Collaborative Therapy with Multi-Stressed Families (second edition) by William C. Madsen, Ph.D., © 2007, The Guilford Press, reviewed by Karen Ziminski, LMFT.
The title is key. Not "multi-problem families," but "multi-stressed families." The mind set of considering people as being problem families or even having problems is not terribly hopeful. Collaborative therapy is about the therapist working with the family to draw out their strengths to deal with the stresses that confront them. This book gives many verbatim examples of how subtle differences in the therapist's phrasing can have a substantial effect on the family's perception of being respected and expected to attain their goals.
I last heard Bill Madsen speak in 1997, I believe, and what I still remember about that talk was his emphasis on the importance of treating clients with respect. Unfortunately, the world of community mental health care where I spend three days a week is not always conducive to this. I am often frustrated by the dilemma of trying to establish a strengths-based, culturally curious, collaborative relationship (p. 12) with a client while by the end of the first session I have to come up with a diagnosis for the insurance company based on symptoms, not strengths. Then typically by the end of the second session I must have the data for the intake evaluation and treatment plan. While the intake evaluation makes a nod to client strengths and supports, it mostly has blanks to be filled in with problems, past and present. Madsen writes with understanding about documentation requirements that make it very difficult to get therapy off on the right foot, and offers some solutions.
Madsen writes about how important it is to take the time to elicit from the client what his or her preferred view of self is. Then the client is more likely to notice the gap between the preferred view of self and how he or she is actually acting (p. 109). This is why we therapists in agencies should usually resist the requests of supervisors or team members to add goals to the treatment plan in which the client isn't yet interested.
Here is a great example of the wrong way and the right way to "externalize" the clients' problems.
Consider the different effects in talking to the parents of a boy struggling with Temper Tantrums between the questions "What toll have the Tantrums taken on your relationship?" and "What toll have his Tantrums taken on your relationship?" That latter question, which reinternalizes Tantrums, runs the risk of being heard as blaming the boy for the deterioration of his parents' relationship. Possessive pronouns tend to internalize and run counter to a process of externalizing. (p.191)
Madsen also talks about how to do other collaborative therapy techniques such as reflecting teams, witnessing teams, and letter writing. I had the rare opportunity to do one of my internships at an agency that did reflecting teams. It was rare, because most agencies considered reflecting teams a luxury back then. These team therapy approaches are probably even more rare now, but Madsen reports "informal research found that clients rated one session using witnessing teams as worth 4.7 regular therapy sessions." (p. 279)
Even if you never do the whole collaborative therapy package, I think you will find a lot of wisdom in this book that you will use no matter what model you work in. I will close this review with a quote about something most of us need to be reminded of from time to time.
Although applauding people's positive steps in life can be grounded in good intentions, clients may experience the process as condescending or patronizing. This experience can invite a minimize-maximize sequence in which clients may perceive witnesses as suggesting, "Don't you see how resourceful you are?" and may end up responding with a version of "Don't you see how difficult my life is?" Although people may dismiss praise (Oh, you are such a resourceful client"), they are more likely to accept acknowledgment ("Here is how I've been touched by what you've said").....Even in pointing out the positives, there is an upholding of judgment. As witnesses, we are still judging people and measuring them against our standards, which places us in a position of superiority...This can have disempowering effects on clients. To summarize, acknowledgment is not about congratulating people, but rather about expressing what it has meant to witness their story, why that is so, and how we have been moved, encouraged, or inspired by them." (p. 272)