DAFT Workshop: 12.30-2.00pm 7th June 2013

Couples Work for DepressionFacilitator: Dr Gary Robinson

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Aims

• Introduction to the Exeter Depression Model• Launching of the DHCFT Couples Project• Transferable Skills for Couples Work• Have fun and learn from each other

Plans12.35 Welcome & Introductions & Aims12.40 Exeter Depression Model12.50 DHCFT Couples Project13.00 Key Ideas13.15 Case example and Skills Practice13.30 More ideas and Practice 13.45 Discussion and Feedback

Exercise: In Pairs 5 minutes • Introductions to each other• Hopes about the workshop • What expertise might you like

to share about couples

Why?• Evidence based. Research and Audit• Best Practice: Think Family• Service user feedback• NICE Guidelines: NHS Guidance• Social Care Guidance (Munro & Hackney)• Serious Case Reviews

Systemic-behavioural/systemic-empathic:The Exeter ModelCouples Work with Depression

• Systemic Empathic• Reframing• Genograms• Interviewing internalised other• Circular questioning• Sculpts• Empathic bridging manoeuvres• Investigating family scripts• Investigating attachments

Janet Reibstein & Hannah Sherbersky

• Systemic Behavioural• circularities• Enactments• Role play• Communication training• Problem solving• Homework tasks• Behavioural exchange• Communication skills training

DHCFT Couples Project

Substance Misuse Couples Project led by Doro CAMHS Couples Project led by Veronica Inpatient Couples Project led by Michael Safeguarding Couples Project led by Karen

The only person you can change is yourself. However the changes you make will influence others and you cannot know what that influence or effect will be. All of which is influenced by context.

Informationally closed systems: Maturanna

Self Reflexivity

Hypothesising & Curiosity

Possibilities, Ideas & Informed Guesses. Tentative explorations, allowing for the consideration of new meanings & possibilities

Anti-Discriminatory PracticeSexual OrientationOccupationClassInterestsAbilities John BurnhamLiteracyGenderRace. ReligionAge. Attributes. AppearanceClass. ColourEthnicity. Economic Status. EducationSexuality. Size: Spirituality

Circularity Circularity

Dave acts

Rose acts

Circularity, Meaning and Circularity, Meaning and Action Action

Dave thinks

Rose acts Dave acts

Rose thinks

ContextContext, History, Gender and Culture , History, Gender and Culture

Dave thinks/feels

Rose acts Dave acts

Rose thinks/feels

Gende

r and

culture

Past experiences

other relationships

Gender and Culture

Past experiences

other

relationship

s

Circularities

Tracking: Talk with the couple about their interactions, for example by:•Reflecting back observations about recurring patterns of relating between the partners•Ask about the possible functions of symptomatic behaviours for each•Be curious about the roles played by each partner and others in creating and maintaining problem behaviours or symptoms, and explore possible reasons for these•Discuss interactive patterns that may maintain symptoms or negative interactions.

Skills Practice

In groups of four pick a Rose and Dave, practitioner and observer/co-worker.

Draw circularities in relation to a recent disagreement. Track behaviours, feelings and thoughts. Do not try to problem solve or give opinions.

Hypothesising(Consider, reflect,

discuss ideas)

Neutrality(Open and curious

To new information)

Circularity(Notice new information)

Strategise(Consider and choose)

Tomm, Karl. (1987). Interventive Interviewing Part I: Strategising as a Fourth Guideline for the Therapist. Family Process 26. (page 12)

Interventive Interviewing Karl Tomm

“He highlighted the fact that every question is a mini-intervention, and he refers to circular questioning guided by specific strategies as ‘interventive interviewing’. Strategising is the process that guides such interviewing. When strategising, therapists, according to Tomm, clarify their intentions about why they are asking particular questions.”

Carr, Alan. (2006). Family Therapy: concepts, process and practice. 2nd Ed. John Wiley and Sons Ltd, Chichester. pp128

Lineal tracking questions:

What happened?Who was involved?What did they do?How did you do?When was that?

Tomm, Karl. (1988). Interventive Interviewing Part III: Intending to ask Lineal, Circular, Strategic, or Reflexive Questions? Family Process 27:1-15

Circular tracking questions:

•When you did that how did your friend react?•How did people react when the fire started?•Who else may have been affected by the death?

Tomm, Karl. (1988). Interventive Interviewing Part III: Intending to ask Lineal, Circular, Strategic, or Reflexive Questions? Family Process 27:1-15

Reflexive Questions

“The questions are reflexive in that they are formulated to trigger family members to reflect upon the implications of their current perceptions and actions and consider new options” (Tomm, 1987.)

Circular QuestioningUsing different types of questions to encourage new perspectives.

Types of circular questions•Scaling questions•Future orientated questions•Ranking questions•New alternative questions•Triadic questions

•Outsider observer questions•Self-reflective on self questions•Same question asked of all•Contrast questions

Circular QuestionsConsider the types of questions and in pairs discuss:

Which types of questions do you most use? Which questions interest or surprise you?

Genograms• Family genograms identify cross-generational family

meanings, norms, and/or expectations, especially with regard to relationship roles and scripts

• Genograms offer tangible and graphic representations of complex family patterns (McGoldrick, 1999)

• The genogram is both an end product and a therapeutic process, moving focus away from the identified patient

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3. Agree what the aims or goals are for the future and how the family will be supported in achieving them, over what period.

Resisting premature knowing, or offering solutions. Inviting families to consider the influences of the past before moving to the future

B Past

A Present

C Future

1. Start with here and now. Who is important in the child’s life, what are the current presenting difficulties. How do family members understand this and who might be involved in the assessment, treatment and support?

2. Move to what is in the past; the history that may be impacting upon the present and potential future.

Skills Practice

In groups of four, pick a Rose and Dave, a practitioner and an observer/co-worker. Use circular questions and explore the present, past and future.

Key Ideas & Concepts From Today• Engagement: Feedback• Curiosity: Neutrality• Contexts: Systems: Safeguarding• Tracking Circularities• I Statements• Relational Empathy• Genograms• Present-Past-Future• Circular Questions• 2nd Order Change = Behaviour + Meaning

Feedback

1. What have you made of today. How have you found the contents and the processes…negatives and positives?

2. Discuss what you are going to take away from today in pairs.

3. Chose one thing each you would like to feedback in the large group

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If you would like to join us at DAFT please come along. If you are interested in having further systemic training or systemic clinical supervision contact: Gary Robinson, Principal Family Therapist on 01332 623700 ext 3261 email gary.robinson@derbyshcft.nhs.uk

Systemic Training and Supervision

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