Common Factors in MFT Supervision Presented by: SHANNON M. ELLER, LPC, LMFT, RPT, CPCS, NCC Brighter...

Common Factors in

MFT SupervisionPresented by:

SHANNON M. ELLER, LPC, LMFT, RPT, CPCS, NCC

Brighter Tomorrows Consulting, LLC1815 North Expressway—Suite B; Griffin, GA 30223

Phone: (770) 486-7424, Fax: (770) 412-1087www.brighter-tomorrows.com

Where Supervision Fits

TEACHING RESEARCH

SUPERVISION / CLINICAL WORK

The State of Couple Therapy Couple therapy effect size (.84) is as good as or better

than individual therapy and many medical treatments (Shadish & Baldwin, 2002).

About six effective couple therapy approaches, yet none have been shown to be differentially effective:◦ Behavioral, Cognitive-Behavioral, Integrative Behavioral, Emotionally-

Focused, Integrative Systemic, and Insight-Oriented

Yet, in only about 50% of couples do both partners show improvement.

30%-60% show significant deterioration at 2-year follow up (Halford & Snyder, in press).

Furthermore, couple therapy effectiveness has not improved over the last several decades (Miller, Hubble, and Duncan, 2007).

The Problem with Model-Driven ParadigmHammer/Nail

◦“Clients shouldn’t have to add ‘figure out how to adapt to my therapist’ to their already lengthy list of problems.” (Blow, Sprenkle, & Davis, 2007).

Sources of couple’s stress varies considerably; so should interventions designed to help them.

Some models ‘fit’ some clients better than others (Johnson & Talitman, 1997).

Possible SolutionsCommon Factors Paradigm:

◦Thorough assessment of client variables that may have a bearing on treatment outcome;

◦Distill smallest meaningful transportable units of an approach;

◦Know how to ‘reassemble’ these units into a coherent yet idiosyncratic treatment approach tailored to each unique client;

◦Treatment proceeds on the basis of the assessment and evolving treatment dynamics—inductive and deductive (Pinsof, 1995; Snyder, 2007).

Moderators effecting pacing/selection of interventionsPartner’s commitment to conjoint

therapy and views towards their own roles in relationship problems;

Acute psychosocial stressors or individual crises precluding sustained attention to relationship issues;

Family organization regarding patterns of influence and emotional attachment.

Moderators effecting pacing/selection of interventions, continuedPartner’s effectiveness in enlisting support

but limiting intrusion from individuals outside their relationship;

Intensity and pervasiveness of hostility;

Levels and resiliency of emotional warmth and positive regard;

Communication skills involving emotional expressiveness, listening, and decision making.

Moderators effecting pacing/selection of interventions, continuedAdditional relationship skills in domains such as

parenting, money management, and physical intimacy;

Disruption of relationship functioning by unrealistic assumptions or standards, faulty attributions, or related cognitive processes;

Recurrent maladaptive relationship patterns rooted in early developmental experiences or operating beyond immediate awareness;

Communication skills involving emotional expressiveness, listening, and decision making.

Moderators effecting pacing/selection of interventions, continuedMuch of this work is left to be

done.What would you add?

◦ Four Horsemen;◦ Levels of emotional reactivity;◦ Cognitively, affectively, of behaviorally

oriented?

Common Factors PresuppositionsIntimately familiar with diverse models

◦ Be passionate about theory rather than a theory.

Ability to respond to unique client demands in the moment with appropriate, coherent interventions that fit within a larger principle-based treatment plan.

Know whish theory-specific treatment units fit together well, at what point in therapy, to what end, and in response to which client variables.

A Sequential, Pluralistic Approach

PRIMARY THERAPEUTIC TASK

Establish developmental sources of relationship distress

Challenge cognitive components of relationship distress

Promote relevant relationship skills

Strengthen the couple dyad

Contain disabling crises

Establish a collaborative alliance

Pinsof’s Integrative Problem-Centered Therapy

Any good integrative model should be specific about which theories and techniques should be used with clients at specific points in treatment.

Progresses from:◦ Present behavioral to historical intrapsychic◦ Broad community to couple to individual

“Shifting Down the Matrix”◦ A “Failure Driven” Progression

Resistance Lack of success Lack of diagnostic evidence

Problem-Centered Orientation /Context Matrix

Orientations Contexts

Family/Community Couple Individual

Behavioral

Bio-behavioral

Experiential

Family of Origin

Psychodynamic

Self Psychology

Davis & Piercy CF Meta-ModelModel-Specific Interventions Aimed at Altering the Cycle

1. Emotional Regulation2. Cognitive Reframing

3. Behavioral Skills

Interventions shift thecycle by helping the

couple:

1. Slow down the process2. Stand meta to self and other3. Take personal responsibility

Partner 2Behavior

Partner 2Affect

Partner 2Cognition

Partner 1Behavior

Partner 1Affect

Partner 1Cognition

Davis & Piercy, 2007a, 2007b

Common Factors Unique to MFT

1. Conceptualizing difficulties in relational terms;

2. Disrupting dysfunctional relational patterns;

3. Expanding the directing treatment system;

4. Expanding the therapeutic alliance.

Common Factors Supervision

The goal of common factors supervision is to foster:◦Formal and en vivo assessment skills of

relevant couple dynamics;

◦Thorough familiarity with diverse models, their portable elements, and the extent to which they fit with and are distinct from elements of other models;

◦Selection and pacing of different clusters of interventions in terms of a larger principle-based developmental framework.

Common Factors Supervision, continuedCommon Factors supervision is

isomorphic to Common Factors therapy.

◦ Sensitive to therapist development:

An entire semester spent mastering a model is appropriate for some;

Gradually start to focus on assessment, integration, selection, pacing, etc. as skill/knowledge base grows.

Common Factors Supervision Structure

Formats:◦Case Presentation,◦Raw Data (video), and◦Live supervision.

Case PresentationSupervisor asks supervisee to

evaluate client system based on “Broad CF” dimensions:◦Client characteristics,◦Therapeutic alliance, ◦Hope/expectancy, and◦Therapist characteristics.

Client Characteristics What are the self-identified strengths in this client

system? How ready is the system for change?

◦ Stages of Change literature: Pre-contemplation Contemplation Preparation Action Maintenance

◦ Coach supervisee on motivational interviewing techniques, if necessary.

How self-aware is the client system? How well is the client system able to utilize existing

resources? How open and receptive is the client system to

therapist feedback?

Client Characteristics, continuedAre my style and interventions matched with the client’s level of motivation? If not, what can I do to match their motivation and stage of readiness for change?Beginning:

1 2 3 4 5 6 7 8 9 10Not proficient Proficient

End:


Comments:

Client Characteristics, continuedIs my conceptualization of the nature of the problem too much of a stretch for them?

Beginning:


End:


Comments:

Client Characteristics, continuedIf my clients don’t ‘buy’ my conceptualization, am I adapting it to them? What specifically am I doing to accomplish this?

Beginning:


End:


Comments:

Client Characteristics, continuedDo I regularly assess what my clients think is not helpful as well as helpful about the therapy?

Beginning:


End:


Comments:

Therpeutic AllianceTasks – the major activities engaged in;

how therapy is conducted (structured)

Goals – the desired outcomes; the extent to which the client experiences the therapist as working with them on the problems for which they are seeking help

Bonds – the affective quality of the relationship like trust, caring, and involvement

Interpersonal Subsystems(Pinsof & Catherall, 1986)

Self – therapist’s relationship with me

Other – therapist’s relationship with my significant others

Group – therapist’s joint relationship with me and my significant others

Within – relationship in treatment between me and my significant others

Integration: Helping Supervisees Link Tasks, Goals, and Bonds Together for Their ClientsSpecific tasks and therapist

interventions should be linked to treatment goals.◦ Don’t take it for granted that your clients

automatically understands why they are being asked to practice a skill or complete s homework assignment between sessions.

Alliance may be threatened, however, is a therapist does not make his or her rationale explicit.

Direct vs. Indirect SystemsThe Structure of the Psychotherapeutic

System

Patient System Therapist System

Indirect IndirectDirect Direct

Help Supervisees to Think Systematically about the Alliance in Individual TherapyDon’t lose sight of the key players outside of the

room—the indirect system.

Supervisees might assess the following questions with their clients:◦ How does your relationship with the important people

outside of this therapy room affect your progress in therapy?

◦ Do you feel that I as the therapist appreciate how important some of your relationship are to you?

◦ What would the people what are important to you think about the way your therapy is being conducted?

◦ Do you feel that the people who are important to you would trust that this therapy is good for your relationships with them?

Therapeutic Alliance, continuedAm I on the same page as my clients regarding the goals of therapy?

Beginning:


End:


Comments:

Therapeutic Alliance, continuedAre my tasks credible to my clients?

Beginning:


End:


Comments:

Therapeutic Alliance, continuedIs our emotional bond strong enough that the clients feel safe?

Beginning:


End:


Comments:

Hope and ExpectancyWhat is your client system’s previous

experience with mental health providers?

What does the system expect this therapy to be like?

How hopeful is the client system that they will be able to overcome the obstacles that have brought them to therapy?

Hope and Expectancy, continuedIf my clients come to therapy demoralized, am I taking specific steps to remoralize them?

Beginning:


End:


Comments:

Hope and Expectancy, continuedAm I conveying a sense of hope?

Beginning:


End:


Comments:

Hope and Expectancy, continuedDo they believe that the treatment plan provides a credible way out of their problems?

Beginning:


End:


Comments:

Therapist CharacteristicsHow confident are you, the supervisee, that

you will be able to help this system?

What makes you a good fit for this client system? What makes working with them a potential challenge?

How easily can you identify areas of health and signs of strength in this system?

How, if necessary, will you modify your primary model or approach in working with this system?

Therapist Characteristics, continuedAm I using a sufficiently high level of activity and structure so as to interrupt dysfunctional patterns and encourage family members to face their cognitive, emotional, and behavioral issues, yet not so much that I am overly controlling or inviting defensiveness?Beginning:


End:


Comments:

Therapist Characteristics, continuedAm I keeping the level of emotional arousal in the sessions moderate?

Beginning:


End:


Comments:

Therapist Characteristics, continuedAm I choosing interventions that are a good match for the learning style of these clients?

Beginning:


End:


Comments:

Focusing Supervisees on the Narrow Common Factors

Couple/Family Behavioral Cycle◦When husband ____, what does wife

do?◦When wife ____, husband responds

by ____?◦Is there an identifiable pattern (i.e.,

attack/attack, avoid/avoid, demand/withdraw)?

◦Track frequency, intensity, duration of problem behavioral cycle.

Pantheoretical InterventionsIf applicable, what am I doing to help my clients change their behavior?

Beginning:


End:


Comments:

Focusing Supervisees on the Narrow Common Factors, continued

Couple/Family Cognitive Cycle◦What are each partner’s core beliefs

and automatic negative thoughts about the other?

◦What cognitive distortions (dichotomous thinking, mindreading, overgeneralization, etc.) exist for each partner?

◦How do each partner’s own standards and assumptions about marriage/relationships influence the interaction?

Pantheoretical Interventions, continuedIf applicable, am I helping my clients to change their cognition?

Beginning:


End:


Comments:

Focusing Supervisees on the Narrow Common Factors, continued

Couple/Family Emotional Cycle◦How are emotions expressed in the

relationship? Overall? Around the presenting problem?

◦What are each partner’s primary and secondary emotions?

Pantheoretical Interventions, continuedIf applicable, am I facilitating healthy, affective expression, regulation, or attachment (affective change)?

Beginning:


End:


Comments:

Pantheoretical Interventions, continuedAm I helping family members ‘slow down’ their process(es)?

Beginning:


End:


Comments:

Pantheoretical Interventions, continuedAm I helping family members stand outside of their own process(es)?

Beginning:


End:


Comments:

Pantheoretical Interventions, continuedAm I encouraging family members to take personal responsibility for their own contributions to the dysfunctional cycle?

Beginning:


End:


Comments:

Video SupervisionSupervisor could ask supervisee to

present footage around:◦The system’s interactional or problem

cycle;◦The therapist’s attempt to frame the

problem in relational terms;◦The therapist’s active work on linking

task, goals, and bonds along with other alliance building behaviors;

◦The therapist’s attempts to: Slow down the process for the system, Help clients stand meta, Coach clients on taking personal responsibility.

Live Supervision: Narrow Common Factors Inventory, Post-SessionWhat, if anything, did you do to help your

clients change the cognition around their problems?

What, if anything, did you to help your clients change the behavior around their problems?

What, if anything, did you do to facilitate affective expression or regulation for your clients?

From what model(s) did the interventions you used in session come?

Live Supervision: Narrow Common Factors Inventory, Post-Session, continuedRegardless of the specific method used during

session to try and interrupt the dysfunctional cycle, you might ask your supervisee:◦ How did you help the system members to ‘slow down’ the

process?◦ How did you help the system members to ‘stand meta’

and develop a self-observing stance to their own process?◦ How did you encourage system members to take personal

responsibility for their own contributions to the dysfunctional cycle?

In group supervision, if your supervisee doesn’t realize how they have activated some of these common factors, don’t forget to utilize other team members for support and feedback.

Other Variables

Do I have a sincere belief in my approach that both enables me to ‘sell’ my view of the problem and its remediation, and also seems credible to my clients?

Beginning:


End:


Comments:

Other Variables, continued

Is my approach organized and coherent enough to give me confidence that I know what I’m doing, and to inspire this same confidence in my clients?

Beginning:


End:


Comments:

Case-Specific Questions and GoalsQuestion/Goal:

Beginning:


End:


Comments:

Common Factors Supervisory ToolsSee Appendices A & B in

Sprenkle, Davis, and Lebow (2009);

Common Factors Client Interview Assignment;

Supervisors can also apply the Common Factors lens to their relationship and alliance with their supervisees;◦Am I on the same page with my

supervisee about the tasks, goals, and bonds of supervision?

Common Factors in MFT Supervision Presented by: SHANNON M. ELLER, LPC, LMFT, RPT, CPCS, NCC Brighter...

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