At 8 o’clock tomorrow morning, I am taking my first round of comprehensive exams for my couples and family therapy program. The purpose is to make sure we understand all of the theory we’ve been learning before we start seeing clients. If I don’t pass, I will be given another chance at it in the summer–I won’t be able to see clients this summer, but I could start in the fall.  I feel good about it. I am ready.

We will be graded Pass, Fail, or Pass With Distinction. I expect to get a Pass. I know the material quite well, but we’re supposed to write 3-4 single spaced pages on each of three questions, all in five hours. With citations. That’s a lot of typing. I’ve done three dry runs through the test, and the most I’ve been able to type, even with my outlines in front of me, is 7 1/2 pages, total. I’m not a fast typist, and I still have to think some about what I’m going to write. I’m fine with a “Pass.” Part of my learning curve is learning how to stop at “good enough.”

We’re allowed to bring food, drinks, ipods, and our reference lists with the references in any order. (I’ll paste in my list below). I’m also bringing my own keyboard (Microsoft Natural Keyboard Elite) and mouse (Logitech TrackMan Wheel). Five hours of fast typing–I need to be comfortable! I’d like to bring my chair, too (Herman Miller Aeron), but it’s difficult to bike with.

Tonight I’m treating myself to some food someone else made and getting into bed early.

Here are the questions. I’ve had them since December. Below them is my reference list. Wish me luck!

Question 1

Describe in detail systems theory, contrasting it with modernism (aka positivism). Be sure to include central concepts of both epistemologies and explain them fully. Also detail the main concepts of communication theory, and the connections between communication theory and system theory. Describe a family problem in detail using a specific model of family therapy (Structural, Strategic, Solution Focused, Experiential, EFT, Bowen) to describe the relevant associated concepts to understand the situation. What are the model specific concepts you will use to understand the family? How will it direct your treatment? What interventions might you utilize to help this family? Why are these interventions systemic? How will you evaluate outcomes based on this model of therapy? How will the common factors research influence your view of intervention with this family?

Question 2

Research ethics includes principles of social justice and dictates competence at each of the following levels: a) conducting research, b) consuming research, and c) utilizing the research literature.

Describe the key social justice considerations when conducting research, when evaluating the merits of a research study, and when utilizing research data as a clinician. In your response include notions of consent, validity, and the characteristics of a well-constructed qualitative and quantitative research designs. Finally, specifically describe how you will incorporate your knowledge of research and its relationship to social justice while a clinician at the CFT.

Question 3

Please describe a process for how you will develop a systemic diagnosis and treatment plan for the client system depicted in the vignette below. Carefully describe how your diagnostic impression and treatment plan are informed by your knowledge of (1) diversity, (2) empirically validated treatments, (3) relational ethics, (4) the diagnostic and statistical manual and (5) CFT theoretical frameworks (systems and communications theories). Finally, based on the vignette below, talk about your treatment approach and how it is informed by the five areas mentioned above. Clearly articulate your systemic diagnosis and treatment plan for this client system.

Kelly (39) and Kris (26) presented for couples therapy. The couple reports they have been together for about two years and are very serious about their future together. Kris reports they have “problems understanding each other. We just can’t communicate.” Kelly agrees and reports it’s been that way for several months. Every time they try to talk with each other about their problems they don’t get along and often engage in escalating verbal arguments. The arguments often lead to Kelly leaving the house very upset and not coming home until the next day. Each partner is hoping for it to get better and want to engage in ongoing couples therapy. Kris reports feeling down and “out of sorts” most of the time and has had difficulty in getting out of bed and making it to work on time the past few months; however, is able to have some good days feeling happy and energetic. After the third session, Kelly discloses to you over the phone that he is thinking of engaging in a sexual relationship with another partner but doesn’t want to bring it up in therapy yet, and doesn’t want you to, either. He states that he feels having another partner will help the relationship because he will “be able to get my needs met.” He further reports to you that they both occasionally seek out partners outside the relationship and feel an open relationship works for them, though made the decision years ago to just not talk about it when it is happening.

Comps References

Becvar, D. S. & Becvar, R. J. (2006). Family therapy: Systemic integration. Boston, MA: Pearson.

Burbatti, G. L. & Formenti, L. (1988). The Milan approach to family therapy. Northvale, NJ: Jason Aronson.

Fisch, R., Weakland, J. H., & Segal, L. (1982). The tactics of change: Doing therapy briefly. San Francisco, CA: Jossey-Bass.

Gehart, D. (2010). Mastering competencies in family therapy: A practical approach to theories and clinical case documentation. Belmont, CA: Brooks/Cole.

Haley, J. (1993). Jay Haley on Milton H. Erickson. New York, NY: Brunner Mazel.

Madanes, C. (1991). Strategic family therapy. In A. S. Gurman & D. P. Kniskern (Eds.) Handbook of family therapy (pp. 396-416). Madison, WI: Routledge.

Nichols, M. P. & Schwartz, R. C. (2008). Family therapy: Concepts and methods. Boston, MA: Pearson.

Sandberg, J. G., Johnson, L. N., Dermer, S. B., Gfeller-Strouts, L. L., Seibold, J. M., Stringer-Seibold, T. A., Hutchings, Andrews, J. B., & Miller, R. B (1997). Demonstrated efficacy of models of marriage and family therapy: An update of Gurman, Kniskern, and Pinsof’s chart. The American Journal of Family Therapy, 25(2). 121-137.

Sprenkle, D. H. & Blow, A. J. (2004). Common factors and our sacred models. Journal of Marital and Family Therapy, 30(2), 113-126.

Watzlavick, P., Bavelas, J. B., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. New York, NY: Norton.

Sells, S. P., Smith, T. E., & Newfield, S. N. (1996). A clinical science for the humanities: Ethnographies in family therapy. In S. Moon & D. Sprenkle (Eds.), Research Methods in Family Therapy (pp. 25-63). New York: Guilford.

National Institutes of Health (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. URL

National Institutes of Health (2010). The Nuremberg code: Directives for human experimentation. URL

Sue, S. (1999). Science, ethnicity and bias: Where have we gone wrong? American Psychologist 54(12), 1070-1077.

Freire, P. (1970). Pedagogy of the oppressed. New York, NY: Continuum.

Aronson, E., Ellsworth, P. C., Carlsmith, J. M., & Gonzales, M. H. (1989). Methods of Research in Social Psychology. Columbus, OH: McGraw-Hill.

Creswell, J. W. (2009). Research design: Qualitative, quantitative, and mixed methods approaches. Los Angeles, CA: Sage.

Corey, G., Corey, M.S., & Callanan, P. (2011). Issues and ethics in the helping professions (8th Ed.) Belmont, CA: Brooks/Cole Cengage Learning.

Fisch, R., Weakland, H., & Segal, L. (1982). The tactics of change. San Fransisco: Jossey-Bass.

American Psychological Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.-TR). Washington, DC: American Psychchological Association.

Bettinger, M. (2006). Polyamory and gay men: A family systems approach. In J. J. Bigner (Ed) An introduction to GLBT family studies (pp. 161-181). New York, NY: Haworth.

LaSala, M. C. (2001). Monogamous or not: Understanding and counseling gay male couples.

Families in Society, 82(6), 605-611.

Yesterday, I participated in my master’s program’s OSCEs–Objective Structured Clinical Exercises–for the students in the year ahead of me, who are about to graduate. My cohort played clients in specific, challenging scenarios for the second-year-cohort therapists. The activity was adapted from a medical school test of clinical ability.

My scenario was the most challenging of the day. The therapists came in expecting to be doing a goal setting exercise with a couple but found that only one of us (me) had showed up. I was to immediately disclose an affair and request that the therapist not tell my wife about it. I had ended the affair, felt very guilty about it, and was certain that revealing it would destroy our relationship. I was to try and get the therapist to help me with the “things that pushed me to do this.”

I am not a good actor, so it took all my attention just to get my part across in a semi-believable way. When I watched my cohort-mates play the same part, though, it was heart wrenching. They did such a good job showing remorse, almost crying, showing the fear of losing their husbands, and over “a stupid mistake.” (Well, three stupid mistakes with one person.) I really felt for them–and they were just pretending! I can see how much preparation I will need to do to handle this kind of situation effectively. I am certain to have clients who have affairs. I just looked up the statistics, and the lowest numbers I found are that about 15% of married women and 25% of married men have sexual affairs. That means that at least one out of four couples I see will have had or are heading towards an affair.

Our clinic has a “no secrets” policy for couples counseling. It’s something we bring up on the first day of therapy. If one member of a family has an individual session, what is said in that session is not going to be confidential to the rest of the family. The idea is that for this work, it is the relationship that is our primary client, not the individuals, and that secrets (differentiated from privacy) are toxic to relationships. Also, if the we are brought into one person’s secret and keep it, we can no longer serve the relationship without bias.

I think that the no-secrets policy is a good idea and I have been planning to use it in my work, but now, seeing it in practice, I see that it’s not just a matter of having a policy. I will need to thoroughly wrap my head around how it will apply in different scenarios. I will need to talk it through with a lot of people so I feel comfortable and confident in my thinking. I will also need to remember to remind clients about the no-secrets policy the moment I see that a couples client has come in alone. We introduce the policy during the first session, but that may not be what a client is thinking about when they disclose an affair. They may think that I have trapped or betrayed them if their disclosure is followed by, “Remember that no-secrets policy we talked about during our first session?”

Ideally, in this case, we would work together with the client on a palatable way to reveal their actions to their partner and then work with the couple to heal the rifts. We don’t automatically tell the partner about affairs, either. There are some things that we are required by law and ethics to report, like death threats or the abuse or neglect of a child, but affairs are not one of them. If the cheating partner refuses to allow revealing the secret, I would have to refer the couple, for suitably non-specific reasons, to another therapist who could be unbiased, if in the dark.

I think that I need to rid myself of some countertransference when it comes to affairs. That is, as it stands, I think I might favor cheat-ee over cheating clients, because it’s harder for me to relate to cheating. I walked out of our role plays thinking, “Wow, it’s so much simpler and less painful to avoid an affair than it is to deal with the aftermath!” Can anyone recommend a good book or movie that could help me empathize with someone having an affair–especially someone who feels like they are not in control of their actions, or just not thoughtful, in sexual infidelity?

This is interesting and sometimes painful work I am getting myself into!