The benefit of using a pluralistic and integrative theoretical approach is apparent when considering the complexity that is embodied within individuals (Carlyle, 2017; McLeod, 2013). The hybrid of theory and technique facilitates a more tailored delivery of treatment designed to meet the individual needs of the client, and enables the therapist to identify significant dynamics (Gehart, 2017). This personalized approach can only be facilitated if a trusting therapeutic relationship exists between the client and the therapist (Thompson, Bender, Lantry & Flynn, 2007). Within this relationship goals and tasks that are needed for positive change to occur can be openly discussed (Thompson, Bender, Lantry & Flynn, 2007). Furthermore, considering both Wampold and Lambert’s common factors’ models, the therapeutic relationship together with client factors (resources, personal strengths and attitude) are shown to be the strongest predictors of positive outcomes (Gehart, 2017). So despite the fact that the therapeutic model does not seem to make a significant difference, only accounting for 8 – 15% of positive outcomes, Gehart (2018) proposes that the theory is of more use to the therapist than it is to the client as it becomes a tool which informs the direction a session may take. Consequently, an integrative approach that combines theoretical ideas and interventions that are grounded in an understanding of human behaviour is the best approach to achieving positive outcomes (Gehart, 2017). To this end then, the decision as to which theories would be best suited for the present case study was determined by addressing the presenting problem. Leda sought counselling for herself and her husband Abdu after receiving a cancer diagnosis of their 18yr old daughter Kirsten, two months prior. Leda is concerned about the lack of communication and increasing isolation that is taking place between all the members of the family, including her 20yr old son, Samuel. Therefore it seems most beneficial to integrate strains from systemic theories, that of Virginia Satir’s Humanistic Communications Theory or Experiential Theory (ET) and White and Epston’s Narrative Theory (NT) (Gehart, 2017; McLendon, 1999). To explain the rationale behind this choice it is necessary to consider the goals, philosophy and role of therapist within each theory.
Satir’s primary goal in therapy is to increase connection by attending to the emotional needs of the family and facilitate congruent communication (Gehart, 2017). Within NT the goal is to understand the unique story of each individual, and to broaden or thicken the outlook, helping the person recognize that the problem saturated story is only one aspect in a multitude of other more positive stories within their life (Sermijn & Loots, 2015). Further, Neimeyer (2004) suggests that healing can be achieved if the individual is able to find new meaning and direction. This sentiment is echoed by Viktor Frankl (2006) who said that “the quest for meaning is the key to mental health and human flourishing”.
The underlying philosophical foundation behind both of these theories is postmodernism (Sermijn & Loots, 2015; Labow & Diamond, 2019; Gehart, 2017). Postmodernists believe that reality is constructed through the perceptions and meanings that individuals assign to events (Gehart, 2017). This meaning is also informed by the opinion of those close to them or even through societal norms, therefore a postmodern therapist strives to help a client to untangle how their meaning is constructed (Gehart, 2017). This is done by utilizing a strength-based approach that accepts that the key to a client’s dilemma is held within them, and that through the awareness and utilization of strengths and resources available to the client, progress can be made (Ward & Reuter, 2011).
In this regard both theories hold that the counsellor plays an essential role in therapy and is a co-constructor of new realities, seeking to open up the emotional space needed to envisage new possibilities (Gehart, 2017). This is done by employing an essentially humanistic approach that is honest, compassionate, creative and dynamic (McLendon, 1999). Within ET, the therapist self is seen to be the principal mechanism that instigates change, whereas in NT the therapist is a co-author that helps a client reframe and rewrite their story (Labow & Diamond, 2019). Within both theories the problem is conceptualized as being separate from the person. Satir proposed that coping is the problem, she suggested that low self-esteem leads a person to reverting to dysfunctional coping or survival stances and incongruent communication with others (Cheung, 1997). NT views the problem as the problem, an external entity separate from the person (Gehart, 2017). So by using elements from each theory the client’s internal experience is externalized allowing them to deal with issues more directly (McLendon, 1999). Therefore by utilizing the above described approach a therapist will be able to direct the sequencing of interventions and techniques to achieve the dominant goal of increasing connection and also addresses the underlying goal of helping this family deal with the grief and loss surrounding Kirsten’s diagnosis.
The following section breaks the therapeutic process into three phases. Firstly the initial contact phase which includes establishing a therapeutic alliance and mapping of interactional patterns (Rasheed, Rasheed & Marley, 2011). The second phase focuses on disrupting the status quo with the intention to bring new awareness to dysfunctional coping styles. A deeper exploration into individual narratives is encouraged during this phase, allowing each member to express their unique perspective (Labow & Diamond, 2019). And finally within the last phase members are encouraged through various experiential exercises to integrate new knowledge into practical application (Rasheed, Rasheed & Marley, 2011).
During this stage of theoretical conceptualization the therapist seeks to get an understanding of the family’s interpersonal patterns and establish a warm, open relationship (Gehart, 2017). As a basic tenant of ET is increasing self-esteem, a therapist could begin the session by modelling preferred behaviour by affirming family members while learning their names and gaining insight into their personality strengths (Rasheed, Rasheed & Marley, 2011). This approach will give the family time to establish a sense of safety, a necessary element for change to occur (McLendon, 1999). In following sessions, the family members could be invited to begin with positively affirming each other, this would set the emotional tone of the session increasing positive interaction.
The next step would be to gather information about relational patterns and family history to form a context for the therapist and family members (Rasheed, Rasheed & Marley, 2011). A genogram can be used to collaboratively gather intergenerational information and highlight relational patterns, attitudes and behaviours (Gehart, 2017). The therapist could gather the family around a central desk with coloured highlighters at hand, allowing each person to comment on relationship aspects and known family trends. The relational alliance between Kirsten and Samuel may become evident, as well as other aspects such as tension between Leda and Kirsten, or the similarity of coping stances between Abdu and Samuel. During this process of sharing and mapping, the therapist pays close attention to the metacommunication that is transpiring between the family members in vivo (Gehart, 2017). Metacommunication refers to the dual impact of the spoken word (the report) and the non-verbal (the command), which enables a therapist to understand when miscommunication is taking place (Gehart, 2017). Within this context, questions can be asked in a non-judgmental way enabling a therapist to not only gain a deeper insight into what is happening in the family but also allowing the family to see how utilizing a non-judgmental approach creates a safe environment for self-disclosure (‘Person-Centred Therapy – AIPC Article Library’, 2010). The information gained during this phase allows a therapist to determine what life and developmental stages the family are in. For example given Kirsten’s age, she would be attempting to overcome the adolescent psychosocial challenge of achieving identity versus role confusion, a task necessary to attain a fully functioning personality (Hoffnung et al., 2016). Her cancer diagnosis may have disrupted this process.
Furthermore, by acknowledging cultural influences, a further layer of understanding can be brought into conscious awareness. Abdu’s African cultural heritage may dictate a man’s role within the family. Exploration into this role could be beneficial as Abdu’s current self-concept may be effected, causing him to withdraw in confusion or question his identity. Furthermore Abdu may be experiencing isolation. This may be a result of his lack of an extended family support structures and his withdrawal from his usual social support systems. The success of the therapy would depend on his willingness to adapt his perspective to include the reframing of, and inclusion of new information that broadens his cultural understanding (Zeman, 2008). Therefore by mapping a family member’s psychological and historical context, a person can become aware of foundational learnings that were possibly influenced by previous generations, enabling a formation of a new perspective (Cheung, 1997).
After addressing the initial task of family mapping, a therapist can offer a hypothesis and receive feedback from the family (Rasheed, Rasheed & Marley, 2011). Through the use of purposeful language a therapist can use this opportunity to reframe and instil hope and encouragement into the family situation and ready the family for positive change. An assessment plan can be verbalized giving form and focus to future therapy sessions (Rasheed, Rasheed & Marley, 2011).
Disturbing the status quo
The theory behind disturbing the current homeostatic environment relies on the shared theoretical notion that families are systems that naturally seek balance (McCleod, 2004). If balance is maintained through dysfunctional roles and communication, then the member’s needs will not be met and breakdown in connection is experienced. Therefore a therapist seeks to disrupt the current homeostasis with the aim of bringing awareness to dysfunction and then allowing the family to naturally re-orientate itself towards healthier functioning (Gehart, 2017). An intervention known as sculpting is used to bring awareness to communication styles and interactional patterns (Gehart, 2017). Sculpting entails allowing each member to externalize internal perceptions by creating a ‘picture’ of how they see the family. This is done by physically manoeuvring members into various poses that reflect how the member perceives them (Rasheed, Rasheed & Marley, 2011). Following this experiential exercise members can be invited to verbalize their rationale for their choices. This NT approach would have the effect of broadening member’s understanding of each other. For example perhaps if Abdu experiences Lena’s perspective he may become motivated to offer her more support. In turn Lena may recognise the effect her super-reasonable coping stance has on her family.
To reinforce new perspectives that are emerging, the therapist may also choose to raise legal and ethical considerations at this point (Gehart, 2017). These may take the form of broadening members understanding of Kirsten’s rights regarding treatment (Frenkel, 2013). The purpose of this would be to raise Lena’s awareness of respecting Kirsten’s rights as a young adult. By addressing these issues Kirsten’s autonomy is reinforced, and space is made possible for a relational change to occur between Lena and Kirsten. The therapist is guided by the ethical principles outlined in their code of ethics, in this case the guiding principles of autonomy, a client’s right to make their own decisions, and veracity, where a therapist is compelled to provide complete and objective information to clients about diagnosis, treatment and possible risks. (‘Australian Counselling Association’, 2019).
These discussions may encourage a closer bond between family members as motivations that underpin coping stances are made more understandable. In relation to this, a therapist could utilize Satir’s six levels of experience model to help members understand incongruences between the different aspects of themselves (Gehart, 2017). Satir’s six levels of experience is a model that assists clients ‘transform their feelings about feelings’, and included a focus on behaviours, coping stances, feelings, perceptions, expectations and yearnings (Gehart, 2017).
The next step within this process could be to give each member the opportunity to map the influence of grief on their lives. Each member could talk about how the problem of processing the grief has effected aspects of their lives. The therapist could take time to psychologically externalize this problem. This process opens up space between the individual and the problem and has multiple beneficial effects (Hutto & Gallagher, 2017). Firstly the problem would be made more understandable and blame between family members would be minimized (Gehart, 2017). Secondly, by noting when the members have had power over the problem, the ‘sparkling moments’ or opportunities to reduce the problem’s influence could be made (Gehart, 2017; Hutto & Gallagher, 2017 ). An example of this could be when Lena is able to attend her gardening group, Abdu to go cycling, Kirsten and Samuel to spend time together with their friends. Thirdly, through the process of externalization the members of the family are given an opportunity to take a united stand against Kirsten’s diagnosis (Gehart, 2017).
Integration of new skills
During this phase, insights and new understanding that has taken place is reinforced (Zeman, 2008). Time is taken to focus on the strengths of the family (Rasheed, Rasheed & Marley, 2011). An intervention of further sculpting could take on the form of allowing members to create a ‘picture’ of how they would like their family to be, based on their new-found information (Reiter, 2016). This would reinforce the member’s power to re-author their stories in a healthier way (Hutto & Gallagher, 2017). Intervention could also include allowing a family to practice new communication styles. During this phase a therapist could explain and reframe what has happened during their chaotic period following Kirsten’s diagnosis (Rasheed, Rasheed & Marley, 2011). Attention could be drawn to why individual coping styles were adopted and as well as highlighting each member’s strengths and resources that fortify the family. The benefit of taking this approach would be to deepen emotional connection between members through understanding and positive affirmation and facilitate a more healthy way of responding in the future.
Amongst other challenges that are presented in this case study, a main task for a therapist would be to ensure that the family does not become re-traumatised during the exploration of their individual stories. Therefore the therapist’s expertise in knowing when to intervene to help the client to reframe their story, becomes imperative (Hutto & Gallagher, 2017). Using this approach empowers a client to broaden and enrich the way they see their lives (Hutto & Gallagher, 2017). The therapist can co-author a new story with the client, where the previous dominant problem saturated story is not as prominent, and a client is empowered to incorporate a new story. This new perspective could include a positive re-framing of their survival stances, a deeper more positive understanding of other family member’s motivations, increasing connections and a more hopeful vision of the future.
An additional challenge a therapist needs to be aware of is that due to the close emotional connection with the family, they may experience vicarious trauma. Vicarious trauma refers to the effect that working with a client’s traumatic issues, in this case the family’s grief associated with the potential death of their child, can have on a therapist (Ungureanu & Sandberg, 2008). Therefore, it is important that attention is paid to self-care rituals that protect a therapist from experiencing burn-out. (Ungureanu & Sandberg, 2008).
In conclusion, positive outcomes can be achieved if careful consideration is paid to adopting therapeutic models designed to suit the individual needs of a client. In this case study, by utilizing aspects of Satir’s Model together with Narrative therapy principles, the goal of facilitating a closer emotional connection between family members was increased. By externalizing the problem of Kirsten’s cancer diagnosis, members would be supported to process the problem as being separate from the individual and family. This would increase the opportunity for the family to stand together against the problem. Additionally, by highlighting individual strengths and coping stances, a richer base of knowledge would be achieved, this would increase empathy and facilitate understanding. This approach will support the dominant goal of increasing connection and address the underlying goal of processing the implications of Kirsten’s diagnosis.