Western Tidewater CSB Supervision Guide

WESTERN TIDEWATER COMMUNITY SERVICES BOARD
PART 2
Notes on the Philosophy and Practice of
Individual, Couple and Family Therapy
Demetrios Peratsakis, LPC, ACS
Revised February 04, 2018
Advanced Methods in
Conseling and
Psychotherapy©

2
CLINICAL SUPERVISION
Chapter
4

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Purpose of Clinical Supervision
“No significant learning occurs without a significant relationship” - Dr. James Comer
The Client, Counselor, and Supervisor form an intimate relationship system called the Supervisory Triad.

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A unique arrangement, its principle purpose is the acquisition of insight as to the process of change.
Just as therapy provides the opportunity to examine one’s own beliefs and thereby modify one’s own
behaviors, so too supervision is a reflective process of self-examination, insight and growth. A core
function of supervision is evaluation & feedback to the supervisee(s) on their strengths and weaknesses
and areas that need to be developed, enhanced or improved (Watkins, 1997).
 To teach, train, and empower the supervisee on their route to becoming an effective clinician able
to serve as a positive agent for change with their clients.
 To continually assess the supervisee’s skills and provide learning experiences that upgrade their
knowledge and experience, such as live supervision and various treatment modalities.
 To empower the supervisee to assume professional and personal risk for their professional growth
and development in a confidential, safe and supportive environment.
 To help protect the welfare of clients and ensure the supervisee is practicing within the guidelines
of the profession. The supervisor’s role includes responsibility as a gatekeeper for the profession.
 To help the supervisee improve self-awareness and taking responsibility for their clinical practice
by adhering to a framework for clinical supervision.
 To challenge the supervisee’s thinking about the profession, including theoretical premises, the
roots of clinical syndromes and the nature of change.
 To work with the supervisee to maintain the quality of the process of clinical supervision.
As with all intimate relationships, the Supervisory Triad is prone to “blind-spots”, areas around which one
avoids, denies, or transfers the true nature of their feelings or beliefs to others. Typically, these are the
areas of high sensitivity within ourselves that are resistant to insight.
Reflection & Resonance
The Transference and Counter-transference processes are specific expressions of unresolved issues
between the client and therapist. Similar processes occur between the supervisee and supervisor (parallel
process) and within the supervisor-supervisee-client triad (isomorphism). Often used interchangeably,
Isomorphism is a construct with philosophical roots in structural and strategic family systems theory that
focuses on inter-relational aspects of supervision, whereas Parallel Process is a construct coined by the
psychodynamic school of thought and focuses on unconscious, intrapsychic occurrences in supervision.
 Parallel Process
Parallel process is an intra-psychic or internal, interpersonal dynamic that occurs in both
counseling and supervision (Bradley & Gould, 2001). It is the transference/counter-transference

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of feelings and attitudes between individuals: it occurs when the emotional resonance expressed
between the client and the therapist is reflected in the therapist-supervisor relationship.
 Isomorphism
Echoing within inter-relational transactions that “presents itself as replicating structural patterns
between counseling and supervision” (White & Russell, 1997). When replicating patterns
between counseling and supervision occur, the role of the supervisee and supervisor duplicate the
role of client and counselor (White & Russell, 1997): 1) the counselor brings the interaction
pattern that occurs between themselves and the client into supervision and enacts the same pattern
but in the client's role, or 2) the counselor takes the interaction pattern in supervision back into
the therapy session, now enacting the supervisor's role.
Attributes of a Good Supervisor
 A clinical supervisor must be open, honest, and aware of her own strengths and weaknesses. She
must be willing to share her own uncertainties and failures.
 She must see her role as a teacher and mentor, and value the relationship and provide support
 She must be self-reflecting, able to give and receive constructive feedback, empathy, and support,
as well as be comfortable with direct challenge and the expression of frustration, anger and fear.
 She must possess advanced knowledge of a variety of clinical methods and technique,
demonstrate them and be open to the supervisee witnessing (and critiquing) her work.
 She must provide a variety of clinical learning experiences, including live consultation, live
supervision and small group case consultation and training.
 She must understand the underpinnings of isomorphism & parallel processes in supervision.
 She must be willing to hold the therapist accountable, require that they be prepared, and work in
tandem to identify what may be working in therapy and what has not, and why.
 She must monitor the limitations of the counselor and be willing to intervene to protect the client.
 She must value the supervision process as a medium for personal transformation & growth
Counselor Preparation for Supervision
1. Counselor-supervisees are students; as such, they should be prepared with all necessary
documentation and client materials, have completed their assignments and forged a bond with
their immediate instructor.
2. They should keep an up to date list of Active Clients and a history of session and supervisory
meeting dates.
3. Each New Case presented should include, at minimum, the following information
a. Referral source, date and initial reason. If client initiated, their stated purpose for seeking
treatment.

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b. Genogram, socio-gram or summary of relational issues or snap-shot of the client system,
including individual backgrounds, such as medical conditions; medications;
presentation/hygiene; occupation/education level; and living arrangements; as well as more
dynamic artifacts, such as life-cycle issues; deaths, births and anniversary dates; family
roles, rules, myths and legacies; trauma events and cut-offs and sources of support and
distress
c. The Presenting Problem, including the contract for therapy goal(s), participants and
expected duration
d. An analysis of who needs to participate and why; what’s the hypothesis on reason from
seeking treatment.
e. Number of sessions to date, frequency of treatment and format
5. Active Case presentations should include the information above as well as a summary of
treatment to date:
a. Overview of treatment goal (s), number of sessions and progress or change to date
b. Relationship with counselor
c. Details on how the Presenting Problem, Symptom(s) or Pain has changed
d. Plans for Termination date and work
6. Counselors are also expected to
a. Follow directives, study assignments, as appropriate to their level demonstrate a working
knowledge of counseling theory, core theoretical constructs, basic counseling techniques
and the major elements inherent in specialty issues
b. Join with the client(s), use one’s self in therapy, bond with the client(s)assume risk
c. To be receptive to feedback on clinical work, progress and personal growth, including
receptivity to supervision
d. To participate in professional training, conference development, peer supervision, and
community-wide presentations
Case Overview for Presentation in Supervision
1. If more than one participant indicates seating pattern and who spoke first.
2. Presenting Problem/Reason for seeking treatment (include each member’s belief).
3. When did the Presenting Problem first appear (Dates/Reoccurrences)?
4. Related or correlating events to date of first appearance/Life-cycle issues.
5. Previous Action Taken; track interactional pattern (who does what and when?).

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6. Who else does the problem affect? How?
7. Has anyone else exhibited this (include all families and intergenerational)?
8. What does the client/couple/family see as the most important concern to first begin work on?
9. If counseling was successful and this problem no longer existed, how would life be different --per
the client(s)?
10. Family “spokesperson”” member(s) most apt to work for change? Member(s) most concerned
about change?
11. Conceptual Summary
a. Genogram
b. Predominant Issues/Life-cycle
c. Structural mapping
d. Presenting Problem and Purpose of Symptom(s)
e. Factor(s) motivating treatment at this time?
f. Specific strategy/interventions made to date and client(s) reactions?
12. Treatment recommendation
a. Method: modality, participants, frequency, and duration
b. Goal(s) (short-term/long-term)
c. Therapist’s expectations for change
Common Problems in Supervision
There are times when problems arise in the supervisory process which could be an indication of concerns
that may indicate the Counselor is experiencing difficulties:
General Process
 conflict or boredom with the supervisor
 ambivalence about the field or frustration with one’s own personal abilities
 problems at work or of a personal nature
 conflicting directives from peers and others, or
 unidentified resonance or “blind spots” resulting from Parallel Process and Isomorphism
Indicators

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 recent change in supervisee behavior, especially withdrawal, aloofness, or avoidance.
 decreased participation in meetings, quality of interaction becoming poor or guarded.
 change in overall style of interaction, such as combativeness or sullenness.
 over-compliance with supervisor suggestions.
 supervisee appearing preoccupied, seeming distant or annoyed, seeming stressed or nervous.
 supervisee confusion or passive-aggressive responses to directives and recommendations
Specific Problems
 Isomorphism/Parallel process resonance : unresolved personal conflict or trauma activated by the
treatment (counselor-client) or supervisory relationship (supervisee-supervisor) that goes
unrecognized or unaddressed, resulting in “blind spots”, transference/counter-transference and the
replication of intergenerational patterns, rules, and roles.
 Skewed power dynamics of the relationship (one-up, one-down as norm, especially for beginning
practitioners)
o Supervisee continually feeling over-powered; high reactivity to limit-setting and rule and
role enforcement by the supervisor
o Misuse of power by the supervisor; fostering feelings of inadequacy, inferiority or shame
(abuse)
 Putting the supervisor on a pedestal: idealization of the supervisor or continual need for
acceptance or approval
 Supervisor having a continual need to be seen as knowledgeable and competent
 Personal dislike or disdain for the client, supervisee or supervisor
 Sexual or romantic attraction by to the client, supervisee or supervisor
 Cultural bias (over-identification or under-sensitivity) between the counselor and client or
counselor and supervisee due to age, gender, religion, political viewpoints, sexual orientation or
personal beliefs
 Shame: feeling ashamed or guilty that one is unable to treat or guide successfully
 Using one’s own personal philosophy or our world-view as the default perspective in treatment
The supervisor should raise their concerns and be open to the need to modify their own style of teaching
as well as the need to re-evaluate the growth of the counselor and target their training more appropriately
Sample Models of Supervision
Chapter 3 of the Clinical Supervision Guidelines for the Victorian Alcohol and Other Drugs and
Community Managed Mental Health Sectors; prepared for Mental Health, Drugs & Regions Division
Department of Health, November 2013:

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3.1 Psychoanalytic Foundations of Clinical Supervision
Psychoanalysis as a discipline was founded by Sigmund Freud towards end of the 19th century. From the
beginning of his working life, Freud was discussing his ideas and practices with others and they with him,
although the terms clinical consultation and clinical supervision had not yet been adopted. As far back as
1902, he was involved as teacher, mentor and observer in the work of young doctors practicing to become
psychoanalysts. This early type of supervision was didactic in form and the work centered on the patients’
dynamic processes.
Other helping professions began to develop their own supervision practices at this time and it is difficult
to know who influenced whom, or precisely in what order events unfolded. Social workers in the U.S.
were introducing supervision as a “supportive and reflective space” (Carroll, 2007, p. 34) and other types
of welfare workers were picking up these ideas at, or around the same time.
No matter which discipline or what form of clinical supervision one practices, psychoanalytic concepts have
brought much richness to clinical supervision in all its phases. Freud’s psychodynamic ideas of parallel process
and creating a working alliance are foundational across models of clinical supervision, having “informed the
work of supervisors of all orientations” (Bernard & Goodyear, 2009 p. 81). It is believed that Max Eitington of
the Berlin Institute of Psychoanalysis first made supervision a formal requirement for psychoanalytic trainees
in the 1920s, just as mandatory standards for both coursework and observational treatment of patients were
established by the International Psychoanalytic Society (Carroll 2007; Bernard & Goodyear, 2009).
The two schools of thought on clinical supervision that competed for dominance in the 1930s were the Budapest
School and the Viennese School. The former held the concept of clinical supervision as a “continuation of the
supervisee’s personal analysis” (Bernard & Goodyear, 2009, p. 82) which meant having the same analyst
(supervisor) performing dual roles as both therapist and supervisor. In therapy, the focus would be on the
supervisee’s transference issues in relation to the analyst; in supervision, the focus would be on the supervisee’s
countertransference issues in relation to his or her own clients. The latter school held the idea that the
supervisee’s transference and countertransference issues were both to be processed in therapy, so that
supervision was retained as a teaching forum.
A psychodynamic model which emerged later on, in the 1970s, had a wide resonance for many practitioners
both inside and outside psychoanalytic circles. This work marks the beginning of the supervisee as the center
and focus of the supervision process. Ekstein and Wallerstein conceptualized clinical supervision as both “a
teaching and learning process that gives particular emphasis to the relationships between and among patient,
therapist and supervisor and the processes that interplay among them” (Bernard & Goodyear, 2009, p. 82).
Thus, the focus was on teaching rather than providing therapy, with the aim being for the supervisee to
understand the overt and covert dynamics between supervisor and supervisee; to learn how to resolve
difficulties which arose, and to develop the skills necessary to help his or her clients in the same fashion.
In the past decade, two psychodynamic therapists and supervisors, Mary Gail Frawley-O’Dea and Joan E.
Sarnat, introduced a fresh psychodynamic supervision model in their book The Supervisory Relationship:
A Contemporary Psychodynamic Approach (O’Dea, M.G. and Sarnat, J.E. , 2001, New York: Guilford
Press), which suggested a new philosophical and practical position for the supervisor in relation to the
supervisee. Previously viewed as an objective expert with a mastery of theory and technique, the

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supervisor in this model is afforded space to act less the dispassionate expert and more an active
participant in the unfolding process of supervision. Thus, his or her authority “resides in the supervisor-
supervisee relational processes” (Bernard & Goodyear, 2009, p. 82), rather than in the absolute,
immutable position of the all-knowing superior. In such a relationship, both parties acknowledge a mutual
influence and the supervisory stance shifts effectively from that of outside, reflective observer to
informed and purposefully influential insider.
Points to remember about psychodynamic supervision:
 Process and relationship oriented, with a focus on intrapsychic phenomena and
interpersonal processes, in order to develop insight and provide containment
 Close parallels between therapy and supervision
References for this section: Bernard & Goodyear (2009); The Bouverie Centre (Moloney,
Vivekananda & Weir, 2007); Carroll (2007).
3.2 Clinical Supervision Based on Counseling Models
In the 1940s - 1950s, there was another shift in the delivery of clinical supervision. The new models
which emerged were based upon and tightly bound to the counseling theories and interventions of the
practicing supervisor.
3.2.1 Person-Centered Supervision
Carl Rogers, the founder of a humanistic, person-centered model of therapeutic practice, did not
differentiate greatly between therapy and supervision, but simply shifted his role during sessions
depending upon what his supervisees required at the time - personal therapy, or professional supervision.
As with the psychodynamic models, the person-centered model, to be effective, relied upon a strong and
trusting relationship between supervisor and supervisee.
Rogers was among the first to use electronically recorded interviews and clinical transcripts in supervision
(Bernard & Goodyear, 2009, p. 83), rather than relying only on the self-report of those he supervised. Carl
Rogers’ influence on both therapy and clinical supervision practices has been profound. Though Rogers’
approach is less focused upon today in the U.S., it is still widely taught in the UK and many of the skills
learnt by new practitioners world-wide can be traced back to him.
Points to remember about person-centered supervision:
 Process and relationship focused, with genuineness, warmth and empathy being
imperative relational traits
 Exploration of self, both personally and in the context of the work, is essential to the process,
with movement towards differentiation and self-actualization the goal of both therapy and
supervision
 Encompasses both teaching and therapy:

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“I think my major goal is to help the therapist to grow in self-confidence and to grow in the
understanding of himself or herself, and to grow in the therapeutic process...Supervision for
me becomes a modified form of the therapeutic interview” (Rogers, cited in Bernard &
Goodyear, 2009, p. 83).
3.2.2 Cognitive-Behavioral Supervision
Cognitive-Behavioral Supervision, like the various models of therapy related to it, emerged in the 1960s.
It was a far cry from what had come before, in that the focus shifted dramatically away from the
relationship and dynamic processes existing between supervisor and supervisee (or therapist and client) to
the development of practice skills. Becoming an effective therapist, like becoming an effective person,
involved mastering specific tasks and learning to think in ways which were beneficial to the personal or
professional self, whilst taking actions to extinguish (in CBT terms) unhelpful thinking and behaviors that
create problems. Thus, success as a therapist depended upon one’s ability to learn the work and to do it
well, rather than on a good fit between therapist and client.
The tasks assigned to supervisees in clinical supervision would mimic that offered to clients in therapy,
such as imagery exercises and role playing. As with cognitive behavioral therapy, this type of clinical
supervision would hold that it is the intervention which counts, and specific interventions lead to specific
outcomes, if followed precisely and faithfully. Assessment and close monitoring of supervisees was
routine, as it was considered essential to the work that they both understood and properly utilized the
theory and practice of the therapy, as expressed in the treatment manuals.
CBT in its current form, or forms, is more variable and open to influence than fifty years ago. For
instance, more attention is now paid to relationship than in the past, and ideas from Eastern philosophy
have been incorporated into the work by some practitioners (e.g., mindfulness, meditation). Similarly,
these ideas tend also to be incorporated into clinical supervision and training in CBT work.
Points to remember about cognitive behavioral supervision:
 Instructional and skills-based (or strategy-based), with focus on achieving technical
mastery, e.g., how to challenge negative automatic thoughts
 Explicit and specific goals and processes followed, e.g., negotiating agendas at the
beginning of each session
 Use of behavioral strategies with supervisee, e.g., role play and visual imagery
3.2.3 Family Therapy (Systemic) Supervision
Family Therapy (Systemic) Supervision theory and practice has been documented since the 1960s, with
family therapists taking the unique step of making therapy a highly interactive and involved team
effort, by observing their colleagues’ clinical work with families and engaging with them and the client
family as part of the treatment team.
Although family therapy had been emerging for several decades, it broke through as a formal discipline

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with its own clear set of ideas in the 1950s, as a direct result of the work of an anthropologist named
Gregory Bateson, and his colleagues at the Palo Alto Institute. Findings from The Bateson Project created
a paradigmatic shift in the field of family therapy and refocused the energies of its practitioners. Family
therapists began to understand the family as an interactive system; to pay close attention to
communications between family members; to view causality as circular rather than linear and to believe
that change could start with any member of a family, thereby impacting the whole. These ideas influenced
the way in which family therapy clinical supervisors approached their work with supervisees, as
supervisees were themselves understood to be part of an interlocking group of systems, all of which
affected how they performed their work (e.g., family of origin; interaction with the client’s family system
and the supervisory system).
There were several models of family therapy and it was considered essential that clinical supervision be
consistent with the model of therapy that the supervisee was learning to practice. Despite differences in
opinion regarding how problems emerged and what might help to solve them, all models held in common
the role of the therapist as “active, directive and collaborative” (Liddle et al., cited in Bernard &
Goodyear, 2009). This was also the case with clinical supervision, in which supervisors were highly
engaged with their supervisees.
It was then and is now common practice for clinical supervisors to observe the work of their supervisees.
Sometimes this was (and is) done live, as in training programs, with the supervisor offering interventive
suggestions via phone through a one-way mirror to the supervisee during sessions. This is a unique
contribution of family therapy to the practice of clinical supervision that is called simply “live
supervision.” More common is for supervisees to present recorded sessions of their work with clients
and/or to offer written transcripts of sessions, which are then reviewed and discussed in clinical
supervision sessions.
Another unique contribution of family therapy to clinical supervision is the reflecting team, a therapeutic
model introduced by Norwegian family therapist Tom Andersen in 1985. A reflecting team is a group of
therapists who observe a colleague conducting a family session, then have an open conversation with one
another, observed by the colleague and client family, about what they noticed in the session. This is done
respectfully and thoughtfully, with great care and consideration taken in relation to the possible impact of
their observations. The idea is to generate fresh possibilities for the clients and to offer multiple
perspectives and a sense of hopefulness. In the same way, a reflecting team can observe a family session
facilitated by a supervisee, focusing their reflective comments on what they noticed in the supervisee’s
work. This is common practice in training programs, where a group of supervisees might act as a
reflecting team, under the guidance of a clinical supervisor.
Points to remember about systemic supervision:
 Focus on relational approach to understanding of and intervention in presenting problems
 Makes explicit connections between people and the wider social context
 Greater use of direct observation and live supervision (compared to other supervision models)
 Supervisor’s role is that of director or consultant

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 Focus on the supervisee’s position within the broader system
 Principles and techniques used in therapy are congruent with those used in supervision and may be
applied to supervisee, e.g., strategic interventions, family of origin exploration
3.3 Developmental and Social Role Model Approaches to Clinical Supervision
Developmental and social role model approaches to clinical supervision have been in use since the
1950s, but began to gain great popularity during the 1970s and 80s.
Developmental models
There are many models of clinical supervision that can be defined as developmental, which can be
further categorized into three types: stage developmental models; process developmental models and
life-span developmental models. These focus on the developmental stages of the supervisee in relation
to the clinical supervision process. Clinical supervisors are also understood to go through developmental
stages as they hone their talents and skills in their work with supervisees.
Stage developmental models describe supervisees moving through progressive stages in their professional
maturity and within the supervisory relationship. The beginning counselor is seen as highly motivated, but
with only limited awareness and quite dependent on the supervisor. Over time and through experience
gained, the counselor becomes more consistently motivated, more fully aware, but less self-conscious, and
more autonomous. An example of a stage developmental model is The Integrated Developmental Model
(IDM) developed by Cal Stoltenberg, Brian W. McNeill and Ursula Delworth.
Process developmental models are those which focus on processes in the supervisee’s work which “occur
within a fairly limited, discrete period” (Bernard & Goodyear, 2009, p. 92).
Examples include:
 Reflective models of practice - models which encourage the use of reflection to improve practice,
by focusing on an experience in a counselor’s professional practice which is having an emotional
or intellectual impact that requires deeper understanding. Originally based on the concepts of
John Dewey in the 1930s, these models continue to be developed and widely used today.
 The Loganbill, Hardy and Delworth model - a counselor development model based on processes
which are “continually changing and recursive” (Bernard & Goodyear, 2009, p. 94) and
expressed by characteristic attitudes towards the work, the self and the supervisor. A key
difference in this model is that it dismisses ideas of linear progression through stages in favor of
continual cycling through “with increasing.... levels of integration at each cycle” (Bernard &
Goodyear, 2009, p. 94).
 Event-based supervision - a task focused model in which the supervisor and supervisee focus on

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analyzing how the supervisee has managed particular discrete events in his or her work.
Supervisee and supervisor decide where to focus their attentions by either a direct request of the
supervisee, or by the supervisor picking up on subtler, or less direct, cues.
Task-focused developmental models of clinical supervision, such as Michael Carroll’s, break down
supervision into a series of manageable tasks. In Carroll’s integrative model (which is also a version of
social role model), he suggests the following seven central tasks of clinical supervision: creating the
learning relationship, teaching, counseling, monitoring (e.g., attending to professional ethical issues),
evaluation, consultation and administration.
Lifespan developmental models, such as The Ronnestad and Skovholt Model, focus on the development
of counselors across the lifespan, rather than just the few years when they are new to their work. This
six-stage model begins with “The Lay Helper Phase” and ends with “The Senior Professional Phase”
(Bernard & Goodyear, 2009, p. 98), and is unique in articulating the differing needs in clinical
supervision for counselors at each stage of their professional lives.
Social models
Social role model approaches to clinical supervision focus on the roles, tasks, foci and functions of
clinical supervision. Two examples are Hawkins and Shohet’s “Seven-eyed Model,” (originally called the
“Double Matrix Model”) and Holloway’s “Systems Approach to Supervision (SAS).”
The “Seven-Eyed Model” (Hawkins and Shohet) recognizes that the clinical supervisor employs different
roles or styles at different times, but also concedes that the role or style, is likely to be most influenced
by the particular focus of the work at the time. This is a process model, which stresses attending to the
processes that occur during supervision and within the supervisory and therapy relationships. Hawkins &
Shohet coined the term the “good enough” supervisor, alluding to the object-relations idea of the “good
enough” mother (i.e. one does not have to be perfect, or get everything right). They believe that a
primary and consistent role of the supervisor is that of providing containment for the supervisee.
The “Seven-Eyed Model” of supervision is called such because it recommends seven areas of focus for
exploration in supervision: (1) content of therapy session; (2) supervisee’s strategies and interventions with
clients; (3) the therapy relationship; (4) the therapist’s processes (e.g., countertransference or subjective
experience); (5) the supervisory relationship (e.g., parallel process); (6) the supervisor’s own processes (e.g.,
countertransference response to the supervisee and to the supervisor-client relationship), and (7) the wider
context (e.g., organizational and professional influences).
Holloway’s “Systems Approach to Supervision Model” is integrative and comprehensive, taking into
account a number of factors which impact upon supervision. Holloway recommends that five systemic
influences and relationships be considered: (1) the supervisory relationship (phase, contract and structure);
(2) the characteristics of the supervisor; (3) the characteristics of the institution in which supervision
occurs; (4) the characteristics of the client, and (5) the characteristics of the supervisee.
Holloway then offers a task and function matrix for conceptualizing the supervision process, in which the
five functions are: monitoring/evaluating, instructing/advising, modeling, consulting/exploring, and
supporting/sharing. The five tasks of the matrix are: counseling skills, case conceptualization, professional

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role, emotional awareness and self-evaluation. The matrix provides twenty-five task-function combinations.
The tasks and functions together are said to equal process, and all are conceptualized to be built around the
“body” of supervision, the relationship.
Points to remember about developmental and social role model approaches to clinical supervision:
 Historically, a point of transition when the focus of supervision shifted from the person of the
worker to the work itself
 Conceptualize clinical supervision as related to, but separate from, counseling, and as a unique
process requiring its own practice principles, knowledge base, and skill set
 Focus on the tasks, roles and behaviors in clinical supervision
3.4 Postmodern Approaches to Clinical Supervision
Postmodern approaches (a.k.a. Social Constructionist or Post-Structural models) to therapy and clinical
supervision have been emerging since the 1980s and include narrative therapy models, solution-focused
models and feminist-influenced models. The therapeutic models built upon postmodernist ideals began to
have a heavy influence on the practice of therapy in general and on family therapy, specifically, in the 1990s,
which inevitably changed the practice of clinical supervision for those involved. This was considered to
represent a major paradigm shift in the practice of systemic therapies in particular. The philosophical
perspective of postmodernists, in their various disciplines, is that:
“Reality and truth are contextual and exist as creations of the observer...grounded in their
social interactions and informed by their verbal behavior” (Philp, Guy, & Lowe, cited in
Bernard & Goodyear, 2009, p. 86).
Thus, there is no objective, observable reality or one truth, but multiple realities and truths based on a
wide range of human experience and interpretation, expressed predominantly through language - itself a
tool with which we construct our worlds.
Anyone practicing narrative, solution-focused, or any other type of therapy underpinned by a postmodern
world view, would give a strong emphasis to language and would understand the power implicit in
words. Practitioners of these models attempt to understand the client’s world as the client understands it
and do not assume a shared reality or truth between themselves and others. Since knowledge is not held
as absolute, open and reflective questions which maintain a stance of curiosity in relation to the client is
a hallmark of the work. These traits would be apparent in clinical supervisors as well as therapists.
Although there are significant differences in the various models of clinical work and supervision which
fall under the umbrella of postmodernism, they have some shared qualities which are distinctive to them.
Firstly, the role of the clinical supervisor is more consultative than supervisory, with the relationship
being valued as a collaboration and dialogue being guided by questions rather than answers. There are
some clinical supervisors working from these modalities, in fact, who refer to themselves as consultants
and their supervisees as colleagues, no matter the difference in their levels of experience.

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This leads to the second distinctive feature of these models, which is that there tends to be a very
conscious effort to avoid emphasizing hierarchical differences between supervisor and supervisee and in
fact, to minimize those differences in status as much as possible. Thirdly, there tends to be a strong focus
on the strengths and successes of the supervisee, with a view to building upon those, rather than close
analysis of perceived failures or faults.
Special mention should be made here of Johnella Bird, from The Family Therapy Centre in Auckland,
New Zealand, who has emphasizes the use of relational language and what she calls “prismatic
dialogue” in evoking directly the voices of all the participants (including the client) in counseling and
supervision. To this end, a thirty to forty minute long prismatic interview (that is, one in which the
counselor is invited to consider aspects of the situation from the position of client) is audio-taped, and
the tape taken back to the client for comment and reflection. According to Bird (2006) counselors:
“...experience a sense of movement as they engage in prismatic dialogue. Invariably this movement
produces awareness of new possibilities for therapeutic directions and conversations. I believe one of
the principal tasks of super-vision is to liberate the mind in order to foster the counselor’s sense of
creativity.”
Points to remember about postmodern models of supervision:
 Focus on subjective experience
 Multiple truths are understood in relation to context
 Strong emphasis on language and its relationship to power (dominant discourse)
 Supervisor’s role is that of consultant
 Effort to subvert hierarchy; striving towards equality between supervisee and supervisor
 Focus on the supervisee’s strengths
 The client’s perspective is included directly where possible
References for this section: Bernard & Goodyear (2009); Bird (2006); The Bouverie Centre (Moloney,
Vivekananda & Weir, 2007); Carroll (2007
Counselors at Different Levels of Clinical Development
The counselor needs be a transformation agent. This must be done with immeasurable caring and respect,
perhaps even love.
Consider-
“ ...if the therapist doesn’t change, then the patient doesn’t, either” -Carl Jung
“Psychoanalysis is in essence a cure through love” -Sigmund Freud (1906)

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“The greatest privilege is to share in the unspeakable dread and heartache of another” - D. Peratsakis
Therapy allows for the continuous possibility of a genuine, human-to-human encounter. As the counselor
develops greater “therapeutic relational competence” (Watchel, 2008), their power as an agent for change
grows. Both the therapist and client grow together through their authentic encounter with each other
(Connell et al.,1999; Napiers & Whitaker, 1978):
 Be authentic and fully accept and care for the person, not despite their foibles and imperfections,
but because of them.
 Push for the outpouring of shame, sadness or rage, despite your own primal fear of losing control
or being consumed.
 Find compassion for the vileness of another’s thoughts, actions or past and discover “What is not
so terrible about them?”
 Fully embrace that the outcome of therapy is your responsibility and that clients do not fail but
are failed by therapy.
 Make session a safe haven in which to practice new ways of thinking, feeling and interacting. Do
so by your own willingness to experiment, be in the moment, and experience risk.
 Whenever possible, pull clients into your own energy, optimism and sense of hope.
 Self-disclose; it is “an absolutely essential ingredient in psychotherapy – no client profits without
revelation” (Yalom).
 Freely step into the abject terror of another’s pain knowing that for at least those few moments,
the other is no longer alone.
First Level Counselors/Beginning Practitioners
Common Characteristics
 Lacks integrated perspective on human nature, including ethical, legal, occupational, and familial
considerations. Tendency to oversimplify the development of self-process.
 Tendency to match theories against their own personal experiences; this tends to develop a
prejudice for the model that merely fits their own experiences best.
 Tendency to overuse one model, developing an over-simplistic understanding of complex
structures. This generalizes behaviors and creates “types” of clients, thereby minimizing
individual differences.
 Tendency to minimize importance of self-awareness and personal growth.
 Tendency to over-focus on learning new information and performing newly acquired skills, in
lieu of understanding the process of therapy and the client’s unique perspective and story.

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 Tendency to over-focus on self, including own anxiety about being a clinician, lack of skills and
knowledge, and the likelihood that they are being regularly evaluated; preoccupations detract
from treatment with cookbook answers and session-to-session planning; less energy for study.
 Tendency to be fearful of more genuine, intimate contact with client, to smooth over volatile
issues, to avoid inclusion of more volatile members and to minimize issues that resonate within
one’s own life. Reluctance to engage client material at a deeper level, especially pain and shame.
Training Issues in Clinician Supervision
 Practical concerns: supervision requirements; caseload size/mix; treatment space; clinical forms
and documentation; etc.
 Supervisee anxiety: provide support and encouragement; promote autonomy and risk-taking;
continuously monitor potential risks to clients; be available to consult or co-facilitate.
 Target overall development in understanding of human nature, culture, and clinical theory and
practical skills:
o Train on various theoretical approaches; purpose and process of treatment; symptom
development and management; role of therapist; intervention tactics and techniques;
therapy modalities (individual, couple, family, group); etc.
o Train on Practical Skills: authenticity and personal risk; accommodation and joining;
assessment; challenging; contracting; assigning tasks and directives; assigning
homework; teaching problem-solving and resolving conflict; etc.
o Train on High-risk concerns: threats; trauma; harm to self or others; depression &
anxiety; domestic violence; etc.
 Observe work using role-plays, case presentation, two-way mirror, videotape, and live
supervision
 Self-growth: use of self in session; comfort with intensity as well as intimacy; personal issues that
impact client care; cultural competency and sensitivity to difference; the supervisory triad
(isomorphism and parallel process); burn out and self-care; etc.
 Legal and ethical issues: mandated reporting,; duty to warn; civil commitment orders; NGRI;
subpoenas; confidentiality (42CFR2/HIPAA); separation, divorce and child-custody decrees;
Advanced Directives; Human Rights laws; etc.
 Professional development, including current events and policies related to the counseling field;
Second Level Counselor/Moderately Experienced Practitioners
 Demonstrated continuation of proficiencies in theoretical premises and core skill competencies.
 Clear growth across various domains, including greater preoccupation with client centered care
(versus self as counselor); a greater sense of independent functioning and autonomy from the
supervisor; broader use of a range of technique; improved use of self; longer-term strategizing in
client care; and improved understanding of the therapy process from contracting to termination.

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 Caution: this period often evidences fluctuating levels of motivation by the counselor, including
periods of resistance, ambivalence, and lethargy. This can lead to conflict between the supervisee
and supervisor and may also result in a deeper understanding of clinicians’ skills and personal
characteristics; typically, therapist confidence is shaken by an increased knowledge of the
complexity of the recovery process; frustrations with client progress and satisfaction; treatment
failure; etc. Supervisee tendency to lay more blame on client for lack of change.
Training Issues in Clinician Supervision
 Encourage broader experimentation; reduce frequency of supervisor directives; allow counselor
to propose and select interventions. Require supervisee demonstrate technique and present to
peers on cases and clinical issues. Arrange peer co-facilitation.
 Encourage more open dialogue and cooperative planning between counselor and clients. Require
treatment planning in stages.
 Increase caseload size and complexity of assigned clients; challenge supervisee’s work by forcing
them to articulate their conceptualizations of the client, the interventions they chose, and possible
alternatives and their predictable outcomes.
 Vary treatment modalities (ie. couple, family therapy); encourage presentations select topic areas
to various audiences; increase outside training and reading assignments; arrange peer case
supervision and (limited) clinical supervision under guidance
Level Three Counselors/Advanced Practitioners
 Counselor is able to fully empathize with, and understand the client’s perspective on the world,
their goals and desire for change and has a better understanding of human behavior and the
therapeutic process.
 Counselor motivation has stabilized with an improved appreciation of their own skill ability and
limitations. Improvement in skill should have reduced treatment outcome variability, improved
dexterity in contracting, and promoted more sophisticated challenging.
 Autonomy increases: counselor has a deeper understanding of treatment methods, accepting of
supervisor with different orientation, broad ethical knowledge, is able to switch tracks with
clients, and appropriately uses self in therapy.
 Is able to lead clinical discussion, supervise Level One counselors, present subject matter
expertise, able to present in court and to law enforcement, comfortable ease in individual, group,
couple family and multi-family therapy modalities. Able to handle high risk and extremely
complex client profiles and syndromes.
Clinician Supervision Issues
 Role of supervisor is to guide the supervisee toward mastery and integration of all domains, from
assessment to treatment to aftercare. Supervision becomes considerably more collegial, and there
becomes a much less differentiation of expertise and power in the supervisory relationship.

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 Structure in supervision usually comes from the supervisee, rather than the supervisor. That is,
this level of clinician knows what they need from supervision at any given time. Supervision
takes on the facilitative tone (support, caring, confrontation when needed) as opposed to the
structured one (specific interventions such as live observations). A common form of supervision
with Level 3 therapists is collegial, informal group supervision. While they can work with a level
2 or even 1 supervisor, they really need a level 3 supervisor.
 Supervisor develops preference for Level One counselors (“open and eager”) and Level Three
counselors (collegial); greater reluctance to accept and work with Level 2
 Need for therapist to move toward supervision of peers and Level 1 supervisees
Group Supervision
“Group supervision is the regular meeting of a group of supervisees (a) with a designated supervisor or
supervisors, (b) to monitor the quality of their work, and (c) to further their understanding of themselves
as clinicians and the clients with whom they work, and of service delivery in general. These supervisees
are aided in achieving these goals by their supervisor(s) and by their feedback from, and interactions with,
each other.” Bernard and Goodyear (2009)
 Types: 1) Case consultation: one member presents for the purpose of feedback, support and
discussion of theory and technique; 2) Peer supervision: a group of similarly trained or skilled
individuals (e.g., all addiction counselors, clinicians at a certain developmental level), meeting
regularly for mutual supervision and support, which may or may not include a group leader or
supervisor; and 3) Team supervision: typically a mixed group with a defined leader or leaders,
often with intra-disciplinary or interdisciplinary members at various skill levels (e.g. students to
level 3 clinicians).
 Size: Groups should not be so large that members are shortchanged nor so small to be unduly
impacted by disruptions such as absences or dropouts. The average group should be no less than
4-6 supervisees and no greater than 12.
 Benefits:
o Economics of time, costs and expertise.
o Skill improvement through vicarious learning, as supervisees observe peers
conceptualizing and intervening with clients.
o Group supervision enables supervisees to be exposed to a broader range of clients and
syndromes than any one person’s caseload
o The normalization of supervisees’ experiences
o Supervisee feedback of greater quantity, quality and diversity; other supervisees can offer
perspectives that are broader and more diverse than a single supervisor
o Quality increases as novice supervisees are likely to employ language that is more readily
understood by other novices
o The group format enriches the ways a supervisor is able to observe a supervisee
o The opportunity for supervisees to learn supervision skills and the manner in which
supervisors approach providing guidance
 Limitations:
o The group format may not permit all individuals to get what they need.

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o Less skilled members may monopolize the available time.
o Group dynamics, such as personality conflicts and inter-member competition, can
negatively affect learning.
o The group may devote too much time to issues of limited relevance to, or interest for
some group members;
o Group supervision does not have a parallel process to individual supervision. While
group supervision could potentially help one out with their group processes, (depending
on the modality) a large portion of discussions in group supervision is regarding
individual work with clients.
 Group Supervision Supervisory Tasks
o Assume an active stance in the group; one that steers a careful course between over- and
under-control
o Assert yourself as necessary to redirect the group; impose limits, set Agenda, etc.
o Listen to and then following the group, challenging direction as necessary
o Be able to choose the right fights when inevitable conflicts emerge between supervisees
or within the group itself
o Communicate clearly just what you want to happen. Be confident, but not autocratic
o As the leader be able to process the groups interaction style and level of development to
understand where members are, rather than where you wish them to be.
Conflicts in Supervisory Directives
It is very common for counselors to receive conflicting feedback from supervisors and peers. This may
broaden one’s insight or create confusion and paralysis.
 There is rarely only one way of interceding; alternatives provide flexibility and spontaneity
 Peer observation may have as much (or more) validity and should not be discounted
 Paralysis often results from a fear of doing, the desire to please, or anxiety about being wrong
 Supervisees are responsible for following the directive of their assigned ‘primary’ supervisor
 Counselors, as well as supervisors, should pay attention to the suggestions they like the least
 Counselors must accommodate feedback to their own language, tempo, and way of working
 Counselors should avoid a method simply because it “feels safer” or is more “comfortable”
 If one is truly “stuck” or confused as to how to proceed, ask the client
 Learning to “trust one’s gut instincts” is the beginning of independence in counseling

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 As counseling is only as good as the counselor, supervision is only as good as the supervisor
 Counselors should be coached on responsible spontaneity
o if one is clear on the plan for the session, one is free take whatever step fits best at the
moment and fully experience the journey;
o one must always be willing to abandon the plan, to go where one must be.
Supervision Formats
 In-supervision formal and informal case presentations
 Review of session progress note(s) and/or case file
 Review of video or audio recordings
o Supervisor reviews and provides feedback
o Supervisor and supervisee review in tandem and discuss

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 Consultation; prearranged intervention with counselor and client(s)
 Group supervision; Peer supervision; Multi-supervisor supervision
 Post-session interview(s) or treatment review(s) with client(s) directly
 Live supervision (supervisor is responsible for treatment outcome; J. Haley, 1996)
 Two-way mirror, tele-med link, monitor, or audio link
 Co-facilitate or supervisor in session as observer
 Greek Chorus arrangements
Live Supervision and Tasks Common to the Lead Supervisor
 In Live Supervision, you are in charge and responsible for the outcome of therapy/treatment
 Ensure an agreed upon format and have everyone follow the same model of treatment
 Decide, in advance, the extent of disclosure with clients of the team’s strategies and techniques
 Be prepared to redirect, block, reframe, or side-line directives by non-lead counselors
 Formats may include Supervisor/Counselor(s) alternating, Lead, Tag-team, Good Cop/Bad Cop
 Require that all participants must be prepared to practice before the group; they must practice
 Require that supervisee is fully prepared to present their case (see next slide)
 Do not permit mocking, horse-play or ridicule of clients or other counselors (either side of mirror)
 Follow 1 or 2 cases from first session to termination, whether the supervisee sees a concern or not

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 Demonstrate: how to effectively interview (therapy is competent interviewing; J. Haley)
 Demonstrate: how to move into the client’s emotional sphere, and then keep inching forward
 Demonstrate: how to introduce in-session tasks and force work by remaining undistracted/on-task
 Demonstrate how to introduce and reach agreement on the need to bring in critical participants
 Demonstrate: how to push for the pain, -the worry, the guilt and shame, the anger, the sorrow
 Demonstrate: how to button-up after each hard push and then at the end of a session
Team Supervision
December 12, 2016 Meeting
Common Group Problem Scenarios
Member roles and participation issues
 Dominating
 Mute
 “Expert” group members
 Echoing the leader
 Inattentive/disengaged
 Defiance
Feedback issues
 Overly critical
 Lack of constructive criticism
 “Deaf” participants (not receptive to feedback)
 Subgrouping (ganging up)
 Challenging the leader
Casework issues
 Button pushing (hitting on personal issues)

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 Time-wasting on irrelevant issues
 Collusion with the client
 Presenting insufficient information
 Ethical impropriety/placing consumer at risk
Feedback to the Case Presenter
Topics of feedback may include:
 Commentary of overall treatment strategy
 Focus on “blind spots”
 Areas for clinical improvement (professional development)
 What would I do? (And how would I get there? See Contracting and Refocusing; page 15
and 45)
Case Presentation: OP Case Sample
Contracting
 What is the chief complaint (presenting problem or symptom)
 What is the desired goal (s) or outcome of treatment
 How is success to be understood or measured, in behavioral terms, and
 Who is to participate and under what terms
Interviewing & Tracking
PP and It’s History
 When did it start? What else was happening then?
 What attempts have been made to fix it? What worked? What did not work?
 What exactly happens? “…and then what happens?” (sequencing)
 Who participates: who does what, when? (transactional pattern)
 What does it prevent or safe-guard from happening: “what would happen if this was no
longer a problem?” = purpose of PP or symptom
 Beware of the search for insight as a means to success
Typical Goal-setting Problems
Common problems that occur during early contracting

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 Cancellations and No-shows
 Too many PPs, too many IPs
 Disagreement on PP or IP
 Commitment to Tx is vague
 Client(s) refuses to do task or is belligerent to directive
Common problems that occur once treatment is underway
 Therapist finds themselves spinning in session or confused as to direction of treatment
 PPs/IPs continually shift; new “emergencies”
 Attendance gets “spotty”; misses homework
 Members change or refuse to attend
 Therapy is stalled, stuck or slow as molasses
Case Overview for Presentation in Supervision
1. If more than one participant indicates seating pattern and who spoke first.
2. Presenting Problem/Reason for seeking treatment (include each member’s belief).
3. When did the Presenting Problem first appear (Dates/Reoccurrences)?
4. Related or correlating events to date of first appearance/Life-cycle issues.
5. Previous Action Taken; track interactional pattern (who does what and when?).
6. Who else does the problem affect? How?
7. Has anyone else exhibited this (include all families and intergenerational)?
8. What does the client/couple/family see as the most important concern to first begin work on?
9. If counseling was successful and this problem no longer existed, how would life be different -
-per the client(s)?
10. Family “spokesperson”” member(s) most apt to work for change? Member(s) most concerned
about change?
11. Conceptual Summary
a. Genogram
b. Predominant Issues/Life-cycle
c. Structural mapping
d. Presenting Problem and Purpose of Symptom(s)
e. Factor(s) motivating treatment at this time?

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f. Specific strategy/interventions made to date and client(s) reactions?
12. Treatment recommendation
a. Method: modality, participants, frequency, and duration
b. Goal(s) (short-term/long-term)
c. Therapist’s expectations for change
Family Therapy Training Syllabus
1. Clinical Supervision and Case Consultation
2. Working From a Systemic Family Therapy Perspective
a. Structures: Rules, Roles, Subsystems And Boundaries
b. Genogram
c. Mapping
d. Family Life-Cycle and Leaving Home and the Individuation Process
e. Triangles
f. Presenting Problems, IPs and Symptom Development
3. Contracting: Establishing Rapport, Interviewing, Problem Delineation And Agreement To Work
4. Giving In-Session And Homework Directives And Working With Client Resistance (Fear)
a. Direct Tasks
b. Ordeals
c. Rituals
d. Techniques
i. Enactment and Working in the Here-and-Now
ii. Challenging the World View
iii. Empty Chair
iv. Fantasy and Guided Imagery
1. Acting As If
2. Time Travel
3. Push Button
4. Sculpting
5. Early Recollections
v. Revenge and Forgiveness
vi. Paradox
vii. Misc
5. Termination
6. Specialties
a. Couple Therapy
i. Problem-Solving And Conflict Resolution
ii. Infidelity
iii. Separation And Divorce
iv. Remarriage and Blended Families
b. Consulting, Co-Therapy And Team Therapy Approachs
7. Special Issues
1. Trauma: Loss, Tragedy and Betrayal

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2. Depression And Suicide
3. Domestic Violence and Abuse
4. Addictions
5. Paraphelia
6. Eating Disorders: Anorexia, Obesity and Bulimia
7. OCDs / Obsessions, Compulsions, Anxieties and Phobias
8. LGBTQ Issues / Gender Identity And Sexual Orientation
9. Criminal Justice
10. Etc

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Demetrios Peratsakis, LPC, ACS and Natalia Tague, LPC
A Model of Evolutionary Psychology
Bowen described an evolutionary process of natural selection over generations of family functioning,
fueled by two primal, counterbalancing forces, the need for intimacy and belonging (fusion) and the
need to be separate and individual (differentiation of self).
Psychological problems are viewed as rooted in the family system’s inability to effectively reconcile
stress. As anxiety increases, relationships become increasingly reactive, deepening the emotional
fusion between members while decreasing their respective differentiation (of self). Unresolved, anxiety
and trauma result in chronic tension expressed as “physiological symptoms, emotional dysfunction,
social illness or social misbehavior” (M. Bowen).
Much of Bowen’s theory retains broad applicability as evidenced by core assumptions common to the
cognitive–behavioral, attachment and interpersonal therapies (the importance of interpretation and the
ability to demarcate between feeling and thought and between one’s own convictions and those of
another), the family therapies (triangulation, family structure and functioning) and the biomedical, on
the role of stress in primary and behavioral health symptom formation.

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1. Differentiation of Self
2. Triangles
3. Nuclear Family Emotional System
4. Family Projection Process
5. Multigenerational Transmission Process
6. Emotional Cutoff
7. Sibling Position
8. Societal Emotional Process
8 Interlocking Concepts
Note: Some of the description of the eight concepts of Bowen Theory are modified excerpts from the Bowen Center for Family Studies and from a literature review by Vermont
Center for Family Studies faculty member, Monika Baege, referencing the following sources: Bowen, 1978;Gilbert, 1992, 1999;Kerr & Bowen, 1988, and Noone, 1995.
1. Differentiation of Self
 Differentiation of self is a measure of the degree of integration of self, describing how people cope with life's demands and
pursue their goals on a continuum from most adaptive to least
 Variations in this adaptiveness depend on several connected factors, including the amount of solid self, the part of self that is not
negotiable in relationships. Greater differentiation = strength of convictions; less solid self = feels more pressure to think, feel,
and act like the other.
 Fusion between people generates more chronic anxiety
 Level of differentiation refers to the degree to which a person can think and act for self while in contact with emotionally
charged issues. It also refers to the degree to which a person can discern between thoughts and feelings.
o Higher levels of differentiation: manages stress, anxiety and reactivity; choose thoughtful action
o Lower levels of differentiation: increased dependence on others to function; increased likelihood of developing severe
symptoms under stress; They act, often destructively, based on anxious reactions to the environment. Their intellectual
reasoning fuses with emotionality. Even highly intelligent people can be poorly differentiated.
 The process of differentiating a self involves a conscious effort at strengthening or raising the amount of solid self by defining
beliefs and principles, managing anxiety and reactivity, and relating differently to the family system; the level of differentiation
is raised in the whole system.
 On a scale of 0-100, most of the population scores below 30; 50 is unusual and 75 occurs rarely within several hundred years

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Relationships function as if they are governed by
two equally intense counterbalancing life forces
- Bowen Family Systems Theory
Individuality/Individuation
“Derived from the drive
to be a productive,
autonomous individual, as
defined by self rather
than the dictates of
the group.”
Differentiation
Togetherness
“Derived from the
universal need for love,
approval, emotional
closeness, and
agreement.”
Fusion
Slide courtesy of Michael E. Kerr, MD
Five Characteristics of Self-differentiation
(Definition of Self Within Relationships; adapted)
Differentiation of Self is a life-long process of developing two essential capacities, between autonomy (separation) and connection
(togetherness), self-definition and self-regulation. The actual process of increasing self-differentiation requires progressive
demarcation of the elements that comprise the Self (self-definition) and the courage and determination to develop responsibility for the
management of one's own anxiety and reactivity (self-regulation). Differentiation is a measure of one’s solidity and centeredness.
SELF-DEFINITION
1. A Mature Understanding of One’s Own Limits and of the Limits of Others
 A clear understandingof where one ends and somebodyelse begins
 Respect for the right of others to be who and how they wish to be while refusing to allow them to define or intrude upon one’s own rights
 The defining characteristic is to have oneself defined from within, rather than adapting to please others or simply to avoid conflict
2. Clarity as to One’s Own Beliefs
 What do I believe, why do I believe it to be so, and from whence does this belief come from?
 How strong are my convictions?
 Of what am I certain, and of what am I not so certain?
SELF-REGULATION
3. Courage to Take Stands
 Defining where one stands on issues and the courage to affirm those beliefs in the face of disapproval
 Refusing to give in to another when it is a matter of principle
 Capacity to stand firm in the face of strong reactions! -ie. “You can't think, act, or feel that way and remain a part of this family!'
4. The Ability to Retain Integrity
 Resolve to follow through on a vision or toward a goal or outcome despite threats or sabotage from others
 Emotional and spiritual stamina to stick with a plan or goal and not let the reactions of others redefine its course
5. Staying Connected
 Maintaining a relatively non-reactive give-and-take with those who are reacting to you
 Resisting the impulse to attack or cut off from those who are most reactive to you.

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Patterns of interaction that reduce conflict and duress within the dyad
Triangles: Problem Solvers and Creators
Triangle Theory
1. Conflict is a continuous condition of human interaction
2. Triangulation is a pattern of interaction that reduces conflict and distress; it is a process whereby anxiety is decreased and
tension dissipated through emotional interaction with others
“The (Bowen) theory states that the triangle, a three-person emotional configuration, is the molecule or the basic building block of
any emotional system, whether it is in the family or any other group. The triangle is the smallest stable relationship system. A two-
person system may be stable as long as it is calm, but when anxiety increases, it immediately involves the most vulnerable other
person to become a triangle. When tension in the triangle is too great for the threesome, it involves others to become a series of
interlocking triangles.” M. Bowen. “Family Therapy in Clinical Practice.” Aronson New York. 1976. P373
3. Unmediated, conflict results in chronic tension expressed as “physiological symptoms, emotional dysfunction, social illness
or social misbehavior” - M. Bowen
4. The resulting conditions are characterized by “1) marital (or partner) discord; 2) dysfunction in a partner; 3) impairment
in one or more of the children; or 4) severe emotional “cut-off”, including isolation, abandonment, betrayal, or expulsion
5. Triangulation may also result in preferred patterns of interaction that avoid responsibilityfor change –Alfred Adler
8

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Triangle’s Simplified
 Two-person dyads become unstable once anxiety increases
 A third persons is pulled into the conflict, creating more space for anxiety and relieving some of the pressure
 When the triad can no longer contain the anxiety, more people are triangulated, forming a series of
interlocking triangles
 If one member of the triangle remains calm and in emotional contact with the other two, the system
automatically calms down.
 When stress and reactivity intensify and remain chronic, members lock into a triangular position which
solidifies and develops symptoms.
dyad
third person or subject of mutual, concern or interest
anxiety
closeness may increase as
anxiety is reduced
10

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dyad
third person or subject of mutual, concern or interest
Anxiety decreases in dyad
 Third party helps mediate conflict or remedy problem in the two-person relationship (dyad). For example:
 siblings cease their disagreement over chores to actively chide their younger brother
 co-workers are unclear on best approach to an issue and seek guidance from their supervisor
11
1. Greater anxiety = more closeness or distance
dyad
third person or subject of mutual,
concern or interest
Alliance
increases trust
and intimacy
 Two members (or all three) are drawn closer in alliance or
support. For example:
 Separated or divorced husband and wife come together as parents
for their child in need
 sisters share greater intimacy after one has been the victim of a
crime (the triangulated my be a person or an issue, such as “work”,
the “neighbors” or in this example, the “crime”)
closeness may increase as
anxiety is reduced
12

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Over time
 Triangulation begins as a normative response due to stress or anxiety
caused by developmental transition, change or conflict
 The pattern habituates, then rigidifies as a preferred transactional
pattern for avoiding stress in the dyad
 The IP begins to actively participate in maintaining the role due to
primary and secondary gains
 The “problem”, which then serves the purpose of refocusing attention
onto the IP and away from tension within the dyad, becomes an
organizational node around which behaviors repeat, thereby governing
some part of the family system’s communication and function
 Over time, this interactional sequence acquires identity, history and
functional value (Power), much like any role, and we call it a
“symptom” and the symptom-bearer, “dysfunctional”
 A key component in symptom development is that the evolving
pattern of interaction avoids more painful conflict
 This places the IP at risk of remaining the “lightning rod” and
accelerating behaviors in order to maintain the same net effect
 When this occurs, it negates the need to achieve a more effective
solution to some other important change (adaptive response) and
growth is thwarted. The ensuing condition is called “dysfunction”.
- d. peratsakis
14
3. Nuclear Family Emotional Process
How members adjust roles and responsibilities in their relationships to mediate tasks and reconcile stress and anxiety
The mechanism by which symptoms develop in families
 Four basic relationship patterns that operate in intact, single-parent, step-parent, and other nuclear family configurations.
 Problems or symptoms develop during periods of heightened and prolonged family tension
 Effects of tension depends on the stress event, family resiliency, and supports from extended family and social networks.
 The higher the tension, the more chance that symptoms will be severe and that several people will be symptomatic
Partner/Maritalconflict As tension increases partners become more anxious, externalizing their anxiety into the couple relationship.
 Partners focuses on what is wrong with the other, each tries to controlthe other, and each resists the other’s efforts at control.
 Partners and members who distance render themselves emotionally unavailable; avoid potentially uncomfortable, though important, topics.
 Reciprocity in relationships occurs when one person takes on responsibilities for the twosome. With chronic tension, the two people slide into
over-adequateand under-adequateroles. This can result in failure or inadequacy in one of the partners.
Dysfunction in one partner One partner pressures the other to think and act in certain ways and the other yields to the pressure
 Partners accommodate to preserve harmony; typically, more one-sided
 When tension rises, the roles intensify, the subordinate partner yield’s more self-controlescalating their anxiety
 Over-functioningand under-functioningreciprocityintensifies, resulting in greater emotional fusion
Impairment of one or more children Partners focus their anxieties on one or more of their children.
 Excessive worry, rigid convictions and beliefs or very negative view of a child results fixed targeting
 Increased attention creates heightened sensitivity and reactivity. Child becomes more reactive to their attitudes, needs, and expectations
 The process undercuts the child’s differentiation from the family, increasing vulnerability to act out or internalize family tensions
 The child’s anxiety can impair schoolperformance, social relationships, and health
Emotional distance Family members distance to reduce the relationship intensity, but risk becomingtoo isolated and avoidant
 Common coping style that concentrates anxiety in other relationships; the more anxiety one person or one relationship absorbs, the less other
members must absorb. This means that some family members maintain their functioningat the expense of others
 While harm may be unintended, distancing pools anxiety in the remaining members increasing emotional fusion
.

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4. The Family Projection Process
“The primary manner in which parents transmit their emotional problems to a child. The projection process can impair the functioning of
one or more children and increase their vulnerability to clinical symptoms. Children inherit many types of problems (as well as strengths)
through the relationships with their parents, but the problems they inherit that most affect their lives are relationship sensitivities such as
heightened needs for attention and approval, difficulty dealing with expectations, the tendency to blame oneself or others, feeling
responsible for the happiness of others or that others are responsible for one’s own happiness, and acting impulsively to relieve the
anxiety of the moment rather than tolerating anxiety and acting thoughtfully. If the projection process is fairly intense, the child develops
stronger relationship sensitivities than his parents. The sensitivities increase a person’s vulnerability to symptoms by fostering behaviors
that escalate chronic anxiety in a relationship system.
The projection process follows three steps:
(1) the parent focuses on a child out of fear that something is wrong with the child
(2) the parent interprets the child’s behavior as confirming the fear; and
(3) the parent treats the child as if something is really wrongwith child.
These steps of scanning, diagnosing, and treating begin early in the child’s life and continue. The parents’ fears and perceptions so shape
the child’s development and behavior that he grows to embody their fears and perceptions. One reason the projection process is a self-
fulfilling prophecy is that parents try to “fix” the problem they have diagnosed in the child; for example, parents perceive their child to
have low self-esteem, they repeatedly try to affirm the child, and the child’s self-esteem grows dependent on their affirmation.
Parents often feel they have not given enough love, attention, or support to a child manifesting problems, but they have invested more
time, energy, and worry in this child than in his siblings. The siblings less involved in the family projection process have a more mature
and reality-based relationship with their parents that fosters the siblings developing into less needy, less reactive, and more goal-directed
people. Both parents participate equally in the family projection process, but in different ways. The mother is usually the primary
caretaker and more prone than the father to excessive emotional involvement with one or more of the children. The father typically
occupies the outside position in the parental triangle, except during periods of heightened tension in the mother-child relationship. Both
parents are unsure of themselves in relationship to the child, but commonly one parent acts sure of himself or herself and the other parent
goes along. The intensity of projection process is unrelated to the amount of time parents spend with a child.” –the Bowen Center
5. Multigenerational Transmission Process
Transmission of information across generations on several interconnected levels, ranging from the conscious teaching and
learning of convictions, rules and regulations, to the automatic and unconscious programming of emotional reactions and
behaviors that, collectively, define the individual’s view of the world and shapes their sense of self.
 Parent and child interactions over a prolonged period of dependency and early development results in differentiation at level of parents’
 The nuclear family emotional process results in variability in differentiation, with one sibling developing a greater sense of “self”
(increased differentiation) while another develops less, providing siblings practice in role reciprocity (over- and under-functioning)
 Multigenerational transmission follows a predictable path to mate selection with similar levels of differentiation of self.
 Where siblings with higher differentiation levels from different families mate, their most differentiated offspring foster a line of progeny
with greater differentiation; over multiple generations, the differences between family lines grow increasingly marked
 Level of differentiation of self “can affect longevity, marital stability, reproduction, health, educational and occupational accomplishments
 Bowen theorized that highly differentiated persons developed stable, productive nuclear families that contributed to society, whereas, low
differentiated individuals raised children over the generations who were more susceptible to social illness and psychological problems*
* Note: “Some concerns have been voiced over what is perceived as an overly deterministic or fatalistic perspective on social growth in
Bowen’s Theory. Perhaps, one could argue, some form of resiliency factor is conveyed as an inheritable trait, making such transmission a
predisposition, rather than a prescriptive condition. One could also argue that this is a critical mechanism in evolutionary psychology and
important to the furtherance of reasoning and innovation in the species”. - d.peratsakis

39
6. Emotional Cutoff
Emotional cut-off is a preferred method of coping by which the individual reduces the anxiety and stress of unresolved conflict with
parents, siblings, and other family members by reducing or totally cutting off emotional contact with them.
 Increase risk of a mismatch between physical proximity and emotional closeness, thereby avoiding sensitive issues
 Increases risk of avoidance as a preferred coping strategy with others
 Cut-off may occur by moving away, abandonment or expulsion
 Distance from family members may be offset with exaggerated closeness with other, non-family member relationships, creating
substitute “families” with social and work relationships
 Unresolved attachment issues can take several forms:
o Feeling infantilized when at home with parents, who are prone to make decisions for them
o Feeling responsible for solving parents’ conflicts or mediating the nuclear family’s distress
o Anger at not being fully accepted as an adult with differences by parents
o Unresolved attachment breeds more immaturity in parents and children
o Siblings foster anger at distancing sibling; adds to household tension
7. Sibling Position
Sibling position, a concept which Bowen adopted from the research of Walter Toman, affects variation in basic
and functional levels of differentiation as well. Oldest, youngest, and middle children tend toward certain
functional roles in families, influenced also by the particular mix of sibling positions in it and the sibling positions
of parents and other relatives.
From Alfred Adler:
1. The psychological situation of each child in the family is different.
2. The child's opinion of himself and his situation determines his choice of attitude.
3. If more than 3 years separate children, sub-groups of birth order may form.
4. A child's birth order position may be seized by another child if circumstances permit.
5. Competition may be expressed in choice of interests or development of characteristics.
6. Birth order is sometimes not a major influences on personality development. The other potentially significant
influences are: organ inferiority, parental attitudes, social & economic position, and gender roles.
POSITION FAMILY SITUATION CHILD'S CHARACTERISTICS
ONLY
Birth is a miracle. Parents have no previous experience. Retains 200% attention from both parents. May become rival of
one parent. Can be over-protected and spoiled.
Likes being the center of adult attention. Often has difficulty sharing with siblings
and peers. Prefers adult company and uses adult language.
OLDEST
Dethroned by next child. Has to learn to share. Parent expectations are usually very high. Often given resposnsibility and
expected to set an example.
May become authoritarian or strict. Feels power is his right. Can become helpful if
encouraged. May turn to father after birth of next child.
SECOND He has a pacemaker. There is always someone ahead.
Is more competitive, wants to overtake older child. May become a rebel or try to
outdo everyone. Competition can deteriorate into rivalry.
MIDDLE Is "sandwiched" in. May feel squeezed out of a position of privilege and significance.
May be even-tempered, "take it or leave it" attitude. May have trouble finding a
place or become a fighter of injustice.
YOUNGEST Has many mothers and fathers. Older children try to educate him. Never dethroned.
Wants to be bigger than the others. May have huge plans that never work out. Can
stay the "baby." Frequently spoiled.
TWIN One is usually stronger or more active. Parents may see one as the older. Can have identity problems. Stronger one may become the leader.
"GHOST CHILD" Child born after the death of the first child may have a "ghost" in front of him. Mother may becime over-protective.
Child may exploit mother's over-concern for his well-being, or he may rebel, and
protest the feeling of being compared to an idealized memory.
ADOPTED CHILD
Parents may be so thankful to have a child that they spoil him. They may try to compensate for the loss of his biological
parents.
Child may become very spoiled and demanding. Eventually, he may resent or
idealize the biological parents.
ONLY BOY AMONG GIRLS Usually with women all the time, if father is away. May try to prove he is the man in the family, or become effeminate.
ONLY GIRL AMONG BOYS Older brothers may act as her protectors.
Can become very feminine, or a tomboy and outdo the brothers. May try to please
the father.
ALL BOYS If mother wanted a girl, can be dressed as a girl. Child may capitalize on assigned role or protest it vigorously.
ALL GIRLS May be dressed as a boy. Child may capitalize on assigned role or protest it vigorously.

40
8. Societal Emotional Process
Societal emotional process describes how the emotional system governs behavior on a societal level, promoting both progressive and
regressive periods in a society.
It refers to the tendency of people within a society to be more anxious and unstable at certain times than others. Environmental stressors
like overpopulation, scarcity of natural resources, epidemics, economic forces, and lack of skills for living in a diverse world are all
potential stressors that contribute to a regression in society.
“This premise, like the Multigenerational Transmission process, has serious implications for evolutionary psychology. The tenet, that
society mirrors the nuclear family process which, in turn, reflects the norms, morays and cultural artifacts of the societal whole posits an
interactive relationship with negative as well as positive trends. Community institutions, such as schools, courts, news outlets and political
bodies reflect the collective tension of a peoples and move to implement measures to reduce stress and reconcile anxiety. The ensuing
trends attempt to regulate broad tension within society and define what is permissible and acceptable at given times.” –d.peratsakis

42
Slide 1
Structural-Strategic Couple and Family Therapy
Demetrios Peratsakis, LPC, ACS

43
Slide 2
Presenter's Notes
1. Slide Notes: This PowerPoint provides information that will not be covered during the presentation, so please review
the material at your convenience and contact me directly for further clarification.
2. Role-Play Demonstration: A structural-strategic family therapy session will be demonstrated; while styles vary broadly,
it will punctuate some common, simple rules that can advantage family practice.
3. F/C Specialization (1980-1995): This was a very active period in my own practice of marriage and family therapy;
while I benefited from my work with many, I am particularly indebted to
- AAMFT Supervisor Robert Sherman, co-founder of Adlerian Family Therapy and developer of the Marriage and
Family Therapy programs at Queens College. From 1980 until 1992 he supervised my training, adjunct faculty work,
and involvement in the department’s annual MFT Founder Series, sponsoring such notable theorists as M. Andolphi,
J. Framo, M. McGoldrick, C. Whitaker, M. Bowen, J. Haley, and the Minuchins;
- AAMFT Supervisor Neil Rothberg for our work together at the ASPECTS Family Counseling Center (1982 to 1992);
- Richard Belson, Director, for a 2-year intensive at the Family Therapy Institute of Long Island in live-supervision and
strategic family therapy (1990 to 1992). Richard collaborated with Jay Haley and Cloe Madanes as faculty at the
Family Therapy Institute of Washington, D.C. from 1980 to 1990 and served on the editorial board of the Journal of
Strategic and Systemic Therapies, from 1981 to 1993;
- Strategic Impact (1992-1995), a professional cooperative for advanced training methods in couple and family therapy.
- Demetrios Peratsakis, LPC, ACS

44
Slide 3
A New Understanding of Human Nature and How to Treat its Problems

45
Slide 4
Rubin Vase
Family Systems Therapy forced a new insight into our customary
view of the individual and their relationship systems.

46
Slide 5
Family Systems Therapy expanded on the belief
that psychological symptoms were the creation of the
individual in service to their family.
IP: Lightning Rod? Scape-goat? Sacrificial Lamb?

47
Slide 6
IMHO, there are three (3) very significant perspectives
that have reshaped our understanding of the purposiveness of human behavior:
1. Psychological symptoms are the creation of the individual in service to their family
2. Thought creates feelings which drive behavior; all reaffirm one’s world-view
3. Psychological symptoms are an excuse, a pretext, for avoiding responsibility

49
Slide 8
1. Families have Purpose
Individuals in trust relationships acting alone and in concert to accomplish and obtain individual and collective
purposes and needs:
 Basic Needs
1) Safety: food; drink; shelter, warmth and protection from the elements; safety and security and freedom from fears
2) Belongingness: nurturance, intimacy, friendship, affection and love; sex. Meaningful connection with community
3) Esteem and Self-Actualization: achievement, mastery, independence, status, dominance, prestige, self-respect,
respect from others; realizing personal potential, self-fulfillment, seeking personal growth and peak experiences
 Life Tasks
a) larger processes that the family, as a group, must accomplish (Life-cycle Tasks); and
b) those each individual must master (Developmental Tasks) and reconcile (Adler Life Tasks/Existential Anxiety)
Structural Family Therapy
8

50
Slide 9
2. Families have Structures - they define Who does What, When, How, and with Whom
 These define the operational organization and atmosphere of the family system
 They define the manner in which transactions occur around tasks, functions and responsibilities.
 They are partly universal (cultural) and partly idiosyncratic (intergenerational): information (rules and myths) on how to
accomplish tasks and assume responsibility; how gender, roles, and functions are defined; how power and emotion is
expressed; how loyalty, intimacy and trust are conveyed; and so on.
Structures
a. Sub-systems: Temporary or enduring subgroupings within the family based on age or generation, gender, and interest or
function:
1) Executive Subsystem;
2) Couple or Marital;
3) Sibling;
4) Grandparental;
5) Extended (cousins, uncles and aunts; 6) Friends/Neighbors/Work
b. Roles: Who does what? What are the established assignments for performing specific functions and tasks?
c. Rules: What is done and how? What are the routine procedures and interactional patterns (transactions) --and their
accompanying rules, which define behavior surrounding functions and tasks of importance?
d. Relationship Boundaries: the degree of reactivity, communication and emotional exchange between
members, subsystems and the system as a whole with the outside world

51
Slide 10
3. Family Structures have Power - the ability to influence the outcome of events
Members have power based on status and prestige and authority to fulfill or direct assignments for performing specific functions
and tasks. Power must accompany responsibilities otherwise failure and conflict occur.
Executive Subsystem
No matter the configuration, is the recognized authority responsible for the decision-making and problem-solving capacity of
the family. Core responsibilities include
 to effectively manage stress and conflict as individual members and the group adapts to change.
 define the relationship between the family and the community
 parenting / child rearing
Specialized Individual Family Member Roles
 Family Spokesperson: family member elected to serve as the representative of the family to the outside world. Often most
controlling or member ascribed the most authority/power
 “Enabler”, “Family Hero”, “Mascot”, “Lost Child” (from Addiction theories): roles adopted to mediate stress and help
bind the family cohesion
 Identified Patient (I.P.) or Symptom Bearer: member that controls (and organizes) the family’s behavior by virtue of their
own problems or behaviors

52
Slide 11
1. Symptoms (excluding organic illness) are purposive; they are voluntary and under the control of the individual
2. While the Identified Patient (IP) may be appear helpless to change, the helplessness is actually a source of power over others
whose lives and actions are restricted and even ruled by the demands, fears, and needs of the symptom bearer (Madanes, 1991)
3. Symptoms are metaphors for the family disturbance and may express the problem(s) of another, non-IP, family member
(example: child IP with school failure expresses mom’s rage against father)
4. Benevolence drives family interaction; interactions must be described in terms of love
5. Problems arise when the family hierarchy, or power allocation is incongruous; re-aligning power remedies the problem
6. Conflicts arise when the intent of the interaction is at cross-purposes; personal gain versus benefit to the group
 if a person is hostile, he or she is being motivated by personal gain or power
 if the person is concerned with helping others or receiving more affection, he or she is being motivated by love
The motivation helps define the treatment strategy or intervention: the therapist targets the same outcome or the identical
pattern of interaction (sequence) without the problematic symptom; when either occur without the symptom occurring the
problem behavior should abate. (Madanes, 1991).

53
Slide 12
Structural-Strategic Therapy Synthesis
Therapy involves disengaging power-struggles that occur in relationships and structures due to
power imbalances, and redirecting them through decision-making and the problem-solving process
Structural: structures are organized constructions of power
 change the Structure in order to change the System
in order to change the Symptom
Strategic: processes are methods by which power is employed
 change the Symptom in order to change the System
in order to change the Structure

55
Slide 14
Overview of
1. Symptoms: how they originate and how to challenge them
2. Life-cycle: its role in family development and problem origination
3. Family Constellation and Atmosphere
4. Triangulation: process of stress reduction and problem origination
5. Boundaries: how to define them and how to manipulate them

57
Slide 16
 Symptoms are the Result of Problems with Power
1. inappropriate alliances, such as cross-generational alliances;
2. inappropriate hierarchies, such as parents ceding excess authority to children; or
3. inappropriate boundaries, such as marked enmeshment or disengagement between members
 Symptoms Originate when the Executive Subsystem is Ineffectual -excessive rigidity or diffuseness
1. difficulty reconciling stress and mending trauma or severe impairment in one of its members
2. difficulty responding to maturational, developmental (life-cycle) and environmental challenges
3. difficulty mediating conflict in the couple or partner relationship resulting in power-struggles and their aftermath
Note:
o unresolved, problems become symptoms characterized by power-struggles and improper methods of resolving them; this includes
betrayal, domestic violence, emotional cut-off or expulsion, infidelity, incest, and severe passive-aggressive acts such as eating
disorders, catastrophic failure, depression and suicide
o when the identified patient (IP) is a child, the problem is a failure of the Executive Subcommittee to effectively parent
1. Triangulation of the child due to marital or couple conflict, including parents who are separated and estranged;
2. Triangulation of the child in a cross-generational coalition (child enlisted to take sides in a in loyalty dispute, ie. parent against parent;
grand-parent (s) against parent(s); in-law(s) against parent(s)
 Symptoms are Maintained by Faulty Convictions and Concretized Sequences of Thoughts and Behaviors
 Interrupting these will necessarily disrupt their power and meaning
16

58
Slide 17
17
1. Create a new symptom (ie. “I am also concerned about
________; when did you first start noticing it?”)
2. Move to a more manageable symptom (one that is
behavioral and can be scaled; ie. chores vs attitude)
3. I.P. another family member (create a new symptom-
bearer or sub-group; ie. “the kids”, “the boys”)
4. I.P. a relationship (ie. “the marriage/relationship makes
her depressed”)
5. Push for recoil through paradoxical intention
6. “Spitting in the Soup” –make the covert intent, overt
7. Add, remove or reverse the order of the steps (having the
symptom come first);
8. Remove or add a new member to the loop
9. Inflate/deflate the intensity of the symptom or pattern
10. Change the frequency or rate of the symptom or pattern
11. Change the duration of the symptom or pattern
12. Change the time (hour/time of day/week/month/year) of the
symptom or pattern
13. Change the location (in the world or body) of the
symptom/pattern
14. Change some quality of the symptom or pattern
15. Perform the symptom without the pattern; short-circuiting
16. Perform the pattern without the symptom
17. Change the sequence of the elements in the pattern
18. Interrupt or otherwise prevent the pattern from occurring
19. Add (at least) one new element to the pattern
20. Break up any previously whole elements into smaller
elements
21. Link the symptoms or pattern to another pattern or goal
22. Reframe or re-label the meaning of the symptom
23. Point to disparities and create cognitive dissonance
Note: 1-4, Minuchin/Fishman; 5-6, 22, 23, Adler; 7-21, O’Hanlon.
Pattern or element may represent a concrete behavior, emotion, or family member
Challenge the Meaning and Power of the Symptom

59
Slide 18
The Process of Challenging
Three Key Concepts
A. “Functional Value” -operational purpose of symptomatic behaviors and conditions
Irrespective of the source or etiology of a symptom or condition, it acquires meaning and power to the individual and the relationship
system when it aides in the ability to function and operate (“functional value”). This will rigidify over time and become a preferred
transaction pattern that defines rules and roles of interacting.
1. The History of the Presenting Problem clues you in to the purpose of the symptom. “Why now?” “Why that?” “Why her?”
2. The sequence and pattern of interaction clues you in to how the symptom is maintained and what triggers it.
3. Noting who participates, who is affected by the symptom and how, will clue you in as to its meaning.
Miscellaneous on Symptoms
1. Symptoms are purposive; moreover, they are metaphors for the family’s disturbance or failure to adequately adapt to change
2. Symptoms are stop-gap measures that preserve a level of safety between the imperative to change and the desire to remain the same
3. Symptoms are maintained by a rigid pattern of convictions and their corresponding feelings and behaviors
4. Symptom recurrence, or substitution, is due to replication of the same pattern of convictions and behaviors
B. Tracking or Sequencing -degree of effectiveness, 1, 2, 3; from lesser to greater 
1. Interviewing client about experience “A” (self-report)
2. Interviewing (family) members about their respective perspective about experience “A” (group report)
3. Enactment or role-play of experience “A”: directive to re-enact problem transaction in session

60
Slide 19
C. Prescribing or Giving Directives
Prescribing or assigning tasks provide practice in new ways of thinking and behaving. It includes simple tasks or assignments as
well as complex sequences of behavioral interactions designed to foster change, such as Re-enactments (repeating pattern with
modifications), Ordeals (patterns designed to be burdensome), and Rituals (ceremonies). In this regard, therapy is nothing more
than a long series of creating deliberate opportunities for change!
1. Give task
Simple introductions include: “Let’s try something…”; “Most/Some people find this helpful…”; “Let’s do an
experiment”; “I’m going to have you do something that may be very difficult/uncomfortable… ”
2. Encourage work by not rescuing
Once a task has been assigned, the therapist's job is to continually redirect straying or direct back to task, while working on
their own anxiety, impatience and need to rescue
3. Work through power-struggles and challenges to therapeutic alliance
Resistance to a task should be expected, but NOT tolerated (see “notes” on client-therapist power struggles)
4. Recap and button-up
a) Explore experience: “Was this worst than you thought it would be?” If the task was not completed, explore a) what would
happen had the task been accomplished? and b) what was going on for the person while struggling with the task?
b) Examine therapeutic alliance for possible back-lash, anger, resentment or fear
c) Predict residual anger
d) Predict back-sliding due to difficulty of change
e) Assign homework
 must be “safe”
 Must anticipate failure or sabotage
 Client must be free to abandon task, unless it is a specific “test” of client’s investment in change

62
Slide 21
Life-cycle
Life-cycle is the context within which developmental change occurs. Stress develops into symptoms at points of intersection when
family of origin rules (Vertical stressors) are too rigid and insufficiently flexible to adapt smoothly to trauma or normative
developmental change. This is illustrated in the diagram below which denotes the concentric context we are each embedded within
(Systems Levels) and the merging pressure to remain the same (Vertical Stressors) and the imperative to change (Horizontal
stressors):
Carter and McGoldrick identify six family life cycle stages and their respective processes and tasks, somewhat modified herein.
Because the processes are universal, understanding the Stages helps identify and predict inherent in the developmental changes each
family undergoes.
Factorsthatdecreaseadaptabilitytochange
ChangeEvents

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