Family Therapies 2nd Edition

Family Therapy 2ndHere is the cover design for the second edition of Family Therapies: A Comprehensive Christian Appraisal. This was a fun book to revisit and update.

We looked at the various schools of family therapy and updated the research that has been conducted in support of the different approaches.

Our main focus was recognizing and reflecting the changing cultural landscape regarding family. The reader will pick this up throughout the book but especially in two new chapters. The first one is on cohabitation and how trends in living together before marriage (or just living together) affect relationship and family dynamics.

The other new chapter deals with LGBT+ couples and families and really expands how we interacted with sexual and gender identity experiences in the first edition of the book.

In any case, here is an overview of the book from the revised preface:

The book is divided into four parts. In part one (chaps. 1-2), we set the stage for the discussion of the first-generation models of family therapy. Chapter one is a discussion of a distinctively Christian perspective on the family. Chapter two is a discussion of the field of family therapy, how it developed and some key terms that will help the reader better understand the field.

Part two of the book (chaps. 3-12) devotes one chapter apiece to the major models of family therapy developed in what is sometimes referred to as the first generation of family therapists (e.g., structural family therapy). If each approach to family therapy is a “map” for getting families from a place of some kind of dysfunction to a place of better functioning, each chapter in this section contains an explanation of the map, followed by a discussion of the theoretical and philosophical assumptions and practical implications. We then focus on Christian critique and engagement of the theoretical and philosophical underpinnings and the practical issues involved in using specific techniques associated with that theory. We also provide brief reflections that tie back to the three foundational themes introduced in chapter one: family identity, family functioning and family relationships. In the closing chapter of this section of the book (chap. 12) we introduce a framework for integrative Christian family therapy.

Part three (chaps. 13-20) extends the discussion by taking topics that are commonly addressed in family therapy and inviting Christians to interact with the relevant materials. We introduce the reader to the issues (e.g., crisis and trauma, marital conflicts) and then review the literature in that area, followed by Christian engagement in light of what we see as particularly valuable from the first-generation models of family therapy and in light of what we propose for an integrative Christian family therapy. In the second edition we added a chapter on cohabitation and significantly revised the chapter on LGBT+ couples and families. We see cohabitation as an increasingly popular entryway into marriage as a a relationship status in and of itself. We want to help the reader grapple with that reality. An additional reality is the success of the marriage equality movement and the likelihood that Christian clinicians will work with LGBT+ couples and families in the years to come. We also want the reader to be familiar with those cultural shifts and to think deeply and well about some of the concerns that arise.  

Part four (chap. 21) reflects our desire to cast a vision for integrative Christian family therapy/counseling/ministry. In particular, we see the need for local family therapy to be influenced by a shrinking, global world in which family therapists will need to expand their understanding of family structure and relationships. Societal and cultural changes will have an impact on our work and the ways in which we think about and engage the families in ministry and service.

Establishing Boundaries

I returned recently from the American Association of Christian Counselors World Conference in Nashville. I was able to do a pre-conference workshop on different lenses for “seeing” sexual and gender identity concerns. I also conducted a regular workshop on counseling Christian parents whose children have come out. At the end of both sessions I received a lot of positive feedback. Many professionals and actual parents came up after the second session to say what they had gained from the workshop for counseling Christian parents.

boundariesIn addition to these positive responses, I also had a couple of people challenge the posture I took toward Christian parents around topics like whether to open their homes to a gay son or daughter, whether to attend important events (e.g., graduations, weddings), and so on. I think of this as establishing boundaries, which is a common challenge most Christian parents face as they respond to a child who has come out. Generally speaking, I work with parents to identify options for responding and setting boundaries and help them think through the potential benefits and drawbacks (to them, their child, and their relationship) of each option.

The main concern expressed to me by those critical of what I shared was the idea that in Scripture the apostle Paul writes about not even associating with someone who is engaged in immoral activity while professing to be a Christian. The admonition occurs in 1 Corinthians 5:11: “But now I am writing to you that you must not associate with anyone who claims to be a brother or sister but is sexually immoral or greedy, an idolater or slanderer, a drunkard or swindler. Do not even eat with such people.” One person quoted this passage; another quoted the passage in which Jesus says, “But he replied to the man who told him, ‘Who is my mother, and who are my brothers?And stretching out his hand toward his disciples, he said, ‘Here are my mother and my brothers! For whoever does the will of my Father in heaven is my brother and sister and mother.’” (Matthew 12:48-50). The person said, “Whoever does the will of my Father is the person I am to associate with; not someone who does not do the will of the Father.”

I wanted to take a few minutes to ‘think out loud’ about some of the feedback from those critical of the posture I took. My position in response to invitations to dinner, hosting meals, special occasions, and so on was to acknowledge that Christian parents have not reached consensus on what to do; they do not all do one thing. Indeed, there is great diversity in how Christian parents respond, and the posture I take is to create an environment for parents to weigh options and decide on boundaries in light of that thoughtful reflection. Among the one or two people who voiced a concern seemed to be the wish that I would tell the parents what they had to do as Christians. This is simply not the posture I take in counseling. The parent-child relationship is one of the most important relationships for the well-being of the child, and I want to help parents weight options and land on strategies after due consideration and prayerful reflection. In response to a wedding invitation, which I see as a little different than some of the other examples, I also discussed helping the parents think through what their concerns are, which usually has to do with having a Christian witness to their son/daughter, and which course of action best helps them communicate what they hope to communicate.

Part of what I was sharing was that there are essentially two tasks Christian parents have shared with us in different studies we have conducted: (1) seeking help/information/resources and (2) maintaining a relationship with their loved one. It is in the context of these two tasks that parents face questions about whether to participate in various activities and whether to host an adult child and his or her partner or spouse.

I do not know anyone who views Jesus’ comments as reflecting a posture you are to take toward family members–as though it was meant as detailed instruction for how to talk with an adult child about the decisions they face or have made. The passage from 1 Corinthians is perhaps more relevant at first glance, but I still do not see it as intending to provide instruction for how parents are to respond to a loved one. It may be that a family is part of a church that provides church discipline and that some behavior may warrant such oversight. But it seems to me that under those conditions any church discipline is carried out not by parents but by leadership in the church. Also, I hope that such church discipline occurs consistently across multiple areas of concern (and not exclusively associated with same-sex behavior) and with appropriate humility and with an eye for restoration of the person. I think it is a misreading of Paul to cut/paste verse 11 and apply it to parents who are responding to a child who has identifies as gay.

I also think it is an unhelpful posture to take toward counseling to simply tell parents how to relate to a loved one. These are very difficulty, weighty, and sometimes quite painful decisions, and such decisions warrant ample time, attention, and respectful engagement as parents consider which boundaries to draw.

Legislation Regarding Gender Dysphoria

Boy Girl signpostFinished up an interview today for a Christian magazine that is working on a story on gender dysphoria. The story was prompted by recent legislation that is being voted on in California. The legislation would “ensure students could participate in school activities and use facilities like bathrooms based on their gender identity, not their physical sex,” according to the LA Times. Here is the key text from the legislation:

Existing law prohibits public schools from discriminating on the basis of specified characteristics, including gender, gender identity, and gender expression, and specifies various statements of legislative intent and the policies of the state in that regard. Existing law requires that participation in a particular physical education activity or sport, if required of pupils of one sex, be available to pupils of each sex.

This bill would require that a pupil be permitted to participate in sex-segregated school programs, activities, including athletic teams and competitions, and use facilities consistent with his or her gender identity, irrespective of the gender listed on the pupil’s records.

Another story coming out of Oregon raises similar questions about access to facilities. In that story, six bathrooms were converted to unisex restrooms. This resolution seemed to meet the concerns of multiple stakeholders, as many families might not be comfortable with where the CA legislation is heading, while at the same time there is a desire among many families to respond compassionately to the needs of the person who experiences gender dysphoria. In any case, the conversion of six bathrooms to unisex restrooms was viewed by the transgender teen featured in the article.

In the interview I participated in, I didn’t really get into a discussion about legislation. I think that is an area where we need wisdom in thinking through how best to respond so that Christians are not reducing the complexities to just how to defend one’s beliefs/values in a culture war. While there is a need to defend religious liberties, there is also a need to respond to a range of issues that arise in these discussions. Unfortunately, when these complex issues are handled through legislation, my experience is that frequently no one comes out ahead. So we need to be wise about political issues while at the same time consider the experience of people who are gender dysphoric and the challenges they may face in a range of situations.

Back to the interview: I discussed what we know and do not know about gender dysphoria in terms of prevalence, etiology, and treatment, including controversial treatment options and current trends. We also discussed how Christians ought to respond from more of a clinical and pastoral standpoint, and I discussed humility and empathy for the family that is navigating gender identity concerns. We certainly do not want to drive them away from the church or contribute to shame (which is essentially self-condemnation that isolates itself from others for fear that if their experiences were know by others, they too would reject/condemn them).

In my role as a psychologist who provides consultation to individuals, couples and families navigating these difficult issues, I make sure that they are familiar with the current state of the research, including what we know and do not know in the areas mentioned above (e.g., etiology). I also want them to know what options are available to them at the present time and in the years to come. I also talked about working with the gender dysphoric person and his or her local church in terms of providing education and encouraging a supportive and sustained presence in the life of that person (and his or her family), as well as providing mature spiritual guidance.

On Legislating around the Complexities of Clinical Practice

There has been a lot in the news recently about whether California will ban the practice of reorientation therapy with teens and have specific wording as part of informed consent for adults who seek such services. The California senate committee has passed Bill 1172 to the full senate for a vote. I was interviewed about this today for a story that may run over the weekend, and let me share a few thoughts.

In terms of practicing cognitive complexity, let’s take a look at this from the perspective of those who are advancing Bill 1172. It appears to be out of a genuine regard to protect young people who are believed to be at risk for a type of therapy that proponents of the Bill believe is ineffective and inherently harmful.

On the other side are those who disagree with the Bill for several reasons. The main concerns that come to my mind are these:

1. Venue. I tend to agree with the various CA mental health organizations that have either opposed the Bill or expressed concern that legislating around the complexities of clinical practice in this area is not a good idea. Although it isn’t the first case of making a technique or practice illegal, it is not a common practice at all. Opponents also point out that mental health professionals have regulating bodies that oversee clinical practice, license practitioners, and follow up on ethical complaints. Further, several mental health professions also convene working groups and task forces to review the extant literature and provide updates on research in this area, trying to make that information available to practitioners and the public alike.

2. Science around SOCE for teens. There is not much by way of well-designed research on adolescents who pursue sexual orientation change efforts (SOCE). I don’t think the 2009 APA task force report on appropriate therapeutic responses to sexual orientation was able to identify one such study (if memory serves); instead, the task force cited published articles with case examples of clinicians who worked with adolescents navigating sexual and religious identity conflicts. The science that seems to be cited is that of adults who participated in SOCE and then extrapolated to the adolescent.

3. Science around SOCE for adults. This brings up the research on SOCE for adults that has been reviewed by a number of professionals and organizations. The Bill references a number of mental health organizations. One concern is that the Bill uses stronger language than the organizations, in at least a few cases. For example, the Bill indicates that SOCE are ineffectual, while the APA task force tends to talk about not have sufficient evidence to support claims of change, that change is “uncommon”, and that newer studies are not sufficient in quality to answer whether or not SOCE does or does not change orientation. I would note that there are those who disagree with these conclusions, but even if you agreed with these conclusions, this language and these nuances are simply not seen in the Bill.

4. Beyond attractions/desires. The other issue that has been brought up by some of the CA mental health organizations that oppose the Bill in its present form has to do with how broad it is. I believe their concern had to do with a possible unintended consequence if clinicians were not to work with teens to explore a range of sexual and gender identity issues for fear of legal ramifications associated with Bill 1172. I would also note that the Bill covers therapies to change attractions, desires, and behavior. That is rather remarkable and extends far beyond therapies that purport to change orientation. Is anyone really wanting to get behind a legal measure that restricts a clinician from helping someone change their behavior?

5. Issues with informed consent. I wrote an article published in 1998 that argued that those who provide reorientation therapy should obtain advanced informed consent for their services. Informed consent refers to the kind of information the average person would need in order to make a meaningful, informed decision about services. Advanced or expanded informed consent provides even more details about services, potential benefits, risk of harm, and so on. What I did not like about the Bill is that the language overreaches in it’s claim of SOCE being ineffective and the extent of potential harms associated with it. These seem to me to be important considerations that need to be tied to well-designed research studies. The existing research (with the use of convenience samples and seeking out those who were not pleased with services) is fraught with too many methodological problems to be the last word on risks associated with this type of therapy. I am not saying that there are not risks. But I am saying that important questions about the interventions, expectations, and competence of the clinician should also be better understood.

I would also like to see an advanced inform consent form co-authored by people who represent the different stakeholders in these discussions. Is the research far enough along that we could see an informed consent form where people who might otherwise disagree on a number of issues can at least agree on what the public needs to know to make truly informed decisions about services?

6. Trends in providing services to minors. One last thought is that Bill 1172 appears to run contrary to current trends in terms of access to services by minors. I do not want to make too much of this because there are legitimate concerns here about potential harm to minors through misinformation about unrealistic expectations, stigma, and so on. But the trend is toward putting mental health and related health care decisions into the hands of adolescents rather than restricting access (think reproductive health, parental notification laws, issues with consent, etc.). This discussion moves in the other direction – toward restricting access even if an adolescent where to assent to treatment.

I want to reiterate that I recognize the concern that minors may be at greater risk in some ways. Of course a competent clinician knows that he or she has to obtain assent from any minor who seeks any kind of mental health services, even in cases where the parent have provided consent. If the minor does not assent to services, the services should not be provided. I also recognize that some minors may give assent because of pressure they feel from their parents – and this is a genuine concern.

Although I do not provide reorientation therapy, I would say that in my experience not that many teens request reorientation therapy. The interest in it tends to come more from the parents, so the idea that there could be  pressure from parents is definitely something that should be addressed with all involved.  I think the best way to handle the potential for undue pressure is to do a good and thorough assessment of goals, expectations, motivations, and so on. I am really open to ideas on this one, but it is worth more reflection.

I am sure that there are other arguments both for and against the Bill. These are just a few thoughts. And I don’t intend to come across as a defender of reorientation therapy for minors. I have mixed feelings about reorientation therapy. It is not something I provide. My preference is to explore sexual identity questions and to navigate conflicts between religious and sexual identity concerns (following the SIT Framework). But I have defended the rights of clients to pursue such therapy if they are given sufficient advanced informed consent. I hadn’t thought about it that much for teens in part because I have not seen that many teens asking for it.

In any case, I hope these reflections show that this is at least a  complicated issue. My main concern is that legal answers such as the one proposed rarely reflect the complexity inherent in providing clinical services.

UPDATE: CBN News ran a story on the CA Bill.

UPDATE: The CA Senate approved Bill 1172. (5.30.12)

Forthcoming Book on Counseling Couples

I have a new book co-authored with James Sells coming out in April of this year. It is titled Counseling Couples in Conflict: A Relational Restoration Model. This is how InterVarsity Press Academic describes it:

Most therapeutic approaches, especially those of a cognitive orientation, are not very effective in dealing with high conflict relationships–couples often heading toward divorce by the time they seek help.

Counseling Couples in Conflict is a resource for counselors and therapists who want to be ready for these uniquely difficult cases. Utilizing a relational conflict and restoration model Mark Yarhouse and James Sells point the way beyond the cycle of pain towards marital healing.

Here is the Table of Contents:

Part I
1 Marriage at a Crucial Stage of Existence
2 Three Fights in One
3 Marriage Is an Us
4 Pastoral and Counseling Boundaries: Invested but not Overinvolved

Part II
5 Pain and Defense
6 Offense and Injury
7 Grace and Justice
8 Empathy and Trust
9 Forgiveness

Part III
10 The Expressive Art of Sexuality
11 The Product of Art: Children and Parenting
12 Sexual Infidelity
13 Divorce and Blended Families
14 Substance Abuse and Behavioral Addictions
15 A Graceful Conclusion

And here are a couple of nice endorsements:

“Addressing the concerns of professional counselors and pastoral counselors alike, Sells and Yarhouse offer a biblically-based, theological-grounded and therapeutically-sound model for working specifically with couples in conflict. I recommend this book for beginning counselors and for seasoned colleagues in the field. It definitely has a home on my bookshelves.”

—Virginia T. Holeman, Ph.D., professor of counseling, Asbury Theological Seminary, and author of Reconcilable Differences

“The institution and even the definition of marriage continue to be in turmoil and the subject of debate and controversy within our culture today. Yet, the Scriptures portray marriage as a beautiful metaphor of the union between Christ and his bride, the church. As such, couples face not only the challenges and obstacles inherent in any human relationship but must also contend with the spiritual forces of darkness that seek to destroy this image. Discord, pain, misunderstanding and hurt are inevitable. Counseling Couples in Conflict offers a solid integration of biblical principles and counseling skills with clinical theory that helps foster relational wholeness. Practical case examples are utilized throughout to illustrate key points and provide a balanced model for restoration. Whether a pastoral counselor or a professional mental health clinician, this book is an essential resource for anyone doing marital work.”

—Eric T. Scalise, Ph.D., LPC, LMFT, Vice President for Professional Development, The American Association of Christian Counselors

CAPS Panel on Ethical Conflicts in Marital Therapy

Yesterday at the CAPS national conference I participated in a panel chaired by my colleague at Regent, Dr. Jennifer Ripley, on Ethics in Couples Interventions. The other panelists were Ev Worthington (Virginia Commonwealth University), Toddy Holeman (Asbury Seminary), and Bill Berman (Christian Family Institute). We had several interesting discussions on a range of topics in marriage therapy. The topics included use of forgiveness protocols, dealing with violence in relationships, confidentiality when working with couples, managed care and billing, and working with same-sex couples.

Ev Worthington discussed his work on forgiveness, and all of the panelists shared how they might introduce the concept of forgiveness, challenges when people come at forgiveness with different assumptions, distinguishing forgiveness from other concepts, such as reconciliation or exoneration, and so on. We also discussed a number of clinical issues, such as timing, the misuse of Scripture, etc.

On dealing with violence in relationships, we discussed again the potential misuse of Scripture to rationalize violence (as justified by some abusers to establish authority or maintain order), issues with the use of separation, what it means for the offender to repent, and so on.

The discussion about confidentiality recognized different models for handling it with couples: (1) not keeping secrets, (2) keeping secrets said in an individual session/phone, and (3) using clinical judgment about whether specific information is kept secret (but not promising to hold secrets). Emphasis was placed on working with the disclosing spouse to share information that the other spouse should know (that they themselves would want to know if their roles were reversed), as well as discerning when disclosing a secret is for the good of the marriage or to get a weight off of the disclosing spouse’s shoulders.

The managed care discussion centered on how to treat individual psychopathology in a marital context. One panelist discussed providing services individually with the other spouse present, while others discussed treating individual psychopathology systemically by improving the marital relationship. Still others discussed having couples pay out of pocket if there is no identifiable disorder that can be diagnosed.

In the discussion about Christian mental health professionals working with same-sex couples, the panelists reflected on the challenges some Christians have faced in whether or not to provide services, issues related to professional competence, and value conflicts. A few current cases were mentioned, including the Ward case at Eastern Michigan University. There was some disagreement among panelists on how Christians can (or should) respond to these issues, with one voice emphasizing more of the issue of religious rights and competence, while another voice emphasized value conflicts being normal and occasionally rising to the level of a referral. The panelists discussed different options for Christians in practice, as well as relevant training concerns and what is in the best interest of the client seeking services.

CAPS East Conference

rhodes groveThe Christian Association for Psychological Studies (CAPS) East Region Conference is this weekend. I am taking a van full of students up to the Rhodes Grove Conference Center in Chambersburg, Pennsylvania. The conference theme is Marriage and Family: Christian Integration in the 21st Century. The schedule is available here. What is particularly fun about this conference is that my colleague, Dr. Jen Ripley, is giving the main plenary addresses, and I am giving the other plenary address. Her talks are titled “Research in couples Reflections from a Christian psychologist” and “Relationship counseling Hope for the future.”

My plenary address is titled “Christian integration in family therapy: Functioning, relationship, and identity.” I’ll be talking about the themes from the integrative Christian family therapy chapter from the Family Therapies book that came out this past winter.

I am also providing a presentation with two doctoral students and ISSI team members on the topic of multicultural competence for working with sexual minority clients.

CAPS East is usually a smaller venue. It provides students with a good opportunity to give a professional talk – a paper or poster presentation – without it being a really large audience. Also, those who attend tend to be really supportive of students who are beginning to form their own professional identity. It is usually a very positive experience for everyone involved, and I’m looking forward to the time with students and colleagues.