Family Therapy for PTSD: Evidence of what, for what, against what.

Or, why evidence based treatments are essential, and usually misapplied or misinterpreted.

Common Factors1. Common factors in general.

1. The strong hypotheses or ‘The Dodo bird verdict’ (Rosensweig, 1936) from Alice and Wonderland. “Everyone has won and all must get prizes.”

2. The moderate hypotheses. Models matter but must coexist with strong common factor variables. (Sprenkle et al 2009).

2. Common factors in family therapy. (Sprenkle et al 2009

1. An understanding of principles of change.

2. An understanding of distressed and healthy couples.

3. An understanding of self-of-the-therapist work.

.

Expertise(All quotes from Foer, 2011)

1. “Experts see the world differently. They notice things that non-experts don’t see. They home in on the information that matters most, and have an almost automatic sense of what to do with it.”

2. Experts aren’t differentiated from others because they remember isolated facts, but because the remember things in context, especially in the complex context of their expertise. “Everything we see, hear, and smell is inflected by everything we have seen, heard, or smelled in the past.”

3. Experts push themselves beyond “the OK plateau.”1. “Put yourself in the mind of someone far more competent in the task you’re trying to master, and try to

figure out how that person works through problems.”1. Chess: “The best single predictor of an individual’s chess skill is not the amount of chess he has played against opponents, but rather the amount time

he has spent sitting alone working through old games.”

2. Typing: “To force yourself to type faster than feels comfortable, and to allow yourself to make mistakes.”

4. Surgeons vs. Mammographers.1. “The outcome of most surgeries is usually immediately apparent… which means that surgeons are

constantly receiving [immediate] feedback on their performance. “

2. “[M]ammographers usually only find out about the accuracy of their diagnoses weeks or months later, if at all, at which point they’ve probably forgotten the details of the case and can no longer learn from their successes and mistakes.” “Ericson suggests that mammographers regularly be asked to evaluate old cases for which the outcome is already known. That way they can get immediate feedback on their performance.”

Expertise Components The need for process

understanding. The need for pathology matching.\ The need for family style/culture

matching. Judging the need for acute and

long-term treatment.

A Tale of Two Families:Adaptation after OIF

“Must you have battle in your heart forever? The bloody toil of combat? Old contender…” --Odyssey 12:132y, Fitzgerald

“I am not sure, I can put parts together, when someday soon, I go away forever, from the hillside house.” --Anon

Two dimensions of war

Trauma—Iliad Separation—Odyssey

Clinical Consideraitions

Individual pathology Family pathology Psychosocial and Environmental

Problems (Axis IV)

Taming the Big Four of Marital Adjustment

Money Sex Kids Inlaws

Current Research efforts(Riggs, 2010)

Monson, Candace, ‘Cognitive Behavioral Conjoint Therapy for PTSD’.

Riggs, David S., ‘Marital and family therapy for men and women with PTSD’.

From Riggs 2010 Systemic focus.

Increase family level of functioning Communication Problem solving

Symptom focus. Decrease symptoms Increase family understanding of symptoms

Triage to levels of treatment

Education Counseling Therapy

Family-Eco System View

Resource and authority structures within family

Resource and authority structures external to family

Alliances and conflicts across family boundaries

Migration disruptions Trauma effects on system

Studied by Laqueur and Detre in ’61 in schizophrenics at state hospitals.

Bergen County Trial ’84. New York State Family Psycho

education Study ’94. Groups tend to end within 5 years

regardless of success due to therapist change and institutional priorities.

Multifamily Groups

1. Functional Assessment History of patient’s disorder History of family interactions Degree of knowledge of patient

and family members about disorder.

4. Problem Solving Agree on the problem Suggest several possible solutions Discuss pros and cons and agree

on best solutions Plan and carry out best solutions Praise efforts; review effectiveness

Partnership Competence Model

Developed in psychosocial rehab program for motivated homeless.

Requires few verbal skills. Common language from multiple staff levels. Weaker and stronger can communicate. Focus on recent events not abstractions. Culturally neutral as possible. Can impact clients continuously from outreach. Impact people who have minimal by-in.

Partnership CompetenceModel 2

Credits existing competencies. Focuses on small change steps. Asks for immediate behavior change. Asks for immediate self evaluation. Acceptance and compliance of model are

diagnostic of: comprehension, resistance, personality factors.

SCIP model

Safety. Might someone be hurt in the next 5 minutes?

Control. Can issues be discussed calmly, with dignity, fairness, and respect.

Issue. Can you talk about one good achievable issue at a time.

Plan. Can you agree: on a specific step, to be taken at a specific time, To be reviewed at a specific time.

Anger Ladder Enraged. Focus is immediate safety threat.

(don’t talk, create safe distance.) Outraged. Focus is threat to basic rights. Offended. Focus is standards of respect. Disappointed. Focus is unmet agreement. Frustrated. Focus is process not people.

Anger ladder 2 Name the anger type. State the focus. Identify the specific event. Make a positive request or action step.

Application Techniques Weekly member led group (family) meeting

to use these models. Weekly therapist led group (family) meeting

to evaluate use of models. Use narrative review of specific incidents

within the past two weeks. Use scale (0-10) for self evaluation of

competencies at specific points of incident.

ReferencesAllison, D.J. (2006, October) Partnership Competence II: levels of multicultural adaptation.

World Association of Psychosocial Rehabilitation-IX World Congress. Athens, Greece.

Burke, D.J. & Robbins, R. (2010). Psychologists’ Authenticity: Implications for Work in Professional Settings. Journal of Humanistic Psychology XX(X) 1-30, 2010.

Burke, D.J. & Robbins, R. (2010). Psychologists’ Interpersonal Experiences with Authenticy By Derrick J. Burks & Rocky Robbins. (Manuscript in Review).

Foer, Joshua (2011). Moonwalking with Einstein. Penguin Press.

Frank, Jerome D. & Frank J.B. (1991). Persuasion and Healing: a comparative study of psychotherapy. (3rd Ed). Baltimore: Johns Hopkins University Press.

Lee, R.E., & Everett, C.A. (2004). The Integrative Family Therapy Supervisor. Brunner-Rutledge.

Nichols, M.P. (2010). Family Therapy: concepts and methods, 9th ed. Allyn & Bacon.

Riggs, David S. (2010) Couple and Family Therapy for Adults, in Effective Treatments for PTSD, Edna Foa et al eds, Guilford.

Rosenzweig, Saul (1936). Some implicit common factors in various methods of psychotherapy. Journal of Orthopsychiatry , 6, 412-415.

Sprenkle, D.S. , Davis S.D., & Lebow, J.L. (2009) Common Factors in Couple and Family therapy. Guilford.