Allen, David M. A Family Systems Approach to Individual Psychotherapy. Northvale, NJ, Jason Aronson, 1988 (Originally entitled, Unifying Individual and Family Therapies. San Francisco, Jossey-Bass, 1988).
Allen, David M. Deciphering Motivation in Psychotherapy. New York, Plenum Publishers, 1991.
In the manual, these techniques have been summarized, updated, and supplemented with interventions designed to target cluster B and C personality disorders (other than Antisocial Personality Disorder), particularly Borderline Personality Disorder. The clinician should already be familiar with the theoretical background and general treatment techniques of the approach (described in the above books) before attempting to treat patients using this manual.
The individual items described in the manual are designed to accomplish one of the following strategic goals:
1) Frame the patient's chief complaint and current difficulties as a response to family of origin issues.
2) Gather information identifying interpersonal relationshippatterns than cue self-destructive behavior.
3) Gather information about the patient's genogram for the purpose of understanding family misbehavior, so that the patient can develop empathy for targeted family members.
4) Make an hypothesis about both the patient's current role in the family and the reasons the family seems to require this role.
5) Plan a metacommunicative strategy designed to help the patient
confront the problem with his or her family.
6) Implement the strategy and obtain feedback about its effectiveness.
The manual is divided into the following general stages of treatment: EVALUATION, EXPLORATION/INTERPRETATION, ROLE PLAY, AND TERMINATION.
1. Identification of co-morbid axis I disorders amenable to psychopharmacological intervention, particularly major depression, panic disorder, and obsessive-compulsive disorder.
The clinician should take a complete and detailed psychiatric history, including a review of symptoms where indicated. For example, in depressed patients the clinician should ask about disturbances of sleep, appetite, energy, and libido; loss of interest in usual activities; severe persistent dysphoria; anhedonia; diurnal variation; early morning awakening, and suicidal ideation. The therapist should observe the patient for psychomotor retardation. For patients with panic symptoms, the clinician should ask about episodic chest tightness or pain, shortness of breath, feeling of dread, dizziness, diaphoresis, paresthesias, nausea, pounding heartbeat, palpitations, depersonalization, choking, flushes, faintness, and symptoms of agorophobia. Patients who describe rage reactions should be quizzed specifically about these panic symptoms. Patients with a high degree of emotional reactivity, bulemia, and/or self-mutilation should be considered for SSRI treatment.
2. Initiation of pharmacotherapy or referral of appropriate patients to a knowledgeable psychiatrist for pharmacotherapy.
Patients with axis I symptoms amenable to pharmacological intervention should be treated with medication, and should be somewhat stabilized, if possible, before initiation of stressful psychotherapeutic interventions. The therapist should discuss the indications for medication, give a rationale for their use (e.g., hypothalamic dysfunction of some sort in genetically prone individuals), and address any patient concerns or resistances. If appropriate patients continue to refuse medication after all resistances have been explored, psychotherapy can be nonetheless initiated. If symptoms later interfere with the process of therapy, the clinician should express concerns that therapy may not be effective if the patient is preoccupied with symptoms yet continues to refuse symptomatic treatment.
For non-medical therapists, it is important to find a psychiatrist who will not interfere with therapy. Psychiatrists unfamiliar with the treatment paradigm should be educated about the treatment, and the rationale for controversial treatment decisions (e.g. not to hospitalize a patient threatening suicide) should be explained to them.
3. Acquisition of a complete social history.
The following information should be obtained in an empathic but matter of fact, leaving-no-stone-unturned style of questioning:
A) Parents/stepparents: Are they living? Still together? When, if separated or divorced, did this take place? Did they get along with each other? Previous marriages? History of mental illness? Did the patient get along with each parent? How did the family get along in general when the patient was growing up?
B) Siblings: birth order, age range, sexes, current marital and career status.
C) Family violence or abuse: The patient should be questioned SPECIFICALLY about this issue. In general, was there any physical, sexual, or psychological abuse? Was there any violence in the family, and if so, who did what to whom? (This discussion need not go into specific details at this point if the patient seems uncomfortable).
D) History of overtly self-damaging acts (e.g. wrist cutting, self mutilation, bularexemia, suicide threats or gestures).
E) Educational history: how far did the patient get in school? What sort of grades?
F) Employment history: types of jobs, periods of disability, reasons for changing jobs, periods of unemployment.
G) Relationship history: any long term relationships? marriages? divorces? Recurrent patterns or themes (e.g. involvement with abusive spouses, alcoholics, partners who won't work, cheaters)? Who is generally dominant? Was a career or a goal interrupted by a relationship?
H) Ethnic and religious background of the family.
4. Recommendation for psychotherapy and proposal for initial treatment frame.
The therapist should frame the patient's complaints, recommend psychotherapy as the treatment of choice, and provide a basic rationale for the recommendation. The basic frame will usually involve one or more of the following themes: chronic affective symptoms of unknown or unclear etiology, self destructive behavior, or overt family discord. The therapist should use some variation on the following basic intervention:
"When someone (is feeling anxious/depressed and is not sure exactly why) (is having relationship problems and cannot seem to solve them) (finds themselves doing things that are making them feel bad), psychotherapy is indicated to try to figure out exactly what is happening and what can be done about it. I recommend that we meet weekly (or every other week if finances are a problem) to do that."
5. Description of the process of therapy.
The therapist should educate the patient on the basic process of therapy. Generally, this includes:
A) A free association instruction (e.g. that the patient should not censor his thoughts in advance as irrelevant, embarrassing, or offensive, but report all thoughts with a general focus on previously identified problem areas).
B) An indication that the therapist retains the option to listen and make no comments until he or she knows enough to say something helpful.
C) An explanation of resistance (e.g. how it is sometimes difficult to discuss the very topics that are most important - that is, those which are creating the anxiety or depression the patient complains of - and how sometimes this leads patients to avoid sessions).
D) An instruction that, should the patient decide to quit therapy, he/she should return one more time to discuss that decision, to see if perhaps the decision was based on discomfort over topics explored in earlier sessions.
6. Addressing patient's concerns.
The therapist should ask the patient if there are any questions about the recommendation or the instructions. If a client seems reluctant to proceed, the therapist should tactfully quiz the client on the source of the reluctance. If a client expresses a concern in metaphor (e.g. describing some untoward event that happened to someone else, or describing how his/her relationships normally turn out), the therapist should make a paradoxical prediction (tells the client that the therapist is concerned that the patient might at some point think that something similar is happening in therapy, and that the patient should bring it to the therapist's attention should those feelings pop up). If the patient goes on to state that the therapist's concern is unwarranted, the therapist should not argue, but answer, "OK, but let's keep an eye out for it."
1. Use of transference reducing techniques.
The therapist should be alert to potential transference reactions which may serve as resistances and impede therapy. The therapist should consistently attempt to change the focus of the client from the therapist back on to a discussion of family dynamics through various interventions. Ongoing transference resistances can not be ignored. The overall strategy for doing so is the avoidance of interventions or attitudes which are pathologizing, i.e., which assume that the patient's reactions to the therapist occur because the patient is overly-dependent, unreasonable, cognitively impaired, immature, foolish, or stupid. All interventions mentioned in this item should be made in a matter of fact, friendly, non-defensive way.
The following are the types of patient behavior to which the therapist should respond accordingly: acting in behavior, seemingly inappropriate or exaggerated responses to or requests from the therapist, metaphorical concerns about the nature of the therapeutic relationship, disqualifications of the therapist, and self-denigrating explanations for maladaptive behavior meant to encourage a negative judgment from the therapist.
The following are some of the useful therapist responses to potential transference resistances: paradoxical predictions, specific counters for disqualifying statements (see separate list at end of this item), and the proposal and discounting of "obvious" or "pop psychoanalytic" explanations (e.g. "some people might think you act the way you do because your all wrapped up in yourself and insensitive to others; I don't believe it; I can see how caring you are").
Personal questions and gifts should be handled in a way designed to avoid reinforcing transference reactions. Examples include the following: the therapist quickly answers questions that are not too personal or intrusive, answers intrusive or extensive questions with, "We're here to talk about you, not me," accepts small gifts at Christmas with thanks but without additional comment, and expresses concern that gifts that are large or inappropriately timed may have some unclear meaning which might affect therapy (without insisting that this must, in fact, be the case).
The therapist should avoid typical psychotherapeutic strategies which are designed to GENERATE a transference neurosis, and instead assume that the patient's reactions to events in therapy are sensible and appropriate unless there is significant, clear evidence to the contrary. For instance, if the therapist is late for a session or makes a mistake in scheduling, he/she should apologize but should NOT make inquiries into the patient's reactions about the error UNLESS the patient continues to focus, directly OR in metaphor, on the event. If the patient is occasionally late for a session, the therapist may inquire as to the reason but should generally assume that the tardiness is not worthy of extensive exploration, EVEN IF the patient indicates that the reason is that the patient is somewhat uncomfortable with the material from the last session. If, on the other hand, there is a PATTERN of lateness, or if the therapist has reason to believe that the patient may be thinking seriously about quitting therapy, more extensive exploration of the patient's concerns is in order. Once again, however, the therapist should begin with the assumption that the patient's actual concerns are reasonable.
If the therapist is about to go on a vacation of more that a week, he/she might make a paradoxical prediction such as "Sometimes when therapy is interrupted, patients have a natural tendency to what to stop coming and dealing with uncomfortable issues. I hope you will persist." The therapist should then drop the issue.
Ignoring transference material of short duration may in some cases be an effective intervention (e.g. in cases where a patient who has been in therapy before makes a statement designed to induce the therapist to focus on the transference).
COUNTERING DISQUALIFICATIONS: The following is a behavioral paradigm for "acting in" behavior by individuals with borderline personality disorder. The premise is that any response by the therapist that indicates rage, guilt or helplessness will, on a basis analogous to a variable reinforcement schedule, increase the frequency of spoiling responses within the relationship with the therapist. Such therapist behavior does not have to be overt; it can be communicated in very subtle ways, such as lecturing a client or making "accusatory interpretations." Lecturing is often a veiled form of anger or defensiveness, as are many interpretations which imply that clients are unconsciously childish, immature, or inherently defective.
If the therapist can, on the other hand, react to various provocations with increased concern, interest, and attempts to understand and be empathic with them - without any guilt or helplessness over the fact that the therapist can not possibly meet unreasonable demands - then the client will stop spoiling and get down to the work of therapy. This paradigm allows a systematic framework for understanding some commonly-used therapeutic counters to spoiling behavior, as well as for the innovation of some new ones.
A word of caution here: because this formulation posits a paradigm analogous to a variable reinforcement schedule, the therapist will get into trouble if he or she even on occasion reacts with rage, guilt, or helplessness. Avoiding these responses can be a real challenge, because borderline clients are experts at determining how best to elicit them. In a sense, they will alter their behavior in ways that are most likely to bring about countertransference. Here are some effective counters for the most typical borderline provocations, as well as some suggestions for countering errors. All of the suggested comments should be said by the therapist in a matter of fact, non-defensive tone of voice.
1. The patient makes wild accusations or exaggerated overgeneralizations such as "You don't care about me; you're only in it for the money" or "Everyone will exploit you if given half a chance; the world is nothing but a toilet bowl." The problem here is that if you agree, you are collaborating in their hyperbole and saying negative things about that denizen of the toilet bowl, yourself. On the other hand, if you tell patients in so many words that they do not know what they are talking about, then you are disqualifying them and putting them down. Solution: In this situation, one looks for the kernel of truth in the patient's statement, validates it, and ignores the hyperbole. To the first statement one might casually reply, "Well as you know this is the way I make my living." To the second, one might reply empathically, "It sounds like you must have been really mistreated in your life."
2. A variation on this theme takes place when the client uses a nasty tone of voice to imply some misdeed on the part of the therapist, but the lexical content of the verbalization does not overtly make an accusation. Most people, including therapists, tend to react to the tone of voice instead of the words; if on the other hand one responds only to the words, the client usually change to a friendlier tone. For example, a client with panic disorder responded to a recommendation for anti-depressant medication with the remark, "Oh, so you want to mess with my brain chemistry?" It sounded as though she suspected that her therapist was some devious, malicious mad scientist. He responded, "Yes, anti-depressants do alter brain chemistry" and went on to describe their purported mechanism of action just as one might do with any other patient. She agreed to the drug trial.
3. The client demands premature therapist actions or immediate and unattainable relief from unhappiness, or makes inappropriate and disruptive claims on the therapist's time. Solution: Admit helplessness. In anticipation of this kind of behavior, such as when the therapist gets an "emergency" telephone call at a strange hour, the first words in response can be, "There's probably not going to be much I can do to help you right now, but go ahead." Often this is enough to nip provocativeness in the bud, but if the patient goes on to criticize one's ineptitude, one can reply, "Yeah, I feel really bad that I can't make this better for you quickly." The advantage of these comments, which may seem to be paradoxical, is that they happen to be true. Another response to a late night phone call might be an earnest and non-accusatory, "Would you do me a favor and call back after 9 a.m.? I'd really appreciate it."
4. The patient makes absurd arguments or patently irrational statements, such as arguing that he takes dangerous drugs because they really are good for him. Solution: Respect the client's intelligence. Refuse to argue. One can say, "I won't insult your intelligence by arguing with that" or "You've already told me how miserable the drugs have made your life; there must be a good reason why you continue to act in such a self-destructive manner." If the client goes on to insist that he or she really does believe that drugs are good, the therapist can look for some way in which the client's self destructive behavior does in fact solve a problem for his or her family, and thereby makes the client "feel better" (but only in that one special sense). Alternatively, one can state, "I do not agree with you," without going on to argue about who is right or wrong. Many of these clients have never experienced a respectful disagreement in their lives.
5. The patient makes vague suicide threats, usually accompanied by some form of oppositional behavior. Solution: the paradoxical offer to hospitalize. Borderline clients are notorious for regressing and getting much worse in hospital situations. The hospital is the last place on earth they should be. A response that is very likely to avoid the need for hospitalization is, "If you really think you might kill yourself, then you need to be in the hospital, but only for your own self-protection. I'd really be concerned that you'd feel a lot worse about yourself than you already do." The client will usually respond with "I'll be alright, I guess" or words to that effect.
6. The client makes a disparaging remark or accusation about an important referral source. This is a variant on the infamous "staff split" in a hospital situation in which the client gets various people to fight with one another. In Transactional Analysis terms, it is a game of "let's you and him fight." Once again, defending the other person would be a disqualification of the patient. Solution: State, "I really was not there, and I have a different impression from my other contacts, so I am not in a position to make a judgment on this." (One major exception to this would be an allegation by the patient that a former therapist had a sexual relationship with the patient. Such an allegation should be taken seriously and appropriate medico-legal steps taken).
7. No matter what the therapist says, the client escalates with more and more outrageous accusations or oppositionalism. Solution: Inquire, "Why are you picking a fight with me?" Once again, the therapist refuses to argue the obvious by debating whether or not the client is indeed picking a fight. The client is then forced to either stop the behavior, or explore it.
8. The patient suddenly drops the transference acting out right in the middle of a heated discussion and begins to describe his or her family interactions. For example, the client may be in a rage over some imagined slight attributed to the therapist, and then suddenly begin to talk about family members as if the feelings about the therapist had never come up. In analytically oriented therapies, where transference is central, the usual response by the therapist would be to bring the discussion back into the transference. However, if the goal of the therapist is to stop acting-in and find out why the patient is acting in such a way, then the therapist should drop the transference battle and let the patient go on with the discussion of the family situation. Because of the abrupt nature of the change in subject, the therapist is often drawn back to the transference issue, because the interaction that preceded the switch feels unfinished. The feeling is somewhat akin to the way one feels when one has tried to get a loquacious friend off the telephone after a protracted conversation, and the friend suddenly says, "OK, good-bye!" The natural response is, "No, wait!" even though ending the conversation had been one's goal in the first place.
9. The patient gets the best of the therapist and the therapist reacts with a statement that disqualifies or insults the patient. Despite being well-versed in these kinds of interventions, the therapist may still find himself or herself eventually reacting in a negative way to the patient's provocation. As mentioned, such a response will induce the client to try even harder and longer to get you to overreact the next time. Solution:
A. Be good natured about your error. After all, you are only human. Be able to laugh at yourself. Say, "Gee, I sure did get frustrated with you that time."
B. Apologize for your error, but not for the feelings that led to it. Example: "I am sorry for sounding so critical, but I just had the feeling that you were dismissing everything I said out of hand."
2. Looking for reasonable motives for dysfunctional behavior.
The therapist should consistently maintain that the patient's apparently dysfunctional behavior must have some understandable and reasonable motivation; the patient is not behaving in a problematic way because the patient is crazy, immature, cognitively impaired, malevolent, masochistic, or mentally retarded. Therapists should maintain a positive regard about the patient's motivation and intelligence, without necessarily condoning BEHAVIOR.
The therapist should counter patient verbalizations that use or imply negative explanations.
EXAMPLES: If the patient describes his or her own jehavior as self destructive, or implies that this is the case, the therapist might make the following type of intervention: "You certainly must have a good reason for doing that to yourself; you are certainly not enjoying yourself and I don't believe in masochism." A variation on this for a patient stuck in an abusive relationship is: "You certainly must care a lot about that person or you wouldn't put up with that."
3. Avoiding use of accusatory interpretations and lecturing.
The therapist should not belabor the obvious, instruct the patient on the obvious drawbacks to certain courses of action, or imply that the patient's reactions are not mature or justified. The therapist may point out that patient's reactions might seem to be unjustified, but that the therapist suspects otherwise.
4. Accepting patient's reactions to therapist's hypotheses.
This item is applicable when the therapist presents an hypothesis about the client's affects, thoughts, conflicts, or relationship patterns.
The therapist should not INSIST on direct verbal agreement if agreement is IMPLIED by the patient. That is, if instead of overtly agreeing, the client goes on to give further examples and/or memories consistent with the therapist's guess, the therapist must not press the patient for overt agreement. For example, if the therapist says, "You must be furious with your Dad," and the patient responds with additional complaints about him, the therapist should take this as a sign that the patient agrees with the therapist's assessment.
If the patient overtly DISAGREES yet continues to offer confirmatory material, the therapist might or might not tactfully point this out, but again, must not INSIST that the guess is correct. If the patient disagrees and does not go on, the therapist should attempt to clarify in what respect the hypothesis is incorrect. If the patient agrees with the therapist merely to please him or her, this will eventually be revealed by inconsistencies and incongruities in the patient's material.
5. Instructing patient to keep spouse informed about therapy.
The therapist should instruct married patients to keep the spouse informed about significant issues in therapy (even if marital issues are not involved directly with the patient's complaints), and occasionally check with the patient to see if this instruction is being followed. Inquiries regarding the spouse's reactions will also serve this purpose. If the patient refuses to discuss the therapy with the spouse, the reasons for the refusal should be explored. The therapist should also express concern that refusal to keep the spouse informed may lead the spouse to attempt to subvert what the patient and therapist are trying to accomplish.
6. Asking follow up questions.
Therapists should follow interesting leads, ask for clarification of vague or confusing statements, ask for specific examples of misbehavior by other family members, and run down unspoken implications. The therapist should keep an eye out for judgments masquerading as descriptions (e.g., "he always wants to dominate me") and descriptions masquerading as explanations (e.g. "I can't speak at the business meeting because I am afraid of public speaking"), and pursue the description or the explanation that is being avoided by the client.
7. Questioning the patient about what would happen if the problem were somehow solved, and pursues the answer.
The therapist should trace the adverse consequences of the patient solving whatever difficulty he or she is presenting. To almost all problems, there is a conventional solution which seems obvious - so obvious in fact, that the therapist should assume that the patient has already thought of it. Presentation by the therapist of such a solution would lead to a game of "why don't you - yes but."
The therapist should first pose the Adlerian question, "If I could magically make this problem go away, what would be the downside?" (Variations: "If somehow you could get over your fear of asking women out, what additional problems would that create?" "You must have a good reason for not following your friend's advice to tell your father that your affairs are none of his business"). The client should then be helped to find a likely adverse consequence entailing some sort of problematic negative reaction from a spouse or important family member. If the patient is confused by the question, the therapist might ask the patient to visualize having successfully overcome the problem and then ask, "What's wrong with this picture?" Alternatively, the therapist might ask the patient directly who might be affected negatively.
The therapist should not accept as complete responses which involve further mortification by the patient, such as, "if I got up the nerve to ask a girl for a date, I would probably end up making a fool of myself over dinner." In such a case, the therapist should go a step further (e.g., "What would be the downside if you were able to make a totally successful relationship?)"
The therapist should not accept as complete answers that indicate that the negative consequence would solely be existential anxiety (e.g. "if I gave up my rituals, I'd the start picking at my skin til I bled"). Again, the therapist should go a step further (e.g., "Well that just means that you would in fact be very anxious about what your success would mean, but what would that anxiety be about?").
In cases where the negative reaction the patient fears comes from a spouse, and the patient seems to be avoiding an obvious solution to the marital problem, this line of inquiry can again be used to find out about the downside of solving the marital problem. The therapist would pursue the issue of who in the patient's family of origin might be negatively affected if the patient were somehow magically able to have a happy marriage.
8. If the material is not developing, offering hypotheses.
This item applies to those sessions in which the therapist's attempts to get more interactional and genogram data from the patient result in any of the following:
A) The patient is consistently quiet or withdrawn.
B) The patient repeats the same stories over and over again without lending any deepening to the therapist's understanding of the client's family dynamics.
C) The patient seems to be making idle chit chat that does not address central concerns or family issues.
In these instances, the therapist should offer the patient speculations about interpersonal processes that might trigger problematic feelings or behavior. Such speculations can be based on any information concerning the patient and his/her family that is already available, and/or descriptions of typical patterns in other patients with similar problems. Such suggestions should be made in a tentative and non-threatening manner (e.g., "I don't know if this applies to you or not, but in other families where a woman's career choice is an issue, mothers are often jealous of their daughters. The daughter gets to do things the mother was not free to do. I wonder if this might apply to your situation?").
9. Focusing on ambivalence and mixed messages in patient and his/her family members.
The therapist should attempt to focus on individual family members' communication and behavior patterns, as reported by the patient in therapy, which indicate ambivalence and confusion over various role functions and mutual expectations.
The therapist might for example ask about incidents which seem to contradict the patient's opinion about a mother's views on various matters (e.g., "You say your mother expects you to drive her around all the time. However, you said she asks you at times when it's most inconvenient for you. She has to notice that this strengthens your resolve to refuse her requests").
An important indicator that such a question is in order is that a patient or family member is exhibiting oppositional, distancing, or ambiguous behavior.
10. Focusing on cross motive reading.
The therapist should attempt to clarify what happens when various family members (including the patient's spouse) read one another's intentions and motives simultaneously, especially in those situations where ambivalence and mixed messages reign. This is done in order to understand family patterns at the systems level. The therapist should try to show the patient how cross motive reading leads to incorrect or incomplete assessments of family member motivation.
11. Tying patient problems at work, problems with peers, or dream material into issues or role functions from the family of origin.
This item apples when the therapist tries to keep the basic therapy strategy on track when:
A) The patient digresses on to temporary problems (even repetitive ones) with peers and co-workers/supervisors. The therapist should attempt to find parallels between such problems and the relevant patient/family dynamics, and to show the patient why family issues prevent or make difficult resolution of the described conflicts.
B) The patient presents dream material. Often patients with previous analytic or gestalt therapy will bring in dreams because this was expected by the previous therapist. The therapist should attempt to link dream themes and symbolism to previously identified areas of family dynamic interaction, thereby further clarifying them. The therapist associates dream elements to previous material from the patient's therapy. If no links are apparent, the therapist should make a comment to that effect.
12. Provision of rationale for interpersonal, family-of-origin focus.
The therapist should discusses the relationship between the dynamics elucidated in items #9 and #10 and the patient's:
A) current symptomatology
B) dysfunctional relationship patterns, and/or
C) self-destructive/self-defeating acting out.
The therapist should try to impart to the patient that the family dynamic patterns, as manifested by specific family verbalizations or behavior, reinforce the patient's difficulties.
The therapist should be alert to, and attempt to counter, patient resistance to the interpersonal focus. If the patient questions the therapist's focus before the therapist has enough information to make a strong case, the therapist should:
A) Tell the patient that such patterns are the primary difficulty in many patients who have similar problems
B) List whatever minimal evidence is available that the patient may be in a
similar position, and
C) Describe this list as suggestive that the therapist's line of inquiry will yield fruit, particularly in light of the absence of any strong competing hypothesis.
If the patient offers a competing hypothesis that is incomplete or overly pat, the therapist should tactfully point out that there must be more to it. If the patient offers an competing hypotheses that seems to be unreasonable, the therapist should tactfully express puzzlement over apparent inconsistencies or logical fallacies, especially if they might indicate family involvement in the problem that is unacknowledged. A common example of a pat explanation is the "single traumatic event hypothesis" (e.g. "My continuing depression over the last 20 years stemmed from being fondled one time by the teenager next door when I was 6 or "My anxiety about going to school was caused by the 7th grade English teacher who humiliated me in front of the class"). The therapist might then inquire as to the family reaction to the event, or what else was going on in the patient's life at that time.
A therapist should never ignore a patient's reservations about the interpersonal focus.
13. Tying marital issues to family of origin issues.
This item is applicable to those patients whose chief complaints (or concerns developed as therapy progresses) center around marital problems. It is only applicable AFTER problems of cross motive reading and ambivalent expectations within the marital relationship have been brought out. The therapist should attempt to correlate these problems to input from the family of origin of the patient and/or the spouse's family of origin. Such family input may include such things as negative comments about the spouse, ambivalent or confused role expectations, or parental jealousy of the patient's marriage. The therapist should indicate how and why the family of origin issues make resolution of the marital difficulties far more difficult than they might be otherwise.
Establishing the relevance of the family of origin to the marital issue may involve the use of the Adlerian question as described in time #7.
14. Interpretation of the patient's bind.
The therapist should attempt to discuss and be empathic with the consequences to the patient and his/her family members if the patient were to give up self destructive/ self defeating/misery producing behavior patterns. These feared consequences should be both probable and serious (e.g., mother might get depressed and suicidal, parents may divorce, etc.).
15. Positively reframing selfishness as altruism.
This item is applicable when a patient responds to the interpretation described in item #14 with the proposition that he/she doesn't care what happens to his/her family, and that his/her motivation for maladaptive behavior is somehow selfish. The therapist should mention to the patient the obvious logical contradiction between self-destructive behavior and selfishness (e.g., that some behaviors such as destructive rages or over-eating can be made to look gratifying, but that the experience, not to mention the consequences, is anything but. The patient is too intelligent to be unaware of this). The only "selfish" motive that the therapist can agree to is the patient's wish to avoid the anxiety associated with watching his family suffer.
16. Praising patient's altruism.
This item is applicable when, in response to the interventions described in items #14 and #15, the patient begins to flagellate himself/herself for being such a patsy. The therapist should respond with praise for the client's caring and concern, and suggest that perhaps there is a way better than self-sacrifice to express it (e.g. "I think it's great, especially in this day and age, that you are so sensitive to your father's concerns. You are really a caring person. Perhaps there's another way to express that concern without destroying yourself in the process").
17. Suggesting benign motives for significant others without condoning their behavior.
This item is applicable when, in response to the interventions rated in items #13 and #14 or at any other time, the patient begins to angrily attribute negative motivations to the behavior of significant family members. That is, whenever the patient begins to blame the misbehavior of others on their being malevolent, crazy, or mentally retarded, the therapist should suggest that perhaps the others are actually reacting badly because of their own internal conflicts and sensitivities. The therapist may bring up any information, previously shared by the patient, which indicates that the family member in question really does care or can act intelligently. This intervention sets the stage for the next intervention (see item #18), giving a rationale for exploring genogram material which might put the family misbehavior in a more understandable light.
18. Giving rationale for gathering genogram data.
The therapist sets the stage for the gathering of genogram information. Such information is later used to clarify the family dynamic patterns and their origins over at least three generations. The therapist should inform the patient that a strategy for altering destructive interpersonal patterns can best be worked out if the patient and therapist can figure out the nature and causes of negative family member reactions. This, in turn, can best be established by examining the background of the family members in question.
19. Actively seeking genogram material.
The therapist should actively and persistently pursue information that will help clarify family dynamics, with the ultimate goal of helping the patient be empathic with important family members. This can be accomplished by direct questioning, follow-up questions, and hypothesizing about possible interrelationships. If the client does not know important information, please refer to item #20.
20. Coaching patient to seek out collateral sources of information.
The therapist should encourage patients to seek out alternate sources for unknown information, including interviews with other relatives (particularly older ones), interviews with the parents themselves, examination of existing family trees, or even looking up old newspaper articles. Generally, traditional genealogical sources such as immigration records or county records do not give usable information regarding relationship patterns, so their use should not be encouraged. If role playing is required to coach a patient on how to extract information from a resistant relative, then the role play should be carried out as described under applicable items in Section III.
21. Protocol for conjoint sessions.
This item describes procedures to use when a patient requests that a spouse or relative come to a therapy session, and when the relative is actually present.
Patients often request conjoint sessions in order to have the therapist get additional information, tell others directly about the issues in therapy, or to have the therapist directly mediate disputes. In a sense, these are requests for the therapist to do what the therapist wants the patient to do for him/herself. The therapist should not take over these tasks for the patient, as the patient is of course expected to eventually learn how to handle these problems without the help of the therapist. Nonetheless, one or two conjoint sessions with a given relative or spouse may still be useful; they can help speed up the learning process. The therapist should follow these procedures when the patient requests conjoint sessions:
A) The therapist says that, in order to be most helpful, he/she needs to be free, as the need arises, to bring up any information that the therapist already knows. Hence, permission to do so (so that confidentiality is not an issue) is requested and obtained from the patient. The therapist may agree not to bring up certain items specified by the patient in advance, such as an extra-marital affair, but must be free to bring up the issues that may have led to the affair. Patients who refuse are warned that the conjoint sessions will probably not be of much help.
B) The therapist should inform the patient about HOW the therapist plans to begin the conjoint session. The therapist plans to ask for the significant relative's opinion about what the PATIENT's problems are. The therapist then assures the patient that this approach does NOT imply that the therapist believes that the interpersonal problem is the fault of the patient alone. The following rationale for the recommended approach is given: it serves two purposes. First, the relative is apt to anticipate that the patient and therapist, having already formed a relationship, will gang up against him/her. The focus on the patient's difficulties is reassuring to the relative on that point. Second, the relative's opinion will tell both the patient and therapist something about how the relative is reading the patient's motives.
During conjoint sessions, the therapist should :
A) Start the conjoint session with the agreed upon intervention, AND
B) As the session develops, boldly bring up any relevant issues, known from earlier sessions, that the patient is clearly avoiding. The therapist should bring up the issue in a matter of fact way, and then immediately throw it back to the dyad without much additional comment. These issues may include:
a) Dyadic interactions from the past that bear on a current misunderstanding within the dyad. b) Issues in therapy on which the relative should have been informed but has not been. c) Questions about family history the patient is afraid to ask.
d) Patient thoughts and feelings previously expressed to the therapist, but about which the patient is being vague or ambiguous in the conjoint session.
22. Providing explicit hypothesis regarding the genesis and maintenance of the patient's self-destructive behavior and symptoms.
The therapist should make a TENTATIVE interpretation about the family dynamics which reinforce the patient's dysfunctional behavior or symptomatology. In doing so, the therapist sets the stage for offering the solution to the problem. If there is more than one significant issue, there may be more than one interpretation. The therapist should spell out which issues are central and salient, and which are secondary and less salient. Interpretations should be presented as hypotheses, not fact.
The therapist should:
A) Review and clarify the interrelationship patterns and cross motive reading, elucidated earlier in therapy, which reinforce the patient's difficulties.
B) Make an informed guess about why family members behave as they do based on the genogram information previously obtained. The therapist should add that this element of the hypothesis is subject to direct confirmation from the involved relatives.
23. Handling questions about blame.
This item is applicable for those sessions in which the patient either puts the blame entirely on him/herself for the problem (other than in situation covered under item #16), or begins to blame other family members individually (e.g., "Dad did this to me"). The therapist should attempt to replace blame with both the idea of shared personal responsibility and empathy for others.
The therapist should try to get across two points to the patient: first, the patient was not forced, but volunteered to make sacrifices because of his/her care and concern. Second, the whole family shares the whole problem; no one is any more responsible for it than anyone else. Everyone is responding to his or her own conflicts. The therapist should, if possible, describe a commonality between the experiences and conflicts of the patient and the blamed relative.
In those situations in which the patient begins to flagellate him/herself for not understanding the problem better prior to therapy, the therapist should reassure the patient that in the past: A) the patient had no way of knowing the reasons for the behaviors of other family members, and B) the conclusions that the patient had reached were in fact logical and based upon the evidence at hand.
24. Presentation of outline of solution to the problem and provision of a rationale for it.
The therapist should present the idea that the solution to the problem rests with empathic metacommunication. The therapist should inform the patient that:
A) Significant others who reinforce the patient's problem behavior and symptoms can be confronted in a way that will get them to stop doing that.
B) That, if successful, the patient will then feel freer to behave and feel differently.
C) That problems must be discussed openly in order to be solved.
D) That, while the patient is not ultimately responsible for changing the behavior of others outside of the patient-other relationship, the behavior within the relationship MUST change if the patient changes his/her responses.
E) That the patient's efforts may possibly be quite helpful to the confronted target, and will most certainly be far more helpful than the sacrifice the patient is already making.
25. Addressing initial patient resistances to the solution.
This item describes how to handles initial resistances to metacommunication. The therapist should be alert to the following resistances, and if present, employ the listed countermeasure.
A) "My family members can not handle such a discussion." Counter: the therapist, while praising the patient for his/her desire to protect relatives from unpleasant feelings, makes the point that people are stronger than they may appear. In fact, protecting the others actually backfires in two key ways. First, significant family members may seem fragile because they feel fragile. They overreact precisely because everyone around them is treating them as if they were weak. Such reactions make people doubt themselves. Second, stopping problem-solving discussions in order to avoid unpleasant feelings prevents the others from resolving issues and eventually feeling better. The therapist may also inform the patient that the other is already feeling depressed and anxious anyway, regardless of whether the patient brings up the issue or not.
B) "My family is not amenable to such a discussion." Patients frequently believe that their family is more difficult to talk to than any other family in existence, and/or that all possible approaches have already been tried unsuccessfully. Counter: reassure the patient that the therapist has seen the solution work with the most dysfunctional of families, and that perhaps there might be some approaches that the patient is unaware of. If the patient still refuses, the therapist can ask the patient to reserve judgment on proceeding until after the patient and therapist have had a chance to complete the role play.
C) The patient wants nothing to do with the family; they are just too awful. Counter: demonstrate that the family still generates strong feelings in the patient even if contact is minimal, that such feelings indicate that the patient still cares about them regardless of what they have done. Point out that the patient really WOULD want a relationship with them IF they changed their behavior, which is exactly what the therapist might help bring about.
D) The prospect of bring up touchy issues is just too terrifying. Counter: name the fear (groundlessness), explain what it is, be empathic without reinforcing the belief that the fear is unbearable, and reassure the patient that the hardest step is getting started, but that the process gets easier as it goes along.
E) "I shouldn't be the one that has to do this; they should take care of this themselves." Counter: point out that the patient's sacrifice indicates that he/she already IS taking responsibility, and besides, the patient is now the only one with enough understanding to do the job.
The therapist should coach the patient on the following strategies (which are not idiosyncratic for any one patient or family but are applicable in almost all cases):
A) The patient should think of him/herself as an observer as well as a participant.
B) The patient should find a way to praise motivation of significant others and question only their actions.
C) The patient should tactfully verbalize anger, not attack or act out.
D) The patient should tactfully verbalize confusion when the motives of the significant others are ambiguous.
E) The patient should avoid blaming statements like "you made me do..." or "you never really cared about me."
F) The patient should use disclaimers when describing his/her reactions to significant others such as "I know you wanted me to be successful, but it often appeared to me that you did not" or "I know you really do care about me but..."
G) The patient should go back and apologize for any blaming or attacking behavior on his/her part which might have derailed earlier attempts at metacommunication, without apologizing for the feelings involved.
These general principles may be brought up and made explicit in advance of the role play or taught only as client errors on these points arise during the role play. When the patient can do these things spontaneously, the therapist need not spell them out. The therapist should be sure that the patient is aware of them before sending him/her out to confront relatives.
2. Actively asking patient about spouses or peripheral relatives who may interfere with homework assignments or triangulate the patient's problem-solving efforts.
The therapist should explore with the patient questions about which relatives, if any, might try to subvert the patient's efforts to metacommunicate with salient significant others. Salient figures are usually parents or stepparents but may include any primary caretakers, role models, or family leaders. Potential triangulators include other salient figures, the patient's spouse, siblings, aunts, uncles, grandparents, or even - in unusual cases - close family friends. The therapist should ask pointed, probing questions about various relatives who are likely triangulators.
3. Presentation of detriangulation strategy.
The therapist should present the overall strategy for detriangulating spouses and peripheral relatives (if any such triangulators were identified: see item #2) from the metacommunication process with salient figures. The therapist should tell the patient that the object of discussions with these relatives is to:
A) Inform the relative about the patient's plans and the justification for them.
B) Ask the relative what concerns he/she has about the consequences of the patient's plan. These concerns are generally nearly identical with the concerns that the patient him/herself expressed initially. For a spouse, concerns usually center around a fear that the patient will not get the hoped-for reaction from the salient figure and will then decompensate in some way. The spouse may also have concerns that the patient's new-found freedoms will adversely affect the spouse's relationship with the spouse's own family of origin. (If the spouse has not been informed of the course of therapy all along, the spouse may feel betrayed). For siblings and other relatives, the concerns usually center around a fear that the salient figure will notbe able to handle the confrontation, and may decompensate in some way, or thatthe confrontation may create tensions in other important dyadic relationships within the family.
C) Reassure the relative on the concerns. The therapist should coach the patient to tell the relative that the patient has had similar concerns him/herself, and that the patient and therapist have worked out a strategy that the patient believes will avoid any harm being done to anyone.
D) Make the following type of statement to the potential triangulator: "I really think it would be best if I handled this myself, so I would appreciate if you did not talk to Mom about this before I have had a chance to do it. However, if you feel that you must warn her or discuss with her the issues as they apply to you, then go ahead and do so."
In order to implement this basic strategy and handle any idiosyncratic reactions which might come up between the patient and the potential triangulator, this therapist may need to role play the interaction with the patient. In this case, the role play should be performed as described in all other applicable items in this section. The above strategy is imparted either by direct education or through incorporation into a role play.
4. Detriangulation of interfering spouses/peripheral relatives prior to beginning confrontations with salient figures.
If at all possible, the therapist should try to stick to the basic strategy of attempting to neutralize relatives who may interfere with the patient's confrontations with salient figures PRIOR TO attempting such confrontations.
5. Initiation of role playing exercises.
The therapist should begin a role playing process as part of teaching metacommunicative strategies for solving the patient's difficulties. Although preferable, the patient need NOT actually get "in character;" role play responses such as, "Dad would respond by saying..." are acceptable.
6. Starting role playing with role reversal.
This item applies when the therapist begins a role play with the patient:
A) whenever some relative who has not been played before is involved, or
B) if the therapist is starting to coach a new strategy or procedure with a relative who has been involved before (e.g., when a therapist who has worked with the patient on extracting genogram information from mother goes on to work on a direct confrontation with mother).
The therapist should always begin with a role reversal (i.e., have the patient play the target while the therapist plays the patient).
7. In role reversal, trying out different strategies and altering according to patient feedback.
The therapist attempts to develop a strategy for achieving a specific goal with a targeted relative (e.g. getting genogram information, discussing family dynamics, or directly confronting the other with a relationship issue). The therapist should try out different approaches, and then shape a strategy based on feedback from the patient who is role playing the relative. The goal is to develop a final approach with a high likelihood of success.
The therapist continually modifies the strategy during the role play by using information, generated by the patient while playing the target, about the potential reactions of targeted others. The information so used is information about responses by the other to interventions that the THERAPIST has tried out during the role play. (Coaching about errors in metacommunication that the patient him/herself might initiate is done during direct role plays - i.e., AFTER the therapist and patient trade places).
The therapist may stick with one approach and try no others, provided that the initial approach is well received by the targeted other (as played by the patient), and can be modified into a successful strategy using feedback.
Alternate strategies for confrontation include:
A) Discussing the current difficulties using past generations as a metaphor and then slowly moving into the present relationship.
B) Confronting the targeted other with the patient's worries about that other, without offering suggestions or advice about how the other person should take care of the problem.
C) Moving right into a direct confrontation about how the target's behavior affects the patient.
D) Starting a discussion with a wish for more closeness as a lever for discussing distancing behavior.
E) Asking the target for advice on how to handle a difficulty that the patient is experiencing outside of the target-patient relationship. The outside difficulty should parallel a difficulty that the target has also experienced within the family (e.g., when the patient's father always gives in to the mother's unreasonable demands, "Mom, I need your advise. My husband is following me around like a puppy dog. How do you think I should handle it?").
The therapist should abandon strategies that can not be successfully modified and refine those that can be used in order to neutralize negative reactions from the target. Anything that causes the significant other, as played by the patient during the role play, to attack, withdraw, or become overly defensive should lead the therapist to alter the strategy under consideration.
The therapist should be alert to disqualifications by the targeted other (as played by the patient), and alter the strategy to employ a countermeasure designed to neutralize the disqualification. The patient is thereby coached to employ the appropriate countermeasures. The following is a list of disqualifications and countermeasures:
A) Borderline disqualifications - see list under section II, item #1.
B) Subject changes - sticking to the subject (e.g., "we need to discuss that (new) subject further, but first let's finishing talking about...").
C) Irrational arguments - tactfully expressing confusion or pointing out contradictions.
D) Double binding - comment on predicament.
E) Blame shifting - acknowledge kernel of truth (e.g., patient admits own contribution to the problem while clarifying how his/her behavior was based on a misunderstanding; acknowledges contributions of other family members without criticism of their motives).
F) Fatalism - "I, too, used to think that you just had to accept these problems."
G) Nit-picking over patient's examples of troublesome interactions - "Well perhaps that wasn't the best example but I think you know what I'm talking about."
H) Accusations that the patient is over generalizing, and offering counterexamples - agree with other's counterexample but reframe as due to ambivalence.
I) Walking out - patient tries again at a later time.
If the role play is being used to re-design a strategy after an initial attempt at in vivo metacommunication has failed, the therapist should incorporate information about negative responses from the relative and an hypothesis about how to alter it.
8. Beginning direct role play after role reversal phase is complete.
After a strategy is devised during role reversal, the therapist should change roles with the patient and allow the patient to try out and practice the strategy. If the patient refuses to trade places, but expresses confidence that he/she can confront the significant other using the strategy agreed upon, and is able to demonstrate by verbal report understanding of the strategy and knowledge about potential difficulties, the therapist need not insist. However, practice during the therapy is preferable.
9. Incorporating feedback from the patient during direct role play.
This item is applicable for sessions in which direct role plays take place.
In playing the part of the targeted relative, the therapist should demonstrate defensive or other negative reactions by the targeted other when the patient:
A) does not maintain empathy during the role play, or
B) does not press on with the metacommunication strategy when the therapist, playing the targeted other, reacts with distress.
The therapist should be alert to blaming or attacking statements by the patient playing him/herself, and to respond (as the other) in a negative way. The negative response should be consistent with the other's past behavior (described earlier in therapy or seen during the role reversal stage). The goal is to teach the patient to become aware of how she/he might subvert the strategy by reacting emotionally.
10. Offering worst case scenarios during direct role play.
During direct role plays, the therapist should play the significant other as being as difficult and disqualifying as possible, consistent with the known characteristics of the targeted other.
11. Checking with the patient regarding accuracy of therapist's portrayal of the targeted other.
The therapist should check with the patient from time to time as to whether or not the therapist's portrayal of the targeted other is accurate. The therapist should ascertain if he/she is responding to the behavior portrayed by the patient in the role play in a way that the patient deems likely. This is often done through direct inquiries. Overt questioning is not always necessary, however (e.g., when the patient makes asides during the role play such as "That's just what she would say").
12. Continuing direct role play until the patient makes no major errors and is confident about proceeding in vivo.
The therapist should persist with the role play until the patient appears competent to confront the target and confident of his/her ability to do so. The therapist should try to continue direct role playing until the patient maintains empathy, sticks to the strategy, and proceeds with persistence.
13. Describing and prescribing homework.
After the strategy for confronting a targeted relative has been established and practiced, and the patient has agreed to proceed, the therapist should attempt to complete three tasks:
A) Set a time and place for the metacommunication to take place. This involves helping the patient devise a strategy for getting the target alone in a place where the conversation can take place without distractions, and deciding exactly when and where this will happen.
B) Instruct the patient to proceed with the interaction until the goal of the conversation has been reached, or until the patient does not know how to continue, or until the target reacts negatively in a way that the patient can not handle. If the patient gets stuck, he/she is instructed to beg off by saying something like, "I'm not sure how to get this across; let's discuss this more later." The patient should be instructed to write down, at the conclusion of the conversation, everything that was said as closely to verbatim as possible, and return to therapy for further instructions.
C) Reassure the patient that no uncorrectable errors can take place; if the patient blows his/her cool, he/she can always go back and apologize.
14. Asking for an explicit and complete report on how the homework proceeded.
This item is applicable for sessions after homework has been assigned. The therapist should inquire whether or not the homework conversation took place, and ask for a blow by blow account of everything that was said. If elements that had been incorporated into the assignment are missing from the patient's report (i.e., the patient does not mention addressing points that were rehearsed in role playing), the therapist must ask specifically if those points had been brought up. Please refer to the homework checklist at the end of this manual for further details.
15. Using report on homework to re-design strategy and explore patient resistances to proceeding.
This item is applicable for sessions following a homework assignment. The therapist should:
A) Inquire about the reasons if the homework (or parts thereof) was not done, and explore the patient's resistance if he/she was hesitant to do it.
B) If the patient had problems during the metacommunication process, offer the patient an hypothesis about why the problem took place and how it may be handled (e.g., how the targeted other may have misread the patient's comments, or felt blamed by them). A new strategy should then be devised. If necessary, role reversal and direct role play may be employed to redesign the strategy.
C) If the homework was a success, instruct the patient about what the next step will be (e.g., bringing up other issues, going on to a different target, etc.).
16. Continuing role plays and homework until all issues and all figures are confronted or until stalemate.
The therapist should stick with the therapeutic process through to the end. The therapist should continue the role playing and homework until the patient has successfully confronted all salient figures about all primary and secondary issues, or until the patient elects, despite the therapist's efforts, to discontinue the process for whatever reason.
In cases where all issues and figures have not been confronted, the therapist should continue to work with the patient's resistances or concerns until the patient adamantly refuses to go on. The patient may refuse because he/she believes enough has been done, or because his/her anxiety over a particular issue or figure is too high. The therapist should express concern that therapy may not be as effective as it might be if the patient were to do the whole assignment. Ultimately, the patient makes the final decision regarding how far to proceed.
1. Discussing the game without end.
The therapist's should educate the patient about the game without end. A successfully confronted figure may test the patient (or may have already done so) to see if the patient is really serious about wanting their relationship to change in a specific way. For example, a once tight lipped husband may begin to share his feelings as the patient requested, but in an obnoxious way, so that she may be induced to criticize him for doing the very thing she asked for, i.e., sharing his feelings.
The therapist should inform the patient that such events are likely, and coach the patient on how to handle this type of problem. Generally, the patient should be coached to make statements of the following type: "I'm very glad that you're starting to tell me how you feel, but it's hard for me to listen if you do it in front of my boss." The goal is to help the patient avoid falling quickly into old patterns due to the game without end phenomenon.
2. Discussing relapses.
The therapist should educate the patient about expecting and handling relapses of old behavior patterns. The therapist should BRIEFLY mention that:
A) old habits die hard, so that
B) old patterns of behavior may recur from time to time, but that
C) the patient now has enough skills to recognize such occurrences and put a stop to them through discussions with the involved other.
3. Praising the patient for his/her own contributions to the therapy.
The therapist should praise the patient for the patient's efforts in therapy. The therapist should make the following type of statement: "I've really been impressed by the way that you've taken what we've talked about and put it to use."
4. Encouraging the patient to experiment with new behavior patterns and new types of relationships.
This item applies in those instances when the patient does not spontaneously start to experiment with activities that were fearfully avoided in the past (e.g. looking for a better job, attending parties, dating non-abusive men).
The therapist should encourage new behavior, obtain the patient's commitment to do a particular activity by a certain date, or advise the patient to date a variety of types of people prior to getting involved. In cases where family reinforcement of old patterns is no longer a factor, but old fears remain, the therapist might suggest to the patient that he/she work out a program of gradual exposure. (Under research conditions only, to avoid contamination of the treatment conditions with direct systematic desensitization by the therapist, this program should be briefly recommended in general terms, but should not be worked out in detail by the therapist).
5. Arrangement of follow up.
This item is applicable for the last regularly scheduled therapy meeting. The therapist should arrange follow up in 4-6 months. Other options, for patients who wish to tapir off sessions, are scheduling 2-3 month follow-ups or gradually but quickly reducing the frequency of sessions.
The therapist should go over the following checklist after each session in which a patient reports back the results of a homework assignment in which there was a confrontation with a salient figure about current interactional patterns.
1. Which relative was confronted?
2. Which primary issues and secondary issues were discussed?
3. For each issue for each relative:
A) Did the patient communicate understanding of the context of the target's behavior?
B) Did the patient acknowledge his/her own contribution to the problem?
C) Did the patient refer specifically to the target's ambivalence
or mixed messages, and their effect on the patient?
D) Was there some sort of confirmation, overt or covert, from the target?
E) If there was abuse between patient and target, was there some expression of regret or apology, directly or indirectly?
F) Did the patient avoid blaming?
G) Did the patient request some specific change in the relationship?