Family therapy, a
type of psychotherapy, is commonly applied in families having gridlocks,
conflicts or misunderstandings, aiming at improving family functioning. The
goals of family therapy include improving communication among family members,
improving autonomy for each member, improve agreement about roles, reducing
conflicts and reducing stress in the member who is the patient. (Gelder,
Harrison & Cowen, 2006) In Virgina Satir’s model, congruence is an essence in achieving good communication between
family members. Congruence refers to a state of being as well as a quality of
communicating. It is viewed at three different levels. First, congruence
entails acknowledging and accepting our inner experiences (sensations,
interpretations, and consequent feelings about those feelings) and being able
to express them. In the second level, it involves listening to our perceptions
and expectations, and translating those into a responsible pattern of meeting
our needs by tapping our yearnings. At level three, we move into harmony with
spiritual essence, or what Satir called the universal life force. (Satir,
Banmen, Gerber & Gomori, 1991)
The Satir Change Model
In the process of
family therapy, change is an
important focus of internal shift that brings about external change. To elicit
change, the concepts of discovery, awareness, understanding and new
applications were examined. (Satir, Banmen, Gerber & Gomori, 1991)
Stages of change
Once an accepting,
positive context for change are established, the client can begin with the
process of change. According to Satir, the process has 6 stages:
Stage 1: Status
When a system is
in status quo, we can make reliable predictions about how it is operating. The
system has set up a clear set of expectations and reactions. We can count on
these. Stable relationship gives member a sense of belonging and identity. They
know what to expect, how to react and how to behave. Nevertheless, the system
could become unhealthy when some members routinely respond to anger or guilt by
placating, blaming, overly reasonable or being irrelevant. In this way, some
individuals may impose a burden to another, resulting in system imbalance. Stress
may lead to physical symptoms such as headache and abdominal pain that could
possibly increase absenteeism.
Introduction of a foreign element
refers to a psychotherapist or a family counselor who was not in the system
before. This outside person needs to be accepted by the majority of the
system’s member so as to make the therapy work. The therapist is responsible
for the process, such as guiding the members to examine the barriers to change
and the resistance. It is helpful for the members to identify the aspects that
they believe they cannot change. In Satir’s model, resistance contains elements
of reframing, in which the therapist helps the clients see themselves as
capable and open to change.
Stage 3: Chaos
Chaos means the
system is operating in ways that are not predictable. The unpredictability
often makes members to become fearful and anxious. Therapist assists client to
normalize the chaotic stage by neutralizing client’s fear and anxiety. Clients
consider a new perception of self and others, and let go of their perceptions
that no longer fit. Attaining positive, healthier, and more functional
possibilities requires moving through a period of chaos. It is significant
because it accepts people’s fear of unknown, anxiety, uncertainty, and panic.
It also moves the person or system from a dysfunctional status quo to a new
functional state of being.
Stage 4: New
Opinions and Integration
In this stage, clients
develop new possibilities, integrating new ideas and reevaluating past and
present expectations. Clients learn to take charge of consciousness and become
more responsible for internal process of self. Joyfulness, new hope and
regained energy become part of new status quo.
As the past
patterns are very strong, family members are encouraged to maintain and
practice new options. To achieve this, they are taught to write things down, or
have reminders in the car, on the refrigerator door, or on the bulletin
board. The longer the practice, the more
familiar and comfortable they feel.
Stage 6: The New
The last stage
provides a new status quo, a healthier equilibrium, and better functioning of
individuals and relationship between family members. A new sense of comfort has
taken the place of old familiarity. Moreover, new sets of predictions develop
about how the system operates. New self-images and new hopes emerge with
enhanced sense of well-being radiating.
Based on the
concepts of family therapy and the change model proposed by Virginia Satir, a
lot of studies were conducted by various practitioners. According to Markus et
al., (1990) the effect of family therapy was found to be comparable to other
forms of psychotherapy. Approximately 75% of clients had a better outcome with
family therapy, when compared to those receiving minimal or no treatment at
all. In a randomized control trial (Diamond et al., 2002) of an
attachment-based family therapy for depressed adolescents, it was found that
the majority of client no longer meet the criteria of major depressive episode
as seen from the post-test result. In a meta-analysis, (Karver, Handelsman,
Fields & Bickman, 2006) family therapy served as a promising intervention
with an examination on youth and parent willingness to participate in
treatment, and their actual participation performance. Besides, therapist’s
professional interpersonal skills and direct influence skills also contribute
to the success of the treatment.
Cognitive Behavioral Therapy
illness has cognitive and behavioral components. Alterations and changes for
cognitive or behavioral, or both features are one of the processes to promote
recovery. Since 1970s’, cognitive behavioral therapy has gained popularity as a
choice of treatment due to the strong evidence base of its effectiveness. The
assessment and case formulation in CBT were used to provide an individualized
treatment program for clients presenting with a variety of clinical problems.
CBT teaches client to recognize their own maladaptive thinking and to become
aware of those thoughts, feelings and situations that trigger negative
automatic thoughts. Once this has been accomplished, CBT aims to clarify if the
client would like to change their current problems. CBT is based on a series of
principles originated from Aaron Beck’s cognitive triad which states that an
individual may be vulnerable to negative thinking about the self, the world and
the future. (Thomas & Drake, 2012) Beck suggested that thinking is
underpinned by attitudes (assumptions), which are based in early childhood
experiences and later life events. It is believed that everyone has a tendency
to react in a certain way for a particular situation. The predisposition is
based on genetics, early experience, environment and life events. Some life
events, nevertheless, could be traumatic and painful which give rise to
negative thinking and lower mood states. Low mood can possibly intensify the
probability of more negative thinking and eventually result in negative circle
that influence daily living. Negative thinking is sometimes known as cognitive
distortion. People with cognitive distortion often establish a negative view of
themselves, the current experience of the work, or about their future. Changing
the way that an individual sees from a negative perspective to a positive one
is referred to the process of cognitive restructuring. However, the process is
not always easy and it takes time to go through.
CBT for depression
has is one of the most effective psychotherapy treatments in many cases. In
fact, CBT has also commonly applied to other psychiatric disorders such as
anxiety disorder and eating disorder. In particular, for generalized anxiety
disorder, Borkovec and Ruscio (2001) pointed out that CBT for GAD has greater
improvement than no treatment or non-specific treatment in terms of the
severity of symptoms. A meta-analysis conducted by Covin, Quimet, Seeds &
Dozois (2008) have found that CBT was effective in reducing worry with the use
of a valid and reliable indicator of pathological worry, The Penn State Worry Questionnaire. In another meta-analysis, it
CBT could not only reduce the main symptoms of anxiety, but also
the associated depressive symptoms, thus improving quality of life (Mitte,
2005). Moreover, the treatment
effect is considered to be satisfactory since the improvements from CBT are
maintained 1 year post-therapy (Borkovec & Ruscio, 2001; Gould, Safren,
Washington & Otto, 2004).
Clients experiencing a major depressive episode is
commonly seen to present with additional symptoms, including anxiety,
worry about physical health, obsessive rumination, irritability, and
of pain. The co-occurrence of anxiety disorders appears to have a
effect on treatment outcome for depression (Gorman, 1996). Clayton et
al., (1991) stated that depressed patients
with higher levels of anxiety took longer time to recover. Due to the
complexity of a co-morbid condition, the advantages and limitations of
different therapies were carefully considered. With regard to family
in Chinese families with prominent hierarchy where parents have the
decision-making for most of the time, it maybe common to see the
or inability for all family members to engage in the therapy sessions
(Lebow, 1984). On the other hand, CBT is well structured and tends to
focus on thinking process rather
than emotion (Riva at al., 2011). It may not be the best therapy for
people who have strong and immediate
emotional reactions. In
other words, when a client becomes very emotional, a focus on cognition
behavior is less effective for change. In this case study, one single
treatment is unlikely to address all the issues including family
depression and anxiety symptoms. In order to achieve a holistic
case adopts the values of both family therapy and cognitive behavioral
Since the presenting problem of this client relates significantly with
members. Family therapy was selected as a part of treatment plan to
family dynamics. In addition, CBT was applied to cope with the client’s
Ethical issue and approval:
All the assessments
and interviews were solely for treatment purpose. The data and information were
kept confidential. Informed consent was obtained from client before
The client was
recruited from the community who attended private psychiatrist consultation
regularly. A total of 14 sessions with 1 session of initial interview, 3
sessions of family therapy and 10 sessions of CBT were conducted between Sept
2012 to Mar 2013. The sessions were run by a registered occupational therapist.
Each session lasted for 60-90 minutes. Pre- and post- assessments were
administered for outcome measures.
Beck Depression Inventory (Beck, et al.,
1961). The BDI is a 21-item self-reported measure designed to assess the
symptoms and attitudes of depression. Each item measure the severity of a
particular symptom from 0 (not at all) to 3 (extremely). The BDI demonstrates
high internal consistency, with alpha coefficients of .86 and .81 for
psychiatric and non-psychiatric populations respectively (Beck et al., 1988).
Hospital Anxiety and Depression Scale (Zigmond
& Snaith 1983). The HADS is a self-assessment scale consists of 14 items,
divided into two subscales: Anxiety (HADS-A) and Depression (HADS-D).
The respondent rates each item on a 4-point scale ranging from 0 (absence) to 3
(extreme presence). Higher score on each subscale reveals a higher level of
anxiety or depression. The HADS
possessed good psychometric properties in terms of factor structure,
inter-correlation, homogeneity and internal consistency (Mykletun et al.,
(Part I) Initial assessment
interview and assessment was conducted before the commencement of
sessions. Client (Ms. K) is a 20-year old, single female. She has
have low mood since 2011. She applied for a diploma course of Child
in a local institute after graduating from secondary 5. Ms. K revealed
had academic stress since Year 1. Later, Ms. K began to develop other
depressive and anxiety symptoms including insomnia, poor appetite, loss
interest, fatigue and difficult to concentrate. In terms of clinical
formulation, the predisposing factor was identified as having the idea
perfectionism. In addition, her parents were strict and over-criticized
times. The precipitating factor was about the distress in facing the
program with challenging assessments and clinical placement. The
factor was that she believed she was always judged by other people for
performance and achievement. She thought people often criticize her
ability. Moreover, if she did not need to go to school, she did not
have to face the
stress and any failure of study.
(Part II) Family Therapy
information obtained from intake assessment, a systemic hypothesis was
developed. It was hypothesized that Ms. K had an intra-psychic conflict. In
conscious level, Ms. K thought it was important for her to complete the 4-year
program and obtained a bachelor degree to become a kindergarten teacher. On the
other hand, in unconscious level, she was afraid of failure because her parents
often compared her with elder sister who already had some bright achievements
in academics and work. The goals of the family therapy are to establish better
communication among family members, enable the family to develop coping skills,
make people to aware that they have the ability to choose, and enhance the
relationship. Three sessions were conducted in total, with the following
Session 1: Ms. K
Session 2: Ms. K
and both parents;
Session 3: Ms. K
and both parents.
In each session,
family members were invited to an interview room with comfortable seats and environment.
The participating members were allowed to choose their sitting arrangement. The
therapist also reminded members that they could still be able to change their
mind if they wished.
of family members
To start with, the
therapist invited each family member to make an introduction of him/her. The
therapist could also observed who was the “spokesperson” of the family. At the
initial stage, family members expressed some ideas and goals to be achieved in
the upcoming sessions. Ms. K wanted to find out a clearer pathway. Mother hoped
Ms. K could utilize the time in a better way. Father did not have much concrete
idea, but he wished to have more understandings about her daughter’s plan and
an important component in family functioning. By assessing the general patterns
of communication in the family, the therapist gains information about the way
in which family members experience their relationships with one another, their
ability to express intimacy, how they pass information back and forth, what
meaning they make of their communication, and in general the ability of family
members to use words appropriately. Since good communication is such an
important factor in healthy family life, modification of the family’s
communication process is essential in family therapy. Nevertheless, it is often
see that people lack methods and skills to do so. During the session, Ms. K
revealed the difficulty of maintaining concentration in class, the physiological
reactions including palpitation, sweating and shortness of breath, and
psychological emotion with a lot of crying. She was overwhelmed by the heavy
workload. She felt unhappy and she wondered why she kept
doing something she did not prefer. She
considered quitting school and began to work. She thought, in this way, she
could earn money to alleviate parent’s financial stress. Her desired occupation
was being a make-up artist or wedding planner. On the other hand, Mrs. K
focused more on the outcome. Mother considered completing the final year as a
more ideal way for Ms. K, since she has already spent 3 years in school. If her
daughter could finish the whole program, she would
rather continue to work at old age home, despite low back pain, in order to earn
sufficient money for daughter’s school fee.
Sculpting is an
in-motion interaction that uses bodies in space to make overt the family’s
patterns of interrelating. It also externalizes people’s inner processes.
(Satir, Banmen, Gerber & Gomori, 1991) Family members were asked to sculpt
their relationships to each other, using gestures and bodily pictures together
with components of distance and closeness, which show the communication and
relationship pattern. Members’ coping would be demonstrated by different
stances. For instance, power is represented by variations in vertical
positions; intimacy is demonstrated by the horizontal distance from each other.
Each family member took a turn in sculpting.
Scenario 1: Ms. K
arranged mother to stand on a chair, and look at other family members from a
high position. Father sat on a chair.
Ms. K stood next to father, but kept a distance with mother and elder sister
(elder sister simulated by therapist). Elder sister stood next to mother, but
on the ground instead of standing on a chair.
Scenario 2: In the
second turn, Mrs. K placed herself and husband sitting on chairs close to each
other. Ms. K sat on the ground, faced to parents. Elder sister walked and
circulated outside three family members, with not greater than one-meter
distance from the members inside the circle.
Lastly, Mr. K arranged all family members sitting on chairs. From the sequence
(left to right) of Ms. K, Mr. K, Mrs. K and elder sister. Ms. K leaned towards
Mr. K. Mr. K put his hand on Mrs. K’s shoulder.
Next, each family
member was given opportunity to share his or her feelings about the sculpting.
Ms. K thought mother and elder sister had more power. Father and her had to
follow their suggested ways or directions usually. Mother stated that elder
sister worked very hard to earn money in mainland. Although she was not living
with the family most of the time, she was thought to be always around. Yet,
Mrs. K thought Ms. K was still not mature enough, therefore husband and her
still have to look after her and give appropriate guidance. Mr. K revealed a
simple mind. He hoped the family to be harmonious.
In summary, all the family members show positive comments to this
exercise. Each family member had a different view of family in space. The
discovery of sculpting differences leads to a greater understanding, acceptance
and openness among family members. In particular, Mrs. K gained more insight
about daughter’s thought and feeling. She learned that her expectation has
imposed great stress on daughter, making them to have a communication gap,
which was depicted in sculpting. For Ms. K, she could see both parents wished
to stay close together with all family members. For the ideas and plans
suggested by parents, they were all out of love, concern and support.
Nevertheless, similar to many traditional Chinese, the wordings or messages
were seldom conveyed among members, resulting in possible frustration or even
conflicts. In addition, they realized some strengths and uniqueness of each
member, which is an essence to move the family from their earlier dysfunctional
picture to a more desired, supportive ways of relationship.
obtaining some ideas of family pattern, communication dynamics and the
presenting problem, the hypothesis proposed in earlier stage could begin to
validate. Circular questioning was considered to be useful in eliciting
systemic information. Some questions were guided by the therapist: "Who
contributed the idea for Ms. K to study child education?", "Did the
problem begin before or after she entered school?", "How was it
decided when Ms. K consider taking a gap year?", "If the problem
persist, would it be more or less likely for her to complete the
program?", " How would it be consider if Ms. K should go on with Year
4 study or choose some other subjects?", "Who will get the greatest
sense of satisfaction when Ms. K graduate?"
During the process, Mr. and Mrs. K revealed that they and elder
daughter had suggested Ms. K to pick the subject of child education since she
did not have a definite direction after graduated from Secondary 5. They wished
she could have a stable job with stable income. In contrary, Ms. K stated some
of her interest and preferences. In fact, she did not want to become a
kindergarten teacher. However, she wanted to please her parents and tried to
meet their expectations. She hoped she could be as successful as her elder
sister. Her elder sister was the manager of a textile factory in Mainland.
Therefore, Ms. K struggled a lot and tried to study hard in the previous 3 years.
In further elaboration, she believed elder sister and her were two different
individuals with different characters. Each of them had merits and shortcomings. Yet, Ms. K kept doing something she
disliked. Eventually she has reached her stress limit, and she could not cope
further. Therefore she accepted the suggestion by school social worker of
taking a gap year.
for each family member’s concern, feeling and expectation was illustrated
during the process of sculpting and validation of hypothesis. They uncover and
discover things that they did not know before. Parents, especially mother,
started to accept the actual condition of daughter. Mrs. K expressed, no matter
daughter chose to continue with Year-4 program, or change to study other
program, or began a full time job, she would offer support to her
daughter. She hoped Ms. K could set some short-term or long-term goal instead of idling at
home all the time. On the other hand, Ms. K felt relieved that she no longer
had to force herself to become a kindergarten teacher. She would like to
transform her energy to her interested fields. In a preliminary plan, she may
consider taking a 6-months course for make-up artist. In order not to create
further financial burden to family, Ms. K decided to choose courses with
“Continuing Education Fund”, with a portion of course fee to be reimbursed upon
completion of program.
(Part III) Cognitive Behavioral Therapy (CBT):
some problems of family disharmony, cognitive behavioral therapy was applied to
deal with client’s anxiety problem.
interview and assessment:
In the first part
of cognitive behavioral therapy, education of CBT and the agenda of the
following sessions were introduced to Ms. K. Next, she was asked to describe her
current situation and mood status. She was also asked to rate her mood with
0-10 point scale. The ratings were used for later comparison. Simultaneously,
the therapist began to identify Ms. K’s automatic thoughts and explore further
with her core beliefs.
with assessments, Ms. K was invited to describe her problems and make a list
for later goal setting. The process was collaborative, and client was
facilitated to devise some goals. To handle Ms. K’s issues, 4 treatment goals are planned.
(1) She would be aware of her current behaviors.
(2) She needs to make clear about the intentions of such behaviors and
the alternative ways in managing some difficult situations.
(3) She began to understand herself
better in order to avoid maladaptive coping strategies or avoidant behavior.
(4) She would have decrease in
symptoms of anxiety: headache, dizziness, palpitation and shortness of breath.
of intake assessment and to elicit automatic thoughts:
background information and detailed intake assessment, Ms. K was found to have
some thinking errors. For example, she mentioned some “should statements” such
as “I should follow my elder sister’s career pathway and become as successful
as her.”, “I should never let down my parents since they have spent a lot of
money for my 4-year higher education program.” Besides, she said, “If I fail
one subject, I may fail in other subjects as well and I need to re-take and
re-take.” (Over-generalization) Moreover, Ms. K stated, “If I cannot graduate
and get a certificate, it would be unlikely for me to find any good job.”
(Jumping to conclusion) In addition, she expressed negative feelings about the
experience of clinical placement. She thought that it was hard to achieve
standard in any aspects. She believed the mentors always criticized her.
(Mental filter) She became anxious when people made comments on her, and she
would experience accelerated heartbeat. She thought people could see her face
became pale and could almost hear her heartbeat.
the automatic thoughts:
In the feedback
session, the therapist made an evaluation of automatic thoughts by identifying
how often and how intense they were. Which of them was most upsetting and how
much did Ms. K believe it? The therapist also attempted to explore any
alternative explanation by Ms. K. Later, Ms. K was challenged by the therapist
with the automatic thoughts. Some questions for challenging were suggested as
“You told me about getting a certificate is important, I wonder if completing
the Diploma course is the only way to become success?”, “Tell me the idea about
‘success’.”, “Are you sure you are not doing well in all aspects during your placement?”,
“Can you recall any piece of satisfactory tasks including preparation of
teaching material, looking after the kids, engaging in play group, etc.?”, “Do
you think your mentors were always judging you? Did they give you any ideas or
feedback which you think they were useful?” “Do you really think other people
can hear your heartbeat when you feel anxious? Would people offer you help in
case if you are not feeling well?”
(F) Core beliefs
With reference to
the case conceptualization, Ms. K’s core beliefs were recognized, as “I
do everything perfectly. I must not let anyone down otherwise they hate
me.” In modifying the core belief, downward arrow technique may
apply. Some leading questions may also be asked, “What if this will
happen? What is the worst
thing that could happen? In the event that the worst would happen, what
you do? What does it mean to you? And then what would happen? And then
Therapist would ask until Ms. K revealed some of the past the
ideas & into the probability that she would cope.
restructuring aimed at establishment of various alternative perspectives.
During the process, Ms. K was taught to alter distorted information processing.
Therapist facilitated her to learn about the interpretation of circumstances
that is threatening, instead of the circumstances themselves that caused the
distress. Moreover, Ms. K was taught to access the actual “probability” in a
rational way, as compared to “possibility” that an undesirable event would
occur. In addition, relaxation training
and problem solving were also apply to Ms. K. Since she reported to have
difficulty in relaxing, especially before assessment in school, or within a
crowd where she felt being compared or judged. Techniques such as progressive
muscle relaxation, diaphragmatic breathing and guided imagery were practiced.
She was taught to tense and relax each of the major muscle groups, thus
allowing herself to focus on the feelings distinguishing tension from
relaxation. After that, she was guided to imagine
a relaxing scenario e.g. resting on a warm beach with sea breeze. For problem
solving approach, she was prompted to raise problems from daily-living
situation. Then, she was guided to brainstorm with possible solutions. The
advantages and disadvantages of each proposed solutions would be examined and
decisions were made in how to implement. The therapist also prepared some
scenarios for role-play with Ms. K so that she could practice with adaptive
Apart from the
practice during the treatment session, Ms. K was taught to do Thought Diary as
a take home assignment, which facilitates her to identify unhelpful thoughts
and encourage her to consider alternative thoughts. From Ms. K’s feedback, the
thought diary was very useful because the thought record would be brought back
to later CBT sessions for the therapist to review, discuss and evaluate with her.
She could compare the ratings of emotion (0-10 scale) after applying more
For the purpose of
maintenance, Ms. K was encouraged to recognize the factors that increased her
worry and anxiety. She was suggested to identify some at-risk situations and
those stressors she was likely to experience, and her interpretation of these
situations. Moreover, she could also review the successful experience and apply
the newly learned skills to upcoming problems. Lastly, he should be rewarded
with positive behaviors such as using new coping skills, or avoid repeating
previous negative behaviors.
The scores of Beck Depression Inventory
indicated a distinguished reduction from 25/63 in pre-test to 11/63 in
post-test. Secondly, from the assessment of Hospital
Anxiety and Depression Scale, the baseline score of anxiety and
12 (moderate level) and 10 (mild level) respectively. Significant
was shown in the result of re-assessment with anxiety score decreased
to 7 (normal) and depression score reduced to 3 (normal). Thirdly, the
mood check from each CBT session also showed gradual improvement in
The followings were essential parameters, which
accounted for the success of intervention and case management.
(I) Choice of intervention
Single case study allowed flexible and various treatment approaches.
Therefore, the choice of relevant intervention based on the results of initial
interview and assessment including family therapy, cognitive behavioral
therapy, relaxation training and problem solving skills was one of the critical
(II) Positive family attitude
The degree of participation of each family member was also an important
factor. If any of the family member(s) refused to participate, or did not speak
at all, the process would probably take longer time and more difficult to go
through. Nevertheless, the K’s family was cooperative throughout the sessions.
They were willing to make changes and improvement. Moreover, they were open to
discussion with guidance by therapist. Mutual help and understandings were
raised between family members, which contribute to later communication and
suggestions for future plan.
(III) Exercise and skill training
Ms. K showed positive feedback on tension-releasing
exercise and rhythmic diaphragmatic breathing in CBT treatment session. The
techniques were useful in reducing anxiety symptoms. Exercise and practice
within session enabled the client to experience and gain more confidence to
perform again in daily living.
Family therapy is helpful in young people and adults, couples, and
families. It enables them to build on strengths and understandings and find
ways forward in their lives. On the
other hand, CBT has been shown to effective in many evidence-based studies,
with reduced negative symptoms for client, more positive health outcomes and
changes in their daily living. A combination of therapies, family therapy and
cognitive behavioral therapy in this case, served different purposes on
systemic and individual needs. Nevertheless, whether single intervention or
combined intervention was more appropriate varied in different cases. In this
single case study, the treatment effect was considered to be most beneficial to
client in dealing with family dynamics and her anxiety symptoms. It has been a
valuable experience to go through a case in details with positive progress
demonstrated. The stages of change in family therapy, from chaos to new status quo,
were also clearly shown in the process.
To achieve higher efficacy of intervention, continuous assessment is necessary
for the monitoring of treatment outcome, and make any necessary adjustments.