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CHAPTER

14Counseling Couples Using Life Cycle and Narrative Therapy Lenses Colleen R. Logan, Aaron H. Jackson, Lee A. Teufel-Prida, and Dawn M. Wirick Walden University

CASE STUDY

Larry and Tom, an African American gay couple, are seeking counseling for a number of reasons. Larry and Tom have been together for 15 years. Larry is a successful accountant, and Tom is a soccer coach at a local high school. They have two children, Mary and Stephen. Mary is 6 years old and Stephen is 12. Larry’s mother lives with the couple and helps care for the children. Larry is very extroverted, affable, and jovial. Tom sits quietly and listens while Larry speaks. Larry reports that the two main issues for the couple are communication and intimacy. He states that he wishes Tom would talk to him more. He states he is disappointedthatheandhismomhavetodoeverythingaroundthehousewhileTom doesn’t take any initiative. He alludes that this is also the same case in the bedroom. He states that Tom never initiates and that it’s been over a year since they have been intimate. Larry goes on to say that, in general, the kids are doing well. Stephen does well at school and is very athletic. He plays football, baseball, and soccer. Mary, on the other hand, seems to struggle in school. She is frequently corrected for disruptive behavior. She also struggles with reading and math. Larry states he is not that concerned about Mary because his mother and Stephen can help her with her homework.Larryfinishes by exalting and praising his mother. “I don’t knowwhat we would do without her, truly,” says Larry, “she is such a big part of our family.”

Tom reports that he agrees that the primary concerns are sex and communi- cation. Tom feels that he does his best to anticipate Larry’s needs and participate in all that goes on at the house. Simply said, Tom feels that he doesn’t have a role or really any authority. He starts to weep as he starts to share his perspective. He shares that the first 5 years of their relationship were idyllic. They talked and

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laughed, went on vacations together, and shared many interests. And then Larry’s mother moved in and that was the beginning of the end, according to Tom. First, she ignores the fact that Tom is in an intimate relationship with her son, and she insists on referring to Tom as the “roommate.” He goes on to say that he never wanted kids, Larry and his mother did! Yes, he loves the kids, but the way he is treated by Larry’s mother and Larry, quite frankly, makes him feel like he is the hired help. Because Tom felt that he never did things “right,” he just stopped trying. Tom states that he is willing to give counseling a try, but he doesn’t really see the point and he doesn’t think the relationship will last. If it weren’t for the kids, Tom says sadly, he’d be long gone.

INTRODUCTION

After presenting some pertinent background material, the focus of this chapter is to provide a broad and yet comprehensive overview of how to work with and evaluate family systems using life cycle analysis and narrative therapy. Family systems theory arose out of von Bertalanffy’s (1968) concept of general systems theory. Systems theory has its own set of theoretical assumptions that are different from the assumptions associated with individual therapy. Chief among these assumptions is that each part of any given system is interrelated with each and every other part. In addition, these various parts are to some degree interdependent on each other. A family is defined as an organization of inter- and intrarelated parts, some of which are internal to the family, and some of which are external to the family (Gladding, 2011). Internal factors include individual interactions between and among the family members, and external factors include various institutions and entities with which the family interacts on a regular basis. Professional counselors working from a family systems perspective consider the family, however defined, in terms of the influence of both internal and external factors.

SIDEBAR 14.1 DEFINITIONS

A systems approach requires that we think about families, presenting problems,andpossiblesolutionsincontext.It isalsohelpfultoconsiderthe many different influences on any given family. These influences are both internal and external. Internal influences are factors that are within the family. Each family has its own unique history, rules, values, and character- istics. External influences come from the world around us. As systemic counselors, attention is paid to the external influences just as much as the internal things that influence the way a family operates. External influences are factors such as the surrounding community, friendship networks, extended family, politics, and cultural values. Space and time limit a thorough presentation of the many internal and external influential factors that impact family functioning. For a more in-depth understanding and analysis of these factors, see Knoff (1986) and von Bertalanffy (1968).

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In general, accurate clinical evaluation requires that counselors thoughtfully and carefully consider all aspects of the presenting problem. Counselors working with couples and families spend time observing, applying what is known (and not known), and then carefully putting together all of the related information in order to conceptualize and determine issues.

Family systems are indeed beautifully complex and difficult to understand. In many cases, it can be said that what appears to be the problem in the family is not the “real” problem that the counselor must consider (Berg & Reuss, 1997; DeJong & Berg, 2001). In other words, sometimes the family views the problem in a completely different way, and it is up to the skilled family counselor to able to see and determine the real issues. It is this set of skills that requires couples and family counselors to be purposeful and intentional when working with families and, in particular, during the evaluation process. This chapter provides guidance on the intensive and critically important process of clinical evaluation, including the unique nature of assessing couples and families, the general differences and similarities between assessing couples and families versus individuals, and general guidelines for the evaluation process.

Individual Versus Family Evaluation

One of the most challenging shifts for emerging counselors who aspire to work with couples and families is the process of moving beyond the idea of simply observing and understanding the individual versus the process of observing and under- standing the entire family system. The family as a whole is defined as the primary client, rather than the individuals, and, as such, the family as a whole is subject to evaluation from the very beginning of the counseling relationship.

The difference between individual and family evaluation is really quite clear. According to Corey (2009), the clinical evaluation process for an individ- ual is primarily guided by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 2013), now in its fifth edition. Typically, issues and symptoms are matched with diagnostic criteria, which are then attached to specific diagnoses. For example, if an individual meets all of the DSM criteria for major depressive disorder, he or she would be given that diagnosis.

Not surprisingly, the process of evaluating and indeed “diagnosing” families is not quite so simple and straightforward. According to Gladding (2011), the DSM offers very little guidance in terms of diagnostic criteria and/or specific diagnostic categories for counselors working with families. The DSM does, however, provide what are referred to as V codes, which provide a diagnostic framework for working with couples and families. These V codes are presented in Section II of DSM-5 (APA, 2013) under the topic heading of “Other Conditions That May Be a Focus of Clinical Attention.” It is of note, however, that these V codes are indicative of an issue that is “not attributable to a mental disorder” (APA, 2013) and, therefore, insurance companies and other third-party payers are reluctant to reimburse counselors for services rendered specifically for those issues. Third-party payers are typically more willing to reimburse clinicians for those diagnoses that are

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“attributable to a mental disorder.” As a result, couples and family counselors are less likely to obtain third-party payment for services.

SIDEBAR 14.2 DIAGNOSTIC CATEGORIES

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) provides helpful diagnostic direction in terms of conceptualizing family-focused diag- noses. The DSM-5 provides diagnostic categories known as V codes. A few of these are summarized here:

V61.20 (Z62.820)—Parent–child relational problem. This code may be used when the relationship between the parent(s) and children is causing problems in family functioning, treatment, and so on. Exam- ples of this include problems with parental involvement, cases of a parent being overly protective of a child, or “feelings of sadness, apathy, or anger about the other individual in the relationship” (APA, 2013).

V61.8 (Z62.29) - Upbringing away from parents. This code may be used when clinical attention is focused on issues related to a child being raised in a different setting than the home. Children who are raised in foster care and other care facilities or institutions may present with clinically significant concerns; this is applicable in those scenarios if the clinical presentation is related to the aforementioned settings.

V61.03 (Z63.5)—Disruption of family by separation or divorce. This code may be used when clinically significant concerns arise out of a situation in which the partners are in the process of separation or divorce.

These are just a few of the V codes available. For a more complete understanding, please refer to Section II of the DSM-5.

Focus of Evaluation

The diagnostic criteria for family systems have yet to be set forth in any systematic format; therefore, the diagnosis is heavily influenced by the theoretical perspective of the clinician. For example, a couples and family counselor would not diagnose a family as having obsessive compulsive disorder. The counselor would, however, use diagnostic language to describe what are observed as obsessive and compulsive behaviors within the particular family system. For example, the counselor who adheres to structural family therapy would use terms associated with structural theory to describe and understand the concerns presented during the initial evaluation. To that end, the structural family therapist might conceptualize the family’s presenting problem of obsessive and compulsive behaviors in terms of dysfunctional relationships related to poor boundaries, alignment, and abuse and/ or misuse of power.

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Family Within Context

Marriage, couples, and family counselors consider the family within the context of all other environmental, social, and cultural arenas. To that end, during the evaluation process, the counselor takes into account and considers such things as the family’s historical context, the impact of laws/legal issues, racial and ethnic domains, and interaction with educational or medical institutions. The family is always seen as an integral part of a larger system. In turn, the larger system has an impact on the family, and vice versa. Initially, an emerging couples and family counselor can become overwhelmed with all that can be and should be considered during the initial evaluation process. Rather than succumbing to the enormity of this task, students areaskedtorememberthatcouplesandfamilycounselorscananddoenlistthehelpof other professionals, such as school counselors, medical practitioners, or spiritual leaders, in an effort to help meet the treatment needs of the family.

Emphasis on Context/Culture

To assess any family without considering its unique nature in terms of the culture of the family would be inappropriate and unprofessional. For more information, review the American Counseling Association (2014) Code of Ethics, American Mental Health Counselors Association (2013) Code of Ethics, and International Association of Marriage and Family Counselors (Hendricks, Bradley, Southern, Oliver, & Birdsall, 2011) Code of Ethics. For the purposes of this chapter, culture can be defined best by Rabin (2005): “[Culture] is loosely used to denote a variety of social environmental factors related to ethnic, racial, and class factors” (p. 16). These include poverty, racism, differences in sexual behavior, immigration and resettlement, and acculturation. Cultural content (this is the definition of this concept) in the helping process refers to the specific meanings through which these social phenomena appear, including patterns of individual behavior, interpersonal reactions, and emotions. Cultural variables also include norms regarding gender roles, attitudes about sexuality, identity, and world and self views that run through an almost infinite number of guidelines for daily life behaviors.

The Family Life Cycle as a Concept

The family life cycle is both a concept and an indispensable tool for the couples and family counselor to use when conducting an evaluation of a family. As a concept, the family life cycle posits that families, over the course of their lives, progress and/or transgress through a series of life stages. These stages are described by several different models, each stage being marked by different characteristics, duties, responsibilities, and developmental trends. The underlying assumption is that in order to move on to the next stage, the family must successfully negotiate the tasks of the current stage. Carter and McGoldrick (1999) describe the family life cycle as having six distinct stages, each of which is described in Chapter 1 of this text. A summary of those stages is presented here for the convenience of the reader. For a more detailed description, see Chaper 1.

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Stage 1: Young Adults Leaving Home

In this stage, an individual takes the first fledgling steps toward independence. The individual is learning self-care in many different areas, including financial, physical, and emotional well-being. The individual begins to separate from the family of origin, establishing new social connections and enhancing his or her sense of individuality.

Stage 2: The New Couple

This stage denotes the birth of a new family system. Two or more individuals are joining through marriage, partnership, commitment, or other form of agreement to establish themselves as a new familial unit. This new family is establishing itself as a unique organization with its own rules, boundaries, communication style, and value system. In addition, prior relationships with friends and family are being adapted to fit into this new family system. It is a time in which cultures blend and a new family culture begins to arise, one that is unique and separate from the previous familial systems and influences.

Stage 3: Families With New/Young Children

In this stage, new members are introduced into the new family. New family members are added through birth of one or more children. In order to accommo- date these new members, the new couple must learn to adjust. The responsibilities of parenting take more time and resources. Finances and personal schedules are altered in an effort to provide the new children with the things they need to thrive. Relationships with extended family members must also be adjusted.

Stage 4: Families With Adolescents

The family is now responsible for launching an adolescent. The child is growing, and with that growth come new developmental tasks for both the child and the family. This stage is marked by an increasing flexibility in boundaries and roles in an effort to accommodate these new developmental tasks. The adolescent is able to provide more self-care, thus providing more flexibility for the parents and grand- parents. The primary family may now learn to focus, or refocus, its energies toward career endeavors or other creative undertakings. The primary family may also have time to reconnect as a couple and work on the adult relationship. At the same time, sandwich family/generation might characterize this stage. The primary family unit now has children to care for, as well as aging parents or other family members for which to provide care.

Stage 5: Launching Children/Moving On

By now you may have picked up on the trend that these stages are most notably characterized by different family members coming into and leaving the primary

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familial unit. These entrances and exits become more noticeable during this stage. Children are now leaving the home. The possibility of aging parents passing away increases. A decline in the couple’s health may be noted during this stage as well. As children leave the home, the parental subsystem can now be restructured. The relationships with adult children must also be restructured. A new genera- tion is ready to launch and be independent, on their way to starting their own family life cycles.

Stage 6: Families in Later Life

In this stage, the primary family unit is faced with new roles. Parents are becoming grandparents, and their roles are being defined. Aging and its related effects are also noted in this stage. The potential death of one’s spouse or partner becomes a reality, and the couple begins to make preparations for the inevitable.

Larry and Tom: Which Life Cycle Stage?

Regarding Larry and Tom, which stage of the family life cycle applies to their family? (Remember, these stages are approximate. Sometimes, clinicians have to find the “best fit” for the family.) Larry and Tom appear to be somewhere between stage 3 and stage 4. In fact, they show characteristics of each stage. They have two children, one of which might be considered an adolescent, and there is an older adult living in the house as well, Larry’s mother. There is no indication that Larry’s mother requires care, but she certainly does have a major impact on the family system. For example, she struggles with accepting her son’s relation- ship with his male partner, and this is an added strain on the couple’s relationship. Mapping out where the couple and/or family is in terms of the family life cycle can provide a wealth of information and insight into the health and well-being of the family system.

The Family Life Cycle as Assessment Tool

How can the family life cycle be used to aid in evaluation and treatment planning? As discussed earlier, each stage is marked by specific characteristics and tasks. The assumption of a stage-based model is that each task associated with each stage must be completed in order for progress to be made. That is, the tasks of the first stages must be successfully negotiated in order for the family system to progress and proceed to the next stage. For counselors working with couples and families, it is helpful to “stage” a client family during the initial evaluation process. By doing so, the clinician can ascertain where the family most closely aligns with the stages of the family life cycle. For example, Larry and Tom closely fit stage 4. Larry and Tom have two children, ages 6 and 12. Now that the family has been staged, it is important to examine and understand the required tasks of this stage, such as the shift in the parent–child relationship in order to afford the adolescent more freedom, as well as the ability to provide more focus on the couple’s relationship.

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In general, counselors can use the family life cycle tasks to guide both evaluation and initial treatment planning. To that end, the counselor would evaluate the family’s progress according to each of the life cycle tasks by asking the following questions:

• How is your family meeting the developmental needs of the children? • What energies and/or resources need to be redirected toward building and

enhancing your relationship as a couple? • Have you had a conversation with Larry’s mom about her roles and responsi-

bilities? Are you in agreement?

The answers to these questions might be helpful in the initial treatment planning process.

Larry and Tom: Presenting Issues From the Family Life Cycle Stage

As was discussed earlier, Larry and Tom are a stage 4 family. On closer examination, the various life cycle challenges they are facing are consistent with the family life cycle model. They are moving ahead with their careers, and they are working toward meeting the developmental needs of both children. In addition, they are in the beginning stages of accommodating an aging parent into their home.

The family life cycle concept is not without its critics. As helpful as it is, it is deficient in some areas. In reality, families will not always fit nicely into any given stage. Families might not progress through the stages in lockstep formation. Therefore, it is wise to consider these stages in a more circular, rather than linear, fashion. For example, a family might be thrust into a given stage without time to prepare for that stage, or a family might be in the new couple stage and still be faced with the tasks associated with prior or later stages. Furthermore, there are important cross-cultural concerns about the family life cycle model. Many families do not fit that description, and the application of this, or any other model of life cycle development, should be taken in the context of the client family’s cultural and ethnic background.

Beyond Life Cycle Assessment: The Importance of Theory

When evaluating and treating couples and/or families, one also has a professional responsibility to create and select concrete techniques that best serve the client (Levitt & Bray, 2010). Professional counselors are to operate from a theoretical stance that is congruent with their own philosophy of human change and change processes. Theory, then, provides the foundation for evaluation and treatment. Theories provide a means to understand what one is doing, how one is serving clients, and, most notably, how to explain the counseling process to clients (Levitt & Bray, 2010). Theories reflect clients’ realities, counselors’ knowledge of what is important, and effective elements of the counseling relationship (Hansen, 2006). Theories help counselors organize clinical data, shed light on complex

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processes, and provide a conceptual framework for evaluation and interventions (Hansen, 2006).

SIDEBAR 14.3 NARRATIVE THERAPY EXERCISE

Review your perceptions of Tom and Larry’s case from the perspective of narrative therapy. How do your own beliefs about their situation impact how you would select a theoretical orientation? How do you see social constructionism, as a philosophical school of thought, impacting how theories such as narrative therapy came into being? Does narrative therapy fit your personal philosophy and worldview?

One way to develop one’s own theoretical approach is to consider questions of how people change; what motivates people to behave, think, and feel in the ways that they do; and how someone grows and develops. These elements are founda- tional and must be considered when developing a theoretical orientation. In addition, one’s view of human nature will influence which type of theoretical orientation the counselor decides on and subsequently selects. For example, if the counselor believes that one’s internal state (e.g., thoughts) leads to the client’s emotional distress, then the counselor will select a theory that specifically focuses on the role of changing thoughts in order to increase mental health and well-being. The techniques that will evolve from this theory will focus on how to work to re-create/reorganize one’s internal state, namely, thoughts. Theory provides the “conceptual framework that explains existing observations in particular contexts and generates hypotheses about new observations” (Hansen, 2006, p. 291). Theory, then, provides the foundation for the counselor’s conceptualization of the couple and/or family’s presenting concerns, primary themes, and which direction(s) the counselor might decide to undertake, according to his or her theoretical orientation.

If one believes that the clients’ narratives or stories have impact on their mental health, then the counselor will more likely select a theory that focuses on the stories that clients create. The techniques used with this theory will focus on how the stories one creates can actually be modified if the client is taught how to reconstruct the story line.

Postmodern Background Underlying Narrative Theory and Therapy

In order to comprehend narrative theory and its subsequent therapeutic tech- niques, it is first essential to outline the philosophical underpinnings of the theory. A primary postmodern school of thought that contributed to narrative therapy’s main themes is social constructionism. In social constructionism, meaning is developed through social interaction and the language used in social interaction.

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Social Constructionism

Social constructionism focuses on how clients compose their own realities through social interactions (Nichols & Schwartz, 1998). Therefore, theoretically speaking, humans derive meaning from social interaction and the language that is present within these interactions. One of social constructionism’s proponents, social psychologist Kenneth Gergen, concluded that not only are humans unable to construct an objective reality, but also the realities constructed are founded within the language systems themselves. In fact, he challenged the notion that historically dominated the psychotherapeutic world, namely, that persons possess innate resources that therapists can draw out (Nichols & Schwartz, 1998). Instead, he contended that realities are reinvented once persons find themselves in new conversational contexts.

This perspective offers several clinical implications for the couples and family therapist. One primary implication is that because everyone’s thinking is governed by social interactions, the couple’s truths are based on these social constructions. This concept encourages therapists to assist clients in understanding cultural and socially derived meanings that they may be facing in the counseling session. The second implication is that therapy is a “linguistic exercise,” in that therapists can lead their clients to new constructions about their problems (Nichols & Schwartz, 1998, p. 324). Third, the postmodern viewpoint of social constructionism implies that the therapeutic process is to be collaborative. Because neither the therapist nor the client brings an objective truth to the session, brand new realities emerge through counseling conversations in which both clients and therapist share mean- ings through conversation.

Narrative Theory and Therapy

In the family therapy field, social constructionism was welcomed by those therapists who wanted to shift from “changing action into changing meaning” (Nichols & Schwartz, 1998, p. 323). In fact, this postmodern view became the basis for narrative therapy, which emphasized that the therapist’s job was to cocreate new realities with clients. As such, counselors are not experts, but instead work with the clients to assist them in understanding that a person’s sense of self evolves when interpersonal conversations are “internalized as inner conversations” (Nichols & Schwartz, 1998, p. 324).

Furthermore, it is believed that problems within couples or families are not located within individuals, but rather in points of view individuals possess about themselves and situations (Guise, 2009). Narrative therapy, then, can become a process by which clients can come to reexamine the narratives that govern their lives. The therapist helps the clients to share their stories and then assists the clients in reexamining the stories by which they live.

In addition, narrative therapy created an avenue through which family thera- pists who wish to address and integrate issues of social justice in their clinical work are able to do so. Clients’ self-loathing, lack of optimism, and fear of making changes can follow from internalizing toxic cultural narratives related to their lives

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and experiences (Nichols & Schwartz, 1998). In fact, narrative therapy has been used to highlight societal impacts of patriarchy, heterosexism, social class, and racism, and to point out to clients how being exposed to these internalized narratives impacts their individual and family narratives. Overall, the goal of narrative therapy is to bring into the open these internalized narratives so they can be replaced with more productive life narratives (Guise, 2009).

The process of rewriting and coconstructing the story begins with “external- izing the problem” (Guise, 2009). In other words, the counselor works to separate the person from the problem. During this process, the counselor and client begin to look more closely at the client’s experiences for any ignored components that might contradict the problem-saturated story, paying particular attention to strengths and competencies. Via these conversations, clients continue to rewrite their story lines, which results in an increased sense that they are not solely defined by problems and deficits.

The counselor is interested in hearing the stories so he or she can gain an appreciation of how the client and/or family members view themselves and their issues (e.g., their narrative); then the counselor works with the client or client family to create an alternative narrative. Therefore, narrative therapists ask a series of questions to delineate the impact of the problem. These questions assist the counselor and family in examining and redefining the problem-saturated narrative and working to help to begin reauthoring an alternative, healthier narrative.

Types of Questions

One of the primary questions that a narrative counselor might ask is the de- construction question, which helps the client externalize the problem. For example, a counselor might ask a question such as: “What does the conflict in your relationship tell you to do?” (Guise, 2009). An opening space question will help the client to uncover unique outcomes; for example: “Has there been a time that insecurity did not take control of your life, even when you thought it would?” A question to extend the story into the future will help to reinforce positive changes; for example: “What will your life be like now that fear of abandonment does not have the upper hand any longer?” Because many clients see themselves as internally possessing or being the problem, it is essential for the counselor, as part of the narrative model, to suggest that the self is not a stable entity, but rather is a constitutionalist self that can become deconstructed and reconstructed continuously through interactions (Nichols & Schwartz, 1998). The first goal, then, is to identify and externalize/separate the person from the problem. Then, the client can see the problem as an unwelcome invader that attempts to dominate the person and that person’s family. Most importantly, externalizing the problem unites the family against the common enemy or problem instead of placing the blame onto self or others.

In summary, questions form the foundation for discovery of the dominant narrative; then the counselor and the client can work together to deconstruct and reauthor the dominant narrative so that a new narrative will bring a higher quality of contentment to the client and the client family. The following section demon- strates how to apply narrative techniques with Tom and Larry.

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Narrative Therapy Applied to Tom and Larry

It is clear that the narratives that Tom and Larry cling to exert an extensively negative impact on their lives and their relationship. Problem-saturated stories (Piercy, Sprenkle, & Wetchler, 1996) affect what Tom and Larry notice in the couple relationship. For example, Larry wishes Tom would talk more and be more active in the relationship, undertake more duties/responsibilities in the home, and initiate intimacy between the two of them. Tom, on the other hand, wants Larry to recognize him as having a role and decision-making power in the relationship. Therefore, Tom tends to cling to his narrative that Larry takes sides with his mom and that their relationship has completely shifted since Larry’s mom moved in with them. Larry, however, praises all that his mother does and claims that without her, their family would not be the same. Tom and Larry’s problem-saturated narratives center on how each is not receiving from the other, and they tend to solely focus on what is wrong in their relationship. For example, Larry notes that Tom does not talk, and the meaning he attaches to it is that Tom does not care. Tom notes that Larry does not recognize him as being equal in the relationship and concludes that Larry does not respect or honor his voice in the relationship. Both Tom and Larry cling to the problem-saturated story and are not able to see past what is wrong in their relationship. The counselor could assist both Tom and Larry in developing alternative stories and help both see that it is not the other one in the relationship who is the problem, but rather that the problem is the problem itself.

Externalizing the Problem

Using a narrative approach with Larry and Tom would mean that much time would be spent working to gain an understanding of, and appreciation toward, the problem-saturated story. It is important to hear from each partner what he believes are his dominant narratives and then help each one deconstruct the problem- saturated story and coauthor more helpful stories (White & Epston, 1990). Therefore, it would be necessary to separate the person from the problem, or work to externalize the members of the couple from the problem. The therapist could work with Tom to examine more closely the potentially ignored elements that contradict the problem-saturated story, paying close attention to competencies in the relationship (Guise, 2009). The therapist would also work with Larry to help him look more closely at elements within the relationship that contradict his problem-saturated story. As therapy progresses, each person in the couple begins rewriting his story, paying close attention to his competencies as a person and as a person in a committed relationship. The therapist communicates with the couple, both collectively and individually, that he or she is interested in listening to the couple’s history to gain appreciation of how the individuals within the couple view themselves and each other. Once the dominant narratives are established, the therapist listens to how individuals view their individual competencies and their competencies as a couple. When the therapist assists the couple in externalizing what they view to be the primary problems in the relationship, they can then work to externalize the problem by asking, “Has there been a time in your relationship

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when the two of you told the ‘lack of communication’ to back away from your relationship?” Or, “When the ‘lack of intimacy’ tries to tell the two of you to distance from one another, how do you work against this external force?” As externalizing the problem progresses in the relationship, questions to extend the story into the future can also be applied, such as: “What will your lives be like now that lack of intimacy does not have the upper hand?” and “How do you see your lives unfolding since you both addressed lack of intimacy together?”

Deconstructing the Dominant Narrative

During this time, the counselor would also work with Tom and Larry to more clearly define how each views the role of being in a nonheterosexual relationship (gay relationship). Because narrative therapy also concerns itself with dominant cultural discourses, it would be important to gauge from Tom and Larry how they may have internalized negative social, political, and cultural messages (Guise, 2009). The counselor could then work with Tom and Larry to deconstruct the dominant cultural discourse and help them rewrite their dominant cultural dis- course away from one that emphasizes that being gay is somehow inferior, morally flawed, and not normal.

When assisting Tom and Larry with rewriting the dominant cultural discourse, the counselor could aid them in coming together against their common enemy, namely, how society views their narrative that celebrates and embraces their relationship. Since shame-based issues around their sexuality might be present, the counselor could assist Tom and Larry with uniting against societal views that do not honor relationships that are not heterosexual.

Mapping the Influence of the Problem

Some issues that Tom and Larry present are related to their interactional sequence. For example, Tom and Larry might be engaged in a distance–pursuit pattern in which Larry pursues by desiring to communicate with Tom, while Tom (according to Larry) does not listen to him when he speaks. The therapist can label this interactional sequence as “the rift,” and then ask questions related to the rift in their lives. One question that the therapist could ask is, “How does the rift make you believe that the other person is trying to pull away from you?” (Guise, 2009, p. 153). The therapist can ask Larry and Tom how they view the rift and how the two of them can work to silence the rift. When their interactional sequence is defined as an external rift, then the interactional sequence can be externalized and no longer defined as housed within either Larry or Tom, or emanating from either of them.

Reconstructing and Reinforcing a New Narrative

As Tom and Larry uncover their individual competencies and their competencies as a couple, the counselor can assist them in further identifying and broadening their competencies, such as helping them to both see that the rift is the challenge that presents itself in both their intimacy and communication. In addition, the rift can be

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identified as getting in the way of their effective communication in regard to Larry’s mother being present. When Tom and Larry are able to see the rift as the personified entity that inserts itself into their relationship and causes negative impacts, then they will be more likely to decrease the amount of time they spend arguing about who did and did not do what was expected. A question that the counselor could use to ascertain the relative influence of the problem would be: “Since the last session, how much were you in control of the rift, and how much was it in control of you?” Tom and Larry can then reflect on their growing ability to be victorious over the effects of the problem and, in the process, reinforce the notion that the challenges and problems are external to them and not an internal part of either person.

SIDEBAR 14.4 ETHICS OF TERMINATION

Please take a minute to review the following ethical codes regarding termination and the potential for abandonment:

• The American Counseling Association, http://www.counseling.org/ resources/aca-code-of-ethics.pdf (specifically A.11)

• The American Mental Health Counselors Association, http://www .amhca.org/assets/news/AMHCA_Code_of_Ethics_2010_w_ pagination_cxd_51110.pdf (specifically B.5)

What challenges do you think are associated with ending the counseling relationship with clients?

TERMINATION

Termination is the final phase of counseling. All marriage, couples, and family counselors must attend to the final steps of the counseling process and consider the clinical and ethical implications of ending the counseling relationship. “Psycho- therapy termination may be conceptualized as an intentional process that occurs over time when a client has achieved most of the goals of treatment, and/or when psychotherapy must end for other reasons” (Vasquez, Bingham, & Barnett, 2008, p. 653). Specifically, marriage, couples, or family counseling reaches a point that counseling goals have been met and/or the couple or family must end counseling for a particular reason. It is important to consider that the couple and/or family, along with the counselor, is likely to benefit the most from termination if the process is planned and systematic instead of abrupt.

There are generally two primary types of termination: client-initiated termi- nation, which is the most common, and therapist-initiated termination (Rappleyea, Harris, White, & Simon, 2009; Renk & Dinger, 2002). There are various reasons

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why clients initiate the end phase of counseling, including goal completion or no resolution of identified issue (Lebow, 1995). Leslie (2004) highlights six reasons why a counselor might initiate termination:

1. The client realizes goal accomplishment, which is a natural ending point in the therapeutic process.

2. The client is unable to pay for counseling. 3. The counselor determines the problem is outside his or her scope of

competence. 4. The counselor determines that the client is no longer benefiting from

counseling. 5. The counselor is unable or unwilling to continue providing counseling. 6. The counselor is no longer employed at the place in which the counseling is

provided.

In the case of Larry and Tom, counseling ends as treatment goals are accomplished.

Given that Larry and Tom discussed termination during the initial phase of counseling and understood that counseling would come to an end at some point, counseling termination for this couple seems natural and justified. Family coun- seling for Larry, Tom, their children, and Larry’s mother ends as a result of goal realization. Larry and Tom participated in counseling with a narrative therapy approach. Both Larry and Tom worked on externalizing the problem, mapping the influence of the problem, and reconstructing and reinforcing a new narrative. This new narrative was especially reinforced after several sessions as a family with Larry’s mom and the children present. During the family sessions, Larry and Tom were able to practice improved communication as unified partners with a shared narrative that was functional for them as a couple.

Termination Strategies

Regardless of the reason for counseling termination, it is important to follow a systematic process during this final phase of the counseling relationship. Ward (1984) offers specific counseling strategies to following during termination. These strategies are described in more detail as related to the case study of Larry and Tom.

Assessment of Goal Completion and Learning

The clients identify with the counselor the various goals that they accomplished. It is often helpful in evaluating progress to list and measure changes that occurred for the clients. Another technique is to review an early session in the counseling relationship and discuss relative progress on a particular goal.

For Larry and Tom, the counselor made the decision to assess for goal completion by reviewing an initial session in which Larry and Tom argued openly about Larry’s mother and were able to list several reasons why their partnership was

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“not working.” As the counselor reviewed this initial session with Larry and Tom, both were able to smile and reflect on why their relationship was not working at the time. Both Larry and Tom discussed with insight the new dialogue they share and how much their perspectives on things have changed.

Closure of Affective and Relationship Issues

Clients and counselors have affective issues around the termination of counseling. Counselors can provide clients an open invitation to discuss feelings of loss, grief, abandonment, and related issues as a way of addressing affective issues and providing an opportunity for appropriate good-byes.

Larry and Tom express to the counselor that they will miss coming to counseling and that they plan to come back if issues arise in the future. Tom discusses that he is surprised to feel some sadness about the end of couples counseling. The counselor openly processes both Larry’s and Tom’s feelings. Similarly, the counselor provides an opportunity for Larry and Tom to say good-bye and find closure to the counseling relationship.

Preparation for Postcounseling Self-Reliance and Transfer of Learning

What are the client’s expectations for transfer of learning to life after counseling? One of the ways to work toward life without counseling and a simple way to achieve termination is to reduce the frequency of sessions. Clients and counselor can assess how counseling gains are maintained outside of counseling and status of self- reliance given goal achievement in counseling.

Larry and Tom expected to improve their intimacy and communication. Although their intimacy and communication have improved greatly, both Larry and Tom now realize that much more effort is needed to maintain healthy intimacy and communication. Larry and Tom feel confident with their new communication style and believe their new narrative is strong and positive.

REFERRAL

Sometimes the end of counseling is not always the end, and a referral to alternative or additional services is needed. Also, the counselor and/or client may deem it appropriate to have periodic counseling sessions to check on whether change was maintained or if old issues resurface.

Referrals can also provide a supplement to current or finished counseling. As a supplement, referrals to various community groups or services can support and enhance wellness that was achieved during the counseling relationship. Based on the case and treatment process of Larry and Tom, no specific referrals were made at termination. However, the counselor did leave the door open for Larry and Tom to return for follow-up couples sessions should any of the issues that were resolved in counseling reemerge.

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SUMMARY

In summary, working with couples and families requires a fundamental paradigm shift for counselors in that the focus of evaluation and treatment must move away from the individual and instead focus on the relationships between and among all family members. To do so requires that counselors understand the differences and similarities between assessing individuals versus evaluation of a family as an entire entity. Moreover, treatment of the family is guided by specific theories and techniques and is always reflective of the notion that families operate in context and therefore must be treated as such. Finally, effective termination and referral require counselors to assess that treatment is indeed complete, providing the couple and family with a list of resources should further assistance be required.

USEFUL WEBSITES

The following websites provide additional information relating to the chapter topics.

American Counseling Association (ACA) Code of Ethics http://www.counseling.org/resources/aca-code-of-ethics.pdf American Mental Health Counselors Association (AMHCA) Code of Ethics http://www.amhca.org/assets/news/AMHCA_Code_of_Ethics_2010_w_pagi

nation_cxd_51110.pdf American Psychiatric Association: DSM-5 Development http://www.dsm5.org/Pages/Default.aspx International Association of Marriage and Family Counselors (IAMFC) Ethical

Codes http://www.iamfconline.org/public/department3.cfm

REFERENCES

American Counseling Association. (2014). Code of ethics. Retrieved from http://www.coun seling.org/docs/ethics/2014-aca-code-of-ethics.pdf?sfvrsn=4

American Mental Health Counselors Association. (2013). Code of ethics. Retrieved from http://www.amhca.org/assets/content/AMHCA_Code_of_Ethics_2010_update_1-20-13_ COVER.pdf

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Berg, I. K., & Reuss, N. H. (1997). Solutions step by step: A substance abuse treatment manual. New York, NY: Norton.

Carter, B., & McGoldrick, M. (1999). The expanded family life cycle: Individual, family, and social perspectives. Boston, MA: Allyn & Bacon.

Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole.

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DeJong, P., & Berg, I. K. (2001). Interviewing for solutions (2nd ed.). Pacific Grove, CA: Brooks/Cole.

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Guise, R. W. (2009). Study guide for the marriage and family therapy examination. Jamaica Plain, MA: Family Solutions Corporation.

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Knoff, H. M. (Ed.). (1986). The assessment of child and adolescent personality. New York, NY: Guilford Press.

Lebow, J. (1995). Open-ended therapy: Termination in marital and family therapy. In R. H. Mikesell, D. D. Lusterman, & S. H. McDaniel (Eds.), Integrating family therapy: Handbook of family psychology and systems theory (pp. 73–86). Washington, DC: American Psychological Association.

Leslie, R. S. (2004, May/June). Termination of treatment. Family Therapy Magazine, 3(3), 46–48.

Levitt, D. H., & Bray, A. (2010). In B. T. Erford (Ed.), Theories of counseling. Orientation to the counseling profession: Advocacy, ethics, and essential professional foundations (pp. 95–123). Upper Saddle River, NJ: Pearson.

Nichols, M. P., & Schwartz, R. C. (1998). Family therapy: Concepts and methods (4th ed.). Boston, MA: Allyn & Bacon.

Piercy, F. P., Sprenkle, D. H., & Wetchler, J. L. (Eds.), Family therapy sourcebook (2nd ed., pp. 79–105). New York, NY: Guilford Press.

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Rappleyea, D. L., Harris, S. M., White, M., & Simon, K. (2009). Termination: Legal and ethical considerations for marriage and family therapists. American Journal of Family Therapy, 37, 12–27.

Renk, K., & Dinger, T. M. (2002). Reasons for therapy termination in a university psychology clinic. Journal of Clinical Psychology, 58(9), 1173–1181.

Vasquez, M. J. T., Bingham, R. P., & Barnett, J. E. (2008). Psychotherapy termination: Clinical and ethical responsibilities. Journal of Clinical Psychology: In Session, 64(5), 653–665.

von Bertalanffy, L. (1968). General systems theory: Foundations, development, and application. New York, NY: Braziller.

Ward, D. E. (1984). Termination of individual counseling: Concepts and strategies. Journal of Counseling and Development, 63, 21–25.

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