Therapist Use of Self and the Development of a Culturally-Aware Professional in Family Therapy

Abstract

It has been well established that strong therapeutic alliances correlate with positive outcomes in the course of any therapy. For therapists who seek to enhance their professional development, the contribution of familial alliances to therapy necessitates information about their proclivities with different types of family systems. Since the early days of family therapy, the genogram has served as a tool for identifying family patterns, resources, and potential hindrances. More recently, genograms have aided trainees to better understand how cultural, gender and other biases and assumptions affect administration of therapy. In this manuscript, we introduce the theoretical framework of a new model where the family-of-origin forms an important resource for the professional development of the therapist in training.

Keywords

family-of-origin alliance supervision genogram therapy differentiation self

Introduction

The capacity to use the “self” in a differentiated manner during therapy begins with an awareness and curiosity about how we make sense of our outer and inner experiences. “The theoretical framework of differentiation of the self focuses on both the intra- and inter—personal aspects” (Noh & Chow, 2019, p. 124). Our unique presentation (e.g., physical appearance, age, racial, and cultural influences) and social factors (e.g., dress, voice tone, eye contact, vocabulary, hairstyle, ability to find common ground, core values, etc.) have immediate impact on the client. “Our identities are meaningful and are embedded in our work” (Dee Watts-Jones, 2010, p. 405). As therapists, the way we see and perceive our clients immediately taps into our historical and associative processes.

Whereas the outer world perceives what we show, the inner world encompasses feelings, associations, and fantasies. The act of deciding to verbalize an inner feeling is complex because it involves many decisions. Disclosures, either consciously or implicitly, pass through a filter that decides the timing and concerns about its worthiness. Ultimately, the litmus test is whether the disclosure advances during the course of therapy and benefits the clients (Garfield, 1987). “Location of the self begins with the therapist engaging in self-disclosure, but the process often goes far beyond what is typical in the use of therapist self-disclosure” (Dee Watts-Jones, 2010, p. 405). It is an ethical duty of a therapist to always subjugate his/her own growth and feelings to accommodate the needs and wellbeing of the patient.

The inner world generates information, but it is the therapist's role to decide if, when, and how to bring forth personal information (Haber, 1994). If a therapist can access selected aspects of this inner world, then this information could result in developing hypotheses or possibly a discourse about a selected experience. Therefore, to be connected, one requires an understanding of his or her own identity. Volf writes, “[p]ersons are not relations; persons stand in relations that shape their identity” (Volf, 1996, p. 180). Therapists who attend to their personhood or “self” in the process of therapy embrace their ability to personally grow through the process of conducting therapeutic relationships (Lambert & Barley, 2002; Whitaker, 1989). “Awareness of self of the therapist is considered essential in managing family-of-origin issues that can get triggered in therapy” (Dee Watts-Jones, 2010, p. 407). To ensure that the therapeutic process is growth-oriented, creative, and respectful, the therapist could make use of the self to foster connection with the patient during therapy and being aware of one’s inner process, accepting of what is, knowing one’s self, and looking at possibilities.

As a trainee who is pursuing the knowledge and skills needed to provide functional assistance, his or her commitment to pursue personal growth serves as a model and inspiration for patients to explore new perceptions, behaviors, and relatedness. This capacity to access different aspects of the “self” is essential to both being part of, and challenging the therapeutic system (Ellenwood et al., 2012). Ignoring cultural differences between supervisors and supervisees and between supervisees and clients leaves both supervisees and clients unacceptably vulnerable (Bernard & Goodyear, 2011). Supervisees may be prone, during conflicts in the relationship or coping with situations that might be challenging or facilitating discussions with supervisors on their experiences in dealing with difficult clients or troubling ethical situations, to make poor ethical decisions that can affect the outcome of judgments of clinical relevance and importance (Bilot & Peluso, 2009).

Where do therapists learn to handle the intense stress and dysfunction of therapeutic relationships? Not surprisingly, the family-of-origin is the laboratory that conveys necessary information on learning to cope and survive when emotionally threatened (Satir & Baldwin 1983). For instance, a codependent family could convey that it is essential for the child to provide essential living care of one or both parents, thereby increasing both psychological and life stressors on the child. Coping with the threats by prioritizing the needs of others before him or herself is necessary to help manage anxiety. Therefore, it is plausible for hidden or overt family rules to manifest during family therapy. Viewed positively, such a therapist might be kind, attentive, and supportive; conversely, these attributes of the therapist could deprive his or her clients the opportunity to learn how to grow from adversity, to handle anxiety, and to become more self-sufficient. These dynamics are also observed in the supervisory process (Pistole & Watkins, 1995).

Genogram as a Clinical and Educational Resource

The traditional genogram and the more recent developments of the genogram have been used in clinical and educational settings to increase the therapist's awareness of his/her own family patterns, to enhance the differentiation of the therapist, and ultimately to improve the quality of the therapeutic alliance with clients. I this paragraph, an overview of the different applications of the genogram will be presented as an introduction to the conceptual framework of the genogram proposed by the authors.

The use of genograms to address cultural dynamics has shown to enhance the development of students’ self-awareness and increase empathy for clients, significantly impacting the quality of the therapeutic relationship, which corroborate the hypothesis that significant benefits can be achieved with genograms applied to small graduate-level practicum class where students have an opportunity to get peer feedback (Lim, 2008). Students who created and presented their family genograms in class experienced positive changes at the personal and professional levels and transformed their relationships with the family-of-origin, which were in line with previous findings (Bahr, 1990; Keiley et al., 1987; Pistole & Watkins, 1995). At the personal and professional levels, growth of the sense-of-self of the counselors in training was a common theme, along with increased self-understanding and self-awareness toward a more differentiated self of the therapist in relation to the therapist's family of origin, in support of the Bowenian theory of the differentiation of self (Bowen, 1978). These effects on counselors in training were attributed to genograms. Central to Bowen's training in intergenerational family therapy is recognition of the theory in the context of one's own family (Titelman, 1987; Wells et al., 1990). Because “clinical and educational uses of genograms are predicated on the premises that individuals are influenced by transmission of relationship styles from generation to generation and that unresolved issues surface in later generations” (Magnuson & Shaw, 2003, p. 46), trainee counsellors examine dynamics within their own families of origin using genograms in the training process (Andersen, 1987; Braverman, 1997; Wells et al., 1990). The end result of differentiation within the therapist's family is the emergence of a clinician who is competent in multifaceted genograms that serve to build relationships.

The professional genogram was introduced by Haber (1994) as a tool to graphically represent the professional influence of mentors, supervisors, and counselor educators on trainee counselors, and to enhance the mutual understanding between supervisors and supervisees. An adaptation of the traditional family genogram professional that led to enhanced self-awareness of the therapist (Magnuson, 2000) provided an opportunity for counselors in training and new professionals to examine how they were influenced by professional training and supervisors, to enhance the effectiveness of, and to ensure the relevance of the supervision with current practices.

The cultural genogram serves as an educational tool to teach health care professionals a structured way to address patients’ and families’ cultural beliefs and practices (Shellenberger et al., 2007). Using this tool, “students must be encouraged to explore how their identities and connected meanings lead them to believe, think, act, and perform their roles as therapists in specific, at times discriminatory, ways. Just as it is necessary that trainees understand as fully as possible what personal issues they carry into their work, it is vital that students comprehend how their membership in identity groups shapes the way they have come to see themselves and others like and unlike themselves. Further, they must understand how their views, transmitted through the subtle process of mundane family and community life, affect their work as therapists” (Halevy, 1998, p. 237).

The use of collaborative genograms is congruent with the Bowenian concept of mutual discovery in therapy, which helps integrate a mutual client-therapist collaboration. It has been said that “training programs need to provide a context for their students where, as therapists, they no longer need to function as the director of the client's experience but can feel free to enter into experience with the client” (Dunn & Levitt, 2000), for which collaborative genograms offer a mutually collaborative and process-oriented approach to satisfy the need of trainees.

The spiritual genogram enhances the self-awareness of trainees through the gain of fresh perspectives on how their religious/spiritual history continues to affect their current family functioning and their work with clients (Frame, 2001). This is achieved, for example, when clinical supervisors assist counselors in resolving issues with their families of origin.

The family career genogram is a postmodern, constructivist intervention that enables clients to identify familial influences in family dynamics and supports students to reflect how familial patterns might influence their career choices (Storlie et al., 2019).

The literature review presented in this paragraph clearly outlines the profound impact of the application of the genogram into the trainees. In the following sections, the authors will focus on the potential of the genogram when used in supervision settings.

Genogram as a Resource to Explore the Family-of-Origin

A client's family-of-origin influence can be better understood using genograms that provide a framework for conceptualizing decision-making processes along with their associated personal and emotional impacts, and as a tool to provide feedback to the client (Peluso, 2003). As professional counsellors and therapists following their training, conflicts can be corrected without harming clients if supervisors and supervisees use the ethical decision-making monitoring form as a reference to comprehend data generated by genograms and understand ethics better (Bilot & Peluso, 2009). It must be borne in mind that in a training setting, the genogram is strictly for educational use and therefore, it is a good ethical practice for supervisors to ensure that trainees are well informed of their right not to disclose personal information (Peluso, 2003). Indeed, trainees who gather information, construct, and present their genograms develop a healthier sense of self and a healthier self-in-relation, which are transformative in nature and enhances their awareness of patterns and dynamics in their families-of-origin (Lim, 2008). Identifying the trainee's symbolic position on the client genogram can be an effective tool in recognizing inter-generational proclivities and possibilities, as noted in the following way: we often ask the trainee questions about his or her position in the therapeutic system. The parenthetical responses are merely an idea of how one would interface the trainee's position with the clients’ genogram:

Identifying the trainee's symbolic position on the clients’ genogram can identify gender or generational biases. In order to further elucidate the trainee's position in the therapeutic system, we might, when warranted, ask some of the following questions of the trainee: -

“Where would you put yourself on the client family genogram?” (e.g., on the same level as the children, parents, or grandparents).

“Where would you (to the trainee) put yourself on the clients’ genogram?”

“Which gender do you feel most comfortable?” (e.g., he and/or she, transgender, cisgender, or other gender identities).

“Where on the client genogram do you think you could be most effective?”

“How do cultural and gender messages from your childhood help to create biases that limit your options with this family?”

“Who in your family could help you handle assuming this more effective position?” (e.g., “My grandmother could help me better understand and connect with the grandparents in the client family”).

“How would your grandparents coach you to act less like a parent and assume more of a position of grandparent or foster parent in the client family?” (e.g., “They could tell me to look at the bigger picture without over-functioning during the interview”).

In summary, questions that identify the influence of acculturation, cultural differences, minority, and majority issues may also add to understanding the complexity and potential resources of the family in various cultural domains. The family-of-origin's historic and current cultural messages are worth considering in the formation of a culturally-competent therapist. On some occasions, therapists need to learn how to connect with multiple generations as peers. “It's particularly critical to explore trainee's family-of-origin experiences as related to in-session behavior” (Kier & Lawson, 1999, p. 123). For example, older trainees need to be playful sometimes and more carefree when dealing with an adolescent; whereas some 25-year-old trainees need to access the patient and assume the wise persona of a non-judgmental grandparent. This is why the use of a genogram as a resource is so important. It's a fundamental resource to help understand family of origin and sense of self.

Family-of-Origin as a Resource in Enhancing the use of Self

Many authors have described how the therapist's “self” plays an important role in effecting therapeutic change (Aponte, 1992, 1994; Bowen, 1978; Haber, 1990; Haber & Hawley, 2004; Jacobs et al., 1995; McDaniel & Landau-Stanton, 1991; Minuchin et al., 2006; Satir & Baldwin, 1983). “Based on the management-of-self supervision model, the effectiveness of the therapist can be enhanced through the accumulated successful experiences of management-of-self within the clinical context” (Keller & Protinsky, 1984, p. 281). Further, “the use of the self-supervisory process helps a trainee understand cognitive beliefs and triangulation patterns. Once these are understood within the clinical setting, behavioral self-management strategies can be used to create change in his or her ineffective patterns of interaction” (Keller & Protinsky, 1984, p. 287).

Family-of-Origin as a Cultural Supervisory Resource

The act of bringing in the family-of-origin as a supervisory consultant, in itself, is a cultural interaction. Bowen (1978) view family-of-origin relationships as templates from which one interrelates with others, particularly in intimacy-demanding relationships (e.g., with spouses, children, and clients). The family's influence is maintained regardless of whether individuals maintain contact with their families of origin. Families of the same ethnicity, same number of children, living grandparents, religion, or state of health can be very different from their next-door neighbors. All individuals are unique and so is the family.

The process of joining and assisting a family must therefore begin with loosely formulated hypotheses and assumptions regarding the family origin, its culture, as well as implicit and explicit values and attitudes. Families are asked for their opinions about the clinical problem presented and how it is handled by the trainee. They are asked to respond as concerned parents, not professional supervisors, who are interested in the growth of their child. Exploring their views and rationale can help the supervisor better understand potential or actual cultural biases, limitations, and resources.

A New Training Model on Inclusion of the Family-of-Origin in Supervision

The proposed training model is an integral method that uses “self” in creative and resourceful ways, and which has been in practice by therapists for over 20 years. The training model was conceived as a three-part self-report design that enabled utilization of the resources of the trainee's family. First, the supervisor explores the supervisee's professional dilemma. Next, the supervisor explores the same theme through narratives of the family-of-origin members. Finally, presenting the case as an example of the theme allows the trainee to formulate new ways to handle the dilemma from information received. It also considered the commute times faced by these families and allowed for modifications to fit the context of a 3 h supervision intervention. Since the nature of the proposed intervention involves disclosure of one's personal and family life, it is necessary to offer this intervention on a voluntary basis. In addition to disclosing the risks and rewards, the family and trainee's right to refuse to answer specific questions has to be respected. Due to the intrusiveness of this method, each trainee must judge whether, and how much, he or she wants to risk exposure. The training model delimits addressing specific content areas with the family, based on the trainee's request.

Since our training model requires that the trainer or supervisor conduct resource-driven, health-seeking interviews rather than conventional types based on patient's compromised health, it is imperative for the trainer to believe in the inherently positive intent of the trainee's family. The trainee's family should be respected and acknowledged as a treasure trove of stories and experiences that can help the trainee become a more sophisticated clinician therapist. The supervisor may ask questions relevant to cultural and familial influences that have a bearing on the trainee's clinical problem to understand its relationship to the impasse, but not challenge cultural values. The questions posed in the genogram can be processed by the trainee and the supervisor can correspond the trainee's responses to cultural and familial values, as described in the literature of a case involving a participant in a marriage and family therapy program (Peluso, 2006).

If the participation of the trainee's family is a reason for fear or pessimism, we will revert to role-playing to enable the trainee request his/her parents to participate in the training intervention. If the trainee considers the participation of the family crucial for professional growth and to be effective during therapy sessions, this will be facilitated, but seeking their help may require time and patience. Indeed, a few trainees’ families have not affirmatively responded to such a request. Considering a scenario where family participation is limited, indirect intervention, could be adopted where the history and resources of the family could be discussed without the family present. The workflow for the indirect intervention to adopt the new model to a client's family comprises of:

Step 1—examine the dilemma or common impasse of the trainee;

Step 2—how does the family story resonate with the impasse; and

Step 3—how fantasied or ideal family members (Pesso, 1973) could offer helpful advice.

Despite the advantages offered when the trainee's family is present, this may not be plausible for several reasons. Nevertheless, the usefulness of an indirect intervention to the trainee can be gauged from the working relationship between the trainee and the trainer. The indirect intervention necessitates that the trainer works with the trainees to help uncover personal resources that can be used for the benefit of their clients, in the presence or absence of the trainee's family. Several goals can be achieved from this exercise—trainees watch and learn how their trainer formulates and implements questions and interventions related to family-of-origin, trainees learn to search for resources, build strength, and aim for competence. Through this indirect intervention, the trainee adapts to the model and applies this skill when dealing with client families.

A Case Study

The concept of adopting the Family-of-origin as a Supervisory Resource Model requires a philosophical approach, which dictates that healthy impulses reside in all systems. The following is a case study of a trainee who consistently adopted a different approach in her couple and family sessions. When asked about the gender messages that she learned from her family-of-origin, the trainee said that her mother consistently beckoned her to become more assertive. Since her mother was obviously a resource, she was requested to attend the following group supervision meeting, wherein the trainee played the role of the therapist in a simulation of one of her families. The mother observed and addressed how her daughter, the trainee, sabotaged her ability to assume a leadership role in the session. However, the daughter responded very favorably to her mother's comments and made more significant progress leading the session than in previous supervisory sessions. In doing so, the mother became a valuable consultant in the supervisory process since this role-playing exercise demonstrated that the parent of a trainee may be an important resource for information and support, which can promote the trainee's professional development. The results of this case study enabled inclusion of family members in supervision sessions that led to a training model, which we present in this study.

Findings

When using ‘self’ in a differentiated manner, it can be deemed to be a sign of health in the family system and the corresponding establishment of well-established relationships. Consequently, differentiated therapists contagiously give rise to differentiated clients. The process of therapy is countercultural, in that it privileges the needs of the individual over the conformist demands advanced by those who are intent on preserving the social order. Therefore, training and supervision are each an ideal context to sort out the internal voices that defy freedom and responsibility in lieu of servitude, as well as lack of agency and direction of the therapist. Our findings on the suggested mode to dissect differentiation incorporating inner experiences and related cultural implications, using a case study, will be presented in a forthcoming manuscript.

Limitations

A limitation of this training model is the use of self-report measures to assess interaction patterns during problem-solving discussions in the family-of-origin. Use of observational, prospective data to test the hypothesis that the use of “self” in a training model allows for integration of family or origin into training and supervision of therapists, will benefit adoption of this training model for therapists-in-training.

Conclusion

The aim of the training model proposed in this study is to enhance the educational quality of a therapist who will take the assistance of his/her own parents in the supervisory process, to fully qualify as a professional who has imbibed the concepts of “self”, taking advantage of the family-of-origin concept, with three genograms operating in tandem. Whereas the genogram helps identify family patterns, resources, and potential hindrances, the three-part self-report design of the training model conceived in this study is an integral method that uses “self” and allows the supervisor to explore the supervisee's professional dilemma, explores the same theme through narratives of the family-of-origin members, and allows the supervisee to formulate new ways to handle the dilemma from information received. Use of the family-of-origin as an important resource in this training model, wherein the trainer/supervisor works in tandem with the trainee to learn from the trainee's family, may assist the therapist-in-training to become a life-long learner through continual personal and professional development.

Practitioner Points

The genogram is a useful tool for therapists in supervision and can help inform trainees how cultural, gender and other biases affect administration of therapy.

Differentiation of a therapist is essential to the therapeutic process, and the family-of-origin can aid as an important resource for a therapist in training.

Paying attention to the self of the therapist provides clues to the family's internal processes. It also provides the consideration of the use of self-disclosure.

There are always three genograms operating in tandem: the therapist's genogram, the genogram of the client family, and where the therapist positions him or herself in juxtaposition to the competing pulls of the genograms.

Cultural, racial and gender messages are passed through our families-of-origin.

The family is usually invested in the professional development of their progeny.

Footnotes

Acknowledgments

Together we relied on the support of our community, colleagues, mentors, friends, and family to write this manuscript. We want to acknowledge the wonderful people who have given guidance, support, and encouragement all contributing to this work. Thank you for your engagement, wisdom, and feedback.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Carrie L. Mitran

Statement of Consent

The authors have gained proper consent from the participants within our submitted conceptual paper. We have been given authorization to continue with publication of the material written. Additionally, we agree that we the author's become liable for any third-party information collated and we take full responsibility for preparing the work and gaining the relevant permissions and consent. We received proper consent to interview the family in front of the training group. The goal of the family interview was to help with the professional skills of the volunteer. Care was taken to remain faithful to this contract. All members of the family agreed to this interview. The family unanimously gave positive feedback at the conclusion of the interview and the volunteer reported that she and her family continued to remain positive about the interview.

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