DAFT Conference 20 th November 2014 - PowerPoint Presentation

1. DAFT Conference 20th November 2014Working Systemically with Couples Facilitators Gary Robinson & Michael Napthine

2. There’s a lot going on!http://www.aft.org.uk

3. There is a lot more going on!http://derbyshireaft.wordpress.com/ http://www.aft.org.uk/view/index.html?tzcheck=1 http://www.derby.ac.uk/search/?q=systemic%20courses

4. To participate with neutrality, curiosity and respect: This topic can evoke powerful feelings To respect confidentialityTo look after yourself and othersRegard all questions as usefulShare experience and expertiseSwitch off mobile phonesMove about as you wishBe positive and constructively criticalRemember everything and nothing is originalHow we start influences where we end up

5. Plans09.30 Welcome10.00 Introductions & Aims & Exeter Depression Model10.45 Tea11.15 Jake and Amy: Skills and Questions12.30 Lunch13.15 Couples Projects: Adult Mental Health14.30 Tea14.50 Couples Projects: Child & Young Person Mental Health 16.00 Discussion and Feedback16.30 Home

6. AimsIntroduction to the Exeter Depression ModelIntroducing the DHCFT Couples ProjectTransferable Skills for Couples WorkLearn with and from each otherGenerate curiosity and creativityPromote Systemic Couples work

7. Smart things women say and other stories“As a housewife and mother, I feel that if the kids are still alive when my husband gets home, then, hey, I’ve done my job.” Roseanne Barr“I can’t mate in captivity.” Gloria Steinem on why she never married.

8. Leona LewisBleeding Love

9. Exercise: In Pairs 10 minutes Introductions to each otherHopes about the Day What expertise might you like to share about couples

10. Context: Why Care Quality CommissionCommissioning FrameworksHealth and Social Care Bill 2012Recommendations from Reviews (2003–2012) Early Intervention: IAPT & CYPIAPT National Service Framework (June 2012)National Psychosis Summit (April 2014)Children and Young People PlanHackney Model & Munro ReportNICE GuidelinesSerious Case Reviews and EnquiriesTroubled and Think Family Agendas

11. Systemic Couple Work: Focus UponStrengths, Abilities and PossibilitiesPower and Anti-DiscriminationPeople in Context: Systems and NetworksSelf of the PractitionerCreativity, Inclusivity and MultiplicityNeutrality, Curiosity and RespectPresent, Past and FutureActions, Thoughts and Feelings

12. Systemic-BehaviouralSystemic-Empathic:The Exeter ModelCouples Work with DepressionSystemic EmpathicReframingGenogramsInterviewing internalised otherCircular questioningSculptsEmpathic bridging manoeuvresInvestigating family scriptsInvestigating attachmentsJanet Reibstein & Hannah SherberskySystemic BehaviouralCircularitiesEnactmentsRole playCommunication trainingProblem solvingHomework tasksBehavioural exchange

13. DHCFT Couples ProjectSubstance Misuse Couples Project led by Doro  CAMHS Couples Project led by Veronica Inpatient Couples Project led by Michael Safeguarding Couples Project led by Gary & Karen

14. SystemicHub & SpokesSupervisionConsultationTrainingResearch & AuditPilot ProjectsPractice: Experts byExperienceUniversityTraining ProgrammesDAFT & AFT

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

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

17. CircularitiesTracking : Talk with the couple about their actions and interactions, for example by:Reflecting back observations about recurring patterns of relating between the partnersAsk about the possible functions of symptomatic behaviours for eachBe curious about the roles played by each partner and others in creating and maintaining problem behaviours or symptoms, and explore possible reasons for theseDiscuss interactive patterns that may maintain symptoms or negative interactions.Explore thoughts and feelings relating to actions

18. 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: MaturannaSelf Reflexivity

19. Love is all around us: Use of self Meatloaf & Sam Smith

20. Circularity Gary actsJan acts

21. Circularity, Meaning and Action Gary thinks Jan acts Gary actsJan thinks

22. Context, History, Gender and Culture Gary thinks/feelsJan acts Gary actsJan thinks/feelsGender and culturePast experiencesother relationshipsGender and CulturePast experiencesother relationships

23. Skills PracticeIn Pairs: 10 minutes each and then swapDiscuss and Draw circularities in relation to a recent couple issue or disagreement. Track behaviours, feelings and thoughts. Do not try to problem solve or give opinions.

24. Tea Break

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

26. 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

27. 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

28. 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

29. 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.)

30. Circular QuestioningUsing different types of questions to encourage new perspectives. Types of circular questionsScaling questionsFuture orientated questionsRanking questionsNew alternative questionsTriadic questionsOutsider observer questionsSelf-reflective on self questionsSame question asked of allContrast questions

31. GenogramsFamily genograms identify cross-generational family meanings, norms, and/or expectations, especially with regard to relationship roles and scriptsGenograms 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 patient31

32. 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 Future1. 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.

33. Tracking Actions, Feelings & Thoughts in the Present, Past and FutureUse the grid to consider questions you might ask whilst watching the couples work with Jake and Amy. Share your ideas with your partner

34. Key Ideas & Concepts For TodayEngagement & FeedbackCuriosity & NeutralityContexts & SystemsCircular & Reflexive QuestionsUse of SelfTracking Circularities: Thought Actions FeelingsTracking Circularities: Present-Past-FutureRelational Empathy2nd Order Change = Behaviour + Meaning

35. Lunch Break

36. Couples therapy in an NHS adult mental health serviceMichael Napthine

37. Couple Therapy in Adult Mental HealthEARLY INTERVENTION TEAMSACUTE ADULT CARECRISIS & INPATIENT SERVICESLESBIAN GAY BISEXUAL AND TRANSGENDER DROP INPractice, Consultation and Supervision

38. Acute careRadbourne In Patient unitDay HospitalCrisis Team

39. Map of adult carePrimary careCrisis teamRecovery teamsInpatient and day hospital areasSpecialist teams E.I. AOT

40. The H family2930735 Steve Sonia

41. Tracking 1SoniaF. Stressed and overwhelmedT. He might help me outA. Asks Steve for moneySteveF. Worried there will be an argumentT. You’ve got enough/why do you need more moneyA. Says noSoniaF. AngryT. Why doesn’t he want to help me?A. Questions Steve and asks again. Raises voice

42. Tracking 2SteveF. Angry and suspiciousT. We need the money to save for a house/is she planning to leave?A. Raises his voiceSoniaF. AngryT. Don’t get treated as a wife/he should help meA. Tells Steve to leave the house or she will call the police as they are shouting and arguingSteveF. Fed upT. I don’t want to be in trouble with the police/she will call the policeA. Starts to leave

43. Tracking 3SoniaF. Scared he will goT. Me and the children would miss himA. Pleads with him not to goSteveF. Fed upT. I need to go but this is my familyA. Stays after persuasionSoniaF. Low and depressedT. I’ve got to make it better/I want to make the marriage workA. Becomes quiet

44. Ideas that were useful in the workActive listeningEncouraging positivesUsing I statementsProblem solvingNegotiating SkillsEmotional regulation

45. Active listeningEncourage partners to listen actively in a manner that supports and validates the speaker.Clarify but don’t debate or interpret what has been said.Summarise and reflect back what you have heard your partner say especially regarding key issues.Don’t make unfounded assumptions about what you’re partner has said. Exeter Model Handbook

46. Active listening exerciseUsing the guidelines for active listening in pairs choose any topic relating to working with or being a couple to talk about. (This does not have to be a problem!)This can be anything from something that has happened or interested you recently or how you feel or think about an idea presented today.Please only share what you are comfortable with.

47. Problem solvingDefining problemsBrainstorming positive alternativesEvaluating the pros and cons of theseIdentifying the components of a contractForming a contractMaintaining a dialogue around more difficult problems without an apparent solution Exeter Model Handbook

48. PROBLEM SOLVING EXERCISE In pairs use the problem solving guidelines to discuss a current or previous couple difficulty personally or professionally.Again please only share what you are comfortable with.

49. Couples Work and Substance MisuseThe service aims to address heroin addiction use of crack/cocaine, amphetamines, cannabis or more recently legal highs. Clients with a long history of drug addiction often face a multitude of problems such as physical and mental health issues, debts, involvement in crime or Social Care issues. Substance Misuse Workers address practical matters, prescription issues, harm reduction advice and managing risk.Working systemically helps to focus on clients’ social networks and important relationships rather than only concentrating on their substance misuse issue. The relationship becomes the focus with all its complexity of communication, behavioural or emotional issues. Elements of the Exeter Model are particularly helpful. Tracking circularities is a very visual tool for highlighting familiar patterns in relationships. It also allows the detailed exploration of each person’s feelings, thoughts and behaviour in a particular situation. This exploration then provides the opportunity to use other elements such as ‘eliciting vulnerability’, ‘empathic questioning’ or ‘validation.Despite ‘Recovery’ being the foundation of the most recent Drug Strategy this has not led to a more systemic approach within our organisation. It can difficult and time consuming to encourage referrals and engagement. Poor or irregular attendance can be an issue for this group due to their complex needs and substance misuse

50. Couples Work and Substance MisuseT is 34 years old and has been in treatment for 8 years. He had been very stable and was in the process of reducing his methadone. He relapsed to daily heroin use about 2 years ago, when experiencing severe depression and anxiety. His girlfriend N. asked to attend meetings with him to help support him and also to help her regain trust as he had lied to her many times. A difficulty in working with them was that N. focused on T being ‘the problem’ as he had relapsed to heroin use. She wanted to support him and also thought that he needed to sort his drug problem out. Tracking the circularities put the focus on the interaction between them and helped them both understand the others behaviours better and they gained insight into each other’s feelings. This enabled them to be more understanding of each other.

51. Tea Break

52. Couples Work & CAMHSWatch this meeting and write down the ideas, areas or questions you might explore if you were working with this couple

53. Couples Work & SafeguardingFamily TherapyIndividual TherapyCouple TherapyNetworkingSafeguarding Registration & Court

54. Elaine’s Family17181494535403860Elaine

55. Helping to become unstuck: ConcernsDomestic violenceEmotional abuseNeglect: PovertyAlcohol misuseDepressionSchool attendance and achievement issuesSafeguarding registrationCare proceedings

56. Working TogetherFamily TherapyIndividual TherapyCouple TherapyNetworkingSafeguarding

57. OutcomesNot depressedNot going backImproved home conditionsImproved school attendance & performanceFamily reorganisation & reconciliationNo safeguarding or care proceedingsClosure: CAMHS & Social Care

58. Differences that make a differenceFocused on Strengths and abilitiesDid what you said you wouldDidn't make me defensiveGave me time to think and decideGave me ideas about what to doListened and did not rushBelieved in meYou were straight

59. WarriorDemi Lovato

60. Systemic Second Order ChangeHi Gary, I want to just tell you that I met with Elaine this morning. We did a lot of talking about how far she has come and changed and she talked about the strength and determination she has. She told me about an incident last week when her new partner became angry with Peter as he was having a temper tantrum in the supermarket. New partner stood over Peter and shouted in his face and wagged his finger at him.Elaine stood firm and told him this was not acceptable behaviour, partner then left and went back to the car. Elaine arranged a lift home with shopping and Peter. When partner came home she told him that his behaviour was not acceptable, he packed and left the house. Later Elaine sent him a text message explaining emotional and physical abuse and that she would no longer tolerate this in her relationships. Partner then rang her, and spoke to both kids and apologised to them and gave assurances that he would not behave in this way again. She says if he does then she will end the relationship. Elaine told me that without working jointly with us she would still be putting up with crap from bullying men and bullying children. She would not have a good life or be happy. She said that the work has changed her thinking as a woman and she would not have been able to do that without the work we did together.

61. FeedbackWhat have you made of today. How have you found the contents and the processes…negatives and positives?Discuss what you are going to take away from today in pairs.Chose one thing each you would like to feedback to the large group

62. Discussion

63. 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.ukSystemic Training and Supervision

64. Eileen Jamieson Workshop Experts by Experience: Learning with and from the people we aim to supportGary Robinson10 November 2015Derby University: £10

65. Contact detailsDr Gary RobinsonPrincipal Family Therapistgary.robinson@derbyshcft.nhs.uk Michael NapthineSenior Family TherapistMichael.Napthine@derbyshcft.nhs.uk

66. ReferencesBurr, Vivien (1995). An Introduction to Social Constructionism. Routledge.Carr, Alan. (2014). Thematic review of family therapy journals in 2013. Journal of Family Therapy. 36: P 420-443. Cecchin. Gianfranco (1987). Hypothesising, Circularity and Neutrality Revisited: An Invitation to Curiosity. Family Process. Vol 26. P 405-413.Hedges, Fran. Lang, Susan. (1993). Mapping Personal and Professional Stories. Human Systems. Vol 4. P 277-298.Lang, Peter W. Little, Martin. Cronen, Vernon. (1990). The Systemic Professional: Domains of Action and the Question of Neutrality. Human Systems. Vol 1. P 34-49.Lee, Bonnie, K. (2014). Towards a relational framework for pathological gambling (Part 1): Five circuits. Journal of Family Therapy. 36: P 371-393. Gary Robinson May 8th 2014

67. ReferencesMason, Barry. (1993). Towards Positions of Safe Uncertainty. Human Systems. Vol. 4. P 189-200.Minuchin, Salvador., and Fishman, H.C. (1981) Family Therapy Techniques. Harvard: Harvard College. Palazzoll Selvini, Mara. Boscolo, Luigi. Cecchin, Gianfranco. Prata, Giuiana. (1980). Hypothesising – Circularity – Neutrality: Three Guidelines for the Conductor of the Session. Family Process. Vol 19. P 3-12.Tomm, Karl. (1987). Interventive Interviewing: Part I. Strategising as a Fourth Guideline for the Therapist. Family Process. Vol 26. P 3-13.Tomm, Karl. (1987). Interventive Interviewing: Part II. Reflexive Questioning as a Means to Enable Self-Healing. Family Process. Vol 26, P 167-183.Gary Robinson May 8th 2014

68. ReferencesTomm, Karl. (1987). Interventive Interviewing: Part I. Strategising as a Fourth Guideline for the Therapist. Family Process. Vol 26. P 3-13.Tomm, Karl. (1987). Interventive Interviewing: Part II. Reflexive Questioning as a Means to Enable Self-Healing. Family Process. Vol 26, P 167-183.Tomm, Karl. (1988). Interventive Interviewing: Part III. Intending to Ask Lineal, Circular, Strategic, or Reflexive Questions? Family Process. Vol 27. P 1-15. Reibstein, Janet and Sherbersky, Hannah (2012). Behavioural and empathic elements of systemic couple therapy: the Exeter Model and a case study of depression. Journal of Family Therapy 34. P 271-283.Gary Robinson May 8th 2014

69. Thank You for participating