DAFT Conference 20 th November 2014 Working Systemically

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

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

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%20 courses

How we start influences where we end up Ø To participate with neutrality, curiosity and respect: This topic can evoke powerful feelings Ø To respect confidentiality Ø To look after yourself and others Ø Regard all questions as useful Ø Share experience and expertise Ø Switch off mobile phones Ø Move about as you wish Ø Be positive and constructively critical Ø Remember everything and nothing is original

Plans 09. 30 Welcome 10. 00 Introductions & Aims & Exeter Depression Model 10. 45 Tea 11. 15 Jake and Amy: Skills and Questions 12. 30 Lunch 13. 15 Couples Projects: Adult Mental Health 14. 30 Tea 14. 50 Couples Projects: Child & Young Person Mental Health 16. 00 Discussion and Feedback 16. 30 Home

Aims • • • Introduction to the Exeter Depression Model Introducing the DHCFT Couples Project Transferable Skills for Couples Work Learn with and from each other Generate curiosity and creativity Promote Systemic Couples work

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.

Leona Lewis Bleeding Love

Exercise: In Pairs 10 minutes • Introductions to each other • Hopes about the Day • What expertise might you like to share about couples

Context: Why Ø Ø Ø Care Quality Commissioning Frameworks Health and Social Care Bill 2012 Recommendations from Reviews (2003– 2012) Early Intervention: IAPT & CYPIAPT National Service Framework (June 2012) National Psychosis Summit (April 2014) Children and Young People Plan Hackney Model & Munro Report NICE Guidelines Serious Case Reviews and Enquiries Troubled and Think Family Agendas

Systemic Couple Work: Focus Upon • • Strengths, Abilities and Possibilities Power and Anti-Discrimination People in Context: Systems and Networks Self of the Practitioner Creativity, Inclusivity and Multiplicity Neutrality, Curiosity and Respect Present, Past and Future Actions, Thoughts and Feelings

Systemic-Behavioural Systemic-Empathic: The Exeter Model Couples 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

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 Gary & Karen

Supervision Consultation Training DAFT & AFT University Training Programmes Systemic Hub & Spokes Research & Audit Pilot Projects Practice: Experts by Experience

Anti-Discriminatory Practice Sexual Orientation Occupation Class Interests Abilities John Burnham Literacy Gender Race. Religion Age. Attributes. Appearance Class. Colour Ethnicity. Economic Status. Education Sexuality. Size: Spirituality

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

Circularities Tracking : Talk with the couple about their actions and 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. • Explore thoughts and feelings relating to actions

Self Reflexivity 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

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

Circularity Gary acts Jan acts

Circularity, Meaning and Action Gary thinks Jan acts Gary acts Jan thinks

Context, History, Gender and Culture r e nd e G d an ture cul Past experience s oth ati er on sh ips rel Gary thinks/feels Jan acts Gary acts Jan thinks/feels Ge an nde r Past Cu d ltu experiences re re r e s h p i t o sh n io lat

Skills Practice In Pairs: 10 minutes each and then swap Discuss 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.

Circularity (Notice new information) Hypothesising (Consider, reflect, discuss ideas) Neutrality (Open and curious To 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 miniintervention, 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. 2 nd Ed. John Wiley and Sons Ltd, Chichester. pp 128

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 Questioning Using 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

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 (Mc. Goldrick, 1999) • The genogram is both an end product and a therapeutic process, moving focus away from the identified patient 31

B Past A Present 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 C Future 2. Move to what is in the past; the history that may be impacting upon the present and potential 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?

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

Key Ideas & Concepts For Today • • • Engagement & Feedback Curiosity & Neutrality Contexts & Systems Circular & Reflexive Questions Use of Self Tracking Circularities: Thought Actions Feelings Tracking Circularities: Present-Past-Future Relational Empathy 2 nd Order Change = Behaviour + Meaning

Couples therapy in an NHS adult mental health service Michael Napthine

Couple Therapy in Adult Mental Health EARLY INTERVENTION TEAMS ACUTE ADULT CARE CRISIS & INPATIENT SERVICES LESBIAN GAY BISEXUAL AND TRANSGENDER DROP IN Practice, Consultation and Supervision

Acute care Crisis Team Day Hospital Radbourne In Patient unit

Map of adult care Primary care Crisis team Recovery teams Inpatient and day hospital areas Specialist teams E. I. AOT

The H family 7 29 30 Steve Sonia 5 3

Tracking 1 Sonia Steve Sonia F. Stressed and overwhelmed F. Worried there will be an argument F. Angry T. He might help me out T. You’ve got enough/why do you need more money A. Asks Steve for money A. Says no T. Why doesn’t he want to help me? A. Questions Steve and asks again. Raises voice

Tracking 2 Steve F. Angry and suspicious T. We need the money to save for a house/is she planning to leave? A. Raises his voice Sonia F. Angry T. Don’t get treated as a wife/he should help me A. Tells Steve to leave the house or she will call the police as they are shouting and arguing Steve F. Fed up T. I don’t want to be in trouble with the police/she will call the police A. Starts to leave

Tracking 3 Sonia F. Scared he will go T. Me and the children would miss him A. Pleads with him not to go Steve F. Fed up T. I need to go but this is my family A. Stays after persuasion Sonia F. Low and depressed T. I’ve got to make it better/I want to make the marriage work A. Becomes quiet

Ideas that were useful in the work • • • Active listening Encouraging positives Using I statements Problem solving Negotiating Skills Emotional regulation

Active listening • Encourage 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

Active listening exercise Using 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.

Problem solving Defining problems Brainstorming positive alternatives Evaluating the pros and cons of these Identifying the components of a contract Forming a contract Maintaining a dialogue around more difficult problems without an apparent solution Exeter Model Handbook • • •

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.

Couples Work and Substance Misuse The 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

Couples Work and Substance Misuse T 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.

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

Couples Work & Safeguarding Ø Ø Ø Family Therapy Individual Therapy Couple Therapy Networking Safeguarding Registration & Court

Elaine’s Family 60 45 40 35 38 Elaine 17 18 14 9

Helping to become unstuck: Concerns Ø Ø Ø Ø Domestic violence Emotional abuse Neglect: Poverty Alcohol misuse Depression School attendance and achievement issues Safeguarding registration Care proceedings

Working Together Ø Ø Ø Family Therapy Individual Therapy Couple Therapy Networking Safeguarding

Outcomes Ø Ø Not depressed Not going back Improved home conditions Improved school attendance & performance Ø Family reorganisation & reconciliation Ø No safeguarding or care proceedings Ø Closure: CAMHS & Social Care

Differences that make a difference • • Focused on Strengths and abilities Did what you said you would Didn't make me defensive Gave me time to think and decide Gave me ideas about what to do Listened and did not rush Believed in me You were straight

Warrior Demi Lovato

Systemic Second Order Change Hi 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.

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 to the large group

Systemic Training and Supervision 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

Eileen Jamieson Workshop Experts by Experience: Learning with and from the people we aim to support Gary Robinson 10 November 2015 Derby University: £ 10

Contact details Dr Gary Robinson Principal Family Therapist gary. robinson@derbyshcft. nhs. uk Michael Napthine Senior Family Therapist Michael. Napthine@derbyshcft. nhs. uk

References Burr, 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 8 th 2014

References Mason, 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 8 th 2014

References 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. 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 8 th 2014