With FamilyTherapy
CIfAPTE R I RationaleForAnIntem §hip
/\ counselling intern shipis anoption availableto grad uatestude nts intheMasterDegreeProgram inEducation alPsychologyat Mem orial University.Theinternshipprovides on thejob experience in awiderange of professionalactivities.These Are carrleuout underthe supervis ionofa field supervisor anda university superv isor.Thefieldselli ngservesto furth er developcompetence of thecounsellor and providesthe oppo rtunity totest counselling theoriesthrough practise.This practicalexperiencethus promotesskill developmentwith agood theoreticalbasis thatCanbe transferr ed intoeffective delivery of counselling serviceswithin theschool enviro nment.
As Slated in the Department of EducationalPsychology Intern ship Guideline s(1975),"the nature,scopeandspecialization encompa ssed in thero leof thecounsellorrequir esintensivetrainin g,aconsidera ble portionof whichshould be devoted to supervisedexperientialtrainin g".
The AmericanPsychologyand GuidanceAssociationdefines an internship
".an on-the-jobexperienceundersystematicsupervision and evaluation. It is usually a fulltimepositionserving as an extension of practicalexperience beyond thecounselling practicum.
TIle role ofthe counsellorinNewfoundlandschools hashad to change tomeettheuniqueneeds oftoday's youth.A broad knowledge andskillsbasedprogram offersthe counsellor the [earningexperiences thill gobeyondthat whichcould be offered throughindividual course workand anarrowly focused selling.Reachingbeyond the scopeof the required practicumfor theMaster Degree inEducational Psychology,Ihishttornship providedlite counsellorwhhtheopportunity10 develop further compe tence in the areasofIndividua land GroupCounselling,Family Therapy,Assessmen t, Consultationandliaison.
Basedon the intern'sown personalexperienceas a counsellorin the Newfoundlandschoolsystem,ithasbecome apparenttoher that deficienciesexist in the training ofcounsellors to performin the Newfoundlandschoolsystem.Someof theseinclude:training in family therapy;exposure 10 II broad varietyof assessmentdevices andtechn iques;
fam iliarity with the facilities andprogramsavailable ill mentalhealthfor childre nandadolescents;and themultidisciplinary approachesto the manageme nt of psychological/psychiatric conditions inchildre nandyouth.
The internshipwas chosenbythis stude ntto provide indepth training in theskillareas necessaryto executethemulti-facetedroles ofa schoolcounsellor in lhe provinceofNewfoundland, Besides providingthe intern withexposureto a widerangeofassessmentandtherapy tech niques.
the settingoftheJaneway Chi!,) Heath Cente renabled theinternto experiencerhchelping profession withinthemedical setting, Thishas alwaysbeenofinterest to theintern havinginitiallybegunhercareer inthe biological sciences,
11,einternshipthen seems tobe a logical mediu m toprovide adequatetrainingwhich could not be obtained from completionofthe Mast erDegre einEd ucation Psychology and it'srequi rem entofa single pracricum,
SettingFor TheInternship
As sta ted inthe Depart ment of Educati onalPsychology Paper onthe Intern ship Program(1975). "the intern shouldworkwitha varie ty of clients appropria te toher eventualemploymen t under conditions that protecttheinteres tof tilecounse lee aswell as contrib ute tothe compe te ncecrthein tern."
Thesettingsho uld provide expe rie nces that arc relatedto tasks judge d to be par t oftherole co ntemp latedbythe internin herinitial voca tionalplace ment. Ther e shouldbeprovisionforassistancetothe intern in integratingtheoryand practi se. Theexperien cesandtime allotment should besufficientto enableher to grow personallyand pro fessionally and todevelopanappropriateleve lofskills.
As a counsellorilltheNewfoundlandurba n ecuool,the intern will
be addressing issues wlthstudents fromthe pre-schooltoGrndc12level.
These childre n andadolescentsexperience difficultiesrelat edttl thefamily and theindividual.TheJaneway ChildHealthCente rPsychology Departmentis a suitablesellingfurtheschoolcounsellor toconduct an internship.
The following factors were taken intoconsiderations illselecting the internship setting:
Thequalityofprofessional supervision;
2. Thequality of learningopportunit iesand experiences;
3. 111erelevancyto, and usefulness ofsuchexperiences in theactual setting inwhich Iheinterneeultimately expectsto work:
4. The availabilityof timeforfull-timeinvolvement of the intern for••
minimumofthirteenconsecutiveweeks:
5. Availabilityofaqualifiedfield supe rvisoron-site;and 6. Re ady accesstotheuniversity supervisor.
Theintern,having severalyearsofexperienceas a schoolcounsellor and rea lizingthe needfor specific experienceinassessment and co unselling,requeste dthe PsychologyDepartme nt at the JanewayChild Health Centerasher setting. There are4 full-time psychologists as wellas several researchassistants offering a widerange ofservices.
As staled in theProgramDescription Guide(November,1993)of
HeJaneway Child HealthCenter Psychology Departme nt, helpis offered throughthefollowing services:
(I) Developmental Psychology Service.Developmental Psychologyis thebranch ofsciencewhichis concernedwith the originandchange in physical,menta l, andsocialfunctioningthat occurs throughout life.
Onoccasions.a youngchild doesnotprogressalongthe expected pathwayofdevelopment or he/shedoes not progressat the expected rateof development.These observedchangesin eithertherate or pattern of the developmentmay bedueto eithergeneticand/or congenitalfactors.The aim of the Development al Service in Psychology at theJaneway is 10 assessthe presen tdevelopmen tal statusof young infants or childrenwho aresuspectedofexhibiting a slower rate of development ora patter nof development thatis differentthanmight be expected. Upo ndiagnosisofa significant development alproblem,appropriate stimulationactivitiescanbe formulated with the aim toreduce or delay orchange the existing pattern of behaviorandcounselling with familymaybeimplement ed atthis time.Counselling may inimpleme nted inthe form of par ent groups, family therapy.behavior modificationprograms, or consult ation with thepreschools or ava rietyof otherways.
Mostreferr alsfor this programinpsychology willcome throug h the Child Developm entProgram.
As well,at thismomen tintime thisservicewillapplytothose preschoo lchildre n whowouldfallunderneuropsych ology whichisthe branch ofpsycho logyconce rnedwith the studyofbrainandbehavioror the relati onshipbetweentltetwo.Clinical psychologistsinthisarea gener ally assess adaptive abilities. Theprimarypurpose of neuropsychologywouldbe toprovide a comprehe nsive description of a child'sabilityandrelate thisinformationtobrain function ing.11Iis informat ionis used tohel pplanprograms forthehome and/orschoo l.
Referral sforpreschool neuropsycho logy areappropriateinthe followingcircum stances:
Where the re isknown or suspected neuro pathology(epilepsy,head injury,Central Nervous System (C NS)infections, congenital neurcanatcr uicalmalfunctions);
b. Wheretherehasbeenitrecent markedalterationin performance, personalit y,or otheraspectsofadapt ive functioning suggesting possibleeNSinvolvement;and
Conge nita lsyndro mes associatedwithpsychological or behavioral outcomes(ie,PKU, William's Syndrome, Turner's Syndrome).
(2) ClinicalEvaluat ion and Treatmen t.This servicesinresponsiblefor
generalevaluationandprogramplanningfor childrenagedfive through sixtee nyears.Thisevaluationmaybe in termsof intelligence,schcel achievement,language skills,personalily factors, adaptivebehavioral. organizationalcapacities,andvisual-spatial motorskills.Based on theresults oftheassessment,specific recommen dations arcmade10the schoolandhome.
A childis referred for psychoeducationa lassessmentin the followingcases only:
Thechildhashad anassessmentanda secondopinionis felt necessary (a retest intervalofatleast6mon thsis requested);and b. Whe nassessmentisnecessary aspre-opera tiveand post-operat ive
evaluatio norpreandpost-therapy.
(3) BehaviorTherapyService.BehaviorThera py involves the applicationoflearning principlesto everyday problems.Research has shown that behavior therapyhas provenapplicationwithchild andado lescentdisorders.The psychologistsets specific trea tment goalswhichare intended to expand the parents'and/orchild'sskills andabilities. Treatmentcan include group and/or individualwork withchildre nandusuallyinvolvesparentcounse lling.
Areas ofservices for behaviortherapy are:
Chronicbehavioralor medical cond itions
Non-complian ce(0medica' procedure Eatingdisturbances
Exceptiool'llchildren Painmanagement Toilet training Encompr esis Enuresis Socia lSkillsTraining
Behavior problem sinhospital orlithome Consultation10 hospitftl staffand communily agencies.
Inorder 10refer10 Behavior Therapythere must be areasonabl e basis10 assumethat thepresent ing problems haveII.behavioralcom pone nt oralterna tively.ther e istheneed. aspartofthemulti-discip line investigationto examinepossiblebehavioral contributio nsto complex symptomatology.
In term s ofoutpatien ts,the feasibilityof usinglocalresourc es shouldbe examinedin allcases.
(4) Social-EmotionalService.This service includespsychodiagnostic assessment,consu ltation.therapyand counsellingforchildren and ado lescen tspresentingwithsocial,personalityandemotional problemsandforthe families ofthese children.Suchproblems
includereactionstoparentalseparation and divorce.bereavement.
depression, socia l skillsdifficulties.family dysfunctio n disease,post traumaticstressandgender identityissue s.TIleform of therapy maybeindividualpsychother apy, groupor familytherapy.
Three formsof parent groups arecurrently being organized in psychology. The se include:
A Groupfor singleparentsof hard to control childre n;
B Traininggroup forparents of children diagnosedwithAttention Deficit HyperactivityDisorde r; and
C Child ManagementSkill TrainingProgram.
5. ClinicalNeuropsychology Service.This service providesa compre hensive description of thechild'sability,and relatesthis informationto brain functioning. The information isthenusedto help planprogramsfor home,
Supervision
The PsychologyDepartmentat the JanewayChild Health Center was approvedastheinternshipsite byDr.Ron Lehr and Dr. Linda Moxley-Haegert. Dr.Lehr wasthe academicsupervisorfromthe EducationalPsychologyDivisionof the Facultyof Educationat Memorial Universityand Dr.Linda Moxley-Haegert,Director ofPsychology atThe JanewayChild Health Center was the fieldsupe rvisor. The internshiptook
10 place over a thirte en wee k periodduringtheFall Semester of 1993.
Duringtheintern ship , serviceswereprovidedbya full-timestaff of four.Psychologists consistingofadirector.and threepsychologistswhose specialized rolesare as follows:
L.Moxley-Haegert Diabetic Team Oncology Crisis Intervention Neurology Team FamilyTherapyReferrals PreschoolReferrals OutpatientReferrals Child ProtectionProgram SocialSkillsand Parenting Group S.Manocha
Cystic Fibrosis Clinic Asthmatic Chnlc
PsychiatryReferralsfromDr. Nagpurkar/Dr.51.John Rele.rals forchildren with Attention Deficit Disorders OutpatientReferrals
AddParentGroups SocialSkillsandParentingGroup S.Downey
Learning!Behavior Clinic Communication/Development Palate Clinic
Down'sand DysmorphfcClinic
PsychiatryReferralsfromDr.WhitclDr.SI. John Referralsfor SleepDisorders, Anxiety and PainManagement OutpatientReferrals
BurnTreatment Team Chronic Pain Team(tobe developed) J.Lee
Communication/Development Clinic OutpatientReferrals
11 Behavio rTherapyServices
SocialEmo tionalService In pati entReferral s
Psychi at ry Referrals ,Dr.51. John lD r.White Ado lesce ntSurvivor sof SexualAbuse ADDParent Group
Internsh ipGoals
As stale d intheEducat ional Psychology Internship Pap er(1975),
"thepurpose of the int ernshipisto provide anexte nsio nof thepracticum and10develop11flexible progra mthatprovides:
Forthe development ofcompetencies for each trainee based onhis need s. previousexpe riences,and futur e vocatio na l plans;
2. Forpractical experi ences thatwillbringintofocusthetheoretical training rece ivedduring theformalpari of the progr am ; 3. Forpractical experiencesthaiwillenable thetrainee andthe
department10evaluate the trainee's ability to effectivelywork ina chosen field;
4. Opportunitiesforthetrainee toevaluatehisperson albeh avior modalitiesand worktowa rdmaking anynecessarychanges;
5. For feedbac k fromtheinternship setting to the depar tment regarding strengthsandweaknessesofitsstudents sothatprogram improvemen tscanbe implemented: and
6. For thedevelopm ent ofresearchandproblem-solving skills
12 appropriatetotheneeds of thestude ntsand the setti ng, conside ring the natureof her placeme ntand her vocatio nalplans", Basedonthe broad goals setbythe Department of Educatio na l P!i)'<'hology and retainedbythe Educauo nal Psychology sectioo altefaculty reorgani zation .theinterndevelopedthefol lowingspecif icgoalsrelatedto thechose nsett ing:
QQ&.l;To gainan understandingand proficiencyin thelise of a wide variety ofassessme nttechniquesandtools.Thisg01\1 wasachieved through a varietyofactivities(RefertoTable I).
A descriptio nofthese IIcliviliesis as follows:
(1) Tests wereadministeredtoIIvarietyof people whocould be classified115inpatients andoutpatients.Depe nding on thediagnosis orhospit alplacement ofthepeople.preparat ionfortestingvaried.
HistorylakingforeachpersonplayedasignifICantrolein determinin gthetypeofassessment1001andthe conditio nsunder whichsuch assessmentdevices were administered.There were occasionswhentestinghad tobe carr ied out overseveralperiods whe n patientshaddifficultyattendingtothetaskdueto psychological. emotiona lor physicalchallengesorafter administrat ion of medicat ion.
(2) Asafollow-up tothe administratio nofassessmentdevices.
Table I
Type andFrequen cy ofTestsAdmi nistered During the Intern sh ip 13
Type otTest Administered
Conners Dehllvior Rillin! &ale TestofWrillcn Language(TO WL) Test of Non-Verba lIntelligence PeabodyPicture VocabularyTest Children'sPersonalityOuestionnaire Ch ildren'sBehaviorChecklist Bender GestaltTestof Visual Inte rpretat ion
MenialSialus ChecklistforChildren MentalStatu s Checklist (or Adolescents WechslerPreschool&PrimaryScaleof Intelligence
WechslerIntelligence Scale(or Children ThirdEdition
DevelopmentalTest of Visu,,1Motor Integration
MinnesotaMultiphasic Personality Inventory
BeckDepressionInventory DeckHopelessnessInventory Wide Range AchievementTestRevisedI WideRangeAchievementTestRevised II Family Assessment Device
Frequencyof Administration
2 2 6 4 10
I.
consultat ionswilh personn el in the psychologydepartment. hospital schoolandpsychiatry depart ment wereconducted.The purposeof these consultationswasto obtain fe edback and direction for the purpose ofenhancing the intern'sskill inadministrationand part icularl yin the interpretatio nofthese assessment devices.
Given the widevariety ofprofessio nal staffavailable for consultation, thedepth andbread thofthe ir inputwasinvaluabl e.
The intern'sconfidence inthe selection.ad ministration.scoring, lind interpret a tion of assessmenttoolsincreasedas a resu ltof the experiencegained.Discussionswithtilestarrpermitte d theinte rn tocritically analyzetheapplicationof a varietyof assessment tools.
(3) Observati onsweremade in various settingswith ind ividuals,in groupeeulngs andwith familymembers.The patientsreferr edto theJanewayChildHealthCenterfor assessment repr esent a broad arrayofchallenges including psychological.emotional,neurolo gical, academic,physical,social,andbeha vioral. Acommonexperience forall these referrals, isthe schoo lsystem.There arcmany occasio nsintheschoo l when a counsellor feelshis/hertrainingis not sufficie nt 10provideastudentwiththepsychologicarpsychlatrlc or othe r help theyrequir e. Onsuch occasion, il is importa nt forthe counsellor 10haveknowled geofsuitablereferralagencies.During
the internship.thestudent became aware of thespeciality services forassessment ava ila.blethrough theJanewayChildHealth Cent er.
Asaresultof the intern'sexperiencewitha wide varietyof assessmenttools,expertiseWit!'gainedwith lessIrRditional typesof assessment devices.This translates intoIIvaluable experience as
therearcmany occasionsinthe schoolsettingwhen children/adolescents present with unusualproblems.Theintern's knowledge andcompetence withthesedevicesenablesherto more effectively assess theneedfor furtherlnterventjon 11.1acenter such as theJanewayPsychologyDepartment.This valuableexperie nce enhancestheintern' s ability 10carl)'outherroleas a school guidancecounsellor.
Q..Q!!UTo becomefamiliarwithtechniques of familytherapy.During the course oftheinternship regular ongoingconsultationswerehe ld with Dr.
linda·Mod ey-Haegertand Dr.Ron Lehr. Both practitionershove long standing experience intheareaofFamilyTherapy andthus they were able tooffervaluable experience totheintern regarding assessment technique andevaluationinFamilyTherapy.Thisexpertisewas accessed througha varietyof activitiesas shown in Table2.
Table 2
Type andFrequencyof Activities Under takenbytheInterntoD('velop Knowledge andSkillsinfamilv llierapyT('chninllcs
,.
Activity
Readinglinddiscessionswith Dr.Moxley-Haegcrtami Dr.Lehr011thetext bookFamilySystem Therapy [Becvar&Becvar, 1993)
Observed counsellingsessions-one-way mirror Co-therapywith Dr.Moxley-Haegen Individual and FamilyTherapy supervised byDr.
LindaMoxley-Haegert
Administrationand Scoring of theFamilyAssessment Device
Use of the McMaster'sStructuredInterviewwith Clients
Vide otaping')fFamilyTherapy Sessions (For supervisionpurposes)
SupervisionbyDr.Moxley-Haegert of FamilyTherapy Sessions
:Read articles inFamilyTherapy Journals(c.g.
MichaelWhiteFamilyTherapy)
Attended a workshopon FamilyTherapy- TIleDI)' andPractisesponsoredbythe Association of NewfoundlandPsychologists and actedasfacilitator in smallgroupsessions
ResearchProjectinFamily Therapy
Adiscussion of the activitiestomeet goal2is asfollows:
Frequency NIA
50
12hours
NIA
I day
N/A
(1) Reading and discussionofa current textOilFamilyTherapy with Dr.Moxley-Hacgert andDr.Ron Lehr. Thistextprovidesthe
11 reader witha baskunde rsta nd ingofthehistoricalccmenof family therapy.Itprese ntsthe SystemsTheo ryinclud ingcontentand proc esswitha major emphasison theappliralionofthistheory.A5 theintern did nothave:atheoretical background in familytherapy.
thistext provided ancxCC'lIenl introdu ctiontofam ilythera py.Both Dr.MOlllcy·I IAcgert and Dr.Ron Uh f havinguse dthis teatastheir main resourceilltheteachingofa graduatecoursein family therapy,werefllmiliar with thecontent lind providedtheinternwith theopportunityfor valuablediscussionon thetopic. (2) Observationof familytherapysessionsthrough uscofIIone-way
mirr orlind video tapes. Thesewerefollowedbydiscussion swiththe therapiststoprocess contentAnd technique.Systemic Family Thera pylind Mkbee l WhileFam ilyTherapy werethetwo theories most freque ntly used.IIwtl.Sin te resting tonotethedifferences in thesetwotechn iques and the valueof each.
(3) ParticipationItSa eo-thera pist withDr.Moxlcy-H acgcrLThese sessionswereagain followedbysupervision. These sessions consistedofassessmentusingth e McMaster Stru ctured Interview andfeedback toclientsfrom theFamilyAssessm e nt Deviceas well asthe liseof varioustechnique s.The discussionswhich followed withDr.Moxley-Haeger!wereve ry valuableinthe developmentof
'8
leach ing skills.Theintern.throughthe courseof thesesessions becamefamiliarwith the skillsofengage me nt.assessme nt. therapy
andtermina tionwhicharccriticalcom ponentsofthefamilythera py process.
(4) Fam ilyTherapysessions ledbytheintern weresuperv isedbyDr.
Moxle y-H aeger!whhfollow-updiscussionsoncon te ntandprocess.
Duringthe courseoftheinternship, theinternreadnumerous articlesreferenced in 111ebibliograph y on the subjec tofFamily Ther apy andpsychologyofchildr enandado lescents(sec Appe ndix
J).This wasdoneinlineffortto stre ngthe n thetheo retical foundation ofthe interninthe areaof FamilyTherapy. (5) The internatte ndedafull day works hop onFllmilyThera py
sponsoredbytheAssociationof Newfoundland Psychologists. This worksho p provided a generaloverviewof the varioustheories of FamilyTherapy aswellaspractical applications of thesetheories.
The intern acted as a facilitator insmallgroupsessions.wh ich pro vedto beavery beneficialexper ience,Duringthis workshop, the intern networkedwith many counse llorsand therapi sts.The exchangeofideas and the contactsmade wereveryvaluable.
(6) Obse rvationand theoretical reviewof iheMcMaster Structured Interview followedbyuse ofthisassessmentdeviceunder the
'9
supervisionof Dr. Moxley-Haege rt.
(7) Videotape sof FamilyTherapy sessionsconductedbytheintern were reviewed byand discussedwithDr.Moxlcy-H acgert.111e purpose ofthesesupervisedsessionswas10 provide feedback on the direction,technique.andskills usedbythe intern.Theinternfound thistobe veryhe lpful especially in theIdentification of inappropriate responsesbythe therapistand theneed forrefocusing of approach.
(8) Theintern ad mi nisteredfindscored50copiesof theFamily AssessmentDevice. Adescriptio n of thisdeviceisincluded inthe research compo nentof theintern ship.The intern'sfamiliarity with this assessmentdevicewillenable her10applyit inothersettings for familythera py evaluati on.
(9) TIleinterncond ucted a researchproject which was ongoing throu ghouttheinternship.Itprovided anexcelle nt learnin g opportu nity in the theo ry and prac tise ofFamily Therapyin particu lar. the Systems Theory. Itoffered the inte rnan opportunity to gain knowledge of the FamilyAssessment Device as well asintervie wtechniqu es withFamily Thera py clientele.Italso provided theJaneway ChildHealth Cen terwithboth quanti tative and qualitativedatato support the efficacyof deliver ingthe service
zo of family therapytotheir clients.
Goal 3: To gain an understanding anddevelopcompetency in the role as IIpsychologistinitmedicalcenterservicing childrenlindadolescents.This goalwasmet throughIIvarietyof lll.'liviliesas shownin Table3.
A discussion of the 1l{'livities10meetGoal3 is asfollows:
(I) Generallyspeaking. understandingand competency was established initially through the orientationprocessthat involved readingof policymanualsfollowedbygroupandindividualdiscussionswith personnelin thePsychology Departmentandotherdepartments of the JanewayChildHealthCenter.Job shadowing ofthefour psychologistsin the Psychology Department alsoenabled chI,'intern to gainIIgood understandingofthe roleofthe psychologistinil
medicalsetting.
(2) Throughout the courseofthe internship,the internattended psychiatryrounds,caseconferences.learnmeetingsof the Learning BehaviorClinic,CysticFibrosis Clinic.andAsthmaticClinic.These sessionsofferedtheintern many opportunitiesfor incidental learning to occur.Italsoprovideda better umlrrstandingofthe inter-departmentaloperationsof thehospilal.IIservedasan opportunity10observeand practisemanagementskillsasthe intern took an active rolein the weeklypsychologydepartment meetings
"
Table 3
Typeand Frequ ency of ActivitiestheIntern Participated in toDevelop Competency inFulfi!!ing theRole of aPsychologist
Activity Hospital Orientation AttendedPsychtarryRou nds
Atte ndedCase Conferences >Teamconsistedof MedicalPerson nel,Psychiatrists.Nurses,Social Workers,HospitalSchoolPersonne l,Parents,and CommunitySchool Personnel
Attend ed Team Meetings of learning Behavior Clinic.CysticFibrosis Clinic.andAsthmaticClinic Attended TeleconferenceonEating Disorde rs Attended SuicideCounsellingWorkshopatthe WaterfordHospitalandConductedStaff Inservice onSuicide Inte rventi onandPrevention for the PsychologyDepartme ntStaff
Peer Counselling Training withAdolescents Servedas a Co nsultant toNursing Studentsand Educational Psychology GraduateCandidates on va rious topics
Grouplln diviLnalCounselling andReport Writing was Supervisedby Staff Psychologists Consultedwith DonnaRonan-aspecialist in the areaofChildAbuse re:TherapyPrograms Viewed 3 films onChildAbuse.Emotional Abuse.
PhysicalAbuse.and SexualAbuse .A follow-up discussion withsocialworkers washeld.
Frequency Sept.30, 1993
weekly bi-weekly
N/A 2hours 1.5days
1 day 6hours
25hour s 3 hours 3hour s
where departmen tal business andpa.ti~ntintake occurred. The intern gained va·juablc experienceinunderstanding qualitycontrolandevaluat ion
Z2 ofservices and programs.Thisknowledge canbeIrltnsferr C'dfor11Kinthe schoolsettingasthe interntakes anactive role inthe evaluationof many progra msandservices offeredintheeducat ional setting.
(3) The inte rnattendedateleconference broadcested Crom Torontoon thetopicofEatingDisorders.Medicalspecialistsin the areaof Eating Disorders presentedresearchandinformationonthetopicof Bulimia and Anorexia.This was followedbyaquestion andanswer sessionwithparticipantsfrom amulti-disciplina ry approach.
(4) 11\eintern attend edIIone-day workshop entitled"BeyondCrisis"
held at theWaterford Hospital oncounsellingsuicidal patients.A psychiatrist(rom Edmonlon,Albertaspecializinginsuicide prevention and treatmentconductedthe workshop.This workshop was afollow-up10 one offered by the WaterfordHospitalon SuicKle Intervent ionandPrevention.Thisworkshopwas extremely or.tluableasthe intern felt a need for traininginthe therapeutic approachesfor suicidal clien ts.Suchclients are found inthe school syste mas well as the hospital setting.The worksho p hadtheoretical and prac tical components. The practicalcompo nentwas very basic:
yetraisedthe inte rn's awareness of theneed forongoing and indepth trainingin thisarea.Asafollow-uptothis workshop,the internconductedItstarr inserviceformembers ofthe Psychology
Depart ment onthctopic ofsuicideassessmentandtreatme nt.
(5) TIleintern conducted aPeerCounsellor TrainingWorkshopfor40 adolescent s in the St. John'sarea.This consistedofintroduct ory counsellingskillswitha particular emphasis onpeer tutor ing.
Evaluationof the worksho pindicated the stude ntsand their supervisors found it to be enlightening, helpful,andenjoyab le.The intern gained feedbackwhich will behelpful in planningfuturePeer CounsellingWorkshops. Thereis usuallythetende ncyto cram too muchconte nt into 100 shortl'ltimeframe.Infuture, theinternwill reducethe scope andconcentrateon asmallernumberofkey skills.
(6) Theintern served asaconsultant to severalNursing students and Educational PsychologyGraduatecandidates ona varietyoftopics including parenting programs,socialskillsdevelopment,peer counselling,and psychoedu cationa Vpsychiatri c assessment.
(7) The intern comp iled individual, group, andfamilycounselling reports underthesupe rvisionof thestaff psychologists.The variety of report writing includedpsychiatric consultations,
psychoedu cational assessments, psychological assessmentandgroup and familyrcportin g.Thisprovidedthe internwithanoppo rtunity to practise writingreports onitwidcspect rumof disorders andfor a variety of purpo ses.
2.
Goal4:To enhanceskills ingroup counsellin g.Theinterncarried0111the following activities tomee tthisgoal. These activitiesare presentedin Table4.
Adiscussionof the activities 10 meetGoal " is asfollows:
(I) The intern facilitatedaSocialSkillsGroup forinpatie ntsand outp atients of the PsychologyandPsychiatry Depar tme nts ofthe JanewayChildHealthCenter(see AppendixG).Thegroup consistedof 10 patien tsand theirfamili es. Thechild ren ranged in age fromIIto15years. Theywere referredtotheSocialSkills Groupbypsychiatri sts, socialworke rsand psychologistsat the hospital.
TIlegroup program consistedof nine sessions. ASocialSkills group wasrun for tbe children eachweek for 8 sessionsof1Vlhours duration.Concurrently,a par ent groupwasoffered toparent sto ad d ress issue stheyhadregarding th eirrole asparent s and their conce rns for their children. Dr.LindaMoxley-Ha cgert facilitated the parentin ggroup.
The sessions forthe pre-tee ngroupaddressedissuesofself-esteem, friend ship,decision-making, assertive ness trainin g,andrelationship building.This nineweekseriesis designedto helppre-adole scents andadolescentslearnhow toinitiat eand maint ainpositive relationsh ips
TAble4
TYpe andFrequencyof ActivitiesUsed toDevelop Group Counselling Skills
"
Activity
Facilitat orofa SocialSkillsGroup.Programwas edited by PamTurp inand HarshaPujara. See Append ix Hfor amor edetailed descriptionofthe program.
Facilita to rof a Pare ntingGroupdeveloped by RussellBarkley totrain parentsinchildmanagement skillsfor dealing withdefiantchildren.
Co-facilitato randFllcililatorof SupportGroupson Psychiatry {Separa tegroupswereheldfor Adolescents, Children to age12,as wellASa combinedgroup)
Co-facilltatcr/Facilitatorof a ParentingGroupfor Pare nts ofPreschoolers
Atten dedanlnservice for PatentingProgram1-2·3 Magic (Video andManua l)
withothers. It's goals for participantsare as follows:
Frequency 9 sessions
9sessions
weekly
9 sessions
~day
To provideeducational material on varioussocial skills;
2. To practise acquiredsocialskillsthroughroleplays andactivity assignment;
3. To gain self-awareness;
4. Toimprove self-esteemand confide ncebuilding;
5. To reducesocialisolation;and 6. To enjoy and have fun.
2.
Attendancefor the Social Ski:lsGroupand the Parentin gGroup was excellent. 1111~introductory and final sessionswere attended hy all parent sand their ch ild ren. Evaluationof theprogramindicated thatparentsand theirchildre n believedit 10 be very successfuland wor thwhile asitattainedthe goalssetout.
The Social Skills Programused was oneeditedbyPamelaTurpin (1992)who had previou slyusedthe program. Pre lind post self- esteeminvent ori es adm inistere dshowedimprove ment in the self- estee mof the participan tsespeciallyin theareas ofHome and Peer issues.This inter ngainedgrea ter knowledgeof group dynamicsby facilitatingthisprogram.In future,the inten. ...xc mmcnds reducing theage rangeof 11 through15 yearsasthis was toobroad . The needsat var iousagesarc sodiversethatit isnotprobably10mee t them in a 9 sessionprogram.Also.theinternbelieved group cohesivenesswasmore difficult toattain probabledueto thisgreat agerange.SeeAppendixHfor a descriptionofthegro upsessions forthisprogram.
(2) Theintern facilitateda Parentin gGroup for par entsof children ages3-6years.Thisprogramentitled'TrainingProgramfor Defiant Child ren"byRussellBarkley(1987),was conductedover an 8 week periodwithItIV:-2hour sessio n perweek.A follow-up
27 review session was heldone month alte rthefinalsession.The paren ts were chose n forthe group program throughpsychologyand psychiat ryreferr als.The programwasdesigned particularly as a therap eutic clinicalprogra m for childre nexhibitingserious behavioraldifficulties.
The groupsessions involved assessmentof behavio r.understand ing of behaviorand temper amentfrom Social Learning Theoryand Genetics.TheInterventi ons taught10par ents included relati onship building,listen ingskills, use of encouragementandpraiseinshaping behavior.time-o ut as a behavioral managementtechniqu e anda token-economy systemof behaviourmanagement.
Most ofthe pare nts report ed successwith the program.They repo rted improveme nts in theirchildren'sbehavior as wellas improvedskills forthemselves. Severalofthepare nts made friend shipswhichtheycont inuedbeyond thegroupsessions. This served as a sourceofsupportafterthetermination of the sessions.
Afollow-upsessionheldonemonthfollowing group termin ation indica tedtheparentswerepractisingthe skills learn ed. Several parents stated theyhadregressionsin managingbeh aviorbut felt theywereequ ippedwith the skillstoremedlntethis.
Thephilosophy of thisprogram is apositive one.Theprogram
prom otesdevelopment ofrelationship with the child through
"special time"spentwith the child as well as useofencourageme nt.
praise,andconsequences.Thisapproach dive rtedfrommallY programswhichconcentrateonpunishment. Theintern seesthat shewillbeabletousethis program inher present school placement where there arechildren aged4through 15 years.The parentin g programwas supervisedby Satinder Manocha who atte ndedall sessionsand provided supervision to theinternwhichwas both focused and instructive.
(3) The intern co-facilitated a second parenting groupwithDr.Linda Moxley Haeger! at alocalday carepare nt-childcenter.The same program wasusedwilhparentsof pre-school agc child ren.
(4) Theinternco-Iacibtatedor facilitatedthree SupportGroups condu cted on the Child/AdolescentPsychiatry Ward ofthcJaneway Hospital on aweekly basis throughouttheinternship.These supportgroupslireongoinggroups forinpatientsatthe hospital.
One groupincludeschildre n to age 12years, anothergroup includes adolescentslind the thirdgroup is a combinedgroupfor all inpatientsofthe Psychiatry ward.TIle purpose ofthe segroupsisto provide support andaforumfor patients to address issues rega rding theirinpatient status. The group leade r'sresponsibility consistsof
z.
facilitat ion of discussions and the str uctur ingoftherap euti c activities. These groupsofferedinsighton individual andgroup issues and theprocessassociated withsuchgroups.Theinte rn gainedIIdeeperunderstandi ng ofpatientsand the processes of psychiatricandpsychologicalintervention. All the patientsare stude ntswhoattendschoolwhentheyarenot inpatien ts.This again offered the intern anopportunityto gaingreaterinsightinto the child/adolescent whois a stude nt.
(5) Theinterneu-nded a one-hair dayinservicebyJanice Lee,a staff Psychologist.The inservice conductedwasIIParenting Program entitled~1·2·3·MllgicH.A videoandmanualateused to conduct the program.
Therearc many occasions in the schoolsettingwhen the counsellor addresses issues of parenti ng asaeffectiveinterventio n for ch ildren and their families.Thisinserviceprogram will be ofgreatbenefit10 thecounsellor in the schoolsetting.
Goal5:Toenha nce coun selling skillsbybecomingfamiliarwithvarious psychotherapy approaches.Clientswerereferredtotheinternby all members of thePsychology Department aswell asbyPsychiatric Consultatio n.Eachof the psychologists at theJan eway Child Healt h Center hasexpertisein a part iculararea of Psychology. Thisoffered the
'0
internitbroadrange ofexperiencesofitvery valuable nature.TIle act ivitiesconducted 10 achievelitis goal arelistedinTable5.
Adiscu ssion of the activities10meet Goal5 ls asfollows:
(I) The inte rn workedwithMr.ScaliDowney.a stnff psychol ogist specializedinCognitive-Behavior Therapy.BehaviorModiljca tion, RelaxationTraining,Att entio nDeficitDisorde r.andLea rning Disabilities. Anumber ofpatientswere referredto the internby Mr.Downeyforindividu altherapyusing a varleiyof psychoth erapeuticmethodo logies.Theintern observed Mr.Downey and thencarried outtherapiesunder his supe rvision. In part icular, patientswe retaught Cognitive-Behaviora l techniqu esfor the ma nagem en t of pain.anxiety, phobias.amiconductdisorders.
Rclaxationtraining wasfou nd to beeffectivewithalargenumber of patient s exhibitingabroadrangeofproble ms.The wide rangelise ofthesetechniqu eswill beusefultothe intcrn in theschoolsetting forusewithindividualsandgroups.Mr.Downeyhasdeveloped a veryusefulaudiotapefor relaxationtrainingwhichcanbeutilizedin a varietyof settin gincludingthe schoo l.As well his expertisein the areaofLearningStrategieswas " valuab leresourcefor theintern whichwill have applicab ilityintheschoolsetting.
31 Table.5
Tyoeandfrequencyor ActivitiesParticipated inilnd theNutlberof OicnlS SecnbytileIntern 10BecomeFam iliiuwith VariousPsvcholhuapy
~
Activity IIClients Thera pyPlan
Pain Man agement Relaxation Training
CogniliveBehavior Therapy Anxiety Management CognitiveBehavior Therapy
Relaxat ionTrain ing ManagementofPhobias SystematicDesensitization
RelaxationTrai ning Cognitive Behavior Therapy Psychoeducati onal Assessment
Referrals Consultationwith Par en ts&
SchoolPersonn el LearningStrategies
Conduct Disorde rs BehaviorModifICation
FamilyTherapy
AttentionDeficit Information Sharing
Disorder Grou p Counselling
MedicationTherapy BehaviorModifK:alion
Grid Therapy N/A Observed Therap ist
Reading Matl"rials (2) Anothe rVi41uab Jeaclivitytheinternengaged inaltheJaneway was
that ofassessmentof patientsusing individualpatient.pare ntand combine dpatient-pa rent interviews.Theintern observed and conductedsuchinterviews under thesupe rvisionof allthe starr psychologists.Thesupervisionandfollow-upofspecific:trea tment
JZ modalitiesbroadenedandenriched theintern'srepertoire of counselling and therapytechniques.
(3) The intern had theoppor tunity toobse rve andwork with Mr.
Safinder Manocba who hasparticularexperti se in the area sof BehaviorModification.AttentionDeficit Disord er, aswellassevera l medical conditions. This experi enceallowedthe intern 10 understandmorefullytheintricacies of thesedisorder sand interventionsthatonlyobservationand practise can provide.
TheParentSupport Programforchildren with AttcnuonDeficit DisorderdevisedbyMr.Manochaisitworthwhile group therapy program.Knowledgeof this programwill beofgreat benefit tothe internupon returnin g10the schoo lsell ingasmanychildrenIIfC initiallyidentified throu gh schoo l personnel.
(4) The internbecam efamiliarwithAspecia lized program ofGrief The rapy practisedby Dr. LindaModcy-Hacgcrt.This the rapy cons ists of three sessionswith parents and pati ents with positive results . The intern identified this programas agood prog ramfor use in theschoo lsystem aschildren oflen expe rience losses while attending schoo l.Ifthisis1101dealtwith properly,ilca ll have negat ive effects on the child's ability toachieve.
~Toconduct aresearch comp on entin which the clients'and
therapist's percept ion sofsuccessin family therapywillbemeasured. A preandpost lestadminist ration oftheFami lyAssessmentDevice (FAD) wasadministeredill('onjullclionwith <In interviewquestio nna ire for both the therapist lind the adultclientsinFamilyTherapy.Thiswillbe describedillmoredeta il inSection 2 of theinternshipreport.
Conclusion
TIleJaneway Child Health Center Psychology Departmentoffers an excellentopportunityfor astudent inthe Ed ucationa l PsychologyMasters Degree Program todevelopknowledge andskills incounsellingbeyond that whichcould be achieved from a practicumplaceme ntalone.The internshipprovided the internwith exposure to a varietyof learning experiences in developmen talpsychology,clinicalevaluation andtreatment, behavior therapy services.socialand emotiona lcounsellingandclinical neuropsycho logyservicesandfamily therapy.The practicalexperience gainedfromsupervisedactivities greatlyimprovedthe intern'scompetence ina widerangeof counsellingareas.The internhadthe opportunity to observe theexpertiseof manystaffmembers thusproviding avery enriching experience.Theinternshiphas been verybeneficialinthatit providedanarena fortheintern to develop bothpersonallyand profession ally.
TIle next chap terof this internship comprisesa research study
conducted attheJaneway Child HelathCenter,IIevalua testhe effectiveness offamilytherapy as perceivedbyclientsand therapist.
,,'
35 CIIAPTER 2
Introduction
To fulfil Ihe requirementsfor thecounselling internship in the MasterDegre e Progra m in EducationalPsychologyat Memorial University of Newfoundland one must unde rtakearesearch project appropriat e10the particular internship sett ing.At theJaneway Child Health Cente r,FAmily TherapyisIIserviceoffered to families. Referralsforthis servicecome from:clients; sta rr psychologists;hospital social workers;thepsychiat ry
departm ent ; and outsideagencies.
The researcherencountersmany families in herpresentpositionas acounsellor/therapistin anelementary-junior high school.Most ofthe problems students present often havea family dynamiccomponent. Family systems theo ry suggests thatin orderto treat aproblem,theentire family unit mustbe involved .If thisapproach isnot adopted, then the therapist is merel ytreatin g a symptomofaproblem. Inordertobe effectivewithin a schoolsell ing.a counsellor/the rapistshould utilize the knowledge gained fromfamilytherapyresear ch.
Research on boththe processandoutco mesof familytherapyhas come 10 occupy asignificant and permanentplacein thefieldof family therap y. Today ther e isgreat interestin investigat ingtheeffectiveness of variou s forms offa mily therapy with differ entpop ulation s.With such
36 diversiryin family structu re present inNorlh Americltnsockly,itis imperativethatboth rhiJdren'shospitals and th..schoolsbeequippedwith theknowledgeandskills necessary10putfamilyIherilpyresearchinto practice.Inordertoprovidethemosteffective formoffamilytherapy.it isimperative10examineclients'andtherapists'views of5Uct'('SSin therapy.
Byexamininghowclients and therapistsperceivesuccessoffamilytherapy.
insightwiJlbegained intoappropriateprogrammingfortherapy.Thiswill bethe centra lfocusof thisinternship researchstudy.
Statementof Purposeand RationAle
Theusefulnessof thehelpingprocesshasbeentiletarget ofdebate forseveralyears.A pivot",'questionhasbeen'Doesprofessionalhelping reallyhelp"i.e.istherapyeffective?OneWRytoanswerthisquestionisto evaluatethe effectiven ess01therapyasviewedby bothclients and therapists.By evaluatingtheeffectivenessoffamilytherapy. afeedback mechanismwillbebuiltintothetherapeuticprocessand inturn.provide thetherapist withinsightintopossible changesthatmayneed10 bemade inorderto makecounsellingsuccessful.
Ge rman,Kniskern andPinsof(1986)state,"bythemiddleof this decade(1980)itwasclearthat...maritalandfamily ther apyhad demonstrated itsgen eralefficacy."Thisreaffirmstheconclusionofearlier reviewsandisalsoin accordwith themajorityofreviewarticlescited by
37 Gutman.Kniske rn find Pinso f(1986) andbyGermanandPinsof(t978, 198 1). In summarizingtheGermanand Knisker n(1978)articleforIhe ir 1986readersh ip. GUTma n,KniskernandPinsof(1986)write.
"non behav iora l mar ital and familytherapyproducebeneficial
outcomesinabout two-thirds of cases and the ir effectsatesuperio r to 'treatmen t"...positiveeffectstypically occurintrea tmen tof shor t duration,tha t is 1·20sessions...familytherapyis probably as effectiveandpossiblymore effective than manycommonlyoffered (usua lly individual)treatmen tsfor problemsattributed to family conflict...".
Someof (he criticisms leveled atfamilytherpeyresearchbyRaffa, SypekandVogel (1990)include meth odological problems. Jtappears that the investigation of effectivenessshou ldinclude therapis tand client inp ut (wllliaurs&Miller,1981).
Since it is importantto be consta ntly mindful of cost, clearlyitis a useful clinicalexercise to conside rwhen we shou ldandsho uldnot olfer familyther apy, Clinical impressions are valuab le butthey arenotthebe allnndendall. According to lask (1980).wedonotknow whichfamilies (0treat ,ther ef or e we must evaluate ourwork sothat eventua llywe can be objectivelycertainthatthe expenditureof time,energy and emotionis justified. Lask also notesthat a determinationto evalua teourwork automaticllllycauses us to ask whatconstitu tesimprovement.
Accordingto Llewelyn&Hume (1979).anessentialtask of evalua tionis thecompa riso nof clientsandtherap istsbeliefsand
38 observableresultsatthe endof therapyandfollow-up.Fcifc l&Ells (1963) poin t outthatitpatient' s viewpointisitvalua blecontrib ution10our understandin g of thetherapyprocess.
The purpose ofthisstudywas10investigate amicompareclients' and therap ists'percept ions of the efficacy of familythe rapy.This study willprovidevaluableinformationfortile planning of servicesforboththe school andhospital settings.
ResearchQuestions
The followingresearchquestions were developedforthis study:
Doesfamilytherapyimprove family functioning asperceivedby clients?
2. Doesfamilythe rapy imp rove familyfunctioni ng as perceived by therapists?
3. Do clientsandtherapists concuron the outcomeoffamily therapy?
4. Howdo clientsview satisfaction offam ily thera py?
5, Do clientsand ther apists concuron theiridentification or problems whichbring families10Iher apy?
6. Do clients andtherapistsconcuronthe reasons for success orlack ofsuccsessinfamilytherapy?
LiteratureRevlew Throughoutthe curre ntand past decade ther ehasbeen
39 considerable debate over theefficacy of familytherapy as an intervention strategy for improvementin family functioning. In thelastfifteen years the ralc ofgrowthofoutco me researchin familyand marit altherapyhas beenphenomenal.111cveryfirst reviews ofoutcome rese archbyWells (1972) identif ied only thirteen reports. In 1973.Germanidentifiedfifteen studieswith 726 cases. By1978, GUTmanand Kniskernexamined 200 reports.
Inherent in allschoo lsof family therapy isthe belief that intimate relationship systems functionto maintainsymptoms and that families thereforerepresentpotentialtherapeuticresources. Accordingtothis systems perspective,thepotentialforchange is significantly increased through the involvement of intimatesin plansfor intervention.The Imnlly asa whole rather than its individualmembersreceivestheatter nlonfrom thefamilytherapist. Th e relationship systemisthe focus of therapyrather than allYsymptom ofan individual member.Thetherapist focuseson the relationship systemwhichsupportsuch problematic symptoms.
The lastfewdecade shave seen a tremendousrateofgrowthin outcomeresearch infamily and maritaltherapy.One of the main questions repealedlyaske dby propon ents of familytherapyis, "How effectiveisfamilytherapy?"Thisquestionhasbeen answered in the results ofseveral studieswhich suggests that such treatmentsareoften
40 effectivebeyondchance. 111e applicationsforfam ilyther apy has been shownwith disorderssuchas alcoholism. drug abuse.child hoodconduct problems.work andschool phobias, psychoscmaucsymptoms, and schizop hre nia.
Stud iesof alcoholicfamilies ha...c indicateda siguiflcant redu ctionin drinkingbehavior when a spouse was involvedinthe treatment process (Cadigan:Corderetal.;Hedberg&Campbell:McCrady:cited inRussell.
1983).
Familieswith membe rs addicted to drugshave alsobee nexamined by family therapyresearche rs. Avery commonfamily treatm enthasbeen conjointfamilytreatm ent (Russelletal.,1983). Stantonetal.(cit ed in Russell. 1983)dida 6-mont hpost-treatmen t follow-up studyand found familytreatme nt tobe1.4 to2.7timesas effectiveas other forms of therapy inproducingdays freefromopiate.non-opiate drugsandalcohol use.Family therapy wasalso effective in reducingconflictandinvolving fat hers morein familyinteractions. The resuhs ofthi~study documented cha ngeinbothsymptomand system functioning.
Ina seriesofstudiesattheUniversityofUtah investigatingthe applicat ionoffamilytherapy tooffensescommitted byjuveniles,Alexander etal.(cited inRussell,1983)provided documentat ionfor thefollowing: (I) differencesin the contentand process ofcommunication inthe families of
41 soft-core delinquent s (e.g.running awayformhome,promiscuity,lind curfew violation) andcontrols;(2)modificationof family communication:
and(3)alower rateof theidentifi edpatientrecidivismandsiblingrefe rra l.
Familytherapyhas also beenused tohelpwillichild hoo dconduct problems.Family programs developedbythe Oregon ResearchInstitute havebeen provenaseffective cha nge methodsforfamilies ofchildren with conduct problemsincluding:hyperactivity.fighting,lying, stealing.bed- wetting. non -complian ce ofautho rity, whining andyelling(Patte rso n&
Cobb; Taplin&Reid cited in Russell.1983).
Pilman eta1.(Cited inRussell,1983)was successful in using insight- orient ed crisis familytherapytohelppartnersdeal with workphobias.
Skynner(CitedinRussell. 1983)reported an85%successrate withschool phobias using aIamilythe rapyintervention approach.
Usingstructural(Minuch in etII!.,1974.1978)andstrateg ic (Palezzoli,1974)familytherapytechn iques.therapistshave documented impressive outcomes in the treatm ent of patient s withanorexia nervosa , brittlediabetes, andasthma. Using structura lfantjly therapy,withS3 anorecticfamilies.Minuchin and his colleagues reported an86%recovery rale. Sixteendifferen ttherapistswere involved in thetherapyandoutcome wasevaluated in terms of remission of anorect ic symptoms[i.e. weight gain)and psychosocialfunctioning inrelationstohome,schoo l andpeers.
42 Another methodwhich has gained recent attent ion10investigatethe efficacy of familytherapy istheuse ofmeta-analysis.Meta-analysis providesa"laighlyCJUillllif<llivemeth odfor integrating researchresu ltsand yieldingconclusions"(Markusctal.,1990).Intheir 1987review,Hazelrigg etal.examined20stud ies withcontrols.Theiranalysis suggested that family thera py had positive effectscompared tono-treatment and alternati vetreatm ent controlsasmeasur edbyfamilyinteraction sand behavior ratings. These effec ts however were diminishedand mote variablewhenassessed at a posttreatment interval.
Subsequent totheHazelri ggctalstudy. MArkus etal.(1990)also performeda meta-analysis. Although 10of their19studies wereuse din theHazelrigg et al.study,Markus etal.did find prooffor theeffectiveness of familytherapyintheir meta-analysis.Of the studies they statistica lly analyzed,atposttreatment theyfound theavera ge patientwho participate d in familytherapy wasbett er off than76'h'of patient swho received alternate treatment,a minimaltreatment , ornotrea tmen t.Once againhowever,these effects tende dto diminishaIteran extendedperiodof timeelapsed[e.g.18months).
Itis theopinion ofsome researchersthatthereismeritinoffering familytherapytodifferentpopulationsofclients, andthat what need s to beinvestigated now arethemor e specificdeta ilsof family therapy.As
43 seeninthis brief literaturereview,the rehas beenanabunda nceof research intheareaoffamilytherapyoutcome.Theresults ofthis research have contributeda greatdeal toanswe ringmany of theques tions regarding efficacy offamily thera py.Alogical step in future research appears10be inthelight ening of meth odological proceduresfor evaluat ing success.IIIorde r10addresssomeof thesemethodologicalconcerns plaguingthis area.Gurma n and Kniskern(1981)slated,"We believethat there isnoneedforfurther detailed reviews of the outcome literature...whatisneeded inouropinionisnotItremasticat ionofwha t has already beendigested buta redirectio nandre-focus towardidenti fying whatneeds 10 bestudiedin l1:e futureand towar d identificationofthe clinically most relevant questions needinganswers"(p.243).
Asen, Dekowitz,Cooklin,Leff,Loader,Piper&Rein(1991)arg ue that whilethe need for family the rapy research has beenwidely acknowledged,many debatescontinueon thequestionsof whatconstitu tes valid research and howitshouldbeimplemente d.Oneofthese questions concer ns !lIe researc h methodologyinterms ofwhat methodofeva lua tion is mostsuitable todetermin e efficacyof family therapy.
In the past.clients'selfreportsandobjectivequestionnaireswere usedindependen tlytodetermin e successin fam ilytherapy.Paolinoand McCrady (1978)state that"clientself reportmeasuresareusefuland
44 informativeindit es of therapeuticchange .However,client reports of increas edrnarua!satisfac tionmustbe viewed with appropri ate scepticism, sincesuch reports of lmpicvemenrmaybedeterminedbyavarietyof factorsotherthanactualchanges". Fo rexample.such improvement smay be duetothe clients'desire to pleasethe therapist.
Cline.Jackson,Klein.Mejia.&Turner(1987) suggestthat measuring therapistand client perceptionsusing bothself report sand objectiv equestionnair es (suchas the Family AssessmentDevice (FAD) or theMarital and Communication Inve n to ry(Me l))improvethe research methodologyand therefore increase thereliabilityof the results.
As stat edbyLask(1980).ifanytherapy is10betaken serio uslyit must beshown tobeuseful.There isHutepointin doingsometh ing time- consuming,costly, andemotio nally dem anding,ifit hasnottherapeutic value. Showing the usefulness of anytypeofservicerequiresan evaluati on of it TIle questionsof what and howtoevaluatefamilytherapyMe centra l to its evalua tionasaneffective therapychoicefor families.
Chase&Holmes(l990)used casenotes ofatherapist10evaluate the success of familytherapy. Inameta-anal ysis study,Markus etal.
(1990) usedmostly objective measures ofsymptom inten sityand frequency, Some evaluationstud ies distinguishbet weenfirst andsecondorde r change made within familytherapywherefirst order referstosymptom
45 improvementandsecondorder concernsareorganizedorstructured in relationto the problem(Stevenson.1993).Lask(1980)suggested that.
"systemimprovementisa~ysaccompa nie dbysymptom improvementbut thatthe reverseisnoralwaysthe case", TheMenIal ResearchInstitute (MRI)group arguelhal firstorderchangeisadequat e.Bennun (riledin Stevenson.1993) suppu rtstbis viewhowe ver,he suggested thatsecond order cha ngeshouldstillbe evaluated . Towns&Seymour(citedin Stevenson. 1993)proposethatfamilytherapyresearchshould include a measureofchangeinfamilyinteractionso thataconsidered decision can bemade aboutitsim portance.
Frudc(1980)believes~hatthefamily'spe rspectiveisa valuable ind icatorof successin ther apysince clien tsatis factionistheultimategoat.
Inthcir resear ch.someresearchers such asSpeed (citcd in Stevenson.
1993) comparedthesubjecuve evaluationofthetherapistwiththatof fantilym£mbt'rs.
Considerabledebate in thisareahasROOcenteredaround the approp riate nessofqualitat iveversusquant itativeresearch.Aswithany quantita tive study.suppo rting dataprovid es evidencefortheutiliI)'ofthe programofchoke.Othersbelieve thatthereisrichnessininformation derived qualitatively [Bryman citedin Stevenson,1993).Comme ntingon thisissue.RiceandGreenbergstatethefollowing.
4.
"suchanapproach mighthelpliStounderstandmoreabout whathappens betweenthe clientand therapi st and consequen tlyabout howtherapywork s or fails10work" (Rkc
&Greenberg.cited inStevenson,1993).
Theresea rch study undertaken aspa rt of this intern'srequirement for theGraduatePrograminEducational Psychology willcornblue the findingsofGUTm an, Kniskern and Pmsof (1986).Chaseand Holmes (1990), Speed (1985),Marku s etal.(1990).Stevenson(1993), andFnulc (1980) toinvestig ate andevaluatethe effecti veness of familytherapy through objectivequestion naireswhichdeterm inesymptomintensityand changeas wellasclients' qualhanvc self-repo rtsatfollow-up.This informat ion com binedwilh therapists'repor tsof perceived effectivenessof thera py will provide valuab leinformat ion fo rtheinternship settingwhich can beused for future planning.
Methodology
This studywasaretr ospective studyof families who hadreceived familyther apy servicesat theJa neway Ch ild Health Centerwithin thepast twoyear s. A gro up01" families who hadrece ived family ther apy andwho hadcom p leted pre andpostfamilytherapyqucsuonn alres were administer edaself-report inventory. The therapi sts for theseclients were alsoadministeredacompatibleself-report inventory. Thesewere administe redtoboth partiesbetween two months 10 oneyea r following
47 therapy.Boththepre-andpostFAD questionnair esand self-repo rtsof clientsand therap ists were analyzed10det er mine perceivedchangesasa result of ther apy.The data from theFA D wasavailablein thefiles of theseclientsinthe PsychologyDepartment ofthe Janeway.The self- report inginvent ories wereadmin istered through persona l interviewbythe resear ch er.Information011gender.age,number ofchildre n,number of therapysessions.and reasonfortermination oftherapywascollected for descriptivepurposesonly andnot for ana lysis.
~
Thesam pleconsistedof 9families who had received familytherapy withinthe previo us two years at theJAneWAyChild Health Cente r.These families were chosenfro m thefiles attheJanewayPsychology Department.
Theywerechose nbecausetheyhad comp letedapre-therapyFamily AssessmentDevice.Three thera pistswho providedtherapy for these familie s were alsoinclud ed in thesample.Thesefamilies included adults and theirchildrenwhowere aged12 orabovewho hadcompleted pre therapyassessments.There wereIItotal of26 clientsofwhich17 were parentslind9were children.The adultsrangedinage fro m33years1047 years. The children ra ngedinage from13yearsto 20 yea rs. Of the adults. 9were femaleand8 were male.Of the children.6 were female and 3were male.Familiesreceived an average of 8therapy sessions.
4.
Clientswerereferredfrom a varietyof so urcesfortherapy.These includedthehospit al PsychiatryDepar tment.schoo ls,Fami ly Physicians andself-referrals.Therea sonsfor these referr alsincluded behaviora l and/or emotional difficult ies of thechildre n.
Instrum en ts
Two instr ume ntswere used in this study.Theseincluded theFamily Assessment Device (FAD)(see AppendixA) and a therapy outcome questionn aire designedspecifically for thisinvestigat ion (sec Appendices B
&Crespectively). Thesequestionnaireswere devised basedalla
previouslydevelopedinstrument used by Dr.RonLehrin anfamily therapy outcomestudyofcouples.A questiononeachof thefollow-up questio nnaires matchedthe FamilyAssessment Deviceforthefirst six dimensions.
ThefAD is based on the McMasterModel offamily Functioning (MMF F),a clink-lillyorie ntedconceptualizat ionof families.The FADWlIS construc ted tocollectinformation on thevariousdimens ionsof the family syste m asa whol e;lindtocollect this informa tion directlyfromthefamily membe rs.Itdescribes structuralandorganizationa lprope rtiesofthe familygroupandthepatte rnsoftransact ions amo ng familymemb ers which have bee n foundto distinguish be tweenhealth y and unhealt hyfamilies.
TheFADismadeupofsevenscales,one,Gene ral Functionin g,
49 assessesllleoverfillhealth/pa thologyofthefamily.TIle other6assessthe 6dimensions of theMMFF,Itis a paper and pencilquestionnaire which can befilled oulbyall familymembers overthe age of 12. The60 items inthe questionnairearc sta te men tsa personcouldmake abo ut his/h er fam ily.Each fam ilymember Taleshis/he ragreemen tordisagreemen t with how wellallitem describes his/her familybyselecting amongthefour alternativeresponses:stronglyagree,agree, disagree. andstronglydisagree.
Thequestio nna iretakes app roximate lyfiftee nto twenty minutes to complete.ThefieldsupervisorDr.LindaMoxley-Haeger!had permission to duplicate the copyrighte dFamilyAssessment Device.themanu al, scoringshee t. instruct ions andFamily Inform ationForm (see Appe ndixG).
11Je McMasterModel ident ifies 6 dimensionsoffami ly functioning.
Theyarc:Problem Solving:the first dimensio nof the MMFF,refers to the family's ability10resolve problems(issues whichthreate ntheintegrity and function al capacityof tbcfamily)litalevel thatmainta inseffective family.Sevensteps of effective problem solvingare identif ied.
Communica tionis thesecond dimension of the MMFF .Itisdefinedas the excha ngeof information amo ngfamily members.TIle foc us is on whet herverbal messages are..'earwith respectto conte ntand direct in the sense thatthe person spokento isthe person for whom themessageis inte nded.Roles is the third dime nsion. Here theMMFF focuseson
'<0 whether the fa milyhas establishedpatte rnsof behaviorforha ndlin g a set of familyfunctio nswhichinclude provisionofresour ces,providing nunurance andsuppo rt.supporting personaldClIdopl1\ cnt.maintainingand managing the family systems and providingadultscxualgratifkation.Also.
assessmentofthe Rolesdime nsionincludesconsiderationof whethe r tas ks are clearlyandequitablyassignedtofamilymembersandwhethe rtasksarc carriedoutrespon siblybyfamilymembers.AHert ive Responsi ve ness, the fourthdimension, assessestheexte nt to whichindividua lfam ilymember s lire abletoexperiencethe appro priate affectover1'1rangeofstimuli.
Affec tive Involvement is the fifthdimen sion.Itisconce rnedwith the exte nt 10whichthefamilymemb ers are intere stedin,And place valueon, eachother'sactivitiesand concerns.Theheal thiestfRm ilieshave inte rmedia televelsof involvement,neithertoolillienortoomuch.
Behavior Controlisthe final dimensionof the MM FF,and assessesthe wayin which R f<'lmilyexpressesandmaintainsstandards0(behaviorof its mem bers. Behaviorin situationsof differentsorts (dangerous, psychological andsocial)isassessed<ISaredifferentpatte rns ofcontro l (flexible,rigid,lalssea-Iaireand chaot ic arc con sidered ).
The psychometricprop ertiesof theFADhave beenresearched with PsychiatricandMed icalPopulations.Kabacoffct1'1.(1990) completed a psychometric study using dataobta ined fromla rgeclinical,nonclinical,and
