PPSY571-Family Therapy Midterm

Structural Family Therapy Key Figure

Minuchin

Genograms were first developed and popularized in clinical settings by:

Monica McGoldrick

Clear Boundaries

"Normal" boundaries, close emotional contact, maintain sense of identity. Each culture has unique style of balancing closeness and distance.

The Macy Conferences

-A group of scholars and researchers met to discuss how groups of things operate to form a "system." -Gave birth to general systems theory and cybernetic systems theory.

Law, Ethics, & Competency

-A solid understanding of ethical principles, such as confidentiality, is a prerequisite for applying theory well -Without a firm grasp of laws and ethical standards that relate to professional mental health practice is dangerous and you won't be practicing too long

Joining

-A unique term for the therapeutic relationship. -Joining is more of an attitude than a technique •The glue that holds therapeutic system together •Attitude of joining requires: •Strong and clear sense of connection and affiliation •Equally clear sense of distance and differentiation

Erikson Stage 5: Identity vs. Role Confusion

-Adolescence age (13- 19 yr) -Peers are the dominant social influence in adolescence. As the body changes into adult form, the individual decides who he or she is becoming in relation to peers and what his or her sexual and occupational roles will be. A positive outcome is reflected in a sense of personal identity and a direction for the future.

Paradoxical Intervention

-Also called symptom prescription, involves instructing clients to engage in the problem behavior in some fashion. -"Paradoxical" because they do not follow linear logic — to the client. - make sense to use when... (a) when making any other therapeutic changes disrupts the family's current level of stability or (b) when the problem seems "uncontrollable" from the client's perspective: -Paradox with families that avoid change -Family stable around problem member; resistant to attempts to change perception -Therapist restrains or cautions against certain changes or encourages relapse to prevent it -Clients with symptoms they claim they cannot control; symptom prescription changes context of problem behavior •If context changes, meaning of behavior must change If meaning changes, thoughts, feelings, and subsequent behaviors automatically change also

Therapist Role/Relationship in Experiential Therapy

-Based on Roger's therapist qualities: • Congruence • Accurate empathy • Unconditional positive regard -Satir's quality of being, therapeutic presence, is difficult to define. -The more congruent therapists are, the better they create therapeutic warmth and humanity characterized by Satir -Strives to be authentic; doesn't follow pretenses considered professional or appropriate boundaries. -Fully themselves and do not hide this from clients. •If bored, they show it; if annoyed, they express it. •If they see an elephant in the middle of the room, they say something. •Being authentic at this level is for client benefit: •Models type of authenticity therapist wants client to develop and creates an environment in which client can do this

Social Courtesy

-Before discussing the problem, the therapist ensures that all members have been properly greeted. -During this first social stage, the therapist is assessing interactions and mood -During social stage, therapist engages in casual social conversation to make clients comfortable and reduce sense of shame •"The model for this stage is the courtesy behavior one would use with guests in the home" (p. 15)

McGoldrick's family life cycle states that new members enter into the family in two ways (which ones?)

-Birth -Marriage

Irreverence

-Captures the therapist's relationship to the problem (not the client) -Irreverent regarding the "catastrophic" appearance of problems -Doesn't acknowledge "personality flaw," "illness," "unresolved childhood issue" -Felt in therapist's confidence and unpanicked response to problem -Systems are inherently self-correcting; therapist maintains an openness, creativity, and flexibility

Stages of Family Development

-Couple formation -Families with young children -Families with school-age or adolescent children -Families with grown children -At each stage, family renegotiates boundaries to define levels of closeness/differentiation to support members' growth needs.

Directives (MRI & Strategic Therapy)

-Directions for the family to complete a specific task -Tasks rarely act as linear solutions to problem; instead they "perturb" system's interaction patterns to create new ones -Get people out of ruts with the smallest change possible -If a couple is arguing, they argue but change key elements •Ex: Directive to have "normal" argument, but fully clothed in tub -Clients experience simultaneous shift in emotions, insight, and behavior

Straightforward Directives

-Do something different: alter behavioral sequence -Stop a behavior (rarely used) -Good advice; psychoeducation (rarely if ever used)

Complementary Relationships

-Each party has a distinct role that complements the other, often resulting in a form of hierarchy. (i.e. pursuer/distancer, emotional/logical) -Conflict in these relationships is less frequent because there are clearly defined, separate roles. Often become a problem with couples when their roles become exaggerated or rigid

Family Roles

-Each person's role in family assessed to understand function of problem. -Possible roles: •The martyr •The victim or helpless one •The rescuer •The good child or parent •The bad child or parent

Erikson Stage 3: Initiative vs. Guilt

-Early childhood age (3 - 5 yr) -Family members are the primary "significant others" during this period. The child begins to discover and learn by using his or her body and language, and, ideally, the family encourages him or her by acknowledging the importance of these activities. If relationships are favorable in this stage, the child develops the ability to set goals and devise and carry out plans without infringing on the rights of others. • During this period the primary feature involves the child regularly interacting with other children at school. -Central to this stage is play, as it provides children with the opportunity to explore their interpersonal skills through initiating activities. • Conversely, if this tendency is squelched, either through criticism or control, children develop a sense of guilt. They may feel like a nuisance to others and will therefore remain followers, lacking in self-initiative.

Complementary Roles

-Examples include pursuer-distancer, emotional-logical, visionary-planner, and easygoing-organized. -These dynamics can provide a counterbalance that is enjoyable and helpful, especially early in the relationship; however, often these roles become exaggerated and rigid, creating a feeling of being "stuck."

Systems Thinking

-Family is a system, a group of individuals who coordinate meaning and their understanding of the world -Family as a whole is greater than sum of its parts -All behaviors make sense in the context of family -No one member is to be blamed

Family Games

-Focuses on the relational rules for how the family interacts, rules that are not consciously created but rather naturally emerge from the family interaction pattern

Self-Actualization

-Fulfilling potential and living authentic and meaningful life •The more a person self-actualizes, the greater the sense of self-worth and self-esteem.

Treatment plan

-General set of directions for how to address client concerns -Select a path: develop this with therapeutic tasks--including how to build a working therapeutic relationship ---and measurable client goals

Goals of Experiential Family Therapy

-Goal of model is transformation: Achieve optimal realization of person's full potential.Two sets of practical goals for treatment planning: •Relational, family, or systemic goals -Congruent communication -Ability to communicate authentically while responding to needs of self and others -Goal: Help family develop ways for members to communicate so system's homeostasis doesn't need initial symptoms to maintain balance -Examples: •Increase congruent communication in relationships with spouse, parent, or child•Change family rules and "shoulds" to general guidelines •Individual goals -To promote the self-actualization of all members of the system • Self-actualization: Fulfilling potential and living authentic and meaningful life • The more a person self-actualizes, the greater the sense of self-worth and self-esteem. -Examples: • Increase a sense of self-worth and self-compassion. • Reduce defensiveness and the use of survival stances.

Use of Co-Therapists

-Good cop/bad cop -One therapist is nurturing and the other more confrontational. •Provides strong base of support as well as process for addressing difficult issues. -In providing a balance of support and challenge, co-therapy team models a co-parenting relationship

Social Constructivism

-Has been the most influential in development of new psychotherapy models, such as solution-focused, collaborative, and narrative therapies. -Textual metaphor: people "story" their lives to create meaning -Relational focus: all about relationships; person's lived reality is rationally constructed; personal identity and an individual's symptoms are related to the social systems of which they are a part; changing one's language and description of a problem alters how it is experienced; Truth can be determined only within relational contexts (objective outsider perspective is impossible)

Double-Bind Messages (MRI & Milan)

-In a therapeutic double bind (counterparadox), no matter what you do, you do something different, something that moves you in a new direction. -More-of-the-same behavior prescription -Undo doublebind message in a family or relationship -Problem-generating form: No matter what you do, you're wrong Therapeutic form: No matter what you do, it's different•Ex: A wife demands her husband spontaneously be romantic. If he does what she asks, it's not spontaneous; if he does nothing, he doesn't care. • Therapeutic doublebind has him show his romantic side in any way other than his wife demands • If he follows directive, he initiates new romantic behavior; if he doesn't and uses wife's suggestions, he does so without command

Homeostasis

-In families refers to the unique set of behavioral, emotional, and interactional norms that create stability for the family or other social group. Dynamic not static.

Erikson Stage 1: Trust vs. Mistrust

-Infancy age (0 - 1 yr) -The infant learns to trust his or her world and to know what to expect if he or she receives affectionate and dependable care from the mother figure: -i.e. a positive relationship with the primary caretaker results in a sense of trust and optimism. -Success in this stage will lead to the virtue of hope. -By developing a sense of trust, the infant can have hope that as new crises arise, there is a real possibility that other people will be there are a source of support. -Failing to acquire the virtue of hope will lead to the development of fear.

Invariant Prescription (Milan Therapy)

-Intervention that is not varied across families -Severs covert coalitions between parent and child -Used primarily with families of anorexic or schizophrenic children -Creates secret between parents. Creates clear boundary between unified parents and child. How it works •Parents arrange date (or other outing), don't tell children where or why•Creates secret between parents •Ends inappropriate coalitions •Creates clear boundary between unified parents and child. •Child loses status of special confidant • Lessens emotional burden and results in fewer problem symptoms •Effective with modern parents who overemphasize open communication

Disengagement and Rigid Boundaries

-Lead to relational disengagement; autonomy emphasized at expense of emotional connection. -Excessive tolerance for deviation, failing to mobilize support for one another.

Enmeshment and Diffuse Boundaries

-Lead to relational enmeshment; don't make clear distinction between members. -Strong sense of mutuality/connection at expense of individual autonomy.

Clinical documentation

-Leave a trail to track where you've been and helps you find your way back if you get lost: others as well as you can see why and how you proceeded -Helps in 2 highly prized aspects of therapy: getting paid by 3rd party payers (i.e., insurance) and avoiding lawsuits (i.e., the state lets you practice)

Map the Family Structure

-Mapping is the visual representation of a family and of its members' relationships with each other and with the outside world

Erikson Stage 8: Integrity vs Despair

-Maturation/old age (65+) • As we grow older (65+ years) and become senior citizens, we tend to slow down our productivity, and explore life as a retired person. It is during this time that we contemplate our accomplishments and are able to develop integrity if we see ourselves as leading a successful life. • Erik Erikson believed if we see our lives as unproductive, feel guilt about our past, or feel that we did not accomplish our life goals, we become dissatisfied with life and develop despair, often leading to depression and hopelessness. • Success in this stage will lead to the virtue of wisdom. Wisdom enables a person to look back on their life with a sense of closure and completeness and also accept death without fear.

Erikson Stage 7: Generativity vs Stagnation

-Middle adulthood (30 - 65 yr) -The people one lives and works with are most important during this stage. The adult becomes less self-involved and moves into a time of mentoring: a "generative" person exhibits commitment to the well-being of younger generations. -We establish our careers, settle down within a relationship, begin our own families and develop a sense of being a part of the bigger picture. • We give back to society through raising our children, being productive at work, and becoming involved in community activities and organizations. -By failing to achieve these objectives, we become stagnant and feel unproductive. Success in this stage will lead to the virtue of care.

circular questioning (Milan)

-Most useful techniques when working with more than one person in the room. -Reframing the problem for all participants without the therapist having to verbally provide a reframe 1. Behavioral SEQUENCE questions: To trace the entire sequence of behaviors that constitute the problem: "After John got mad, what did mom do? Dad? What happened next?" 2. Behavioral DIFFERENCE questions: When clients start labeling people and assuming that a particular behavior is part of a person's inherent personality: Ask for a definition of the label then ask if others the client knows behaves simmarily? 3. COMPARISON and ranking questions: Useful for reducing labeling and other rigid descriptions in the family: "Who is the most upset when Jackie has an episode? Who is the least affected?" 4. BEFORE-AND-AFTER questions: When a specific event has occurred, these questions can be useful in assessing how the event affected the family dynamics: "Did you and your mother fight more or less after your dad got sick?" 5. HYPOTHETICAL circular questions: Offer a scenario and have family members describe how each is likely to respond.

Negative Feedback Loop

-No new information, system remains the same - homeostasis. -Any behavior outside homeostatic norms is quickly corrected with negative feedback to maintain systemic homeostasis. When this doesn't work the new information is required to reach a new homeostasis.

Neutrality (Milan)

-Nonpartiality toward particular family members or problem descriptions AND also multipartiality. -also implies not becoming attached to particular meanings, descriptions, or outcomes

Goals of Systemic Therapy

-Not linear instruction, but interrupting the problem sequence of behaviors, allowing the family to reconfigure itself around the new information that has been introduced to the system -The main goal is to get people to behave differently and so to have different subjective experiences -Help clients find ways to love without dominating, intruding upon, or harming the other

Case conceptualization

-Our maps are considered this -Assessments of the client using family therapy theories

Symmetrical Relationships

-Parties have "symmetrical" or evenly distributed abilities and roles in the system: an equal relationship. -Conflict in symmetrical systems generally takes the form of two equals fighting until there is a winner: each is viewed and experienced as a relative equal, and the outcome is not predictable.

Manueverability

-Refers to the therapist's freedom to use personal judgment in defining the therapeutic relationship. -Therapist can be the expert, use the one-down stance or even be the "bad guy"

System-Reframing (MRI)

-Reframe is an alternative yet equally plausible explanation of the same facts -Considers symptom in relational system: how it helps maintain homeostasis -LIE: "If my husband doesn't call me he doesn't love me." -FACT: "Even if my husband doesn't call I know he sill loves me." -"FACT" that supports one categorization used to support another

Authentic Encounters

-Relies on in-the-moment authentic encounters to directly experience other in holistic way. -Therapist focuses primarily on family's emotional system rather than behavioral interactions. •When sensing boundaries or triangles, focus on emotional exchange between parties rather than actions. -Therapists "feel" their way through the system.

Congruent Communication

-Respectfully balances needs of self and others while responding appropriately and acknowledging context. • Client's communication stance can help design effective interventions. • Therapists can communicate with wide range of clients.

Boundaries

-Rules for managing physical/psychological distance in family members -Define regulation of closeness, distance, hierarchy, and family roles -Boundaries are organic, living processes

Erikson Stage 4: Industry vs. Inferiority

-School age (6 -12 yr) -The most important influences at this stage are people in the neighborhood and the school. The child starts to take on intellectual challenges, and, ideally, involved adults will guide and admire his or her efforts. To avoid feelings of inferiority, a school age child must master certain social and academic skills. • It is at this stage that the child's peer group will gain greater significance and will become a major source of the child's self esteem. The child now feels the need to win approval by demonstrating specific competencies that are valued by society and begin to develop a sense of pride in their accomplishments. • If children are encouraged and reinforced for their initiative, they begin to feel industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by parents or teacher, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his or her potential.

Asian American Families

-Share many cultural values, such as respect for elderly, extended family support, family loyalty, and high value on education, as well as values associated with self-discipline, order, social etiquette, and hierarchy. • Assess support available to the family• Assess past history of immigration • Establish professional credibility• Be problem focused/present focused • Be directive in guiding the therapy process • Provide reframing that encourages the family

Battle for Structure

-Should be won by therapist, who sets boundaries and limits for therapy. -Ensure necessary structure for change is in place: •That the necessary people attend therapy •That therapy occurs frequently enough to produce progress •That the session content and process will produce change

Post Modernism

-Skeptical of objective reality -Truth and realities are constructed, language and consciousness develop meanings -The values of objects -Reality is negotiated through relationships -Cultural traditions make a framework for (a) making meaning of our individual lives and (b) successfully coordinating our actions with others

Person-of-the-therapist

-Specific personal qualities are identified as competencies for mental health professionals -Integrity, honesty, diligence -Empathy, compassion, charisma, spirituality, transpersonal communication, patient responsiveness, optimism, and expectancies -Avoid advice-giving -Address countertransference

The Therapist Role and Relationship in Strategic Therapy

-Systemic and strategic therapies focus solely on resolving the presenting problem, with the therapist imposing no other goals or agendas. -Therapists see the presenting problem not as an individual problem but as a relational one, specifically an interactional one -Once the therapist has identified the interactional behavioral patterns and meanings associated with the problem, he or she uses one of many potential interventions to interrupt, not correct, this sequence -Therapists respect the family system, and have a deep trust that the family can reorganize themselves without the therapist forcing change -Adapt the client language and viewpoint -Use neutrality and collaboration -Use Intervene, maneuverability, and one-down stance

Feedback Loop

-Systems thinking is not linear, it happens not in a straight line — it happens in cycles, loops, contours. -All parts of the system are connected, so a feedback/change in one part generates waves of feedback/change that reach all other parts. -Thus, the action returns to the starting point (homeostasis) or in a modified form (new normal): either way we have a loop.

Observation Team (MRI)

-Teams would sit behind one-way mirror to observe sessions -Hallmark of MRI systemic viewing -Team could see systemic dance more rapidly/completely than therapist -Reason therapists still train with a mirror is to develop ability to see system's dynamics

Enactments

-Techniques in which the therapist prompts the family to reenact a conflict or other interaction -Used to assess and alter problematic interactional sequences •Map, track, and modify the family structure

Alliance

-The aim of structural family therapy is to ensure effective working of the family order to establish a harmonious atmosphere in a family. 1. Making an Alliance: The therapist should make an alliance with each family member so that he/she can understand how this family interacts

Self-Correction

-The key to maintaining stability is the ability to self-correct, which requires feedback.

Helplessness (one-down stance)

-The one-down stance is used to increase clients' motivation, often paradoxically by claiming, "I'm not sure if I am able to handle such a problem" -Paradoxical purpose. Usually used when client acts as if their situation is hopeless. -Works because in most systems there is a counterbalance: if one person is hopeless, the other feels compelled to be hopeful to maintain a balance.-

Diversity and Multicultural Competence

-The use of therapeutic theory is always con-textualized by diversity issues, which means that the application and applicability vary—sometimes dramatically—based on diversity issues, such as age, ethnicity, sexual orientation, ability, socioeconomic status, immigration status, etc.

General Systems Theory

-The whole is greater than the sum of its parts. -Systems can be viewed in terms of hierarchy, executive organization, and subsystems. -Systems strive toward self-preservation and therefore their members work in service of the system as well as themselves. -Systems operate using the same basic principles.

Evocative Responding

-Therapist elicits and captures the implicit aspects of a client's experience in a tentative manner. -The therapist will often ask questions about a client's present experience including internal responses and reactions to in-session dynamics. -Examples — a) "What's happening right now, as you say 'what about the kids?' What's that like for you?" b) "Your face just seemed to change now, can you tell me what is happening for you right now?" -Main Functions: Increases awareness and expands elements of experience to help reorganize the experience; accesses unclear or marginalized elements of experience and encourages exploration and engagement.

Heightening

-Therapist highlights specific responses or interactions to intensify a client's emotional experience. This enables the client to better engage his/her experience as it is made more evident. -Examples — a) "so you want to crawl into a ball, a tight ball, this is painful, so painful, when he says he still loves her, it hurts so deep, it's so painful, so difficult that you just want to crawl into a tight ball." b) "It seems like this is so hard for you, like climbing a cliff, it so scary, you're right on the edge, it's awful." c) "Can you turn to him and tell him, 'it's too hard to ask. It's too hard to ask you to take my hand?'" -Main Functions: Highlights and intensifies key emotions, experiences and new formulations of experience that help reorganize the interaction and relationship as important and yet vulnerable.

Validation

-Therapist reinforces that each partner is entitled to his/her emotional response and experience. -A clear message is given teach partner that there is nothing wrong or deficient about one's response. -Validation is important both for present responses and especially for newly expressed primary emotion. -Example — -"Yes, when you are in this kind of pain, of course you have a hard time concentrating, that is completely normal." -Main Functions: Legitimizes responses and supports clients to continue to explore how they construct their experience and their interactions. It also build alliance.

Empathic Conjecture

-Therapist works on the "leading edge" of a client's experience to move the client forward in his/her experience such that a new meaning can emerge. -Often these conjectures address the attachment fears related to self and others

Therapist Roles/Relationship in Structural Therapy

-Therapist's job is to find way to help family achieve desired change. -Do whatever it takes to make change happen. -Therapists' roles vary widely: •Producer: Ensures conditions that make therapy possible. •Stage director: Pushes family toward more functional patterns. •Protagonist: Directly uses himself/herself to alter stuck family interactions. •Narrator or coauthor: Collaboratively helps family revise their script.

Common threads of competency (diversity, L&E, research & evidenced based, person-of-the-therapist)

-Therapists need to be competent in a wide range of theories and techniques to be helpful to all of the clients with whom they work -Diversity and multicultural competence -Research and evidence-base -Law, ethics, and competency -Person-of-the-therapist

Family Life Chronology

-Timeline that includes major events in individual's or family's life: •Births and deaths •Important family events such as marriages, moves, tragedies, major illnesses, job loss •Important historical events such as wars, natural disasters, economic downturns -Gives both therapist and client insight into context of problem as well as strengths and resources that might exist.

Research and Evidence Based

-To be competent, therapists must be aware of the research and the evidence base related to their theory, client populations, and presenting problem

Erikson Stage 2: Autonomy vs. Shame and Doubt

-Toddlerhood age (2 yr) -A sense of self (autonomy) develops out of positive interactions with one's parents or other caretakers: -i.e. a toddler learns to master his or her body if the parents or other caretakers reassure him or her and set limits without smothering.

Systemic Therapy

-Truth: Contextual -Reality: Contextual; emerges through systemic interactions; no one person has unilateral control -Therapist as participant in therapeutic system -Therapist role: "Perturbing" system, allowing system to reorganize itself; no direct control of system -Therapies: First-Order Cybernetics & Second-Order Cybernetics

Post-modern Therapy

-Truth: Multiple, coexisting truths -Reality: Coconstructed through language and social interaction; occurs at individual, relational, and societal levels -Therapist is a nonexpert; coconstructor of meaning -Therapist role: Facilitating a dialogue in which client constructs new meanings and interpretations -Therapies: Constructivism, Social Constructionism, and Structuralism and Poststructuralism -Based on the premise that objective truth can never be fully known. • Objectivity is not humanly possible. • Language and words greatly affect how one's identity is shaped/experienced. • Three influential schools: Constructivism, social constructivism, and structuralism/poststructuralism

Humanism

-Truth: Subjective -Reality: Subjective; individually accessible -Therapist is the empathetic other -Therapist role: Creating a context that supports natural self-actualization process -Therapies: Satir's Communication Approach & Whitaker's Symbolic-Experiential Approach -Founded on phenomenological philosophy that prioritizes the individual's subjective truth. • Supportive, nurturing environments promote therapeutic change. • Includes: Carl Roger's client-centered therapy, Fritz Perl's Gestalt therapy, Virginia Satir's communications approach among others

Modernism

-Truth: objective -Reality: Objective, observable -Therapist is expert-hierarchial Therapist role: teaching, guiding clients in better ways of being and interacting -Therapies: psychodynamic and cognitive-behavioral

Double Binds (Catch 22)

-Two people in an intense relationship with high degree of survival value -Within the relationship, message is given that is structured with: a) primary injunction (request or order) and b) a simultaneous secondary injunction that contradicts the first. Receiver senses that he/she cannot escape or step outside the cognitive frame of the contradiction.

Unbalancing

-Used for extreme difficulties in hierarchy or when IP is being scapegoated. -Therapists use expert position to temporarily "join sides" with scapegoated individuals or subsystems that need stronger boundaries. -Done only briefly and with specific realignment goals in mind. •Only after more direct interventions, such as enactments and challenging assumptions, have failed. **LAST RESORT IN THERAPY

Mimesis

-Used to refer to process of accommodating family's way of being. -AKA imitation

Accommodating

-When elements of a system automatically adjust to coordinate their functioning -"Join" system by accommodating to its style:•How people talk, words used, how they walk, etc.

Prescribing the Symptom

-When the therapist attempts to exaggerate a specific symptom within the family to help the family understand how damaging that symptom is to the family. -The relabeling intervention is done within the session by the therapist to change the connotation of one symptom from negative to positive

Multipartiality

-Willingness to honor all perspectives.

Positive Feedback Loop

-Yes, new information is coming in, the system is changing. -In most systems, response to positive feedback is — return to homeostasis.

Erikson Stage 6: Intimacy vs Isolation

-Young adulthood (20 - 30 yr) -The main task during early adulthood is the establishment of intimate bonds of love and friendship. As the adult identity evolves, different sorts of relationships are attempted that lead to closeness. If such bonds aren't achieved, self-absorption and isolation or alienation will result. -Successful completion of this stage can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Success in this stage will lead to the virtue of love.

Sibling Rivalry

-competition between siblings, often for parental attention -It's hard enough for a child to compete with siblings in a nuclear family. When it's step-siblings that they're not entirely comfortable with, the problem can magnify. For a child who hasn't had to share a parent in a long time, that adjustment period might be a little bit longer

Coalitions

-cross-generational coalition is a subsystem that forms between a parent and child against the other parent or other key caretaker -Common family dynamic: •Mother has grown closer to children and has unresolved marital or parenting conflicts with spouse. •Father in coalition with children against the mother. •Family divides into "teams;" father and mother heading their team in opposition to other. •Coalitions very common in divorces. •Coalitions often covert.

Second-order Change

-is when a system restructures its homeostasis ("new norm") in response to positive feedback and the rules that govern the system fundamentally shift. -change after positive feedback. -solutions seem odd and illogical because they are introducing new rules into the system.

Survival Stances

-placator, blamer, superreasonable, and irrelevant; used to " survive" as a child during difficult times.

Cultural Competency

-sensitivity to factors such as race, gender, ethnicity, socioeconomic status, and sexual orientation and the ability to respond appropriately in a therapeutic manner to persons with a different cultural background than their own -Therapists who are not culturally competent risk undervaluing, misunderstanding, and/or pathologizing client behaviors

Subsystems

-smaller systems within the main system: parents together/parent and child -Some subsystems found in every family: •Couple •Parental •Sibling •Some families have other subsystems: •Gender-based •Hobbies/interests •Personalities •Most important subsystem issues: •Is there a clear distinction between the parental and couple subsystems? •Is there a clear boundary between the parental and child/sibling subsystems?

First-order Change

-system returns to previous homeostasis after positive feedback.

Multiculturalism

-the cultural groups within a region or nation and their needs -Assumption that conceptual, theoretical, and methodological frameworks already developed would be appropriate for everyone, regardless of color or background

Cybernetics

-the interdisciplinary study of the structure of complex systems, especially communication processes, control mechanisms and feedback principles. -With first-order cybernetics, the therapist is an objective, neutral observer describing the family as an outsider. Such therapy relies on assessment instruments and the therapist's perception of the family system. -Second-order cybernetic theory applies the rules of first-order cybernetics on itself, positing that the therapist cannot be an objective, outside observer but instead creates a new system with the family: the observer-observed or therapist-family system.

Process of Systemic Therapy

1. Assess interactional sequence and associated meanings 2. Intervene by interrupting the interactional sequence 3. Evaluate outcome and the client response 4. Interrupt the new pattern

Boundary Making

1. Definition: Special form of enactment targeting: •Over/under-involvement to help families soften rigid boundaries or strengthen diffuse boundaries. 2. Technique: Used to direct who participates and how. Actively setting boundaries. -Therapists interrupt habitual interaction patterns. •Allows members to experience underutilized skills and abilities. 3. Examples: -Asking family members to change seats. -Asking family members to move seats further or closer together or turn toward one another. -Having separate sessions with individuals or subsystems to strengthen subsystem boundaries. -Blocking interruptions or encouraging pauses for less dominant persons to speak.

Hierarchy

1. Effective: Parents set boundaries and limits while still maintaining emotional connection with children. 2. Insufficient: Parents not able to effectively manage child's behavior; often adapt a permissive parenting style. 3. Excessive: Rules are developmentally too strict/unrealistic and consequences too severe; almost always rigid boundary between children and parents.

5 steps to competent therapy

1. Map the Territory -Conceptualize the situation with the help of theory 2. Identify Oases and Obstacles -Assess the client's mental status and provide case management 3. Select a Path -Develop treatment plan with therapeutic tasks --including how to build a working therapeutic relationship--and measurable client goals 4. Track Progress -Evaluate client's response to treatment 5. Leave a Trail -Document what happens

Indirect Directives: Paradoxical Interventions

1. Symptom prescription: Instructing clients to engage in problem behavior in some fashion 2. Paradox with families that avoid change Family stable around problem member; resistant to attempts to change perception -Therapist restrains or cautions against certain changes or encourages relapse to prevent it Paradox with uncontrollable symptoms 3. Clients with symptoms they claim they cannot control; symptom prescription changes context of problem behavior•If context changes, meaning of behavior must change If meaning changes, thoughts, feelings, and subsequent behaviors automatically change also

Use of Touch

1. Then • Satir used touch to connect with clients and encourage/reassure them, underscoring emotional content and providing palpable support. • Used touch with children to help teach alternatives to violent behavior and model for parents how to manage difficult children. 2. Today • Touching generally discouraged because it can be seen as sexual harassment or make client uncomfortable. • Carefully consider legal and ethical issues of using touch. • Touch may be appropriate in certain practice and cultural contexts. • Coach clients in touching each other—their children and spouses—in more loving and helpful ways.

Communication Enhancement

1. What it is -Hallmark of Satir's approach; involves "ingredients of an interaction" combined with specific communication coaching strategies. 2. How it works -Satir had clients turn chairs toward one another and gave them prompts. •"Tell your partner how you feel about what happened Saturday night." •If client able to congruently address partner about this, prompt partner to respond in kind. •When client reverts to survival stance, interrupt conversation and suggest how to rephrase to make more congruent. •"Now, can you say that starting the statement with 'I' instead of 'you?'"

Family Cohesion

1. What it is -Increasing cohesion and authenticity of family relationships. -Increasing sense of love and meaningful connection between family members. 2. How it works -Cohesion: Emotional connection between family members •Characterized by strong sense of belonging, being loved, being wanted, and loyalty. -Interpersonal boundaries: Relational rules that regulate closeness and distance -Should allow each person to have freedom to be authentic and have strong emotional connection/intimacy between family members. -Transgenerational boundaries: Should allow for autonomy of nuclear family while encouraging connection with extended families.

Family Sculpting

1. What it is -Putting family members in physical positions that represent how "sculptor" sees each person's role in the family. 2. How it works -Each family member given opportunity to sculpt family as they see it. -Gives nonverbal, symbolic depiction of family process from each person's perspective. •Nonverbal confrontation that bypasses cognitive defenses •Able to literally see how he or she is contributing to problematic family process -Best to let each person sculpt before allowing discussion of sculptures. -Encourage family members to respect the subjective experience and deepen understanding of one another.

How many stages are in McGoldrick's Family Life Cycle?

8 stages

How many stages does Erikson have in his psychosocial stages?

8 stages

System Reframing

All behavior has reciprocal antecedents: •Person A affects person B's response, which then affects A's response, ad infinitum (A ・ B). •Highlights complementary relationships in family. -Removes blame from one person (IP) and "spreads" blame equally. -Pieces together members' description of problem and reframing to reveal broader systemic dynamic.

Successful resolution of a crisis in Erikson's stages result in the acquisition of

Basic virtues

Competency

Detailed lists of the knowledge and skills professionals need to effectively do their job

In a genogram, males are represented by a circle while females are represented by a square

FALSE

TRUE or FALSE: A genogram is the same as a traditional family tree

FALSE

TRUE or FALSE: Erikson placed a great deal of emphasis on the infancy stage as a crucial stage for identity formation

FALSE

TRUE or FALSE: Genograms do not show emotional relationships between family members

FALSE

TRUE or FALSE: McGoldrick's family life cycle stages begin in childhood

FALSE

Peers have the most impact on self-esteem in which stage of Erikson's Psychosocial stages?

Industry vs. Inferiority

Experiential Family Therapy Key Figure

Satir

Erikson's first stage involves trust and consistency of care by the caregiver to the infant, leading to a

Secure attachment

Softening Family Rules

Softening rigid family rules by changing them to guidelines. •Ex: Instead of "I should not get angry," family encouraged to revise limiting rule to "When I am angry, I will express this anger in a way that is respectful to the others and myself." •Satir encouraged families to have as few rules as possible and to be flexible. •Adapt them for each context and as children's developmental needs change

Evidence-based treatment

Specific and structured approaches for working with distinct populations and issues

Goals of Structural Family Therapy

Strengthen parental subsystem, Realign coalitions, establish boundaries

Extra Credit: TRUE or FALSE-Tom's Interpersonal Pattern is an easier approach to systemic conceptualizing of interpersonal patterns

TRUE

TRUE or FALSE: A genogram allows therapists to analyze hereditary patterns and psychological factors in relationships

TRUE

TRUE or FALSE: A genogram is a graphic representation of a family tree that displays detailed data on relationships among individuals

TRUE

TRUE or FALSE: Each of Erikson's psychosocial stages attempts to resolve some crisis in order to successfully move to the next stage

TRUE

TRUE or FALSE: Erikson was an ego psychologist while Freud was an Id psychologist

TRUE

TRUE or FALSE: For twins, a genogram would show the child links as being joined together

TRUE

TRUE or FALSE: McGoldrick views the family life cycle as changing, shifting, and refining itself constantly

TRUE

TRUE or FALSE: There is no limitation as to what type of data can be included on a genogram

TRUE

TRUE/FALSE: Erikson's Psychosocial Stages emphasized the role of culture and society more than sexual factors

TRUE

Parts Party

What it is •Group activity similar to family reconstruction, involves client identifying group members to represent aspects of the self. •How it works •Members enact generic characteristics (martyr, victim, savior) or famous figures to represent different aspects of self. •Client is better able to accept different aspects of self and identify contexts where they've been and continue to be useful.

Symbolic-Experiential Family Therapy Key Figure

Whitaker

This virtue is gained when one successfully navigates the ego integrity vs. despair stage

Wisdom

Blended Families-STAGE 5: COMMITMENT

• Accept that commitment means a choice to succeed • Recognize that the blended family has begun to feel solid and reliable • Be aware of traditions and rituals that have become ingrained • Take full responsibility for choices • Accept change as a non-threatening reality • Accept ambivalence, sadness and joy, closeness and distance • Coexist • Restore and renew difficult relationships • Begin to reap the rewards that your blended family has worked for!

STAGE 4 = STABILITY - COMING TOGETHER

• As the blended family begins to stabilize, the key attitude is mutuality, building a sense of "us" or "we" or "our family." • Responsibility for making family work well together is now shared by all, the family begins to look and act like a team. Acceptance of each other and tolerance of differences is much more prominent during this stage. • The family moves toward being close rather than being right. The family will still experience problems, but the reaction will be different. The family tends to pull together and cooperate rather than being chaotic and fragmented as in previous stages. • Feelings and thoughts are freely shared during this phase and respect is much more present. As the family continues to fine tune and become more and more efficient at being together, they begin to move into the final stage, commitment.

STAGE 3 = CRAZY TIME - THE PAIN AND DISAPPOINTMENT OF CRISIS

• At this stage, the highly charged issues find the blended families two groups on different teams. Suddenly everything seems to be out in the open, yet nothing gets resolved. Struggles between the marriage partners, combined with those of the two families snowball into one large battle. • The blended family has reached the point of CRISIS. In Greek crisis means decision or turning point and the final result of the crisis is a decision to either stay together or separate. Crisis forces the family to begin to resolve differences. For if they don't the blended family will not survive. • The process starts with renegotiating, rebuilding and creating a new set of rules for the blended family to live by. The OLD RULES WILL NOT WORK in the new setting. Attempts to push the old rules on the family will further delay the task completion at this stage. Many families get stuck here in trying to be right and do it the old way. • As movement through this stage begins, the family will begin to define new roles, rules, communication processes and decision making procedures. As the blended family moves through this very difficult stage, trust can begin to take root and grow. • Adolescent challenges are amplified in this stage and intensified. Most blended families tend to overlook the fact that teens in the family are in many turning points in their own individual development (think identity vs. role confusion). When a teen's individual development is out of sync with the family's development everyone is affected and crisis often erupts. Shifting custody and loyalty conflicts often manifest during this stage. The chaos and turmoil that occur during this stage can push the family toward resolution and the next stage. . . stability

Blended Families-STAGE 2: CONFUSION

• Begin to resolve decisions that you failed to negotiate during courtship • Let go of the notion that your blended family can make up for the past • Say final good-byes so new beginnings can happen • Avoid taking all stepchildren's misbehavior personally • Decide how to relate constructively with ex-spouse • Define and begin establishing step-parents' role • Work to create a system of shared discipline • Learn to share children and accept that they live between two homes • Explore any uncomfortable feelings about sexual attraction among family members • Clarify relationships with school • Discuss feelings, especially fears

Blended Families-STAGE 4: STABILITY

• Build a sense of family - "we"/"ours" • Become aware of the roles that have finally emerged • Connect with family members in a meaningful way • Share memories; build traditions and goals • Continue to plan family activities and enrich the couple relationship

Survival Triad

• Child, mother, and father and quality of relationship between them. • In this primary triad, a child learns how to be human. • The triad should serve as nurturing system for child. •When child is experiencing difficulty, therapist considers how the nurturing function of these relationships can be improved.

Cybernetic Theory

• Closely related, but more focused on social systems. • Most influence on family therapy. • They are self-correcting, moving towards dynamic homeostasis.

Hispanic/Latino Families

• Collectivistic • Dignidad (dignity) • Orgullo (pride and self-reliance) • Confianza (trust and intimacy)• Respeto (respect)• Simpatía (smooth, pleasant relationships) • Personalismo (Individualized self-worth) • Familismo (family connectedness) • Marianismo (female self-sacrifice) • Machismo (male self-respect and responsibility)

European American Families

• Consider using an existential approach, as it focuses on uniqueness • Consider incorporating universal techniques, such as genuineness, empathic understanding, and structuring • Majority of people in the U.S. • It is assumed that European Americans embrace WASP values such as individualism, mastery over nature, competitiveness, and Christianity, but that is not necessarily the case • Comprise of a diverse group of people

Blended Families-STAGE 1: FANTASY

• Decide where to live • Discuss money and discipline issues • Plan a marriage ceremony that includes children in a meaningful way • Begin to recognize and resolve leftover grief • Help children deal with fears and let go of fantasies about parents reuniting • Learn as much realistic and practical information about blended family living • Agree about whether to have an "ours" baby • Complete as many tasks as possible in this stage during courtship

McGoldrick Stage 4: Childless Couple

• During this phase the main tasks are: -Developing a way to live together both practically and emotionally -Adjusting relationships with families of origin and peers to include partner

McGoldrick Stage 1: Family of Origin Experiences

• During this phase the main tasks are: -Establishment of self in respect to work and financial independence -Maintaining relationships with parents, siblings, and peers -Completing education -Developing the foundations of a model of family life

STAGE 2 = CONFUSION - WHAT ARE WE DOING IN A BLENDED FAMILY?????

• During this stage everyone starts to sense that something is wrong, but no one really knows what it is. • Suppressed feelings start to emerge. • Fear of failure makes the parents anxious. Unclear roles cause confusion. Children begin to show indifference or hostility. • As the discipline dilemma deepens, tension rises. • Sex between the parents may still satisfy, but it will usually become less and less frequent. As the adults are confronted with the courtship tasks that weren't completed, they begin to doubt the decisions they have made. • Children sense the tension and begin to fear that maybe this family won't work either. To protect themselves from more loss, they either withdraw or stop building trust in the new step-parent. Boundary issues begin to flare. . . children become more and more confused and worried about the definition of the family. • Conflicting needs and expectations emerge, but most are left unexamined. As the differences emerge, family members are usually quiet during the initial stages and then gradually as the tension builds, the painful feelings begin to manifest and more and more often negative feelings are displayed and that moves the family into the next stage, which is crazy time.

McGoldrick Stage 7: Launching Children

• Emotional Process of Transition: -Accepting a multitude of exits from and entries into the family system. • During this phase the main tasks are: -Resolving midlife issues -Negotiating adult to adult relationships with children -Adjusting to living as a couple again -Adjusting to including in-laws and grandchildren within the family circle -Dealing with disabilities and death in the family of origin

McGoldrick Stage 2: Leaving Home

• Emotional Process of Transition: -Accepting emotional and financial responsibility for self • During this phase the main tasks are: -Differentiation of self from family of origin and parents and developing adult to adult relationships with parents -Developing intimate peer relationships. -Beginning work, developing work identity, and financial independence.

McGoldrick Stage 5: Family with Young Children

• Emotional Process of Transition: -Accepting new members into the system • During this phase the main tasks are: -Realigning family system to make space for children -Adopting and developing parenting roles -Realigning relationships with families of origin to include parenting and grandparenting roles -Facilitating children to develop peer relationships

McGoldrick Stage 8: Later Family Life

• Emotional Process of Transition: -Accepting the shifting generational roles. • During this phase the main tasks are: -Coping with physiological decline in self and others -Adjusting to children taking a more central role in family maintenance -Valuing the wisdom and experience of the elderly -Dealing with loss of spouse and peers -Preparation for death, life review, reminiscence, and integration

McGoldrick Stage 3: Premarriage Stage

• Emotional Process of Transition: -Commitment to new system • During this phase the main tasks are: -Selecting partners -Developing a relationship -Deciding to establish own home with someone. -Formation of Marital System -Realignment of relationships with extended families and friends to include spouse

McGoldrick Stage 6: Family with Adolescents

• Emotional Process of Transition: -Increasing flexibility of family boundaries to permit children's independence and grandparents' frailties • During this phase the main tasks are: -Adjusting parent-child relationships to allow adolescents more autonomy -Adjusting family relationships to focus on midlife relationship and career issues -Taking on responsibility of caring for families of origin

Blended Families-STAGE 3: CRAZY TIME

• Examine needs and expectations of family members to see which/whose aren't being met • Restructure and clarify boundaries between the two families • Be honest about problems that exist, don't deny them • Reduce power struggles and competition • Consider custody shifts if they seem in the child's best interest • Recognize crisis as a need for change. • Confront it and stick through it • Recognize which issues are not specifically blended family issues (abuse, alcoholism, adolescence, etc.) • Identify destructive blended family interactions (games)

Arab American Families

• Family is the most significant element in most Arab American subcultures • Traditionally, a patriarchal, hierarchical structure exists in the family • May be reluctant to seek family therapy • Be aware of the potential emphasis on honor and shame • Be aware of cultural context in which the family operates • Be mindful of the issue of leadership and importance of authority figures in family • Be attentive to the role of the extended family in decision-making • Be aware of the influence of culture on therapy • Consider a strengths-based approach • Balance activity so as not to be seen as a rescuer or a threat • Consider exploring identity issues • Concentrate on couple dynamics • When appropriate, focus on religious and other group support

Fantasy Stage: The Grand Illusion

• In this stage the family/couple are caught up in many fantasies concerning both the marriage and the family. Some common thoughts and dreams during this time are; • 1) This new marriage will return me to "square one," where I used to be before my previous marriage/relationship. • 2) I've finally found the "right mate/partner/one," so this time I'll get it right. • 3) The new step-parent can rescue the kids from the inadequacies or excesses of the absent biological parent. • 4) children often fantasize that their biological parents will magically get back together. • 5) There will be instant love between all blended family members. • 6) This will be easier than before. • 7) The general public will see and understand how great our new family is. • As the family begins to realize how much work is involved in a blended family and honest feelings come out about each other, the family begins to move into the next stage, confusion.

Mental Research Institute (MRI; a.k.a. The Palo Alto Group)

• Jackson, Watzlawick, Fisch, and many others • The Brief Therapy Project designed to find the quickest resolution to client complaints, typically relying on action-based interventions

African American Families

• Kinship bonds are strong • Religious orientation and spirituality • Cooperation • Motivation to achieve • Role adaptability • Caring parenting • Family structure • Strong work orientation

LGBTQ Families

• Life cycle issues are crucial to understand gay and lesbian family life • Gay and lesbian families are varied • Gay and lesbian couples have mixed levels of satisfaction in their relationships • Many gay and lesbian couples and families suffer from a lack of affirming role models • Gay and lesbian couples and families still face discrimination from society in general • Work with self to sort out feelings regarding gay and lesbian families, ethically we can not turn anyone away • Address both external and internal issues associated with being a gay or lesbian couple or family • Work with society at large and its institutions to deal with matters of prejudice and discrimination • Recognize that gay and lesbian families deal with matters besides their sexual orientation

Milan Systemic Therapy

• Mara Selvini Palazzoli, Gianfranco Cecchin, Giuliana Prata, and Luigi Boscolo formed the Milan team • Designed model embodying cybernetic systems theory of Gregory Bateson • Milan therapists closely attend to how client language shapes family dynamics

Battle for Initiative

• Needs to be won by client. • Therapists should never work harder than their clients. • Sometimes must let tension and crisis build until client develops incentive to change. • When client has greater motivation for change, process flows more smoothly. • Clients may feel frustrated that therapist is not taking the lead.

Strategic Therapy

• One of the original associates at MRI, Jay Haley, developed his own form of systemic therapy with his wife, Cloe Madanes • Their approach focuses on the use of power and love in family systems

Problematic Family Dynamics

• Power struggles: Can be within family and couple or with extended family member. • Parental conflicts: Can involve parents disagreeing about how to parent and care for children. • Lack of validation: Family openly expresses little emotional support or validation. • Lack of intimacy: Minimal sharing of significant personal information and one's emotional life.

Dynamics of Culturally Diverse Families

• The ways in which families from different cultural backgrounds view and respond to life events differs from other families • Jewish families often marry within the group, encourage children, value education, and use guilt to shape behavior • Italian families place importance on expressiveness, personal connectedness, enjoyment of food and good times, and traditional sex roles • Certain events in the family life cycle represent greater crises for one culture than another • Irish families view death as the most significant life cycle transition and will go to great lengths not to miss a wake or a funeral • Puerto Rican families stress interdependence in their culture and therefore experience death as an especially profound threat to the family's future and often experience extreme anxiety • Culturally diverse families often experience overt as well as covert criticisms of their patterns of family interaction that may not be universally accepted • Women who are treated as inferior by certain families may be taken to task • Majority culture may ignore or disdain important civic or religious holidays in particular cultural groups • Physical appearance (e.g., skin color, physical features, dress) may lead to subtle and blatant prejudice and discrimination • Minority culture families are faced with the task of nurturing and protecting each other in ways unknown to majority culture families • Access to mental health services may be difficult for minority culture families, i.e., institutional barriers • Location, formality, advertising of services, clinic operation hours, language used, and lack of culturally diverse practitioners may limit access and utilization of services by culturally diverse families • Economic factors such as exclusion from certain jobs and limited employment opportunities result in many culturally diverse families living in poverty

STAGE 5 = COMMITMENT - CHOOSING TO CONNECT

• This welcome calm allows for insight and a time for reflection. • Commitment means choice and that usually entails the choice to be very committed to the idea of the family as a unit, long-term, working to be largely unaffected by the conflicts within and outside the family. • Commitment becomes a way to show love. It is a decision to stick together, the choice that it is worth it, and that energy and loyalty now flow to the family. In this stage the family members accept the rhythm of change and the concept of balance, both between the marriage partners and the family members. • Denial becomes a thing of the past, because the family realizes that it is from the courage of confronting difficulties that strength and closeness produce lasting loyalty and closeness.

American Indians and Alaska Native Families

• Traditionally, their lives built around harmony, acceptance, cooperation, sharing, and respect for family and nature • Importance of extended family • No one size fits all model • Cultural knowledge, sensitivity, and innovation • Build relationships with local leaders and communities • Recognize culturally sensitive techniques • Recognize interconnectedness between physical and psychological distress • Consider the use of home-based therapy if applicable • Consider therapeutic techniques that are directive

Communication Stances

•Congruent, placator, blamer, superreasonable, and irrelevant •Stance acknowledges or minimizes realities: self, other, and context.

Blamer

•Has need to increase awareness of others' thoughts and feelings •Must learn to communicate personal perspectives in respectful ways •Direct confrontation often strengthens therapeutic relationship. •Prefers more upfront communication than is tolerated in polite society

Superreasonable

•Logic and rules reign supreme •Therapist must refer to context to gain validity. •Goal is to help clients value internal, subjective realities of themselves and others.

Irrelevant

•No consistent grounding in self, other, or context •Therapist must "float" along with client's distractions to identify unique "anchors" of client's reality. •Must increase ability to recognize thoughts and feelings of self and others •Progress typically slower

Placator

•People-pleasing tendencies •Needs less directive therapy methods •May make up things to give impression that therapy is progressing •Not until placator regularly and openly disagrees with therapist has rapport been established.

Complementarity

•Therapist assesses for rigid complementary patterns between family members. •Family members develop complementary roles: •The over/underfunctioner, good/bad child, understanding/strict parent, logical/emotional partner, etc. •Roles become viewed as inherent personality characteristics/unchangeable. •The more exaggerated/rigid roles become, the less adaptable individuals and family become.

Indirect Directives: Metaphorical Tasks

•Used when it's not appropriate to explicitly address a problem 1. Pretend techniques •"Fake it 'til you make it." •Clients "pretend" they achieved their goal for a designated period of time to help make desired changes •Faking behavior leads to genuine change in perspective, feeling, or behaviors 2. Ordeal therapy •Ordeals used when client feels helpless in controlling symptoms •"If one makes it more difficult for a person to have a symptom than to give it up, the person will give up the symptom." •Allow symptom with twist: client must complete another task, "ordeal," first or afterwards • Need not be directly related to undesired activity; often carries metaphoric relation